Case Reports in Critical Care

Background. Mitral valve prolapse (MVP) is a common condition with an estimated prevalence of 1-3%, in which there is systolic displacement of a morphologically redundant mitral valve towards the left atrium. Mitral annular disjunction (MAD) is a separation of the MV attachment with the left ventricle, with hypermobility of the leaflets, and with systolic “curling” of the basal LV (left ventricle) myocardium. It is frequently associated with MVP and may confer an increased arrhythmic risk. Case Description. A 28-year-old male had ventricular fibrillation leading to out-of-hospital cardiac arrest, which was successfully resuscitated. His coronary arteries were unobstructed on invasive coronary angiography. Transthoracic echocardiogram (TTE) demonstrated MAD, confirmed by cardiac magnetic resonance (CMR) imaging and transoesophageal echocardiogram (TOE). The LV was severely dilated with reduced EF (ejection fraction), and the QTc interval was also prolonged. His father had died suddenly aged 50 years. Conclusions. This report describes the clinical dilemma of identifying and treating a patient with multiple potential causes of cardiac arrest. Despite being relatively common, the clinical significance of MAD is still uncertain and the extent to which it may be linked with complications such as ventricular arrhythmias and sudden cardiac death. MAD appears to confer an increased risk of ventricular arrhythmias, particularly when associated with MVP, particularly nonsustained VT.

Introduction. Extracorporeal membrane oxygenation (ECMO) support for severe acute respiratory distress syndrome (ARDS) is nowadays widely used with notable results on the overall survival as reported in the ELSO registry near to 55% at 90 days. This is the reason why ECMO teams force the use of this extreme technique to several populations, even though there is still a lack of data about its use on hematological patients. Case Report. A 39-year-old woman without a history of previous diseases, but a new diagnosis of acute myeloblastic leukemia (AML) was admitted to intensive care unit (ICU) for worsening hypoxia and respiratory acidosis, presenting an ARDS with in spontaneous breathing treated with noninvasive ventilation via full-face mask. Meanwhile, chemotherapy was started leading to a severe bone marrow aplasia that was managed with multiple blood and platelet transfusions. These conditions did not allow physicians to start any invasive approaches. After 14 days, ARDS worsened whereas bone marrow recovered, making possible the beginning of an invasive mechanical ventilation, with low positive end-expiratory pressure and a low tidal volume. Moreover, an immediate extracorporeal CO₂ removal (ECCO₂R) therapy was added. Despite these efforts, no improvement was achieved, and that is why venovenous ECMO throughout femoral-jugular cannulation was applied. A full protective lung ventilation by ultralow tidal volumes was guaranteed. After 2 weeks of ECMO, a gradual weaning from ECMO support was started and completed after two days. No ECMO-related complications were registered. In the end, the patient started her weaning from the mechanical ventilation and reached 12 hours of spontaneous ventilation in oxygen therapy. Discussion. ECMO is used as a rescue therapy in patients affected by severe respiratory failure with life-threatening hypoxia and respiratory acidosis nonresponsive to other maneuvers. However, immunosuppression and coagulopathies of hematological malignancies are considered relative contraindications for ECMO, while long-lasting respiratory failure represents another relative contraindication to extracorporeal support. ECMO could be a valid option to improve the survival of hematological patients with severe ARDS and thrombocytopenia, and management could change case by case, even if high incidence of recurrency.

Ketamine, initially developed as an anesthetic, has shown versatility in medical applications, including pain management, treatment-resistant depression, and sedation in the intensive care unit (ICU). While generally well-tolerated, long-term use at high doses raises concerns about potential toxicities, particularly in the liver. We present a case of a 27-year-old female with a complex medical history who received ketamine infusion for ICU sedation and experienced a sudden rise in liver function tests (LFTs), indicating possible ketamine-induced liver injury (KILI). The patient’s liver function normalized after ketamine discontinuation. KILI is infrequent with short-term ketamine use, but emerging case reports suggest it may be associated with chronic or intermittent exposure. The underlying mechanisms for KILI are not fully understood but may involve the accumulation of ketamine metabolites, causing direct toxic effects on the liver. As ketamine’s use expands, especially in critical care settings, clinicians should be vigilant for the potential development of KILI. Further research is needed to better understand its risk factors and mechanisms, as early detection and management of KILI are crucial to ensuring patient safety and optimizing ketamine’s therapeutic benefits.

A 56-year-old woman was transferred to the intensive care unit (ICU) two days after an allogeneic stem cell transplantation (ASCT) when she presented acute respiratory distress due to the relapse of a SARS-CoV-2 infection. Following that, she received two intravenous doses of 100 mg remdesivir. Subsequently, the patient developed multiple instances of diarrhea, progressing to oliguria and acute kidney injury, necessitating continuous venovenous hemofiltration (CVVH). Despite the absence of signs of hypoxemia or cardiocirculatory failure requiring vasopressor intervention, a progressive lactic acidosis emerged. Two days after the onset of lactic acidosis, a significant rise in aminotransferases and lactate dehydrogenase occurred, in the absence of encephalopathy and coagulation disorders. Remdesivir therapy had been interrupted upon the initial signs of lactic acidosis. Despite an improvement in liver function tests and lactic acidosis, the patient’s condition deteriorated, ultimately leading to her demise on day 29 due to newly arising hematological complications.

The differential diagnosis for febrile asplenic patients must always include opportunistic infections. Capnocytophaga canimorsus is one such infection. In this report, we discuss the case of a 73-year-old woman with a medical history significant for splenectomy for splenic sarcoma with prophylactic vaccination for pneumococcus who presented with rigors, emesis, and abdominal pain. Initial vital signs were 39.6°C (103.3°F), 166/70 mmHg, 92 bpm, and 95% SpO₂ on room air. A physical examination revealed mild epigastric tenderness. Initial labs and imaging were unremarkable. Eight hours after the presentation, she became hypotensive. Repeat labs revealed leukopenia with 51% bands, hemoglobin 11.0 g/dL down from 13.9 g/dL, platelets 74 K/μL trending down to 15 K/μL, PT 23.5 sec., aPTT 60.3 sec., D-dimer greater than 20 μg/mL, fibrinogen 190 mg/dL, LDH 1515 IU/L, haptoglobin less than 20 mg/dL, and creatinine 1.84 mg/dL. A peripheral smear showed schistocytes. Blood cultures identified gram-negative rods and Capnocytophaga canimorsus. After further questioning, she recalled her dog licking an abrasion on her left index finger. Four days after the presentation, she developed a purpuric rash on her bilateral hands and feet with areas of Nikolsky’s negative bullae along the dorsum of her left foot. She also developed acute renal failure requiring renal replacement therapy and hemodialysis. Capnocytophaga canimorsus is an encapsulated facultative anaerobic gram-negative bacillus. Infection can result in bacteremia and sepsis and carries a high mortality rate, even with treatment. Those with hyposplenism/asplenia are particularly susceptible to infection and can deteriorate quickly, as seen in this case. Although this infection is rare, our case highlights how all asplenic patients must be assessed and treated for encapsulated bacterial infections when presenting with an acute febrile illness, regardless of initial laboratory analysis.

A percutaneous tracheostomy is a common surgical procedure done in intensive care. Several different techniques have been described. Recently, the addition of bronchoscopy or ultrasound has been advocated to decrease the risks and complications associated with the procedure; however, both aids used alone, bronchoscopy or ultrasound, have some drawbacks and pitfalls. In this manuscript, we describe a new technique implementing a new technology, Microendoscopy coupled with ultrasound to perform percutaneous dilation tracheostomy MUGPT. MUGPT relies on dual real-time feedback microendoscopy and ultrasound to perform percutaneous dilation tracheostomy. This technique helps reduce the risk of bleeding, airway loss, tracheal wall injury, tracheal ring fracture, damage to adjacent structures, pneumothorax, pneumomediastinum, subcutaneous emphysema, false placement, hypoxia, carbon dioxide retention bronchospasm, cardiac dysrhythmias, and cost reduction. Methods. This is a case series of 6 patients who underwent single-step percutaneous dilation tracheostomy using the MUGPT technique. All the patients were in ICU and were candidates for tracheostomy. Intraoperative data collection, vital signs, oxygen saturation, and end-tidal CO2 were measured. No postoperative or intraoperative complications were documented. Conclusion. Microendoscopic ultrasound-guided percutaneous tracheostomy (MUGPT) is a promising technique with minimal complications. It is a procedure that can be performed and taught easily to Junior physicians and is a lifesaver in difficult cases.