Category: Airway Management
Keywords: HLH, Hemophagocytic Lymphohistiocytosis (PubMed Search)
Hemophagocytic Lymphohistiocytosis (HLH) – Part I
A rare, but important disease that is becoming more widely recognized and more frequently diagnosed. This disease, while uncommon, is rapidly progressive and caries a high mortality rate.
Causes are not completely understood, but involve abnormal activation of the immune response due to a failure of the typical downregulation in hyperinflammatory processes.
Two types exist:
Congenital/Familial – genetic predisposition which usually requires a triggering event to occur
Acquired – occurs in adults with no known predisposition (often have underlying genetic predispositions) – triggering events include infections , immunodeficiency, rheumatologic disorders, and malignancy in addition to many others.
Diagnosis is challenging due to the wide variety of symptoms and constellation of symptoms, which often mimic more common infections/sepsis presentations. Common symptoms include the following:
Symptoms can, and do, occur in any body system – rashes, conjunctivitis, DIC, LFT abnormalities, hypotension/shock, and respiratory failure are all common concomitant findings in the presentation of HLH
More on the specific diagnosis and treatment to follow in part II...
McClain KL. Clinical features and diagnosis of hemophagoctyic lymphohistiocytosis. UpToDate.Waltham, MA:UpToDate Inc. https://www.uptodate.com (Accessed on December 24, 2019.)
Category: Critical Care
Keywords: Pregnant, difficult airway (PubMed Search)
Most non-OB physicians experience some fear or anxiety over taking care of the average pregnant patient. There are two patients to consider when caring for these women. Critical illness adds another layer of complexity to an already challenging patient population. Due to the normal physiologic changes that occur during pregnancy there are specific and important factors to be aware of when considering and preparing for intubation.
Djabatey EA, Barclay PM. Difficult and failed intubationin 3430 obstetric general anesthesics. Anaesthesia 2009;64: 1168.
Izci B, Vennelle M, Liston WA, et al. Sleep-disordered breathing and upper airway size in pregnancy and post part. Our Respir J 2006; 27:321.
Lebowitz PW, Shay H, Straker T, et al. Shoulder and head elevation improves laryngoscope view for tracheal intubation in non obese as well as obese individuals. J Clin Anesth 2012; 24:104.
Category: Critical Care
Keywords: Right Ventricle, RV Size (PubMed Search)
Rapid Assessment of the RV on Bedside Echo
There are several causes of acute RV dysfunction resulting in a patient presenting to the ER with unstable hemodynamics. Some of these include acute cor pulmonale, acute right sided myocardial infarction and acute submassive or massive pulmonary embolism. While bedside assessment of the LV function is often performed by the ED physician, simultaneous evaluation of the RV can provide crucial information that can help guide therapeutic decisions to prevent worsening of the patient’s clinical condition. A rough guideline to determine RV size and function is below using the apical 4 chamber view.
Normal RV size : <2/3 the size of the LV
Mildly enlarged RV : >2/3 the size of the LV, but not equal in size
Moderately enlarged RV: RV size = LV size
Severely enlarged RV: RV size > LV size
Patients who are found to have RV dilation should be given fluids in a judicious fashion as the RV is not tolerant of fluid overload. Early diagnosis of the cause of acute RV failure should be sought to guide definitive therapy, but early institution of inotropic support should be considered. Frequent reassessments of biventricular function during resuscitation should be performed.
Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography, J Am Soc Echocardiogr 2010;23:685-713