No abstract

Alcohol withdrawal syndrome (AWS) continues to be a challenge to manage in the ICU setting, and the ideal pharmacological treatment continues to evolve. Dexmedetomidine is a newer agent approved for short-term sedation in the ICU, but its use in the treatment of AWS has been limited. We report a retrospective case series of ten patients who were identified as receiving dexmedetomidine for AWS as designated by electronic pharmacy records. All subjects were male, with a mean age of 53.6 years, and a mean ICU length of stay of 9.3 days. They were all diagnosed with AWS by DSM-IV criteria. All the study patients received dexmedetomidine during their hospital course as a treatment for AWS. Studied variables included demographic data, dose and duration of dexmedetomidine, other pharmaceutical agents, and hemodynamics. Dexmedetomidine was safe to use in all patients, although mechanical ventilation was still required in three patients. With dexmedetomidine, the autonomic hyperactivity was blunted, with a mean 12.8% reduction in rate pressure product observed. Consideration should be given to the combined use of dexmedetomidine with benzodiazepines in the treatment of AWS.

The objective of this study is to discuss the presentation, diagnosis, and surgical management of a young, healthy patient with a symptomatic mesenteric cyst. He had a 5-month history of abdominal pain from this disorder, and the case is presented to illustrate the clinical picture and operative management of this rare disorder.

Current RecommendationsThe most recent guidelines to address prophylaxis of VTE in the trauma patient were published in 2012 from the American College of Chest Physicians. They suggest that for "major trauma patients... the use of LDUH or LMWH, or mechanical prophylaxis, preferably over IPC, over no prophylaxis" [19]. The use of the Caprini risk assessment model is encouraged to stratify the level of risk [20]. The Eastern Association for the Surgery of Trauma (EAST) has practice management guidelines regarding DVT prophylaxis which were published in 2002 [11]. Using the Caprini risk assessment model, developed at the University of Michigan health system, assessing patients for risk of VTE is essential for initiating appropriate prophylaxis [20]. Patients are given a base risk assessment which results in a cumulative risk score, which is then correlated with the incidence of DVT. Based on this stratified risk assessment for each patient, appropriate prophylaxis is recommended, based on the current ACCP Guidelines (9 th Edition) [21]. There are several challenging trauma patient subtypes that will be detailed below and their VTE prophylaxis issues. AbstractTrauma patients are at high risk for venous thromboembolism. While a variety of risk factors predispose them to deep venous thrombosis and pulmonary embolism, the goal of aggressive chemical prophylaxis needs to be balanced against the risk of hemorrhage, making this a most challenging population to adequately prophylax. The use of titration of the prophylaxis to ant factor Xa levels is discussed. Special consideration needs to be taken in some particularly challenging trauma subpopulations, including those with renal failure, nonoperatively managed solid organ injury, traumatic brain injury with intracranial hemorrhage, spinal cord injury and the bariatric trauma patient, which are reviewed.

Patients with chronic obstructive pulmonary disease and congestive heart failure exacerbations, as well as pneumonia benefit from the use of non-invasive ventilation (NIV), due to increased patient comfort and a reduced incidence of ventilator-associated pneumonia. However, some patients do not tolerate NIV due to anxiety or agitation, and traditionally physicians have withheld sedation from these patients due to concerns of loss of airway protection and respiratory depression. We report our recent experience with a 91-year-old female who received NIV for acute respiratory distress secondary to pneumonia. The duration of NIV was a total time period of 86 h, using the bilevel positive airway pressure mode via a full face mask. The patient was initially agitated with the NIV, but with the addition of the dexmedetomidine, she tolerated it well. The dexmedetomidine was administered without a loading dose, as a continuous infusion ranging from 0.2 to 0.5 mcg/kg/hr, titrated to a Ramsey score of three. This case illustrates the safe use of dexmedetomidine to facilitate NIV, and improve compliance, which may reduce ICU length of stay.