Background: Compartment syndrome is a well-recognised complication from trauma, burns, orthopaedic, vascular, or other surgery of the limbs. Hyponatremia related rhabdomyolysis leading to compartment syndrome of all four extremities with renal and hepatic impairment is rare.1,2,3 Although the rhabdomyolysis can occur without hyponatremia. Young men have the highest incidence of compartment syndrome, particularly after long-bone extremity fractures and strenuous exercise.4,5 We present a case of compartment syndrome of all four extremities following a brief episode of recreational jogging. Case: A 39-year-old Indian male, known hypertensive on nifidipine and indapamide was presented to the emergency department with generalized weakness, lower leg pain and cramps for 3 days. He had jogged for 2 km in warm temperatures. His symptoms worsened and he was unable to walk. Other complaints were headache, pain in both arms, and passing dark coloured urine for two days. Both his calf muscles were tender, tense to feel, and painful on flexion and extension. Dorsalis pedis pulses were weak but palpable bilaterally. Capillary refill was less than three seconds and sensation were intact in both lower limbs. Oxygen saturation of toes on both feet was 99%. Other body systems were unremarkable. His respiratory rate was 20 min− 1, blood pressure 210/110 mmHg, temperature 36.6°C, oxygen saturation (SpO2) 99%. Initial biochemistry results were serum creatinine 142 umol.l− 1, myoglobin 5791 ng.ml− 1, creatinine phosphokinase 19032 U.l− 1, sodium: 124 mmol.l− 1, aspartate aminotransferase (AST) 167 U.l− 1, and alanine aminotransferase (ALT) 49 U.l− 1 (Table 1). Doppler ultrasound of leg vessels showed no evidence of deep venous thrombosis, echogenicity of the muscles in the thigh and lower leg appeared within normal limits. Rhabdomyolysis was diagnosed and rehydration begun with Hartman's solution 1000 ml followed by 125 ml.h− 1. The patient was admitted to the ward for continued hydration and analgesia to treat the pain. His leg pain worsened overnight despite intravenous analgesia. His pulse in both feet became feeble and renal and hepatic function worsened. Compartment syndrome was suspected and orthopaedic surgery was consulted. He had an emergency fasciotomy of all compartments and in all four limbs. Post-procedure pulse oximetry of digits and toes had a 99% saturation, but peripheral pulses remained weak. He was able to move fingers of both hands, but had no movement of his ankles and toes. The patient was transferred to the intensive care unit (ICU) for further management. His maintenance intravenous fluid was changed to 0.9% sodium chloride due to persistent hyponatremia. His wounds were re-explored and debrided on the fifth post-operative day. Wounds culture were growing pseudomonas aeruginosa that was treated with Meropenam according to the sensitivity. Six sittings of wound debridement and irrigation were performed. Over two weeks his renal function, liver function, and serum sodium concentration normalised (Table 1) withou...

Hemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are described as acute syndromes with multisystem abnormalities and pentad of thrombocytopenia, microangiopathic hemolysis, neurological symptoms, renal impairment and fever. Both diseases were believed to form a continuum of the same disease, but recently it was found, that they were having a different pathophysiology, as TTP patients have a deficiency in von wilbrand factor (vWF) cleavage protease. When renal involvement is severe with little or no neurological manifestation, this microangiopathy is termed as haemolytic-uraemic syndrome. If the hemolytic uraemic syndrome is not associated with diarrhoea, it is called Dnegative or atypical HUS. This subdivision is of etiological and prognostic importance. TTP-HUS is associated with high maternal and fetal morbidity and mortality. Treatment of these syndromes differs from syndrome of hemolysis with elevated liver enzymes (HE LLP syndrome) and acute fatty liver of pregnancy hence accurate diagnosis is important for optimal therapy. Plasma transfusion and plasmapheresis have revolutionized management of TTP and HUS by increasing survival 80% to 90%. Here we are reporting a case of D-negative hemolytic uraemic syndrome associated with pregnancy causing intrauterine fetal death. Diagnosis made on clinical and hematological findings, successfully treated by plasmapheresis with residual maternal renal impairment. We are presenting this case, as it is rare disorder associated with high mortality and morbidity, to increase awareness about disease, its diagnosis and management.

Background: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review of the literature has shown clear advantages over the traditional sedation namely lesser respiratory depression, less delirium, better sedation, analgesia, organ protection and anti-shivering effect.3,4 Optimal sedation in critically ill patients is of vital importance, under sedation will raise work of breathing and causes adverse hemodynamic effects. Whereas over sedation will lead to increased number of imaging studies and higher morbidity and mortality.4,5 The aim of our study was to investigate the efficacy of dexmedetomidine (Dex), its use in intubated patients and post-extubation period, rescue sedation, safety and analgesic sparing effect in critically ill surgical patients. Patients and Methods: All patients sedated with dexmedetomidine (Dex) in the surgical intensive unit of a tertiary healthcare facility were included prospectively in the study. Patients' demographic data, diagnosis, surgical interventions, traditional sedation, Dex dosage and days, post-extubation Dex use, general adverse effects, adverse effects associated with lower or higher Dex doses, analgesic, and rescue sedation requirements were recorded. Patients were intubated and ventilated, the initial dose of Dex infusion was 0.5 mcg/kg/hr along with either fentanyl or remifentanil infusion. Dex infusion was titrated to keep the Ramsay sedation score of 3 to 4. Analgesia was titrated according to the NRS (numeric rating scale) in extubated patients and the Critical-Care Pain Observation Tool (CPOT) score in intubated patients. The infusion of fentanyl and remifentanil were titrated and decreased according to the CPOT score. Some of the patients extubated required continuation of the Dex infusion in the post-extubation period to maintain analgesia and to keep them calm.Chi-square test was performed to compare among the groups. P-value ≤ 0.05 was considered as statistically significant. Results: A total of 428 patients were enrolled in the study. The majority of patients were male (73.3%). The most common diagnosis was acute abdomen and frequently the performed surgery was laparotomy (28.9%) (Figure 1a). The duration of Dex treatment ranged from 2 to 28 days; the most commonly used dose was 0.5 to 1.4 μg/kg/hours (Figure 1b). Seventy-eight percent (78%) of patients required Dex in the post-extubation period at a dose of 0.2 μg /kg/hours. There was significant reduction in the analgesic requirements in the post-Dex period (p < 0.001) (Table 1(a)). Adverse effects such as bradycardia 6.1%, hypertension 4% and hypotension 1.6% were observed (Figure 2) and there was no significant difference in lower and higher dose of Dex and occurrence of adverse effects (p < 0.82). Patients administered a higher dose of Dex required significantly higher rescue traditional sedation (p < 0.01) (Table 1(b)). Conclusion: We used dexmedetomidine in different surgical critical patients. The occurrence of adverse effects such as bradycardia, hypotension and hypertensio...