Delirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in critical patients. Here, we review the main risk factors, clinical manifestations and preventative and therapeutic approaches (pharmacological and non-pharmacological) for this illness.

Eustachian valve endocarditis is rare. A literature review revealed that only 29 cases have been reported and, among them, there is only one mention of an intensive care unit (ICU) admission. We present an 82-year-old man without previous medical records who presented with septic shock with multiple organ dysfunction. The patient was admitted to the ICU and deteriorated with combined shock (septic + cardiogenic). A second ultrasound screen detected a prominent Eustachian valve with mobile multilobulated vegetation attached. Transesophageal echocardiography confirmed a 12 mm oscillating mass attached to a visible Eustachian valve.

Spindle coma is an electroclinical entity that has been used to describe an EEG pattern of “sleep-like” activity in comatose patients. Although it has been associated with favourable prognosis, its aetiology is one of the key factors for patient outcome. The authors present three cases of spindle coma with different aetiologies (amitriptyline overdose, pontine myelinolysis and hypoxic-ischaemic encephalopathy) that culminated in different outcomes.LEARNING POINTSSpindle coma (SC) is an electroclinical “sleep-like” pattern that appears in comatose patients.It implies the functional preservation of the cerebral hemispheres which can be associated with a good prognosis.The aetiology of SC is a key factor for outcome.

Introduction: Therapeutic plasmapheresis is a therapeutic procedure in which the patient’s blood is passed through a medical device which separates out plasma from other components of blood. The plasma is removed and replaced with a replacement solution. Studies on the use of plasmapheresis in critically ill patients are scarce. The aim of this study was to review all therapeutic plasmapheresis sessions carried out in the Hospital Beatriz Ângelo intensive care unit.Material and Methods: An observational retrospective study was conducted between April 2012 and March 2019. All patients who underwent therapeutic plasmapheresis in the intensive care unit were included, and plasmapheresis sessions held outside the intensive care unit were excluded.Results: Of 46 patients, 63% were men (n = 29), with a median age of 53 years. The most frequent diagnoses were hypertriglyceridemia-induced pancreatitis, vasculitis, autoimmune haemolytic anaemia, and atypical haemolytic-uremic syndrome. A total of 198 plasmapheresis sessions were carried out in the intensive care unit. Most of the used replacement solutions were fresh frozen plasma (34.4%), albumin/crystalloid (24.2%), and albumin/fresh frozen plasma (19.2%). The most common complications were hydroelectrolytic changes (84; 42.4%) and coagulation disorders/thrombocytopenia (65; 32.8%). There was no need to interrupt any plasmapheresis session due to complications related to the patient.Discussion: Therapeutic plasmapheresis is an urgent procedure that can reduce morbidity and mortality in critically ill patients. This justifies that 37% of patients started the technique before the diagnostic confirmation. The indications for plasmapheresis and the choice of replacement solution were in agreement with the guidelines. Despite the risk of bleeding, no haemorrhagic complications were recorded.Conclusion: Therapeutic plasmapheresis is a complex technique that requires specific training. The indications are diverse, and some are not consensual. Complications were frequent, but they did not increase morbidity.

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