Journal of Intensive Care Medicine

Advances in prenatal screening and diagnosis, combined with an understanding of the pathophysiology of congenital anomalies, have brought incredible impetus to the field of fetal surgery. Identification of fetal anomalies can lead to counseling of the affected family so that informed decisions can be made on how to proceed with the pregnancy. Counseling may lead to pregnancy termination, changes in the timing or mode of delivery, and, in select cases, prenatal intervention. Open fetal surgery may be considered in severe cases of congenital diaphragmatic hernia, congenital chest lesions, sacrococcygeal teratoma, urinary tract obstruction, and myelomeningocele. The ex utero intrapartum treatment procedure may be lifesaving for fetuses with giant neck masses. Finally, fetoscopic surgery may be offered for select cases of twin-twin transfusion syndrome and twin reversed arterial perfusion sequence. Fetal intervention in all of these cases depends on a team approach to the patient and on the objective comparison of outcomes with and without fetal therapy. In the future, further understanding of the genetic basis of congenital diseases may enable minimally invasive treatments such as stem cell transplantation or gene therapy.

During placement of a central venous catheter (CVC), the vessel dilator and/or combination dilator/sheath-introducer are recognized as potential causative agents in numerous traumatic complications that may be erroneously ascribed to the catheter, placement needle, or guidewire. A review of the literature and device-user survey are offered in support of the need for additional training in safe dilator use, as well as the need to address device labeling and device design.

Invasive mechanical ventilation can successfully support the patient with acute respiratory failure, but it is associated with considerable risks. Numerous complications of invasive mechanical ventilation have been identified, and these may contribute to increased mortality. Therefore after clinical improvement has occurred, considerable emphasis is placed on expeditiously freeing the patient from the ventilator. This process of getting a patient off mechanical ventilation has been variably termed weaning, liberation, or discontinuation (terms which may be used interchangeably), and can be further divided into “readiness testing” and “progressive withdrawal.” Over the last decade, new developments in our understanding of the process of weaning have provided investigators with the tools to address a number of key questions: How should readiness for weaning (and trials of spontaneous breathing) be determined? What is the role of weaning parameters in deciding when to initiate the weaning process? What is the best mode for conducting a spontaneous breathing trial and how should the patient be monitored? What are the mechanisms for weaning (and spontaneous breathing trial) failure? What is the best technique to facilitate progressive withdrawal? What other factors can facilitate liberation from mechanical ventilation? What are the risks of extubation failure and how can extubation outcome best be predicted? What is the role for protocols in facilitating weaning from mechanical ventilation?.

Pleural effusions and empyemas may complicate 20–57% of bacterial pneumonias. Clinical experience supports the use of fibrinolytic agents as a means of dissolving fibrin, releasing loculations and adhesions, thereby allowing for free drainage via thoracostomy tubes. Currently available thrombolytic agents include urokinase, tissue plasminogen activator (TPA), and streptokinase. Due to manufacturer-related issues, the supply of urokinase has become somewhat limited while streptokinase has the potential for allergic reactions in pediatric patients. The authors report the use of TPA as an adjunct to other therapies for treatment of empyema in a 6-year-old boy with pneumococcal pneumonia.

We report the case of a critically ill patient with Lemierre syndrome. Lemierre syndrome is characterized by septic thrombophlebitis of the internal jugular vein and metastatic abscesses in different organs, most frequently in the lungs. The disease usually occurs in young, previously healthy individuals. Most cases are caused by Fusobacterium necrophorum, an anaerobic gram-negative rod. Oropharyngeal infection occurring 2–3 weeks prior to septicemia is a harbinger of the syndrome. Frequently oropharyngeal symptoms and local signs are absent at the time of presentation. Computed tomography (CT) scan of the neck with contrast is the most helpful diagnostic study to identify internal jugular vein thrombosis. Treatment involves a prolonged course of intravenous antibiotics with anaerobic coverage. It is important for an intensivist to keep this syndrome in mind, especially when dealing with a young, otherwise healthy patient with sepsis. Mortality is high if the disease is not diagnosed and treated promptly. The syndrome is rare in the antibiotic era, therefore a high index of suspicion is essential.