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Biomedical subjects

Paul E Marik

Publications and source records attributed to Paul E Marik.

At least 19 recordsLinked to original sources
PubMed2006

Osborn wave in hypothermia from Vibrio vunificus sepsis unrelated to exposure.

A 58 year old man with history of cirrhosis presented with Vibrio vunificus sepsis. The patient developed multiorgan failure despite appropriate antibiotic therapy and fluid resuscitation. The patient developed moderate hypothermia. Electrocardiography showed Osborn wave. Osborn wave is commonly seen in accidental hypothermia. Although sepsis is known to cause hypothermia, Osborn wave in sepsis is not widely appreciated.

Diagnosis, Differential↗
PubMed2006

Sublingual capnometry: a non-invasive measure of microcirculatory dysfunction and tissue hypoxia.

With improvement in supportive care patients rarely die from their presenting illness but rather from its sequela, namely sequential multi-organ failure. Tissue hypoxia is believed to be the causation of multi-organ dysfunction syndrome (MODS). The expedient detection and correction of tissue hypoxia may therefore limit the development of MODS. The standard oxygenation and hemodynamic variables (blood pressure, arterial oxygenation, cardiac output) which are monitored in critically ill patients are 'upstream' markers and provide little information as to the adequacy of tissue oxygenation. Global 'downstream' markers such as mixed venous oxygen saturation and blood lactate are insensitive indicators of tissue hypoxia. Sublingual PCO(2) is a regional marker of microvascular perfusion and tissue hypoxia that holds great promise for the risk stratification and end-point of goal directed resuscitation in critically ill patients. This paper reviews the technology and application of sublingual PCO(2) monitoring.

Blood Gas Monitoring, Transcutaneous↗
PubMed2006

Complete neurological recovery following delayed initiation of hypothermia in a victim of warm water near-drowning.

Induced hypothermia has been demonstrated to improve outcome following cardiac arrest and is now widely endorsed. However, the optimal method of cooling and the identification of patients most likely to benefit from this therapy remains to be determined. We report a patient in whom there was a long delay in return of spontaneous circulation (at least 45 min) and the initiation of induced hypothermia (12 h) who made an almost complete neurological recovery following cardiac arrest from warm-water near-drowning.

Electroencephalography↗
PubMed2006

Pulmonary blastomycosis masquerading as metastatic disease in the lung: a case report.

We report a case of pulmonary blastomycosis appearing as metastatic laryngeal squamous cell carcinoma. Pulmonary blastomycosis was discovered as right lower lobe subpleural activity consistent with metastatic disease on a positron emission tomographic (PET) scan following total laryngectomy and bilateral neck dissection for locally invasive laryngeal squamous cell carcinoma. A computed tomographic (CT) scan of the chest showed a right lower lobe, subpleural pulmonary nodule. CT-guided fine-needle aspiration of the nodule revealed broad-based budding yeast consistent with blastomycosis. To our knowledge, this is the first case of a PET-positive pulmonary blastomycosis lesion mimicking pulmonary malignancy reported in the literature.

Aged↗
PubMed2006

Adrenal-exhaustion syndrome in patients with liver disease.

OBJECTIVE: Adrenal failure is emerging as an important cause of excess morbidity and mortality in critically ill patients. We have recently reported the high incidence of adrenal failure in patients with liver disease, the so called "hepato-adrenal syndrome." It has been noted that patients who on initial testing may have "normal" adrenal function subsequently progress to overt adrenal failure, the adrenal-exhaustion syndrome. The goal of this study was to further characterize this syndrome. DESIGN: Retrospective review of the "Hepatic Cortisol Research and Adrenal Pathophysiology Study" database. SETTING: Liver transplant ICU of a tertiary care university hospital. PATIENTS AND METHODS: Patients who on initial testing had "normal" adrenal function were followed, and adrenal function testing was repeated in those who failed to improve. The patients were grouped as follows: (1) patients who developed adrenal failure on follow-up testing; and (2) patients who had normal adrenal function during their ICU stay. The incidence and risk factors for the development of adrenal-exhaustion syndrome were determined. MEASUREMENTS AND RESULTS: The study cohort consisted of 221 patients, of whom 120 (54%) were diagnosed with adrenal insufficiency on initial diagnostic testing and were excluded from further analysis. The remaining 101 patients comprised those who made up the group of interest. On follow-up, 16 (16%) of these developed adrenal failure a mean of 3 days after initial testing. The only factor that predicted the development of adrenal-exhaustion syndrome was a low HDL level (p<0.001). CONCLUSION: This study demonstrates that adrenal failure is a dynamic process and that repeat adrenal function testing is indicated in patients who remain hemodynamically unstable or fail to improve with aggressive supportive treatment. Low HDL levels may be pathogenetically linked to the development of adrenal failure.

Adrenal Cortex Function Tests↗
PubMed2006

An Intranet-based system for inpatient billing in an academic medical center.

Academic physicians face great economic challenges. There is therefore a growing need to increase the efficiency of academic practice. One potential target for improving the "business" of medicine is inpatient billing. Currently many academic centers use "yellow" cards for inpatient billing. This is an inefficient system for capturing patient charges. We describe an Intranet-based system for inpatient billing that improves physician "productivity," reduces billing lag time, and increases the collection rate and total revenues.

Academic Medical Centers↗
PubMed2006

Dyslipidemia in the critically ill.

Total and HDL cholesterol levels fall at the onset of acute illness and the cholesterol levels normalize as the patient recovers. Hypocholesterolemia may predispose the critically ill patient to sepsis and adrenal failure. Early enteral nutrition and tight glycemic control accelerate the recovery of the cholesterol levels.

Critical Illness↗
PubMed2006

Management of sepsis during the early "golden hours".

Severe sepsis and septic shock are common causes of morbidity and mortality. Interventions directed at specific endpoints, when initiated early in the "golden hours" of patient arrival at the hospital, seem to be promising. Early hemodynamic optimization, administration of appropriate antimicrobial therapy, and effective source control of infection are the cornerstones of successful management. In patients with vasopressor-dependent septic shock, provision of physiologic doses of replacement steroids may result in improved survival. Administration of drotrecogin alfa (activated), (activated protein C) has been shown to improve survival in patients with severe sepsis and septic shock who have a high risk of mortality. In this article we review the multi-modality approach to early diagnosis and intervention in the therapy of patients with severe sepsis and septic shock.

Adrenal Cortex Hormones↗
PubMed2006

Stress hyperglycemia and adrenal insufficiency in the critically ill.

Critical illness evoked by trauma, extensive surgery, or severe medical illnesses is the ultimate example of acute severe physical stress. The endocrine response in a critically injured and stressed patient is varied and complex. Although the acute and chronic phases of critical illness are characterized by distinct endocrine responses, the diagnosis of these disorders is controversial. The inability to define the endocrine change as either adaptation or pathology renders the issue of treatment even more controversial. In addition, patients may have preexisting endocrine diseases, either previously diagnosed or unknown, and hence endocrine evaluation in a critically ill patient poses a major challenge to the health care provider. This review provides a novel insight into the dynamic endocrine alterations that occur during evolution of stress hyperglycemia and adrenal insufficiency in the critically ill patient and the available evidence for the therapy of these disorders.

Adrenal Insufficiency↗
PubMed2006

Management of the critically ill geriatric patient.

OBJECTIVE: To review the effect of an aging society on the utilization of critical care services and the physiology of aging as it applies to critical illness and prognosis and management issues in the intensive care unit (ICU). DATA SOURCE: MEDLINE, Embase, and citation review of relevant primary and review articles. DATA SYNTHESIS: Elderly patients (age of >65 yrs) currently account for 42-52% of ICU admissions and for almost 60% of all ICU days. Aging is associated with decreased cardiopulmonary and renal reserve and with a high rate of co-morbidities, increasing the risks of the elderly developing progressive organ failure. Elderly ICU patients are at a particularly high risk of developing delirium, which is associated with significant morbidity. Severity of illness and age are the important factors determining ICU survival. Age and functional status before ICU admission are the major determinants of survival at 6 and 12 months after ICU discharge. Age alone should not be used to triage ICU patients; the decision to admit an elderly patient to an ICU should be based on the patients co-morbidities, acuity of illness, prehospital functional status, and preferences with regard to life-sustaining treatment. CONCLUSIONS: The management of critically ill elderly patients is a complex issue and involves an understanding of the changing demographics of our society and the physiology of aging. The reality of our aging society dictates that we must focus on how to best care for the elderly who develop critical illness.

Aged↗
PubMed2006

Multiple venous thromboses in a young man with sarcoidosis: is there a relation between sarcoidosis and venous thrombosis?

We describe the case of a 33-year-old African-American male who presented with multiple deep venous thromboses of the upper and lower extremities. Hypercoagulable workup was unrevealing. A chest x-ray showed bilateral hilar lymph node enlargement. Mediastinoscopy with hilar lymph node biopsy was performed. Lymph node histopathologic examination showed noncaseating granulomas. Lymph node tissue culture and special stains were negative for mycobacterial or fungal infection. This is an unusual case of multiple deep venous thromboses and sarcoidosis. The subject of sarcoidosis and venous thrombosis is discussed.

Adult↗
PubMed2006

The diagnosis of adrenal insufficiency in the critically ill patient: does it really matter?

The definition of what constitutes a 'normal' adrenal response to critical illness is unclear. Consequently, published studies have used a variety of biochemical criteria to define 'adrenal insufficiency'. These criteria have been based on the baseline cortisol level or the increment in cortisol following corticotropin administration. However, in critically ill patients there are a number of confounding factors that make interpretation of these tests difficult. Furthermore, in those patients who are most likely to benefit from treatment with low-dose glucocorticoids, there is no evidence that treatment should be based on adrenal function testing. In those patients in whom the diagnosis of adrenal insufficiency may be important, this diagnosis may best be made based on the free cortisol level or the total cortisol level stratified by serum albumin.

Adrenal Insufficiency↗
PubMed2006

Therapy of intracranial hypertension in patients with fulminant hepatic failure.

Severe intracranial hypertension (IH) in the setting of fulminant hepatic failure (FHF) carries a high mortality and is a challenging disease for the critical care provider. Despite considerable improvements in the understanding of the pathophysiology of cerebral edema during liver failure, therapeutic maneuvers that are currently available to treat this disease are limited. Orthotopic liver transplantation is currently the only definitive therapeutic strategy that improves outcomes in patients with FHF. However, many patients die prior to the availability of donor organs, often because of cerebral herniation. Currently, two important theories prevail in the understanding of the pathophysiology of IH during FHF. Ammonia and glutamine causes cytotoxic cerebral injury while cerebral vasodilation caused by loss of autoregulation increases intracranial pressure (ICP) and predisposes to herniation. Although ammonia-reducing strategies are limited in humans, modulation of cerebral blood flow seems promising, at least during the early stages of hepatic encephalopathy. ICP monitoring, transcranial Doppler, and jugular venous oximetry offer valuable information regarding intracranial dynamics. Induced hypothermia, hypertonic saline, propofol sedation, and indomethacin are some of the newer therapies that have been shown to improve survival in patients with severe IH. In this article, we review the pathophysiology of IH in patients with FHF and outline various therapeutic strategies currently available in managing these patients in the critical care setting.

Ammonia↗