A 365-Day Record of Maternal Admissions in Intensive Care Unit at the University of Port Harcourt Teaching Hospital in Nigeria

BACKGROUND. The intensive care unit provides critically ill patients with the necessary monitoring, care and supports to optimize their organ/system functions. Parturients are often at risk of sudden deteriorations or exacerbation of chronic illnesses from direct or indirect causes and would often require admissions into the intensive care or high dependency unit. This study is aimed at looking at the trends of maternal admissions in 365 days at the intensive care unit of a tertiary teaching hospital in Southern part of Nigeria, a country that contributes significantly to the global proportion of maternal morbidity and mortality. METHODS. The study adopted a retrospective approach. All critically ill parturients admitted and requiring organ support or close monitoring in the ICU had their files and ICU documents reviewed. The review was held from January-December 2018. RESULTS. Thirty-nine (39) parturients with a mean age (years) of 33 ± 1.3 were admitted, representing 2.9% of annual deliveries. All admissions were postnatal and came predominantly from the unbooked labour ward (51%) and the time lag from maternal deteriorations to presentation to the ICU was 72 ± 10 hours. The main indications for admissions were due to postpartum haemorrhage (33.3%), complications of hypertensive disorders of pregnancy (30.9%) and sepsis (25.6%). Nineteen (48.7%) patients died from obstetric haemorrhage, complications of hypertensive disorders of pregnancy, sepsis and pulmonary embolism. CONCLUSION. The trend of maternal admissions at this specific time frame reflects the burden of maternal critical care in our environment. It highlights the need to holistically tackle the known scourge with improved care.

Causative bacteria of ventilator-associated pneumonia in intensive care unit in Bahrain:Prevalence and antibiotics susceptibility pattern

BACKGROUND Ventilator-associated pneumonia(VAP)is defined as pneumonia that occurs two calendar days following endotracheal intubation or after that.It is the most common infection encountered among intubated patients.VAP incidence showed wide variability between countries.AIM To define the VAP incidence in the intensive care unit(ICU)in the central gove-rnment hospital in Bahrain and review the risk factors and the predominant bacterial pathogens with their antimicrobial susceptibility pattern.METHODS The research was a prospective cross-sectional observational study over six months from November 2019 to June 2020.It included adult and adolescent patients(>14 years old)admitted to the ICU and required intubation and mechanical ventilation.VAP was diagnosed when it occurred after 48 h after endotracheal intubation using the clinical pulmonary infection score,which considers the clinical,laboratory,microbiological,and radiographic evidence.RESULTS The total number of adult patients admitted to the ICU who required intubation and mechanical ventilation during the study period was 155.Forty-six patients developed VAP during their ICU stay(29.7%).The calculated VAP rate was 22.14 events per 1000 ventilator days during the study period,with a mean age of 52 years±20.Most VAP cases had late-onset VAP with a mean number of ICU days before the development of VAP of 9.96±6.55.Gram-negative contributed to most VAP cases in our unit,with multidrug-resistant Acinetobacter being the most identified pathogen.CONCLUSION The reported VAP rate in our ICU was relatively high compared to the international benchmark,which should trigger a vital action plan for reinforcing the implementation of the VAP prevention bundle.

Metabolic Acidosis in the Surgical Intensive Care Unit: Risk Factors, Clinical Correlates and Outcome. Findings from a High Dependency Heart and Vascular Surgical Center in Nigeria

Background: Metabolic acidosis (MA) is a common finding on the surgical ward, more so in the intensive care unit. Diseases affecting the major organ systems of the body and higher grades of surgery are common risk factors for MA. It is associated with poor treatment outcome. Aim: To determine the risk factors and clinical correlates of metabolic acidosis and assess its relationship with treatment outcome. Methodology: A retrospective study at the “Tristate Heart and vascular Center” in Ilishan-Remo South west Nigeria, on patients that had cardiac and vascular surgeries from January 2015 to December 2019. Three hundred and forty two participants took part in the study. The demographic, clinical and laboratory findings were entered. Statistical analysis was with Student’s t-test and Chi square. Results: Two hundred and six males and 136 females were studied. The incidences of metabolic acidosis prior to induction, on post-operative day one (POD1) and on POD28 were 20.7%, 39.8% and 14.1% respectively. Nine (2.6%) participants died during admission, of this, 6 (66.7%) had MA at presentation but all (100%) had MA on POD1. The Risk factors for MA were advanced age, comorbidities, open heart surgery, elevated systolic blood pressure and low eGFR. Metabolic acidosis was a risk factor for prolonged hospital stay, perioperative death and declining kidney function which was commoner among participants with preexisting kidney dysfunction. Conclusion: The incidence of metabolic acidosis was 20.7% at induction of anesthesia, rose to 39.8% on POD1 and by POD28, it has significantly reduced to 14.1%. While advancing age and comorbidities were risk factors for MA, the occurrence of MA increased the risk of declining kidney function, prolonged hospital stay and death.

Diagnosis and management of malaria in the intensive care unit

Malaria is responsible for approximately three-quarters of a million deaths in humans globally each year.Most of the morbidity and mortality reported are from Sub-Saharan Africa and Asia,where the disease is endemic.In non-endemic areas,malaria is the most common cause of imported infection and is associated with significant mortality despite recent advancements and investments in elimination programs.Severe malaria often requires intensive care unit admission and can be complicated by cerebral malaria,respiratory distress,acute kidney injury,bleeding complications,and co-infection.Intensive care management includes prompt diagnosis and early initiation of effective antimalarial therapy,recognition of complications,and appropriate supportive care.However,the lack of diagnostic capacities due to limited advances in equipment,personnel,and infrastructure presents a challenge to the effective diagnosis and management of malaria.This article reviews the clinical classification,diagnosis,and management of malaria as relevant to critical care clinicians,highlighting the role of diagnostic capacity,treatment options,and supportive care.

Severe dengue in the intensive care unit

Dengue fever is considered the most prolific vector-borne disease in the world,with its transmission rate increasing more than eight times in the last two decades.While most cases present mild to moderate symptoms,5%of patients can develop severe disease.Although the mechanisms are yet not fully comprehended,immune-mediated activation leading to excessive cytokine expression is suggested as a cause of the two main findings in critical patients:increased vascular permeability that may shock and thrombocytopenia,and coagulopathy that can induce hemorrhage.The risk factors of severe disease include previous infection by a different serotype,specific genotypes associated with more efficient replication,certain genetic polymorphisms,and comorbidities such as diabetes,obesity,and cardiovascular disease.The World Health Organization recommends careful monitoring and prompt hospitalization of patients with warning signs or propensity for severe disease to reduce mortality.This review aims to update the diagnosis and management of patients with severe dengue in the intensive care unit.

Left ventricular thrombosis caused cerebral embolism during venoarterial extracorporeal membrane oxygenation support: A case report

BACKGROUND Venoarterial(VA)extracorporeal membrane oxygenation(ECMO),an effective short-term circulatory support method for refractory cardiogenic shock,is widely applied.However,retrospective analyses have shown that VA-ECMO-assisted cases were associated with a relatively high mortality rate of approximately 60%.Embolization in important organs caused by complications of left ventricular thrombosis(LVT)during VA-ECMO is also an important reason.Although the incidence of LVT during VA-ECMO is not high,the consequences of embolization are disastrous.CASE SUMMARY A 37-year-old female patient was admitted to hospital because of fever for 4 d and palpitations for 3 d.After excluding the diagnosis of coronary heart disease,we established a diagnosis of“clinically explosive myocarditis”.The patient still had unstable hemodynamics after drug treatment supported by VA-ECMO,with heparin for anticoagulation.On day 4 of ECMO support,a left ventricular thro-mbus attached to the papillary muscle root of the mitral valve was found by transthoracic echocardiography.Left ventricular decompression was performed and ECMO was successfully removed,but the patient eventually died of multiple cerebral embolism.CONCLUSION LVT with high mobility during VA-ECMO may cause embolism in important organs.Therefore,a"wait and see"strategy should be avoided.

Treatment of a patient with severe lactic acidosis and multiple organ failure due to mitochondrial myopathy:A case report

BACKGROUND Mitochondrial myopathy is a rare genetic disease with maternal inheritance that may involve multiple organ systems.Due to the lack of typical characteristics,its clinical diagnosis is difficult,and it is often misdiagnosed or even missed.CASE SUMMARY The patient was a young college student.When he presented at the hospital,he had severe lactic acidosis,respiratory failure,and shock with multiple organ dysfunction syndrome(MODS).He was treated by mechanical ventilation,venoarterial extracorporeal membrane oxygenation,and other organ support.However,his condition continued to worsen.After a thorough and detailed medical and family history was taken,a mitochondrial crisis was suspected.A muscle biopsy was taken.Further genetic testing confirmed a mitochondrial gene mutation(TRNL13243A>G).The final diagnosis of mitochondrial myopathy was made.Although there is no known specific treatment,intravenous methylprednisone and intravenous immunoglobulin were started.The patient’s shock eventually improved.The further course was complicated by severe infection in multiple sites,severe muscle weakness,and recurrent MODS.After 2 mo of multidisciplinary management and intensive rehabilitation,the patient could walk with assistance 4 mo after admission and walk independently 6 mo after admission.CONCLUSION More attention should be paid to mitochondrial myopathy to avoid missed diagnosis and misdiagnosis.

Evaluation of Brain CT Images of Eclamptics in Portharcourt Nigeria

Eclampsia is a common complication of hypertensive disorders of pregnancy and in the puerperium with the attendant risk to both the mother and baby. Although it is a multi-systemic disorder, its manifestation that affects the brain and resulting in altered sensorium demands brain imaging to define the possible brain lesions and the implications for critical care management and outcome. We evaluated the CT brain lesions in the patients with eclampsia who were admitted in the intensive care unit, University of Port Harcourt, Port Harcourt Nigeria. Objective: To analyse the CT brain images of eclamptic parturients and the outcome following their admission in the intensive care unit. Methods: We undertook this observational study after obtaining ethical exemption from the University of Portharcourt Teaching Hospital ethical review board, and commenced the review between March 2021 to February 2023. We included all parturients that were admitted into the intensive care unit of the University of Portharcourt Teaching Hospital, a nine-bedded open intensive care unit with the clinical diagnosis of eclampsia. Every admitted parturient was required to obtain a brain computed tomography (CT) by local protocol. The brain CT images were retrieved for review from the parturients’ relatives, radiology department and the ICU. Parturients included were aged ≥ 18 years. The radiological reports of these brain images which were also reviewed by a neurosurgeon in case of any need for secondary opinion were subjected to statistical analysis. Result: Thirty-one parturients were admitted with eclampsia with a mean age of 30 years ± 5.29. Sixteen (16) parturients died representing 52%. Only twenty-four (24) CT brain images were retrieved for review (77%). The following brain lesions were identified from the brain CT and they comprised the following: intracerebral haemorrhage, including extensions into the ventricles 7 (29.17%), cerebral oedema 12 (50%), subdural hematoma 1 (4.17%) and normal imaging 4 (16.66%). The subdural haematoma was promptly evacuated with a good outcome. Conclusion: Neuro imaging comprising computed tomography and magnetic resonance imaging of the brain are basic ancillary investigations for patients with eclampsia presenting with neurologic deficits and low GCS. Early presentation and access to brain CT could influence outcome as it was demonstrated in the prompt intervention in the patient with subdural haematoma which was evacuated with a satisfactory outcome.

Implementation experience of a 12-month intervention to introduce intermittent kangaroo mother care to eight Chinese neonatal intensive care units

Kangaroo mother care(KMC)is recommended by the World Health Organization for the care of preterm and low-birth-weight newborns.KMC has been shown to increase survival rates and the quality of life of preterm and low-birth-weight infants,including improved clinical outcomes,weight gain and thermoregulation when compared to conventional care[1,2,3].More recent research focused on KMC in high-risk preterm,critically ill newborns and newborns requiring special care,which suggested that KMC helped to stabilize the vital signs of preterm infants[4,5].KMC is well accepted and promoted by medical associations and professional organizations around the world[6,7].In November 2015 with support from the National Health Commission of China,participants from ten hospitals based in different areas of China received theoretical and practical training on KMC.During a four-year period,health professionals from these hospitals participated in theoretical and practical training,which included two operation training from foreign experts,two academic lectures,and three study tours to hospitals in the UK,Sweden and the Netherlands.During this period,the KMC Operational Manual for Premature Infants in China was developed,and a 12-month prospective multicenter study of KMC for preterm infants was conducted in the eight hospitals.In the present study,we further examine whether KMC was sustained as a practice during a 12-month period from April 2018 to March 2019 and the characteristics of preterm infants that received KMC.

Endoscopic transluminal pancreatic necrosectomy using a self-expanding metal stent and high-flow water-jet system

Walled-off pancreatic necrosis and a pancreatic abscess are the most severe complications of acute pancreatitis. Surgery in such critically ill patients is often associated with significant morbidity and mortality within the first few weeks after the onset of symptoms. Minimal invasive approaches with high success and low mortality rates are therefore of considerable interest. Endoscopic therapy has the potential to offer safe and effective alternative treatment. We report here on 3 consecutive patients with infected walled-off pancreatic necrosis and 1 patient with a pancreatic abscess who underwent direct endoscopic necrosectomy 19-21 d after the onset of acute pancreatitis. The infected pancreatic necrosis or abscess was punctured transluminally with a cystostome and, after balloon dilatation, a non-covered self-expanding biliary metal stent was placed into the necrotic cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation. After 5-7 d, the metal stent was removed endoscopically and the necrotic cavity was entered with a therapeutic gastroscope. Endoscopic debridement was performed via the simultaneous application of a high-flow water-jet system; using a flush knife, a Dormia basket, and hot biopsy forceps. The transluminal endotherapy was repeated 2-5 times daily during the next 10 d. Supportive care included parenteral antibiotics and jejunal feeding. All patients improved dramatically and with resolution of their septic conditions; 3 patients were completely cured without any further complications or the need for surgery. One patient died from a complication of prolonged ventilation severe bilateral pneumonia, not related to the endoscopic procedure. No procedure related complications were observed. Transluminal endoscopic necrosectomy with temporary application of a self-expanding metal stent and a high-flow water-jet system shows promise for enhancing the potential of this endoscopic approach in patients with walled-off pancreatic necrosis and/or a pancreatic abscess.

Physical restraint in mental health nursing: A concept analysis

Objective: Physical restraint is frequently used in medical services,such as in mental health settings,intensive care units and nursing homes,but its nature varies in different institutions.By reviewing related literature,this study aims to clarify the concept of physical restraint in mental health nursing.Method: Three databases (PubMed,PsyclNFO and CINAHL) were retrieved,and Walker and Avant's concept analysis method was used to analyze the concept of physical restraint in mental health nursing.Results: Physical restraint is a coercive approach that enables the administration of necessary treatment by safely reducing the patient's physical movement.It should be the last option used by qualified personnel.Antecedents of physical restraint are improper behavior (violence and disturbance) of patients,medical assessment prior to implementation and legislation governing clinical usage.Consequences of physical restraint are alleviation of conflict,physical injury,mental trauma and invisible impact on the institution.Discussion: This study defined the characteristics of physical restraint in mental health nursing.The proposed concept analysis provided theoretical foundation for future studies.

Glucagon-like peptide-1 protects against cardiac microvascular endothelial cells injured by high glucose

Objective:To investigate the protective effect of glucagon-like peptid-1(GLP-l) against cardiac microvascular endothelial cell(GTFCs) injured by high glucose.Methods:CMECs were isolated and cultured.Superoxide assay kit and dihydroethidine(DHE) staining were used to assess oxidative stress.TENEL staining and caspase 3 expression were used to assess the apoptosis of CMECs.H89 was used to inhibit eAMP/PKA pathway:fasudil was used to inhibit Rho/ROCK pathway.The protein expressions of Rho.ROCK uere examined by Western blol analysis.lesults:High glucose increased the production of ROS.the activity of NADPH.the apoptosis rate and the expression level of Rho/ROCK in CMECs.while GLP- 1 decreased high glucose-induced ROS production.the NADPH activity and the apoptosis rate and the expression level of Rho/ROCK in CMECs,the difference were statistically significant(P<0.05).Conclusions:GLP-1 could protect the cardiac microvessels against oxidative stress and apoptosis.The protective effects of GLP-1 are dependent on downstream inhibition of Rho through a cAMP/PKA-dependent manner,resulting in a subsequent decrease in the expression of NADPH oxidase.

Perioperative thromboprophylaxis in liver transplant patients

Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation(LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications(intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors(portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ‘‘rebalanced hemostasis' ' can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors(venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.

Predictive factors of short term outcome after liver transplantation: A review

Liver transplantation represents a fundamental therapeutic solution to end-stage liver disease. The need for liver allografts has extended the set of criteria for organ acceptability, increasing the risk of adverse outcomes. Little is known about the early postoperative parameters that can be used as valid predictive indices for early graft function, retransplantation or surgical reintervention, secondary complications, long intensive care unit stay or death. In this review, we present state-of-the-art knowledge regarding the early posttransplantation tests and scores that can be applied during the first postoperative week to predict liver allograft function and patient outcome, thereby guiding the therapeutic and surgical decisions of the medical staff. Post-transplant clinical and biochemical assessment of patients through laboratory tests(platelet count, transaminase and bilirubin levels, INR, factor V, lactates, and Insulin Growth Factor 1) and scores(model for end-stage liver disease, acute physiology and chronic health evaluation, sequential organ failure assessment and model of early allograft function have been reported to have good performance, but they only allow late evaluation of patient status and graft function, requiring days to be quantified. The indocyanine green plasma disappearance rate has long been used as a liver function assessment technique and has produced interesting, although not univocal, results when performed between the 1th and the 5th day after transplantation. The liver maximal function capacity test is a promising method of metabolic liver activity assessment, but its use is limited by economic cost and extrahepatic factors. To date, a consensual definition of early allograft dysfunction and the integration and validation of the above-mentioned techniques, through the development of numerically consistent multicentric prospective randomised trials, are necessary. The medical and surgical management of transplanted patients could be greatly improved by using clinically reliable tools to predict early graft function.

Effect of axial vertical vibration on degeneration of lumbar intervertebral discs in modified bipedal rats: An in-vivo study

Objective: To assess the effects of axial vibrations on gene expression and lumbar intervertebral disc degeneration in vivo. Methods: A modified bipedal rat model was established using a brachial plexus rhizotomy approach to imitate human upright posture. The experimental animals were randomly divided into three groups: control, vertical vibration, and whole-body vibration. Gene expression in degeneration of the intervertebral discs was assessed by reverse transcription-quantitative polymerase chain reaction. Results: The expression of aggrecan, Col1α1, Col2α1, and decorin were shown to be up-regulated in 14-week-old rats in the vertical vibration and whole-body vibration groups, whereas biglycan and versican expression was down-regulated in 14-week-old rats of the two experimental groups. Furthermore, biglycan and versican expression levels were shown to be lower in the whole-body vibration group than in the vertical vibration group(P<0.05). Conclusions: This in-vivo study demonstrated that vibrations can influence the expression of anabolic genes. Furthermore, whole-body vibrations seem to have a greater effect in this regard than vertical vibrations. A new method is expected to relieve the low back pain of the patients through our research.

Gastroesophageal reflux and congenital gastrointestinal malformations

Although the outcome of newborns with surgical congenital diseases(e.g.,diaphragmatic hernia;esophageal atresia;omphalocele;gastroschisis) has improved rapidly with recent advances in perinatal intensive care and surgery,infant survivors often require intensive treatment after birth,have prolonged hospitalizations,and,after discharge,may have longterm sequelae including gastro-intestinal comorbidities,above all,gastroesophageal reflux(GER).This condition involves the involuntary retrograde passage of gastric contents into the esophagus,with or without regurgitation or vomiting.It is a well-recognized condition,typical of infants,with an incidence of 85%,which usually resolves after physiological maturation of the lower esophageal sphincter and lengthening of the intra-abdominal esophagus,in the first few months after birth.Although the exact cause of abnormal esophageal function in congenital defects is not clearly understood,it has been hypothesized that common(increased intra-abdominal pressure after closure of the abdominal defect) and/or specific(e.g.,motility disturbance of the upper gastrointestinal tract,damage of esophageal peristaltic pump) pathological mechanisms may play a role in the etiology of GER in patients with birth defects.Improvement of knowledge could positively impact the long-term prognosis of patients with surgical congenital diseases.The present manuscript provides a literature review focused on pathological and clinical characteristics of GER in patients who have undergone surgical treatment for congenital abdominal malformations.

Impact of disease severity on gastric residual volume in critical patients

AIM: To investigate whether illness severity has an impact on gastric residual volume (GRV) in medical critically ill patients. METHODS: Medical intensive care unit (ICU) patients requiring nasogastric feeding were enrolled. Sequential Organ Failure Assessment (SOFA) score was assessed immediately preceding the start of the study. Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ scores were recorded on the first, fourth, seventh, and fourteenth day of the study period. GRV was measured every 4 h during enteral feeding. The relationship be-tween mean daily GRV and SOFA scores and the correlation between mean daily GRV and mean APACHE Ⅱ score of all patients were evaluated and compared. RESULTS: Of the 61 patients, 43 patients were survivors and 18 patients were non-survivors. The mean daily GRV increased as SOFA scores increased (P < 0.001, analysis of variance). Mean APACHE Ⅱ scores of all patients correlated with mean daily GRV (P = 0.011, Pearson correlation) during the study period. Patients with decreasing GRV in the first 2 d had better survival than patients without decreasing GRV (P = 0.017, log rank test). CONCLUSION: GRV is higher in more severely ill medical ICU patients. Patients with decreasing GRV had lower ICU mortality than patients without decreasing GRV.

Iatrogenic pneumothorax related to mechanical ventilation

Pneumothorax is a potentially lethal complication associated with mechanical ventilation. Most of the patients with pneumothorax from mechanical ventilation have underlying lung diseases; pneumothorax is rare in intubated patients with normal lungs. Tension pneumothorax is more common in ventilated patients with prompt recognition and treatment of pneumothorax being important to minimize morbidity and mortality. Underlying lung diseases are associated with ventilatorrelated pneumothorax with pneumothoraces occurring most commonly during the early phase of mechanical ventilation. The diagnosis of pneumothorax in critical illness is established from the patients' history, physical examination and radiological investigation, although the appearances of a pneumothorax on a supine radiograph may be different from the classic appearance on an erect radiograph. For this reason, ultrasonography is beneficial for excluding the diagnosis of pneumothorax. Respiration-dependent movement of the visceral pleura and lung surface with respect to the parietal pleura and chest wall can be easily visualized with transthoracic sonography given that the presence of air in the pleural space prevents sonographic visualization of visceral pleura movements. Mechanically ventilated patients with a pneumothorax require tube thoracostomy placement because of the high risk of tension pneumothorax. Small-bore catheters are now preferred in the majority of ventilated patients. Furthermore, if there are clinical signs of a tension pneumothorax, emergency needle decompression followed by tube thoracostomy is widely advocated. Patients with pneumothorax related to mechanical ventilation who have tension pneumothorax, a higher acute physiology and chronic health evaluation Ⅱ score or Pa O2/Fi O2 < 200 mm Hg were found to have higher mortality.

Metastatic infection caused by hypervirulent Klebsiella pneumonia and co-infection with Cryptococcus meningitis: A case report

BACKGROUND Klebsiella pneumoniae(K.pneumoniae)used to affect mainly people with compromised immunity or weakened by other infections,but recent emergence of hypervirulent strains has increased infections even in healthy individuals.These infections include liver abscess,pneumonia,bacteremia,meningitis,necrotizing fasciitis,and endophthalmitis.Although metastatic infection by hypervirulent K.pneumoniae(hvKP)is increasingly recognized,co-infection with Cryptococcus neoformans(C.neoformans)meningitis in immunocompetent hosts is rare but fatal.So,it is necessary to determine the risk factors,complications,and comorbidity of this disease.CASE SUMMARY This report describes a 58-year-old man with hvKP pulmonary abscess,bacteremia,and meningitis,accompanied by fatal Cryptococcus meningitis.This patient presented with fever for 1 wk and drowsiness for 3 d.Laboratory findings revealed pulmonary abscess and bacteremia of K.pneumoniae.He was given intravenous antibiotic therapy,and the infection was under control for about 1 wk.However,his condition deteriorated rapidly because of metastatic purulent meningitis.Although hvKP and C.neoformans were isolated and confirmed,the patient died of spontaneous respiratory and cardiac arrest caused by cerebral hernia.CONCLUSION HvKP has emerged as a cause of metastatic infections in immunocompetent hosts.polymicrobial co-infections should be taken into consideration when metastatic infection is present.

Fluid and electrolyte overload in critically ill patients: An overview

Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renalprotection from endogenous and exogenous substances, for the safe dilution of medications and as "maintenance" fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities(hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit lengthof-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit.