Rose, Mariah Q.

Susac Syndrome was first described as an inflammatory microangiopathy of the brain and retina. Since then, multiple articles have been published in attempts to improve the understanding of this rare disease. Clinically Susac Syndrome is known to present with triad of encephalopathy, sensorineural hearing loss and branch of retinal artery occlusion (BRAO), along with characteristic “snowball” or “spoke” appearing white matter lesions of the corpus callosum. It has been characterized by vast heterogeneity in terms of its presenting symptoms, severity, and clinical course. Although subset of patients present with severe forms of Susac Syndrome and can develop prominent residual neurologic deficits, it has been reported to be mostly non-life-threatening and only few fatal cases have been described in the literature. Based on the available case reports with fatal outcome, mortality has been related to the systemic complications either during acute disease flare or during chronic-progressive phase. We describe a case of fulminant Susac Syndrome complicated by the sudden and rapid progression of diffuse cerebral edema leading to brain herniation and ultimate brain death, in order to increase awareness of this rare and catastrophic complication.

IntroductionGuillain-Barré syndrome precipitated by hepatitis E virus infection is rare, yet its incidence is increasing.Clinical FindingsA 57-year-old man was transferred from another facility with fatigue, orange urine, and progressive weakness over 4 to 6 weeks. Initial laboratory results included total bilirubin, 9.0 mg/dL; direct bilirubin, 6.4 mg/dL; aspartate aminotransferase, 1551 U/L; alanine aminotransferase, 3872 U/L; and alkaline phosphatase, 430 U/L. Immunoglobulin M and quantitative polymerase chain reaction test results were positive for hepatitis E virus. Contrast-enhanced magnetic resonance imaging of the brain and spine showed no gross abnormalities. Analysis of cerebrospinal fluid obtained by lumbar puncture revealed the following (reference values in parentheses): total white blood cell count, 15/μL (0–5/μL), with 33% neutrophils and 54% lymphocytes; protein, 0.045 g/dL (0.015–0.045 g/dL); and glucose, 95 mg/dL (within reference range). Neurological examination revealed weakness in both upper extremities, with proximal strength greater than distal strength. The patient could not elevate either lower extremity off the bed and had areflexia and reduced sensation throughout all extremities.DiagnosisGuillain-Barré syndrome secondary to acute hepatitis E virus infection was diagnosed on the basis of clinical characteristics, serum and cerebrospinal fluid analyses, and nerve conduction studies.ConclusionsNurses and clinicians should obtain a thorough history and consider hepatitis E virus infection as a precipitating factor in patients with sensory and motor disturbances consistent with Guillain-Barré syndrome. The case gives insight into the diagnostic process for Guillain-Barré syndrome and highlights the vital role of bedside nurses in evaluating and treating these patients.

Introduction Antipsychotics are a treatment option for delirium in the intensive care unit. Atypical antipsychotics are preferred over first-generation antipsychotics because of their lower incidence of extrapyramidal adverse effects. The most common such effect is akathisia or restlessness. This report describes a case of atypical antipsychotic–induced akathisia and addresses the clinical distinction between extrapyramidal movements and movements due to intensive care unit delirium. Clinical Findings A 56-year-old man who had a prolonged hospital stay after orthotopic liver transplant complicated by multisystem organ failure, primary graft failure requiring a second transplant, and enterocutaneous fistula developed agitated delirium on hospital day 28. Initial treatment included intravenous haloperidol and scheduled sublingual olanzapine (5 mg daily). His delirium and insomnia persisted, requiring dexmedetomidine infusion. Olanzapine dosing was increased to 10 mg daily on hospital day 34 and 15 mg daily on hospital day 45. The following day, his mentation improved; however, he exhibited asynchronous, nonrhythmic, involuntary rolling motions of his hands and choreiform gait. Diagnosis and Outcomes Antipsychotics were immediately discontinued owing to acute akathisia. All symptoms resolved within 2 days, and the patient was transferred out of the intensive care unit on hospital day 52. Conclusion Although extrapyramidal adverse effects are less common with olanzapine than with typical antipsychotics, they sometimes occur and can mimic manifestations of delirium. Restlessness should alert the nurse to assess for possible extrapyramidal adverse effects. If they are suspected, antipsychotic medications should be reduced or discontinued to prevent progression to functional disability.

ABSTRACT Background and purpose: Daily chest radiographs (CXRs) have long been a routine part of care. However, evidence as well as changing technology has promoted on-demand CXRs as beneficial to patient care. We found that a substantial number of routine daily CXRs were being ordered, with some of the orders staying active even after extubation. Methods: Within a 19-bed adult medical ICU, we prospectively utilized 3 intervention phases from October 1, 2014, to February 28, 2018, to reduce routine CXRs. Nurse Practitioners (NP) initiated this quality improvement (QI) project, aiming to reduce the number of unnecessary of CXRs. Interventions included staff survey, routine CXR order removal, duplicate alerts, visual reminders, and an electronic clinical decision support tool. Monthly education of appropriate CXRs and bedside ultrasound were facilitated by NPs. The outcome measures of interest include: the number of CXRs per patient-day, the number of routine and on-demand CXRs, mortality rate, ICU length of stay, and ventilator days, radiation and cost. Conclusions: Total number of CXRs per patient-day decreased by 36.1%. The proportion of routine CXRs decreased from 55.37% to 13.18%; on-demand orders increased, from 44.63% to 86.82%; and calculated radiation-exposure per census decreased, from 0.011 to 0.008 mSv. In addition, charges to patients for CXRs decreased by $7,750/month. ICU mortality and ventilator days per census remained stable. Implications for practice: By an orchestrated process that included creating awareness and desire to change CXR ordering practices, we were able to decrease routine CXRs and increase on-demand utilization while maintaining counterbalance measures.