Outcome following organ removal from poisoned donors in brain death status: a report of 12 cases and review of the literature

Experience with organ procurement from poisoned donors in brain death status is still limited in comparison with other etiologies. From 1963 to 1993, 2769 grafts (heart 141, kidney 1922, liver 623, pancreas 43) were performed in our University Hospital. Since 1975, among 1174 patients admitted to the ICU for acute poisoning, 12 patients who developed brain death status were considered for organ donation. The toxics involved were: methaqualone (1), benzodiazepines (1), benzodiazepines plus tricyclic antidepressants (2), barbiturates (2), insulin (2), carbon monoxide (1), cyanide (1), methanol (1), and acetaminophen (1). Exclusion criteria for organ removal were applied according to the nature of the toxin and the general criteria used for organ donation. The organs removed were: heart 5, heart valves for graft bank 2, kidneys 22, liver 4, pancreas 2, pancrease islet cells 2. Pertinent follow-up was obtained in 23 of 32 recipients. Immediate outcome was favorable in 20/23 patients (85%). Three patients died either from stroke, heart failure or preexisting encephalopathy. Two patients died from either chronic hepatic or renal graft rejection. None of these events could be directly related to a toxic origin. The one year survival rate of 75% is similar to that observed in the population who received organs from nonpoisoned donors. Organ procurement can be considered in few selected cases of acute poisoning. The accuracy of the diagnosis of irreversible brain damage is essential in this setting.

Fatal encephalopathy after otoneurosurgery procedure with an aluminum-containing biomaterial

Refractory status epilepticus was observed in two patients who underwent vestibular neurectomy. We investigated the relationship with the use of an aluminum containing bone cement during the procedure. Two patients developed focal and thereafter generalized seizures in the late postoperative period of vestibular neurectomy (respectively after 42 and 35 days). A cement (1 g aluminum-calcium fluorosilicate) was used during the procedure to bridge bone defects. Both patients presented cerebrospinal fluid fistula. Investigations excluded common etiologies, in particular infections, and a toxic origin was suspected. Aluminum concentration was determined repeatedly in serum urine, cerebrospinal fluid and retroauricular fistula. The highest aluminum values were respectively in case 1 and 2, 112 and 63 micrograms/L for the cerebrospinal fluid, 495 and 1440 micrograms/L for the fistula, 4.4 and 4.4 micrograms/L in serum. Desferrioxamine was used as chelating agent and aluminum elimination was analyzed in the urine. Status epilepticus became refractory to intensive care therapy. The patients never recovered normal consciousness. Case 1 died 143 days after the procedure and case 2 at 80 days from brain failure. Brain post-mortem examination was obtained in Case 2. Brain aluminum concentration was 2.5 micrograms/g (wet weight) (0.85 micrograms/g in a control non exposed cadaver). The cement (0.2 g) was incubated in vitro (16 h-37 degrees C) with the cerebrospinal fluid of a control patient (cerebrospinal fluid aluminum 8 micrograms/L): aluminum concentration reached 2750 micrograms/L. A close contact between an aluminum containing cement and the cerebrospinal fluid may have resulted in encephalopathy and fatal status epilepticus in these two patients.

Severe diltiazem poisoning with intestinal pseudo-obstruction: case report and toxicological data

This case report concerns a 30-year-old man who survived a 4.2 g diltiazem overdose. He sustained vasoplegic shock with a junctional escape rhythm which required high doses of norepinephrine and epinephrine. Among other complications, ileus with paralytic intestinal pseudo-obstruction developed on day three. Cecal distention was demonstrated by abdomen computed tomodensitometry. The ileus resolved on day seven following the poisoning. Diltiazem plasma concentrations were determined during the first three days. The possible role of other medications, activated charcoal and sufentanil, is noted.

Rabies encephalitis mimicking the electrophysiological pattern of brain death. A case report

A 48-year-old woman was referred from Zaire with suspected rabies encephalitis. Survival was 34 days after the onset of symptoms and the diagnosis of rabies was ultimately proven after brain autopsy. Serial neurophysiological investigations, including EEG and multimodality evoked potentials and radiological examinations (cerebral magnetic resonance imaging and computed tomodensitometry) were performed. Whereas the clinical findings and EEG were compatible with brain death at the end of the course, this diagnosis could be definitely ruled out by multimodality evoked potentials, magnetic resonance imaging and autopsy. The validity of multimodality evoked potentials is discussed in this particular setting.

Severe acetaminophen poisoning with favorable outcome after medical treatment: report of 2 cases

We report two cases of severe acetaminophen poisoning with favorable outcome after delayed medical treatment with N-acetylcysteine, despite severe hepatic disturbances. We briefly review the most commonly accepted prognostic criteria and the role of liver transplantation.

Repeated doses of activated charcoal and cholestyramine for digitoxin overdose: pharmacokinetic data and urinary elimination

A 48-year-old man chronically treated with digitoxin and verapamil for prevention of atrial fibrillation voluntarily ingested 2.2 mg of digitoxin. Serum digitoxin concentrations and the urinary elimination of the drug were followed over a 12-day period. Urinary data indicate that a large percentage (50%) of the drug was eliminated renally despite administration of multiple doses of activated charcoal, cholestyramine and hyperosmotic laxatives. The possible interaction with two other drugs, heparin and verapamil, is also discussed.

Amrinone for refractory cardiogenic shock following chloroquine poisoning

Cardiac arrhythmias and circulatory collapse account for the high mortality reported after severe chloroquine poisoning. We have recently observed a 17-year-old man who ingested an 8 g chloroquine overdose. Cardiac arrest occurred within 1 h. Cardiogenic shock was refractory to epinephrine, dopamine and molar sodium lactate. Amrinone, a bipyridine analog, was then successfully used to improve haemodynamic conditions.

Hydrocephalus in Guillain-Barré syndrome

Hydrocephalus developed in a 16-year-old boy with a severe Guillain-Barré syndrome and was demonstrated by computerized tomography (CT) and magnetic resonance imaging. No papilledema was observed. The spontaneous resolution of hydrocephalus was achieved in a 6-month period. Ventricular changes were followed by CT scan.

Fatal Capnocytophaga canimorsus septicemia in a previously healthy woman

A previously healthy 47-year-old woman presented to the emergency department with septic shock five days after a small dog bite on the dorsum of her hand. Capnocytophaga canimorsus was isolated from blood cultures. Despite intensive therapy, multiple organ failure developed, and the patient died 27 days after admission. Characteristics of Capnocytophaga (formerly CDC group Dysgonic Fermenter-2) infection are briefly discussed. This unusual outcome in a previously healthy patient and the need for careful management of dog bite wounds, even if initially very small, is emphasized.

Intensive care management of Guillain-Barré syndrome during pregnancy

A particularly severe case of Guillain-Barré syndrome occurring during pregnancy is reported. The therapeutic approach including plasmapheresis, ventilation, analgesia, sedation, metabolic requirements and heparin therapy is discussed with the consequences on foetal development and the early days of life.

Poisoning by some insecticides, herbicides and fungicides

To avoid accidental poisoning, pesticides must be handled according to prescribed rules. Furthermore, the exact composition of the pesticide formulation should be known. Cases of acute poisoning usually occur by ingestion and less frequently by the other routes. Symptoms may appear immediately but sometimes they can appear later and/or be more prolonged giving rise to delayed death and/or delayed morbidity. Acute poisoning by raticides and by organophosphate insecticides should deserve all our attention. Poisoning by herbicides containing chlorate salts, oxidative phosphorylation uncouplers or bipyridilium derivatives may be particularly dangerous. The ingestion of Paraquat, in particular, which is a veritable lesional poison, could be beyond all therapeutic resources.

Fulminant pulmonary edema following intravenous administration of radiocontrast media

A 29-year-old woman who developed fulminant pulmonary edema several minutes after intravenous administration of radiocontrast media (RCM) is reported. The low pulmonary-capillary wedge pressure and the high protein concentration in pulmonary edema fluid indicated a noncardiogenic pulmonary edema related to increased lung vascular permeability. Laboratory studies showed a slight decrease of several complement components (C3, C4 and factor B) and a transient consumption coagulopathy. Potential pathophysiologic mechanisms involved in RCM- induced pulmonary edema are discussed.

Trichloroethylene and cardiac toxicity: report of two consecutive cases

About two consecutive cases of acute intoxication by trichloroethylene, the authors want to point out the possible occurrence of serious disturbances in cardiac conduction which are less frequently described in the literature than disturbances in myocardial excitability.