Management of complex pleural disease in the critically ill patient

A rare presentation of pleural pseudocyst in chronic calcific pancreatitis: A case report

Chronic calcific pancreatitis (CP) is a progressive inflammatory disorder that can lead to complications in multiple organ systems. Pleural pseudocysts, a rare thoracic manifestation of chronic pancreatitis, pose significant diagnostic and therapeutic challenges. This case report highlights the presentation, diagnostic approach, and management of a patient with pleural pseudocyst associated with chronic calcific pancreatitis. A 41-year-old male presented with a one-month history of abdominal pain and a persistent cough. Clinical evaluation and imaging revealed chronic calcific pancreatitis with multiple pseudocysts, left-sided hydropneumothorax, a right pleural pseudocyst, and massive ascites. Diagnostic imaging, including high-resolution computed tomography (HRCT) of the thorax and contrast-enhanced computed tomography (CECT) of the abdomen, confirmed the diagnosis. Biochemical analysis showed elevated amylase levels in pleural and ascitic fluids, consistent with pseudocyst rupture. The patient was managed conservatively with intercostal drain (ICD) insertion, pigtail catheterization, nasojejunal feeding, and broad-spectrum antibiotics. Despite stabilization, the patient declined further surgical interventions, including decortication and endoscopic retrograde cholangiopancreatography (ERCP). This case underscores the importance of a multidisciplinary approach in managing rare complications of chronic pancreatitis. Advanced imaging and biochemical analysis are pivotal for diagnosis, while nutritional optimization and minimally invasive interventions form the cornerstone of management. Definitive surgical or endoscopic procedures are often required but may be limited by patient preferences or resource constraints. Pleural pseudocyst is a rare but significant complication of chronic pancreatitis requiring prompt diagnosis and tailored management. This report emphasizes the role of a patient-centric approach in addressing complex clinical scenarios.

Penetration of linezolid into the pleural cavity in critically ill patients with proven or suspected Gram-positive bacterial infections: a retrospective pharmacokinetic study

OBJECTIVES

To describe the pharmacokinetics (PK) of linezolid in plasma and pleural fluid (PF) in critically ill patients with proven or suspected Gram-positive bacterial infections.

PATIENTS AND METHODS

Observational PK study in 14 critically ill patients treated with linezolid at standard doses. Blood and PF samples were collected and analysed by HPLC. The ratio between PF and plasma concentrations was calculated. The PK/pharmacodynamic (PD) target of linezolid in plasma was defined as 100% of the duration of the dosing interval in which concentrations were above the MIC (%100 T > MIC).

RESULTS

The median (5th and 95th percentiles) linezolid concentration values for plasma pre-dose at steady state (Cmin,ss) and at the end of the 1-h infusion at steady state (Cmax,ss) were 1.1 (0.02-28.3) and 13.8 mg/L (2.9-38.1), respectively, and the PF pre-dose concentration (PF0 h) and PF concentration at the end of the 1-h intravenous infusion (PF1 h) were 2.8 (0.1-31.6) and 4.2 mg/L (0.1-45.2), respectively. At both times (pre-dose and post-infusion), a strong positive correlation was observed between PF and plasma linezolid concentrations (Spearman's rho coefficients = 0.8 and 0.9, with P < 0.001 for both). The defined PK/PD target in plasma was achieved in 8 (57.1%), 4 (28.6%) and 3 (21.4%) patients assuming an MIC of 1, 2 and 4 mg/L, respectively.

CONCLUSIONS

Linezolid seems to penetrate well into the PF, with concentrations exceeding those in plasma. However, high inter-individual variability, both in plasma and PF concentrations, was observed. A high proportion of patients did not achieve the PK/PD target in plasma, especially in the presence of high MIC strains.

Unraveling the Predictive Potential of Rapid Scoring in Pleural Infection: A Critical Review

Pleural infection, or pleural empyema, is a severe medical condition associated with high morbidity and mortality rates. Timely and accurate prognostication is crucial for optimizing patient outcomes and resource allocation. Rapid scoring systems have emerged as promising tools in pleural infection prognostication, integrating various clinical and laboratory parameters to assess disease severity and quantitatively predict short-term and long-term outcomes. This review article critically evaluates existing rapid scoring systems, including CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥ 65 years), A-DROP (age (male >70 years, female >75 years), dehydration, respiratory failure, orientation disturbance, and low blood pressure), and APACHE II (acute physiology and chronic health evaluation II), assessing their predictive accuracy and limitations. Our analysis highlights the potential clinical implications of rapid scoring, including risk stratification, treatment tailoring, and follow-up planning. We discuss practical considerations and challenges in implementing rapid scoring such as data accessibility and potential sources of bias. Furthermore, we emphasize the importance of validation, transparency, and multidisciplinary collaboration to refine and enhance the clinical applicability of these scoring systems. The prospects for rapid scoring in pleural infection management are promising, with ongoing research and data science advances offering improvement opportunities. Ultimately, the successful integration of rapid scoring into clinical practice can potentially improve patient care and outcomes in pleural infection management.