Faculty Bibliography

Obesity is a growing problem around the world, and radiology departments frequently encounter difficulties related to large patient size. Diagnosis and management of suspected venous thromboembolism, in particular deep venous thrombosis (DVT) and pulmonary embolism (PE), are challenging even in some lean patients, and can become even more complicated in the setting of obesity. Many obstacles must be overcome to obtain imaging examinations in obese patients with suspected PE and/or DVT, and to ensure that these examinations are of sufficient quality to diagnose or exclude thromboembolic disease, or to establish an alternative diagnosis. Equipment limitations and technical issues both need to be acknowledged and addressed. Table weight limits and scanner sizes that readily accommodate obese and even morbidly obese patients are not in place at many clinical sites. There are also issues with image quality, which can be substantially compromised. We discuss current understanding of the effects of patient size on imaging in general and, more specifically, on the imaging modalities used for the diagnosis and treatment of DVT and PE. Emphasis will be placed on the technical parameters and protocol nuances, including contrast dosing, which are necessary to refine and optimize images for the diagnosis of DVT and PE in obese patients, while remaining cognizant of radiation exposure. More research is necessary to develop consistent high-level evidence regarding protocols to guide radiologists, and to help them effectively utilize emerging technology.

CONTEXT/BACKGROUND:Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions. OBJECTIVES/OBJECTIVE:To determine if intensity of vasopressor therapy accurately predicts in-hospital death. METHODS:This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship. RESULTS:A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival. CONCLUSION/CONCLUSIONS:When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family.

We present a case of a 36-year-old female who came into the emergency department with right-side abdominal pain. She went to the operating room for a diagnostic laparoscopy and appendectomy. She received intravenous (IV) acetaminophen every six hours both preoperatively and postoperatively for pain control. The patient's aspartate aminotransferase and alanine aminotransferase levels were elevated and peaked at 4,833 and 6,600 IU/L, respectively, from baselines of 14 and 15, respectively, while she was receiving 16 doses of IV acetaminophen. The patient was transferred to a regional liver transplant center for evaluation for a transplant. She was treated with IV N-acetylcysteine and discharged with a normal liver-function test without a transplant. This case report supports the possibility of hepatotoxicity associated with IV acetaminophen.