Vasopressors used in critically ill patients with refractory shock pose a serious risk of non-occlusive peripheral limb ischemia leading to tissue necrosis and amputation. Acute limb ischemia is associated with high morbidity and mortality. There is a scarcity of evidence-based medical literature on the prevention and management of vasopressor induced acute limb ischemia (VIALI). Despite being a well-known and frequent complication of vasopressors, there is no standardized guideline for the prevention and management of vasopressor-induced limb ischemia. Vasopressors are required for the management of refractory shock which is defined as hypotension not responsive to intravenous fluid resuscitation alone. Distributive shock, which includes septic shock, causes inadequate tissue perfusion in adjunct with vasopressor use and is the most common cause of non-occlusive peripheral limb ischemia. This case study will focus on how early recognition and prompt treatment of VIALI are crucial in minimizing tissue necrosis and preventing amputations. We present a case of a middle-aged woman who developed distributive shock from sepsis of a urinary source secondary to obstructive uropathy (ureteral calculi). She presented with refractory shock and continued to remain in shock while undergoing emergent rigid cystoscopy with the placement of a ureteral stent. Despite adequate volume resuscitation, she required high doses of vasopressors resulting in peripheral extremity ischemia and necrosis of all her fingers and toes. By promptly initiating mitigation and preventive management strategies, we succeeded in minimizing tissue ischemia and reducing morbidity resulting from iatrogenic vasopressor-induced peripheral non-occlusive ischemia. These strategies include but are not limited to external warming of bilateral lower extremities, nitroglycerin paste application over the entire extremity, arterial assist pump, and low-dose therapeutic anticoagulation. The novel use of the arterial pump in acutely ischemic lower extremities likely helped salvage the toes which appeared to be at high risk of amputation.

Obstructive sleep apnea (OSA) is a common disease with a high degree of association with and possible etiological factor for several cardiovascular diseases. Patients who are admitted to the Intensive Care Unit (ICU) are incredibly sick, have multiple co-morbidities, and are at substantial risk for mortality. A study of cardiovascular manifestations and disease processes in patients with OSA admitted to the ICU is very intriguing, and its impact is likely significant. Although much is known about these cardiovascular complications associated with OSA, there is still a paucity of high-quality evidence trying to establish causality between the two. Studies exploring the potential impact of therapeutic interventions, such as positive airway pressure therapy (PAP), on cardiovascular complications in ICU patients are also needed and should be encouraged. This study reviewed the literature currently available on this topic and potential future research directions of this clinically significant relationship between OSA and cardiovascular disease processes in the ICU and beyond.

A 35-year-old male greenhouse worker presented with myalgia, fatigue, and fever. Initially, he was thought to have an unspecified viral infection and was treated with conservative therapy. However, the patient’s symptoms persisted, and he reported additional symptoms of mild abdominal pain and headaches. Laboratory evaluation was significant for elevated liver enzymes. Due to concern for acute hepatitis and persistent fever the patient was hospitalized. During his hospital course, no infectious etiology was found to explain his symptoms. After discharge from the hospital, additional testing showed positive serology for Q fever IgG phase II antibody (1:8192) and phase II antibody IgM (> 1:2048). He was treated with doxycycline and had a good clinical response. Upon follow-up, he had worsening Phase I IgG serologies. Transesophageal echo demonstrated vegetations consistent with endocarditis.

Eosinophilic granulomatosis with polyangiitis (EGPA) also referred to as Churg-Strauss syndrome is a rare vasculitis of the small to medium vessels. We present a rare case of acute coronary artery dissection brought on by EGPA, which generally has a poor prognosis. A 41-year-old male with history of bronchial asthma presented to the emergency room with a 2-week history of dyspnea, cough with clear phlegm, and fever. For the past eight months he had experienced episodes with similar symptoms relieved by steroids. CT chest showed bilateral upper lobe patchy opacities with extensive workup for infectious etiology being negative. He had peripheral eosinophilia with sinusitis. He had acute coronary syndrome and Coronary angiogram showed Right coronary artery dissection. After making a diagnosis of EGPA based on American college of Rheumatology criteria, he was successfully treated with high dose immunosuppression. Coronary artery dissection is a fatal and uncommon complication of EGPA which is usually diagnosed postmortem. Early recognition of this condition ante mortem and aggressive treatment can be lifesaving as demonstrated in our case.