Colonic necrosis secondary to hypotension and shock in previously healthy, young patients is a rare occurrence with only ten cases reported in the literature. In all but one instance the necrosis was limited to the right colon. Three additional cases of transmural necrosis involving both the right and left colon following a documented episode of shock are reported. Two cases were related to hemorrhagic shock following trauma and the third case followed a drug overdose with associated hypotension. An episode of hypotension was the common denominator in all cases previously reported. The lowest mean blood pressure in the present series was 35 mmHg. A diagnosis of subtotal colonic infarction was made at laparotomy in these three patients two to nine days after the initial hypotensive episode. Pathologic examination of the excised colon revealed transmural necrosis in all three cases with no evidence of a thrombotic or embolic process accounting for the colonic necrosis. The etiology was felt to be a low flow state within the splanchnic circulation. The data suggests that patients who present with a history of prolonged hypotension and shock are at risk for the development of colonic infarction. Successful management involves early diagnosis and resection of the infarcted colon.

Shock-associated right colon ischemia and necrosis. J Trauma. 1995 Dec;39(6):1171-4.

Ischemic complications associated with hemorrhagic shock after blunt or penetrating trauma can result in acute renal, pulmonary, or hepatic failure. Less well described is the association between hemorrhagic shock and ischemic necrosis of the right colon, with only 14 cases reported in the literature. Herein, we report three previously healthy young trauma victims with shock-associated right colon necrosis. Each patient suffered a period of hypotension after injury. Diagnosis and operation took place within 2 days of initial injury in all three cases. In each patient, a right colectomy and primary anastomosis was performed without complication. Pathologic examination of the resected specimens showed ischemic necrosis, but no evidence of vascular thrombosis or embolic occlusion of the mesenteric vessels. The etiology of this type of ischemic colitis is not clear, but seems to represent a form of nonocclusive mesenteric ischemia. Knowledge of this disease process will lead to early recognition, prompt treatment, and a satisfactory outcome.

Haemorrhagic shock and encephalopathy syndrome: neurological course and predictors of outcome. Intensive Care Med. 1999 Mar;25(3):293-9.

The haemorrhagic shock and encephalopathy syndrome (HSES) is a devastating disease. The aetiology of this syndrome is unknown, and, despite intensive treatment, the outcome is often fatal or associated with severe neurological sequelae. OBJECTIVE: To assess the neurological features and potential prognostic markers of the disease. DESIGN: Retrospective study. SETTING: Division of Neuropaediatrics in a children's university hospital. PATIENTS AND METHODS: Fourteen patients fulfilling the HSES criteria out of 42 children admitted with fever and shock to the Paediatric Intensive Care Unit between 1986 and 1994, were analysed for clinical, biological, neuroradiological, EEG and neuropathological findings. RESULTS: The patients (age range from 2 to 33 months) were found at night or in the morning either comatous (n = 3) or convulsing (n = 11). All but one were healthy before admission, although eight had had a brief prodromal infectious disease. All were febrile (mean body temperature 39.9 degrees C +/-0.9 degrees). Seasonal clustering during the winter months was observed. Coma and seizures with frequent status epilepticus were the main neurological manifestations. All children recovered from their multiple organ failure within a few days. Seven died (50%); four survivors had neurological sequelae (29%) with a developmental quotient (DQ) of 50% or less in three and a DQ of 75% in one and three infants (21%) had normal outcomes. Computed tomography (CT) displayed a diffuse area of low density mainly in the cerebral cortex and intraventricular and parenchymal haemorrhages. Magnetic resonance imaging (MRI) showed haemorrhagic cortical lesions. Postmortem examination of the brain conducted in three patients showed necrotic and haemorrhagic lesions, mainly in cortical areas. Comparison of the children with adverse outcome (death or neurological sequelae) with those with normal outcome revealed that predictors of poor outcome were status epilepticus (p = 0.003) and coma for more than 24 h (p = 0.01). Infants without disseminated intravascular coagulation, without a biphasic course and without brain hypodensities or haemorrhages on CT scans performed at least 4 days after onset had a normal neurodevelopmental outcome. CONCLUSION: The central nervous system appeared to be the main target of the HSES lesions. The most common outcome was brain death or severe brain damage. Further studies with a larger sample are necessary to determine whether the prognostic indicators we identified are reliable.

Adrenal function in different subgroups of septic shock patients.Acta Anaesthesiol Scand. 2008 Jan;52(1):36-44. Epub 2007 Nov 12.

BACKGROUND: Relative adrenal insufficiency (RAI) is a common complication during septic shock and may be more frequent in specific subgroups. The main objectives of this study were to determine the adrenal function and the RAI incidence in different subgroups of septic shock patients considering: main admission categories (medical, elective or emergency surgery); source of infection; nosocomial or community-acquired infections; gender, age <65 years or >65 years; and the presence or absence of neurological diseases, acute respiratory distress syndrome (ARDS) and bacteremia. METHODS: Prospective study in a medical-surgical ICU, including adults with septic shock, from May 2002 to May 2005. All patients had total serum cortisol measured at baseline and 60 min after a high-dose ACTH test within the first 96 h of shock onset. RAI was defined as a serum cortisol increment after ACTH test (Deltamax(249)) <90 microg/l. RESULTS: One hundred and two subjects were enrolled, and the overall RAI incidence was 22.5%. Patients with ARDS before ACTH test or bacteremia showed lower Deltamax(249) values than patients with ARDS after ACTH test (96 vs. 153 microg/l, P=0.02) or without bacteremia (140 vs. 175 microg/l, P=0.04). Multivariate regression analysis revealed that female gender, development of ARDS before ACTH test, and bacteremia were associated with greater RAI incidence. There was no difference in RAI incidence considering neurological diseases, age, type and source of infection and the main admission categories. CONCLUSIONS: Female gender, bacteremia and early-onset ARDS were variables independently associated with greater RAI incidence in septic shock patients. There was no difference in the RAI incidence concerning other subgroups.

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