Systemic rheumatic diseases in the ICU

Introduction

Patients with systemic rheumatic diseases may be admitted to the ICU because of pulmonary, renal or multiple organ dysfunction, caused by worsening of the rheumatic disease, infection or adverse effects of immunosuppressive drugs.

Methods

In a 3-year period, 14 patients (six males/eight females), 18 to 80 years old (average 56.78), with systemic rheumatic diseases were admitted in the ICU. Four of them had rheumatoid arthritis, one systemic lupus erythematosus, three dermatopolymyositis, one Sjogren's syndrome, two vasculitis, two systemic sclerosis and one psoriatic arthritis. Three of them were admitted to the ICU after major surgical operation, nine of them because of respiratory failure and the others because of coma and/or shock. The admission APACHE II score, chest X-ray, bronchial secretion cultures, and PaO₂/FiO₂ were recorded, as well as the bronchoalveolar lavage findings, when it was necessary, and the final outcome.

Results

Nine patients were admitted because of acute respiratory failure: APACHE II score ranged from 17 to 28, X-ray showed diffuse alveolar infiltrates, PaO₂/FiO₂ ranged from 75 to 184, only two patients had positive cultures of bronchial secretions. Two patients were admitted after major surgical operation, one after necrotizing pancreatitis: APACHE II score ranged from 9 to 21, X-ray showed diffuse alveolar infiltrates with a cavity in one, PaO₂/FiO₂ >300, the bronchial secretions cultures were negative. One patient was admitted because of coma and one other because of shock: APACHE II score was 25 and 32, respectively, X-ray without any acute process, PaO₂/FiO₂ was >200 and none of them had positive cultures of bronchial secretions. Bronchoalveolar lavage was performed on six patients: on the second day from ICU admission in four patients, on the eighth day in one patient and on the 21st day in one patient. The total mortality rate was 50% (7/14).

Conclusion

Early bronchoalveolar lavage (during the first 48 hours from admission) could help in differential diagnosis between: exacerbation of rheumatic disease, infection, drug-induced respiratory failure, and alveolar hemorrhage.