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One of the major challenges for intensivists is resolving the conflicting interests in end-of-life care. We reviewed patients' characteristics in an intensive care unit to determine the major barriers of practicing good end-of-life care and the medical ethics involved for the care team to resolve these conflicts.

Background: Spontaneous pneumomediastinum is clinically distinct from pneumomediastinum occurring secondary to thoracic hollow organ perforation. The latter may be a catastrophic event requiring invasive intervention, but it is questionable whether such interventions are necessary in spontaneous pneumomediastinum. Limited data are available regarding the characteristics of history and radiologic manifestations in spontaneous pneumomediastinum. The present study aimed to systematically evaluate the initial and subsequent clinical and radiologic manifestations of spontaneous pneumomediastinum as well as the need for additional diagnostic procedures and therapy. Methods: A retrospective study of patients with a diagnosis of spontaneous pneumomediastinum in a tertiary medical center from January 1990 to November 2006 was performed. The patients' clinical information and results of radiologic interventions were analyzed. Results: A total of 42 patients were included. Spontaneous pneumomediastinum was diagnosed in all cases by chest films. A left pericardial airstrip was the most common initial manifestation. In this series, there was only one patient with a pneumothorax, and none of the patients developed pleural effusion or mediastinal fluid as shown by chest X-rays after the disease onset. Conclusion: Spontaneous pneumomediastinum occurs mostly in non-elderly patients. Evaluation of typical clinical information and uncomplicated serial chest X-ray findings of spontaneous pneumomediastinum could avoid unnecessary invasive procedures and intensive care unit stays, which could put pressure on medical resources. A plain film X-ray is adequate for diagnosing spontaneous pneumomediastinum as long as the appropriate findings are sought and there is adequate application of lateral radiography.

We report a 75-year-old man with septic shock induced by ventilator-associated pneumonia caused by multiple drug-resistant Acinetobacter baumannii and catheter-related infection by vancomycin-resistant enterococci. He failed to respond to the initial management, including antibiotics (linezolid, imipenem, sulbactam and colistin) and hemodynamic-guided fluid challenge. However, his condition improved dramatically after the antibiotic regimen was changed to tigecycline and ceftazidime. In addition to the superiority of the antibacterial effect of tigecycline, fluid control can be achieved more easily while using a single antibiotic instead of multiple drugs, which is also important for care of a critically ill elderly man with compromised cardiorespiratory or renal function. Here, we present a patient infected with multiple drug-resistant pathogens, who improved clinically after being treated with tigecycline, to demonstrate the benefits of this antibiotic.