Rehabilitation, weaning and physical therapy strategies in chronic critically ill patients.

In critically ill patients, a prolonged hospital stay, due to the initial acute insult and adverse side-effects of drug therapy, may cause severe late complications, such as muscle weakness, prolonged symptoms, mood alterations and poor health-related quality of life. The clinical aims of physical rehabilitation in both medical and surgical intensive care units (ICUs) are focussed on the patient to improve their short- and even long-term care. The purpose of this article is to review the currently available evidence on comprehensive rehabilitation programmes in critically ill patients, and describe the key components and techniques used, particularly in specialised ICUs. Despite the literature suggesting that several techniques have led to beneficial effects and that muscle training is associated with weaning success, scientific evidence is limited. Due to limitations in undertaking comparative studies in ICUs, further studies with solid clinical short- and long-term outcome measures are now welcomed.

Physiotherapy in critically ill patients.

Prolonged stay in Intensive Care Unit (ICU) can cause muscle weakness, physical deconditioning, recurrent symptoms, mood alterations and poor quality of life. Physiotherapy is probably the only treatment likely to increase in the short- and long-term care of the patients admitted to these units. Recovery of physical and respiratory functions, coming off mechanical ventilation, prevention of the effects of bed-rest and improvement in the health status are the clinical objectives of a physiotherapy program in medical and surgical areas. To manage these patients, integrated programs dealing with both whole-body physical therapy and pulmonary care are needed. There is still limited scientific evidence to support such a comprehensive approach to all critically ill patients; therefore we need randomised studies with solid clinical short- and long-term outcome measures.

Noninvasive positive pressure ventilation in the acute care setting: where are we?

Noninvasive positive pressure ventilation (NPPV) is a technique used to deliver mechanical ventilation that is increasingly utilised in acute and chronic conditions. The present review examines the evidence supporting the use of NPPV in acute respiratory failure (ARF) due to different conditions. Strong evidence supports the use of NPPV for ARF to prevent endotracheal intubation (ETI), as well as to facilitate extubation in patients with acute exacerbations of chronic obstructive pulmonary disease and to avoid ETI in acute cardiogenic pulmonary oedema, and in immunocompromised patients. Weaker evidence supports the use of NPPV for patients with ARF due to asthma exacerbations, with post-operative or post-extubation ARF, pneumonia, acute lung injury, acute respiratory distress syndrome, or during bronchoscopy. NPPV should be applied under close clinical and physiological monitoring for signs of treatment failure and, in such cases, ETI should be promptly available. A trained team, careful patient selection and optimal choice of devices can optimise outcome of NPPV. Noninvasive positive pressure ventilation is increasingly being used in the management of acute respiratory failure but caregivers must respect evidence-supported indications and avoid contraidincations. Additionally, the technique must be applied in the appropriate location by a trained team in order to avoid disappointing results.

Responses of the skin microcirculation to acetylcholine in patients with essential hypertension and in normotensive patients with chronic renal failure.

AIMS: To assess the endothelial function of the skin microcirculation in chronic renal failure (CRF) independent of hypertension, we investigated the changes of the cutaneous blood flow induced by iontophoretic delivery of acetylcholine (ACh) and of sodium nitroprusside (SNP) in CRF patients free from arterial hypertension and in patients with essential hypertension. METHODS: The study included 20 patients affected by CRF (mean creatinine clearance 12+/-2 ml/min) without arterial hypertension (mean blood pressure 96+/-1 mm Hg), 15 patients affected by essential hypertension (mean blood pressure 124 +/-1 mm Hg), and 20 normal controls. The changes of skin blood flow following iontophoretic delivery of ACh and of SNP were measured by laser Doppler flowmetry. RESULTS: Following maximal ACh or SNP delivery, the change of blood flow from the baseline was similar both in normals (683+/-92 vs. 684 +/- 87%) and in CRF patients (778+/-108 vs. 803+/-124%), whereas in the hypertensives the response to ACh was lower than to SNP (434+/-48 vs. 702 +/- 98%, p<0.01). Since the third ACh delivery dose, the skin blood flow increments were significantly lower in the hypertensive than in the CRF or in the normal control groups, whereas no difference was observed between uremics and controls. CONCLUSIONS: The endothelium-dependent hyperemia following ACh iontophoretic delivery is impaired in the skin microcirculation of essential hypertensive patients, but this is not the case in CRF patients with no history of arterial hypertension. This suggests that CRF per se, independent of arterial hypertension, is not associated with endothelial dysfunction of skin microcirculation.

Responses of the skin microcirculation to acetylcholine and to sodium nitroprusside in chronic uremic patients.

The aim of the present study was to assess the endothelial function of the microcirculation in chronic renal failure. We investigated the responses of the cutaneous blood flow to locally delivered acetylcholine and sodium nitroprusside in uremic patients. The study included 60 chronic uremic patients: 40 patients with a creatinine clearance of 4-25 ml/min were on conservative treatment and 20 patients were on maintenance hemodialysis. The changes in skin blood flow following iontophoretic delivery of acetylcholine (an endothelium-dependent vasodilator) and sodium nitroprusside (an endothelium-independent vasodilator) were measured by laser Doppler flowmetry. Acetylcholine induced a progressive increase in blood flow in both groups, reaching approximately 100% of the maximal hyperemic response obtained by sodium nitroprusside delivery. The percent increase in blood flow from baseline was lower in hemodialysis patients than in patients on conservative treatment, after both acetylcholine (550 +/- 44 vs. 718 +/- 61%, P < 0.05) and sodium nitroprusside (553 +/- 46 vs. 735 +/- 69%, P < 0.05) delivery. In the hemodialysis group, the hyperemic responses to acetylcholine and sodium nitroprusside did not improve after the hemodialysis session. Hence, the hyperemic responses of the skin microcirculation are lower in hemodialysis patients than in patients on conservative treatment, and did not ameliorate after hemodialysis. It seems to be independent of endothelial dysfunction, and associated with the severity of uremia and with the maintenance hemodialysis treatment. This microcirculatory abnormality is in keeping with the arterial stiffness and vascular wall damages described in dialysis patients, which contribute to the cardiovascular morbidity of chronic uremia.

Microvascular involvement in systemic sclerosis: laser Doppler evaluation of reactivity to acetylcholine and sodium nitroprusside by iontophoresis.

OBJECTIVES: To investigate the skin vasodilatory response to iontophoretically applied acetylcholine (Ach), an endothelium dependent vasodilator, and to sodium nitroprusside (SNP), an endothelium independent vasodilator, in patients with systemic sclerosis (SSc). METHODS: Eleven SSc patients were preliminarily studied (10 females, mean age 40.5; mean disease duration 6.5 years), and 16 age and sex matched control subjects. By means of laser Doppler flowmetry skin blood flow was evaluated at third finger, at baseline, and after postischaemic hyperaemia test and during iontophoretically transcutaneous application of 1% solution of Ach and SNP. RESULTS: No significant differences in basal skin blood flow were detected between SSc patients and controls. Cutaneous vasodilatory response to ischaemia, Ach, and SNP was significantly less pronounced in SSc patients compared with controls (p < 0.001). Moreover, among SSc patients a lower (p < 0.05) vasodilatory response to Ach compared with ischaemia and SNP was recorded. CONCLUSIONS: These data confirm a reduction of skin digital vasodilatory reserve in SSc patients and suggest a defect of both endothelial dependent arteriolar relaxation and wall compliance in the pathogenesis of this dysfunction.

Atherosclerosis vascular damage in elderly athletes and sedentary people.

The objective of this study was to determine the degree of vascular atherosclerotic damage at the carotid and femoral levels in a group of subjects over sixty years old practicing endurance sports. Using high-resolution Doppler-color flow ultrasonography the authors carried out a vascular screening, comparing two distinct groups of subjects, the first consisting of 20 elderly male subjects (age 65.6 +/- 5.6 years) practicing endurance sports (runners) and the second of 20 subjects of the same gender and age (63.5 +/- 4.5 years), clinically healthy, but leading a sedentary life. All subjects were nonsmokers, nondiabetics, with normal lipid values and normal blood pressure. The authors examined the internal, external, and common carotid arteries, bilaterally, as well as the common femoral, deep femoral, and superficial femoral arteries of both legs. For each vessel they documented: (1) presence of plaques, (2) position and quantity of the plaques, (3) stenosis percentage produced by the plaques, (4) echographic structure of the plaques. In the group of sportsmen they calculated a global score of atherosclerotic damage of 5.58 +/- 2.21. This is statistically significant (P < 0.001) as compared with the global score observed in the sedentary group (9.24 +/- 3.9, range 6-14). The sportsmen exhibited small atherosclerotic plaques that were not hemodynamically significant; these plaques were present in 7 subjects (35%). In 4 of them (20%) the lesions were located in one carotid artery system. In the other 3 subjects (15%) the lesions were identified in one femoral artery system. In none of the sportsmen were they able to demonstrate simultaneous atherosclerosis of carotid and femoral arteries. In the sedentary subjects, atherosclerotic lesions were identified in 15 of them (75%). In 2 subjects hemodynamically significant plaques were located in one carotid artery system. In the other 13 subjects the plaques found were not hemodynamically significant; in 6 subjects this type of lesion was present in both femoral and carotid arteries; in 5 the lesions were located in one carotid artery system, and in 2 in one femoral artery system. In conclusion, endurance exercise appears to protect the elderly against atherosclerotic vascular damage.

Laser Doppler flowmeter assessment of skin microcirculation in uremic patients on hemodialysis treatment.

Vascular disease is frequent in uremics and may contribute to tissue malnutrition and damage. The aim of this study was to detect whether uremic patients show also changes of microcirculation and to evaluate the effects induced by hemodialysis (HD) session. Eleven uremics on HD (7 males, 4 females, aged 25-65 years) were studied; 11 healthy subjects, age- and sex-matched, served as controls. Skin microcirculatory basal flow (BF), maximal postischemic flow (PIF-max) and flow motion index (FMI) were determined at the upper limb contralateral to arteriovenous fistula, by means of a laser Doppler flowmeter. The measurements were taken before, at 1 and 2 h after starting HD and 30 min after the end of HD. In uremics, FMI was lower than in controls (mean +/- SD: 15.2 +/- 13.6 vs. 29.1 +/- 7.4%; p < 0.005); just 1 h after the start of HD, a significant improvement (28.4 +/- 17.7%; p < 0.01) versus basal values was observed and it persisted throughout the HD session. No statistical correlation was observed between the changes of FMI and those of plasma levels of Na+, K+, HCO-3, urea, iPTH or rate of ultrafiltration. BF and PIF-max were similar in uremics and controls, and no changes were observed during HD. Our study shows that the physiological flow motion is reduced in the skin microcirculation of uremics on HD. This abnormality is rapidly corrected by HD.

[Ultrasonic evaluation of early atherosclerotic damage in patients with type 1 diabetes mellitus]. / Valutazione ultrasonografica del danno aterosclerotico precoce in diabetici di tipo 1 insulino-dipendenti.

UNLABELLED: The aim of this study was to evaluate the influence of metabolic control on the development of atherosclerotic lesions in type 1 insulin-dependent diabetic patients (IDDM). MATERIALS AND METHODS: Twenty-eight well controlled IDDM patients, without known risk factors or clinical evidence of cardiovascular disease, together with 28 age-matched healthy controls spontaneously underwent high-resolution echographic evaluation of carotid femoral arteries. A global score of atherosclerotic damage as been assigned to the four investigated vessels on the basis of 1-6 scale, which takes into account most important ultrasound atherosclerotic lesion found in every artery. RESULTS: Diabetic and healthy controls differed significantly as regard to medio-intimal carotid thickness (p < 0.001), but were similar as for score of atherosclerotic damage. CONCLUSIONS: Our results suggest that, in spite of a carotid wall medio-intimal thickness more pronounced in IDDM patients, well controlled IDDM is associated with atherosclerotic damage almost identical to that of healthy age-matched controls.