[Clonidine abstinence syndrome. A clinical case]. / Sindrome da astinenza da clonidina. Caso clinico.

During hospitalization a patient with acute pulmonary oedema caused by myocardial dilation and chronic kidney failure presented high blood pressure and repeated episodes of supraventricular tachycardia. The complication was attributed to the withdrawal of clonidine and was treated by reintroduction of the drug combined with nifedipine, nitroderivates and antiarrhythmic drugs.

[The estimation of p50 by the algorithm proposed by Siggard-Andersen. Its experimental assessment in critical patients]. / Calcolo della p50 mediante l'algoritmo proposto da Siggaard-Andersen. Valutazione sperimentale in pazienti critici.

STUDY OBJECTIVE: To determine the ability of O. Siggaard-Andersen algorithm in the estimation of the "in vivo" p50 and standard p50 values from a single blood sample with sO2% less than or equal to 97. DESIGN: comparison between measured and calculated standard p50 values. SETTING: Intensive care unit. PATIENTS: thirteen cardio-pulmonary critical ill patients. Mean age of seventy-four years (range 53-84 years). MEASUREMENT: The experimental measurement of p50 standard (p50st sper) was performed tonometering the venous blood samples (60 specimens) using an IL-237 tonometer at 37 degrees C, with two different gas mixtures to obtain pCO2 at 5.33 kPa (DS = 0.06), and pO2 at levels to achieve sO2% values close to 50%. The gases's complete equilibration was not deemed important. The pO2 values were corrected to a pH of 7.40 using a Bohr factor = -0.48 and the p50 was taken by simple interpolation of points on the sO2%/pO2 diagram. Calculated standard p50 (p50st calc) and calculated "in vivo" p50 on the venous specimens (No. 60) and the correspondent arterial specimens with sO2% less than or equal to 97 (No. 40) were obtained by Siggaard-Andersen's computerized algorithm. Blood specimen analysis was performed by means of an ABL3 Radiometer gas analyzer and an OSM3 Radiometer oximeter. Statistical analysis was made by Anova test for liner regression. RESULTS: There was excellent correlation between the 60 experimental p50st determined by Siggaard-Andersen's oxygen dissociation curve on the same blood samples. The regression equation was: p50st sper = -0.79 + 1.21 x p50st calc, r = 0.90, R2 = 81.1%; with F = 249.5 and less than 10(-5). No good correlation was found between p50st and standards p50 calculated on arterial specimens (p50st calc art): p50 = 1.38 + 0.52 x p50st calc art, r = 0.52, R2 = 26.6%, F = 14 e P less than 10(-3). Regression of in vivo P50 calculated on correspondent venous samples (p50 ven) was: p50 ven = 0.79 = 0.77 x p50 art, r = 0.93, R2 = 87.2%, F = 256 and P less than 10(-5). CONCLUSION: Our results suggest that the curve describes the curve also at high saturation when it is not longer linear. Accurate measurement (including dishemoglobin percentage) and sO2% less than or equal to 97 are necessary. We did not perform experimental measurements of "in vivo" p50 but we postulate that as the p50st was well calculated so too would be the p50 "in vivo" at 37 degrees C.

The oxygen status of the arterial blood in the critically ill.

In Critical Care medicine the concepts of Oxygen Delivery, Oxygen Consumption and Tissue Oxygenation have become fundamental in clinical practice but measurements of Oxygen Content and O2 Transport variables require invasive procedures that could be dangerous for critically ill patients and trigger a septic process. Derived indices obtained combining data from a Blood Gas Analyzer with the data from a multi-wavelength spectrophotometer and using the Ole Siggaard-Andersen pH/Blood Gas computerised algorithm might be the non-invasive answer. On 115 arterial blood samples from critically ill patients, we measured pH, pCO2, pO2, oxygen saturation, total hemoglobin concentration and fractions of carboxy- and methemoglobin. The new algorithm was used to calculate: active hemoglobin concentration, total oxygen concentration, actual half-saturation tension, 2,3-diphosphoglycerate concentration, estimated functional shunt, uncompensated mixed venous pO2 (assuming an arterio-venous oxygen difference of 2.3 mmol/L based on a standard oxygen consumption of 11.2 mmol/min and a standard cardiac output of 4.9 L/min) and the cardiac oxygen compensation factor. In Intensive Care all the oxygen parameters may be determined with sufficient accuracy and precision provided the oxygen saturation level is less than 0.97 and provided the definition of oxygen saturation is properly settled and measurements are performed according to the highest state of the art. However, in critically ill patients in evolution our aim is to maintain an 'optimal' paO2 on the plateau of the Oxygen Dissociation Curve (ODC) and the use of mechanical ventilation, high FIO2, fluid challenges and the rapid improvement of the patient's conditions can cause a value for sO2 greater than or less than 0.97 and an improvement or worsening of the paO2. The p50 calculation both in simultaneously drawn arterial and venous blood permits utilisation of derived indices (pO2uv-, CQ) for sO2 greater than 0.97. The Ole Siggaard-Andersen algorithm seems to give correct p50 values, at high saturation values, particularly when discarding unrealistic values for calculated cDPG. The correlation between p50 calculated by the Ole Sigaard-Andersen algorithm with that derived from classical formula shows the superiority of the findings obtained by means of the new algorithm. In critically ill patients the ODC is usually shifted to the right. The new parameters, pO2uv- and CQ, contain useful informations for clinical practise; but rapid changes in Cardiac Index (CI) and VO2/m2 can be ignored by the new algorithm, if these changes are not associated with a rise in ctO2 or pH and pCO2 changes.(ABSTRACT TRUNCATED AT 400 WORDS)

Compound A, formaldehyde and methanol concentrations during low-flow sevoflurane anaesthesia: comparison of three carbon dioxide absorbers.

AIM: To determine compound A, formaldehyde and methanol concentrations in low-flow anaesthesia using different carbon dioxide absorbers. METHODS: Fifteen patients scheduled for general or urological surgery were exposed to low-flow (500 ml/min) anaesthesia with sevoflurane. The patients were randomly allocated to three groups: soda lime, DrägerSorb Free or Amsorb Plus. The concentrations of compound A, formaldehyde and methanol were sampled and analysed from the limbs of the anaesthesia circuit at T30 (30 min after the start of low-flow sevoflurane anaesthesia), T90 (90 min) and T150 (150 min). The temperatures of the absorbers were measured at the same time. RESULTS: Statistically significant differences (P < 0.05) were found in the production of compound A from soda lime (with the highest values), DrägerSorb Free and Amsorb Plus at each measurement time. Only traces of methanol (ranging from < 0.131 to 3.799 mg/m(3)) were measured, higher with Amsorb Plus (statistically significant differences were found only at T90). The formaldehyde values (ranging from < 0.1227 to 17.79 mcg/m(3) p.p.b.) were higher with soda lime, and the difference was statistically significant at T150 and, in the inspiratory limb only, at T90. The temperatures of the absorbers were higher for soda lime and lower for Amsorb Plus; the difference was statistically significant at T0 in the upper canister and at T30 in both canisters. CONCLUSION: The concentrations of harmful products in the circuit were negligible and were lower using the new-generation absorbers. Using Amsorb Plus, the temperatures in the canisters were lower than with the other two absorbers.

Critical points for sepsis management at the patient bedside.

Following an interpretative philosophy, dyna-mic and faithful to the complexity theory, a clinical pathway is outlined close to the reality, at the patient bedside, that is comprehensive of the diagnostic process in its temporal dynamism, of the therapeutic process in its specificity (antibiotic therapy, surgical souce control), in the use of organs supportive therapy (haemodynamic, respiratory, renal, etc.) and in the use of adjunctive and immunomodulatory therapies (APC, AT, etc.). The importance of the contextual activation of microbiological, immunological and coagulative monitorings is underlined. Through a critical review of the more recent literature, a strict relationship, in sepsis and septic shock, between inflammation and coagulation is described, that allowed the activated protein C (drotrecogin alpha activated) success, in terms of reduction of the absolute and relative mortality. This therapeutic success is contextualized into two other important therapeutic successes, recently obtained in severe sepsis and septic shock, based on the medical evidence, one using low doses of corticosteroids and the other using the early (6 h) goal directed haemodynamic therapy to restore a balance between oxygen delivery and oxygen demand. Once systemic inflammation is complicated by organ failure, there are few options. Treatment with activated protein C lowers the risk of death but is associated with an increased risk of bleeding and is likely to be expensive. The strategies described by the groups of Rivers and Annane offer the opportunity for good therapeutic results, by preventing the progression or even the development of sepsis and its complications: septic shock and multiple organ dysfunction.

[Gastric tonometry. Experience of a polyvalent intensive care unit]. / Tonometria gastrica. Esperienza di una TI polivalente.

Tonomitor NG tube was positioned in the stomach of 11 critical ill patients during their stay in ICU and 48 measurements of intramucosal pH (pHi) have been performed. In 7 patients haemodynamic measurement were performed in concomitance with each pHi measure. The Authors looked for statistical relations between pHi and SAPS, pHa, HCO3-a, MAP, DO2/BSA, VO2/BSA, SvO2, diuresis and outcome. A good correlation was found between pHi and MAP (r = 0.47). Dividing the considered parameters into 2 groups in agreement with pHi values < or = and > 7.32 significant relations (p < 0.05) results between pHi and SAPS, MAP, pHa. More significant relations were found between pHi and outcome (p = 0.0015) and between the mean of the pHi values obtained from each patient (pHi-m) and outcome (p = 0.0005). The pHi-m of the surviving patients was always > 7.32 while the pHi-m of the deceased patients was always < 7.32. This results confirm the importance of the pHi measured during the stay in ICU as a prognostic index and suggest that the MAP may be the most important haemodynamic parameter which correlate with pHi values.

[Description of a case of Reye's-like syndrome with fatal outcome]. / Descrizione di un caso di Reye like syndrome ad esito fatale.

A Reye Like Syndrome case occurred in a twelve year-old little girl with a previous familiar history is reported. The little patient was admitted in the pediatric ward for fever, vomiting and aspecific respiratory symptoms and developed very quickly a severe metabolic acidosis, alterations of consciousness, hypoxia, tissular hypoperfusion, multiple organ failure (MOF) and a fatal outcome. The postmortem diagnosis pointed out a methyl malonic acidaemia, a fairly frequent cause of acute metabolic distress, which may occur also in prepuberal age. The correct diagnostic and therapeutic approach of these cases is stressed since they need a prompt and careful monitoring in intensive care unit and a close cooperation among pediatricians, intensive care specialists and the nearest centre for the study of metabolic diseases.

[Propofol-midazolam in continuous infusion for sedation in intensive care]. / Propofol-midazolam in infusione continua per la sedazione in terapia intensiva.

Two groups of 11 ICU respiratory patients ventilated with PSV have been sedated with propofol (group I) or with midazolam (group II). After the endovenous administration of the induction dose (propofol 1.5 mg/kg; midazolam 0.15 mg/kg) sedation was obtained with continuous infusion of the drugs (propofol 2 mg/kg/h; midazolam 0.24 mg/kg/h). In this setting the Authors evaluated the level of sedation (Ramsey scale) and the side effect of the two drugs. At induction midazolam caused a reduction of tidal volume for some minutes and a greatest sedation in comparison with propofol, while propofol caused reduction of MAP (p < 0.01) and transitory apnoea. Even if during the infusion of propofol the level of sedation decreased with time (p < 0.05; y = -0.0357 x + 3.07) it was more stable in comparison with that registered during continuous infusion of midazolam (p < 0.01; y = -0.2018 x + 5.19.

[Cardiac tamponade: an unusual cause. Clinical case]. / Tamponamento cardiaco: una causa inusuale. Caso clinico.

The Authors describe an unusual case of acute cardiac tamponade caused by fistulization in the pericardial cavity of an amebic abscess of the left lobe of the liver. The availability of echocardiography facilitated prompt diagnosis and treatment.

[Acute carbamazepine poisoning treated with plasmapheresis. Description of a clinical case]. / Intossicazione acuta da carbamazepina trattata con plasmaferesi. Descrizione di un caso clinico.

A case of severe Carbamazepine poisoning initially misdiagnosed is reported. Treatment consisted in plasmapheresis (3.5 liters exchanged) repeated for 3 consecutive days, in conjunction with activated charcoal and advanced life support. It was obtained a rapid decay in Carbamazepine plasmatic level (with rebound phenomenon only after first treatment day) and a contemporary improvement in clinical conditions. The patient was discharged without complications after 6 days stay in ICU. Taking pharmacokinetic characteristics into account, it is suggested that plasmapheresis may be useful in this kind of poisoning.

[Tetanus disease. Experience with 2 intensive treatments during 13 years]. / Malattia tetanica. Esperienza di due terapie intensive nell'arco di 13 anni di attività.

The Authors present a retrospective analysis of 58 cases of tetanus hospitalized in two ICU in 13 years of activity. The mortality reported (39.7%) is comparable to other Authors or statistical analysis but it is better if correlated to patient age. Patients of the highest classes (III and IV classes of Edmonson e Flowers) had the highest mortality but no significant variation was seen between patients of the III and IV class. The most frequent cause of death has been cardiac arrhythmia. Cardiac arrhythmias happened in most cases in the first 15 days of hospitalization. 37.9% of patients developed pneumonia: prolonged hospitalization (more than 15 days) and high classes of the disease have been the most important risk factors for Hospital-acquired pneumonia in tetanic patients.

[Hypoxia and oxygen content during dialysis]. / Ipossia e contenuto di ossigeno durante dialisi.

In a study of 72 patients treated with acetate and bicarbonate dialysis, the Authors verified if hypoxic hypoxia caused by dialysis depends on a deficit in oxygen content with an inherent risk of tissue hypoxia. PO2uv (uncompensated venous oxygen partial pressure) and CQ (cardiac compensation factor) derived from the oxygen absorption curve were studied by a new Ole Siggard-Andersen algorithm. The results do not show a risk of tissue hypoxia in the postdialytic period.

[Usefulness of monitoring the mixed venous blood saturation (SvO2) in the diagnosis of heart rupture. A clinical case]. / Utilità del monitoraggio della saturazione del sangue venoso misto (SvO2) nell'iter diagnostico di rottura del cuore. Caso clinico.

We describe a case report of acute left ventricular free wall rupture during acute myocardial infarction in a sedated and curarised patient. Continuous monitoring of SvO2 was very useful on early diagnosis.

[Operative central unit for coordinating the emergencies-urgencies department. Proposal for a mini-unit to solve the problems caused by the relation between volunteer associations and the public structure]. / La centrale operativa di coordinamento nel dipartimento della emergenza-urgenza. Proposta di una "mini-COC" per la risoluzione dei problemi di rapporto tra le associazioni del volontariato e la struttura pubblica.

One of the most important problems, of very difficult solution, in organizing an A/E department is to co-ordinate the emergency in the field. This peculiar task is carried on by an operative central station, the core of an A/E Dept. The organizer in Arezzo try to find out the efficiency and a cost benefit ratio of this central station and try to jump over an historical hindrance to operate by mutual consent with voluntary service. This seems to be possible with the technological development of telephone system and broadcast system. Staff, technical qualifications, connections, reception, modulation, sorting out of different calls are discussed in conjunction with problems of health education concerning the operative central station that coordinates A/E Dept in Arezzo.

[Multiple organ failure syndrome in infection caused by ictero-hemorragic Leptospira. Description of a clinical case]. / MOFS (multiple organs failure syndrome) in corso di infezione da Leptospira ittero-emorragica. Descrizione di un caso clinico.

A 53 years old fisherman was admitted to General Intensive Care Unit in Arezzo with signs and symptoms of Weil disease. An early acute respiratory failure developed. Radiological and haemodynamic findings confirmed a diagnosis of ARDS. The patient developed a severe jaundice, acute renal failure and ARDS (MOF multiple organs failure). To support different failures of the organs, CMV (continuous mandatory ventilation: CPPV with PEEP max 10 cm H2; IRV max 2:1) and AMV (assisted mandatory ventilation: Pressure Support Ventilation), haemofiltration, haemoperfusion and plasmapheresis were simultaneously used, that got better and better renal and respiratory performances. Haemodynamic worsening by PEEP during extracorporeal treatment was overcome by PSV very useful new ventilatory procedure even during weaning period. The patient treated in such manner survived without important disabilities. This care confirms that ARDS (non cardiogenic edema) and MOF can develop during Icterohaemorrhagic Leptospirosis.

[Survey carried out by land of the intervention time for territorial health care]. / Rilevazione via terra dei tempi di intervento per il soccorso sanitario territoriale.

While organizing the Catchment area of A/E Department in Arezzo, a recording of intervention time of prehospital care system (primary transport) was made by land. The analysis recorded that one third of the field on the Catchment area of the A/E Dept was in a red dangerous zone reachable in 15 minutes and more. Such analysis confirmed the importance of local operation bonds all for a correct redistribution of ambulances in the Catchment area and a rational choice of vans and staff suitable for an advanced life support only where and when really necessary.

[Percutaneous dilatational tracheostomy. Critical considerations after one year's experience]. / La tracheostomia percutanea dilatativa. Considerazioni critiche dopo un anno di sperimentazione.

The authors discuss a series of 57 patients submitted to percutaneous dilational tracheostomy (PDT) in an Intensive Care Unit during a fifteen months periods. Patients were admitted for cardiac and/or respiratory failure in 27 cases (47%), sepsis in 13 cases (23%), shock in 12 cases (21%), coma in 5 cases (9%). Length of orotracheal intubation before PDT was 8.3 days +/- 3.9 without significant differences between Apache II and Saps scores at this time (17.4 +/- 6.3 and 20.4 +/- 4.3 respectively) and on admission day (19.3 +/- 6.25 and 20.8 +/- 3.6). The main complications we had to deal with during PDT were damage to previously inserted orotracheal tube, a pneumomediastinum, a small oozing of blood in three cases a serious bleeding in a septic patient with coagulation disorder. After these we performed PDT always coupled with fibrotrachoscopy in the aim to ameliorate PDT safety. On subsequent days the more frequent complication come up at the time of changing tracheal cannula and consisted in troubles ascribed to tracheal shreds (four cases) and one major bleeding after the maneuver always overcome. We also report one death due to impossibility cannula repositioning and subsequent failed intubation in a previously decannulated patient who developed trachobronchial obstruction. Although a supposed midline approach between second and third tracheal rings, was supposed autopsy (performed in three patients) revealed a lateralized cut in one case and an approach higher in another patient. The main advantages in our practice were the absence fo PDT related infections and an optimal and fast tracheal closure after cannula removal. In spite of some limits, this technique has quickly and totally replaced in our practice surgical tracheostomy.