Effects of the volume of processed plasma on the outcome, arterial pressure and blood procalcitonin levels in patients with severe sepsis and septic shock treated with coupled plasma filtration and adsorption.

AIMS: To understand how coupled plasma filtration and adsorption (CPFA) could influence the time course of the advanced stages of sepsis, mean arterial pressure (MAP) and norepinephrine dosage. METHODS: Patients with severe sepsis and septic shock with ≥2 organ failures not responding to volume resuscitation and vasopressor infusion were treated with CPFA within 8 h of admission to the intensive care unit. RESULTS: Thirty-nine patients were treated (median age: 63 years, median SAPS II score: 45) and 28 survived advanced sepsis. In the latter, the median MAP increased and the norepinephrine dosage decreased significantly after CPFA, whereas in the nonsurvivors these values did not change significantly. The volume of treated plasma was significantly higher in survivors than nonsurvivors. CONCLUSION: These results suggest a possible existence of a dose-response effect for CPFA. Future studies are therefore recommended to evaluate the efficacy of this treatment and to determine its best timing and intensity.

Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit.

OBJECTIVE: To test the effects of positive expiratory pressure on the leakage of fluid around cuffs of different tracheal tubes, in mechanically ventilated patients and in a benchtop model. DESIGN: Randomized clinical trial and experimental in vitro study. SETTING: Intensive care unit of a university hospital. PATIENTS: Forty patients recovering in the intensive care unit were ventilated in volume-controlled mode. Twenty patients were randomly intubated with Hi-Lo tubes (HL group), whereas the remaining 20 subjects were intubated with SealGuard tubes (SG group). INTERVENTIONS: Immediately after intubation and cuff inflation with 30 cm H2O, Evans blue was applied onto the cephalic surface of the tracheal tube cuff. A 5-cm H2O positive expiratory pressure was used during the first 5 hrs of stay, and thereafter it was removed. Bronchoscopy verified whether the dye leaked around the cuff. The experiment lasted 12 hrs. Leakage was also tested in vitro with the same tracheal tubes with incremental level of positive expiratory pressure. MEASUREMENTS AND MAIN RESULTS: At 1 hr, 5 hrs, and thereafter hourly until 12 hrs, bronchoscopy was used to test the presence of dye on the trachea caudal to the cuff. At the fifth hour, two patients of the HL group failed the test. One hour after positive expiratory pressure removal, all subjects in group HL exhibited a dyed lower trachea. On the other hand, one patient in group SG presented a leak at the eighth hour, and at the 12th hour three of them were still sealed. In vitro, the same level of positive expiratory pressure delayed the passage of dye around the cuff; after 30 mins positive expiratory pressure was removed, and in 10 mins all dye leaked only in the Hi-Lo tube. CONCLUSIONS: We found that 5 cm H2O positive expiratory pressure was effective in delaying the passage of fluid around the cuffs of tracheal tubes both in vivo and in vitro. The SealGuard tube proved to be more resistant to leakage than Hi-Lo.

Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews.

OBJECTIVE: To evaluate the effectiveness and potential complications of simple thoracostomy, as first described by Deakin, as a method for prehospital treatment of traumatic pneumothorax. METHODS: Prospective observational study of all severe trauma patients rescued by our Regional Helicopter Emergency Medical Service and treated with on-scene simple thoracostomy, over a period of 25 months, from June 1, 2002 to June 30, 2004. RESULTS: Fifty-five consecutive severely injured patients with suspected pneumothorax and an average Revised Trauma Score of 9.6+/-2.7 underwent field simple thoracostomy. Oxygen saturation significantly improved after the procedure (from 86.4+/-10.2% to 98.5%+/-4.7%, P<0.05). No difference exists in the severity of thoracic lesions between patients with systolic arterial pressure and oxygen saturation below and above or equal to 90. A pneumothorax or a haemopneumothorax was found in 91.5% of the cases and a haemothorax in 5.1%. No cases of major bleeding, lung laceration or pleural infection were recorded. No cases of recurrent tension pneumothorax were observed. Forty (72.7%) patients survived to hospital discharge. CONCLUSIONS: Prehospital treatment of traumatic pneumothorax by simple thoracostomy without chest tube insertion is a safe and effective technique.

Relationship between the timing of administration of IgM and IgA enriched immunoglobulins in patients with severe sepsis and septic shock and the outcome: a retrospective analysis.

PURPOSE: Because the use of IgM and IgA enriched polyclonal intravenous immunoglobulins (eIg) is a standard of care in critically ill patients admitted to our intensive care unit (ICU) with the diagnosis of severe sepsis or septic shock, we investigated if the delay from the onset of severe sepsis and septic shock and their administration could influence the outcome. MATERIALS AND METHODS: The medical records of all patients with severe sepsis or septic shock admitted to our ICU from July 2004 through October 2009 and treated with eIg (Pentaglobin®; Biotest, Dreieich, Germany) were retrospectively examined. RESULTS: A total of 129 adult patients with severe sepsis or septic shock were considered eligible. Thirty-two percent of patients died during the ICU stay. Survivors were given eIg significantly earlier than nonsurvivors (23 vs 63 hours, P < .05). The delay in the administration of eIg and the Simplified Acute Physiology Score II were the only variables that entered stepwise a propensity score-adjusted logistic model. The delay in the administration of eIg was a significant predictor of the odds of dying during the ICU stay (odds ratio for 1 hour of delay, 1.007; P < .01; 99% confidence interval from 1.001 to 1.010) and proved to be independent from the Simplified Acute Physiology Score II and other variables. CONCLUSIONS: The efficacy of eIg, being maximal in early phases of severe sepsis and/or septic shock, is probably time dependent.

Pulmonary embolism in critically ill patients receiving antithrombotic prophylaxis: a clinical-pathologic study.

PURPOSE: The true incidence of pulmonary embolism (PE) in critically ill adult patients receiving antithrombotic prophylaxis is unknown, as well as the impact on the outcome. The aim of this study was to assess the incidence of PE in a surgical and medical intensive care unit and to evaluate the presence of risk factors that could be helpful in identifying patients at higher risk of missed diagnosis. MATERIALS AND METHODS: We retrospectively reviewed the autopsies and clinical data of all patients who died in our intensive care unit from 1996 to 2007. All patients received prophylaxis with subcutaneous low-molecular weight heparin. RESULTS: Among the 600 autopsies, the clinical diagnosis of PE was confirmed in 13 patients (true positives) and not confirmed in 20 patients; in 73 patients, the PE was discovered only at the autopsy (false negatives [FNs]). The overall incidence of PE in our patients was 14.3%. Pulmonary embolism was considered the cause of death in 45% of FNs and 77% of true positives. Among all comorbidities, only a recent abdominal surgery and the presence of acute renal failure were associated with a higher risk of missed diagnosis. In the FN group, there was a significantly higher frequency of cases of septic shock. CONCLUSIONS: Despite thromboprophylaxis, critically ill patients remain at risk for PE; and because of the difficulty in diagnosing it clinically, the death certificate diagnosis of PE underestimates the problem.

Methylprednisolone infusion for life-threatening H1N1-virus infection.

BACKGROUND: During winter 2009 we treated with prolonged corticosteroid infusion eight consecutive patients affected by H1N1-virus infection and severe pneumonia. The most severe patient was a previously healthy 30-year-old man admitted to hospital because of bilateral pneumonia and severe acute respiratory failure. METHOD: H1N1-virus infection was detected by broncho-alveolar lavage performed on day 1. After some days following admission the patient was still in a life-threatening state, not responding to oseltamivir, protective mechanical ventilation and veno-arterial extracorporeal membrane oxygenation (ECMO). RESULTS: The addition of methylprednisolone infusion at a stress dose (1 mg/kg/24 h) as rescue therapy significantly and rapidly improved the clinical condition. Weaning from ECMO and invasive mechanical ventilation was possible within a relatively few days. CONCLUSION: According to the literature reports more than 34% of H1N1-virus severe infections were treated with corticosteroids. This report and our experience may suggest a possible life-saving use of corticosteroids at a stress dose in severely ill patients with an H1N1-virus infection that is not responding to the most advanced treatments.

Influence of prehospital treatment on the outcome of patients with severe blunt traumatic brain injury: a single-centre study.

UNLABELLED: AIM, PATIENTS, AND METHODS: To compare retrospectively the outcomes of patients with severe traumatic brain injury (Injury Severity Score, ISS total >or=15; the Abbreviated ISS-head, aISS(head) >or=9) admitted to our Intensive Care Unit by helicopter (helicopter emergency medical service, HEMS group = 89) with those transported by ambulance (GROUND group = 105) from January 2002 to December 2007. RESULTS: The groups were comparable for age, Glasgow Coma Scale, ISS total, and aISS(head). The preadmission time of the HEMS group was significantly longer as compared with the GROUND group, but the interval from admission to definitive care was significantly shorter. In the prehospital phase, HEMS patients were more aggressively treated, as indicated by a significantly greater number of procedures performed (i.e. tracheal intubation and positioning of intravenous lines) and larger volumes of fluids infused. The overall mortality was lower in the HEMS than in the GROUND patients (21 vs. 25% respectively, P<0.05). The survival with or without only minor neurological disabilities was higher in the HEMS than in the GROUND group (54 vs. 44% respectively, P<0.05); among the survivors, the rate of severe neurological disabilities was lower in the HEMS than in the GROUND group (25 vs. 31%, P<0.05). CONCLUSION: In our experience, aggressive early treatment of patients with severe traumatic brain injury was associated with a better outcome likely because of the prevention of secondary brain injury and a shorter interval elapsing from the trauma to definitive care despite more time spent on the scene by the intervening team.