Intermediate intensive units: definition, legislation and need in Italy.

This paper deals with the definition of intensive care medicine and the organization of different levels of care; intermediate and high level. The organization, facilities and personnel for intermediate care are discussed. The available public data on the organization of intensive medicine and modifications planned by the Legislator are considered. Finally, the usefulness of intermediate care and an estimate of the actual need, based on prospective multicentre ad hoc studies, are discussed.

[Monitoring and protection of the central nervous system in subarachnoid hemorrhage during intensive care]. / Monitoraggio e protezione del sistema nervoso centrale in Terapia Intensiva dopo ESA.

Subarachnoid hemorrhage has cerebral and systemic consequences as well. The main purpose of admitting a patient in the Intensive Care setting is to provide protection, mainly by stabilizing fundamental physiological parameters. There are both systemic parameters and cerebral parameters to be controlled continuously, and cerebral parameters may consider the brain as a whole (global cerebral parameters as intracranial pressure) or may provide information on specific areas. Cerebral protection may be achieved only when multiparametric monitoring is instituted, since only the combination of many physiologic parameters provides information capable of identifying, and hopefully of treating, deleterious derangements.

[Cranial trauma and multiple trauma: from the street to the operating room]. / Trauma cranico e politrauma: dalla strada alla sala operatoria.

Brain injury occurs with a range of severity: even less severe cases should be carefully observed since they may deteriorate. By definition severe head injury has a Glasgow Coma Scale score of 8 or less; comatose patients are defined as cases who do not obey commands, do not open their eyes and do not speak. Very often (50% of case in our series) brain injury is associated with relevant extracranial injuries that may add to the severity of cases and may worsen outcome. The conceptual framework for treating head injury is based on the evidence that after the impact, the initial damage may be exacerbated by insults capable of further disturbing cerebral metabolism, leading to a final damage defined as secondary damage. Secondary damage represents the final end of many pathways that can be studied at the biochemical level and are centered in a calcium influx into the neuronal cell. Most probably there is a genetic susceptibility to secondary damage leading to a range of cellular dysfunctions for any given level of insult. The management of traumatic brain injury is aimed at interrupting the chain of events leading to secondary brain damage and from this perspective the fact that damage may develop over time can be seen as a window of opportunity for timely treatment. The milestone of treatment is the removal of surgical masses. This surgical treatment can be performed only in a brain that is properly perfused and once coagulation is preserved. Therefore the organization of treatment from rescue to neuro-traumatological centers should provide appropriate restoration of the volume and a normal oxygen delivery to the brain and to the overall organism.

[Neurosheet: an electronic sheet for neurosurgical intensive care]. / Neurosheet: un foglio elettronico per la terapia intensiva neurochirurgica.

PURPOSE: A growing number of monitoring and diagnostic instruments has considerably increased the amount of information available in the intensive care unit. A data collection system which can be useful in highlighting and processing the most relevant data for the care of head-injured patients (Neurosheet) has been set up. The purpose of this study is to describe Neurosheet and to analyse the results achieved through its use. ENVIRONMENT: Neurosurgical Intensive Care Unit. METHODS: Neurosheet consists of a data sheet which follows the course of some "key" variables in head-injured patients who undergo ICP monitoring for a period of more than 48 hours. SURVEY: Through a questionnaire distributed to the medical staff, the learning period and the opinion of the staff concerning the clinical usefulness of this instrument has been evaluated. The amount of time needed to compile Neurosheet has been measured and some criteria indicating its completeness identified. RESULTS: It has been found that Neurosheet can be learned quickly and is rather easy to use. Data resulting from the study of the learning curve and from the answers to the questionnaire, suggest that its learning period is quite short (10 to 20 minutes). Among the 28 eligible patients, Neurosheet was used for 24 (86%). The data collected show 1,912 hours of monitoring, with an average of 112.8 (+/- 55) hours per patient. Neurosheet was completed in 83% of the cases. CONCLUSIONS: The aim of Neurosheet is to provide an answer to the overload of information using computerised systems able to simplify and support the daily clinical work.

[An index of daily intensive care unit activity]. / Studio sequenziale per giorno indice dell'attività di reparti di Terapia intensiva. GiViTI. Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva.

OBJECTIVE: To set up an index for the evaluation of type of interventions and procedures applied a prerequisite for the evaluation of appropriateness of ICU's activity. DESIGN: Observation prospective study. PATIENTS: 2507 patients out of the 5030 enrolled in the cohort study. MEASUREMENTS: A cross-sectional assessment of the volume and intensity of treatment--level of care--delivered to patients was performed at a preidentified index day. A check list of procedures was utilized. Intensive high level treatment was demonstrated by the application of procedures suggesting one or more organs or vital functions intensively supported. Sub-intensive treatment was defined by the application of procedures indicating monitoring or treatments not exclusively performed in intensive environment. RESULTS: 3955 samples were collected over 9 index days; 2707 (68.3%) resulted in intensive, 1227 (30.7%) subintensive or intermediate and 41 (1%) ward treatments. Out of the intensive samples, 63.4% received only one intensive procedure, while 27.9% two. Ventilatory support was the most frequently (90.4%) utilized intensive procedure. Overall 99% of the samples were characterized by treatments/procedures too invasive for normal ward. CONCLUSIONS: The proposed method gives the opportunity to easily evaluate the level of care and then the appropriateness of ICU care.

[Determination of the best amino acid input after orthotopic liver transplantation]. / Determinazione dell'apporto aminoacidico ottimale dopo trapianto ortotopico di fegato.

Ten-three patients were investigated during the early postoperative phase after orthotopic liver transplantation to assess the adequacy of the amino acid (AA) supply during both parenteral (days 1-5) and enteral (days 6-9) nutrition. Plasma AA profile was determined preoperatively, on day 4 and 5 during TPN and on day 8 and 9 during EN, urea production rate was measured every day. Calories input was 28 kcal.kg-.day as glucose, nitrogen intake was 0.25 g.kg- day, supplying individual AA on the basis of previous studies. Urea nitrogen production during TPN (9-11 gN/m2.day) outlines the ability of the transplanted liver to manage the overall nitrogen load. Individual AA plasma profile was considered the expression of an adequate input when comprised between 1 and 1.5 times the normal value, in this respect we obtained adequate levels of all essential AAs. Particularly phenylalanine, methionine and branched chain AA, critical during liver failure, were kept in this range by supplying 68, 48 and 500 mg.kg-1.day. According to AA profile the supply of cystine and tyrosine (conditionally essential AAs), and of histidine, taurine, proline and serine could be safely increased. Not given dispensable AAs (glutamine, asparagine, citrulline and alfa amino butyric) showed a plasma level below the norm and should be added to the diet.

[Respiratory failure caused by myopathy in severe sepsis]. / Insufficienza ventilatoria da miopatia in corso di sepsi severa.

OBJECTIVE: To describe a generalized myopathic disorder occurred in the convalescence phase of illness of a critically ill patient. SETTING: Neurological Intensive Care Unit. PATIENT: A 43-year-old man with acute leukoencephalopathy and severe sepsis complicated by sustained and prolonged cardiovascular, respiratory and renal failure. After 15 days of complete respiratory autonomy, the patient presented an acute ventilatory failure associated with generalized muscle weakness. Neither a relapse of sepsis nor neurological worsening were detected. MEASUREMENTS AND RESULTS: Electromyogram resulted in normal conduction velocity in both motor and sensitive nervous fibers. Muscular biopsy showed marked fiber size variability with several hypotrophic fibers type II fiber grouping, several areas of degeneration-necrosis with macrophage invasion, dishomogeneous oxidative enzymatic activity, no increase in glycogen or lipid content. CONCLUSIONS: These results excluded critical illness polyneuropathy and all the other known myopathies. Prolonged period of sepsis with multiple organ failure can result in a direct generalized myopathy. This possibility should be kept in mind while treating long term critically ill survivors.

[Adequacy of admission in neurosurgical intensive care]. / Appropriatezza dei ricoveri in terapia intensiva neurochirurgica.

OBJECTIVE: The Intensive Care Units of Milano metropolitan area are characterized by difficulties of hospitalization for acutely injured patients due to the low bed availability. We evaluated the problem trying to find out possible solutions. DESIGN: On the day of achieved neurological and neurosurgical stability-defined as the day when the intracranial pressure and jugular venous oxygen saturation monitoring, hyperventilation, osmotic therapy were considered no longer needed--the monitoring procedures and instrumental and/or pharmacological treatments that the patients received were recorded and classified as follows: 1) intensive, 2) intermediate, 3) non-intensive. PATIENTS: All the acutely injured patients admitted at five Neurosurgical ICUs during June-July and October-November 1994 have been studied. Only one of these ICUs had a "sub-intensive unit". MEASUREMENTS AND MAIN RESULTS: 391 patients (29.9%) aneurysms and arteriovenous malformations, 25.1% tumours, 2.8% head injuries, 8.7% spontaneous intracranial haematomas, 13.5% various pathologies) were studied. Out of them 358 had an acute brain failure. 16.5% died during brain failure and 83.5% reached neurological stability within 3 days. When neurological stability was reached 32.1% of patients could be classified as "intensive", 63.6% as "intermediate" and 4.3% as "unintensive". In the four ICUs, without sub-intensive ward facilities, 361 patients were admitted with a total amount of 2292 days of hospitalization. Among them 61.9% were spent for a) patients with no brain injury (32 pts/113 days), b) postoperative patients (113 pts/167 days), c) patients in stable neurological conditions (159 pts/1139 days). Therefore, only 38% of the days recorded were given to patients that needed neurointensive care. CONCLUSION: Out data suggest that the receptivity for acute injured patients could be increased creating recovery room units and intermediate post-intensive units together with a better interchange between general and neurosurgical ICUs.

[Daily survey of procedures as markers of resources utilization]. / Rilevazione giornaliera di procedure come tracciante dell'utilizzo di risorse.

OBJECTIVE: To assess and to follow along the time-span of ICU stay the process of resources allocation and utilization. DESIGN: Prospective study. PATIENTS: A cohort of 778 patients consecutively admitted to 7 multipurpose general ICU in the Milano area were enrolled in a survey of the daily performed interventions/procedures. MEASUREMENTS AND MAIN RESULTS: The majority of diagnostic procedure/interventions were performed during the first two days. The number and quality of interventions were transferred into points obtaining a score system in non-monetary units. The resource allocation process shows a regular trend in the sub-intensive patients who were only monitorized. On the contrary the 258 patients who were intensively treated and survived show a phase of high resource-consumption (about 30 daily points: roughly twice the score of monitorized patients) then followed by a post-intensive phase with a resource consumption resulting in a daily score absolutely equal to the sub-intensive patients. The intensive patients who die show a significantly higher score than survived patients. Both daily and cumulative scores do not show differences among different type of patients. CONCLUSION: The evaluation of the process of resources allocation, even if in non-monetary units enables the knowledge of the trend of ICU costs and allows the elaboration of the appropriate budget mechanism.