Good neurological recovery after cardiopulmonary resuscitation and thrombolysis in two old patients with pulmonary embolism.

The use of thrombolysis as an emergency treatment for cardiac arrest (CA) due to massive pulmonary embolism (MPE) has been described. However, there are no reports of successful treatment of MPE-associated CA in patients over 77 years of age. We report two cases of successful cardiopulmonary resuscitation for an MPE-associated CA in two very old women (87 and 86 years of age). In both cases, typical signs of MPE were documented using emergency echocardiography, which showed an acute right ventricle enlargement and a paradoxical movement of the interventricular septum. Emergency thrombolysis was administered during resuscitation, which lasted 45 and 21 min, respectively. Despite old age and prolonged resuscitation efforts, both patients had good neurological recovery and one of them was alive and neurologically intact 1 year later. Thrombolysis is a potentially useful therapy in MPE-associated CA. A good neurological outcome can be obtained even in very old patients and after prolonged resuscitation.

Taking Care of Relationships in the Intensive Care Unit: Positive Impact on Family Consent for Organ Donation.

BACKGROUND: Organ donation refusal from relatives of potential donors with brain death significantly reduces organ availability. The need for organ donation has increased over time, but the shortage of available donors is the major limiting factor in transplantation. We analyzed the impact of a new systematic communication approach between medical staff and patients' relatives on the rate of consent to organ donation. METHODS: The study was conducted as a single-center, non-randomized, controlled, before-and-after study at an 18-bed intensive care unit (ICU) of a university hospital. We compared the rate of consent for organ donation before and after the introduction of the new communication approach. RESULTS: A total of 291 brain-dead patients were studied. The consent rate increased from 71% in the pre-intervention period (2007-2012) to 78.4% in the post-intervention period (2013-2015), with an 82.75% increase in the 2014 to 2015 period. During these periods, no significant variation of consent to organ donation was recorded at the national and regional levels. CONCLUSIONS: The introduction of a new communication approach between medical staff and relatives of brain-dead patients was associated with a significant increase in the rate of consent to donation. Our results highlight the importance of empathy with relatives in the ICU.

What is the best test to predict outcome after prolonged cardiac arrest?

Multimodality evoked potentials (EPs), linear electroencephalograms and Glasgow Coma Scale (GCS) scores were recorded within 24 h of cardiac arrest in 62 patients who were comatose following cardiopulmonary resuscitation. The cardiac arrest had a cardiac cause in 35 patients and a non-cardiac cause in 27 patients. The Glasgow Outcome Scale (GOS) scores were established 6 months after resuscitation. The prognostic value of all the recorded variables was calculated in terms of sensitivity, specificity and accuracy. Spearman's rank test was also used for the determination of the correlation coefficients with GOS. EP recordings furnished no falsely pessimistic predictions, with a specificity of 100%. In other words, when EPs were altered, the prognosis was always poor. However, while all patients who regained consciousness had normal EPs, not all patients in whom EPs were recordable survived. The GCS score showed a higher sensitivity and correlation with GOS score than EPs, but it was associated with a high percentage of false positive results, and its specificity was only 67%. The combination of the GCS score with EPs may be a promising strategy to counterbalance the respective limits of these methods and to reduce the loss of information due to sedation and myorelaxation, which impede clinical examination but not EP results.

[Computerized multiple-choice questions: an efficacious method of evaluation in medical instruction?]. / Domande a scelta multipla computerizzate: un metodo di valutazione efficace nella didattica medica?

To evaluate the efficacy of Multiple Choice Questions (MCQ) as an evaluation tool in medical education, were analyzed the responses to 80 MCQ delivered by 300 physicians working in emergency departments and following a course on Basic and Advanced Life Support. Pre- and post-test were administered using a dedicated computer application running on PC. Students' scores were high and demonstrated both course and test validity. More than 95% of the students used the computer application without interface difficulties. However, some limits of MCQ were individuated: first, misinterpretation of some questions, especially when two or more similar answers were presented; from the other side, the student's personal experiences during the course practice could influence student's responses bringing him to different conclusions on respect to the instructor. These difficulties should be kept in mind in the development of a MCQ session, and students should have the possibility to give to the instructor a feedback of problems encountered during the course. This is especially important when MCQ are the sole evaluation technique.

Management of oxygen and carbon dioxide pressure after cardiac arrest.

Experimental evidence shows that derangements of arterial partial pressures of either oxygen (PaO2) and carbon dioxide (PaCO2) immediately after resuscitation from cardiac arrest may increase the severity of organ dysfunction due to whole body ischemia and subsequent reperfusion. Hyperoxia is believed to increase reperfusion injury, especially to mitochondrial membrane due to increased production of reactive oxygen species. Two large observational studies in human adults showed that hyperoxia (defined as a PaO2≥300 mmHg) in the first 24 h after hospital admission was associated with increased mortality or lower likelihood of independent functional status at hospital discharge. Evidence of the effects of hyperoxia in children were less consistent. A reduction of PaCO2 below normal values may cause cerebral vasoconstriction and increase the severity of delayed brain hypopefusion which usually occurs within 24h from resuscitation. Cerebrovascular reactivity to CO2 is preserved during therapeutic hypothermia. According to recent clinical studies, a low PaCO2 after resuscitation is associated with increased mortality and higher rates of poor neurological outcome both in children and in adults, while the effects of a PaCO2 above 45 mmHg are less clear. The PaCO2 derangements are very common in resuscitated patients. Maintaining normal levels of both PaO2 and PaCO2 and in particular avoiding both hyperoxia and hypocapnia may reduce morbidity and improve survival of cardiac arrest survivors. Available clinical evidence is however almost exclusively limited to observational studies which may be biased by potential uncontrolled confounders.

ERC 2010 guidelines for adult and pediatric resuscitation: summary of major changes.

The new European Resuscitation Council (ERC) guidelines for cardiopulmonary resuscitation (CPR) published on October 18th, 2010, replace those published in 2005 and are based on the latest International Consensus on CPR Science with Treatment Recommendations (CoSTR). For both adult and pediatric resuscitation, the most important general changes include: the introduction of chest compression-only CPR in primary cardiac arrest as an option for rescuers who are unable or unwilling to perform expired-air ventilation; increased emphasis on uninterrupted, good-quality CPR and minimisation of both pre- and post-shock pauses during defibrillation. For adult resuscitation, the recommended chest compression depth and rate are 5-6 cm and 100-120 compressions per minute, respectively. Both a specific period of CPR before defibrillation during out-of-hospital resuscitation and use of endotracheal route for drug delivery during advanced life support are no longer recommended. During postresuscitation care, inspired oxygen should be titrated to obtain an arterial oxygen saturation of 94-98%, to avoid possible damage from hyperoxemia. In pediatric resuscitation, the role of pulse palpation for the diagnosis of cardiac arrest has been de-emphasised. The compression-to-ventilation ratio depends on the number of rescuers available, and a 30:2 ratio is acceptable even for rescuers with a duty to respond if they are alone. Chest compression depth should be at least 1/3 of the anterior-posterior chest diameter. The use of automated external defibrillators for children under one year of age should be considered.

Systolic anterior motion causing hemodynamic instability and pulmonary edema during bleeding.

Systolic anterior motion (SAM) of mitral valve is the prolapse of a mitral leaflet into the left ventricle outflow tract (LVOT) during systole, causing LVOT obstruction and mitral valve regurgitation. We report the case of a patient who developed SAM-induced hemodynamic instability during bleeding with a clinical picture resembling pulmonary edema. A 77-year-old woman was admitted to our emergency room for abdominal bleeding in polycystic renal disease. Upon arrival, she was normotensive, despite being anuric and acidotic. After infusion of fluids and packed red blood cells (total 3 680 mL in 6 hours) she developed atrial fibrillation and clinical and radiological signs of pulmonary edema. Sedation and non-invasive ventilation brought to immediate severe hypotension. A transesophageal echocardiogram showed an "empty" hypertrophic hypercontractile left ventricle, SAM with LVOT obstruction (intraventricular gradient 154 mmHg) and moderate-to-severe mitral regurgitation. With further fluid infusion hemodynamic stability and sinus rhythm were recovered. SAM, LVOT obstruction and mitral regurgitation disappeared. SAM is a rare but dangerous cause of hemodynamic instability. It has been described in patients with and without left ventricular hypertrophy, in presence of hypovolemia and sympathetic stimulation. In our case it presented with a misleading clinical picture of pulmonary edema simulating fluid overload in an actually hypovolemic patient. In fact, SAM-associated mitral regurgitation together with diastolic dysfunction and tachycardia induced a pulmonary edema whose treatment worsened hypovolemia and precipitated LVOT obstruction and hypotension. Further fluid infusion was resolutive. Echocardiography was fundamental for diagnosis and treatment.

The 2005 European Guidelines for cardiopulmonary resuscitation: major changes and rationale.

During the 2005 International Consensus Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science, a rigorous evidence-based evaluation process was conducted. The consensus reached during that Conference constituted the basis of the current CPR guidelines of the European Resuscitation Council (ERC), published in December 2005. Those guidelines included many important changes, made on the basis of emerging evidence. For example, the compression-ventilation ratio for CPR in non-intubated patients was increased from 15:2 to 30:2 and a strong recommendation to minimize interruptions in chest compression was issued in order to maximise organ perfusion. Energy levels for monophasic defibrillation were increased and specific energy levels for biphasic defibrillation have been recommended, in order to maximise the efficacy of the first shock. New timing of defibrillation shocks is now advised: the three-stacked shock sequence has been replaced by high-energy single shocks followed by two-minute cycles of CPR, in order to reduce CPR interruptions. Timing for administration of drugs has been adapted to the new shock sequence and the advanced life support (ALS) universal algorithm has been modified. Some controversial topics are still a matter of investigation and debate, including the use of therapeutic hypothermia in non-shockable cardiac arrests, the efficacy of a period of CPR before defibrillation in long-lasting cardiac arrests, and the chest-compression-only CPR for first responders of out-of-hospital cardiac arrests.

Functional hemodynamic monitoring and dynamic indices of fluid responsiveness.

Knowing whether or not a fluid infusion can improve cardiac output (fluid responsiveness) is crucial when treating hemodynamically unstable patients. Generally, cardiac filling pressures (central venous pressure, pulmonary artery occlusion [''wedge''] pressure) and volumes (end-diastolic left and right ventricular volume) are used, although they are not reliable predictors of fluid responsiveness. For this reason, new indices, the so-called dynamic indices of fluid responsiveness, have been recently introduced in clinical use. If stroke volume, or stroke volume-derived parameters (pulse pressure and aortic flow) show wide variation during mechanical ventilation, a good response to fluid therapy can be predicted. As these indices are based upon the effects of controlled mechanical ventilation on stroke volume, they can be used in deeply sedated or apneic patients whose cardiac rhythm is regular. To overcome these limitations, new dynamic indices have been introduced. Among them, variation of cardiac output induced by passive leg raising (PLR) has raised particular interest since it can identify fluid responders even among spontaneously breathing and non-sinus rhythm patients. Although promising, the dynamic indices of fluid responsiveness have been studied only retrospectively in a relatively small number of patients and evidence that clinical use of these indices can improve outcome is still limited. Further investigations are needed to confirm their clinical validity.

Enoximone in cardiac arrest caused by propranolol: two case reports.

We report two clinical cases of cardiac arrest, the former due to an adverse effect of intravenous (i.v.) propranolol in a patient with systemic sclerosis, the latter from a propranolol suicidal overdose. In both cases, conventional advanced life support (ALS) was ineffective but both patients eventually responded to the administration of enoximone, a phosphodiesterase III (PDE III) inhibitor. After the arrest, both patients regained consciousness and were discharged home. The chronotropic and inotropic effects of PDE III inhibitors are due to inhibition of intracellular PDEIII and are therefore unaffected by beta-blockers. These cases suggest that PDEIII inhibitors may be useful in restoring spontaneous circulation in cardiac arrest associated with beta-blocker administration when standard ALS is ineffective.

[Acute tubular necrosis after renal transplantation. Multifactoral analysis]. / Necrosi tubulare acuta dopo trapianto di rene. Analisi multifattoriale.

Acute Tubular Necrosis (ATN) is a relatively common complication occurring after cadaver kidney transplant. In 64 human renal grafts performed in our center the influence of some factors on the incidence of ATN, related to donor and recipient, was evaluated. The total incidence of ATN was 26.5%. As far as factors related to donor are concerned, the donor's provenance (our medical center versus other centers) resulted statistically significant (p less than 0.01). The incidence of ATN was 17% when the donor came from our intensive care unit, compared with 52% of incidence observed when donor came from other medical centers. As far as factors related to recipients are concerned, the mean and systolic arterial pressure (both measured at the time of unclamping the renal vessels) resulted statistically significant (p less than 0.01 and 0.05 respectively). The influence of mean arterial pressure on the incidence of ATN suggests the administration of inotropic and vasopressant drugs in selected patients before and after organ reperfusion in order to maintain an adequate renal perfusion.

Successful treatment with enoximone for severe poisoning with atenolol and verapamil: a case report.

Combined poisoning with calcium channel blockers (CCBs) and beta-blockers is usually associated with severe hypotension and heart failure. Due to the block of the beta receptors, treatment with adrenergic agonists, even at high doses, can be insufficient, and beta-independent inotropes, such as glucagon, may be required. Phosphodiesterase III (PDEIII) inhibitors represent a possible alternative to glucagon in these cases as they have an inotropic effect which is not mediated by a beta receptor.