Blood Lactate Concentrations Before and After Withdrawal of Life-Sustaining Treatments in Controlled Donation After Circulatory Death: A Case Report From Italy.

A 20-minute hands-off period with isoelectric electrocardiography (ECG) monitoring is currently required for the declaration of cardiac death in Italy, thus prolonging the warm ischemia time (WIT) during donation after circulatory death (DCD). Normothermic regional perfusion (NRP) can be a valid tool to optimize organ perfusion as a bridge to donation. A 62-year-old woman with catastrophic brain injury due to massive intracranial hemorrage, not fulfilling brain death criteria, underwent controlled DCD after withdrawal of life-sustaining therapies (WLST). NRP was established after a functional WIT of 43 minutes. Despite concerns regarding a prolonged WIT imposed by the national legislation on declaration of cardiac death, NRP was successful in restoring an adequate perfusion to liver and kidneys, as evidenced by a sustained reduction in blood lactate concentration. Liver and kidneys were successfully transplanted after ex vivo machine perfusion.

Non-invasive ventilation after surgery in amyotrophic lateral sclerosis.

BACKGROUND: Surgery in patients affected by amyotrophic lateral sclerosis (ALS) presents a particular anesthetic challenge because of the risk of post-operative pulmonary complications. AIMS OF THE STUDY: We report on the use of non-invasive ventilation (NIV) to prevent post-operative pulmonary complications (PPCs) in nine patients affected by ALS enrolled in a phase-1 clinical trial with stem cell transplantation. METHODS: All patients were treated with autologous mesenchymal stem cells implanted into the spinal cord with a surgical procedure. Anesthesia was induced with propofol and maintained with remifentanil and sevoflurane. No muscle relaxant was used. After awakening and regain of spontaneous breathing, patients were tracheally extubated. Non-invasive ventilation through nasal mask was delivered and non-invasive positive pressure ventilation and continuous positive pressure ventilation were started. RESULTS: The average time on NIV after surgery was 3 h and 12 min. All patients regained stable spontaneous breathing after NIV discontinuation and had no episodes of respiratory failure until the following day. CONCLUSIONS: Our case series suggest that the use of NIV after surgery can be a safe strategy to prevent PPCs in patients affected by ALS. The perioperative procedure we chose for these patients appeared safe even in patients with advanced functional stage of the disease.

Epidemiology and outcome of sepsis syndromes in Italian ICUs: a muticentre, observational cohort study in the region of Piedmont.

BACKGROUND: Sepsis is an important cause of mortality and morbidity in the intensive care unit (ICU). We performed a study to describe the epidemiology of sepsis syndromes in patients admitted to ICUs of the Piedmont region. METHODS: In this prospective, multicentre, observational study, all 3902 patients admitted to a network of 24 ICUs from 17 hospitals during a 180 day period (April 3-September 29, 2006) were included. Patients were followed from the first day of admission until death or ICU discharge. RESULTS: The incidence of sepsis during the ICU stay was 11.4% (N.=446), corresponding to an incidence of 25 cases/100,000 inhabitants/year; 141 (31.6%) patients had only sepsis, 160 patients had severe sepsis (35.9%) and 145 patients (32.5%) had septic shock In 227 patients (50.9%), sepsis was observed within 48 hours after admission to the ICU, and 219 patients (49.1%) developed ICU-acquired sepsis. The main sources of infection were the lungs, abdomen, and urinary tract. ICU mortality was higher (41.3 vs. 17.3%, P<0.0001) and the median ICU length of stay longer (15 vs. 2 days, P<0.0001) in patients with sepsis than in those without sepsis. The mortality rate increased with the severity of sepsis. ICU-acquired sepsis was associated with higher ICU mortality rates than sepsis occurring within 48 hours of ICU admission (49.8 vs. 33.0%, P<0.0001). CONCLUSION: Sepsis is a common occurrence in critically ill patients. Our data underscore the regional variability in the epidemiology and outcome of sepsis syndromes and may be useful to guide appropriate resource allocation.

Epidemiology of nosocomial infection in 125 Italian intensive care units.

AIM: A continuous infection surveillance program was conducted by GiViTI throughout 2006 in Intensive Care Units (ICUs). METHODS: This was a prospective epidemiological study carried out in 125 Italian intensive care units. All patients have been included in the study. Aside from the detailed clinical information collected for all patients, in cases of infection upon ICU admission and for the first site-specific episode that occurred during the patient's stay, the following data were collected: severity upon admission, micro-organisms and their antibiotic resistance patterns, subsequent multiple episodes in the same site, origin of infections and maximum severity reached. The diagnostic criteria for all infections are explicitly stated. RESULTS: A total of 34,472 patients entered the study. Infection upon admission was present in 12.6% of patients, with a high level of ICU and hospital mortality (29.4% and 38.7%, respectively). In 3148 patients one or more infections were reported as ICU-acquired with an overall incidence of 9.1% and an ICU and hospital mortality of 27.2% and 35.1%, respectively. Out of the device-related infections, ventilator-associated pneumonia was the most frequently diagnosed (8.9/1000 days on ventilator). Catheter-related blood stream infection was reported with a low incidence (1.9/1000 central venous catheter days). Nearly 20% of more than 5000 isolated microorganisms were classified as multi-drug resistant, with methicillin-resistant Staphylococcus aureus as the most frequently reported bug. CONCLUSIONS: The ad hoc expanded GiViTI software "Margherita2" allows continuous infection surveillance in Italian ICUs, annually providing an extensive and updated database. Interventions to improve infection prevention and patient safety should be tailored to accommodate these data.

[Treatment of septic shock with the use of CPFA (associated plasma filtration and adsorption): impact on hemodynamics monitored with PiCCO ]. / Trattamento dello shock settico con l'impiego della CPFA (plasmafiltrazione e adsorbimento associate): impatto sull'emodinamica valutata con sistema PiCCO

BACKGROUND: Septic shock represents an emerging pathology and sepsis and its complications are the main cause of death in medical and surgical intensive care units. Single-target therapeutic trials failed to demonstrate any benefit, suggesting that the unselective removal of different mediators may be a more appropriate approach. METHODS: We evaluated a new technique (CPFA) combining a plasma-adsorption (with plasma filter and sorbent cartridge) with a traditional 'slow' extracorporeal treatment on 10 patients, 7 men and 3 women (mean age 53.8+/-16.3), all on mechanical ventilation, with septic shock and multiorgan failure. To identify easily comparable clinical data, the hemodynamic parameters of the patients were monitored with a recently developed, minimally invasive technology, Pulsion PiCCO . RESULTS: We obtained significant improvement of pre- versus post-treatment mean arterial pressure 77.2+/-12.5 vs. 83.3+/-14.1 mmHg (p<0.0001), cardiac index 4.03+/-0.89 vs. 3.46+/-0.82 L/m2/min (p<0.0001), indexed systemic vascular resistances 1388+/-496 vs. 1753+/-516 dynes x sec/cm5 (p<0.0001), PaO2/FiO2 ratio 204+/-87 vs. 232+/-81 (p<0.0001), and norepinephrine requirements 0.13+/-0.07 vs. 0 y/kg/min after a mean of 5.3+/-2.7 consecutive treatments. The survival at day 28 was 90%. Seven patients were discharged from the intensive care unit after a mean of 37.8+/-24 days (range 10-93). CONCLUSIONS: Our data suggest a promising role for CPFA in improving hemodynamics and correcting vasoparalysis in septic shock. Moreover, the noninvasive monitoring of hemodynamic parameters with PiCCO could become a useful tool for estimating the effect of treatment and gaining easily comparable data in different patients.

Major surgery (radical cystectomy with urethrectomy) in a patient with von Willebrand's disease type I. Reliability and limits of hemocoagulative tests.

Patients with bleeding disorders frequently need medical or surgical care. The case is reported of a man with von Willebrand's disease type I undergoing radical cystectomy with urethrectomy for multicentric bladder cancer with neoplastic involvement of prostatic urethra, who developed serious bleeding complications which can not be predicted with conventional coagulation in laboratory. The use of the thromboelastograph (TEG) in the critical postoperative period was decisive. The tracing alterations allowed to assess the clotting disorder, constantly counterbalancing the baseline deficit and the blood loss.

[SPECT in cerebral fat embolism. Report of a clinical case]. / SPECT nell'embolia grassosa cerebrale. Presentazione di un caso clinico.

The authors describe a case of post-traumatic cerebral fat embolism in a 17-year-old patient. SPECT with HM-PAO was used in this case to confirm the suspected diagnosis: where CT and evoked potentials were negative, SPECT showed the changes in vascular flow at the level of the frontal lobes responsible for the vegetative state of the patient. SPECT is therefore a valuable method for the early definition of the conditions of patients in a vegetative state.

[The use of nefopam in the prophylaxis and treatment of postoperative shivering]. / Impiego del nefopam nella profilassi e nella terapia del brivido postoperatorio.

Chlorhydrate nefopam was used in the prophylaxis and treatment of postoperative shivering in 54 patients undergoing general anesthesia for radical cystectomy with trans-intestinal anastomosis. Postoperative shivering was not observed in any of the patients treated with nefopam before coming round, whereas it occurred in 55% of patients treated with placebo. Chlorhydrate nefopam subsequently stopped shivering in all these patients. The main side effects observed took the form of delayed awakening in 11% of patients receiving prophylactic treatment and somnolence lasting 5-10 minutes in all other patients.