Early predictive factors on mortality in head injured patients: a retrospective analysis of 112 traumatic brain injured patients.

AIM: Early hyperglycemia is a feature of traumatic brain injured (TBI) patients. The aim of our study was to analyze the impact of early hyperglycemia on in-ICU mortality in isolated TBI and its correlations with other factors responsible for secondary injury. METHODS: We studied admission values (AV) and worse values in the first 48 hours (WV 48 h) of 112 ICU TBI patients (mortality 29.6%) of blood glucose (BG), base excess (BE), mean arterial pressure (MAP), PaO2/FiO2 ratio and serum hemoglobin (Hb). Predictive strength as the area under the receiver operating curves (AUROC) and correlation between all variables were calculated. RESULTS: Data are expressed as median, 1st-3rd quartile. Both BG AV (147.5, 126-182 mg/dL; AUROC 0.716, P=0.0002) and WV 48 h (156.5, 132-192 mg/dL; AUROC 0.721, P=0.0001) are predictive of mortality. AV and WV 48 h are respectively: PaO2/FiO2 (366.8, 237.2-477.6 vs. 320, 214.4-426; P=0.05), MAP (90, 80-100.5 vs. 75, 66-83 mmHg; P<0.0001) and Hb (11.4, 9.7-13.1 vs. 10.6, 9-12.2 g/dL; P<0.02). BG AV and WV 48 h correlates with: age (r=0.419, P<0.0001 and r=0.489, P<0.0001), PaO2/FiO2 AV (r -0.223, P<0.03 and r -0.236, P<0.02), PaO2/FiO2 WV 48 h (r -0.215, P<0.03 and r -0.279, P<0.005) and MAP WV 48 h (r -0.216, P<0.03 and r -0.261, P<0.007). CONCLUSION: Early hyperglycemia is a major predictor of mortality and correlates with other factors responsible for secondary injury. Early hyperglycemia seems to be a marker of inflammatory reaction responsible for early cardiovascular and respiratory impairment.

Mechanical loads modulate tidal volume and lung washout during high-frequency percussive ventilation.

High-frequency percussive ventilation (HFPV) has been proved useful in patients with acute respiratory distress syndrome. However, its physiological mechanisms are still poorly understood. The aim of this work is to evaluate the effects of mechanical loading on the tidal volume and lung washout during HFPV. For this purpose a single-compartment mechanical lung simulator, which allows the combination of three elastic and four resistive loads (E and R, respectively), underwent HFPV with constant ventilator settings. With increasing E and decreasing R the tidal volume/cumulative oscillated gas volume ratio fell, while the duration of end-inspiratory plateau/inspiratory time increased. Indeed, an inverse linear relationship was found between these two ratios. Peak and mean pressure in the model decreased linearly with increasing pulsatile volume, the latter to a lesser extent. In conclusion, elastic or resistive loading modulates the mechanical characteristics of the HFPV device but in such a way that washout volume and time allowed for diffusive ventilation vary agonistically.

An uncommon cause of lower limb weakness.

We describe a case of a severely mentally disabled patient diagnosed as suffering from Guillain-Barré syndrome and treated with repeated plasma exchange. However, the abrupt onset of a cardiovascular collapse prompted a more in-depth diagnostic workup which demonstrated that the neurologic symptoms were likely to be ascribed to poisoning with heavy metals from a large number of ingested coins and other metallic items.

Plasmapheresis in the critically ill patient.

Despite the wide number of diseases currently or previously treated with plasma exchange and plasmapheresis, the clinical effectiveness of these treatments has been established by large, controlled clinical trials only in few clinical conditions. The firmly accepted and the possible indications for these techniques in critically ill patients are reviewed and discussed, as well as their complications and possible side effects.

Drug-induced hyperthermia in a patient with persistent vegetative state. Case report and review of the literature.

The case of posttraumatic patient with persistent vegetative state and severe and prolonged hyperthermia (T = 39-40 degrees C for more than 20 days), in absence of infection, is described. Diffuse muscular rigidity, treated with L-dopa, slightly preceded the onset of hyperthermia, which was treated with several antipyretics, including phenotiazines. The withdrawal of these drugs and the administration of dantrolene and bromocriptine was followed by the restoration of the normal body temperature.

Postoperative Wernicke's encephalopathy.

We report the case of a patient in whom Wernicke's encephalopathy occurred after a prolonged postoperative starvation. The pathophysiology of WE and the possible differential diagnoses of neurologic disturbances occurring in the postoperative phase are reviewed and discussed.

Fatal Streptococcus viridans descending mediastinitis: case report and review of the literature.

Mediastinitis is a life-threatening complication of cardiac, neck and oesophageal surgery. It has also been reported following upper digestive and respiratory procedures and as a consequence of oesophageal perforation following the ingestion of foreign bodies. Much more infrequently, mediastinitis can occur in association with oropharyngeal or cervical infections. We describe the case of a patient with fatal mediastinitis and septic shock. The onset of mediastinitis was preceded by a 2-day course of sore throat and other flu-like symptoms.

Traumatic blunt carotid injury: clinical experience and review of the literature.

To evaluate the symptoms, the associated lesions, the treatment and the outcome of patients with blunt carotid injury (BCI), we reviewed the records of all patients admitted to our intensive care unit with head trauma between May 1991 and May 1995. A patient's assessment included the commonly used severity scores and cranial computed tomography (CT). Other diagnostic investigations were performed according to the clinical setting. Four patients (2 males, 2 females, age 29 +/- 13 years) out of 145 were diagnosed to have BCI. At admission, the Glasgow Coma Scale (GCS) was > or = 12 in all patients, and was associated with hemiparesis in three of them; the fourth became paretic 48 hours later. No pathological elements were demonstrated at the initial CT scan, whilst subsequent examinations showed signs of ischaemia after a variable interval from admission. In every patient the radiologic investigations demonstrated a thrombotic obstruction of the internal carotid artery (ICA), associated with an intimal dissection in two cases. Three patients were discharged with only minor neurologic symptoms. The fourth patient was referred to our ICU after the development of a massive hemispheric infarction, and died 3 days after admission.

Does the length of stay in the intensive care unit influence the diagnostic accuracy? A clinical-pathological study.

To evaluate the rate of diagnostic errors leading to preventable deaths among patients admitted to our intensive care unit (ICU), we retrospectively reviewed the medical and autopsy records of all patients who died in the ICU between 1 January 1991 and 31 December 1993. Excluded were patients with traumatic injuries, cerebrovascular accidents and primary cardiac arrest. According to their length of stay (LOS) in the ICU, patients were subdivided into Group A (LOS 0-24 hours), Group B (LOS > 24 hours-14 days), and Group C (LOS > 14 days). Errors were divided into Type 1 (failure to recognize a treatable life-threatening condition); Type 2 (failure to recognize a life-threatening condition, which treated, however, would unlikely alter the outcome), and Type 3 (failure to recognize a condition unrelated to the outcome). Overall, 159 consecutive patients were enrolled. Type 1 errors were 5% in Group A, 4% in Group B and 9% in Group C. Type 2 errors were 18% in Group A, 34% in Group B, and 30% in Group C. Fully correct diagnoses or Type 3 errors were present in 77% of patients in Group A, 62% of patients in Group B, and 61% of patients in Group C. Clinical errors of any type were not related with the LOS in the ICU or in the hospital, age and the number of underlying chronic diseases.

Impact of emergency medical helicopter service on mortality for trauma in north-east Italy. A regional prospective audit.

The hypothesis that high level on-the-field ATLS could influence mortality in severe trauma patients was tested by means of a prospective study. During a 7 month period, data of all the victims of severe involuntary trauma (road traffic accidents, work and sport accidents) in 3 Provinces of north-east Italy were entered in a database and analysed. The whole area is covered by a single emergency service which has direct control over all the ambulances and the Emergency Helicopter Service (EMHS). The area concerned by the study has a surface of 7,300 kmq with a population of 1 million inhabitants and is served by 12 first level hospitals and 4 second level institutions (trauma centres). All the patients who were still alive at the time of arrival of the first rescuers were considered, but only severe trauma patients with ISS > 15 were enclosed into the study. All the patients were followed up to their discharge from the ICUs (end point). There were three different rescue approaches: 82 Patients (GROUP A) were rescued by EMTs with BLS training, transported to the nearest level 1 hospital for stabilisation and subsequently transferred to a trauma center; 98 Patients (GROUP B) were rescued by EMTs and directly transported to a trauma centre which was the nearest institution; 42 Patients were rescued on the scene by the EMHS team including an anaesthesiologist with 10 years experience in trauma care and directly transported to a trauma centre after full on-the-field stabilisation (GROUP C) RESULTS: 222 severe trauma patients (ISS > 15) were considered. Mean ISS was 35.1 +/- 18.2 in group A, 33.4 +/- 19.6 in group B and 36.0 +/- 17.8 in group C. 67 patients died previous to ICU discharge (31%). 31 over the 82 pts in Group A (38%) died. 23 of them died even before reaching the trauma centre. The mean time elapsed between the first emergency call and the arrival at the trauma centre was 162 min (90'-300'). Mean ICU stay for patients who survived was 15 days. In Group B 31 over 98 patients (32%) died before ICU discharge. The mean time between the emergency call and hospital admission was 27'. Mean ICU stay for patients who were discharged, was 13 days. 5 over 42 patients rescued by the EMHS (Group C) died, none of them in the pre-hospital setting. Stabilisation included tracheal intubation in 34 cases (81%) and thoracic drainage in 6 (14%). All the patients arrived at the hospital with 2 i.v. line. The average amount of infused fluids were 600 mls of colloids and 810 mls of crystalloid. 13 patients with hypotension received and average of 1000 mls of colloids and 1200 mls of crystalloid. The average time elapsed between the emergency call and the final admission to the definitive care institution was 55'. Mean ICU stay was 11 days. Mortality rate in this group was 12%, significantly lower than in group A (p < 0.005) and group B (p < 0.05).

[Medical therapy of acute cardiogenic pulmonary edema. Critical review]. / La terapia medica dell'edema polmonare acuto cardiogeno. Revisione critica.

After a survey of conventional and modern therapeutic strategies in pulmonary edema, a simple clinical approach to the management of this cardiac emergency is suggested. The central role of chlorpromazine, as a vasodilator drug, is also stressed.

[Extracorporeal support technics in the treatment of multisystem failure. Our experience]. / Tecniche di supporto extracorporeo nel trattamento dello scompenso multisistemico. Nostra esperienza.

Mortality rate among patients with septic, oliguric, multiple organ failure is high. Conventional hemodialysis has often detrimental effects on critically ill patients. Continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVH/D) and continuous arteriovenous hemodialysis associated with sequential plasmapheresis (CAVHP/D) could reduce mortality in septic (hypercatabolic, oliguric) ARDS induced MOF patients. These techniques are simple and can be managed without superspecialized personnel.

[Botulinum poisoning in adults: a case report and differential diagnosis]. / Intossicazione botulinica nell'adulto: descrizione di un caso e diagnosi differenziale.

The authors reports the case of a patient with quadriplegia associated with respiratory failure. A few days before, a paralysis of the oculomotor nerves appeared, which rapidly spreads in cranio-caudal fashion. The occurrence of a similar symptomatology in a patients' relative addressed the diagnosis toward a possible Clostridium botulinum intoxication. Other possible differential diagnoses are reviewed and discussed.

Pulse pressure variation as a predictor of fluid responsiveness in mechanically ventilated patients with spontaneous breathing activity: a pragmatic observational study.

INTRODUCTION: Pulse pressure variation predicts fluid responsiveness in mechanically ventilated patients passively adapted to the ventilator. Its usefulness in actively breathing ventilated patients was examined only by few studies with potential methodological shortcomings. This study sought to describe the performance of pulse pressure variation as a predictor of fluid responsiveness in hypotensive critically ill patients who trigger the ventilator. METHODS: We studied forty two hypotensive, mechanically ventilated patients with documented spontaneous breathing activity in whom a fluid challenge was deemed necessary by the attending physician. All patients were ventilated with a Maquet Servo-i Ventilator in different ventilatory modes with a flow-regulated inspiratory trigger set on position 4. Pulse pressure variation, mean and systolic arterial pressure were observed before and after the fluid challenge, which consisted in the intravenous administration of a 250 ml bolus of 6% hetastarch. Fluid responsiveness was defined as a more than 15% increase in arterial pressure after volume expansion. RESULTS: The area under the receiver operator characteristic curve for pulse pressure variation was 0.87 (95% CI 0.74 -0.99; p<0.0001) and the grey zone limits were 10% and 15%. Pulse pressure variation was correlated with increase in systolic arterial pressure (r2=0.32; p<0.001) and mean arterial pressure (r2=0.10; p=0.037). CONCLUSIONS: Pulse pressure variation predicts fluid responsiveness in patients who actively interact with a Servo-i ventilator with a flow-regulated inspiratory trigger set on position 4.

Changes in microvascular blood flow during coupled plasma filtration and adsorption.

A 51-year-old man with septic shock underwent three consecutive sessions of coupled plasma filtration-adsorption each lasting 12 hours. Sublingual microvascular perfusion was assessed using the orthogonal polarisation spectral imaging technique at three different times: immediate pre-coupled plasma filtration-adsorption phase, two hours following commencement and two hours after its termination. The video images of the sublingual microcirculation were analysed by an investigator blinded to the time of image acquisition. The De Backer's score was calculated. During the coupled plasma filtration-adsorption, the number of perfused vessels increased compared with the pre-coupled plasma filtration-adsorption period, but decreased again after its termination. It is arguable that the elimination of septic mediators during the procedure could account for the observed variations.

B-type natriuretic peptide as a predictor of outcome in a general intensive care unit.

BACKGROUND: B-type natriuretic peptide is a hormone secreted by the heart in response to ventricular wall stress. Increased B-type natriuretic peptide plasma levels are also found as a consequence of noncardiac conditions including sepsis, surgery-induced systemic inflammatory response syndrome and kidney failure. Since these conditions are common in general intensive care unit patients, we hypothesized that B-type natriuretic peptide could be a helpful marker in predicting outcome in this setting. METHODS: We measured plasma B-type natriuretic peptide concentrations in 228 patients at admission to our general intensive care unit. The primary aim of the study was to investigate the relationship between B-type natriuretic peptide and hospital mortality. The secondary aim of the study was to investigate the association between B-type natriuretic peptide and severity of disease, quantified by the Simplified Acute Physiology Score II. RESULTS: Logistic regression revealed a positive association between B-type natriuretic peptide level and in-hospital death (OR= 1.59; 95% CI 1.30 to 1.95; p<0.0001) and a Cox proportional hazards regression model showed that B-type natriuretic peptide was significantly associated with the risk of death (HR=1.27; 95% CI 1.11 to 1.46; p=0.0005). B-type natriuretic peptide was higher in patients who died in the hospital than in those who survived (371.20 pg/ml vs. 127.10 pg/ml; p<0.0001). There was a positive correlation between B-type natriuretic peptide and Simplified Acute Physiology Score II (r=0.50; 95% CI 0.40 to 0.59; p<0.0001). DISCUSSION: B-type natriuretic peptide on admission is an independent prognostic marker of outcome in an unselected cohort of critically ill patients.

Early and prolonged ECG alterations resembling a myocardial injury after severe amitriptyline poisoning.

Evidence of cardiovascular toxicity is present in the majority of tricyclic antidepressant overdoses. We report the case of a 63-year-old woman admitted to our department with a severe amitriptyline poisoning. The ECG at admission showed a pattern mimicking an acute anteroseptal subepicardial infarction. This pattern persisted for 11 days. Myocardial enzymes and echocardiographic findings never confirmed an ischemic event. At discharge, the ECG returned normal without cardiac or neurologic sequelae. Our experience suggest that after severe tricyclic antidepressant ingestion, ECG alterations resembling myocardial injury may occur early and last for a longer period than previously reported.

The role of admission surveillance cultures in patients requiring prolonged mechanical ventilation in the intensive care unit.

We undertook a prospective observational cohort study in intensive care unit (ICU) patients requiring mechanical ventilation for four days or more to evaluate normal and abnormal bacterial carriage on admission detected by surveillance cultures of throat and rectum. We assessed the importance of surveillance and diagnostic cultures for the early detection of resistance to third generation cephalosporins employed as the parenteral component of the selective decontamination of the digestive tract. Finally, we sought the risk factors of abnormal carriage on admission to the ICU. During the 58-month study 621 patients were included: 186 patients (30%) carried abnormal flora including methicillin-resistant Staphylococcus aureus (MRSA) and aerobic Gram negative bacilli (AGNB) on admission to the ICU Both MRSA and AGNB carriers were more commonly present in the hospital group of patients than in patients referred from the community (P < 0.001), although overgrowth was equally present both in community and in hospital patients. The incidence of infections during ICU stay was higher in abnormal (n=120, 64.5%) than in normal carriers (n=185, 42.5%) (P < 0.0001), with an odds ratio of 2.46 (95% confidence interval 1.72 to 3.51). Third generation cephalosporins covered ICU admission flora in 482 (78%) of the studied population. AGNB resistant to cephalosporins and MRSA were detected in surveillance cultures of 139 patients (22%), while the same resistant micro-organisms were identified only in 49 diagnostic samples (7.9%). Parenteral cephalosporins were modified in patients with abnormal flora (P < 0.0001). One hundred and ninety-six patients received antibiotics before admission to the ICU and 42% carried AGNB resistant to cephalosporins. Previous antibiotic use was the only risk factor for abnormal carriage in the multivariate analysis (OR 3.5; 95% confidence interval 2.1 to 5.8). The knowledge of carriage on admission using surveillance cultures may help intensivists to identify patients with abnormal carriage on admission and resistant bacterial strains at an early stage even when diagnostic samples are negative. Third generation cephalosporins covered admission flora in about 80% of the enrolled population and were modified in patients with abnormal flora who received antibiotic therapy before ICU admission. Our finding of overgrowth present on admission may justify the immediate administration of enteral antimicrobials.