Bilirubin in the early course of venovenous extracorporeal membrane oxygenation support for refractory ARDS.

Bilirubin is known as a marker of hepatic dysfunction and is incorporated in scoring algorithms to assess prognosis in critically ill patients. No data are so far available on the prognostic role of hepatic dysfunction in patients with severe ARDS on venovenous extracorporeal membrane oxygenation (VV-ECMO) support. In 112 consecutive patients with severe ARDS treated with VV-ECMO, we aimed at assessing whether increased bilirubin during the first 72 h could affect early death. Increased serum bilirubin (≥1.2 mg/dl) was detectable in 29 patients (25.9%) who were older (p = 0.031), exhibited a higher SOFA score (p = 0.006), were more frequently given pre-ECMO muscular blockers (p = 0.001) and supported with ECMO for a longer period (p = 0.024), when compared to patients with normal bilirubin. No difference in in-ICU mortality rate was observed between the two subgroups. In survivors, bilirubin showed a progressive and significant decrease (p = 0.032) during the first 72 h of ECMO support, while it increased in dead patients (p = 0.007).The mortality rate was higher in patients with increased bilirubin at 24, 48 and 72 h after ECMO start in respect to that of patients with normal values. Pre-ECMO increased bilirubin values (≥1.2 mg/dl), being detectable in about one-fourth of the entire population, is not associated with increased in-ICU mortality, while the persistence of increased bilirubin values after 24 h of ECMO start and within the first 3 days identified a subgroup of patients at higher risk of death.

A Case of Insect Colonization Before the Death.

Forensic entomology is a branch of forensic science in which insects are used as evidence in legal investigations relating to humans, domestic animals and wildlife. One of the theoretical pillars on which the discipline is based concerns the fact that flies colonize a body after death. However in cases of myiasis, maggots are present before death, with consequences in the correct estimation of the minimum postmortem interval (mPMI). We report here the case of a woman, largely colonized by fly larvae, who has lain alive in her garden for four days prior to being rescued. Larvae were found on the conjunctivae, the bronchi, the rectum and vagina. The woman's death, two months later, was caused by tetanus. The consequences of myiasis on mPMI estimation are here discussed. In fact, despite she was still alive larvae, indicated and estimated age of 1.5-2.5 days, based on environmental and body temperature.

Outcome and quality of life of elderly critically ill patients: an Italian prospective observational study.

The demand of critical care admissions to intensive care unit (ICU) is projected to rise in the next decade. The aim of this study was to evaluate short and long-term mortality and quality of life (QoL) of elderly patients (80 years and older) admitted to two ICUs for medical conditions, abdominal surgery (planned and unplanned) and orthopedic surgery for hip fractures, over a 6-year period. Three months and one year after ICU discharge, patients or family members were contacted by telephone to obtain follow-up information using the EuroQoL questionnaire. The data were compared with an age-matched of the Italian population. Two hundred eighty-eight patients were included in the study. ICU mortality of medical (14.8%) and unplanned surgical patients (26.4%) was higher than that of planned surgical (5.0%) and orthopedic patients (2.5%), as was hospital mortality (27.7% vs. 50.0% vs. 5.0% vs. 14.3%). Three months and 12 months mortality rates after ICU discharge were 40.7% and 61.1% in medical patients, 70.5% and 76.4% in unplanned surgical patients, 20.0% and 30.0% in planned surgical patients, 36.2% and 46.2% in orthopedic patients. QoL measures revealed that, one year after ICU discharge, medical and orthopedic patients had significantly more severe problems vis-à-vis mobility, self-care and activity than abdominal surgical patients and control population. Type of admission was the independent risk factor associated with ICU and long-term mortality, whereas age 90 year and older was associated with long-term mortality. Orthopedic surgery for hip fractures seems to influence QoL similar to medical diseases.

Outcome predictors and quality of life of severe burn patients admitted to intensive care unit.

BACKGROUND: Despite significant medical advances and improvement in overall mortality rate following burn injury, the treatment of patients with extensive burns remains a major challenge for intensivists. We present a study aimed to evaluate the short- and the long-term outcomes of severe burn patients (total body surface area, TBSA > 40%) treated in a polyvalent intensive care unit (ICU) and to assess the quality of life of survivors, one year after the injury using the EuroQol-5D (EQ-5D) questionnaire. METHODS: A prospective-observational study was performed in an ICU of a University-affiliated hospital. Logistic regression analysis was used to identify the factors predicting in-hospital mortality. The EQ-5D questionnaire was used to asses participant's long term self-reported general health. RESULTS: During a period of five years, 50 patients participated in the study. Their mean age was 53.8 +/- 19.8; they had a mean of %TBSA burned of 54.5 +/- 18.1. 44% and 10% of patients died in the ICU and in the ward after ICU discharge, respectively. Baux index, SAPS II and SOFA on admission to the ICU, infectious and respiratory complications, and time of first burn wound excision were found to have a significant predictive value for hospital mortality. The level of health of all survivors was worse than before the injury. Problems in the five dimensions studied were present as follows: mobility (moderate 68.5%; extreme 0%), self-care (moderate 21%; extreme 36.9%), usual activities (moderate 68.5%; extreme 21%), pain/discomfort (moderate 68.5%; extreme 10.5%), anxiety/depression (moderate 36.9%; extreme 42.1%). CONCLUSIONS: In severe burn patients, Baux index, severity of illness on admission to the ICU, complications, and time of first burn wound excision were the major contributors to hospital mortality. Quality of life was influenced by consequences of injury both in psychological and physical health.

Comfort and satisfaction during axillary brachial plexus block in trauma patients: comparison of techniques.

STUDY OBJECTIVE: To investigate the comfort and satisfaction of patients with trauma of the upper limb during two different techniques of axillary brachial plexus block, electrical nerve stimulation and fascial pop. DESIGN: Randomized-prospective, observational study. SETTING: University surgical center. PATIENTS: 100 ASA physical status I and II patients undergoing surgery for trauma of the hand and forearm. INTERVENTIONS: Patients received axillary brachial plexus block with a mixture of 0.5% bupivacaine and 2% lidocaine. They were then allocated to one of two groups to receive either electrical nerve stimulation (Group 1, n = 50), or fascial pop technique (Group 2, n = 50) for nerve location. MEASUREMENTS: Data were collected on patient demographics, surgery, frequency of complications, and sedation required during the block. Discomfort during the block and surgical comfort were quantified by visual analog scale (0-10). Satisfaction was determined by the following scale: very satisfied, satisfied, dissatisfied, and very dissatisfied. Patients also indicated if in the future they would like to receive the same method of anesthesia. MAIN RESULTS: No differences in demographic or surgical data were found. No serious complications were observed. Eighteen Group 1 patients (36%) and none in Group 2 needed sedation during the blocks. Discomfort during the procedures was greater in Group 1 than Group 2 (4.5 +/- 1.2 vs 1.5 +/- 1, P < 0.05), while patients reported good surgical comfort with both techniques (2.4 +/- 2.9 vs 2.2 +/- 2.1, NS). Eighteen patients in Group 1 and 48 patients in Group 2 would accept the same block for future surgery. CONCLUSIONS: In trauma patients, the fascial pop technique is effective, reduces sedation during axillary brachial plexus block, and has a higher patient acceptance rate than the electrical nerve stimulation technique.