Inspiratory Effort and Respiratory Mechanics in Patients with Acute Exacerbation of Idiopathic Pulmonary fibrosis: A Preliminary Matched Control Study.

BACKGROUND: Patients with acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) may experience severe acute respiratory failure, even requiring ventilatory assistance. Physiological data on lung mechanics during these events are lacking. METHODS: Patients with AE-IPF admitted to Respiratory Intensive Care Unit to receive non-invasive ventilation (NIV) were retrospectively analyzed. Esophageal pressure swing (ΔPes) and respiratory mechanics before and after 2 hours of NIV were collected as primary outcome. The correlation between positive end-expiratory pressure (PEEP) levels and changes of in dynamic compliance (dynCRS) and PaO2/FiO2 ratio was assessed. Further, an exploratory comparison with a historical cohort of ARDS patients matched 1:1 by age, sequential organ failure assessment score, body mass index and PaO2/FiO2 level was performed. RESULTS: At baseline, AE-IPF patients presented a high respiratory drive activation with ΔPes = 27 (21-34) cmH2O, respiratory rate (RR) = 34 (30-39) bpm and minute ventilation (VE) = 21 (20-26) L/min. Two hours after NIV application, ΔPes, RR and VE values showed a significant reduction (16 [14-24] cmH2O, p<0.0001, 27 [25-30] bpm, p=0.001, and 18 [17-20] L/min, p=0.003, respectively) while no significant change was found in dynamic transpulmonary pressure, expiratory tidal volume (Vte), dynCRS and dynamic mechanical power. PEEP levels negatively correlated with PaO2/FiO2 ratio and dynCRS (r=-0.67, p=0.03 and r=-0.27, p=0.4, respectively). When compared to AE-IPF, ARDS patients presented lower baseline ΔPes, RR, VE and dynamic mechanical power. Differently from AE-IPF, in ARDS both Vte and dynCRS increased significantly following NIV (p=0.01 and p=0.004 respectively) with PEEP levels directly associated with PaO2/FiO2 ratio and dynCRS (r=0.24, p=0.5 and r=0.65, p=0.04, respectively). CONCLUSIONS: In this study, patients with AE-IPF showed a high inspiratory effort, whose intensity was reduced by NIV application without a significant improvement in respiratory mechanics. In an exploratory analysis, AE-IPF patients showed a different mechanical behavior under spontaneous unassisted and assisted breathing compared with ARDS patients of similar severity.

Clinical performance of a commercial real-time PCR assay for Aspergillus DNA detection in serum samples from high-risk patients: comparison with a galactomannan enzyme immunoassay.

We investigated the clinical performance of a polymerase chain reaction (PCR)-based commercial platform, the Myconostica MycAssay™ Aspergillus (MAP), for fungal DNA detection in the serum of patients at risk of invasive aspergillosis (IA). Sixty-four hospitalized patients were prospectively enrolled and a total of 71 different episodes were investigated (30 episodes were clinically/microbiologically classified as IA and 41 as control episodes). When MAP was compared to the galactomannan (GM) assay, no significant differences were found in terms of sensitivity (46.7% vs. 50.0%), specificity (97.6% vs. 95.1%), positive predictive value (PPV) (93.3% vs. 88.2%), and negative predictive value (NPV) (71.4% vs. 72.2%). The corresponding areas under the curve (AUC) of the receiver operating characteristic (ROC) curves were also superimposable. Overall, because of the good agreement between the two assays and considering the high specificity and PPV of the MAP, we suggest the use of this PCR-based platform as a second-level examination for the evaluation of clinically undefined cases where culture or GM have provided positive results.

Characteristics and outcome predictors of patients involved in an outbreak of Burkholderia cepacia complex.

A Burkholderia cepacia complex outbreak occurred among ventilated non-cystic fibrosis patients in an intensive care unit (ICU) in Italy: 33 colonized and 13 infected patients were included in a retrospective study aimed at investigating factors related to clinical infection and mortality. Demographic/clinical conditions and mortality did not vary significantly between colonized and infected patients, both groups showing high mortality rates compared with the overall ICU population and similar to that observed in patients with other infections. In multivariate regression analysis, disease severity (defined by the Simplified Acute Physiology Score II) and age were the only independent predictors of early mortality (odds ratio: 1.12; 95% confidence interval: 1.02-1.26; and 1.07; 1.01-1.15, respectively).

Acute renal failure and renal replacement therapy in the postoperative period of orthotopic liver transplant patients versus nonelective abdominal surgery patients.

Acute renal failure (ARF) often complicates the postoperative period of patients undergoing orthotopic liver transplantation (OLT); it is habitually associated with high mortality rates. Similarly, patients undergoing major nonelective abdominal surgery are prone to ARF because of their frequent preexistent morbidities, abdominal sepsis, and needed for extended surgical procedures. The aim of this study was to evaluate the incidence of ARF and use of renal replacement therapy (RRT) among OLT versus nonelective abdominal surgery patients and associations with clinical outcomes. We studied all the patients admitted to a surgical intensive care unit (ICU) from January 2008 to December 2009 after OLT or nonelective abdominal surgery. The inclusion criteria were an ICU stay of at least 48 hours and without prior end-stage renal failure. OLT patients (n=84) were younger and less severly ill than surgery patients (n=60). ARF occurrence was lower among the OLT (29%) than the surgery group (47%) requiring RRT in 71% and 53% of patients due to ARF, respectively. The ICU mortality of ARF patients in both groups (29% OLT and 51% surgery) were greater than among subjects without ARF (2% and 6%). The occurrence of ARF is common among these two patient groups, and associated with increased risk of death among in surgery (+45%) versus in OLT (+27%) patients.

Usutu virus infection in a patient who underwent orthotropic liver transplantation, Italy, August-September 2009.

We report a case of Usutu virus (USUV)-related illness in a patient that underwent an orthotropic liver transplant (OLT). Post transplant, the patient developed clinical signs of a possible neuroinvasive disease with a significant loss of cerebral functions. USUV was isolated in Vero E6 cells from a plasma sample obtained immediately before the surgery, and USUV RNA was demonstrated by RT-PCR and sequencing. This report enlarges the panel of emerging mosquito-borne flavivirus-related disease in humans.

Perioperative red blood cell transfusion and outcome in stable patients after elective major vascular surgery.

OBJECTIVES: Definitive evidence that red blood cell transfusion improves outcome after vascular surgery is lacking. The aims of the study were to determine, among stable consecutive patients who underwent elective major vascular surgery, (1) the association between postoperative transfusion and 30-day death, myocardial infarction, and both, and (2) and if this association differs according to the presence of postoperative anaemia (haemoglobin value less than 9.0 g/dL within 7 days after surgery). METHODS: A retrospective observational study was conducted on 359 patients prospectively screened according to the ACC/AHA guidelines for preoperative risk in non-cardiac surgery. Main outcome was 30-day death; secondary outcomes 30-day myocardial infarction, and composite of 30-day myocardial infarction or death. RESULTS: Of the patients included, 95 (26.5%) received at least one unit of red blood cells. Patients who received transfusion had a significantly increased hazard of 30-day death (hazard ratio [HR] 11.72, 95% confidence interval [CI] 3.92-35.10; p<0.0001), myocardial infarction (HR 3.3, 95% CI 1.7-6.1; p=0.0003), and both (HR 4.0 95% CI 2.2-7.3; p<0.0001). Such associations held even after adjusting for baseline characteristics, surgical risk, bleeding, and propensity to receive transfusion. There was a significant interaction between transfusion and postoperative anaemia (p=0.012). In patients without anaemia, transfusion was associated with higher risk of 30-day death (HR 19.20, 95% CI 3.99-92.45; p=0.007), myocardial infarction (HR 5.05, 95% CI 2.23-11.44; p=0.0001), and both. Conversely, in patients with anaemia this association was not significant. CONCLUSIONS: In patients who underwent elective major vascular surgery, perioperative transfusion was associated with a significantly increased risk of 30-day events which was more attributable to patients with lesser degree of anaemia. Our data caution against the use of liberal transfusion in stable vascular surgery patients.

Incidence and clinical outcomes of ventilator-associated pneumonia in liver transplant and non-liver transplant surgical patients.

The aim of this study was to compare the incidence of ventilator-associated pneumonia (VAP) and clinical outcome among patients undergoing orthotopic liver transplantation (OLT) admitted to our surgical intensive care unit (ICU). Patients with an ICU stay longer than 4 days who had undergone surgery within 48 hours of admission were included in the study. Patients were subdivided into a liver transplant group (OLT) and no-liver transplant group (noLT). Diagnosis of VAP was based on microbiological data with a positive culture from a sample collected >or=48 hours after admission. VAP was defined as early if the positive culture occurred within the 4th day of admission, and late if after the 4th day. Three hundred seventy-three noLT and 71 OLT patients showed no differences in sex, mean severity score on admission (SAPS II), length of stay, and outcomes. The incidence of VAP was also similar in the 2 groups (27.3% in the noLT group vs 25.3% in the OLT group). Both in the OLT and noLT groups, the VAP patients showed higher (P< .05) SAPS II scores on admission, length of ICU stay, and mortality rates than the non-VAP patients, without any difference between the 2 groups. VAP is a frequent complication in ICU surgical patients, particularly those with high severity scores on admission. In an ICU surgical population, liver transplantation per se does not seem to increase the patients' risk either for VAP acquisition or for bad outcomes.

Peri-operative respiratory failure in a cirrhotic patient: a misleading diagnosis.

Patients with chronic liver disease may present with different degrees of respiratory dysfunction whose differential diagnosis is important before elective surgery. We report the case of a misleading diagnosis of peri-operative respiratory failure in a cirrhotic patient who underwent mastectomy. Intra-operative respiratory failure was ascribed by the anaesthetic team to pulmonary embolism and after the operation this diagnosis was still suspected. Despite postoperative heparin treatment, pulmonary gas exchange remained severely impaired. On the hypothesis of a right to left shunt, we performed transoesophageal echocardiography with a bubble test and confirmed hepatopulmonary syndrome. We administered anticoagulant therapy to the patient following surgery, increasing the risk of haemorrhage. We also continued orotracheal intubation and mechanical ventilation longer than was needed. Respiratory symptoms in a patient with liver disease should not be underestimated and up to 20% of these patients may have hepatopulmonary syndrome.

Intra-abdominal hypertension in nonelective surgery: a preliminary report.

Intra-abdominal hypertension (IAH) is recognized to be associated with adverse outcomes in critically ill patients. Etiologic factors for IAH can be divided into three categories: medical, posttraumatic, and surgical/postoperative. No studies have been performed on patients who underwent nonelective surgery, so our aim was to determine prospectively the incidence of IAH among these patients during their intensive care stay to correlate intra-abdominal pressure (IAP) and other parameters. Abdominal pressure was recorded twice daily with the standard method. The study group enrolled 22 patients who underwent an abdominal operation that met urgency criteria and with a postoperative intensive care unit (ICU) stay of at least 48 hours. Several serum and clinical parameters were studied for the first 5 postoperative days as well as during ICU and hospital stay as well as monitored hospital mortality. Our results demonstrated that mortality was definitely higher among patients who developed IAH compared with non-IAH patients. Our results highlighted that a strong correlation existed between increasing values of IAP and worsening serum creatinine and PaO2/FiO2 quotient among patients who underwent nonelective surgery.

[Outcome of isolated small bowel transplantation in adults: experience from a single Italian center]. / Risultati del trapianto di intestino isolato nell'adulto: esperienza di un singolo centro italiano.

AIM: Isolated small bowel transplantation is becoming the treatment of choice for adult patients with serious parenteral nutrition (PN) related complications: we report our three-year experience (December 2000-December 2003) from a single Italian center (Modena-Italy), with one of the larger European series. METHODS: We transplanted 14 patients, with a previous mean PN course of 27 months and a mean 21-month post-transplantation follow-up (range 3-36 months), obtaining a one-year actuarial survival rate of 92.3% with no intraoperative deaths. RESULTS: We lost 1 patient (7.2%), died for post-transplantation overwhelming sepsis following Cytomegalovirus (CMV) enteritis. Thirteen patients are alive, with one-year actuarial graft survival rate of 85.1%: 1 patient underwent graft removal (7.2%) for intractable severe acute rejection. Our immunosuppressive regimen was based on tacrolimus and 3 induction protocols: daclizumab (8 patients) with steroids, alemtuzumab (4 patients) and thymoglobulin (2 patients) without steroids. In 9 cases, we added sirolimus. Nine recipients experienced 22 episodes of acute cellular rejection (ACR), treated successfully in all cases but one. One patient (7.2%) was treated successfully for Post Transplant Lymphoproliferative Disease (PTLD) and is disease-free after 8 months. CONCLUSIONS: Small bowel transplantation can achieve optimal results depending on appropriate immunosuppressive management and candidate selection, added to shorter ischemia time and careful donor and graft selection.

Early experiences with a porcine hepatocyte-based bioartificial liver in acute hepatic failure patients.

Orthotopic liver transplantation (OLT) is the only effective therapeutic modality in severe acute hepatic failure (AHF). The scarcity of organs for transplantation leads to an urgent necessity for temporary liver support treatments in AHF patients. A hepatocyte-based bioartificial liver (BAL) is under investigation with the main purpose to serve as bridging treatment until a liver becomes available for OLT, or to promote spontaneous liver regeneration. We developed a novel radial-flow bioreactor (RFB) for three-dimensional, high-density hepatocyte culture and an integrated pumping apparatus in which, after plasmapheresis, the patient's plasma is recirculated through the hepatocyte-filled RFB. Two hundred thirty grams of freshly isolated porcine hepatocytes were loaded into the RFB for clinical liver support treatment. The BAL system was used 8 times in supporting 7 AHF patients in grade III-IV coma, all waiting for an urgent OLT Three patients with no history of previous liver diseases were affected by fulminant hepatic failure (FHF) due to hepatitis B virus, 3 by primary non-function (PNF) of the transplanted liver, and one by AHF due to previous abdominal trauma and liver surgery. Six out of 7 patients underwent OLT following BAL treatment(s), which lasted 6-24 hours. All patients tolerated the procedures well, as shown by an improvement in the level of encephalopathy, a decrease in serum ammonia, transaminases and an amelioration of the prothrombin time, with full neurological recovery after OLT Our initial clinical experience confirms the safety of this BAL configuration and suggests its clinical efficacy as a temporary liver support system in AHF patients.

[Life threatening asthma associated to severe pneumonia and acute myopathy]. / Stato di male asmatico complicato da polmonite trilobare e da miopatia acuta.

A young male was transferred to our intensive care unit (ICU) from the intensive care unit of a local hospital where he was admitted for life-threatening asthma ten days before. As severe hypoxemia, we immediately started inhaled nitric oxide (iNO) that improved significantly pulmonary gas exchange. The first day after admission in our ICU, a chest computed tomography showed a three-lobar pneumonia and, therefore, a broad-spectrum antibiotic therapy was decided. iNO therapy was withdrawn 96 hours after the beginning because of a stable improvement of pulmonary gas exchange and a relative loss of efficacy. Five days after arrival in our ICU, sedative and neuromuscular blocking drugs initiated 15 days before were stopped and, after the awakening, the patient presented tetra-paresis. Muscle biopsy and electromyography indicated an acute myopathy that was probably caused by the association between large doses of steroids and neuromuscular blocking agents. In spite of an intensive physiotherapy program, the patient was extubated only 15 days after admission and he underwent non-invasive mechanical ventilation for further 7 days. The patient was discharged from our ICU 10 days after extubation with a good restore of muscle functioning which was complete two months later.

The hemodynamic and metabolic effects of tourniquet application during knee surgery.

UNLABELLED: We evaluated the effects of tourniquet application on the cardiovascular system and metabolism in 10 young men undergoing knee surgery with general anesthesia. The duration of inflation was from 75 to 108 min. Heart rate, mean arterial pressure, cardiac index (CI) by pulse contour method, and systemic vascular resistance were measured before, during, and after tourniquet inflation. pH, PaO(2), PaCO(2), and lactate blood concentrations were also measured. VO(2) and VCO(2) were assessed every minute from tracheal intubation up to 15 min after tourniquet deflation and VO(2) in excess of the basal value over the 15 min after deflation (VO(2)exc) was calculated. Mean arterial pressure increased 26% (P: < 0.05) during inflation and returned to basal values after deflation. CI did not change immediately after inflation; although, thereafter, it increased 18% (P: < 0.05). Five minutes after deflation, CI further increased to a value 40% higher than the basal value. Therefore, systemic vascular resistance increased 20% suddenly after inflation (P: < 0.05) and decreased 18% after deflation (P: < 0.05). VO(2) and VCO(2) remained stable during inflation and increased (P: < 0.05) after deflation. VO(2)exc depended on duration of tourniquet inflation time (Tisch) (P: < 0.05). After deflation, PaCO(2) and lactate increased (P: < 0.05) while Tisch increased. We conclude that tourniquet application induces modifications of the cardiovascular system and metabolism, which depend on tourniquet phase and on Tisch. Whether these modifications could be relevant in patients with poor physical conditions is not known. IMPLICATIONS: The clinical effects of tourniquet application were evaluated in 10 young men undergoing knee surgery. Our data indicate that tourniquet application causes hemodynamic and metabolic changes which may become clinically relevant after a long period of tourniquet inflation, particularly in patients with concomitant cardiovascular diseases.

[Non-invasive evaluation of cardic output by analysis of peripheral pressure profile in patients recovering in intensive care]. / Misura non invasiva della gittata cardiaca attraverso analisi del profilo pressorio periferico in pazienti ricoverati in terapia intensiva.

BACKGROUND: The analysis of the arterial pulse contour obtained by means of a non-invasive device (Finapres) seems to be an ideal method to measure cardiac output (CO). An individual calibration factor (Z) dimensionally equal to aortic impedence is the necessary pre-requisite to calculate CO by pulse contour analysis. To verify the reliability of non-invasive pulse contour method, we compared the COs measured from Finapres tracings with those measured from thermodilution method in Intensive Care patients. METHODS: In 9 patients undergoing cardiac and general surgery, CO was measured from thermodilution (COTD) within 24 hours of postoperative period (total of 67 measurements). During COTD measurements, Finapres tracings were recorded and then analysed to calculate CO by two different procedures. In the former (COA), Z was calculated from an algorithm which takes into account heart rate, mean arterial pressure and age of the patient. In the latter procedure (COB), Z was experimentally determined from the initial COTD measure and then updated for the hemodynamic conditions of the patient. RESULTS: COTD ranged between 3.5 and 9.5 L.min-1 (mean value 5.53 +/- 1.29 L.min-1). The mean difference between COTD e COA was 0.485 +/- 1.537 L.min-1 and the mean percentage error was 25.1 +/- 14.5%. The experimental determination of Z reduced the mean difference and the mean percentage error between thermodilution and Finapres method to--0.002 +/- 1.056 L.min-1 and 15.5 +/- 11.0%, respectively. The regression line between COTD and COB turned out to be: COB = 0.68 + 0.88.COTD (r = 0.73). CONCLUSIONS: The pulse contour analysis applied to Finapres tracing allows to calculate CO with reasonable accuracy in the intensive care patients. An initial experimental determination of Z is recommended to improve the accuracy of Finapres method.

The effect of laparoscopic cholecystectomy on cardiovascular function and pulmonary gas exchange.

Hemodynamic changes, pulmonary CO2 elimination (VECO2) and gas exchange were evaluated during laparoscopic cholecystectomy. An algorithm to calculate inspired ventilation (VI) needed to maintain constant PaCO2 was also developed. In 12 ASA physical status I patients undergoing laparoscopic cholecystectomy, heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), and systemic vascular resistance index (SVRI) were measured by the analysis of a radial artery pressure profile before, during, and after CO2 insufflation. Alveolar-arterial oxygen pressure gradient (P(A-a)O2), physiological and alveolar ventilatory dead space fractions (VDphys/VT; VDalv/VT), and PaCO2 were measured as well. VECO2 was assessed every minute in the patients maintained in the head-up position. HR did not significantly change during pneumoperitoneum, whereas MAP showed a transient increase (24.9%; P < 0.05) after CO2 insufflation. CI remained stable during pneumoperitoneum, but increased (25.0%; P < 0.05) after deflation. As a consequence, SVRI transiently increased after CO2 insufflation and decreased by 15.8% (P < 0.05) 5 min after deflation. P(A-a)O2 increased slightly (P < 0.05) with increased anesthesia time. VDphys/VT and VDalv/VT did not change after pneumoperitoneum onset, but VDalv/VT decreased after CO2 deflation (13.4%; P < 0.05). VECO2 increased (decreased) after a monoexponential time course during (after) CO2 insufflation in 8 of 12 patients. The mean time constants (t) of the monoexponential functions were 26.3 and 15.4 min during and after pneumoperitoneum. A monoexponential time course was shown also by PaCO2 during CO2 insufflation (tau = 27.8 min). Finally, the VI needed to maintain PaCO2 at a selected value could be calculated by the following algorithm: VI = [0.448.(1-e(-t/tau) + 2.52].(VA.PaCO2.713)-1, where VA corresponds to alveolar ventilation and t must be chosen according to the pneumoperitoneum phase. We conclude that CO2 insufflation in the abdominal cavity does not induce significant changes in cardiopulmonary function in ASA physical status I patients. The algorithm proposed seems to be a useful tool for the anesthesiologists to maintain constant PaCO2 during all surgical procedures.

[Effects of age, body weight, and ventilatory pattern on the difference between arterial and end-tidal PCO2]. / Effetti di età, peso corporeo e pattern ventilatorio sulla differenza tra PCO2 arteriosa e fine espirazione.

OBJECTIVE: To evaluate the effects of physiological ventilatory patterns on P(a-ET)CO2 gradient and on the alveolar dead space production during controlled mechanical ventilation. DESIGN: Prospective and experimental comparison among three different ventilatory settings in three different groups of subjects. SETTING: General surgery's operating-theatre in university hospital. PATIENTS: Twenty-eight patients subdivided randomly in 3 groups differing for ventilatory setting. I group: constant tidal volume (VC = 8 ml.kg-1) and 3 different respiratory frequencies (f = 10, 12 and 14 breaths.min-1); II group: constant ventilation (112 ml.kg-1) but VC and f modified in three different ways; III group: inspiratory volume was set to give an end-tidal PCO2 (PETCO2) of about 35 mmHg. The cases were subdivided, on the basis of P(a-ET)CO2 distribution, in three groups: group with values larger than mean plus 1 standard deviation, group with values between +/- 1 standard deviation and group with values lower than mean minus 1 standard deviation. Moreover in two homogeneous groups for age. INTERVENTIONS: General surgery but not important because measures were performed before surgical manoeuvres. MEASUREMENTS AND MAIN RESULTS: Anthropometrical data (age and body weight), PaCO2, PETCO2, heart rate, invasive arterial pressure, ventilatory parameters and airway pressure were collected for every subject and ventilatory setting; arterial to end-tidal difference P(a-ET)CO2 and P(a-ET)CO2.PaCO2(-1) were calculated during data analysis. The P(a-ETFCO2 and P(a-ET)CO2.PaCO2(-1) values were not significantly different among the three different ventilatory patterns both in the first and in the second group. P(a-ET)CO2 values were significantly correlated with age, body weight and airway pressure. These parameters were correlated significantly also with P(a-ET)CO2.PaCO2(-1) values. CONCLUSIONS: Ventilatory setting, used in a normal physiological range, don't affect P(a-ET)CO2 difference during mechanical ventilation. Age, body weight and airway pressure of the patient must be considered to obtain a correct value of PaCO2 by the measure of PETCO2.