Sternal osteomyelitis due to Aspergillus fumigatus after cardiac surgery.

Sternal osteomyelitis due to Aspergillus fumigatus after cardiac surgery occurred in two nonimmunosuppressed patients. The clinical features of the infection were markedly different in the two cases. In the first patient, sepsis showed a late and insidious onset followed by slow progression. In the second case, fungi were isolated from wound swabs within a few days of surgery and the clinical picture showed acute onset and rapid progression. Only a few cases of sternal osteomyelitis due to Aspergillus have been described previously after cardiac surgery. Aspergillus infection should be considered in the differential diagnosis of mediastinitis after cardiac surgery, especially in a clinical setting of otherwise unexplained sepsis or nonhealing wound despite apparently adequate treatment.

Sinus infection in intensive care patients.

Sinusitis is a complication known to accompany nasotracheal intubation, but its frequency has not been well established. During a two-year-period, 1,126 patients in an intensive care unit have been studied. Twenty-seven of them (2%) developed a bacterial sinusitis. The diagnosis is established on the basis of an unexplained clinical sepsis, imaging evidence of fluid in the maxillary sinus, and antral puncture. Microbiological samples showed Gram-negative micro-organisms, in particular Pseudomonas aeruginosa, and an elevated percentage of Staphylococcus aureus and Escherichia coli. The likely predisposing factors (nasogastric and/or nasotracheal tubes) are discussed. Aetiology, diagnosis and management of the disease are discussed in detail. The importance of prompt removal of nasal instrumentation and of early sinus drainage, in addition to broad-spectrum antibiotic therapy, is emphasized.

Whole lung lavage.

Bronchoalveolar lavage is universally employed as a diagnostic procedure and also, both in the massive (whole lung) and limited forms, has important therapeutic applications. Since the second half of the century whole lung lavage (WLL) has been applied in patients with pulmonary alveolar proteinosis and has proved successful. The procedure has improved over the years in terms of safety and efficacy, whilst indications and methods for WLL are not yet completely defined and standardized. In this paper, we summarize the history of the development of WLL, and describe the procedure used eight times in five patients in our department.

Anesthesia for MRI in the paediatric patient.

The magnetic resonance imaging suite is a challenging environment for the anaesthesiologists, and carries inherent risks. Several factors account for this, including the remote location, the unique features of the magnetic resonance imaging scanner and patient-related factors. A systematic approach, similar to that of anesthesia provided in the operating room (i.e. proper fasting, informed consent, focused airway examination, medical and surgical history, family history, previous sedation experiences) is mandatory. Understanding the implications of the magnetic resonance imaging environment will facilitate ensuring the safety of the patient. A well-equipped anesthesia machine, standard monitoring (electrocardiogram, oxygen saturation and non-invasive blood pressure), trained personnel and adequate planning should be standard for all out of the operating room procedures. Finally, rigorous discharge criteria are recommended to detect residual sedation.

[Various genetic cardiac diseases predispose to arrhythmias and the risk of sudden death]. / Sindromi aritmiche ereditarie: importanza in anestesia e rianimazione.

Identification of underlying genetic factors has added to understanding of arrhythmogenic triggers and determinants of sudden death. Many factors (medications, bradycardia, temperature changes) during general anesthesia could precipitate malignant dysrhythmia in these patients. Criteria for risk stratification for surgical patients are not available: we can only extrapolate information collected from medical patients. We describe 4 patients with suspected Brugada syndrome (only one was confirmed) during genera anesthesia and propose an anesthesiologic management during operation and for the postoperative period (36 hours).

[Nitric oxide inhalation test in patients with ARDS: preliminary assessment of the effect on arterial oxygenation]. / Test di inalazione di ossido nitrico (NO) in pazienti con ARDS: valutazione preliminare dell'effetto sull'ossigenazione arteriosa.

OBJECTIVE: Inhaled NO can improve arterial oxygenation in ARDS. We evaluated the incidence and the magnitude of this effect during a short test of NO inhalation. This was performed in 24 consecutive mechanically ventilated patients with ARDS in order to assess the interest of NO for the therapy of hypoxemia in each case. DESIGN: Retro-spective study. SETTING: ICU in a University Hospital. PATIENTS: 24 hypoxemic patients with ARDS (lung injury score, LIS, 2.9 +/- 0.52), treated with conventional mechanical ventilation. INTERVENTIONS: Tests were performed using a mean inhalatory NO dose of 14 +/- 6 ppm. A pair of PaO2 data was obtained for each patient from two blood gas analysis, performed one just before and one 15 min after the start of NO inhalation. RESULTS: The mean baseline PaO2 was 76 +/- 21 mmHg and significantly increased with NO inhalation to 97 +/- 34 mmHg (p = 0.0001). Considering the individual response to NO, patients were arbitrarily classified as responders when the increase of PaO2 from baseline was > or = 10%. Sixteen patients were identified as responders, showing a mean increase of PaO2 from baseline by 40 +/- 26%, while the remaining 8 patients resulted non responders (mean change 1 +/- 5.7%). In no case a clinically significant decrease of PaO2 was observed during NO inhalation. The response to NO did not correlate with the LIS (r = 0.019) and with baseline PaO2 (r = 0.31). CONCLUSIONS: Inhaled NO doses of 14 +/- 6 ppm increased on the average the PaO2 in a group of ARDS patients, the individual response being however variable. A deterioration of arterial oxygenation was never observed. Even if the criteria for predicting the response to NO still remain to be defined, a short test seems to reliably provide a first estimate of the magnitude of the response.