Fulminant multiorgan failure due to varicella zoster virus and HHV6 in an immunocompetent adult patient, and anhepatia.

Varicella is a well-known contagious disease of childhood that can also affect both immunodepressed and immunocompetent adults. The present observations concern a previously healthy adult patient who presented with a fulminant hepatitis evolving in multiorgan failure (MOF), associated with an atypical papulo-ethemateous cutaneous rash without fever. An hepatic biopsy showed massive necrosis. Because of the persistent MOF and severe hemodynamic instability, total hepatectomy was performed as a bridge to urgent liver transplantation (OLT). Despite temporary improvement, the patients condition progressively deteriorated and he died 11 hours after the hepatectomy, i.e. 7 days after admission to the intensive care unit. High viral loads of varicella zoster virus (VZV) and human herpes virus 6 (HHV6) were demonstrated in the blood and in DNA at post mortem examination of the liver, kidneys, lung, and heart. We hypothesize that VZV infection may occasionally occur in immunocompetent patients due to extremely virulent strains that can be rapidly fatal. The clinical influence of simultaneous infection with HHV6 is not clear. Moreover, the role of a previous steroid treatment as a trigger for a temporary immunodepressed state must be considered. The diagnosis of liver disease from VZV should always be clinically suspected in the presence of concurrent atypical skin lesions and a temporarily immunocompromised state. Therapy with acyclovir was ineffective in our patient. Based on the wide spectrum of VZV infections, fulminant MOF in immunocompetent adults must raise the possibility of VZV with simultaneous HHV6 infection with early listing of the patient for a urgent OLT, possibly with a total hepatectomy as a bridge, due to the therapeutic uncertainty of medical treatments.

Total hepatectomy, recombinant activated factor VII and rescue liver transplantation.

The aim of this paper was to describe a case of acute liver failure treated with total hepatectomy, recombinant activated factor VII and rescue liver transplantation. We reported our experience with a 51-year-old-woman who developed a massive portal thrombosis after cadaveric liver transplantation for hepatic epithelioid hemangioendothelioma and who then required a total hepatectomy and porto-caval shunt as a bridge procedure while waiting for an urgent new liver transplantation. Subsequently, the patient developed severe hemodynamic instability, massive abdominal and mucosal bleeding and acute renal failure that were managed with infusion of high doses of inotropes, red blood cells and fresh frozen plasma as well as continuous veno-venous hemofiltration. Due to persistent, uncontrolled bleeding, we considered the off-label use of rFVIIa. This caused a correction of the prothrombin times and allowed for sufficient hemostasis. The patient received a new cadaveric liver that was reperfused 38 hours after the first graft was removed. The transplanted liver showed immediate recovery, the hemodynamics ameliorated and the patient was fully awake at day five. In the case of an anhepatic phase complicated by severe bleeding that is unresponsiveness to several transfusions, a single administration of rFVIIa should be considered as a rescue therapy to control massive bleeding.

Prolongation of antibiotic prophylaxis after clean and clean-contaminated surgery and surgical site infection.

AIM: Several guidelines have recommended that antibiotic prophylaxis (AMP) should be given only at premedication, except in selected cases. Conversely, in clinical practice, AMP is often unnecessarily prolonged after the surgical procedure. In this observational study, we evaluated the risk of surgical site infection (SSI) associated with the prolongation of AMP after clean and clean-contaminated surgery. METHODS: All consecutive patients who underwent a surgical procedure were eligible. AMP was always administered before the surgical incision. Prolongation of AMP for the first 24 hours was allowed only in presence of at least one risk factor for SSI: an ASA score >2 or surgical procedure longer than the specific cutoff (as indicated by the NNIS--the National Nosocomial Infections Surveillance System). SSIs were evaluated during the hospital stay and after hospital discharge. RESULTS: Three hundred fifty-eight patients were enrolled; 19 (5.3%) and 17 (6.5%) patients developed respectively intra-hospital and post hospital discharge SSIs. AMP prolongation for 24 hours in patients with at least one risk factor did not reduce the risk for intra-hospital SSI (OR 1.102; 95% CI: 0.336-3.612; P=0.873), while it increased the risk in patients without risk factors (OR: 8.99; 95% CI: 1.46-55.4; P=0.018). AMP longer than 24 hours raised the risk for intra-hospital and post hospital discharge SSI, regardless of the presence of risk factors (OR: 3.39; 95% CI 1.11-10.35; P=0.032 and OR: 5.39; 95% CI: 1.64-17.75; P=0.006, respectively.) CONCLUSION: Postoperative AMP prolongation should be avoided.

Heat stress: characteristics, pathophysiology and avoidable mistakes.

In August 2003 an exceptional heatwave was recorded in Europe. The authors would like to describe 6 patients for which the intensivist was called as a consultant. All patients had a skin temperature >40 degrees C, central nervous system impairment, severe hyponatremia [124.7 mEq/l+/-5.6 (range 117-130)] and severe metabolic acidosis [BE -6.28 mEq/l+/-3.55 (range -9.5-0), HCO3- 17.75 mEq/l+/-3.25 (range 13.4-21.9)]. All patients had decreased platelet count and coagulation abnormalities. Two patients were hypertensive, 4 hypotensive. The heat stress due to the hot environment is characterized by systemic inflammatory response (as in severe sepsis) and hemodynamic impairment (as in hypovolemic shock). The association between hypovolemia and altered microcirculation leads to cell energy failure with metabolic lactic acidosis. The energy failure may induce structural irreversible damage of mitochondria. It is possible to differentiate, during energy failure, the irreversible or reversible condition by volume loading and vasoactive drugs challenge tests. In fact, if the hemodynamic correction is associated with normalization of SvO2 with disappearance of metabolic acidosis, this suggests hemodynamic impairment with intact mitochondrial function. In contrast, if the hemodynamic improvement with normalization of SvO2 is associated and acidosis persists, this suggests irreversible structural mitochondrial damage. The threshold between reversibility and irreversibility is likely time dependent, as suggested by biochemical consideration and by 2 large randomized studies on hemodynamic treatment. The comparative analysis of these 2 studies suggests that the time of intervention may lead to significant differences in mortality. In these patients time is essential.

Constant mean airway pressure with different patterns of positive pressure breathing during the adult respiratory distress syndrome.

Twenty-one ARDS patients were divided into two groups of severity according to FIO2 and PEEP required to maintain an adequate gas exchange. The 10 most severe patients (group A) underwent continuous positive pressure ventilation (CPPV) (I/E 3:1) with the mean airway pressure maintained at 21 +/- 6.2 cmH2O. The PEEP values were 12.6 +/- 4.3 cmH2O during CPPV and 6.5 +/- 3.7 cmH2O during IRV (p less than 0.01). Eleven less severe ARDS patients (group B) underwent CPPV and positive pressure spontaneous breathing (CPAP) at constant mean airway pressure of 14.3 +/- 3.8 cmH2O. The PEEP was 7 +/- 2.5 cmH2O during CPPV and 14.9 +/- 4.3 cmH2O during CPAP (p less than 0.001). In five patients of each group, the SF6 shunt was measured as representative of true shunt. The results showed that gas exchange, including true shunt, and haemodynamics did not change between CPPV and IRV and between CPPV and CPAP tests. Taken with previous work on mean airway pressure, our results further support the concept that the main determinant of oxygenation and haemodynamics is the mean airway pressure, irrespective of the PEEP level and of the mode of ventilation.

The role of total static lung compliance in the management of severe ARDS unresponsive to conventional treatment.

A group of 36 patients with severe adult respiratory distress syndrome (ARDS) meeting previously established blood gas criteria (mortality rate 90%) became candidates for possible extracorporeal respiratory support [low frequency positive pressure ventilation with extracorporeal CO2 removal (LFPPV-ECCO2R)]. Before connecting the patients to bypass we first switched the patients from conventional mechanical ventilation with positive end expiratory pressure (PEEP) to pressure controlled inverted ratio ventilation (PC-IRV), and then when feasible, to spontaneous breathing with continuous positive airways pressure (CPAP). Forty eight hours after the patients had entered the treatment protocol, only 19 out of the 36 patients in fact required LFPPV-ECCO2R, while 5 were still on PC-IRV, and 12 were on CPAP. The overall mortality rate of the entire population was 23%. The only predictive value of success or failure of a particular treatment mode was total static lung compliance (TSLC). No patients with a TSLC lower than 25 ml (cm H2O)-1 tolerated either PC-IRV or CPAP, while all patients with a TSLC higher than 30 ml (cm H2O)-1 were successfully treated with CPAP. Borderline patients (TSLC between 25 and 30 ml (cm H2O)-1) had to be treated with PC-IRV for more than 48 h, or were then placed on LFPPV-ECCO2R if Paco2 rose prohibitively. We conclude that TSLC is a most useful measurement in deciding on the best management of patients with severe ARDS, unresponsive to conventional treatment.