Microbiological findings of culture-positive preservation fluid in liver transplantation.

Bacterial and fungal infections are the leading cause of mortality in liver transplant (LT) recipients. Few studies have examined the incidence of culture-positive preservation fluid (PF) and the outcome of related recipients. The aim of this study was to determine the incidence and the microbiologic findings of PF positive cultures, and to evaluate the impact on morbidity and mortality of LT recipients. A retrospective analysis of PF cultures performed after 477 LTs from cadaveric grafts between January 2001 and February 2008 was conducted. Forty-five (9.5%) PFs were found to be positive with 1 or 2 pathogens. The demographic profiles of recipients of PF with positive or negative cultures were similar. Enterobacteriaceae species were the most frequent organisms (n = 30), followed by Staphylococcus aureus (n = 5), coagulase-negative staphylococci (n = 5), enterococci (n = 4), and yeasts (n = 3). Mortality rate at 1 month was not significantly different in recipients with positive or sterile PF cultures (88.1% vs. 87.7%, respectively). The rate of bacteremia among LT recipients with positive or negative PF cultures was not statistically different. Systemic infections caused by the pathogen cultured from the PF occurred in 8 (18%) of the 45 recipients, including bacteremia (4/8) or intra-abdominal sepsis (5/8). Causative organisms were Enterobacteriaceae species (n = 5), Candida species (n = 2), and Enterococcus faecium (n = 1). Among the 8 patients who developed infection with the PF organism, 4 (50%) died in the intensive care unit (ICU) vs. an ICU mortality rate of 8% (3/37) in those who did not develop infection with the PF organism (P < 0.05). Infection occurred less frequently in recipients who received antimicrobial therapy with activity against the PF isolate than in those without appropriate treatment (41% vs. 3.8%, P < 0.005). Those who develop infection with organisms recovered from PF cultures appear to have high early mortality rates; therefore, appropriate antimicrobial therapy against organisms cultured from PF should be given.

Yeast contamination of kidney, liver and cardiac preservation solutions before graft: need for standardisation of microbial evaluation.

Contamination of preservation solution (PS) with yeasts during solid organ recovery can lead to life-threatening complications in the recipients. The prevalence of such a contamination needs to be established. From January 2004 to December 2008, we prospectively investigated the potential fungal contamination of all the PSs collected in our institution using a standardised procedure consisting in centrifugation of 10 mL PS and incubation of the pellet seeded on fungal-specific medium for 15 days at 30 degrees C. During the study period, 728 transplantations (397 kidneys, 262 livers and 69 hearts) were performed for which 659 PSs (90.5%) were available. The yeast contamination rate was 0% (0/62), 3.1% (11/356) and 4.1% (10/241) for heart, kidney and liver transplants, respectively. We identified 10 Candida albicans, five C. glabrata, two C. krusei, one C. tropicalis, one C. valida, one Pichia etchelsii and one Rhodorula sp. Routine bacterial analysis identified only five of these 21 fungal contaminations. Twenty recipients were alive after at least one year of follow-up and one died from meningeal carcinomatosis at seven months. Three patients were found to have the same species of Candida from their surgical drains but did not develop any infection or abnormalities upon ultrasound investigation. Fourteen patients received antifungal drugs. Yeast contamination occurred in 3.4% of all kidney and liver PSs tested. Its clinical consequences and therapeutic management remain to be defined. Our study also suggests that optimisation/standardisation of microbiological procedures is warranted, including analysis of large PS volume, seeding of fungal-specific medium and prolonged incubation.

Intestinal microflora in early infancy: composition and development.

The neonatal intestinal microbiota is a complex ecosystem composed of numerous genera, species and strains of bacteria. This enormous cell mass performs a variety of unique activities that affect both the colonic and systemic physiology. Its primary activities include nutritive, metabolic, immunological and protective functions. Most studies of infants have been based on faecal samples using the classical plating techniques with culturing on specific media. The limitations of these methods must be taken into account when evaluating the varying results of the different studies. The establishment of the gut microbial population is not strictly a succession in the ecological sense; it is rather a complex process influenced by microbial and host interactions and by external and internal factors. The climax intestinal flora is attained in successive stages. The foetal intestine is sterile and bathed in swallowed amniotic fluid. Following delivery, multiple different antigens challenge the intestine of the newborn. The maternal intestinal flora is a source of bacteria for the neonatal gut. The bacterial flora is usually heterogeneous during the first few days of life, independently of feeding habits. After the first week of life, a stable bacterial flora is usually established. In full-term infants a diet of breast milk induces the development of a flora rich in Bifidobacterium spp. Other obligate anaerobes, such as Clostridium spp. and Bacteroides spp., are more rarely isolated and also enterobacteria and enterococci are relatively few. During the corresponding period, formula-fed babies are often colonized by other anaerobes in addition to bifidobacteria and by facultatively anaerobic bacteria; the development of a "bifidus flora" is unusual. In other studies the presence of a consistent number of bifidobacteria in infants delivered in large urban hospitals has not been demonstrated, whether the babies were bottle fed or exclusively breastfed. The predominant faecal bacteria were coliforms and bacteroides. According to these studies, environmental factors may be more important than breastfeeding in gut colonization after delivery. Environmental factors are indeed extremely important for the intestinal colonization of infants born by caesarean section. In these infants, the establishment of a stable flora characterized by a low incidence of Bacteroides spp. and by the isolation of few other bacteria is consistently delayed. In extremely low-birthweight infants, hospitalization in neonatal intensive care units, characterized by prolonged antibiotic therapy, parenteral nutrition, delayed oral feedings and intubation seems to affect the composition of the intestinal microbiota. The gut is colonized by a small number of bacterial species; Lactobacillus and Bifidobacteria spp. are seldom, if ever, identified. According to the few studies so far performed, the predominant species are Enterococcus faecalis, E. coli, Enterobacter cloacae, Klebsiella pneumoniae, Staphylococcus epidermidis and Staphylococcus haemolyticus. Hygienic conditions and antimicrobial procedures strongly influence the intestinal colonization pattern.

Remifentanil conscious sedation during regional anaesthesia for carotid endarterectomy: rationale and safety.

OBJECTIVES: to prospectively evaluate the safety and efficacy of remifentanil during regional anaesthesia for carotid endarterectomy. METHODS: twenty-eight consecutive patients underwent carotid endarterectomy with combined superficial and deep cervical plexus block supplemented with continuous intravenous 0.04 microg.kg(-1).min(-1)remifentanil infusion. Depth of sedation was monitored using the Observer's Assessment of Alertness/Sedation Scale (OAA/S). The degree of pain, discomfort and anxiety was self-assessed by the patients using a horizontal visual analogue scale. RESULTS: all patients experienced adequate comfort and analgesia. No local anaesthetic supplementation was necessary. No patient had a OAA/S score lower than 4 (with 5=awake/alert to 1=asleep). Respiratory depression did not occur. Selective shunting was required in four cases. No patient was converted to general anaesthesia. There were no permanent neurological deficits, cardiopulmonary complications or deaths. CONCLUSION: remifentanil as a supplement to regional anaesthesia for carotid endarterectomy, provides comfort and analgesia without hampering mental status evaluation.

What is liquid breathing and ventilation?

Liquid ventilation is a rapidly growing ventilation technique. In spite of the large number of scientific and technical papers on the argument, the general concepts, particularly useful for the non-specialist physician, are not easy to acquire. The scope of this simple review is to explain the present general aspects and uses of liquid ventilation, analysing their chronological development.

[Prenatal steroids, cesarean section, and cerebral hemorrhage in newborns with birth weight under 1500 g]. / Steroidi prenatali, parto cesareo ed emorragia cerebrale nel neonato con peso alla nascita inferiore a 1500 g.

OBJECTIVE: To identify perinatal risk and protective factors for peri-intraventricular hemorrhage (PIVH) in 214 very low birth weight (VLBW) infants. METHOD: Perinatal risk and protective factors for PIVH were examined by univariate analysis and by multivariate logistic regression analysis that adjusted simultaneously for the effects of year of birth and perinatal characteristics. Because mode of delivery and antenatal use of steroid represent the only factors, among those considered, that could in most cases be controlled by the clinician, we calculated for each of the four combinations the relative risk of PIVH. RESULTS: By univariate analysis, antenatal steroid administration, cesarean section delivery, increasing birth weight and increasing gestational age were protective perinatal factors. By using logistic regression, significant protective factors against PIVH included a complete course of antenatal steroid therapy and increasing gestational age. Intrauterine growth retardation was associated with an increased risk of PIVH. The relative risk of intraventricular hemorrhage for each of the four combination of mode of delivery and antenatal steroid exposure demonstrate that antenatal steroid exposure and cesarean section delivery are most protective with a relative risk of 14% compared with vaginal delivery and no antenatal steroid exposure. CONCLUSIONS: Association of antenatal steroid administration with cesarean section delivery has an important role in lowering the risk of PIVH in VLBW infants.

[Nasal CPAP in newborns with birth weight under 1500 g]. / Assistenza respiratoria con CPAP nasale nei neonati con peso alla nascita inferiore a 1500 g.

OBJECTIVE: To evaluate the efficacy and safety of early nasal continuous positive airway pressure (CPAP) in the pulmonary management of very low birth weight (VLBW) infants. METHOD: Since 1993 in our neonatal intensive care unit we decided to reduce the rate of tracheal intubation and mechanical ventilation (IPPV) using more extensively nasal CPAP. By Student's t test and c2 analysis, VLBW infants with gestational age < 32 weeks born in 1988-92 were compared with those born in 1993-97. RESULTS: The 144 enrolled infants were comparable for birth weight and gestational age. There was a difference in the rate of antenatal steroid administration and cesarean section delivery, significantly more used in the second period. In both groups, 93% of the infants required respiratory support. The use of IPPV decreased from 68% in the first period to 30% in the second, conversely the use of CPAP increased from 25 to 63%. With regard to the primary outcome, in the second period the mortality rate and the incidence of pneumothorax were significantly lower. CONCLUSIONS: As the long-term survival of VLBW neonates continues to improve, pulmonary management is increasingly directed at minimizing the invasivity. This study demonstrated that early nasal CPAP may be successfully used in most VLBW infants. Also in the smallest neonates the procedure is safe and effective and may be important in lowering pulmonary morbidity and subsequent mortality.

[Closed abdominal trauma: diagnostic and therapeutic orientations]. / Traumatismes fermés de l'abdomen: orientations diagnostiques et thérapeutiques.

In France, traumas are the third leading cause of mortality. There are no clear statistics concerning abdominal injuries among all traumas. Nevertheless abdominal traumas are directly responsible for 10 to 30% of traumatic death. Over the past few years, improvement in imaging technics has allowed to establish very precise damage toll and to consider new therapy approaches. The development of conservative treatments has led to a reduction in the number of unnecessary coeliotomy. The treatment of such pathologies requires a multidisciplinary, effective and constantly available staff.

Neonatal spinal muscular atrophy with diaphragmatic paralysis is unlinked to 5q11.2-q13.

Two sibs affected by the severe neonatal form of spinal muscular atrophy (SMA) with diaphragmatic paralysis are described. The two sibs were discordant for the haplotypes determined by DNA markers flanking the SMA locus. This supports non-linkage of SMA to chromosome 5 in this family and indicates that the uncommon SMA type I variant associated with early onset respiratory failure maps outside the 5q11.2-q13.3 region.

[Operative stress and neuroendocrine changes: influence of anxiety, pain, and drugs]. / Stress operatorio e modificazioni neuroendocrine: influenza di ansia, dolore e farmaci.

In this study we took into consideration the neuroendocrine alterations caused by surgical stress, studying the cortisol and prolactin's course in plasma, during the period between preanesthesia and the morning after operation. Our research was particularly interested in identifying the influence of anxiety, pain and drugs. At this purpose, twenty-four patients (ASA 1-2) submitted to abdominal surgery, were subdivided in to two groups of twelve members each. In the first (group G) a general inhalising anesthesia with analgesic component was performed; in the second (group B) a selective peridural anesthesia associated with slight general anesthesia, the so-called blended anesthesia. The interpretation of the results showed an action particularly on prolactin, and of pain on cortisol. Thus, a proper use of anesthetic drugs, even if some of them have sure stimulating properties, is useful to reduce the hormonal response. Therefore as good is the control of anxiety and pain, so good is the hormonal metabolic reaction to surgical stress. If the measures to reduce anxiety are limited to a suitable preanesthesia (possibly combined with psychological preparation), on pain, on the contrary, it is possible to act with suitable technology, first of all by locoregional anesthesia. It is, however, important to underline that the best therapy of pain is its prevention.

Systematic transesophageal echocardiography for detection of mediastinal lesions in patients with multiple injuries.

A prospective study assessing the interest in and the results of systematic transesophageal echocardiography (TEE) examination in nonselected intubated multiple injury patients was carried out from January 1992 through June 1993. Seventy patients were included and divided into two groups according to the results of admission screening, including clinical examination, EKG, CK-MB and chest radiograph. Group 1 (60 patients) had abnormalities on initial screening, while group 2 (10 patients) had no symptom of thoracic or mediastinal injury. TEE was performed within 48 hours following admission and its results were compared with those of the initial screening. TEE usefulness was evaluated on a score grade from 0 (no interest) to 4 (outstanding interest). Myocardial contusion was suspected in 25 patients. TEE invalidated 18 suspected and found 5 unsuspected myocardial contusions. Pericardial effusion was suspected in only one case, while TEE documented 13 additional cases. A mediastinal enlargement was seen in 13 patients, but TEE invalidated aortic lesions in all these cases and made an unsuspected diagnosis of aortic tears. Eight cases of severe hypovolemia and seven cases of left ventricle dysfunction were detected by TEE. The score of interest showed that TEE allowed new interesting diagnoses in 70% of group I patients and in 33% of group II patients. TEE is of utmost importance in multiple injury patients, with or without any evidence of thoracic or mediastinal injury, providing a safe and rapid examination of the mediastinal structures and an evaluation of the hemodynamic status.

Human milk fortifiers.

Unsupplemented human milk does not normally provide enough protein and minerals to secure optimal growth in low birthweight infants. We compared the growth and biochemical status of 21 very low birthweight infants, fed on their own mothers' fortified milk (seven infants) or a high-caloric-density formula (14 infants). The human milk fortifier is made from a mixture of cows' milk proteins (40% whey, 45% casein) and amino acids (15%) and has been demonstrated to be appropriate to achieve a plasma amino acid profile similar to that of normal infants fed exclusively on human milk. Infants receiving fortified human milk showed growth and biochemical profiles comparable to those receiving high-caloric-density formula. The supplementation that we describe here confirms the good results well documented by other authors. It is easy to perform and can be an acceptable alternative to the more sophisticated procedure of "lacto-engineering".

Traumatic laceration of the ascending aorta detected by transesophageal echocardiography.

The diagnosis of aortic injury after blunt chest trauma is of utmost importance to emergency physicians. We present a case in which transesophageal echocardiography was successful in diagnosing a transectional intimal tear on the posterior wall of the ascending aorta. Potential usefulness of transesophageal echocardiography is discussed.

[X-ray computed tomography of thoracic injuries. Apropos of 40 cases]. / Tomodensitométrie des traumatismes thoraciques. A propos de 40 observations.

On chest radiographs, the precise assessment of thoracic injuries consecutive to blunt trauma is often compromised by the nonspecific appearance of many lesions. Furthermore, significant injuries are frequently overlooked. However, the management of the patients with chest trauma is still often based primarily upon clinical and radiographic findings and Computed Tomography (CT) is often performed secondarily on the basis of unexplained clinical signs or suspected radiographic abnormality. Some authors have reported that CT was a highly sensitive method for detecting thoracic lesions frequently not seen or underestimated on conventional supine chest radiographs. However, the value that these new CT findings could have in the therapeutic management of these patients, have not been systematically investigated to our knowledge, except in a limited series suggesting that the course of critically ill patients could be substantially altered after thoracic CT. In order to estimate the role of early CT in the management of patient care, we report the therapeutic consequences of CT findings in forty patients who we report the therapeutic consequences of CT findings in forty patients who had a thoracic CT within few hours following a chest injury. We showed that early thoracic CT scan in patients with blunt trauma detected significantly more lesions than did chest X-Ray and appreciably modified the treatment modalities in 70% of our patients. We then recommend that all the patients admitted in ICU after chest trauma undergo a thoracic CT scan as soon as possible in order to optimize their treatment modalities.

[Carotid artery injury: value of Doppler screening in head injured patients]. / Lésion carotidienne traumatique: intérêt d'un dépistage Doppler chez les traumatisés craniofaciaux.

A case is reported of a patient with a traumatic aneurysm of the intracranial part of the carotid artery occurring after a traffic accident. The patient was admitted in coma (Glasgow score 5), and presented with a depressed fracture of the frontal and parietal bones, a fracture of the left petrous pyramid and of the left anterior clinoid process, as well as of the right tympanic bone and temporomandibular joint. The borders of the left carotid canal seemed unaltered. Despite the lack of localised neurological signs, cervical and transcranial Doppler ultrasonography was carried out. Intracranial carotid blood flow was found to be altered on both sides. Angiography showed a false carotid aneurysm on the left side (carotid siphon portion C3), and a moderate irregular stenosis of the C2 part on the right. There were no brain lesions on the CT scan. Prophylactic treatment with heparin was started. The patient recovered normal consciousness within a fortnight. The false aneurysm increased in volume and was treated by embolisation. Flow speeds in the carotid siphons also returned to normal. The usefulness of routine screening of patients with petrous bone fractures with Doppler ultrasound is discussed.

Contribution to the assessment of steroid therapy in the prevention of respiratory distress syndrome in the neonate.

The respiratory distress syndrome (RDS) is a physiological manifestation of neonatal pulmonary immaturity and it is still the major cause of neonatal morbidity and mortality. In order to promote early fetal lung maturity when a preterm delivery is anticipated, a number of pharmacological agents have been investigated. Corticosteroids, in particular, have been extensively used and the results of several trials are reported in literature. A cohort of 246 consecutive singleton preterm infants, liveborn at the Obstetric Clinic of Ferrara University during a 5-year period, was studied to assess whether antenatal steroid therapy reduces the incidence of RDS. Respiratory distress developed in 18.6% of 102 babies who received treatment and in 15.3% of 144 controls, without difference at the statistical analysis. According to previous studies, a lower incidence of RDS was only observed in the treated females compared to non-treated controls (35% vs 46%) at the gestational age of 28-33 weeks. Since the efficacy of steroids seems to be restricted to a very small and specific group of babies, who, moreover are relatively mature by modern intensive care standards, the Authors suggest that the prevention of RDS and its related complications should rely much more on appropriate surveillance and management of the mother and infant than on specific pharmacological interventions.

[Short- and long-term outcome of 250 patients admitted in surgical intensive care units after multiple injuries]. / Devenir à court et à long terme de 250 patients admis en réanimation chirurgicale, au décours d'un polytraumatisme.

Two hundred and fifty polytrauma patients (mean age: 30 years) had been hospitalizated in the same trauma center, along a period of two years. Hospital mortality rate was 33% (11% in the first day). The mean I.S.S. of alive patients was 25, and 35 for dead patients. Long term survey was analysed by three questionnaires (before one year, between one and two years and after two years). Answer rate was about 80%. Sixty hundred p. cent of patients worked less than one year after multiple trauma, and 80% between one and two years; 75% noted that their family life was normal less than one year after injury; 80% presented sequelae two years after; they were subjective in 60% of cases. These sequelae did not interfere with family life or work. There was no parallelism between objective sequelae and duration of work stop in one side and gravity of lesions (I.S.S.) in other side.

[Subcutaneous tunnelization of the subclavian vein. A bacteriological study of 400 catheters in hematologic intensive care]. / Tunnélisation percutanée de la voie sous clavière. Etude bactériologique de 400 cathéters en réanimation hématologique.

Infectious complications are the highest risk in hematology. In this study, subclavian approach and tunnellization are reviewed. Four hundred (400) catheters were evaluated by the Isolator Culture method. Catheters are left in place a long time (mean time 30 days). Colonization occurs rarely (about 10.5%). In hematology, subclavian tunnelized catheter occurs to be a safe and reliable central venous catheter.