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.

Candidosis in the intensive care unit: a 20-year survey.

Deep-seated candidosis is a major problem in critically ill patients. Colonization with candida has been identified as an important independent risk factor for the development of candidaemia. Since the 1980s routine surveillance cultures have been performed on patients admitted for six or more days to the 'E. Vecla' intensive care unit (ICU) of the IRCCS Ospedale Maggiore di Milano. Colonization was observed on admission to the ICU in 59 of 117 (50%) patients in 2000 and 10 others developed colonization during their stay on the unit. A similar colonization rate was found in a survey performed 16 years earlier. The incidence of non-albicans Candida species, however, increased in 2000. In particular, 24 patients were culture positive for Candida glabrata at some point during their hospital stay, whereas this species was isolated from only one patient in 1983-1984. Antifungal susceptibility testing performed by Sensititre Yeast One revealed no resistance among 19 C. albicans strains tested. In contrast, fluconazole resistance was observed in two of 39 (5%) C. glabrata isolates from 23 patients. In the period 1983-2002, 28 candida bloodstream infections were identified and 12 were considered to be ICU-acquired (2.6/1000 hospitalized patients; 0.33/1000 patient days). The low rate of ICU-acquired candidaemia despite the inclusion of severely compromised patients in this study confirms the usefulness of routine mycological surveillance in preventing deep-seated candidosis.

Customization of SAPS II for the assessment of severity in Italian ICU patients. ARCHIDIA. Archivio Diagnostico.

BACKGROUND: To assess the accuracy of SAPS II on the Italian population and to perform a customization of the model. DESIGN: observational prospective study. PATIENTS: 24 participating centers. 6794 patients out of 9185 enrolled in the cohort study. MEASUREMENTS: the performance of SAPS II was assessed with calibration and discrimination. In the case of standard model not fitting the data, new logistic regression equation has been calculated using Archidia database. RESULTS: SAPS II showed a good discrimination, but a bad calibration. The new logit has been calculated on the population examined in 1995 and successively tested on the population collected during 1996. In both samples discrimination and calibration results were good. CONCLUSIONS: Our customized model reaches a high standard in calibration and discrimination. We suggest this model for future application in Italian ICU.

Probability model of hospital death for severe trauma patients based on the Simplified Acute Physiology Score I: development and validation. Archivio Diagnostico.

BACKGROUND: We evaluated whether or not the Simplified Acute Physiology Score (SAPS) I is a suitable audit system for trauma patients admitted to general intensive care units (ICUs). A probability model for SAPS I was retrospectively assessed on trauma patients admitted to general ICUs from 1990 to 1992. Because it was determined that SAPS did not fit the data well, we developed a customized probability model of SAPS I for trauma patients and validated it prospectively on an independent data set (patients admitted to general ICU in 1993-1994). Measures of calibration (goodness of fit) and discrimination (receiver operating characteristic curve) were adopted to assess the performance of the model. METHODS: A multicenter study was performed involving general ICUs in northern Italy that participated in a project of standardized data collection. This project is known in Italy under the acronym of ARCHIDIA (Diagnostic Archive). All patients consecutively admitted to the ICU were registered in the data base from January 1, 1990, to December 31, 1994 (16,767 patients). For the SAPS analysis, we considered only patients who fulfilled the following criteria: older than 17 years, length of stay longer than 24 hours, and SAPS I correctly computed. Inclusion criteria resulted in 12,156 patients analyzed; there were 1,936 patients with trauma. RESULTS: Trauma patients represented more than 15% of all patients admitted to ICUs during the period considered. Compared with the general population, they were younger (41.2 vs. 56.7 years), stayed in ICUs for longer periods (12.4 vs. 9.5 days), and had a lower hospital mortality rate (17.8 vs. 28.7%). Because the original probability model did not perform well among patients with trauma, a new model was developed and prospectively validated only for trauma patients (customization). Measures of calibration and discrimination showed a good performance both in the developmental (goodness of fit: chi2 = 8.47; p = 0.38; area under the curve = 0.94 +/- 0.01) and in the validation (goodness of fit: chi2 = 12.75; p = 0.12; area under the curve = 0.85 +/- 0.01) data sets. CONCLUSION: Customization of SAPS I for trauma patients has shown good calibration and high discriminatory power in Italian ICUs and when applied to an independent data base. The advantage of customization would be the collection of the same set of variables for all patients admitted to ICUs against the use of specific scoring systems.

The influence of length of stay in the ICU on power of discrimination of a multipurpose severity score (SAPS). ARCHIDIA.

OBJECTIVE: To assess how the power of discrimination of a multipurpose severity score (Simplified Acute Physiology Score; SAPS) changes in relation to the length of stay (LOS) in the intensive care unit (ICU). DESIGN: In order to compute the SAPS probability, a model derived from logistic regression was developed in a cohort of 8059 patients. Measures of calibration (goodness-of-fit statistics) and discrimination [receiver operating characteristic (ROC) curve and relative area under the curve (AUC)] were adopted in a developmental set (5389 patients) and a validation set (2670 patients), both randomly selected. Once the logit was developed and the model validated, the whole database (8059 patients) was again assembled. To evaluate the accuracy of first-day SAPS probability over time, area under the ROC curve was computed for each of the initial 10 days of ICU care and for day 15. SETTING: 24 Italian ICUs. PATIENTS: A total of 8059 patients out of 10065 consecutive admissions over a period of 3 years (1990-1992) were included in this study. Patients whose SAPS was not correctly compiled (n = 687), patients younger than 18 years (n = 442), and patients whose LOS was less than 24 h (n = 877) were excluded from this analysis. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The logistic model gave good results in terms of calibration and discrimination, both in the developmental set (goodness-of-fit: chi 2 = 9.24, p = 0.32; AUC = 0.79 +/- 0.01) and in the validation set (goodness-of-fit: chi 2 = 8.95, p = 0.537; AUC = 0.78 +/- 0.01). The AUC for the whole database showed a loss in discrimination closely related to LOS: 0.79 +/- 0.01 at a day 1 and 0.59 +/- 0.02 at day 15. CONCLUSION: The logistic model that we developed meets high standards for discrimination and calibration. However, SAPS loses its discriminative power over time; accuracy of prediction is maintained at an acceptable level only in patients who stay in the ICU no longer than 5 days. The stay in the ICU represents a complex variable, which is not predictable, that influences the performance of SAPS on the first day.

[Daily survey of procedures as markers of resources utilization]. / Rilevazione giornaliera di procedure come tracciante dell'utilizzo di risorse.

OBJECTIVE: To assess and to follow along the time-span of ICU stay the process of resources allocation and utilization. DESIGN: Prospective study. PATIENTS: A cohort of 778 patients consecutively admitted to 7 multipurpose general ICU in the Milano area were enrolled in a survey of the daily performed interventions/procedures. MEASUREMENTS AND MAIN RESULTS: The majority of diagnostic procedure/interventions were performed during the first two days. The number and quality of interventions were transferred into points obtaining a score system in non-monetary units. The resource allocation process shows a regular trend in the sub-intensive patients who were only monitorized. On the contrary the 258 patients who were intensively treated and survived show a phase of high resource-consumption (about 30 daily points: roughly twice the score of monitorized patients) then followed by a post-intensive phase with a resource consumption resulting in a daily score absolutely equal to the sub-intensive patients. The intensive patients who die show a significantly higher score than survived patients. Both daily and cumulative scores do not show differences among different type of patients. CONCLUSION: The evaluation of the process of resources allocation, even if in non-monetary units enables the knowledge of the trend of ICU costs and allows the elaboration of the appropriate budget mechanism.

["ARCHIDIA": a system for patients' data collection and computerized filing. Part I. Methodology]. / Sistema di raccolta dati paziente e archiviazione computerizzata "ARCHIDIA". Parte I--Metodologia.

This report describes a computer based program of patient clinical data collection: the ARCHIDIA system. The project relies on descriptive analysis of clinical events according to well defined methodological criteria. This allows the formulation of a concise diagnosis which is, at the same time, exhaustive of all essential information. Two are the basis principles of this methodology: To define, as accurately as possible, the logical steps necessary to elaborate the diagnosis, that is construed by a sequence of codes. To define all the conditions that must be followed so to use any code in a controlled and independent way. These criteria were derived from literature. The major claim of the system is likely to be the introduction of a "common language" between different ICUs. Uniformed diagnostic and clinical criteria are the main source of large data collection for descriptive, analytic and prospective studies. After a one year pilot study performed by 4 ICUs, ARCHIDIA was used, in 1991, by 20 centers from the area of Milan, Pavia, Como, Varese (70% of total) and 4148 patient data were collected. A descriptive analysis will be reported in the following paper.

["ARCHIDIA": a system for patients' data collection and computerized filing. Part II. General description of a caseload]. / Sistema di raccolta dati paziente e archiviazione computerizzata "ARCHIDIA". Parte II--Descrizione generale della casistica.

OBJECTIVE: To describe a population of patients admitted in ICU in an homogeneous urban area by means of a computed system. EXPERIMENTAL DESIGN: Observational study. SETTING: 20 general intensive care units of general and university hospitals. PATIENTS: Patients admitted in ICU from 1-1-1991 to 31-12-1991. 3 centers collected patients only for 6 months, starting on 1-6-1991. MEASUREMENTS: For each patient demographic data, hospitalization data, outcome, diagnosis and diagnostic procedures used during hospitalization according to defined criteria previously described, were collected. Data have been collected on PC using dedicated software. RESULTS: All centers concluded data collection, none abandoned the study. General characteristics of 4148 valuable patients were reported. Age was 52.9 years, SAPS 12.4 and mortality 21.7%. The patients spent 8.7 days in ICU and, when transferred to a general ward, the following hospitalization was 21.5 days. CONCLUSIONS: Data collection demonstrated the project feasibility. It realizes a continue up to date system inside each unit and allows the use of a "common language" and homogeneous methodology between centers.

[Continuous infusion of enoximone in the treatment of acute myocardial ischemia with low output syndrome]. / Enoximone in infusione continua nel trattamento dell' ischemia miocardica acuta con sindrome da bassa gittata.

OBJECTIVE: To evaluate efficacy and tolerability of enoximone, a phosphodiesterase inhibitor, in the treatment of cardiogenic shock. DESIGN: A prospective non randomized, non comparative study. SETTING: A general intensive care unit of a university hospital. PATIENTS: Six patients with cardiogenic shock (cardiac index < 2.5 l/min/m2, PWP > 15 mmHg) unsuccessfully treated with catecholamines. INTERVENTIONS: Enoximone was administered (0.5-1 mg/kg)by iv bolus according to clinical response (CI > or = 2.5 l/min/m2), then was continued by iv infusion (5-16 micrograms/kg/min). Dopamine infusion at low doses (3 micrograms/kg/min) was maintained during the study. In all patients a pulmonary artery catheter was inserted before the study began. MEASUREMENTS AND MAIN RESULTS: Direct and measured (using standard formula) haemodynamic parameters were registered. Basal data (before treatment) were compared with values after 30 minutes (bolus) and 8 hours (maintenance). CI (+57%) and O2 delivery (+74.7%) were significantly increased after 30 minutes and 8 hours, O2 extraction ratio normalized whereas heart rate and systemic blood pressure were unchanged. CONCLUSIONS: Enoximone proved to be safe and effective in the treatment of cardiogenic shock. Its pharmacological effects combines inotropic and vasodilatant action without any change of heart rate thus avoiding an increase of O2 consumption in the jeopardized myocardium. Further studies will define better its routine use in critically ill patients with acute heart failure.

[Automatic fluid control during high-flow continuous hemofiltration: the Equaline system]. / Il controllo automatico dei fluidi durante emofiltrazione continua ad alti flussi: il sistema Equaline.

OBJECTIVE: To describe the use of an automatic fluid control system, Equaline, during high flux continuous hemofiltration. DESIGN: Prospective descriptive study. SETTING: General intensive care unit in a general hospital. PATIENTS: 15 consecutive patients suffering from septic shock, hypercatabolic with acute renal failure. INTERVENTION: Pump driven continuous veno-venous hemofiltration (PDCVVH) with high flux was performed. All pts were intubated, under mechanical ventilation and treated with vasoactive agents for hemodynamic instability. Fluid balance was achieved with an automatic fluid control system, Equaline, on daily basis according to clinical needs. MEASURES: Length of treatment, daily amount of ultrafiltrate and urea removal, urea and creatinine blood level before and after the treatment were registered. RESULTS: Age was 59.1 years, SAPS 17.2. Patients were treated for an average period of 9 days obtaining a daily ultrafiltrate production of 21.4 L. In all pts, though the high catabolism (daily nitrogen production > 30 g), there was a significant decrease of urea and creatinine concentration. CONCLUSION: Equaline system was able to maintain intravascular volume in the face of high ultrafiltration rate avoiding clinically important discrepancies between ultrafiltrate formation and fluid replacement. We conclude that PDCVVH management is greatly improved with use of such servo-controlled feedback system.

Continuous veno-venous hemofiltration in critically ill patients with multiple organ failure.

18 critically ill patients, with multiple organ failure (MOF) (from shock either septic, n = 15, or cardiogenic, n = 3), oliguria and increase in BUN and creatinine were treated with pump driven, high flux continuous veno-venous hemofiltration (CVVH). Replacement fluids were administered in predilution mode. All patients were under respiratory support and vasoactive drugs, and received early nutritional support (N input: 0.2-0.3 g/kg/day). Mean duration of treatment was 9.2 days and mean ultrafiltrate production was 21.4 l/day; treatment resulted in a significant reduction of both urea nitrogen and creatinine blood levels (-20 and -40% of initial values respectively) in spite of a very severe catabolism. The total amount of urea nitrogen removed through CVVH ranged from 15 to 73 g/day (mean 33.5), the median value of urea nitrogen clearance was 12.8 ml/min with a median ultrafiltration coefficient of 0.8. The mean duration of hemofilters was 69 hours (38-108); the efficacy of filters remained stable throughout the entire lifespan and changes were made in case of sudden decrease of ultrafiltration (< ml/min). No major complication was observed in over than 4000 hours of treatment. Pump driven, high flux CVVH proved effective in the control of water electrolyte balance and metabolic homeostasis in a group of critically ill, hemodynamically unstable, catabolic patients with MOF and acute renal failure. In no case we had to add intermittent hemodialysis or to use hemodiafiltration. The constant extracorporeal blood flow and the stable efficacy of hemofilters allowed an easy control of the overall effectiveness of this technique.

[Intensive care of AIDS patients. Clinical experience]. / L'assistenza intensiva al paziente con AIDS. Esperienza clinica.

Six patients with AIDS and severe respiratory failure from diffuse interstitial pneumonia, have been treated in one year in ICU. The authors describe diagnostic and therapeutic characteristics and management problems, underlining the good results in the short and medium term.

[Propofol-ketamine vs propofol-fentanyl in short gynecologic surgery]. / Propofol-ketamina vs propofol-fentanyl nella piccola chirurgia ginecologica.

The study was performed to investigate efficacy and tolerability of the association propofol-ketamine as alternative to propofol-fentanyl. Forty female, classified ASA I-II, aged 18-50 years and scheduled for short gynecologic procedures under general anesthesia were included in a comparative, randomized, single blind study. Patients were divided in two groups; in group K anesthesia was induced with propofol 1.5 mg/kg and ketamine 1 mg/kg i.v. In group F anesthesia was induced with propofol 2.5 mg/kg and fentanyl 1.5 micrograms/kg. Arterial blood pressure (BP), heart rate (HR), respiratory rate (RR) and arterial O2 saturation (SATO2) were measured. Though preliminary, our data suggest that the association propofol-ketamine reach an adequate level of anesthesia with few and negligible effects on cardiorespiratory system, thus allowing a better operability and safety. The incidence of post operative psychotic disturbances seems to be low and moderate. We can't draw any definitive conclusion, but we think that other studies should be performed to clarify the possible role of ketamine in propofol anesthesia.

[Acute polyneuropathy in the critical patient. Description of a clinical case]. / Polineuropatia acuta nel paziente critico. Descrizione di un caso clinico.

Polyneuropathy syndromes were described during prolonged sepsis and multiple organ failure. This kind of polyneuropathy should be discriminated from Guillain-Barré syndrome. The authors report their experience concerning a clinical case.

Recombinant alpha-2a interferon plus vinblastine in the treatment of metastatic renal cell carcinoma.

Twenty consecutive metastatic renal cell carcinoma patients were treated with a combination of recombinant alpha-2a interferon (18 X 10(6) U three times weekly) and vinblastine (0.1 mg/kg every 3 weeks). Two patients (10% response rate; 95% confidence limits 1.23-31.7%) achieved partial response and 11 (55%) stable disease. Toxicity was significant but always acceptable: most frequently, patients complained of fever and flu-like symptoms (18 of 19 patients), fatigue (18 of 19 patients), worsening in performance status (15 of 19 patients), and anorexia (15 of 19). The combination of recombinant alpha-2a interferon and vinblastine is active in renal cell carcinoma.