[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.

[Emergency diagnostic imaging in thoracic trauma. A clinical case]. / Diagnosi d'urgenza per immagini nel trauma toracico. Caso clinico.

The authors report a case of thoracic trauma with pulmonary contusion in which chest X-ray was not significant, nevertheless severe clinical state. They underline the importance of CT in the early evaluation of pulmonary lesions and in their development.

[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.

[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.

Antipyretic therapy in ICU patients: evaluation of low dose diclofenac sodium.

The antipyretic effect of diclofenac sodium 0.2 mg/kg i.v. was studied prospectively in 10 ICU patients. Patients with renal failure and hypovolaemia were excluded from the study; mean basal temperature (measured by the pulmonary artery thermistor) was 38.92 degrees C +/- 0.413 SD. In 9 of the 10 patients, the temperature fell by more than 0.5 degrees C within 1 h of administration of the drug. A minimum mean of 37.80 degrees C +/- 0.636 SD was obtained by the hour 3; the temperature then remained lower than basal throughout the entire observation period (6 h). Changes in haemodynamics and oxygen consumption were consistent with the reduction in temperature. Changes in renal function were transient and did not require any therapeutic intervention. We conclude that the proposed dosage (in the selected patient population) constitutes effective antipyretic treatment devoid of major side effects.

Mean airway pressure vs. positive end-expiratory pressure during mechanical ventilation.

To investigate the effects of both positive end-expiratory pressure (PEEP) and mean airway pressure (Paw) on gas exchange, we used lung lavage to induce severe respiratory insufficiency in six lambs. The animals were then mechanically ventilated at constant tidal volume, respiratory rate, and inspired O2 fraction. PEEP levels were varied -5, +5 and +10 cm H2O around the pressure (Pflex) corresponding to a major change in slope of the inspiratory limb of the respiratory volume-pressure curve. In each animal the effects of the three PEEP levels were studied at two Paw levels, differing by 5 cm H2O. Increasing Paw significantly improved PaO2 and reduced venous admixture. A 5-cm H2O PEEP increase from +5 to +10 did not affect oxygenation; however, oxygenation was significantly better when PEEP was greater than Pflex. Both PaCO2 and anatomic dead space were higher at higher PEEP, and decreased with increasing Paw. Hence, Paw was a major determinant of oxygenation, although a PEEP greater than Pflex appeared necessary to optimize oxygenation at a constant Paw.

Venous admixture (Qva/Q) and true shunt (Qs/Qt) in ARF patients: effects of PEEP at constant FIO2.

Venous admixture (Qva/Q) in ARF patients is due to both true right to left shunt (Qs/Qt: perfusion of truly unventilated areas) and to maldistribution [Qva-Qs)/Qt: effects of unevenness of ventilation/perfusion ratio). Using the retention rate of sulphur hexafluoride we determined the effects of PEEP on Qs/Qt and (Qva-Qs)/Qt at a constant FIO2 for each patient (0.57 +/- 0.19 SD, range 0.4-0.95). Eleven patients with ARF (treated either by CPPV or CPAP) were studied on 16 occasions. Each measurement was repeated at two levels of PEEP, 5 cm H2O below and 5 cm H2O above the patient's clinically determined PEEP level. The increase in PEEP resulted in: - a decrease in Qva/Q (from 0.37 +/- 0.13 to 0.27 +/- 0.12, p less than 0.01); - a parallel decrease in Qs/Qt (from 0.29 +/- 0.16 to 0.22 +/- 0.14, p less than 0.01); there was a positive correlation between Qva/Q and Qs/Qt changes (r = 0.53, p less than 0.05). No significant variation was demonstrated in (Qva-Qs)/Qt (from 0.074 +/- 0.045 to 0.054 +/- 0.048). On the other hand there was a negative correlation between the fraction of Qva/Q due to the maldistribution and FIO2: (Qva-Qs)/Qva = 0.75-0.86 FIO2 (r = 0.74, p less than 0.01). We conclude that: PEEP decreased Qva/Q mainly through changes in Qs/Qt but did not have a definite effect on (Qva-Qs)/Qt. Maldistribution was responsible for a significant portion of Qva/Q in those ARF patients tolerating a relatively low FIO2 (0.4-0.6).

Simple estimate of the true right to left shunt (Qs/Qt) at maintenance F1O2 by sulphur hexafluoride retention.

Differentiating Qs/Qt over Qva/Q (as measured by the standard O2 content formula) appears to be of great interest in applying and evaluating different therapeutic approaches. The estimation of Qs/Qt by 100% O2 breathing may alter "per se" the lung condition and is unsatisfactory. We used Sulphur Hexafluoride (SF6; lambda = 6.10(-3) ml ml-1 760 mmHg-1) to identify the true shunt (VA/Q less than 0.05) at maintenance F1O2. A simple and rapid determination of SF6 retention is performed by ECD gas chromatography from contemporaneous arterial and mixed venous blood samples, taken during i.v. infusion of an SF6 containing solution. QS/Qt estimate is then given by the ratio: PaSF6/PvSF6. It is not necessary to know the absolute gas partial pressures or concentration, hence absolute gas calibrations are not required. This method is suggested as feasible and satisfactory for clinical use, allowing the determination of QS/Qt at the maintenance F1O2.