Multimodal neurological approach can lead the treatment in postcardiac arrest persistent refractory status epilepticus.

Refractory status epilepticus (RSE) is a common challenge in the setting of post resuscitation care. We describe how multimodal neurological approach can lead treatment and improve the prognosis. We report on three survivors of cardiac arrest (CA) who had good neurological outcomes after mild hypothermia (TH), despite exhibiting persisting RSE requiring treatment with several antiepileptic (AED) and anesthetic drugs, including barbiturate-induced coma. No evidence-based data exist to guide management of RSE in the setting of anoxic brain injury. Our cases emphasize the need for continuous active treatment led by a multimodal approach in order to improve neurological outcome.

Early outcome of liver transplantation performed with organs procured from brain death donors with transient or sustained cardio-circulatory collapse.

BACKGROUND: Aim of this study was to compare early graft function after transplantation of recipients transplanted with livers procured from donors after brain death who experienced transient or sustained cardio-circulatory collapse. METHODS: We retrospectively analysed patients who underwent liver transplantation (LTx) at our Institution from January 2010 to May 2012. Recipients were divided into 3 groups: those who received livers from brain death donors who experienced reversible cardio-circulatory arrest before organ procurement (RCA); those who experienced sustained cardio-circulatory collapse, treated with extra-corporeal membrane oxygenation support as rescue therapy of refractory cardiogenic shock (ECMO). Standard donors were considered as reference group (REF). Postoperative graft function, Primary Non-Function (PNF), and complications during the first 30 days were analysed. RESULTS: 102 LTx were analysed (76 REF, 22 RCA and 4 ECMO). The main cause of donor's death was post-anoxic coma in RCA and ECMO, cerebrovascular accident in REF. SGOT in REF, RCA, and ECMO donors were 27 [17-43], 54 [34-92], 716 [190-962] respectively, SGPT 17 [12-34], 46 [27-73], 84 [51-175] UI/L respectively, both P<0.01. All recipients had similar SGOT (P=0.48), SGPT (P=0.75) and Model for End-Stage Liver Disease scores (P=0.98) before LTx; similar graft cold and warm ischemia time and serum lactate levels at the end of surgery. After LTx, Intensive Care Unit stay and the incidence of PNF were similar. CONCLUSION: The use of livers procured from donors after brain death that experienced transient or sustained cardio-circulatory collapse was associated with early graft function comparable to that of standard donors.

Inter-hospital extracorporeal life support.

A 60-year-old man with history of hypertension and unspecified left ventricular dysfunction had chest pain at home at 9 am. At 1 pm he was transported to a peripheal hospital and treated for acute myocardial infarction. At 4.30 pm, despite pharmacological and intra aortic balloon pump support , the extreme hemodynamic instability and the echocardiographic signs forced the doctors in charge to contact the "extracorporeal membrane oxygenation team" of our Intensive Care Unit. The team, that in our hospital is composed of an intensivist, a cardiac surgeon, a perfusionist and a nurse, reached the hospital at 5.15 pm and performed a percutaneous cannulation of right femoral artery and left femoral vein connecting the patient to the extracorporeal membrane oxygenation circuit. At 6.30 pm the patient on extracorporeal membrane oxygenation was transferred by ambulance to the Cardiac Surgery Intensive Care Unit of San Gerardo Hospital in Monza. On day 20 he was transferred back to the original hospital without neurological deficits, with normal renal function and normal blood gas analysis.

[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.

Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study.

To investigate the relationship between lung anatomy and pulmonary mechanics in acute respiratory failure (ARF), 20 patients with ARF underwent computerized tomography (CT) at 3 levels of positive end-expiratory pressure (PEEP) (5, 10, and 15 cm H2O). The static pressure-volume curve of the total respiratory system and the lung volumes (helium dilution method) were also measured. By knowing the lung volumes and analyzing the CT number frequency distribution, a quantitative estimate of normally aerated, poorly aerated, and nonaerated lung tissue was obtained at each level of PEEP. The recruitment was defined as the percent increase of normally aerated tissue from 5 to 15 cm H2O. We found that the different compliances (starting compliance, inflation compliance, and deflation compliance) were correlated only with the amount of normally aerated tissue present in the range of pressures explored by a given compliance (5 cm H2O for starting compliance and 15 cm H2O for inflation and deflation compliances). No relationship was found between the compliances and the poorly aerated and nonaerated tissue. The specific compliance was in the normal range, whereas the amount of recruitment was related to the ratio of inflation compliance to starting compliance. Our data suggest that (1) the pressure-volume curve parameters in ARF investigate only the residual healthy zones of the lung and do not directly estimate the "amount" of disease (poorly or nonaerated tissue), (2) the pressure-volume curve may allow an estimate of the anatomic recruitment, and (3) the residual normally aerated zones of the ARF lung seem to maintain a normal intrinsic elasticity.

Volume/pressure curve of total respiratory system in paralysed patients: artefacts and correction factors.

The volume/pressure (V/P) curve of the total respiratory system in paralysed patients is drawn assuming that volume changes of the respiratory system (delta V resp) equals volume displacement of the measuring apparatus (delta V syr), usually a supersyringe. However, in 93 VP curves we found that O2 removed from the lung-syringe system during the procedure (proportional to the time) largely exceeds the CO2 added to the lung-syringe system (delta V gas). This results in a net loss of volume from the system (delta V resp less than delta V-syr). Deflation compliance, hysteresis area and ratio are significantly affected by this phenomenon. Inflation compliance is less influenced by delta V gas, partially compensated by the intrapulmonary gas expansion due to the temperature changes. We conclude that the parameters computed on the deflation limb of V/P curve are misleading if proper correction of the volume scale is not introduced.