Warning! fire in the ICU.

At 5:30 pm on December 17, 2010, shortly after a power failure, smoke filled the Intensive Care Unit (ICU) of Federico II University Hospital in Naples, Italy, triggering the hospital emergency alarm system. Immediately, staff began emergency procedures and alerted rescue teams. All patients were transferred without harm. The smoke caused pharyngeal and conjunctival irritation in some staff members. After a brief investigation, firefighters discovered the cause of the fire was a failure of the Uninterruptible Power Supply (UPS).

Terlipressin in brain-death donors.

BACKGROUND: Metabolic management of brain-death organ donors includes correction of the hormonal perturbations that occur after cerebral death and impair circulatory function. Vasopressin is a hormone secreted by the posterior pituitary gland, which contributes to maintain systemic blood pressure by regulating urine secretion and small arteriole tonus. During brain death, the pituitary gland is damaged and hormone secretion rapidly ceases. Low-dose vasopressin increases systemic blood pressure and decreases the need for catecholamines in brain-dead organ donors but it is not available in many countries. Terlipressin is a synthetic analog of vasopressin characterized by greater selectivity for the V1 receptor than vasopressin. To date, the efficacy of terlipressin as a pressor agent in humans has been reported in a few studies. METHOD: Pharmacology and literature about the use of terlipressin in shock and in particularly in neurogenic shock following brain death is summarized and our personal experience is reported. RESULTS AND CONCLUSION: Terlipressin is helpful in controlling severe hypotension; its use allowed to reduce the infusion rate of norepinephrine about 50% in two of three brain-death organ donors, but there are not yet enough data to define its therapeutic range and incidence of collateral effects on the grafts.

Persistence of carbapenem-resistant Acinetobacter baumannii strains in an Italian intensive care unit during a forty-six month study period.

The aims of this study were to analyze carbapenem-resistance Acinetobacter baumannii isolates (CRAB) and their molecular epidemiology in an ICU of Southern Italy. Clinical outcomes and therapeutic management of patients are also described. The study was performed from January 2007 to October 2010. The presence of carbapenemases was determined by PCR. Strains were typed by PFGE. All A. baumannii isolates were carbapenem-resistant with imipenem MIC≥16 µg/mL. Molecular characterization showed the occurrence of a predominant clone. The most frequent infection by CRAB was ventilator-associated pneumonia; colistin was the drug of choice for this infection. The therapy was safe in all cases except in one where therapy was suspended due to the onset of acute renal failure. We documented the presence of CRAB in this ICU, besides the occurrence of a predominant clone, over all the study period. Despite the infection control procedures used, intra-facility A. baumannii transmission is evident as well as the significant capacity for long-term survival in the hospital environment.

Aneurysmal subarachnoid haemorrhage in pregnancy: a case series.

Pregnancy is a recognized risk factor for aneurysmal subarachnoid hemorrhage (SAH). Headache is very frequent in normal pregnancy and it is a common sign shared between several intracranial diseases. We present a case series of 10 women in the third trimester of pregnancy admitted to our intensive care unit (ICU) with neurological signs and symptoms. 4 of these patients were diagnosed with SAH. Data in this study suggest that a timely diagnosis and an appropriate treatment is crucial for mother and baby.

Prognostic differences between VAP from Acinetobacter baumanii and VAP from other microorganisms.

Nosocomial infection, in particular pneumonia, is an important risk factor for hospital mortality and morbidity. Acinetobacter baumanii is a common multi-resistant microorganism responsible of Ventilator Associated Pneumonia (VAP). Currently Colistin is a rescue therapy for this pathogen. The purpose of this retrospective study is to compare the outcome of VAP caused by Acinetobacter baumanii and VAP from other microorganisms in critical patients. Comorbidity, prognostic scores, mortality and eradication frequency did not turn out significantly different between the two study groups. Colistin safety was tested.

Respiratory failure presenting in H1N1 influenza with Legionnaires disease: two case reports.

INTRODUCTION: Media sensationalism on the H1N1 outbreak may have influenced decisional processes and clinical diagnosis. CASE PRESENTATION: We report two cases of patients who presented in 2009 with coexisting H1N1 virus and Legionella infections: a 69-year-old Caucasian man and a 71-year-old Caucasian woman. In our cases all the signs and symptoms, including vomiting, progressive respiratory disease leading to respiratory failure, refractory hypoxemia, leukopenia, lymphopenia, thrombocytopenia, and elevated levels of creatine kinase and hepatic aminotransferases, were consistent with critical illness due to 2009 H1N1 virus infection. Other infectious disorders may mimic H1N1 viral infection especially Legionnaires' disease. Because the swine flu H1N1 pandemic occurred in Autumn in Italy, Legionnaires disease was to be highly suspected since the peak incidence usually occurs in early fall. We do think that our immediate suspicion of Legionella infection based on clinical history and X-ray abnormalities was fundamental for a successful resolution. CONCLUSION: Our two case reports suggest that patients with H1N1 should be screened for Legionella, which is not currently common practice. This is particularly important since the signs and symptoms of both infections are similar.

Update on transfusion solutions during surgery: review of hydroxyethyl starches 130/0.4.

OBJECTIVES: Restoration of circulation is crucial in the surgical patient management. Colloids and crystalloids are widely used for blood volume therapy. We reviewed recent trials to evaluate efficacy and safety of hydroxyethyl starch (HES) 130/0.4 during surgery. MATERIAL AND METHODS: A subjective, not systematic, review of literature was performed. Papers were searched to answer questions about efficacy of HES, its impact on coagulation and inflammation and its effects on pulmonary mechanics and renal function. CONCLUSIONS: HES 130/0.4 is effective for volume therapy and is less expensive than human albumin. Its effects on coagulation and renal function are manageable; it may ameliorate pulmonary permeability and reduce inflammation.

Thrombin antithrombin complex and IL-18 serum levels in stroke patients.

The complex picture of inflammation and coagulation alterations comes to life in acute stroke phases. Increasing evidence points to a strong interaction and extensive crosstalk between the inflammation and coagulation systems: the interest towards this relationship has increased since recent experimental research showed that the early administration of antithrombin III (ATIII) decreases the volume of ischemia in mice and might be neuroprotective, playing an antiinflammatory role.We aimed to establish the extent of the relationship among markers of inflammation (S100B and IL-18) and procoagulant and fibrinolytic markers (ATIII, thrombin-antithrombin III complex (TAT), Fibrin Degradation Products (FDP), D-dimer) in 13 comatose patients affected by focal cerebral ischemia.Plasma levels of TAT, D-dimer and FDP, IL18 and S100B were increased. IL-18 and S100B high serum levels in ischemic patients suggest an early activation of the inflammatory cascade in acute ischemic injury.The basic principles of the interaction between inflammatory and coagulation systems are revised, from the perspective that simultaneous modulation of both coagulation and inflammation, rather than specific therapies aimed at one of these systems could be more successful in stroke therapy.

Typing of Pseudomonas aeruginosa isolated from patients with VAP in an intensive care unit.

Aim of this study was to characterize isolates of Pseudomonas aeruginosa responsible for ventilator-associated pneumonia (VAP) in patients admitted to an ICU in order to evaluate a possible strain clonality. The study was performed from October 2004 to June 2005 in one Southern Italy ICU and 29 patients suspected of having VAP were enrolled. The etiology of VAP was established by quantitative cultures of endotracheal aspirations. Molecular characterization was carried out by PFGE. P. aeruginosa was responsible for 51% of all cases of VAP (15/29) and 12/15 strains were multi-drug resistant. High mortality (44.8%) was connected to this pathogen and evidence of strain clonality was found. The early identification of strain clonality and the application of infection control procedures are necessary to avoid the spread of pathogens such as P. aeruginosa involved in nosocomial infections.

Sepsis associated encephalopathy studied by MRI and cerebral spinal fluid S100B measurement.

The pathogenesis of sepsis associated encephalopathy (SAE) is not yet clear: the blood-brain barrier (BBB) disruption has been indicated among the possible causative mechanisms. S100B, a calcium binding protein, originates in the central nervous system but it can be also produced by extra-cerebral sources; it is passively released from damaged glial cells and neurons; it has limited passage through the BBB. We aimed to demonstrate BBB damage as part of the pathogenesis of SAE by cerebral spinal fluid (CSF) and serum S100B measurements and by magnetic resonance imaging (MRI). This paper describes four septic patients in whom SAE was clinically evident, who underwent MRI and S100B measurement. We have not found any evidence of CSF-S100B increase. Serum S100B increase was found in three out of four patients. MRI did not identify images attributable to BBB disruption but vasogenic edema, probably caused by an alteration of autoregulation, was diagnosed. S100B does not increase in CSF of septic patients; S100B increase in serum may be due to extracerebral sources and does not prove any injury of BBB. MRI can exclude other cerebral pathologies causing brain dysfunction but is not specific of SAE. BBB damage may be numbered among the contributors of SAE, which aetiology is certainly multifactorial: an interplay between the toxic mediators involved in sepsis and the indirect effects of hyperthermia, hypossia and hypoperfusion.

Antithrombin reduces ischemic volume, ameliorates neurologic deficits, and prolongs animal survival in both transient and permanent focal ischemia.

BACKGROUND AND PURPOSE: Antithrombin (AT), a glycoprotein belonging to the serpin family, blocks thrombin formation and activity at several steps. Thrombin, beside its relevant role in the coagulation cascade, exerts neurodetrimental effects through the activation of a family of protease-activated receptors, which can be implicated in stroke pathophysiology. The aims of the present study were to evaluate whether AT could reduce brain damage, ameliorate neurologic deficits, and prolong animal survival. METHODS: Two different doses of AT (10 and 30 IU/kg IP) were administered 3 hours, 6 hours, or 3 and 6 hours after an ischemic insult to mice and rats subjected to either transient or permanent focal ischemia. Ischemic volume was evaluated 24 hours or 7 days after the ischemic insult. Neurologic deficits were also scored. RESULTS: In mice, 10 or 30 IU/kg AT administered twice, at 3 and 6 hours after transient ischemia, and 30 IU/kg AT administered 3 hours only after transient ischemia substantially reduced total ischemic volume, significantly improved neurologic deficits evaluated 24 hours after the insult, and prolonged animal survival. In rats, the same doses given at the same time intervals significantly reduced ischemic volume, evaluated 24 hours after permanent ischemia. CONCLUSIONS: These results indicate that AT remarkably reduces infarct volume, ameliorates neurologic deficit scores, and prolongs animal survival in 2 rodent models of brain ischemia. Taken together, our data suggest that AT, delivered via systemic administration, an easily achievable route of administration and in a clinically useful time window, could represent a new therapeutic strategy to be validated for the clinical treatment of human stroke.

Posterior reversible encephalopathy syndrome in intensive care medicine.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a well-recognized clinico-neuroradiological transient condition. Early recognition is of paramount importance for prompt control of blood pressure or removal of precipitating factors and treatment of epileptic seizures or status epilepticus. Delay in the diagnosis and treatment may in fact results in death or in irreversible neurological sequelae. DISCUSSION: PRES is characterized by headache, altered mental status, seizures, and visual disturbances and is associated with a number of different causes, most commonly acute hypertension, preeclampsia/eclampsia, and immunosuppressive agents. Clinical symptoms and neuroradiological findings are typically indistinguishable among the cases of PRES, regardless of underlying cause. Magnetic resonance studies typically show edema involving the white matter of cerebral posterior regions, especially parieto-occipital lobes but frontal and temporal lobes, and other encephalic structures may be involved. CONCLUSIONS: Intensivists and other physicians involved in the evaluation of patients with presumed PRES must be aware of the clinical spectrum of the associated conditions, the diagnostic modalities, and the correct treatment.

Effects of dopamine infusion on forearm blood flow in critical patients.

BACKGROUND: In critical care, dopamine is administered by infusion at low doses (or=5 microg/kg/min) for assessment of hemodynamics. The present study was conducted to explore the effects of dopamine infusion on the vast microvascular network of skeletal muscle in the early phases of sepsis. MATERIAL/METHODS: An observational study was performed which included twelve critically ill patients. Patients' response to dopamine infusion (3 microg/kg/min) was studied within 24 hours from admission to the ICU. The forearm blood flow (FBF) and vascular resistance (FVR) were measured by near-infrared spectroscopy (NIRS). RESULTS: Dopamine did not ameliorate forearm regional oxygenation. The infusion of dopamine caused an increase in MAP, while FBF decreased with the resistance increase (p>0.05). CONCLUSIONS: NIRS was suitable to measure bedside the vascular resistance and to test the effects of low doses of dopamine on forearm blood flow. A dopamine infusion of 3.0 microg/kg/min caused a reduction in forearm blood flow and an increase in vascular resistance in our patients.

Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential hypoxia.

Elderly patients are more prone than younger patients to develop cerebral desaturation because of the reduced physiologic reserve that accompanies aging. To evaluate whether monitoring cerebral oxygen saturation (rSO(2)) minimizes intraoperative cerebral desaturation, we prospectively monitored rSO(2) in 122 elderly patients undergoing major abdominal surgery with general anesthesia. Patients were randomly allocated to an intervention group (the monitor was visible and rSO(2) was maintained at > or =75% of preinduction values; n = 56) or a control group (the monitor was blinded and anesthesia was managed routinely; n = 66). Cerebral desaturation (rSO(2) reduction <75% of baseline) was observed in 11 patients of the treatment group (20%) and 15 patients of the control group (23%) (P = 0.82). Mean (95% confidence intervals) values of mean rSO(2) were higher (66% [64%-68%]) and the area under the curve below 75% of baseline (AUCrSO2(2)< 75% of baseline) was lower (0.4 min% [0.1-0.8 min%]) in patients of the treatment group than in patients of the control group (61% [59%-63%] and 80 min% [2-144 min%], respectively; P = 0.002 and P = 0.017). When considering only patients developing intraoperative cerebral desaturation, a lower Mini Mental State Elimination (MMSE) score was observed at the seventh postoperative day in the control group (26 [25-30]) than in the treatment group (28 [26-30]) (P = 0.02), with a significant correlation between the AUCrSO(2) < 75% of baseline and postoperative decrease in MMSE score from preoperative values (r(2)= 0.25, P = 0.01). Patients of the control group with intraoperative cerebral desaturation also experienced a longer time to postanesthesia care unit (PACU) discharge (47 min [13-56 min]) and longer hospital stay (24 days [7-53] days) compared with patients of the treatment group (25 min [15-35 min] and 10 days [7-23 days], respectively; P = 0.01 and P = 0.007). Using rSO(2) monitoring to manage anesthesia in elderly patients undergoing major abdominal surgery reduces the potential exposure of the brain to hypoxia; this might be associated with decreased effects on cognitive function and shorter PACU and hospital stay.

Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients.

OBJECTIVE: To describe clinical, neuroradiological and evolutionary findings in obstetric patients with posterior reversible encephalopathy syndrome (PRES). DESIGN: Retrospective case series. SETTING: University intensive care unit (ICU). PATIENTS: Four critically ill patients. Two patients experienced PRES in late postpartum without the classical pre-eclamptic signs. All patients showed impairment of consciousness and epileptic seizures; two of them presented cortical blindness and headache, too. True status epilepticus (SE) occurred in two cases. In all patients MRI showed the typical feature of gray-white matter edema, mainly localized to the temporo-parieto-occipital areas. INTERVENTIONS: Normalization of high blood pressure (BP) and treatment of seizures. Two patients with SE and severe impairment of consciousness were treated with an intravenous valproate (ivVPA) bolus followed by continuous infusion. MEASUREMENTS AND RESULTS: In three cases, neurological and MRI abnormalities completely resolved in about a week. Another patient died due to subarachnoid hemorrhage. CONCLUSION: Posterior reversible encephalopathy syndrome is a well described clinical and neuroradiological syndrome characterized by headache, altered mental status, cortical blindness and seizures, and a diagnostic MRI picture; usually reversible, PRES can sometimes result in death or in irreversible neurological deficits, thus requiring early diagnosis and prompt treatment. PRES can have various etiologies, but pregnancy and postpartum more frequently lead to this condition. Treatment of seizures deserves special attention since the anti-epileptic drugs currently used in SE management may worsen vigilance as well as autonomic functions. Extensive research is needed to assess the role of ivVPA in this condition.

The upper inflection point of the pressure-volume curve. Influence of methodology and of different modes of ventilation.

OBJECTIVE: The pressure-volume (P/V) curve has been proposed as a tool to adjust the ventilatory settings in cases of acute respiratory distress syndrome (ARDS). The aim of this study was to test the influence of P/V tracing methodology on the presence and value of the upper inflection point (UIP). METHODS: In 13 medical ARDS patients, the interruption and the automated low flow inflation methods were compared while the patients were ventilated at conventional (10-12 ml/kg) and at low (5-6 ml/kg) tidal volume (Vt). Two levels of inspiratory flow and insufflation time were used (3 and 6 s). RESULTS: No significant difference in UIP was found between the static and the dynamic methods, whatever the flow used. At Vt 10-12 ml/kg, the static and dynamic UIPs were 22.4 +/- 4.4 cmH(2)O and 22.1 +/- 4.5 cmH(2)O ( p = 0.86), respectively; at Vt of 5-6 ml/kg, the static and dynamic UIPs were 26.6 +/- 4.1 cmH(2)O and 25.5 +/- 5 cmH(2)O ( p = 0.34), respectively. Significant differences in UIP were found, in the static and dynamic conditions, between the two levels of Vt ( p < 0.005): it was lower with the higher Vt, suggesting that UIP is dependent on previous tidal alveolar recruitment. CONCLUSION: Interruption and continuous flow techniques gave similar results, but the previous Vt influences the pressure value of the UIP.