Kawasaki disease and cardiac involvement: an update on the state of the art.

Kawasaki disease (KD) is an acute systemic vasculitis of unknown etiology. It has a self-limiting course and so far, represents the most common cause of coronary heart disease acquired in children aged between 6 months and 5 years. The inflammatory process can involve the coronary arteries with the formation of aneurysms and thrombotic occlusions with the risk of sudden death, especially in infants. Myocardial inflammation and abnormalities of cardiac contractility can occur acutely or many years after the disease onset. Therapy must be started within 10 days after the onset of symptoms to reduce the risk of heart complications. Immunoglobulin and aspirin treatment are effective in reducing heart complications. Recent studies have shown new therapeutic strategies (corticosteroids, immunosuppressive and biological drugs) in case of ineffectiveness of treatment with immunoglobulins.

Different patterns of lung recruitment maneuvers in primary acute respiratory distress syndrome: effects on oxygenation and central hemodynamics.

BACKGROUND: The aim of this study was to test if different recruitment maneuver (RM) patterns, that achieve the same maximum pressure for the same length of time in humans, have a similar efficacy on alveolar recruitment, intrathoracic vascular pressures and flows, and on cardiac function and ventricular filling. METHODS: Forty patients were randomly allocated to undergo different RM patterns: sustained inflation (SI) or pressure controlled ventilation (PCV). The RM methods tested are as follows: SI was achieved by raising peak inspiratory pressure to 45 cmH(2)O and sustaining it for 40 seconds. The PCV was set to obtain a 45 cmH(2)O peak inspiratory pressure for 2 minutes, I:E 1:2, PEEP 16 RR 8/min. During the study period, patients were mechanically ventilated to obtain a volume of 6 mL/kg, FiO(2) 0.7, PEEP 14, RR 14, Pplateau < or =30 cmH(2)O according to the ARDSnet trial. All patients were sedated and paralyzed during the study period. All patients were given i.v. norepinephrine. Heart rate, pulse oxymetry, blood pressure, pulmonary artery catheter data (C.I., PVRI, MPAP, PAOP, SvO(2), CVP), and arterial and right heart side venous blood gas analysis data (ph, PaO(2), PaCO(2), SatO(2), HCO(3)(-), SvO(2)) were recorded before and immediately after the lung recruitment maneuver. The static compliance of the respiratory system (CRS) was recorded. Echocardiographic spot evaluations before and after RM were obtained in all cases. RESULTS: Central venous pressure increased during RM. Mean pulmonary artery pressure, pulmonary capillary wedge pressure and pulmonary vascular resistance index were reduced during PCV RM compared to SI RM (P<0.05). The right ventricle stroke work index decreased to a major extent during PCV RM (P<0.05). The P/F ratio was significantly increased after PCV RM compared to SI RM (P<0.05). PaCO(2) levels were similar in the two groups. Compared to baseline, the Qs/Qt decreased significantly after the PCV recruitment maneuver. Ventricular end-diastolic and end-systolic areas decreased during both RM protocols, but they were decreased to a greater extent after SI RM than after PCV RM (P<0.05). The eccentricity index increased from baseline after the SI RM (P<0.05). CONCLUSION: Given its comparable, or even superior, performance over the SI RM, we favor the PCV technique over the time-honored SI maneuver.

Severe scombroid fish poisoning syndrome requiring aggressive fluid resuscitation in the emergency department: two case reports.

Scombroid fish poisoning (scombrotoxism, scombroid ichthyotoxicosis) is a food-related illness typically associated with the consumption of dark and white meat fish. Two patients presented to the emergency department. Metilprednisone 1000 mg and ranitidine 150 mg were administered initially. A large amount of crystalloids and colloids in in combination with vasoactive drugs were required to maintain normopressure. Levels of histamine and N-methylhistamine were far above the normal mean. Carboxyhemoglobin levels were also tested to exclude a superimposition of carbon monoxide intoxication. In both cases, major symptoms occurred and were treated aggressively. Early goal directed fluid therapy corrected the DO2/VO2 unbalance, due to a distributive pattern of hypovolemic impending shock, and permitted a rapid stabilisation of both patients. It is important to recognize the syndrome as an intoxication (rather than an allergic reaction) so that the source of the toxin can be identified and further cases prevented. It is also important to investigate where the fish was cooked (i.e. in an open space vs. closed space), to exclude the possibility of a concomitant carbon monoxide intoxication, which would require transfer the patient to a hospital facility equipped with a hyperbaric chamber.

Postraumatic ARDS: how to place patients who may offer technical problems in a prone position.

Ventilation in the prone position is a valid choice in the treatment of trauma patients with acute respiratory distress syndrome (ARDS). Two cases of trauma patients with ARDS treated in the prone position are described. The technique was very easy to use and safe. The prone position technique proved very useful in the treatment of post-traumatic ARDS in these 2 cases.

[A case of acute nimodipine poisoning. Cardiac and vascular effects]. / Su di un caso di intossicazione acuta da nimopidina. Effetti cardiaci e vascolari.

The authors report a clinical case of acute poisoning after ingestion of nimodipine. The patient, pulseless with a reduced level of consciousness and a third degree AV block, was treated with calcium salts, high doses of dopamine and temporary cardiac pacing. Nimodipine, a nifedipine-like calcium channel blocker, is widely used in cerebrovascular diseases with a low incidence of side effect. No cases of acute poisoning are reported in the literature. The possibility of loss of selectivity at higher doses suggests a cautious use of the drug in patients with alterations of AV conduction.

[Microbiological survey in an Intensive Care Unit] / Indagine microbiologica in un reparto di Rianimazione e Terapia Intensiva.

An epidemiological survey on 417 sample from ICU patients, was carried out from January '97 to December 98 to verify the epidemiology of bacteria responsible for nosocomial infections and to monitor the susceptibility patterns to antimicrobial drugs during this period. Microbiological cultures were positive in 47.7% of the samples. P. aeruginosa was the most frequent pathogen, followed by Staphylococcus aureus, Candida spp, coagulase-negative staphylococci, E.coli, with a clear prevalence of Gram-negative over Gram-positive isolates. The evaluation of the antibiotic susceptibility profile of this bacterial pathogens suggests the importance of a costant epidemiological surveillance in ICU.