Alessandro Di Filippo

Bedside diagnostic laparoscopy to diagnose intraabdominal pathology in the intensive care unit

IntroductionDelayed diagnosis of intraabdominal pathology in the intensive care unit (ICU) increases rates of morbidity and mortality. Intraabdominal pathologies are usually identified through presenting symptoms, clinical signs, and laboratory and radiological results; however, these could also delay diagnosis because of inconclusive laboratory tests or imaging results, or the inability to safely transfer a patient to the radiology room. In the current study we evaluated the safety and accuracy of bedside diagnostic laparoscopy to confirm the presence of intraabdominal pathology in an ICU setting.MethodsThis retrospective study, carried out between January 2006 and June 2008, evaluated the diagnostic accuracy of bedside diagnostic laparoscopy performed on patients with a suspicion of ongoing intraabdominal pathology. Clinical indications for bedside diagnostic laparoscopy were: ultrasonography (US) images of gallbladder distension or wall thickening of more than 3 to 4 mm, with or without pericholecystic fluid; elevation of laboratory tests (bilirubin, transaminases, myoglobin, lactate dehydrogenase, creatine phosphokinase, gamma-glutamyltransferase); high level of lactate/metabolic acidosis; CT images inconclusive for intraabdominal pathology; or inability to perform a CT scan. Patients did not undergo bedside diagnostic laparoscopy if they presented clear indications for open surgery, coagulopathy, abdominal wall infection or high intraabdominal pressure.ResultsThirty-two patients underwent bedside diagnostic laparoscopy (Visiport Plus, Autosuture, US), 14 of whom had been admitted to the ICU for major trauma, 12 for sepsis of unknown origin and 6 for complications after cardiac surgery. The procedure was performed on an average of eight days after ICU admission (95% confidence interval = 5 to 15 days) and mean procedure duration was 40 minutes. None of the procedures resulted in complications. Bedside diagnostic laparoscopy was diagnostic for intraabdominal pathology in 15 patients, who subsequently underwent surgery, except in two cases of diffuse gut hypoperfusion. Diagnosis of cholecystitis was obtained in seven cases: two were treated with laparotomic cholecystectomy and five with percutaneous gallbladder drainage positioning.ConclusionsBedside diagnostic laparoscopy represents a safe and accurate technique for diagnosing intraabdominal pathology in an ICU setting and should be taken into consideration when patient transfer to radiology or the operating room is considered unsafe, or when routine radiological examinations are not conclusive enough to reach a definite diagnosis.

Altered pharmacology in the intensive care unit patient

Critically ill patients, not infrequently present alterations of physiological parameters that determine the success/failure of therapeutic interventions as well as the final outcome. Sepsis and polytrauma are two of the most common and complex syndromes occurring in Intensive Care Unit (ICU) and affect drug absorption, disposition, metabolism and elimination. Pharmacological management of ICU patients requires consideration of the unique pharmacokinetics associated with these clinical conditions and the likely occurrence of drug interaction. Rational adjustment in drug choice and dosing contributes to the appropriateness of treatment of those patients.

Infection prevention in the intensive care unit: Review of the recent literature on the management of invasive devices

Abstract Over the last 5 y, clinical trials investigating products, procedures, and treatments aimed at preventing infections in the intensive care unit have been described. The findings of these studies appear to confirm the effectiveness of certain preventive procedures. With regard to ventilator-associated pneumonia, the efficacies of decontamination of the oral cavity, continuous suction of subglottic secretions, positioning of the patient, selective decontamination of the digestive tract, and (for higher-risk patients) endotracheal tubes coated with silver, have been demonstrated. Medicated catheters and chlorhexidine-based dressings have been found useful for catheter-related bloodstream infections, and medical catheters have also been shown to be efficacious against urinary tract infections. All these procedures can be incorporated into departmental protocols for the prevention of nosocomial infections in the intensive care unit.

Out-of-hospital asystole caused by hanging treated with endovascular mild therapeutic hypothermia: a case report

Hanging may result in death either from direct, immediate damage to vital organs (spinal cord injury, airway disruption, carotid artery laceration), or from indirect effects on the cardiovascular system (autonomic reflex through the carotid sinus body compression, airway occlusion), with cardiac arrest representing the worst clinical complication [1]. Here we report a case of out-of-hospital cardiac arrest caused by hanging, which has been treated with mild therapeutic hypothermia by an endovascular technique, with complete neurological recovery. A 53-year-old man attempted suicide by hanging. The Mobile Pre-hospital Emergency Team was alerted by his wife, and arrived on the site 10 min after the event. At the scene, the medical team found the patient positioned on the floor in cardio-respiratory arrest (first cardiac rhythm detected was asystole). A cervical collar and an intravenous line were immediately put in place, and the Advanced Life Support protocol was started by the paramedics and the emergency physician on the scene. The patient was immediately intubated, artificially ventilated, and received epinephrine (2 mg) and atropine (1 mg). After 5 min of resuscitation, during which time the patient remained in asystole, the patient recovered a spontaneous cardiac sinus rhythm (heart rate 90 beats/ min), with an arterial blood pressure of 120/70 mmHg. The Glasgow Coma Scale (GCS) was 4, and pupil assessment was normal. The patient was transferred to the Trauma Center by Emergency Helicopter after medication with midazolam, morphine, atracurium. The patient was admitted to the ED 1 h after the event. An anesthesiologist from the Intensive Care Unit (ICU) was present at admission, and followed the patient during ED assessment, as provided in the internal protocol of the Trauma Center. A central venous oximetry catheter (PreSep, Edwards Lifesciences LLC, Irvine, CA, USA) was inserted in the right internal jugular vein, under the guide of a bedside ultrasonography, and a catheter for invasive arterial pressure monitoring (Leadercath, Vygon, Ecouen, France) was placed in the left femoral artery. A mean arterial pressure (MAP) above 65 mmHg, and a central venous oxygen saturation (CvO2 sat) above 70% was achieved with fluid [saline and 6% hydroxyethylstarch (HES 130/0.4)] infusions. After stabilization, the patient underwent a computerized tomography (CT)-scan of the head–neck–spinal vertebrae region, which demonstrated no encephalic alteration or traumatic dislocation of the cervical vertebrae, and was transferred to the ICU. On admission to the ICU, the patient had a GCS of 7. He presented myoclonus limited to the upper limbs. Empiric therapy for post-anoxic seizures was started with valproic acid which was maintained until discharge. After sedative (propofol and fentanyl) wash-out, we performed an electroencephalographic (EEG) examination that showed signs of post-anoxic cerebral distress, but no seizure-like electrical activity. Somatosensory evoked potentials (SEPs) did not show cortical–subcortical signal alterations. A mild therapeutic endovascular hypothermia was started almost 5 h after the event and maintained for 24 h (tympanic temperature at admission: 35.9-C). The CoolGard Icy Catheter (Alsius corp., Irvine, California, USA; 8,5 fr) was positioned in the right femoral vein. The patient’s core temperature was maintained between 32 and 34 C. An G. Zagli (&) S. Batacchi M. Bonizzoli A. Di Filippo A. Peris Intensive Care Unit, Emergency Department, Careggi Teaching Hospital, University of Florence, Viale Morgagni 85 6, 50134 Florence, Italy e-mail: giovanni.zagli@unifi.it

Pneumopericardium after major trauma.

CASE REPORT A 20-year-old male, after falling from 15 meters, reported a major trauma that consisted with hemorrhagic shock, PNX and pneumopericardium, lung contusions, retroperitoneal bleeding, lumbar vertebral fractures, leg and arm multiple fractures. The patient, in emergency room, was intubated and submitted to first-line diagnostic evaluation for major trauma that revealed a negative for intra-abdominal bleeding FAST, and a negative for PNX thorax Rx. Because an episode of hypotension and hypoxemia with reduction of breathing sound in right thorax, a chest drainage tube was inserted in midclavear line on the second intercostal space. The maneuver was successful and the symptoms were reduced. But, during computed tomography scan evaluation, the patient developed a new hypotension, hypoxemia, edema and cyanosis of the neck and superior thorax, and jugular veins over distension. The computed tomography scan of thorax revealed a tension PNX and pneumopericardium (Fig. 1). Therefore, the physician inserted a tube in the fifth intercostals space in axillary line that resolved the PNX and the pneumopericardium too (Fig. 2).

Minimum anesthetic volume in regional anesthesia by using ultrasound-guidance

The ultrasound guidance in regional anesthesia ensures the visualization of needle placement and the spread of Local Anesthetics. Over the past few years there was a substantial interest in determining the Minimum Effective Anesthetic Volume necessary to accomplish surgical anesthesia. The precise and real-time visualization of Local Anesthetics spread under ultrasound guidance block may represent the best requisite for reducing Local Anesthetics dose and Local Anesthetics-related effects. We will report a series of studies that have demonstrated the efficacy of ultrasound guidance blocks to reduce Local Anesthetics and obtain surgical anesthesia as compared to block performed under blind or electrical nerve stimulation technique. Unfortunately, the results of studies are widely divergent and not seem to indicate a dose considered effective, for each block, in a definitive way; but it is true that, through the use of ultrasound guidance, it is possible to reduce the dose of anesthetic in the performance of anesthetic blocks.

Influence of OPRM1 Polymorphism on Post-operative Pain After Intrathecal Morphine Administration in Italian Patients Undergoing Elective Cesarean Section

Objectives: The aim of this prospective observational study was to evaluate the influence of OPRM1 polymorphism on the analgesic efficacy (including visual analog scale [VAS] scores and requirement for rescue analgesia) of a standard dose of intrathecal morphine. Materials and Methods: An Italian cohort of 63 parturients, scheduled for elective cesarean section at a tertiary University Hospital, received spinal anesthesia with hyperbaric bupivacaine and morphine 100 mcg. For the first 48 hours in the postoperative period the patients received acetaminophen 1 g IV q6hr. Incident pain was treated with ketorolac 30 mg IV. Every 6 hours the following parameters were registered: VAS at rest, VAS during movements, postoperative nausea and vomiting, pruritus, and rescue analgesic medications requirements. Age and anthropometric data, number of pregnancies, educational level, OPRM1 genotype, were also obtained. Results: Of the 63 patients enrolled, 45 (71%) were homozygous genotype A/A (118A group), whereas 18 carried the G variants of OPRM1 (A/G or G/G) (118G group). No significant differences in analgesic rescue doses’ administration and in incidence of moderate/severe postoperative pain (VAS>3) between the 2 groups were observed. Pruritus was more frequent in the 118A group than in the 118G group in the first 24 hours of the postoperative period. Discussion: In the Italian population participating in this study there was a different incidence of pruritus in the postcesarean period in response to intrathecal opioids related to OPRM1 gene polymorphism, but not of postoperative pain.

Anesthetic Volume for Ultrasound-Guided "Double Bubble" Infraclavicular Block: Comparison of Ropivacaine 0.75% 30ml Vs 35ml

For an UltraSound guided Infraclavicular Block, a non-inferiority randomized study was conducted comparing two volumes of ropivacaine 0.75%: 35 ml vs 30ml. Fifty 18-70 years old patients undergoing upper limb surgery, ASA I-II were enrolled. Exclusion criteria included existing neurologic disease, coagulopathy, allergy, pregnancy, previous surgery in clavicular region, BMI more than 30 kg/m2 or patients unable to give written consent. Using US guidance, a 22 gauge/80 mm SonoPlex needle (Pajunk®) was advanced until the tip was located dorsally to the artery at a 6-o’clock position. Correct placement was ensuring by a “double bubble” sign. The block was performed by delivering ropivacaine 0.75% via an infusion pump (Alaris® PK) at 600 ml/h.