Andrea A. Cogliati

Noninvasive ventilation for the treatment of acute respiratory failure in patients with hematologic malignancies: a pilot study

Objective: To evaluate treatment with noninvasive ventilation (NIV) by nasal mask as an alternative to endotracheal intubation and conventional mechanical ventilation in patients with hematologic malignancies complicated by acute respiratory failure to decrease the risk of hemorrhagic complications and increase clinical tolerance. Design: Prospective clinical study. Setting: Hematologic and general intensive care unit (ICU), University of Rome “La Sapienza”. Patients: 16 consecutive patients with acute respiratory failure complicating hematologic malignancies. Interventions: NIV was delivered via nasal mask by means of a BiPAP ventilator (Respironics, USA); we evaluated the effects on blood gases, respiratory rate, and hemodynamics along with tolerance, complications, and outcome. Measurements and results: 15 of the 16 patients showed a significant improvement in blood gases and respiratory rate within the first 24 h of treatment. Arterial oxygen tension (PaO2), PaO2/FIO2 (fractional inspired oxygen) ratio, and arterial oxygen saturation significantly improved after 1 h of treatment (43 ± 10 vs 88 ± 37 mmHg; 87 ± 22 vs 175 ± 64; 81 ± 9 vs 95 ± 4 %, respectively) and continued to improve in the following 24 h (p < 0.01). Five patients died in the ICU following complications independent of the respiratory failure, while 11 were discharged from the ICU in stable condition after a mean stay of 4.3 ± 2.4 days and were discharged in good condition from the hospital. Conclusions: NIV by nasal mask proved to be feasible and appropriate for the treatment of respiratory failure in hematologic patients who were at high risk of intubation – related complications.

Do we know the costs of what we prescribe

Objective: To evaluate the level of cost awareness of drugs and devices among intensive care unit (ICU) doctors with variable levels of experience (senior intensivists, junior intensivists, residents). Design: Interview-questionnaire. Setting: ICU of the University of Rome “La Sapienza”. Participants: 60 ICU doctors (40 specialists in anaesthesia and intensive care, 20 residents). Measurements and results: The estimated prices of drugs and devices were compared with the correct prices; responses within a range ± 20 % of the true price were arbitrarily considered correct; all the subgroups of doctors made inaccurate estimates of the prices, showing an absence of any impact of professional experience of cost awareness. Conclusion: The doctors in the study showed a high level of inacurrate cost awareness of drugs and devices.

Treatment of acute respiratory failure by prolonged non-invasive ventilation in a child

PurposeTo evaluate the feasibility and the efficacy of non-invasive ventilation (NIV) by nasal mask in a paediatric patient.Clinical featuresA four-year-old girl with acute lymphocytic leukaemia (ALL L1 pre-pre B) complicated by acute respiratory failure was treated with NIV On admission she exhibited hyperpyrexia (40C), pancytopaenia and severe hypoxia with hypocapnia (PaO2 = 45 minHg; PaCO2 = 28.2 mmHg; pH = 7.30; SpO2 = 76%; ABE = −7.3 mmol · L−1. With NIV, PaO2 improved (PaO2 = 78 ± 8 mmHg; SpO2 = 86 ± 2; PaCO2 = 39 ± 2) throughout the first day. Treatment was continued for six days until the patient was discharged. No complications were recorded.ConclusionNon-invasive ventilation by nasal mask may represent a choice in the treatment of acute respiratory failure of parenchymal origin in paediatric haematological patients.RésuméObjectifÉvaluer la faisabilité et l’efficacité de la ventilation non invasive (VIN) administrée par masque nasal en pédiatrie.Éléments cliniquesUne fillette de quatre ans atteinte de leucémie lymphocytaire aiguë (ALL L1 prepre B) compliquée d’une insuffisance respiratoire aiguë a été traitée par VIN. À l’admission, elle était hyperpyrexique et profondément hypoxémique avec de l’hypocapnie (PaO2 = 45 mmHg; PaCO2 = 28, 2 mmHg; pH = 7, 30; SPO2 = 76%; ABE = −7, 3 mmol · L−1. La première journée, sous VIN, sa condition s’est améliorée (PaO2 = 78 mmHg; SPO2 = 86±2; PaCO2 = 39±2). La ventilation a été continuée pendant six jours jusqu’au congé de la patiente. II n’y a pas eu de complications.ConclusionLa ventilation non invasive par masque nasal peut représenter une option thérapeutique valable de l’insuffisance respiratoire aiguë d’origine parenchymateuse en hématologie pédiatrique.

Successful weaning from cardiopulmonary bypass with central venous prostaglandin E1 and left atrial norepinephrine infusion in patients with acute pulmonary hypertension.

OBJECTIVE Postoperative pulmonary hypertension increases the mortality risk in cardiac surgery. We have used central venous prostaglandin E1 (PGE1) and left atrial norepinephrine (NE) infusion to wean from cardiopulmonary bypass (CPB) patients with refractory postoperative pulmonary hypertension. DESIGN Observational, nonrandomized study. SETTING Department of Cardiac Surgery in a university hospital. PATIENTS We studied 10 nonconsecutive American Society of Anesthesiologists III and New York Heart Association class III-IV patients with postoperative pulmonary hypertension and low cardiac output syndrome preventing separation from CPB. INTERVENTIONS Patients received right atrial PGE1 (31.5 +/- 6.26 ng/kg/min) and left atrial NE (0.11 +/- 0.02 microg/kg/min) infusion. Hemodynamic data were obtained before CPB (T0), after CPB under maximal inotropes and vasodilator infusion (T1), 10 mins (T2) and 12 hrs (T3) after PGE1 and NE infusion, and 48 hrs after withdrawal of PGE1 and NE (T4). MEASUREMENTS AND MAIN RESULTS All patients were successfully weaned from CPB and survived. The biatrial infusion of PGE1 and NE caused a dramatic reduction in mean pulmonary artery pressure (from 42.8 +/- 5.1 mm Hg at T1 to 28.5 +/- 2.6 mm Hg at T2 and 20.5 +/- 2.0 mm Hg at T4), pulmonary vascular resistance index (from 1158 +/- 269 dyne x sec/cm5 x m2 at T1 to 501 +/- 99 dyne x sec/cm5 x m2 at T2 and 246 +/- 50 dyne x sec/cm5 x m2 at T4), and pulmonary-to-systemic vascular resistance index ratio (from 0.61 +/- 0.17 at T1 to 0.20 +/- 0.04 at T2 and 0.11 +/- 0.03 at T4). Cardiac index increased from 1.7 +/- 0.2 L/min/m2 at T1 to 2.3 +/- 0.2 L/min/m2 at T2 and 2.9 +/- 0.1 L/min/m2 at T4. CONCLUSIONS In patients with refractory postoperative pulmonary hypertension, the combined administration of low-dose PGE1 in the right atrium and NE in the left atrium is an effective means to wean patients from cardiopulmonary bypass.

Calcium Chloride Minimizes the Hemodynamic Effects of Propofol in Patients Undergoing Coronary Artery Bypass Grafting

OBJECTIVE To assess the hemodynamic effects of propofol and the counteracting effect of calcium chloride (CaCl2) in patients undergoing coronary artery bypass grafting (CABG). DESIGN Prospective, randomized study. SETTING University hospital, department of cardiac surgery. PARTICIPANTS Fifty-eight patients undergoing elective CABG, divided into group A (n = 29) and group B (n = 29). INTERVENTIONS Anesthesia was induced with a combination of fentanyl, 7 microg/kg; pancuronium, 0.1 mg/kg; and propofol, 1.5 mg/kg, administered over 60 seconds. A blinded investigator administered saline in group A patients and 10 mg/kg of CaCl2 in group B patients at the same speed and same time as propofol administration through another lumen of the central venous catheter. MEASUREMENTS AND MAIN RESULTS Hemodynamic data were obtained at baseline (T0), 2 minutes after anesthesia induction (T1), and 2 minutes after tracheal intubation (T2). Heart rate decreased significantly in group A patients (86.2+/-11.3 beats/min at T0 and 72.8+/-7.5 beats/min at T2; p < 0.001). Mean arterial pressure decreased significantly in patients in both groups (group A, 108.0+/-12.0 mmHg at T0; 74.6+/-14.6mmHg at T2;p < 0.001 and group B, 106.0+/-10.2 mmHg at T0; 90.4+/-10.0 mmHg at T2; p < 0.05). Stroke volume index, cardiac index, and cardiac output decreased in group A patients (39.4+/-4.1 mL/beat/m2 at T0 and 28.8+/-5.2 mL/beat/m2 at T2; p < 0.05; 3.4+/-0.6 L/min/m2 at T0 and 1.9+/-0.3 L/min/m2 at T2; p < 0.001; 5.9+/-0.9 L/min at T0 and 3.4+/-0.4 L/min at T2; p < 0.001, respectively), whereas in group B patients, changes were negligible (38.1+/-7.0 mL/beat/m2 at T0 v 35.7+/-6.6 mL/beat/m2 at T2; (NS) 3.3+/-0.5 L/min/m2 at T0 v 2.7+/-0.3 L/min/m2 at T2; (NS) 5.7+/-0.9 L/min at T0 v 4.7+/-0.5 L/min at T2; (NS), respectively). CONCLUSION Simultaneous administration of CaCl2 during the induction of anesthesia minimizes the potential negative effect of propofol on cardiac function in cardiac patients.

Noninvasive ventilation in the treatment of acute respiratory failure induced by all-trans retinoic acid (retinoic acid syndrome) in children with acute promyelocytic leukemia.

Purpose To evaluate the feasibility of noninvasive ventilation through a nasal mask in the treatment of acute respiratory failure induced by all-trans retinoic acid. Design Observational, nonrandomized report of two cases. Setting Intensive care unit in a university hospital. Patients Two pediatric patients (an 11-yr-old male and a 12-yr-old female) affected by acute promyelocytic leukemia. Interventions Pressure support ventilation was delivered via a nasal mask by means of a bilevel positive pressure ventilator (Respironics, Murrysville, PA). Measurements and Main Results We evaluated the effects of the bilevel positive pressure ventilator on blood gas analysis, respiratory rate, hemodynamics, patient tolerance, complications, and outcome. Patients showed an improvement of blood gas analysis and respiratory rate after 3–6 hrs of noninvasive ventilation. The nasal mask was well tolerated by the two patients. No complications were observed. Patients were discharged from the intensive care unit in stable clinical conditions after 3–4 days. Conclusions Noninvasive ventilation by a nasal mask can offer effective ventilatory support and improve gas exchange in the treatment of acute respiratory failure in pediatric hematologic patients. In addition, noninvasive ventilation may decrease the risk of life-threatening complications associated with endotracheal intubation and conventional mechanical ventilation in patients with hematologic malignancies.

Neuromuscular relaxants in non-cardiac surgery after cardiomyoplasty

PurposeDynamic cardiomyoplasty is a therapeutic alternative to heart transplantation in irreversible cardiac insufficiency. Little information exists about the use of muscle relaxants in patients with cardiomyoplasty. In particular, it is not clear if the muscle flap is responsive to neuromuscular blockers. The purpose of this report is to describe the safe use of vecuronium in a patient with cardiomyoplasty.Clinical featuresA 59-yr-old man, after cardiomyoplasty for dilated cardiomyopathy two years earlier, underwent general anaesthesia with fentanyl, propofol and vecuronium during surgery for intestinal ischaemia. Intraoperative transthoracic echocardiography showed that vecuronium did not affect muscle flap motion. Two days after surgery he died in septic shock. Post-mortem histological and immunohistochemical examination showed nervous degeneration of the flap probably as a result of the chronic low frequency pacing. There was also an increase in extrajunctional receptors and an alteration in junctional receptors, as demonstrated by the negative reaction to anti-synaptophysin antibodies, used to identify the neuromuscular plate.ConclusionIn patients undergoing non-cardiac surgery after previous cardiomyoplasty, muscle relaxants, such as vecuronium, may be used safely. Depolarising agents, such as succinylcholine, should probably be avoided because of the possible exaggerated actions on extrajunctional receptors.RésuméObjectifLa cardiomyoplastie dynamique est une alternative thérapeutique à la greffe cardiaque dans l’insuffisance cardiaque irréversible. Il existe peu d’information sur l’utilisation des relaxants musculaires chez les patients ayant subi une cardiomyoplastie. De façon plus précise, la réponse du lambeau musculaire aux bloqueurs neuromusculaires est controversée. Le but de cet article est de décrire l’utilisation sécuritaire du vécuronium chez un patient ayant subi une cardiomyoplastie.Aspects cliniquesUn homme de 59 ans, ayant subi une cardiomyoplastie il y a 2 ans pour une cardiomyopathie, a subi une anesthésie générale à base de fentanyl, propofol et vécuronium pour une chirurgie pour ischémie intestinale. Une échographie transthoracique peropératoire a démontré que le vécuronium ne modifiait pas le mouvement du lambeau musculaire. Deux jours après son opération il est décédé de choc septique. L’examen post-mortem tant histologique qu’immunohistochimique a montré une dégénérescence du tissu nerveux du lambeau, probablement comme conséquence de la stimulation chronique à basse fréquence. On retrouvait aussi une augmentation des récepteurs membranaires extrajonctionnels et une altération des récepteurs jonctionnels, tel que démontré par la réaction négative aux anticorps antisynaptophysine, utilisés pour identifier les jonctions neuromusculaires.ConclusionChez les patients subissant une chirurgie non cardiaque après cardiomyoplastie, les relaxants musculaires, tel le vécuronium, peuvent être utilisés sécuritairement. Les agents dépolarisants, tel la succinylcholine, devraient probablement être évités à cause des risques d’effets excessifs sur les récepteurs extrajonctionnels.