Anselmo Caricato

Sequential N-Terminal Pro-B-Type Natriuretic Peptide and High-Sensitivity Cardiac Troponin Measurements During Albumin Replacement in Patients With Severe Sepsis or Septic Shock.

Objectives:Myocardial dysfunction is a frequent complication in patients with severe sepsis and can worsen the prognosis. We investigated whether circulating biomarkers related to myocardial function and injury predicted outcome and were associated with albumin replacement. Design:A multicenter, randomized clinical trial about albumin replacement in severe sepsis or septic shock (the Albumin Italian Outcome Sepsis trial). Setting:Forty ICUs in Italy. Patients:Nine hundred and ninety-five patients with severe sepsis or septic shock. Interventions:Randomization to albumin and crystalloid solutions or crystalloid solutions alone. Measurements and Main Results:Plasma concentrations of N- terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T were measured 1, 2, and 7 days after enrolment. We tested the relationship of single marker measurements or changes over time with clinical events, organ dysfunctions, albumin replacement, and ICU or 90-day mortality in the overall population and after stratification by shock. N-terminal pro-B-type natriuretic peptide levels were abnormal in 97.4% of the patients and high-sensitivity cardiac troponin T in 84.5%, with higher concentrations in those with shock. After extensive adjustments, N-terminal pro-B-type natriuretic peptide concentrations predicted ICU or 90-day mortality, better than high-sensitivity cardiac troponin T. Early changes in N-terminal pro-B-type natriuretic peptide or high-sensitivity cardiac troponin T concentrations were independently associated with subsequent mortality in patients with shock. Patients given albumin had significantly higher N-terminal pro-B-type natriuretic peptide levels; in addition, early rise in N-terminal pro-B-type natriuretic peptide was associated with a better outcome in this subgroup. Conclusions:Circulating N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T are frequently elevated in severe sepsis or septic shock and have relevant prognostic value, which may be important in monitoring the clinical efficacy of supporting therapy.

Quantitative cerebral blood flow and metabolism determination in the first 48 hours after severe head injury with a new dynamic spect device

SummaryObjectiveTo determine cerebral blood flow (CBF) and metabolism in the acute phase after severe head injury by a new dynamic SPECT device using133Xenon and to evaluate a possible role of CBF and metabolism in the determination of prognosis.DesignProspective studySettingGeneral intensive care unit in a universitary teaching hospitalSubjects23 severely head injured patients having CT scan and CBF determination, intracranial pressure (ICP) and jugular bulb oxygen saturation monitoring in the first 48 hours.Measurements and main resultsCBF varied from 18.0 to 60.0 ml/100 g/min. No correlation was found between early CBF and severity of trauma evaluated with the Glasgow Coma Score (GCS) (F = 2.151, p = 0.142) and between CBF and prognosis at 6 months evaluated with Glasgow outcome score (GOS) (F = 0.491, p = 0.622; rs = 0.251, p = 0.246). CMRO2 was depressed in relation to the severity of injury, specifically ranging from 0.9±0.5 ml/ 100 g/min in patients with GCS 3 to 1.7 ±0.8 ml/100 g/min in patients with GCS 6–7. In no patient with a CMRO2 less than 0.8 ml/100 g/min was a good outcome observed. A significant correlation was found between GCS and GOS (rs = 0.699, p = 0.0002), between CMRO2 and GOS (F = 4.303, p = 0.031; rs = 0.525, p = 0.013) and between AJDO2 and GOS (F = 3.602, p = 0.046; rs = 0.491, p = 0.017). Fronto-occipital ratio (F/O) of CBF distribution was significantly lower than normal values (χ2=18.658, p = 0.001) but did not correlate either with prognosis (χ2 = 1.626, p = 0.443) or with severity (χ2 = 1.913, p = 0.384).ConclusionsCBF in the first 48 hours after trauma varies within a large range of values and is not correlated with severity and prognosis. Clinical evaluation with GCS and CMRO2 are much more reliable indicators of severity of head trauma and have a significant role in the determination of prognosis. F/O ration is significantly altered from normal values confirming “post-traumatic hypofrontalism” but does not correlate with severity and prognosis.

usefulness of transcranial echography in patients with decompressive craniectomy: a comparison with computed tomography scan*

Objective:To assess the agreement between computed tomography and transcranial sonography in patients after decompressive craniectomy. Design:Prospective study. Setting:The medical intensive care unit of a university-affiliated teaching hospital. Patients:Thirty head-injured patients consecutively admitted to the intensive care unit of “A. Gemelli” Hospital who underwent decompressive craniectomy were studied. Immediately before brain cranial tomography, transcranial ultrasonography was performed. Measurements and Main Results:The mean difference between computed tomography and echography in measuring the dislocation of midline structures was 0.3 ± 1.6 mm (95% confidence interval 0.2–0.9 mm; intraclass correlation coefficient, 0.979; p < .01). An excellent correlation was found between computed tomography and transcranial sonography in assessing volumes of hyperdense lesions (intraclass correlation coefficient, 0.993; p < .01). Lesions that appear hypodense on computed tomography scan were divided in ischemic and late hemorrhagic. No ischemic lesion was localized on echography; a poor correlation was found between computed tomography and echography in assessing the volume of late hemorrhagic lesions (intraclass correlation coefficient, 0.151; p = .53). A quite good correlation between transcranial ultrasonography and computed tomography was found in measuring lateral ventricles width (intraclass correlation coefficient, 0.967; p < .01). Sensitivity and specificity of transcranial ultrasonography in comparison with computed tomography to detect the position of intracranial pressure catheter was 100% and 78%. Conclusions:Echography may be a valid option to computed tomography in patients with decompressive craniectomy to assess the size of acute hemorrhagic lesions, to measure midline structures and the width of lateral ventricles, and to visualize the tip of the ventricular catheter.

Echography in brain imaging in intensive care unit: State of the art

Transcranial sonography (TCS) is an ultrasound-based imaging technique, which allows the identification of several structures within the brain parenchyma. In the past it has been applied for bedside assessment of different intracranial pathologies in children. Presently, TCS is also used on adult patients to diagnose intracranial space occupying lesions of various origins, intracranial hemorrhage, hydrocephalus, midline shift and neurodegenerative movement disorders, in both acute and chronic clinical settings. In comparison with conventional neuroimaging methods (such as computed tomography or magnetic resonance), TCS has the advantages of low costs, short investigation times, repeatability, and bedside availability. These noninvasive characteristics, together with the possibility of offering a continuous patient neuro-monitoring system, determine its applicability in the monitoring of multiple emergency and non-emergency settings. Currently, TCS is a still underestimated imaging modality that requires a wider diffusion and a qualified training process. In this review we focused on the main indications of TCS for the assessment of acute neurologic disorders in intensive care unit.

Bedside detection of acute epidural hematoma by transcranial sonography in a head-injured patient

Sir: A 24 year-old boy was brought to the ED with head injury after a motorcycle accident. On his arrival, he was alert, and his GCS was 14 (V5, M5, E4). A head CT scan was performed, and a small (max width 0.9 cm) temporal epidural hematoma was observed. Since its small dimension, it was not scheduled for surgery, and a new CT scan after 4 h was planned. Transcranial echography (TCE) was performed with a 2.0 MHz transducer insonating in a transverse plane through the temporal acoustic bone window: after identifying the arteries of the circle of Willis, the depth of the insonation window was adjusted (usually 16 cm), so that the butterfly-shaped mesencephalic brainstem and the contralateral skull became visible [1]. In these conditions an epidural hematoma was observed as an hyperechogenic image just inside the skull (Fig. 1). One hour later, the clinical condition was unchanged. TCE was repeated, and an enlargement of the hematoma with a maximum width of 2.5 cm (Fig. 1). CT scan was immediately performed, and the enlargement was confirmed. The hematoma was promptly evacuated, and 7 days later the patient was discharged from the hospital with no neurological deficit. Recently, transcranial sonography of brain parenchyma in adults has been proposed by several authors for the evaluation of the ventricular system, monitoring of midline shift, diagnosis and follow-up of intracranial mass lesions. Seidel G et al. [2] found a good correlation between CT and TCE in the measurements of third (r = 0.83, P \ 0.0001) and lateral ventricles (r = 0.73, P \ 0.0001). Similar agreement between these two imaging techniques were observed by Tang et al. [3] in the measurement of midline shift (gamma = 0.91, P \ 0.01). Maurer et al. [4] used TCE to differentiate ischemic from hemorrhagic stroke. On 151 patients, 18 (12%) had no sufficient acoustic bone window. Of the remaining 133 patients, they observed that a correct sonographic diagnosis was made in the 95% of the cases (126 patients). To our knowledge, this is the first report that shows echographical finding of acute epidural hematoma in adults. Actually, we found that, thanks to the improvement of technology of ultrasound machines, high resolution images of the contralateral skull may be often obtained by the transtemporal approach, so that epidural mass lesion can be rapidly detected by trained physicians. According with recent guidelines [5], morphologic criteria for surgery are based on the volume and thickness of the hematoma, and on the extent of midline shift. All these data may be obtained by transcranial sonography that can be used bedside, together with CT scan, to monitor these patients in case of non-operative management. In conclusion, in our opinion transcranial echography may be a useful tool to monitor epidural hematomas before clinical conditions deteriorate. In all patients with a sufficient acoustic window in the temporal bone, it is a rapid and noninvasive neuroimaging technique that can complement the results of CT scan, and may help to reduce delays in surgical management. Further prospective studies are needed to evaluate sensitivity, specificity and accuracy of this technique

Enoximone in cardiac arrest caused by propranolol: two case reports.

We report two clinical cases of cardiac arrest, the former due to an adverse effect of intravenous (i.v.) propranolol in a patient with systemic sclerosis, the latter from a propranolol suicidal overdose. In both cases, conventional advanced life support (ALS) was ineffective but both patients eventually responded to the administration of enoximone, a phosphodiesterase III (PDE III) inhibitor. After the arrest, both patients regained consciousness and were discharged home. The chronotropic and inotropic effects of PDE III inhibitors are due to inhibition of intracellular PDEIII and are therefore unaffected by beta‐blockers. These cases suggest that PDEIII inhibitors may be useful in restoring spontaneous circulation in cardiac arrest associated with beta‐blocker administration when standard ALS is ineffective.

Post-injury multiple organ failure and late outcome. Is it just an association?

Multiple organ failure (MOF) is associated with a high rate of mortality in trauma patients. Several studies focused on long-term outcome in these patients, and showed that MOF is related to both in-hospital and late mortality and functional status. Exact mechanism of sequelae in MOF is still unclear. The distinction between early and late MOF probably helps to separate two different clinical conditions and find a stronger relationship with outcome.

Continuous Electroencephalography Monitoring in Adults in the Intensive Care Unit

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Are rapid response systems effective in reducing hospital mortality

Critical Care Medicine www.ccmjournal.org 679 evaluations. The objectives were rated by number scales for all candidates, and the objectives were observed by the entire class. In the resulting media firestorm, minority interest groups assured the Department of Defense that any such database, no matter how it was constructed, was fundamentally flawed because the conclusions drawn from it were not compatible with conventional politically correct wisdom. General Mundy found out that accuracy and truthfulness are not the same thing. Political correctness had established that all members of minority groups are as “good” as everyone else, any evidence to the contrary is discriminatory, and anyone who supports that discrimination needs to be censured. Ultimately, the Marine Corps spokesperson apologized for Mundy’s remarks, suggesting that he had been quoted out of context (3). Following this character-building experience, it became apparent to the Marines that this episode was an example of what has come to be called “Clark’s correctness kerfuffle.” In a conversation in August of 2012, Col. James L. Clark, USMC (Ret.), said: “The truth may be constant, but our capability to verbalize the truth is wholly dependent on how politically correct it is.” Correspondingly, the truth may be that certain minority groups do not choose to donate organs with the same frequency as other social groups, but the telling of that truth may invoke the principle of unintended consequences.

Levels of vancomycin in the cerebral interstitial fluid after severe head injury: reply to letter by Magnoni et al.

Sir: We appreciate the interest of Magnoni et al. in our study, as well as the opportunity to clarify their comment. We agree that the analysis of antibiotics’ concentration by microdialysis has several limitations, related mainly to the recovery of the substance in the dialysate, the position of the probe, the diffusion of the antibiotic in the tissue, and the technique of the analysis in the microdialytic sample. Nevertheless, it has two major strengths: