Emanuela Biagioni

Acute Renal Failure and Renal Replacement Therapy in the Postoperative Period of Orthotopic Liver Transplant Patients Versus Nonelective Abdominal Surgery Patients

Acute renal failure (ARF) often complicates the postoperative period of patients undergoing orthotopic liver transplantation (OLT); it is habitually associated with high mortality rates. Similarly, patients undergoing major nonelective abdominal surgery are prone to ARF because of their frequent preexistent morbidities, abdominal sepsis, and needed for extended surgical procedures. The aim of this study was to evaluate the incidence of ARF and use of renal replacement therapy (RRT) among OLT versus nonelective abdominal surgery patients and associations with clinical outcomes. We studied all the patients admitted to a surgical intensive care unit (ICU) from January 2008 to December 2009 after OLT or nonelective abdominal surgery. The inclusion criteria were an ICU stay of at least 48 hours and without prior end-stage renal failure. OLT patients (n=84) were younger and less severly ill than surgery patients (n=60). ARF occurrence was lower among the OLT (29%) than the surgery group (47%) requiring RRT in 71% and 53% of patients due to ARF, respectively. The ICU mortality of ARF patients in both groups (29% OLT and 51% surgery) were greater than among subjects without ARF (2% and 6%). The occurrence of ARF is common among these two patient groups, and associated with increased risk of death among in surgery (+45%) versus in OLT (+27%) patients.

Heat wave in Italy and hyperthermia syndrome.

In the city of Modena, Italy, daily temperatures registered during the year 2003 showed a higher mean increase of 3° C compared with the previous three years, with average temperature of 26.1° C, compared with 22.8° C. The reported ambient temperature was higher than 32.3° C in 84% of the recorded days, and daily values exceeded 35.1° C in 62% of the days. During the summer, four heat waves occurred (June 11–15, July 21–23, August 3–15 and August 17–24). Nine patients affected by hyperthermia syndrome with a mean body temperature of 41.4 ± 1.3° C were admitted to the Intensive Care Unit (ICU) of the Modena Teaching Hospital. Another patient with similar clinical features was not admitted to ICU, but to a general ward, and eventually died a few hours later. Mortality reached 80% and the mean survival time was 4.2 days with median values of one day. All patients except for one were admitted during one of the four above-mentioned heat waves, and in particular, 7 patients were admitted during the period from August 3rd to 15th. A common feature among 8 of the 10 patients was the chronic consumption of psychoactive drugs. According to these observations, it is important to identify a population at risk in case of bioclimatological alarm, to find prevention strategies. It is extremely important in patients with hyperthermia to lower body temperature levels in the early hours to influence the malignant evolution of this severe pathologic process.

Use of recombinant factor IX and thromboelastography in a patient with hemophilia B undergoing liver transplantation: a case report.

Hemophilia B is a congenital recessive disorder caused by deficiency of coagulation factor IX (FIX). Surgical procedures can be performed in patients with hemophilia using high-purity and/or recombinant FIX, which has been shown to be safe and effective in surgical hemostasis. Liver transplantation is the only potentially curative treatment available for these patients, providing a long-term phenotypic cure for hemophilia. End-stage liver disease together with hemophilia exposes patients to greater risks of bleeding complications during the perioperative period with consequent difficulties in managing coagulopathy. The limited experiences reported by different investigators and the various strategies for clotting factor replacement make it difficult to define a single approach with respect to the optimal dose and method of administering FIX to achieve perioperative hemostasis. The limits of plasma-based coagulation tests--prothrombin time, activated partial thromboplastin time--have made thromboelastography a valid alternative in this kind of surgery. It has been demonstrated to be a useful tool for real-time analysis of clot formation using a whole-blood assay format. Further, it accurately illustrates the clinical effects of procoagulant or anticoagulant interventions. In this article, we have described the usefulness of thromboelastography to monitor the ability of high-purity FIX supplementation to restore a normal coagulation state and to guide the perioperative administration of blood products in a successful orthotopic liver transplantation in a hemophilic patient with deficiencies of factors IX and X, presenting with hepatitis C virus-related cirrhosis and hepatocellular carcinoma.

Endotoxin activity levels as a prediction tool for risk of deterioration in patients with sepsis not admitted to the intensive care unit: A pilot observational study

PURPOSE The aim of this prospective observational study was to evaluate in patients with sepsis not requiring intensive care unit admission the relationship between the levels of endotoxin activity assay (EAA) early after sepsis recognition and the risk of development of organ dysfunction (OD). METHODS Endotoxin activity assay levels were drawn immediately after sepsis identification (baseline) and at 6, 24, and 48 hours postbaseline in 50 patients with signs of sepsis of a duration of less than 24 hours. An EAA 0.60 units or greater was considered as highly elevated. RESULTS Logistic regression showed independent association between EAA levels at baseline and the appearance of new OD (adjusted odd ratio, 2.41; 95% confidence interval, 1.18-4.90; P<.05). Fifteen patients (30%) who developed new OD after baseline had at least 1 EAA level 0.60 or greater. The adjusted linear regression analysis showed that across the 4 time points, EAA levels were significantly higher in patients who developed new OD (0.11; 95% confidence interval, 0.01-0.20; P<.05). CONCLUSIONS Endotoxin activity assay levels 0.60 or greater early after sepsis diagnosis in patients not requiring intensive care unit admission predict risk of development of new organ dysfunction. High EAA levels in the first 48 hours of recognition of sepsis are also predictive of risk of deterioration.

Il monitoraggio perioperatorio del paziente settico

L’elevata mortalita perioperatoria del paziente settico da sottoporre a intervento chirurgico fa si che grande attenzione debba essere indirizzata alla ricerca di un corretto approccio multidisciplinare al problema. La condizione di shock settico e il sequestro massivo di liquidi determinato dall’irritazione del peritoneo, elementi presenti in una infezione addominale complicata, spingono il medico rianimatore a somministrare un’aggressiva fluidoterapia per il mantenimento di un’adeguata perfusione d’organo. Peraltro una resuscitazione volemica aggressiva rappresenta un momento patogenetico nella comparsa di un quadro di ipertensione addominale favorente l’insorgenza di complicanze postoperatorie e insufficienza d’organo. In questo complicato equilibrio, il monitoraggio del paziente attraverso segni clinici e tramite una valutazione emodinamica e di perfusione d’organo rappresenta una risorsa indispensabile per ottimizzare le nostre scelte terapeutiche sul singolo caso. Il capitolo affrontera queste problematiche discutendo la gestione di un paziente con una peritonite nosocomiale nelle fasi preoperatorie, intraoperatorie e postoperatorie.

Purpura Fulminans and Septic Shock due to Capnocytophaga Canimorsus after Dog Bite: A Case Report and Review of the Literature

Primary infection by Capnocytophaga canimorsus after dog bite is rare but may be difficult to identify and rapidly lethal. We describe a case of fatal septic shock with fulminant purpura occurred in a patient without specific risk factor two days after an irrelevant dog bite. The patient was brought to hospital because of altered mental status, fever, and abdominal pain. In a few hours patient became hypoxic and cyanotic. The patient became extremely hypotensive with shock refractory to an aggressive fluid resuscitation (40 ml/kg crystalloids). She received vasoactive drugs, antibiotic therapy, and blood purification treatment, but cardiac arrest unresponsive to resuscitation maneuvers occurred. Case description and literature review demonstrated that, also in patients without specific risk factors, signs of infection after dog bite should be never underestimated and should be treated with a prompt antibiotic therapy initiation even before occurrence of organ dysfunction.

The Role of Adjunctive Therapies in Septic Shock by Gram Negative MDR/XDR Infections

Patients with septic shock by multidrug resistant microorganisms (MDR) are a specific sepsis population with a high mortality risk. The exposure to an initial inappropriate empiric antibiotic therapy has been considered responsible for the increased mortality, although other factors such as immune-paralysis seem to play a pivotal role. Therefore, beyond conventional early antibiotic therapy and fluid resuscitation, this population may benefit from the use of alternative strategies aimed at supporting the immune system. In this review we present an overview of the relationship between MDR infections and immune response and focus on the rationale and the clinical data available on the possible adjunctive immunotherapies, including blood purification techniques and different pharmacological approaches.

Therapeutic Hypothermia in the Intensive Care Unit

Therapeutic hypothermia (TH) is a strategy aimed to provide a controlled lowering of body temperature by means of appropriate cooling systems. The hypothesis that low temperatures could have positive impact on critically ill patients went through the centuries, but only the recent technological development allows to reconsider a systematic application of TH. The application of hypothermia may have significant side effects and its pathophysiological mechanisms are still unclear. International guidelines suggest to use hypothermia in patients with return of spontaneous circulation after cardiocirculatory arrest and persistent coma, but several key issues remain still open such as the target temperature.

Loss of Self-Regulation in Interstitial Fluid Dynamics of Septic Patients, and Oedema Development Patterns

Attempts to effectively intervene on sepsis mechanisms by correcting the dysfunction and the pathological activation of microcirculation—and, therefore, of the endothelium—represent the most fascinating challenge for physicians and researchers dealing with these patients. However, to date there is no evidence that specific therapeutic strategies aimed at controlling micro-vascular endothelium may, in patients suffering septic shock, provide clinical benefits and increased survival probability. As for oedema and sepsis, the news is even worse: we know that the formation of oedema is a constant in patients with sepsis, we know that the development of oedema can cause the deterioration of organ functioning due to deficient perfusion and cellular oxygenation and we know that, unfortunately, today there is no effective drug nor winning strategy.

Abdominal Compartment Syndrome and Fluid Replacement: A Dog That Bites Its Own Tail?

It’s 5:50 in the evening and the phone rings in the ICU. “Hi, Massimo, I was wondering if you had any beds free. Someone has been brought back to the operating room after undergoing surgery at the beginning of the week, because he had wound dehiscence on one of the sutures with a build-up of necrotic material and pus around the pancreas. I wanted to bring him to you as I’m having trouble maintaining correct pressure and have given anaesthesia. I’ve been told that since this morning he has had difficulty breathing and saturation is low. I have had to provide PEEP and 60% oxygen. He can urinate but before being transferred he took Lasix on the recommendation of his cardiologist because pulmonary oedema was suspected. But I don’t think that’s right. CVP is 6 and there are no X-rays. I still haven’t understood what they want to do, but so far they have only washed him; I’m sending you the cultures taken in the ward that were sent for microscopic analysis…”. The reality is that we have no free beds in intensive care, and so begins the customary “dance” that leads to unplanned discharge of the patient: selection of a lower-risk patient (what indicators? SOFA score, destination and good sense), bed availability in intended ward (always difficult), preparation of patient and documents, communication with patients and parents. Meanwhile the trainee doctor says: “Do you not think that this year we have had a few too many repeated surgical procedures? Why?” (perhaps it’s true, I’ll think about it). Immediately afterwards the nurse says, “Doctor, do we have to prepare anything in particular?”.