Grazia Portale

Cardiopulmonary bypass in man: role of the intestine in a self-limiting inflammatory response with demonstrable bacterial translocation

BACKGROUND Cardiopulmonary bypass provokes a systemic inflammatory reaction that, in 1% to 2% of all cases, leads to multiorgan disfunction. The aim of this study was to evaluate the possible role of the intestine in the pathogenesis and development of this reaction. METHODS Eleven selected patients scheduled for elective coronary artery bypass graft surgery were enrolled in a open, prospective clinical study. Gastric tonometry, chromium-labeled test and double sugar intestinal absorption tests, polymerase chain reaction microbial DNA test, and measurement of cytokines and transcriptional factor (nuclear factor kappaB) activation were performed. RESULTS During the postoperative period, gastric pH remained stable (range,7.2 to 7.3). The partial pressure for carbon dioxide gradient between the gastric mucosa and arterial blood increased significantly (from 1 to 23 mm Hg), peaking in the sixth postoperative hour. Interleukin 6 increased significantly over basal levels, peaking 3 hours after cardiopulmonary bypass (96.3 versus 24 pg/mL). Nuclear factor kappaB never reached levels higher than those observed after lipopolysaccharide stimulation. Escherichia coli translocation was documented in 10 patients: in eight cases from removal of aortic cross-clamps and in two cases from the first postoperative hour. With respect to basal value (6.4%), the urine collection revealed a significant increase in excretion of the radioisotope during the first 24 hours after surgery (39.1%), although there were no significant variations with the double sugar test. CONCLUSIONS The results obtained showed a correlation between the damage of the gastrointestinal mucosa, subsequent increased permeability, E coli bacteremia, and the activation of a self-limited inflammatory response in the absence of significant macrocirculatory changes and postoperative complications.

Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects.

The purpose of this study was to set an effective standardized method to assess diaphragmatic kinetics by ultrasound. Forty healthy volunteers were submitted to a B- and M-mode ultrasound study using a convex transducer positioned in the subcostal anterior area for transverse scanning. Ultrasound examination was completed in 38/40 cases (95%), spending on average <10 min for examination. The resting and forced diaphragmatic excursions were 18.4 ± 7.6 and 78.8 ± 13.3 mm, respectively, unrelated to demographic or anthropometric parameters: intraobserver variability on three successive measurements resulted in 6.0% and in 3.9%, respectively. An inexperienced sonographer completed the ultrasound examination in 37/40 cases, spending on average >15 min, with significant, although marginal, interobserver variability (31.9% and 14.7% for resting and forced diaphragmatic excursion, respectively). Bedside ultrasonography by an anterior subcostal transverse scanning on semi-recumbent patient proves to be a safe, feasible, reliable, fast, relatively easy and reproducible way to assess diaphragm movement.

Early recognition of the 2009 pandemic influenza A (H1N1) pneumonia by chest ultrasound

IntroductionThe clinical picture of the pandemic influenza A (H1N1)v ranges from a self-limiting afebrile infection to a rapidly progressive pneumonia. Prompt diagnosis and well-timed treatment are recommended. Chest radiography (CRx) often fails to detect the early interstitial stage. The aim of this study was to evaluate the role of bedside chest ultrasonography (US) in the early management of the 2009 influenza A (H1N1)v infection.Methods98 patients who arrived in the Emergency Department complaining of influenza-like symptoms were enrolled in the study. Patients not displaying symptoms of acute respiratory distress were discharged without further investigations. Among patients with clinical suggestion of a community-acquired pneumonia, cases encountering other diagnoses or comorbidities were excluded from the study. Clinical history, laboratory tests, CRx, and computed tomography (CT) scan, if indicated, contributed to define the diagnosis of pneumonia in the remaining patients. Chest US was performed by an emergency physician, looking for presence of interstitial syndrome, alveolar consolidation, pleural line abnormalities, and pleural effusion, in 34 patients with a final diagnosis of pneumonia, in 16 having normal initial CRx, and in 33 without pneumonia, as controls.ResultsChest US was carried out without discomfort in all subjects, requiring a relatively short time (9 minutes; range, 7 to 13 minutes). An abnormal US pattern was detected in 32 of 34 patients with pneumonia (94.1%). A prevalent US pattern of interstitial syndrome was depicted in 15 of 16 patients with normal initial CRx, of whom 10 (62.5%) had a final diagnosis of viral (H1N1) pneumonia. Patients with pneumonia and abnormal initial CRx, of whom only four had a final diagnosis of viral (H1N1) pneumonia (22.2%; P < 0.05), mainly displayed an US pattern of alveolar consolidation. Finally, a positive US pattern of interstitial syndrome was found in five of 33 controls (15.1%). False negatives were found in two (5.9%) of 34 cases, and false positives, in five (15.1%) of 33 cases, with sensitivity of 94.1%, specificity of 84.8%, positive predictive value of 86.5%, and negative predictive value of 93.3%.ConclusionsBedside chest US represents an effective tool for diagnosing pneumonia in the Emergency Department. It can accurately provide early-stage detection of patients with (H1N1)v pneumonia having an initial normal CRx. Its routine integration into their clinical management is proposed.

Use of non-invasive mechanical ventilation in the Emergency Department, clinical outcomes and correlates of failure

Background: Despite several studies having been carried in this organizational context, there is an absence of information about the effectiveness of non-invasive mechanical ventilation (NIV) in Emergency Departments (ED), based on a number of suitable patients with acute respiratory failure (ARF) of different aetiology. In particular, it has not yet been defined as to whether the context of the ED suits the necessary requirement of quality for the correct application of the method and if the obtained results are different from those taken in other studies in general or respiratory intensive care unit. Finally there are few data related to the predictive factors to NIV failure (endotracheal intubation, in-hospital mortality) when applied in the emergency setting. Methods: To answer these questions we have retrospectively studied a population of 210 patients (95 with COPD exsacerbation ; 92 with acute cardiogenic pulmonary oedema; 23 with severe community acquired pneumonia) treated for ARF in the “critical area” of four Italian level II Emergency Departments. For all patients demographic data; some comorbidities (diabetes, dementia, sopraventricular arrhythmias, obesity); the physiological scores (Kelly, SAPS II, Apache II); the need for pharmacological sedation; vital and blood gas parameters (evaluated at entry, after one hour of treatment and before its suspension); the ventilatory modality applied (CPAP or PSV + PEEP) and some parameters of in-hospital stay (duration of the hospitalization in the critical area, duration of ventilation, compliance to the treatment, patients refusal to continue it, development of skin necrosis, need for endotracheal intubation, in-hospital mortality) were considered. Finally demographic, event of death with Cox regression or to the need for ETI through linear regression analysis. Results: Globally, in-hospital mortality reached 13,3%, the percentage of failure with consequent endotracheal intubation amounted to 10,4% . Considering the single aetiologic groups in the patients with COPD, exsacerbation mortality and ETI percentage were 12,6% and 13,7% respectively; in ACPO patients these data respectively amounted to 3,3% and 4,3%; while for patients with severe CAP they respectively reached 34,7% and 21,7%. The following factors were independently correlated with in-hospital mortality: SAPS II > 35, presence of dementia for COPD patients; SAPS II > 35; presence of dementia, presence of sopraventricular arrhythmias for ACPO patients; SAPS II > 35, presence of sopraventricular arrhythmias, presence of dementia for CAP patients. Considering the whole population of 210 patients, the predictive factors of in-hospital mortality were the following: SAPS II > 35; presence of dementia; presence of sopraventricular arrhythmias; maintenance of a respiratory rate above 24 bpm during tratment. The following were factors independently correlated with the need for endotracheal intubation: male gender, pH 24 bpm, mean arterial pressure > 96 mmHg, all measured at one hour of treatment, for COPD patients; male gender sex, pH 24 bpm, PaCO2 > 54,5 mm Hg all measured after one hour treatment for ACPO patients. Given the low number of patients, it was not possible to perform the logistic regression and to calculate the matrix of covariance of the parameter for the CAP group. Considering the whole series of patients, the factors independently correlated to ETI resulting in the following: male gender; diagnosis of COPD; pH 24 bpm, mean arterial pressure >96 mm Hg, PaCO2 >54,5 mm Hg, all measured after one hour treatment. Conclusions: In conclusion, our study shows that NIV is practicable in the ED with safety and clinical results

Abstract 309 Continuous positive airway pressure versus noninvasive positive pressure ventilation in acute cardiogenic pulmonary edema: a prospective, randomized, multicentric study

309 Continuous positive airway pressure versus noninvasive positive pressure ventilation in acute cardiogenic pulmonary edema: a prospective, randomized, multicentric study G. Ferrari, P. Groff, G. De Filippi, F. Giostra, M. Mazzone, G. Portale, N. Gentiloni Silveri, F. Aprà, E. Vitale and F.Olliveri Emergency Department, St Giovanni Bosco Hospital, Turin, Policlinico St Orsola Malpighi, Bologna, Policlinico A. Gemelli, Rome, Policlinico St Anna, Ferrara, Italy. Background Although noninvasive airway positive pressure has shown to be an effective treatment for acute cardiogenic pulmonary edema (ACPE), the literature still lacks large randomized prospective multicentric studies that compares continuous positive airway pressure (CPAP) and noninvasive positive pressure ventilation (NIV). Aim Assess the efficacy and the safety of CPAP and NIV in patients with ACPE. Study design Multicentric, prospective randomized. End points are intubation rate, resolution time with the two methods, length of stay (LOS) in the ED, improvement in gas exchange, improvement in respiratory rate (RR) and heart rate (HR) and mortality. Methods Inclusion criteria are severe dyspnea at rest, RR430, PaO2/FiO2o250 and muscle fatigue. PSV was started at 10 cmH2O and increased to reach a Vte of 6–8ml/kg and to reduce RR; PEEP/ CPAP was started at 5 cmH2O and increased to keep SpO2492%, with a maximum level of 10 cmH2O allowed. Inspiratory fraction of oxygen (FiO2) was included between 1.0 and 0.4. Results A total of 110 patients were enrolled. Four were excluded because they did not meet clinical/radiological inclusion criteria; 106 patients were randomly assigned to receive CPAP or NIV. Mean age was 76.8710 and 77.4710.1 years and SAPS II score was 40.479.1 and 41.1710.2 in CPAP and NIV, respectively (P1⁄4NS). Initial mean values at randomization were as follows: CPAP – pH 7.2270.11, PaCO2 58.8718.5, PaO2/FiO2 132.2766.4, RR 32.776.03, HR 110.3721.6, mean arterial pressure (MAP) 125.1728.8 and SpO2 80.7717.1; NIV – pH 7.2570.010, PaCO2 58.2719, PaO2/FiO2 159.6796.4, RR 36.575.7, HR 107.4725.7, MAP 115.6725.7 and SpO2 83.2712.4. The two groups were homogenous for all physiological variables except for RR (P1⁄40.033). CPAP and NIV were applied for 6.876.82 and 7.2975.11 h, respectively (P1⁄40.184). No difference was observed for LOS in the ED (CPAP: 63.9751.2, NIV 60.978.4 h; P1⁄40.881) and for hospital LOS (CPAP: 13.271.9, NIV: 7.3671.08 days; P1⁄40.375). After 1 h of treatment, in both groups, a significant improvement was observed in gas exchange and in clinical–physiological variables: pH, PaO2/FiO2, CO2, RR, HR, SpO2 and MAP. Time course analysis also showed a significant improvement over time for all these variables (Po0.001); no difference was shown between the two treatments (P1⁄4NS). Three patients were intubated in the NIV group and no one was intubated in the CPAP group: no statistical difference was observed (P1⁄40.243); all patients who underwent ETI were also those with chronic obstructive pulmonary disease (COPD). No difference was observed in mortality rate: 15 patients died – four in the CPAP group and 11 in the NIV group (P1⁄40.092). Both CPAP and NIV improved gas exchange in normocapnic and hypercapnic patients. Severe obesity did not affect the outcome of CPAP or NIV in patients with ACPE. Conclusions Both CPAP and NIV result in early improvement of gas-exchange and vital signs in patients with ACPE, with no difference in resolution time and hospital LOS. Patients with ACPE and COPD may have a higher percentage of intubation rate.

Goal-directed Ultrasonography for Detecting Traumatic X-ray Missed Fibula Fracture in the Emergency Department

We present the case of a 45-year-old man who presented to the emergency department (ED) for ankle trauma sustained during a football match. Physical examination and X-ray of his ankle were negative for bone fractures. He was discharged from the ED, but returned 3 weeks later with a painful and swelling leg. Compressive ultrasonography of his right lower limb was negative for venous thrombosis, but ultrasound evaluation of the leg clearly showed a fibula fracture. Although the diagnosis of fractures usually relies on X-ray, the literature contains many reports of goal-directed ultrasound diagnosis of long bone fracture in military settings and remote locations. The usefulness of a noninva-sive examination like bedside ultrasonography and goal-directed evaluation of patients in the ED are discussed, with reference to the literature.