Maria Grazia Bocci

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.

Good neurological recovery after cardiopulmonary resuscitation and thrombolysis in two old patients with pulmonary embolism

The use of thrombolysis as an emergency treatment for cardiac arrest (CA) due to massive pulmonary embolism (MPE) has been described. However, there are no reports of successful treatment of MPE‐associated CA in patients over 77 years of age. We report two cases of successful cardiopulmonary resuscitation for an MPE‐associated CA in two very old women (87 and 86 years of age). In both cases, typical signs of MPE were documented using emergency echocardiography, which showed an acute right ventricle enlargement and a paradoxical movement of the interventricular septum. Emergency thrombolysis was administered during resuscitation, which lasted 45 and 21 min, respectively. Despite old age and prolonged resuscitation efforts, both patients had good neurological recovery and one of them was alive and neurologically intact 1 year later. Thrombolysis is a potentially useful therapy in MPE‐associated CA. A good neurological outcome can be obtained even in very old patients and after prolonged resuscitation.

Alfentanil does not increase resistance of the respiratory system in ASA I patients ventilated mechanically during general anesthesia.

PurposeSeveral experimental and clinical studies have demonstrated a direct bronchoconstrictor effect of opioids on smooth bronchial musculature followingiv administration. The aim of this study was to evaluate the effects of alfentanil on respiratory system mechanics in a group of ASA I patients ventilated mechanically during general anesthesia.Clinical featuresTwenty consecutive ASA I patients (ten men and ten women) scheduled for general surgery interventions were studied (mean age 45.4 ± 9.9 yr, mean weight 61.9 ± 6.7 kg). Exclusion criteria were a history of chronic obstructive pulmonary disease, asthma or other pulmonary disease, atopy, wheezes, smoking and age below 18 yr. Subjects were randomly divided in two groups: Group A, receiving alfentanil at a 15 μg·kg−1 dose and Group B receiving alfentanil at a 30 μg·kg−1 dose. Respiratory mechanic variables were acquired at baseline (T0) and after three, ten and 15 min (T1, T2 and T3, respectively). We compared the basal values to the values measured at each time interval; basal values, prior to drug administration, served as control for each patient. P values < 0.05 were considered statistically significant.ResultsWe did not observe significant differences in respiratory mechanic variables after the administration of alfentanil, 15 and 30 μg·kg−1. More specifically, respiratory system compliance and the different subcomponents of respiratory system resistances (i.e., maximum, minimum and delta resistance of respiratory system) were within normal limits and did not vary after alfentanil administration.ConclusionNo respiratory adverse effect was reported after alfentaniliv administration.RésuméObjectifDe nombreuses études expérimentales et cliniques ont démontré un effet bronchoconstricteur direct des opioïdes intraveineux sur la musculature lisse bronchique. Le but de notre étude était d’évaluer les effets de l’alfentanil sur la mécanique du système respiratoire chez un groupe de patients ASA I ventilés mécaniquement pendant une anesthésie générale.Éléments cliniquesVingt patients consécutifs ASA I ont été étudiés (dix hommes) pendant une intervention de chirurgie générale (âge moyen 45,4 ± 9,9 ans, poids moyen 61,9 ± 6,7 kg). Les critères d’exclusion étaient: un historique de bronchite chronique obstructive, asthme ou autres maladies pulmonaires, allergies, tabagisme, sibilances à l’auscultation pulmonaire et un âge inférieur à 18 ans. Les sujets ont été randomisés en deux groupes: Groupe A, recevant 15 μg·kg− 1 d’alfentanil et Groupe B recevant 30 μg·kg− 1 d’alfentanil. Les variables de la mécanique respiratoire ont été mesurés au départ (T0) et après trois, dix et 15 min (T1, T2 et T3, respectivement. Les données de base ont été comparées avec les données mesurées après chaque intervalle de temps, les valeurs de P < 0,05 ont été jugées statistiquement significatives.RésultatsAucune différence significative entre les variables de mécanique respiratoire n’a été observée après l’administration d’alfentanil, aussi bien après une dose de 15 que de 30 μg·kg− 1. En particulier, la compliance du système respiratoire et les différentes variables des composantes des résistances du système respiratoire (les résistances maximale, minimale et delta du système respiratoire) se situaient dans des limites normales et n’ont pas montré de variations significatives après alfentanil.ConclusionAucun effet secondaire sur la mécanique respiratoire n’a été remarqué après l’administration iv d’alfentanil.

Lice, rodents, and many hopes: a rare disease in a young refugee

Migrants from countries with scarce resources represent an increasing worldwide phenomenon providing a daily challenge for governments and humanitarian organizations [1, 2]. A teenage refugee from East Africa was admitted to our intensive care unit (ICU) with acute respiratory distress syndrome (ARDS), hypotension, and jaundice. Nits were present on her scalp and she had no relevant past medical history. She arrived in Italy after travelling for 7 months under poor hygienic conditions. ARDS was managed with protective mechanical ventilation (tidal volume 350 ml, plateau pressure 28 cmH2O), high positive end-expiratory pressure (15 cmH2O), neuromuscular blocking agents, prone positioning, and inhaled nitric oxide. Septic shock and sepsis-induced cardiac dysfunction required administration of high doses of norepinephrire (0.8 μg/kg/min) and dobutamine (8 μg/kg/min). Continuous renal replacement therapy (CRRT) was started for acute kidney injury. Laboratory findings were relevant for anemia, low platelet count, altered blood coagulation, and high procalcitonin. Microbiological tests were performed before the administration of piperacillin-tazobactam and levofloxacin along with the application of pyrethrins foam. In the differential diagnosis we evaluated epatotropic viruses, Legionella species, miliary tuberculois, intestinal parasites, Schistosoma Haematobium, Rickettsia species, Leptospira species, Borrelia species, Leishmania species, and Malaria species related infections. On day 3, the blood and urine samples were positive on real-time polymerase chain reaction (PCR) [3, 4] for Leptospira spp. (Fig. 1a) and Borrelia recurrentis (only in the blood sample; Fig. 1b). Antibiotic therapy with 100 mg doxycycline every 12 h and 2 g ceftriaxone every 12 h was started, leading to a progressive improvement of the patient’s clinical status. On day 21 she was moved to the infectious disease ward, and 10 days later she ran away the hospital and has never come back for clinic follow-up. Borrelia recurrentis infection is a louse-borne disease and Leptospirosis is a rat-borne zoonosis, both endemic in areas characterized by a low hygiene condition. This is the first case of life-threatening Borrelia recurrentis and Leptospira species co-infection [1, 2, 5]. Spirochetosis-related disease is considered a rare pathology in nonendemic areas whereby the infection might be underdiagnosed. Delay in diagnosis and therapy may lead to dangerous outbreaks in refugees camps leading to severe clinical pictures in infected subjects. Our patient ran away from the hospital without completing the path of care, being afraid of being repatriated. Indeed, even though we are able provide such patients with all the latest technologies, we cannot completely care for them without taking into account their social, psychological, and human needs.