Maria Nucera

The increase of endothelial progenitor cells in the peripheral blood: a new parameter for detecting onset and severity of sepsis.

Sepsis is a clinical syndrome characterized by non-specific inflammatory response with evidence of profound changes in the function and structure of endothelium. Recent evidence suggests that vascular maintenance, repair and angiogenesis are in part mediated by recruitment from bone marrow (BM) of endothelial progenitor cells (EPCs). In this study we were interested in whether EPCs are increasingly mobilized during sepsis and if this mobilization is associated with sepsis severity. Our flow cytometry data demonstrate that in the CD34+ cell gate the number of EPCs in the blood of patients with sepsis had a four-fold increase (45 ± 4.5% p<0.001) compared to healthy controls (12 ± 3.6%) and that this increase was already evident at 6 hours from diagnosis (40.6 ± 4.2%), reaching its maximum at 72 hours. Also the percentage of cEPCs identified in the patients with sepsis (35 ± 4.6% of the CD34+ cell) was statistically different (p<0.001) compared to that found in the blood of patients with severe sepsis (75 ± 4.9%). In addition, we proved that at six hours after sepsis diagnosis, VEGF, CXCL8 and CXCL12 serum levels were significantly higher in septic patients compared to healthy volunteers 559 ± 82.14 pg/ml vs 2.9 ± 0.6 (p<0.0001), 189.8 ± 67.3 pg/ml 15 vs 11.9 ± 1.6 (p=0.014) and 780.5 ± 106.5 pg/ml; vs 190.2 ± 71.4 (p < 0.001). Our data suggest that the cEPC evaluation in peripheral blood, even at early times of diagnosis, in patients with sepsis can be envisaged as a valuable parameter to confirm diagnosis and suggest further prognosis.

Ketamine, propofol and low dose remifentanil versus propofol and remifentanil for ERCP outside the operating room: Is ketamine not only a “rescue drug”?

Summary Background Endoscopic retrograde cholangiopancreatography ERCP is a painful and long procedure requiring transient deep analgesia and conscious sedation. An ideal anaesthetic that guarantees a rapid and smooth induction, good quality of maintenance, lack of adverse effects and rapid recovery is still lacking. This study aimed to compare safety and efficacy of a continuous infusion of low dose remifentanil plus ketamine combined with propofol in comparison to the standard regimen dose of remifentanil plus propofol continuous infusion during ERCP. Material/Methods 322 ASAI-III patients, 18–85 years old and scheduled for planned ERCP were randomized. Exclusion criteria were a predictable difficult airway, drug allergy, and ASA IV–V patients. We evaluated Propofol 1 mg/kg/h plus Remifentanil 0.25 μg/kg/min (GR) vs. Propofol 1 mg/kg/h plus Ketamine 5 μg/kg/min and Remifentanil 0.1 μg/kg/min (GK). Main outcome measures were respiratory depression, nausea/vomiting, quality of intraoperative conditions, and discharge time. P≤0.05 was statistically significant (95% CI). Results Respiratory depression was observed in 25 patients in the GR group compared to 9 patients in the GK group (p=0.0035). ERCP was interrupted in 9 cases of GR vs. no cases in GK; patients ventilated without any complication. Mean discharge time was 20±5 min in GK and 35±6 min in GR (p=0.0078) and transfer to the ward delayed because of nausea and vomiting in 30 patients in GR vs. 5 patients in GK (p=0.0024). Quality of intraoperative conditions was rated highly satisfactory in 92% of GK vs. 67% of GR (p=0.028). Conclusions The drug combination used in GK confers clinical advantages because it avoids deep sedation, maintains adequate analgesia with conscious sedation, and achieves lower incidence of postprocedural nausea and vomiting with shorter discharge times.

Regional anticoagulation and antiaggregation for CVVH in critically ill patients: a prospective, randomized, controlled pilot study

Background: The aim of this study is to assess the efficacy and clinical safety of regional anticoagulation (heparin pre‐filter plus post‐filter protamine) plus antiaggregation (pre‐filter prostacyclin) [Group 1 (G1)] vs. only systemic heparin anticoagulation without antiaggregation [Group 2 (G2)] in critically ill patients with acute renal failure undergoing continuous veno‐venous haemofiltration (CVVH).

An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest

We describe a case of more than 5 h cardiac arrest in a 60-year-old patient who underwent general anesthesia for a urologic operation. Before extubation, the patient suddenly developed ventricular fibrillation, pulseless ventricular tachycardia and asystole which was immediately treated by advanced life support (ALS) measures. Thirty minutes later seizures developed and were controlled by 200 mg of thiopentone and 10 mg of diazepam. A pattern of ventricular tachycardia, coarse ventricular fibrillation and asystole lasted for nearly 120 min. Termination of resuscitation maneuvers was considered, but long-term life support was continued for 5 h. After this time, peripheral pulses, with a supraventricular tachycardia-like rhythm and regular spontaneous breathing reappeared. Seven hours later, the patient had a Glasgow Coma Scale (GCS) of 5, dilated unresponsive, absence of pupils, and a systolic arterial pressure of 100 mmHg. He was then transferred to intensive care unit (ICU). The morning after, the patient was awake, responded to simple orders, breathing spontaneously, and free from sensomotor deficit. He was, therefore, extubated. Subsequently, other episodes of transitory ST-line upper wave followed by ventricular fibrillation appeared, suggesting Prinzmetal angina. This was successfully treated by percutaneous coronary angioplasty. The first electroencephalogram recorded the day after cardiac arrest showed a mild widespread background slowing. An electroencephalogram 6 days later showed a return to alpha rhythm with only mild theta-wave abnormalities. Four weeks after the first cardiac arrest the patient was discharged. This is an exceptional experience compared with the others reported. We believe that all the efforts must not be given up when such an event occurs during anesthesia and there are optimal conditions for resuscitation maneuvers.

Correlation Between Markers of TH2-Oriented Response and SOFA Score in Sepsis

A shift from Th1- to Th2-type cell immune response has been suggested to occur during sepsis, contributing to cell-mediated immunity suppression and to poor prognosis. The aim was to study the relationship between old and new Th2 markers and the clinical outcome of sepsis. 30 critically ill patients with sepsis for � 48 hours were enrolled in a pro- spective clinical study. Blood samples were collected at the enrolment, at the 5 th and 10 th day. Serum levels of total IgE and soluble chemokines related to Th1- and Th2 responses were evaluated. The percentages and absolute number of CD4+ and CD8+Tcells as well as CRTH2+Tcell subsets were detected by flow cytometry. Sepsis severity was assessed with SOFA score. The mean values of total IgE in septic patients were significantly higher than in controls(p<0.01). Moreover, IgE levels of septic patients who died were higher than those of survived patients(p<0.05). It has been found that IgE levels directly and RANTES inversely correlated with SOFA score at different time points(p<0.01). A significant correlation between the percentages of CRTH2+/CD4+(but not CRTH2+/CD8+)T cells and SOFA at different time points was observed(p<0.05). The direct correlation between total IgE, the percentages of circulating CRTh2+CD4+T cells and the clinical outcome suggests that clinical worsening of sepsis is closely linked to the shift towards a predominant less protective Th2 phenotype. Although these are preliminary results, the longitudinal analysis of these parameters during the disease could be proposed as useful prognostic tools in sepsis.

Erratum to “An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest”

Erratum Erratum to ‘‘An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest’’ [Resuscitation 48 (2001) 175–180] Lea Poala Fabbri *, Maria Nucera , Aureliano Becucci , Antonello Grippo , Francesco Venneri , Vismara Merciai , Sergio Boncinelli a a Department of Pathophysiology, Unit of Anaesthesiology and Intensi e care, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. b Department of Internal Medicine, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. c Department of Neurological Sciences, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. Received 1 February 2000; received in revised form 22 August 2000; accepted 22 August 2000 www.elsevier.com/locate/resuscitation

Erratum: An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest (Resuscitation (2001) 48 (175-180) PII: S0300957200003270)

Erratum Erratum to ‘‘An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest’’ [Resuscitation 48 (2001) 175–180] Lea Poala Fabbri *, Maria Nucera , Aureliano Becucci , Antonello Grippo , Francesco Venneri , Vismara Merciai , Sergio Boncinelli a a Department of Pathophysiology, Unit of Anaesthesiology and Intensi e care, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. b Department of Internal Medicine, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. c Department of Neurological Sciences, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. Received 1 February 2000; received in revised form 22 August 2000; accepted 22 August 2000 www.elsevier.com/locate/resuscitation

ErratumErratum to “An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest”: [Resuscitation 48 (2001) 175–180]

Erratum Erratum to ‘‘An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest’’ [Resuscitation 48 (2001) 175–180] Lea Poala Fabbri *, Maria Nucera , Aureliano Becucci , Antonello Grippo , Francesco Venneri , Vismara Merciai , Sergio Boncinelli a a Department of Pathophysiology, Unit of Anaesthesiology and Intensi e care, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. b Department of Internal Medicine, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. c Department of Neurological Sciences, Uni ersity of Florence, Viale Morgagni 85, 50134 Florence, Italy. Received 1 February 2000; received in revised form 22 August 2000; accepted 22 August 2000 www.elsevier.com/locate/resuscitation