High-dose fluconazole therapy in Intensive Care Unit.

AIM: Fungal infections have become one of the emerging complications in intensive care patients and the morbidity and mortality linked to these infections underlines the importance of managing these pathologies. METHODS: The clinical and laboratory difficulties of diagnosing candidiasis prompted us to identify patients at risk and to intervene as soon as possible, where there was the "suspicion" of active infection, using adequate, so-called "empiric" treatment. The major risk factors include the use of invasive devices (central venous catheters), the administration of multiple antibiotic treatment and parenteral nutrition. In our Intensive Care ward (multi-purpose), we examined 1933 patients who had undergoing 1211 urine cultures (following consolidated clinical criteria). "Empiric treatment" was used in 378 high-risk patients with unstable clinical symptoms and positive urinary fungal colonisations using high-dose fluconazole (800 mg/die) according to the guidelines set down by BSAC. The mean duration of treatment was 12+2 days and urine cultures became negative in all patients after 1 or 2 weeks of treatment. RESULTS: We observed that fluconazole was generally well tolerated: only 10% of patients presented augmented hepatic transaminase. This phenomenon was always transient. Renal function remained unchanged (creatinine clearance). A severe infection with hematogenous dissemination was reported in 6 cases: "empiric treatment" was used in 5 cases with 800 mg/die of fluconazole and 1 case received amphotericin B 1 mg/kg/die (because no clinical improvement was observed after 48-72 hours of fluconazole treatment). Three of these 6 cases died, 2 of which were not directly linked to fungal infection, and 3 patient were discharged from the ward. CONCLUSIONS: We found that fluconazole offers a treatment option that is less toxic, less expensive and equally effective for these infections, provided that it is used at an adequate dose and that high-risk patients are identified for "empiric treatment". No significant increases in resistance were noted, as is demonstrated by the fact that only 1 case of candidemia required conversion to amphotericin B.

[Experience with remifentanil in the ICU]. / Esperienza con remifentanil in Terapia Intensiva.

BACKGROUND: Analgesia and sedation are indispensable in patients admitted to intensive care for the following, principal reasons: to control their state of anxiety, induce amnesia, improve their adaptation to mechanical ventilation, make invasive manoeuvres tolerable. The purpose of the present retrospective analysis is to assess the effectiveness of remifentanil in a total of 1085 patients admitted to our Resuscitation and Intensive Care Department in 1997-2001. METHODS: A sample of 60 adults was taken from these patients. The group was homogeneous in terms of age (67.3+/-10.2 kg), weight (66.7+/-10.2 kg), duration of sedation (6.8+/-1.6 days) and index of gravity (SAPS 30.1+/-4.4). The patients were suffering from chronic obstructive bronchopneumopathy, subjected to mechanical ventilation and sedated with remifentanil. The sample was then compared with another 2 groups (homogeneous with the first) of 20 patients each, treated with propofol and midazolam as the only drug. Following an initial bolus of 2 mg/kg (+/-0.04) for propofol and 0.15 mg/kg (+/-0.03) for midazolam (no bolus for remifentanil), the doses of subsequent continuous infusion (initial doses in the case of remifentanil) were: 0.05 mcg/kg/m (+/-0.01) for remifentanil; 1 mg/kg/h (+/-0.04) for propofol; 0.03 mg/kg/h (+/-0.006) for midazolam. In order to assess the level and quality of sedation, 2 subjective evaluation scales (Ramsey score and the Sedation-Agitation Score: SAS) and one system of objective evaluation (Bispectral Index; BIS) were employed. The BIS is a direct measure of the effects of anaesthetics on the brain. It is represented by a single digit (between 100, state of arousal, and zero, EEG flat), derived statistically and empirically from the EEG. RESULTS: No significant differences were encountered as regards quality of sedation among the 3 groups but there was a significant difference in negative cardiovascular activity in patients treated with propofol (12% reduction in Cl, 13.8% reduction in SVR). A significant accumulation of the drug was observed in cases treated with midazolam, whereas there was no accumulation for remifentanil and propofol in relation to the duration of the infusion. CONCLUSIONS: Of the various sedation modalities employed, we prefer the one which uses remifentanil as the sole drug because a good level of sedation is obtained, there is no accumulation, little interference with cardiovascular parameters and lower costs in comparison with the others.

[Dynamic phonocardiography in the study of mitral valve prolapse. Our experience]. / La poligrafia dinamica nello studio del prolasso della mitrale. Nostra esperienza.

The purpose of this paper is to check the usefulness of dynamic phonocardiography for mitral valve prolapse (MVP) diagnosis, especially in apparently silent cases, or with late-systolic click. In fact, possible MVP or mitral valve regurgitation can be shown. 148 patients (58 males, 90 females) have been examined by basal and dynamic phonocardiography and M-echocardiography. Patients were recruited for routine medical examination or during investigations for other causes or to explain evocative MVP troubles. Provocative tests by amyl nitrite, isoproterenol and methoxamine registered a late-systolic click in 17 normal cases and a late-systolic murmur in 22. M-echo demonstrated MVP in 142 cases (96%), with a slight prevalence of late-systolic MVP; tricuspid valve prolapse coexisted in 8 cases and aortic regurgitation in 12. Today echocardiography is the most important examination, but all our data point to the usefulness of dynamic phonocardiography for MVP diagnosis: in our opinion, the integration of both techniques represents the most correct approach.