[Obesity and outcomes in the ICU: an observational study]. / Obesità ed outcome in UTI: uno studio osservazionale.

OBJECTIVES: We examined the relationships among Body Mass Index (BMI) with or without Metabolic Syndrome (MetS), ICU length of stay (ICU-LOS), duration of mechanical ventilation and mortality among ICU patients. MATERIALS AND METHODS: This prospective observational study included all patients hospitalized in a 10-bed polyvalent ICU over a period of one year and seven months. We divided the studied population into 4 groups by BMI values: group A: between 18.5 and 24.9 (n=369); group B1: 25-39.9 without MetS (n=86); B2 group: 25-39.9 with MetS (n=72); group C: >40 (n=42). Major exclusion criteria were: age <18 years, death or cerebral death within 24 hours from ICU admission. The chi square test and the variance analysis were used to compare groups. Variables significantly associated with ICU mortality were entered in a multiple regression model, allowing the determination of independent predictors. RESULTS: 620 patients were included in the study. Their SOFA score was between 8 and 15. Significant differences between B1 and B2 subgroups were observed in ICU-LOS (p <0.01), duration of mechanical ventilation (p <0.01) and ICU mortality (p <0.01). We found no statistically significant differences in mortality between B2 and C groups, as well as between A and B1 groups (42.34%/45.15% vs 16.27%/19.07%, respectively). We found that a BMI >25 with MetS was an independent predictive factor of: lower ICU-LOS, lower duration of mechanical ventilation, higher mortality rate. CONCLUSIONS: In our study, a BMI >25 with MetS was significantly associated with increased morbidity and mortality in ICU patients.

Intensive versus conventional insulinotherapy after elective and on-pump myocardial revascularization: a prospective and randomized study.

OBJECTIVES: Strict glycemic control is increasingly recognized as an important goal in a broad spectrum of critically ill patients. We analyzed the inflammatory and clinical response of patients submitted to intensive or conventional insulinotherapy in a specific clinical context. MATERIALS AND METHODS: We analyzed a prospective and randomized collected database of an Intensive Care Unit (ICU) in a University Hospital. The database comprised a total of 50 patients aged 30 to 80 (ASA II-III) who underwent elective and on-pump myocardial revascularization from September 2006 to June 2008. On ICU admission, patients were randomly assigned to Group 1 (intensive insulinotherapy) or Group 2 (conventional insulinotherapy). Data collected included glucose and lactate blood levels, haemodynamic parameters, cytokines (TNFalpha, IL-6, IL-8, IL-10), C-Reactive Protein, white blood cells and platelets blood levels, body temperature, Sequential Organ Failure Assessment (SOFA) score, Infection Probability Score (IPS) and ICU length of stay (LOS). Within-between group analysis, one-way ANOVA and unpaired t-test were used when appropriate. RESULTS: Pre- and perioperative variables were comparable between the two groups (p=NS for all measurements). Glucose and lactate blood levels were lower in Group 1 (p less than 0.0001). Stroke Volume Index was higher in Group 1 (p less than 0.05). Moreover, we observed statistically significant differences between groups in terms of inflammatory parameters and severity scores. No difference was observed in ICU LOS. CONCLUSIONS: Intensive insulinotherapy after elective on-pump myocardial revascularization significantly modulates the inflammatory response. Different inflammatory patterns could correlate with different clinical response as suggested by SOFA and IP score analysis.

Inflammatory response after cardiopulmonary bypass: a randomized comparison between conventional hemofiltration and steroids.

AIM: Recent reports have shown anti-inflammatory effects with conventional hemofiltration (CUF) in patients undergoing cardiopulmonary bypass (CPB). The aim of this study was to evaluate the immunological and the hemodynamic response to CUF or metilprednisolone in patients undergoing coronary artery bypass grafting. METHODS: Twenty-four consecutive patients were prospectively randomized to receive CUF (12 patients, Group A) or metilprednisolone (12 patients, Group B). Hemodynamic response was evaluated by Swan-Ganz catheter, immunological response was analyzed by IL-2, IL-4, IL-6, TNF-alpha, IFN-gamma, IL-10 before anesthetic induction (T0), at aortic-declamping (T1), at the end of surgery (T2), ITU admission (T3) and 24 hours (T4). Troponin I was measured at the same time-points. Hematological and coagulative controls were performed. RESULTS: Morbidity and mortality were comparable between the two groups. Group A demonstrated lower cardiac index at T1 (2.1 +/- 0.69 L/min m2 vs. 3.917 +/- 1.28, P = 0.034) without significantly higher indexed-systemic-vascular-resistances at the end of surgery (1 101 +/- 434.3 dyne s cm(-5) m(-2) vs. 797.7 +/- 316.67, P = 0.233). When proinflammatory and anti-inflammatory cytokines were considered, all improved during the postoperative time course, without differences between the 2 Groups (P = NS). Hematological and coagulative data were similar in the two groups, in terms of white blood cells, platelets, prothrombin time, and activated partial thromboplastin time (P = NS). CONCLUSIONS: Anti-inflammatory action of CUF was comparable to steroids, thus determining a similar proinflammatory response to CPB. However, hemodynamics was slightly impaired by CUF. Therefore, there is no reason to prefer CUF to steroids in patients undergoing elective CABG.

Inflammatory response to cardiopulmonary bypass with enoximone or steroids in patients undergoing myocardial revascularization: a preliminary report study.

OBJECTIVE: Recent reports have showed an antiinflammatory effect of phosphodiesterase III inhibitors (PDEi) in patients undergoing cardiopulmonary bypass (CPB). We sought to evaluate the immunological and hemodynamic response to enoximone and methylprednisolone in patients undergoing CABG. DESIGN: Prospective, randomized, controlled study. SETTING: Cardiac surgery unit in a university hospital. PATIENTS: 40 patients undergoing CPB-CABG. INTERVENTIONS: Patients receive enoximone (20, Group A) or methylprednisolone (20, Group B). MEASUREMENTS AND MAIN RESULTS: Hemodynamic response was evaluated by Swan-Ganz catheter serial measurements and perioperative Lactate and Troponin I leakage, immunological response was analyzed by IL-2, IL-4, IL-6, TNF-alpah, IFN-gamma, IL-10 before anesthetic induction (T0), at aortic-declamping (T1), at the end of surgery (T2), ITU admission (T3), 24 hs (T4) postoperatively. Morbidity and mortality were comparable between the two groups. Group A demonstrated higher cardiac index at T2 (2.93 l/min m2 vs 2.06, p < 0.001), at T3 (3.01 vs 2.18, p < 0.001), lower indexed systemic vascular resistance at T2 (2,044 dyne s cm-5 m-2 vs 3,132, p < 0.001). Except for higher TNF-alpha in Group B at T2 (15.89 vs 22.68, p = 0.005) proinflammatory cytokines were comparable. IL-10 was higher in Group B at any postoperative time (IL-10: T1 80.74 vs 143.3, p < 0.001, T2 165.7 vs 377.4, p < 0.001, T3 203.4 vs 443.5, p < 0,001, T4 251.8 vs 437.1, p < 0.001), whereas IL-4 and IFN-gamma proved higher in Group A at all time-points (IL-4: T1 45.9 vs 31.2, p = 0.008, T2 67.2 vs 39.7, p < 0.001, T3 77.9 vs 39.2, p < 0.001, T4 102.9 vs 42.2, p < 0.001. IFN-gamma: T1 25.8 vs 15.8, p < 0.001, T2 52.2 vs 30.3, p < 0.001, T3 78.4 vs 40.8, p < 0.001, T4 159.9 vs 67.4, p < 0.001). CONCLUSIONS: Despite comparable major clinical endpoints enoximone showed a different antiinflammatory pattern compared to methylprednisolone, however, the better hemodynamic response in enoximone compared to methylprednisolone suggests enoximone as a potential antiinflammatory tool to improve the outcome in cardiac surgery.

Body perfusion during adult cardiopulmonary bypass is improved by pulsatile flow with intra-aortic balloon pump.

PURPOSE: To evaluate if the use of an intra-aortic balloon pump (IABP) during cardioplegic arrest improves body perfusion. METHODS: 158 coronary artery bypass graft (CABG) patients were randomized to linear cardiopulmonary bypass (CPB) (n=71, Group A) or automatic 80 bpm intra-aortic balloon pump (IABP) induced pulsatile CPB (n=87, Group B). We evaluated hemodynamic response by Swan-Ganz catheter, inflammation by cytokines, coagulation and fibrinolysis, transaminase, bilirubin, amylase, lactate and renal function (estimated glomerular filtration rate (eGFR), creatinine, and incidence of renal insufficiency and failure). RESULTS: IABP induced Surplus Hemodynamic Energy was 15.8-/+4.9 mmHg, with higher mean arterial pressure during cross-clamping (p=0.001), and lower indexed systemic vascular resistances during cross-clamping (p=0.001) and CPB discontinuation (p=0.034). IL-2 and IL-6 were lower, while IL-10 proved higher in Group B (p<0.05). Group B showed lower chest drainage (p<0.05), transfusions (p<0.05), INR (p<0.05), and AT-III (p=0.001), together with higher platelets, aPTT (p<0.05), fibrinogen (p<0.05) and D-dimer (p<0.05). Transaminases, bilirubin, amylase, lactate were lower in Group B (p<0.05); eGFR was better in Group B from ITU-arrival to 48 hours, both in preoperative kidney disease Stages 1-2 (p<0.03) and Stage 3 (p<0.05), resulting in lower creatinine from ITU-arrival to 48 hours (p<0.03). Incidence of renal insufficiency (p=0.004) and need for renal replacement therapy (p=0.044) was lower in Group B Stage 3. Group B PaO2/FiO2 and lung compliance improved from aortic declamping to the first day (p<0.003) with shorter intubation time (p=0.01). CONCLUSION: Pulsatile flow by IABP improves whole-body perfusion during CPB.

Weaning from mechanical ventilation: an open issue.

Weaning from mechanical ventilation represents one of the main challenges facing ICU physicians. Difficult weaning affects about 25% of critical patients undergoing mechanical ventilation. Its duration correlates on one hand with pathophysiological aspects of the underlying disease and, on the other hand, with other factors such as the development of neuromyopathy of the critically ill patient, prolonged use of sedative-hypnotic drugs and, most of all, physicians' reluctance to identify the correct timing of therapeutic steps for weaning and subsequent extubation. The goal of adopting weaning protocols is to overcome problems due to an exclusively clinical opinion. Protocols have to be used together with daily clinical evaluation of the patient and the procedure must be carried out by an ICU team of both medical and nursing staff. Attempts to wean a patient from a ventilator and extubate him should be made through a spontaneous breathing trial (SBT) with T-tube or pressure support ventilation (PSV) with pressure support of 7-8 cmH(2)O +/- PEEP =/> 4 cmH(2)O. Proper recourse to non invasive mechanical ventilation (NIMV) and an accurate timing for tracheostomy are effective tools which can be used by physicians to facilitate weaning and to improve patient outcomes.

[Neuronal plasticity and neuropathic pain]. / Neuroplasticità e dolore neuropatico.

The authors have analysis the physiopathology of neuropathic pain, focusing in particular on the plastic phenomena at the level of the central nervous system. Plastic phenomena take the form of anatomic and neurochemical alterations. In relation to the former, excitatory amino acids play a fundamental role, causing a state of hypersensitivity of N-menthyl-D aspartate (NMDA) receptors (excitation toxicity) which in turn cause the degeneration of inhibitory interneurons localised in the I-III laminae of the dorsal cornu. This hyperactivation is responsible for the presence of a discharge input that lasts for minutes after a nociceptive stimulus, a phenomenon known as long-term potentiation (LTP) on long term depression (LTD). The authors also analysed the role of other neurotransmitters and their possible interactions. Neurochemical alterations are coupled with anatomic modifications, like sprouting, at the level of the dorsal cornu laminae and dorsal root ganglia. These neuroplastic phenomena lead to an alteration in the central mechanisms of pain, for A-fibre mediated mechano-allodynia, a clinical phenomenon that differs from thermal hyperalgesia in both physiopathology and clinical prognosis. The role played by the sympathetic system in neuropathic pain is also discussed. The authors also raise a number of clinical considerations regarding the different nature of spontaneous pain, allodynia and hyperalgesia. New physiopathological knowledge is a useful tool for pharmacological and clinical research, as well as for treatment of syndromes secondary to neuropathic pain.

[Persistent atrial paralysis. Observation of a clinical case and review of the literature]. / Paralisi atriale persistente. Osservazione di un caso clinico e revisione della letteratura.

A total, primitive, persistent, non-familial auricular standstill was observed in a twenty-two year old female with right hemiplegia and aphasia. The diagnosis was confirmed by electrocardiogram, fluoroscopy, echocardiography and intra-atrial recording and pacing. The patient was treated with permanent pacemaker and anticoagulant drugs. The various clinical presentations, diagnostic criteria, and therapeutic choices are reviewed.