Posterior Reversible Encephalopathy Syndrome in late postpartum eclampsia.

Posterior Reversible Encephalopathy Syndrome (PRES) is a neurological complication associated with several medical conditions and it has been described in clinical findings of seizures, headache, vomiting, altered mental status, and visual changes and focal neurologic deficit, in conjunction with radiological findings of primarily posterior cerebral white matter edema of both cerebral hemispheres. PRES can develop in a wide array situations including pregnancy and postpartum in patients with or without symptoms and signs of eclampsia. A prompt diagnosis of PRES by magnetic resonance imaging and an immediate antihypertensive and anticonvulsant therapy can help to prevent serious complications. The clinical case presented deals with a 35 year-old pregnant woman whose history of eclampsia was observed after a cesarean section.

[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.

Serotonin syndrome caused by olanzapine and clomipramine.

We describe a case of severe serotonin syndrome. The patient was simultaneously taking the atypical antidepressant olanzapine and a tricyclical antidepressant, clomipramine. Symptoms included altered mental state resulting in coma, myoclonus, hyperreflexia, diaphoresis, diarrhoea, disorientation and fever. After suspension of antidepressant drugs, intensive symptomatic treatment and administration of biperiden and cyproheptadine, the patient's condition improved.

Use of natural surfactant in an infant with aspiration syndrome.

The remarkable effectiveness of surfactant in neonatology suggested its use also in adults as well as in children on the basis of the pulmonary pathophysiology. We describe a case of an 18 month-old child affected by acute respiratory distress syndrome (ARDS) due to asphyxy by gastric juice inhalation, successfully treated with porcine surfactant (Curosurf) associated with ventilatory therapy.

Use of recombinant activated factor VII in a case of severe postpartum haemorrhage.

We describe the case of a 24 year old woman, affected by haemorrhagic shock due to post-partum uterine atony, who underwent an emergency hysterectomy with persistent postoperative bleeding, successfully treated with recombinant activated factor VII (Novoseven).

[Use of levosimendan after cardiac arrest by ventricular fibrillation: a case report]. / Uso del levosimendan dopo arresto cardiocircolatorio da fibrillazione ventricolare: descrizione di un caso clinico.

We describe the case of a patient admitted in intensive care, after cardiac arrest by ventricular fibrillation treated by electrical defibrillation, that showed a serious deficit of the cardiac index and increase of the systemic vascular resistances. The patient was treated by levosimendan (Simdax): a starter dose of 12 microg/Kg in ten minutes and then a continuous perfusion of 0.1 microg/Kg/min. for 24 hours. He had a continuous amelioration of the clinical conditions and of the hemodynamics parameters. In the fifth day the patient was transferred to the Cardiology department and after 20 days he was discharged from hospital.

Use of activated protein C in a case of paediatric septic shock.

We describe a clinical case of a 7 year old girl, affected by peritonitis, septic shock and multiorgan failure, treated successfully with drotrecogin alpha associated with conventional therapy.

[Pharmacological sympathetic block in complex regional pain syndrome]. / Blocco farmacologico del simpatico nella Complex Regional Pain Syndrome.

PURPOSE: The Complex Regional Pain Syndrome (CRPS) is a chronic pain state provoked by lesions of the soft tissues or of the bony tissues (type CRPS-I or reflex sympathetic dystrophy-RSD) or by lesions of the nerves (type CRPS-II or causalgia) with vegetative alterations (perspiration, vasomotory alterations) and trophic alterations (bony cutaneous atrophy, alopecia, articular contractures). The pharmacological block of the sympathetic nerves through a peripheral vein is inserted in the multidisciplinary approach that characterizes the therapy of this syndrome. MATERIALS AND METHODS: A retrospective survey was carried out on a group of 185 patients affected by RDS/CRPS with block of the sympathetic nerves through a peripheral vein with guanethidine. Superior limb: Inflation of the tourniquet till disappearance of the radial wrist. Cannulation of a peripheral vein with Butterfly needle n. 23. Guanethidine 10 mg, lidocaine 20 mg, sodic heparin 500 u.i, NaCl 0.9% 20 ml. Injection in 5 minutes. Permanence of the pneumatic tourniquet inflated above systolic blood pressure for 15 minutes. Deflation slowly. Inferior limb: Inflation of the tourniquet till disappearance of the pedidium wrist. Cannulation of a peripheral vein with Butterfly needle n. 23. Guanethidine 20 mg, lidocaine 40 mg, sodic heparin 1000 u.i, NaCl 0.9% 40 ml. Injection in 5 minutes. Permanence of the pneumatic tourniquet inflated above systolic blood pressure for 15 minutes. Deflation slowly. RESULTS: The first stage (hyperemic) showed the highest incidence of remissions: (83, 33%). Even in the second stage (dystrophic) the answer to the therapy has been fundamentally positive: (53, 68%). In the third stage (atrophic) the results have been more modest: (8, 33%). CONCLUSIONS: The block of sympathetic system with guanethidine is still an important method in the therapy of the CRPS; in fact it is surely less invading than the blocks of the stellate ganglion or of the lumbar sympathetic.

[Early postoperative hypoxemia: incidence and effectiveness of oxygen administration]. / Ipossiemia postoperatoria precoce: incidenza ed efficacia della somministrazione di ossigeno.

OBJECTIVE: To determine the incidence of hypoxaemia and the efficacy of oxygen therapy in the early postoperative period. DESIGN: Prospective, randomized study. SETTING: Regional hospital. PATIENTS: 89 patients undergoing general anaesthesia divided into two groups, I (n = 45) and II (n = 44). INTERVENTIONS: Patients of group I breathed room air while patients of group II received supplementary oxygen. MEASUREMENTS AND MAIN RESULTS: Oxygenation was monitored continuously for 60 minutes with a pulse oximeter after the end of surgery; hypoxaemia was graded into four values of SpO2: mild (86-90%), moderate (81-85%), severe (76-80%), extreme (< or = 76%). One or more episodes of mild hypoxaemia were recorded in 68% of patients in group I and in 36% of patients in group II (p < 0.005); moderate hypoxaemia were recorded in 51% of patients in group I compared with 13% of patients in group II (p < 0.001). Episodes of severe or extreme hypoxaemia were recorded in 22% and in 6% of patients in group I; no patients in group II exhibited such small values of saturation. The smallest recorded SpO2 values were 81 +/- 5.94% in group I and 89 +/- 8.63% in group II (p < 0.001). CONCLUSIONS: There is a high incidence of clinically unsuspected hypoxaemia in the early postoperative period, the use of supplemental oxygen reduces but does not prevent hypoxaemic episodes, every patient should be monitored continuously with a pulse oximeter in the recovery room.

[Clinical experience with imipenem-cilastatin in intensive therapy]. / Esperienza clinica con imipenem-cilastatina in terapia intensiva.

The authors describe their experience with imipenem-cilastatin in 36 patients in critical conditions due to multiresistant bacterial infections. The efficacy and tolerability of the antibiotic are stressed.