A simplified endoscopic third ventriculostomy under local anesthesia.

The aim of this study is the analysis of our experience with awake endoscopic third ventriculostomy (ETVS) in hydrocephalic patients. From September 1994 to December 2001, 24 neuroendoscopic procedures were performed under local anesthesia. Local infiltration was administered using a bupivacaine and lidocaine mixture. Analgesics were titrated to the effect. A free-hand technique with a flexible endoscope was adopted in 24 patients with primitive and secondary (neoplastic) hydrocephalus. ETVS was performed successfully in all cases. No procedure needed to be discontinued due to seizures, bleeding or agitation. Dural incision/coagulation and Fogarty dilatation proved to be the most painful maneuvers requiring, sometimes, supplemental analgesic administration. No intraoperative complications were observed; however, two asymptomatic trajectory hematomas were incidentally discovered two and three days after the operation, respectively. Awake ETVS is a valuable alternative procedure that can be adopted in adult cooperative patients, provided that the procedure is done in an essential and fast way with the free-hand technique, by means of a flexible endoscope, and with the assistance of an anesthesiologist.

Slow-resolving pneumonia secondary to bronchiolitis obliterans organizing pneumonia.

We report a case of slow-resolving pneumonia secondary to bronchiolitis obliterans organizing pneumonia (BOOP) in a 73-year-old woman. Owing to a delayed diagnosis of BOOP, the clinical course was quite long. This syndrome is caused by a nonspecific inflammatory pneumonitis, either idiopathic or associated with infectious or irritant agents (or drugs). It generally presents as a flu-like illness, followed by progressive dyspnea, cough, fever, and bilateral patchy alveolar infiltrates, and lasts several weeks. The diagnostic work-up of slow-resolving pneumonia is discussed.

Guillain-Barré syndrome with associated thrombocytopenia: prompt response to combined corticosteroid and immunoglobulin treatment.

We report a case of Guillain-Barré syndrome (GBS), requiring prolonged mechanical ventilation, associated at its presentation with thrombocytopenia, in a 50-year-old woman. She was treated with immunoglobulin, and short-term corticosteroids for thrombocytopenia. In spite of the severe presentation we observed a very good and rapid recovery, which could have been determined by the therapeutic association. The incidence of thrombocytopenia in GBS patients could be underestimated, and should be kept in mind in order to avoid hemorrhagic complications.

Multiple organ failure due to Clostridium difficile sepsis. A case report.

A case of severe sepsis caused by Clostridium difficile infection in a 66-year-old cirrhotic female is described. Severe systemic symptoms evolved rapidly to septic shock and ARDS, with signs and symptoms suggesting an acute abdomen requiring exploration for exclusion of surgical treatable diseases. The delayed diagnosis of Clostridium difficile infection probably contributed to the severity of the clinical course.

Evaluation of trauma care: validation of the TRISS method in an Italian ICU.

OBJECTIVE: To validate the TRISS method as an audit system on a group of patients with severe trauma admitted to an Italian general intensive care unit (ICU). DESIGN: Prospective, cohort study of consecutive admissions to the ICU. SETTING: A 6-bed general ICU in a 500-bed general hospital. PATIENTS: 190 patients with severe trauma admitted from January 1992 to December 1993 were considered eligible. Patients lacking the data necessary to calculate the TRISS probability of survival, or for whom the ultimate outcome was unknown, were excluded. 162 patients were included in the study. INTERVENTIONS: None. OUTCOME MEASURE: Vital status at discharge from the last hospital that admitted the patient for the trauma being considered. RESULTS: The Hosmer-Lemeshow goodness-of-fit tests were: H = 16.9, df = 10, p = 0.076; C = 5.8, df = 10, p = 0.831; H 3.5, df = 3, p = 0.31. The area under the receiver operating characteristic curve was 0.963 (SE +/- 0.019). Classification measures at a decision criterion of 0.5 were: sensitivity 0.857, specificity 0.964, positive predictive value 0.782, negative predictive value 0.978, total correct classification 0.950, and the Youden index 0.821. The positive likelihood ratio (LHR) was 24.17, whereas the negative LHR was 0.14. CONCLUSIONS: The results of the validation of the TRISS method showed adequate calibration and high discriminatory power in Italian ICU trauma patients also, allowing confidence in the use of this method as an audit tool in our ICU. Some caution is advisable in extending these results to patients with operable intracranial injuries, due to the relatively low number of such cases included in the study.

[Respiratory obstruction caused by retropharyngeal hematoma secondary to cervical spinal injury. Report of a case]. / Ostruzione respiratoria da ematoma retrofaringeo secondario a trauma della colonna cervicale. Descrizione di un caso.

A case of severe airway obstruction secondary to retropharyngeal hematoma in a young multiple trauma patient with a stable occipitoatloid capsular-ligamentous injury is reported. The onset of mechanical obstruction occurred eight hours after the trauma requiring emergent oral intubation, and lasted seventeen days. The initial lateral cervical spine radiograph was negative, whereas the second one performed 7 hours after and initially underestimated, showed a large prevertebral soft tissue swelling. The initial difficult radiological diagnosis of trauma is described, and the therapeutic implications are discussed.

[Comparison of 2 modified Fick methods and thermodilution for determining the cardiac output in patients with mechanical ventilation]. / Confronto tra due metodi di Fick modificati e la termodiluizione per la determinazione della gittata cardiaca nei pazienti in ventilazione meccanica.

OBJECTIVE: To evaluate the effectiveness of two cardiac output measurement methods based on a modified Fick equation, that calculate the O2 consumption (VO2) dividing the CO2 production (VCO2) by a fixed respiratory quotient (RQ). DESIGN: Comparative study. SETTING: One 5 beds general intensive care unit in a 500 beds general hospital. PATIENTS: Ten mechanically ventilated critically ill patients requiring the right heart catheterization. The mean age was 65.5 years and the mean APACHE II score at admission was 24. MEASUREMENTS: The cardiac output was measured using two modified Fick methods. The VO2 was calculated dividing VCO2 by 0.9, while the arteriovenous O2 content difference was calculated using the mixed venous O2 content in the first method (COF), and the central venous O2 content in the second one (COFra). Moreover the cardiac output was measured with the thermodilution technique (COTD) as gold standard. RESULTS: The mean difference between the COTD and COF determinations was 0.571 L +/- 1.81 L, with limits of agreement ranging from -3.057 to +4.200 L. The mean difference between the COTD and COFra determinations was -0.322 L +/- 2.05 L, with limits of agreement ranging from -4.430 to +3.785 L. Both differences were nonsignificant. The correlation coefficients with COTD were: COF determinations 0.72, COFra determinations 0.70. In the group of COFra determinations less than 7 L the mean difference between COTD and COFra was 0.495 L with limits of agreement ranging from +2.208 L to -1.218 L. CONCLUSIONS: The correlation coefficients of the two modified Fick methods with COTD are good, and the mean differences between their results and the gold standard are small, but the low precision of both tested methods demonstrated by the very large limits of agreement, severely reduce the clinical reliability of the measurements. Only for the less than 7 L cardiac outputs the COFra limits of agreement with COTD are narrow enough, and in this range the technique can be useful e.g. revealing a low cardiac output.

[Acute adrenal failure due to adrenal hemorrhagic necrosis secondary to heparin-induced thrombocytopenia]. / Insufficienza surrenalica acuta da necrosi emorragica surrenalica secondaria a trombocitopenia indotta da eparina.

The authors describe a clinical case with a peculiar sequence of unhealthy events. An operated by osteotomy woman presented a deep venous thrombosis of lever lower extremity with following pulmonary embolism. The patient was treated with heparin. After 5 days, the patient showed a thrombocytopenia, that was not determined by an immune mechanism. The heparin was stopped and the thrombocythemia returned to normal values. But the patient still presented somnolence, asthenia and hypotension. The tests of adrenocortical function showed below normal values. The abdominal CAT showed haemorrhagic necrosis of the suprarenal glands.

[Nasocardiac reflex evoking during rhinoseptoplasty. Description of a clinical case]. / Evocazione del riflesso nasocardiaco in corso di rinosettoplastica. Descrizione di un caso clinico.

We report a case of nasocardiac reflex which occurred during a septorhinoplasty. Management and preventive treatment is briefly discussed.

[Prospective evaluation of the role of abdominal echocardiography in the treatment of seriously traumatized patients]. / Valutazione prospettica del ruolo dell'ecografia addominale nel trattamento del grave traumatizzato.

The reliability of abdominal ultrasonography (US) in a clinical algorithm for emergency management of blunt trauma was evaluated prospectively. From November 1, 1987 to December 31, 1988, of 111 severe trauma victims admitted to our ICU, 63 were screened according to protocol by US for peritoneal fluid and splenic and/or hepatic injuries. The mean age was 49.6 years. The mean ISS and APACHE II Score was 26.9 and 13.7 respectively. The sensitivity of US for detection of peritoneal fluid was 95%, specificity 97.6%, positive predictive value 95%, negative predictive value 97.6% with a prevalence of 31.7%. For hepatic and splenic injuries instead the results were not as good as for abdominal fluid. Twelve patients underwent laparotomy and 6 with abdominal injuries were successfully treated nonoperatively with serial US examinations. Overall mortality was 12 (19%). No patients died for delayed or missed diagnosis of abdominal injury.