Glomerular permeability and trauma: a correlation between microalbuminuria and Injury Severity Score.

OBJECTIVE: To determine if there is a correlation between an increase in glomerular permeability, the magnitude of trauma, and the severity of illness. DESIGN: Prospective study. SETTING: Two university hospital intensive care units. PATIENTS: Forty consecutive critically ill trauma patients admitted directly to the intensive care unit within 120 mins of their injuries. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For each patient, urine was collected from the time of admission until 7 am the next day. Within 48 hrs, only one sample of all urine collected (5 mL) was examined for microalbuminuria and urinary creatinine. Results were expressed as the microalbuminuria/urinary creatinine ratio (MACR). The mortality rate in the intensive care unit, Injury Severity Score at the moment of admission, Acute Physiology and Chronic Health Evaluation III score, and Simplified Acute Physiology Score in the first 24 hrs were calculated for each patient. The data were analyzed using the Pearson test for linear regression and Student's t-test. During the first 24 hrs after trauma, there was an increase of MACR (6.9 +/- 0.6 mg/mmol) above normal (reference range, <3 mg/mmol) that was positively correlated with Injury Severity Score (31.4 +/- 1.9; r2 = .73, p < .05). However, there was no correlation between MACR, Acute Physiology and Chronic Health Evaluation III score, Simplified Acute Physiology Score, and mortality rate. CONCLUSIONS: Patients with trauma show an increase in glomerular permeability during the first 24 hrs after injury. The magnitude of this increase is correlated with the extent of trauma but does not seem significant enough to be predictive of severity of illness and/or outcome.

[Assessment of intensive therapy: 4-year experience using the Apache II severity score]. / Valutazione di una Terapia Intensiva: esperienza di quattro anni usando il punteggio di gravità Apache II.

OBJECTIVE: To determine the outcome of critically ill patients and to study the characteristics of the population admitted to the intensive care unit. DESIGN: Retrospective chart review. SETTING: Intensive Care Unit in a civic hospital. METHODS: The medical records of 1156 patients admitted to the intensive care unit over a period of 4 years were analysed according to the Apache II system on day one of admission. Demographic information, severity of illness, major interventions; mortality rate were examined. RESULTS: Of 1156 patients 888 (76.8%) survived and 268 (23.2%) died. The mean Apache II score was 17 (SD 6), 15 (SD6) and 22 (SD7) for survivors and non-survivors respectively, the mean risk of death was 29 (SD 14), 25 (SD14) for survivors and 43 (SD 21) for nonsurvivors. mortality in emergency surgical admission was 28.3%, in booked elective surgical admission 3.8% and 14.3% in unbooked admission after elective surgery, against a predicted mortality of 34%, 16% and 27% respectively. No significant variations of the number of admissions were observed for each month of the year, day of the week and daily duty. Mortality ratio (actual death/predicted death) was 0.79. Apache II score showed in this series a specificity of 95.72% and a sensitivity of 25.37%. CONCLUSION: These findings suggest that Apache II score is able to investigate critical ill patients, to stratify patients into disease groups and to quantify correctly the overall risk of death but cannot be used in decision making or to govern admissions in intensive care unit.

[Potential organ donors at an Italian intensive care unit]. / Potenziali donatori d'organo in una Rianimazione italiana.

AIM: To determine evaluate the number and characteristics of the population diagnosed as being cerebrally dead and the reasons why organs were not donated. EXPERIMENTAL DESIGN: Retrospective study from 1.1.1990 to 31.5.1994. SETTING: Intensive care ward at Arezzo Hospital. PATIENTS: 46 patients diagnosed as being cerebrally dead owing to primary intracranial pathology. RESULTS: Of the 1256 patients admitted to intensive care, 46 were diagnosed as being cerebrally dead. Five became organ donors. The study examines the reasons why the organs of the remaining patients dwere not donated. CONCLUSIONS: In spite of the fact that the number of donors corpses was broadly in line with national figures (8 per million inhabitants versus 9.7 for the NITp average and 6 for the national average), it is worth underlining the high percentage of patients (26.8%) for whom it was not possible to identify the reasons why the commission for the ascertainment of cerebral death was not summoned. This emphasises the need for greater commitment in the early identification of cerebral death, the monitoring and maintenance of organ functions in potential donors, and likewise the need for increased clarity in the formulation of statutory requirements regarding cerebral death.

Transcranial Doppler and brain death diagnosis.

OBJECTIVES: a) To examine the clinical utility of transcranial Doppler and continuous-wave Doppler in monitoring nonsurgical patients with severe intracranial disease until intracranial circulatory arrest and brain death; and b) to investigate if hemodynamic phenomena that occur under such conditions are correlated to specific transcranial Doppler and continuous-wave Doppler waveforms. DESIGN: Prospective, observational study. SETTING: Medical intensive care unit (ICU) in a city hospital. PATIENTS: Thirty-seven consecutive patients with Glasgow Coma Scores of < 7. MEASUREMENTS AND MAIN RESULTS: Transcranial Doppler examination was conducted transtemporally on the left- and right-middle cerebral artery four times daily. In all patients, transcranial Doppler waveforms exhibited high resistance profiles with low, zero, and then reversed diastolic flow velocity. Only three waveform patterns, consisting of diastolic reverse flow without diastolic forward flow, brief systolic forward flow, and undetectable flow in the middle cerebral artery were registered in the 22 brain-dead patients, but in none of the other comatose patients. CONCLUSION: Transcranial Doppler offers a noninvasive method to document deterioration of cerebral perfusion pressure and in the future could be included in protocols for brain death diagnosis.

[Transcranial Doppler in the diagnosis of brain death]. / Il Doppler transcranico nella diagnosi di morte cerebrale.

The delay in the diagnosis of brain death represents a cause of deficiency of organs for transplant. In this prospective study we evaluate the role of Doppler sonography, to investigate typical velocimetric profiles of brain death, and to evaluate the delay between finding the typical profiles and diagnosis expressed according to law. In this ongoing study, we evaluated 32 patients affected from serious primitive intracranial diseases (Glasgow Coma Scale < or = 7). Of the 32 patients examined, 18 underwent or still remained in brain death. All the patients showed typical profiles, classified in 3 fundamental types. Start of monitoring, according to the current law, showed a delay from 12 to 27 hours. The authors conclude that Transcranial Doppler and Doppler c.w. represent an early and sensitive technique, rightly to include in the procedure of the diagnosis of brain death.

[Tetanus disease. Experience with 2 intensive treatments during 13 years]. / Malattia tetanica. Esperienza di due terapie intensive nell'arco di 13 anni di attività.

The Authors present a retrospective analysis of 58 cases of tetanus hospitalized in two ICU in 13 years of activity. The mortality reported (39.7%) is comparable to other Authors or statistical analysis but it is better if correlated to patient age. Patients of the highest classes (III and IV classes of Edmonson e Flowers) had the highest mortality but no significant variation was seen between patients of the III and IV class. The most frequent cause of death has been cardiac arrhythmia. Cardiac arrhythmias happened in most cases in the first 15 days of hospitalization. 37.9% of patients developed pneumonia: prolonged hospitalization (more than 15 days) and high classes of the disease have been the most important risk factors for Hospital-acquired pneumonia in tetanic patients.

[Operative central unit for coordinating the emergencies-urgencies department. Proposal for a mini-unit to solve the problems caused by the relation between volunteer associations and the public structure]. / La centrale operativa di coordinamento nel dipartimento della emergenza-urgenza. Proposta di una "mini-COC" per la risoluzione dei problemi di rapporto tra le associazioni del volontariato e la struttura pubblica.

One of the most important problems, of very difficult solution, in organizing an A/E department is to co-ordinate the emergency in the field. This peculiar task is carried on by an operative central station, the core of an A/E Dept. The organizer in Arezzo try to find out the efficiency and a cost benefit ratio of this central station and try to jump over an historical hindrance to operate by mutual consent with voluntary service. This seems to be possible with the technological development of telephone system and broadcast system. Staff, technical qualifications, connections, reception, modulation, sorting out of different calls are discussed in conjunction with problems of health education concerning the operative central station that coordinates A/E Dept in Arezzo.

[Multiple organ failure syndrome in infection caused by ictero-hemorragic Leptospira. Description of a clinical case]. / MOFS (multiple organs failure syndrome) in corso di infezione da Leptospira ittero-emorragica. Descrizione di un caso clinico.

A 53 years old fisherman was admitted to General Intensive Care Unit in Arezzo with signs and symptoms of Weil disease. An early acute respiratory failure developed. Radiological and haemodynamic findings confirmed a diagnosis of ARDS. The patient developed a severe jaundice, acute renal failure and ARDS (MOF multiple organs failure). To support different failures of the organs, CMV (continuous mandatory ventilation: CPPV with PEEP max 10 cm H2; IRV max 2:1) and AMV (assisted mandatory ventilation: Pressure Support Ventilation), haemofiltration, haemoperfusion and plasmapheresis were simultaneously used, that got better and better renal and respiratory performances. Haemodynamic worsening by PEEP during extracorporeal treatment was overcome by PSV very useful new ventilatory procedure even during weaning period. The patient treated in such manner survived without important disabilities. This care confirms that ARDS (non cardiogenic edema) and MOF can develop during Icterohaemorrhagic Leptospirosis.

[Survey carried out by land of the intervention time for territorial health care]. / Rilevazione via terra dei tempi di intervento per il soccorso sanitario territoriale.

While organizing the Catchment area of A/E Department in Arezzo, a recording of intervention time of prehospital care system (primary transport) was made by land. The analysis recorded that one third of the field on the Catchment area of the A/E Dept was in a red dangerous zone reachable in 15 minutes and more. Such analysis confirmed the importance of local operation bonds all for a correct redistribution of ambulances in the Catchment area and a rational choice of vans and staff suitable for an advanced life support only where and when really necessary.