Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: single center experience.

BACKGROUND AND AIM: Enteric fistulas are defined by their sites of origin, communication and flow. We evaluate the treatment of complex patients with entero-cutaneous fistulae with large abdominal wall defects. MATERIALS AND METHODS: Retrospective case note review of 19 patients (15 males, median age 46 years) treated at the Department of Surgical Sciences, University of Insubria, Varese, Italy. These were distinguished by multiple/wide gastrointestinal fistula orifices, with total discontinuity of bowel. Fistulas were not covered by abdominal wall thus presenting with a giant abdominal wall defects. Surgery was planned once adequate nutritional status was present. RESULTS: All fistulas resulted from previous surgery for IBD in 7 cases (37%), abdominal trauma 4 (21%), acute necrotic infected pancreatitis 3 (16%), intra-abdominal malignancy 3 (16%), and diverticular disease 2 (10%). The most common site of presentation was ileum (80%). Median fistula output was 800ml/day (range 400-1600ml/day). Seltzer's prognostic index identified malnutrition in 70% of patients at the time of presentation. The elapsed mean time from onset of fistula and elective time of surgical management were 184 days (range 20-2190 days). The VAC system was used in the last 7 patients preoperatively and in 6 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. There were no complications from the VAC therapy. Surgery was successful in 69% of cases. Mortality rate was 21%. Factors related to mortality were persistent malignancy, malnutrition and sepsis. CONCLUSIONS: After optimization of nutritional status surgery with en bloc resection of fistula offers best results. In this series, cancer and sepsis were unfavourable factors for outcome. These fistulas may be successfully managed with a multidisciplinary approach.

Use and nursing of the helmet in delivering non invasive ventilation.

Continuous positive end-expiratory pressure (CPAP) and Pressure Support Ventilation (PSV) are commonly used for the therapy of several forms of respiratory failure. CPAP and PSV can be delivered both during invasive respiratory treatment, by means of an endotracheal tube or tracheostomy, and during non invasive respiratory treatment. Non Invasive Ventilation (NIV) is commonly used for the therapy of several forms of respiratory failure (COPD, Weaning period from Invasive Mechanical Ventilation, Cardiogenic Edema,.) and the helmet could be a good new device to deliver it with a better compliance instead the common facial mask without increasing the nurses' workload.

The abdominal compartment syndrome. Clinical relevance.

Increased intra-abdominal pressure (IAP) may occur in a number of different situations encountered by intensivists, such as tense ascites, abdominal hemorrhage, use of military antishock trousers, abdominal obstruction, during laparoscopy, large abdominal tumors and peritoneal dialysis.1-3 Both clinical and experimental evidence indicate that increased IAP may adversely affect cardiac, renal, respiratory and metabolic functions.1-5 Despite this, increased IAP is rarely recognized and treated in Intensive Care Unit (ICU) settings. There appears to be two reasons for this: the physiologic consequences of increased IAP are not well know, to most physicians and, more importantly, the capability of easily measuring IAP has not been well documented. In this chapter, we will discuss: 1) the different methods proposed to evaluate IAP in ICU; 2) the physiopathological consequences of increased IAP; 3) the existing clinical data about IAP in critically ill patients. Considering overall our data, we can conclude that: 1) different techniques are available at the bedside to estimate the IAP; 2) the IAP ranges between 10 and 20 cmH2O, substantially increased compared to normal subjects. Most of the patients have IAH, while few of them (<5%) present clinical characteristics of ACS; 3) the IAP is different among different categories of patients and its increase is not limited to surgical patients only; 4) the increase in IAP appears to influence respiratory function, homodynamic, kidney, gut and brain physiology; 5) the IAP seems to be correlated with severity scores but its relation to mortality is controversial; 6) the routine measurements of IAP by means of bladder pressure are not associated with an increased rate of urinary tract infections.

Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses of mannitol: a randomized trial.

OBJECTIVE: To evaluate clinical outcomes and postoperative physiological findings for comatose patients with acute subdural hematomas who received preoperative high-dose mannitol (HDM) versus conventional-dose mannitol treatment. METHODS: One hundred seventy-eight adult patients with non-missile, traumatic, acute, subdural hematomas were prospectively and randomly assigned to receive emergency, preoperative, intravenous HDM treatment (91 patients), compared with a control group treated with a lower preoperative mannitol dose (87 patients). RESULTS: Preoperative improvement of abnormal pupillary widening was significantly more frequent in the study group than in the control group of patients (P < 0.0001). Preoperative HDM treatment was also associated with significantly better clinical outcomes at 6-month follow-up evaluations (P < 0.01). Postoperative physiological findings revealed statistically significant between-group differences, with higher intracranial pressure and lower cerebral extraction of oxygen (relative cerebral hyperperfusion) in the control group, compared with the HDM group. Postoperative global brain ischemia (abnormally low arteriojugular lactate difference values) was rare and was detected in 2.2 and 3.4% of the patients in the study and control groups, respectively. CONCLUSION: Emergency preoperative HDM administration was associated with improved clinical outcomes for patients with acute subdural hematomas. Preoperative improvement of abnormal pupillary widening and better postoperative control of intracranial hypertension and associated relative cerebral hyperperfusion seemed to be relevant factors associated with improved outcomes.

The clinical use of 99m-Tc-labeled WBC scintigraphy in critically ill surgical and trauma patients with occult sepsis.

OBJECTIVE: To evaluate the clinical use of radionuclide-labeled white blood cell scintigraphy in the detection of focal sepsis. DESIGN: Prospective clinical study. SETTING: A medical/surgical 12-bed intensive care unit (ICU) in a university hospital. PATIENTS: 26 trauma and surgical patients affected by sepsis of unknown origin were studied. MEASUREMENTS AND RESULTS: After the usual diagnostic approach, patients were submitted to a total body scan by using the patient's leukocytes labeled with technetium-99m (99m-Tc) HMPAO; three scintigraphy were performed within 20 h of tracer injection; the result of scan was completed with all clinical and instrumental data, including ultrasound (US) arnd computed tomography (CT), and the diagnostic efficacy was demonstrated for each patient on discharge from the ICU. The scan was able to detect 20 sites of infection; it was possible to rule out 11 suspected sites; only in two cases was the result considered to be false positive or false negative; in two cases the result was considered to be uncertain. These results show the high sensitivity (95%), specificity (91%) and accuracy (94%) of the method. CONCLUSIONS: In ICU patients with sepsis, nuclear medicine can provide additional data, as the injection of radionuclide-labeled white blood cells (WBCs) allows the imaging of sites of infection. Analysis of our results suggests that scintigraphy with 99m-Tc-labeled WBCs can be considered a useful tool in the detection of the source of infection.

Effect of recombinant IL-1 beta and recombinant gamma interferon on septic acute lung injury in mice.

The effect of recombinant human interleukin 1B (IL-1B) and recombinant human gamma interferon (IFN-g), when given prophylactically, in a mouse model of septic acute lung injury was studied. Mice were treated with various doses of IL-1B and IFN-g for 3 consecutive days prior to administration of lipopolysaccharide of Escherichia coli (1 mg/kg given intraperitoneally). To determine the histologic changes occurring after prophylactic administration of such cytokines, a scoring system was assessed. A significant reduction of edema and neutrophil accumulation into the lungs of mice was observed, especially at doses of 100 U per mouse and 10,000 U per mouse of IL-1B and IFN-g, respectively. Prophylactic administration of IL-1B or IFN-g caused histologic changes, including marked reduction of edema and neutrophil accumulation in the interstitial and alveolar spaces. Combined prophylactic administration of IL-1B and IFN-g provoked a marked decrease of neutrophil accumulation into the lungs, but was not accompanied by significant reduction of edema or hemorrhage. These results provide evidence for the beneficial role of IL-1B and IFN-g in the abnormality of septic acute lung injury by reducing inflammatory lesions.

Use of heat and moisture exchanging (HME) filters in mechanically ventilated ICU patients: influence on airway flow-resistance.

OBJECTIVE: To investigate the flow-resistance of a new generation of Heat Moisture Exchanging Filters (HME filters) during 24 h of clinical use. DESIGN: Before-after trial. SETTING: A general Intensive Care Unit of a university hospital. PATIENTS: A consecutive series of 96 patients undergoing mechanical ventilation for respiratory insufficiency of various etiology and severity. METHODS: The characteristics of the secretions collected by tracheal suctioning and the pressure/flow relationship of the HMEs before and after 24 h of clinical use were analyzed. RESULTS: The resistance of the HMEs when dry was 2 hPa/l.s, and it increased to a maximum of 1 hPa/l.s in 83% of the patients after 24 hours; in four patients with particularly heavy secretions HME resistance was 4-5 hPa/l.s. There were no significant modifications of the secretions within the investigation period, excluding, in particular, an increase in density with consequent tracheal tube obstruction. CONCLUSION: The gas conditioning efficiency and design performance of the tested HMEs did not create a significant obstacle to airflow medium term mechanical ventilation; however, these devices should be cautiously used in patients with heavy bronchial secretions.

Effectiveness of ibopamine in the management of ascitic liver cirrhosis--a controlled study v placebo and frusemide.

1 Thirty in-patients of both sexes suffering from ascitic liver cirrhosis were divided into three groups treated with (a) a placebo, (b) ibopamine (SB 7505, a new oral dopaminergic drug) and (c) frusemide, for 10 days. 2 Body weight decreased with both frusemide and ibopamine, diuresis and urinary excretion of Na+ and Cl- increased with both drugs; whereas urinary excretion of K+ increased only with frusemide. 3 An important difference between the frusemide and ibopamine treatment was encountered in creatinine clearance, which increased only with ibopamine, and in blood uric acid which increased only with frusemide. 4 The antidiuretic hormone (ADH) in the plasma of cirrhotic patients was lower than the sensitivity limit of the radioimmunoassay method, whereas in a group of healthy subjects it could be clearly measured. 5 The treatments did not affect systolic or diastolic blood pressure, heart rate, or a series of haematochemical parameters. 6 The increase in diuresis and creatinine clearance and the very good tolerability encountered with ibopamine highlight this new oral dopamine agonist as a useful drug in the management of liver cirrhosis.

Renal effect of SB 7505: a double-blind study.

Two groups of 20 patients with no evidence of cardiovascular, hepatic, renal or gastrointestinal failure were treated orally for five days with placebo or SB 7505 100 mg/day. No change was observed in heart rate or blood pressure. Urine output, the excretion of Na, K and Cl, and creatinine clearance were significantly increased.

Clinical tolerability of ibopamine hydrochloride (SB 7505).

The clinical tolerance of ibopamine hydrochloride (Sb 7505) was investigated in 12 volunteers. The drug was administered on alternate days (2nd, 4th, 6th, 8th, 10th, 12th), starting at 100 mg and increasing by 50 mg each time to reach 350 mg on the 12th day. On the other days (1st, 3rd, 5th, 7th, 9th, 11th and 13th) a placebo was given. Diuresis increased progressively with the dose, reaching a maximum increase of 88% after the last dose, and showing a small residual effect on each subsequent placebo day. Body weight showed a marginal change and decreased by 2% in the last two days of treatment. Heart rate, systolic, diastolic and mean blood pressure showed only marginal fluctuations of about 7% around the mean values, which were of little statistical and of no clinical significance. Haematological and biochemical parameters were not affected. No side effect was noticed. The dose of 350 mg may probably be increased without leading to side effects.

[Effects of dopamine, noradrenaline and isoproterenol on pulmonary circulation in anesthetized dogs]. / Effetti della dopamina, della noradrenalina e dell'isoproterenolo sul circolo polmonare di cani anestetizzati.

Experiments were performed on 19 anaesthetized open-chest dog instrumented with polyethylene catheters inserted: into the aorta, in pulmonary artery and in left atrium and with an electromagnetic flow-transducer placed around the ascending aorta in order to record : systemic arterial and pulmonary pressures, mean left auricular pressure and phasic aortic flow. Heart rate, stroke volume, total systemic and pulmonary resistance, cardiac work were moreover calculated. Each dog was given intravenously by slow infusione : Dopamine (micrograms 5--10--20/kg/min/ 5 min), Isoproterenol (microgram 0.125--0.25--0.5/kg/min/5 min) and Norepinephrine (microgram 0.25--0.5--1 /kg/min/5 min). Results obtained on systemic hemodynamics agree with those reported by many other investigators. On pulmonary circulation : Isoproterenol, at the tested doses, elicited vasodilator effects, Norepinephrine increased total pulmonary resistance but not pulmonary vascular resistance, while Dopamine did not modify or slightly reduced vascular pulmonary tone.

Acute clinical tolerance of creatinol O-phosphate.

Acute clinical tolerance to N-methyl-N-(beta-hydroxyethyl) guanidine O-phosphate (creatinol O-phosphate, COP) was investigated in volunteer human subjects without heart or renal disease and without other serious illness. COP was administered i.v. at three different dosages, 1020 mg (group A), 2040 mg (group B) and 3060 mg (group C), in comparison with a placebo (group D). Arterial pressure, heart rate, ECG pattern and a complete blood analysis showed no change at any COP dosage, with the exception of blood phosphate, which increased in groups B and C. Cumulative urinary excretion of phosphate and creatinine and diuresis increased, whereas other urine parameters did not change. The phosphate and creatinine increases derived from the COP molecule and the increase in diuresis from a simple osmotic process required to dilute the phosphate in the tubular fluid. All these alterations were statistically significant and dose-related with COP and had been expected. COP proved to be a very well tolerated drug without any evident side effect.