Warning! fire in the ICU.

At 5:30 pm on December 17, 2010, shortly after a power failure, smoke filled the Intensive Care Unit (ICU) of Federico II University Hospital in Naples, Italy, triggering the hospital emergency alarm system. Immediately, staff began emergency procedures and alerted rescue teams. All patients were transferred without harm. The smoke caused pharyngeal and conjunctival irritation in some staff members. After a brief investigation, firefighters discovered the cause of the fire was a failure of the Uninterruptible Power Supply (UPS).

Terlipressin in brain-death donors.

BACKGROUND: Metabolic management of brain-death organ donors includes correction of the hormonal perturbations that occur after cerebral death and impair circulatory function. Vasopressin is a hormone secreted by the posterior pituitary gland, which contributes to maintain systemic blood pressure by regulating urine secretion and small arteriole tonus. During brain death, the pituitary gland is damaged and hormone secretion rapidly ceases. Low-dose vasopressin increases systemic blood pressure and decreases the need for catecholamines in brain-dead organ donors but it is not available in many countries. Terlipressin is a synthetic analog of vasopressin characterized by greater selectivity for the V1 receptor than vasopressin. To date, the efficacy of terlipressin as a pressor agent in humans has been reported in a few studies. METHOD: Pharmacology and literature about the use of terlipressin in shock and in particularly in neurogenic shock following brain death is summarized and our personal experience is reported. RESULTS AND CONCLUSION: Terlipressin is helpful in controlling severe hypotension; its use allowed to reduce the infusion rate of norepinephrine about 50% in two of three brain-death organ donors, but there are not yet enough data to define its therapeutic range and incidence of collateral effects on the grafts.

Respiratory failure presenting in H1N1 influenza with Legionnaires disease: two case reports.

INTRODUCTION: Media sensationalism on the H1N1 outbreak may have influenced decisional processes and clinical diagnosis. CASE PRESENTATION: We report two cases of patients who presented in 2009 with coexisting H1N1 virus and Legionella infections: a 69-year-old Caucasian man and a 71-year-old Caucasian woman. In our cases all the signs and symptoms, including vomiting, progressive respiratory disease leading to respiratory failure, refractory hypoxemia, leukopenia, lymphopenia, thrombocytopenia, and elevated levels of creatine kinase and hepatic aminotransferases, were consistent with critical illness due to 2009 H1N1 virus infection. Other infectious disorders may mimic H1N1 viral infection especially Legionnaires' disease. Because the swine flu H1N1 pandemic occurred in Autumn in Italy, Legionnaires disease was to be highly suspected since the peak incidence usually occurs in early fall. We do think that our immediate suspicion of Legionella infection based on clinical history and X-ray abnormalities was fundamental for a successful resolution. CONCLUSION: Our two case reports suggest that patients with H1N1 should be screened for Legionella, which is not currently common practice. This is particularly important since the signs and symptoms of both infections are similar.

Assessment of ventilation during the performance of elective endoscopic-guided percutaneous tracheostomy: clinical evaluation of a new method.

STUDY OBJECTIVES: To evaluate the feasibility of uninterrupted translaryngeal open ventilation delivered through a pediatric, uncuffed endotracheal tube during percutaneous endoscopic tracheostomy (PET). DESIGN AND SETTING: Prospective, observational clinical study in a six-bed ICU of a university hospital. PATIENTS: Forty consecutive adult patients requiring an elective tracheostomy. INTERVENTIONS: We employed the basic Ciaglia technique with multiple dilators (n = 10), a single dilator (n = 15), and the Fantoni method (n = 15). During PET, pressure-controlled ventilation was maintained through an uncuffed, 4-mm inner-diameter pediatric tube. The fraction of inspired oxygen was 1.0. Ventilator settings were as follows: pressure-controlled ventilation, 40 cm H(2)O; respiratory rate, 25/min; inspiratory time, 1.2 s of inspiratory time (inspiratory/expiratory ratio, 1:1); and positive end-expiratory pressure, 0 cm H(2)O. MEASUREMENTS AND RESULTS: Measurements of arterial blood gas (ABG) tensions were obtained before the start of each tracheostomy and every 3 min during the procedure. An average of 8.28 +/- 2.28 ABG measurements were obtained from each patient (+/- SD). All patients were successfully assisted during performance of the tracheostomy, and no patient required ventilation through a cuffed endotracheal tube. The maximum increase in PaCO(2) was 8.49 +/- 5.50 mm Hg, and the maximum decrease in pH related to hypercarbia was 0.04 +/- 0.04. The PaO(2) increased in all patients (maximum change, 69.75 +/- 57.00 mm Hg; p < 0.01), and no patient had desaturation during the procedure. CONCLUSIONS: The technique that we propose for airway management during PET was safe and effective. A mild increase in PaCO(2) was not associated with significant metabolic and hemodynamic consequences, and an adequate PaO(2) was maintained throughout the study.