Use of quinupristin/dalfopristin in a critical patient with a methicillin-resistant Staphilococcus aureus infection

The growing incidence of infections due to Gram-positive multiresistant germs has stimulated research into new drugs endowed with broader activity, that are useful in case of infections unresponsive to common antibiotics. The case of a 28-year-old man infected with a methicillin resistant Staphylococcus aureus non responder to therapy with glycopeptide antibiotics is reported. At admission the patient presented a septic condition and required mechanical ventilation. Antibiotic therapy was immediately started with teicoplanin+meropenem. Blood culture and bronchial aspirate evidenced a methicillin resistant Staphylococcus aureus with high sensibility to glycopeptide antibiotics. Although this therapy produced a slight improvement in clinical condition and the patient was extubated, fever and leucocytosis associated with a BAL positive to methicillin resistant Staphylococcus aureus, in vitro susceptible to glycopeptides, persisted. Considering the possibility of a non-responder condition of the patient to glycopeptide antibiotics, quinupristin/dalfopristin was added. The streptogramin produced a quick improvement in clinical condition with resolution of sepsis and culture sterilization. The patient improved progressively and was discharged. In conclusion, in our experience the association quinupristin/dalfopristin was effective in the resolution of a critical methicillin resistant Staphylococcus aureus infection non responder to classical treatment with glycopeptide antibiotics that showed a high sensibility in vitro.

A prospective, randomized, double-blind comparison of epidural levobupivacaine 0.5% with epidural ropivacaine 0.75% for lower limb procedures

BACKGROUND AND OBJECTIVE

This prospective, randomized, observer-blinded study compared onset time and duration of epidural anaesthesia produced by with levobupivacaine and ropivacaine for lower limb surgery.

METHODS

ASA I-III adult patients undergoing elective lower limb procedures were randomized to receive epidural levobupivacaine 0.5% 15 mL (n = 30) or epidural ropivacaine 0.75% 15 mL (n = 35). A blinded observer evaluated onset time and regression of motor and sensory block, and intraoperative needs for fentanyl supplementation (0.1 mg intravenously).

RESULTS

With levobupivacaine, onset time was 29 +/- 24 min, with ropivacaine it was 25 +/- 22 min (P = 0.41). Complete resolution of motor block required 105 +/- 63 min with levobupivacaine and 95 +/- 48 min with ropivacaine (P = 0.86). The time for regression of sensory block to T12 was 185 +/- 77 min with levobupivacaine and 201 +/- 75 min with ropivacaine (P = 0.46). Analgesic supplementation was required in one patient receiving levobupivacaine (3.5%) and in two patients receiving ropivacaine (5.7%) (P = 0.99).

CONCLUSIONS

In adults undergoing lower limb surgery, levobupivacaine 0.5% 15 mL produces an epidural block with the same clinical profile as ropivacaine 0.75% 15 mL.

[Organ donor and health policy: the anaesthesia and reanimation]

The possibility of tissues and organs transplantation is nowadays an ordinary surgical procedure for patients that do not have other way of treatment. Today the principal objective of the National Health Care System is the improvement in the transplantation activities. To achieve this objective it is necessary to sustain and promote donation, which is still the principal resource that can be used to satisfy the needs of the patients in waiting list for transplantation. In Italy much has been done by Institutions and physicians with excellent results, both in terms of number of donations and quality of transplantations. But it is still not sufficient. A non homogeneity is still observed between different Provinces, not only in terms of donation, but also in terms of number of transplantation. This situation does not contribute to guarantee the same level of accessibility to health care assistance, which patients deserve. To solve these problems the National Health Care Plan 2003-2005 has indicated, among the strategic objectives, a better utilization of organs and a more deep campaign of information for all citizens. It is important that all the Institutions and all the operators involved would give more attention to the donation process problems and would always be active and efficient. Only keeping a high level of involvement of the local coordinators and of the anaesthetists and intensive, pivotal figures in the process of donation, and reminding to all citizens the possibility of a "love sign", fruit of a decision born by a personal analysis, it will be possible to offer a possibility of life to the patients for whom up today no other treatments exists.

Candidemia in Intensive Care patients. Risk factors and mortality

AIM

Aim of this study was to evaluate if the risk factors for candidemia could be used to identify patients who have a greater possibility of death after Candida spp blood infection.

METHODS

A retrospective observational comparative study.

SETTING

the Intensive Care Unit of an University Hospital.

PATIENTS

478 critical patients were included in this study. Neutropenic and immuno-suppressed patients were excluded.

INTERVENTIONS

routine care for acutely ill patients, with regard to their pathology.

MEASUREMENTS

age, APACHE II at the admission, length of stay in the ICU before the diagnosis of candidemia and whole length of stay, outcome, risk factors for candidemia (Candida colonisation, previous antibiotic therapy, central vein, mechanical ventilation, abdominal surgery, hemodialysis, adult respiratory distress syndrome, chronic obstructive pulmonary disease, diabetes, malignancy, splenectomy, immunosuppression, total parenteral nutrition, malnutrition) and clinical signs of multiorgan failure, systemic inflammatory response syndrome, sepsis or shock, concomitant presence of other infections.

RESULTS

Twelve Candida spp blood infections were diagnosed. All the risk factors were homogenously distributed between patients who survived and those who died with the exception of the malnutrition state, associated with a higher mortality rate.

CONCLUSION

If the candidemia is present, none of the risk factors for the onset of fungemia considered in this study, but the malnutrition state, are mortality predictors.

Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients

OBJECTIVE

To describe clinical, neuroradiological and evolutionary findings in obstetric patients with posterior reversible encephalopathy syndrome (PRES).

DESIGN

Retrospective case series.

SETTING

University intensive care unit (ICU).

PATIENTS

Four critically ill patients. Two patients experienced PRES in late postpartum without the classical pre-eclamptic signs. All patients showed impairment of consciousness and epileptic seizures; two of them presented cortical blindness and headache, too. True status epilepticus (SE) occurred in two cases. In all patients MRI showed the typical feature of gray-white matter edema, mainly localized to the temporo-parieto-occipital areas.

INTERVENTIONS

Normalization of high blood pressure (BP) and treatment of seizures. Two patients with SE and severe impairment of consciousness were treated with an intravenous valproate (ivVPA) bolus followed by continuous infusion.

MEASUREMENTS AND RESULTS

In three cases, neurological and MRI abnormalities completely resolved in about a week. Another patient died due to subarachnoid hemorrhage.

CONCLUSION

Posterior reversible encephalopathy syndrome is a well described clinical and neuroradiological syndrome characterized by headache, altered mental status, cortical blindness and seizures, and a diagnostic MRI picture; usually reversible, PRES can sometimes result in death or in irreversible neurological deficits, thus requiring early diagnosis and prompt treatment. PRES can have various etiologies, but pregnancy and postpartum more frequently lead to this condition. Treatment of seizures deserves special attention since the anti-epileptic drugs currently used in SE management may worsen vigilance as well as autonomic functions. Extensive research is needed to assess the role of ivVPA in this condition.

Derecruitment of the lung induced by stepwise lowering of positive end-expiratory pressure in patients with adult respiratory distress syndrome

BACKGROUND AND OBJECTIVE

It has recently been suggested that recruitment proceeds far above the lower inflection point of the elastic pressure-volume (Pel/V) curve of the respiratory system. Accordingly, the value of the lower inflection point as a guide to set the positive end-expiratory pressure (PEEP) has been challenged. Our aim was to evaluate the derecruitment induced by stepwise decreasing PEEP levels.

METHODS

Seven consecutive sedated and paralysed patients with acute respiratory distress syndrome were studied. Multiple Pel/V curves of the respiratory system were recorded at PEEP levels progressively decreasing in steps of 3.75 cmH2O from + 15 to zero according to the principles of the low flow inflation method.

RESULTS

Multiple Pel/V curves shifted towards lower volumes at decreasing PEEP. Dynamic compliance was higher for Pel/V curves recorded from lower PEEP levels. A high correlation (r = 0.99) was found between dynamic compliance and PEEP. The lower inflection point was on average 9.2 cmH2O. However, the transition between the lower segment and the linear part of the Pel/V curve was in general smooth to the eye. The upper inflection point was on average 23.8 cmH2O. A high correlation (r = 0.98) between the upper inflection point and PEEP was found.

CONCLUSIONS

The lower inflection point is a poor indicator of alveolar closure. The evaluation of derecruitment induced by a stepwise reduction in PEEP seems to be more useful than individual titration of PEEP and tidal volume in patients with adult respiratory distress syndrome.

The upper inflection point of the pressure-volume curve. Influence of methodology and of different modes of ventilation

OBJECTIVE

The pressure-volume (P/V) curve has been proposed as a tool to adjust the ventilatory settings in cases of acute respiratory distress syndrome (ARDS). The aim of this study was to test the influence of P/V tracing methodology on the presence and value of the upper inflection point (UIP).

METHODS

In 13 medical ARDS patients, the interruption and the automated low flow inflation methods were compared while the patients were ventilated at conventional (10-12 ml/kg) and at low (5-6 ml/kg) tidal volume (Vt). Two levels of inspiratory flow and insufflation time were used (3 and 6 s).

RESULTS

No significant difference in UIP was found between the static and the dynamic methods, whatever the flow used. At Vt 10-12 ml/kg, the static and dynamic UIPs were 22.4 +/- 4.4 cmH(2)O and 22.1 +/- 4.5 cmH(2)O ( p = 0.86), respectively; at Vt of 5-6 ml/kg, the static and dynamic UIPs were 26.6 +/- 4.1 cmH(2)O and 25.5 +/- 5 cmH(2)O ( p = 0.34), respectively. Significant differences in UIP were found, in the static and dynamic conditions, between the two levels of Vt ( p < 0.005): it was lower with the higher Vt, suggesting that UIP is dependent on previous tidal alveolar recruitment.

CONCLUSION

Interruption and continuous flow techniques gave similar results, but the previous Vt influences the pressure value of the UIP.

Luxatio cordis due to right pericardium tear, a difficult diagnosis: report of a case

BACKGROUND

Dislocation of the heart is a rare complication of thoracic blunt trauma. A high index of suspicion of pericardium rupture is necessary to formulate an early diagnosis to reduce morbidity and mortality.

PATIENTS

A 23-year-old man suffered a blunt thoracoabdominal trauma and was admitted 3 days later to a university hospital ICU for right heart luxation due to right pericardial tear. Mechanical ventilation delayed radiological findings.

METHODS AND RESULTS

Surgery by repositioning the heart and repairing the pericardial tear allowed restoration of hemodynamic equilibrium.

Focus on risk factors for fungal infections in ICU patients

Systemic fungal infection are increasing in number throughout the developed world. Numerous studies have identified common risk factors for patients developing fungal infection. The most common recognised factors are: colonization, broad-spectrum antibiotics, indwelling central catheter, total parenteral nutrition, immunosuppression, burns, and general measure of severity of illness. Given the benefit of an early therapy, an accurate and prompt diagnosis is crucial. Because the current techniques of securing a diagnosis of fungal infections are imperfect, diagnosis of these infection is often made on clinical grounds. It is thus important for the clinician to know and identify the risk factors to have a high index of suspicion in critically ill patients.

Aspiration of dead space allows isocapnic low tidal volume ventilation in acute lung injury. Relationships to gas exchange and mechanics

OBJECTIVE

In acute lung injury (ALI) mechanical ventilation damages lungs. We hypothesised that aspiration and replacement of dead space during expiration (ASPIDS) allows normocapnic ventilation at higher end-expiratory pressure (PEEP) and reduced tidal volume (V(T)), peak and plateau pressures (Paw(peak), Paw(plat)), thus avoiding lung damage.

SETTING

University Hospital.

PATIENTS

Seven consecutive sedated and paralysed ALI patients were studied.

INTERVENTIONS AND MEASUREMENTS

Single breath test for CO(2) and multiple elastic pressure volume (Pel/V) curves recorded from different end-expiratory pressures guided ventilatory setting at ASPIDS. ASPIDS was studied at respiratory rate (RR) of 14 min(-1) and then 20 min(-1) with minute ventilation maintaining stable CO(2) elimination.

RESULTS

Alveolar and airway dead spaces were 24.3% and 31.3% of V(T), respectively. Multiple Pel/V curves showed a shift towards lower volume at decreasing PEEP, thus indicating that patients required a higher PEEP. At ASPIDS, PEEP was increased from 8.9 cmH(2)O to 12.6 cmH(2)O and VT reduced from 11 ml/kg to 8.9 ml/kg at RR 14 min(-1) and to 6.9 ml/kg at RR 20 min(-1). A significant decrease in Paw(peak) (36.7 vs 32 at RR 14 min(-1) and 28.7 at RR 20 min(-1)) and Paw(plat) (29.9 vs 27.3 at RR 14 min-1 and 24.1 at RR 20 min-1) were observed. PaCO(2) remained stable. No intrinsic PEEP developed. No side effects were noticed.

CONCLUSIONS

ASPIDS allowed the use of higher PEEP at lower V(T) and inflation pressure and constant PaCO(2). Multiple Pel/V curves gave insight into the tendency of lungs to collapse.

Differential vulnerability of cortical and cerebellar neurons in primary culture to oxygen glucose deprivation followed by reoxygenation

The effects of glucose and O2 deprivation (OGD) on the survival of cortical and cerebellar neurons were examined to characterize the biochemical mechanisms involved in OGD and OGD followed by reoxygenation. To this aim, neurons were kept for different time periods in a hypoxic chamber with a controlled atmosphere of 95% N(2) and 5% CO2 in a glucose-free medium. After OGD, reoxygenation was achieved by exposing the cells to normal O2 and glucose levels. Neither MTT, an index of mitochondrial oxidative phosphorylation, nor malondialdehyde (MDA) production, a parameter measuring lipid peroxidation, were affected by 1 hr of OGD in cortical neurons. When OGD was followed by 24 hr of reoxygenation, MTT levels were reduced by 40% and MDA was significantly increased, whereas cellular ATP content did not change. Cerebellar granule cells, on the other hand, did not show any reduction of mitochondrial activity after exposure to 1 hr OGD or to 1 hr OGD plus 24 hr of reoxygenation. When OGD was prolonged for 2 hr, a significant reduction of the mitochondrial activity and of cellular ATP content occurred, coupled to a significant MDA increase in cerebellar granule cells, whereas in cortical neurons a reduction of MTT levels after 2 hr OGD was not accompanied by a decrease of cellular ATP content nor by an increase of MDA production. Moreover, 24 hr of reoxygenation further reinforced lipid peroxidation, LDH release, propidium iodide positive neurons and the reduction of ATP content in cerebellar granule cells. The results of the present study collectively show that cortical and cerebellar neurons display different levels of vulnerability to reoxygenation followed by OGD. Furthermore, the impairment of mitochondrial activity and the consequent overproduction of free radicals in neurons were observed for the first time occurring not only during the reoxygenation phase, but already beginning during the OGD phase.

Allograft dermal implant (AlloDerm) in a previously irradiated field

OBJECTIVE

To evaluate the integration of AlloDerm (LifeCell Corp., The Woodlands, TX) in a field exposed to external-beam radiation (EBR) by analyzing graft thickness, fibroblast recellularization, and neovascularization.

STUDY DESIGN

Randomized control.

METHODS

Thirty-six male Sprague-Dawley rats (n = 36) were randomly assigned to four groups. One hind leg of each rat was exposed to 20 Gy of EBR; the other limb served as the nonirradiated control. Two weeks after irradiation, AlloDerm was implanted into both hind legs. Grafts were harvested at 3, 4, 6, and 14 weeks after implantation and underwent histological analyses.

RESULTS

There was no statistically significant difference in graft thickness, fibroblast count, or neovascularization between the grafts placed in the irradiated bed and the controls (n = 33, P = .332, P = .336, and P = .057, respectively). However, at week 3, fibroblast counts in the graft placed in the field exposed to EBR were significantly lower than those of controls (P = .019), although at week 14 the counts in the experimental limb were higher than those of the controls (P = .002). Graft thickness (P = .001) and fibroblast count (P < .004) were lower at week 14 than at earlier time periods for both the experimental and control grafts.

CONCLUSIONS

In the rat model, graft thickness and neovascularization of the AlloDerm dermal implant do not appear to be adversely affected by a field that has received EBR. Fibroblast ingrowth may be hindered in the early postimplantation period but appears to normalize in the long term. Furthermore, overall graft thickness and fibroblast counts decrease over time, regardless of irradiation status.

[The utility of bispectral index monitoring in general anesthesia]

BACKGROUND

The Bispectral Index (BIS), a parameter derived from the electroencephalograph, has been shown to correlate with increasing sedation and loss of consciousness. This study was designed to investigate whether using BIS would improve anaesthetic drug management and immediate recovery after anaesthesia.

METHODS

160 patients undergoing abdominal surgery were studied. The patients were randomised to receive either propofol or sevoflurane anaesthesia. In each group 40 patients were anaesthetised with BIS monitoring and 40 without BIS. In BIS groups, propofol and sevoflurane dose was adjusted to achieve a target BIS values between 40-60 during the whole procedure. Drug consumption, intraoperative responses, times of recovery after anaesthesia and a "Clinical Quality Scale of Recovery" score were recorded from blinded observators.

RESULTS

Demographic data were similar between groups. BIS monitoring improved the immediate recovery after propofol anaesthesia, while no significant differences were observed in patients receiving sevoflurane. The consumption of both propofol and sevoflurane significantly decreased (30 and 40%, respectively). There was no significant differences in the incidence of intraoperative responses between groups. The BIS groups had a higher percentage of patients with better ICU assessments.

CONCLUSIONS

BIS monitoring decreased the consumption of both propofol and sevoflurane and facilitated the immediate recovery after propofol anaesthesia. Intraoperative course was not changed. These findings indicate that the use of BIS may be a valuable guide of the intraoperatively administration of propofol and sevoflurane.

The measurement of the pressure-volume curves with computerized methods

The authors analyze the physiological basis, technical aspects and clinical usefulness of several methods for pressure-volume curves determinations in mechanically ventilatory, acute respiratory failure patients.