Biomedical subjects
Publications and source records attributed to Antonino Gullo.
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Sepsis and related aspects has become an area of active and intense research, leading to important advances for an early diagnosis and appropriate management useful to improve patient outcome. The septic response is an extremely complex cascade of events, including proinflammatory, anti-inflammatory, humoral, cellular, and circulatory involvement. The pathophysiology of this syndrome, its various and changing clinical aspects, and the vast variety of therapeutic options available, not always of well-proved efficacy, make its management a goal difficult to achieve.
Health care systems stem from specific political, historical, cultural,and socioeconomic traditions. As a result, the organizational arrangements for health care differ considerably between Member States of the European Union. Health care in the European Union is at a crossroads between challenges and opportunities. The Member States are facing common challenges in delivering equal, efficient, and high-quality health services at affordable cost in times when the amount of care to be delivered is starting to exceed the resource base.
Despite decades of studies and experiences, an evidence-based medicine consensus on the more appropriate treatment of trauma patients in the out-of-hospital setting has not yet been achieved. Different approaches exist and no one has been demonstrated clearly superior over the others for all circumstances and for all patients. A number of factors likely account for this finding.
The evidence supports quality controlled chest compression as the initial intervention after "sudden death" before attempted defibrillation, if the duration of cardiac arrest is more than 5 minutes. The new guidelines mandate lesser interruptions for ventilation, before and following electrical shocks, and single rather than multiple electrical shocks before resuming chest compression. The new guidelines refocus on uninterrupted chest compression after cardiac arrest of nonasphyxial cause and modifications in practices that reduce the need for interruptions.
OBJECTIVE: Microvascular alterations may play an important role in the development of sepsis-induced organ dysfunction. Drotrecogin alfa activated (DAA) improves outcome in patients with severe sepsis, but its precise mechanism of action is not entirely defined. We investigated whether DAA can influence microcirculatory alterations in patients with severe sepsis. DESIGN: Prospective, nonrandomized study. SETTING: A 31-bed, medico-surgical intensive care unit of a university hospital. PATIENTS: Forty adult patients with severe sepsis who met the EU criteria for DAA administration. INTERVENTIONS: Twenty patients received the drug (DAA) and 20 had a contraindication to DAA administration (control). MEASUREMENTS AND MAIN RESULTS: An orthogonal polarization spectral imaging technique was used to visualize the sublingual microcirculation. In all patients, measurements were obtained at baseline, 4 hrs later, and then every 24 hrs for up to 7 days. In patients receiving DAA, measurements were also obtained just before and 4 hrs after the end of DAA infusion. The two groups were well matched for severity of disease, number of failing organs, and the degree of microvascular alterations at baseline. The proportion of perfused capillaries increased in the DAA treated patients already at 4 hrs (from 64% [51-80%] to 84% [71-88%], p < .01) but not in the control group (from 67% [59-76%] to 68% [61-71%], p = not significant). Microvascular perfusion decreased transiently at the end of DAA infusion. The improvement in microvascular blood flow was associated with a more rapid resolution of hyperlactatemia. CONCLUSIONS: DAA administration rapidly improves sepsis-induced microvascular alterations, whereas its cessation is associated with a transient deterioration.
OBJECTIVE: To evaluate the effect of intrapulmonary percussive ventilation (IPV) by mouthpiece during noninvasive positive-pressure ventilation with helmet in patients with exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN: Randomized clinical trial. SETTING: General intensive care unit, university hospital. PATIENTS: Forty patients with exacerbation of COPD ventilated with noninvasive positive-pressure ventilation by helmet were randomized to two different mucus clearance strategies: IPV (IPV group) vs. respiratory physiotherapy (Phys group). As historical control group, 40 patients receiving noninvasive positive pressure and ventilated by face mask treated with respiratory physiotherapy were studied. INTERVENTIONS: Two daily sessions of IPV (IPV group) or conventional respiratory physiotherapy (Phys group). MEASUREMENTS AND MAIN RESULTS: Physiologic variables were measured at entry in the intensive care unit, before and after the first session of IPV, and at discharge from the intensive care unit. Outcome variables (need for intubation, ventilatory assistance, length of intensive care unit stay, and complications) were also measured. All physiologic variables improved after IPV. At discharge from the intensive care unit, Paco2 was lower in the IPV group compared with the Phys and control groups (mean +/- sd, 58 +/- 5.4 vs. 64 +/- 5.2 mm Hg, 67.4 +/- 4.2 mm Hg, p < .01). Pao2/Fio2 was higher in IPV (274 +/- 15) than the other groups (Phys, 218 +/- 34; control, 237 +/- 20; p < .01). In the IPV group, time of noninvasive ventilation (hrs) (median, 25th-75th percentile: 61, 60-71) and length of stay in the intensive care unit (days) (7, 6-8) were lower than other groups (Phys, 89, 82-96; control, 87, 75-91; p < .01; and Phys, 9, 8-9; control, 10, 9-11; p < .01). CONCLUSIONS: IPV treatment was feasible for all patients. Noninvasive positive-pressure ventilation by helmet associated with IPV reduces the duration of ventilatory treatment and intensive care unit stay and improves gas exchange at discharge from intensive care unit in patients with severe exacerbation of COPD.
OBJECTIVE: The aim of the present study was to investigate the role of intraperitoneal microdialysis (IPM) techniques in monitoring the evolution of postoperative critically ill patients requiring urgent laparotomy. SUMMARY BACKGROUND DATA: Postoperative intraabdominal sepsis is associated with an important degree of morbidity and mortality in acutely ill patients. Early diagnosis is critical to improve outcomes. METHODS: : The study included 25 consecutive patients admitted to the intensive care unit (ICU) after urgent laparotomy. Measurements of microdialysate fluid were performed through a microdialysis catheter, positioned intraperitoneally, during the first 5 postoperative days and lactate/pyruvate (L/P) ratios calculated. Patients were followed until hospital discharge. RESULTS: Ten patients had a complicated postoperative course, including 4 deaths (3 refractory shock, 1 mesenteric ischemia), 3 reinterventions (1 necrotic collection, 1 mesenteric ischemia, 1 biliary leak), 2 secondary peritonitis, and 1 intraabdominal collection. The IPM L/P ratio in these patients was already significantly higher during the first 24 postoperative hours compared with patients who had no complications (35 +/- 21 vs. 18 +/- 6, P < 0.01). An IPM L/P ratio above 22 on postoperative day 1 had a sensitivity of 0.64 and a specificity of 0.79 for complications. There were no significant differences between the two groups in pH, lactate, white blood cell count, or subcutaneous L/P ratio. No complication was associated with the technique. CONCLUSIONS: IPM is safe and reliable and provides valuable information after urgent laparotomy. Persistently high L/P values should raise the possibility of serious postoperative complications.
Among the models describing respiratory mechanics none has been published with the characteristics of two lung compartments including the viscoelastic properties. We used such a model to describe the inspiratory compartmental volume distribution under homogeneous and inhomogeneous conditions. The present mathematical model was tested against actual data and proven accurate. The volume distribution was studied using data from normal subjects and from patients with COPD and ARDS. In a normal lung, changes in viscoelastic constants in one compartment can modify substantially the volume distribution diverting more or less gas to the other compartment. In diseased compartments, the increase of viscoelasticity increased the difference between the compartments and the opposite was true in the less affected compartment. In conclusion, the viscoelastic properties are of paramount importance in determining gas distribution in normal and sick lungs.
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We investigated the pharmacodynamic effects of rocuronium on morbidly obese patients. Twelve morbidly obese female patients (body mass index >40 kg/m(2)) admitted for laparoscopic gastric banding were randomized into two groups. Group 1 (n = 6) received 0.6 mg/kg of rocuronium based on real body weight, whereas Group 2 (n = 6) received 0.6 mg/kg of rocuronium based on ideal body weight. In a control group of six normal-weight female patients admitted for laparoscopic surgery, rocuronium was dosed on the basis of their real body weight. Neuromuscular transmission was monitored by using acceleromyography of the adductor pollicis; anesthesia was induced and maintained with remifentanil and propofol. The onset time tended to be shorter in Group 1 and the control group compared with Group 2, but this did not achieve statistical significance. Duration of action to 25% of twitch tension was more than double in Group 1 (55 min) compared with the other two groups (22 and 25 min; P < 0.001). Duration of action was similar between Group 2 and control. Recovery index tended to be longer in Group 1, but without a significant difference. In conclusion, in morbidly obese patients, the duration of action of rocuronium is significantly prolonged when it is dosed according to real body weight. Therefore, the dosage should be assessed on the basis of ideal rather than on real body weight in clinical practice.
There is conflicting evidence on the duration of action of atracurium in obese patients. Cisatracurium is one of the stereoisomers of atracurium. We investigated the neuromuscular effects of cisatracurium in morbidly obese patients. Twenty obese female patients (body mass index >40) were randomized in two groups. Group I (n = 10) received 0.2 mg/kg of cisatracurium on the basis of real body weight (RBW), whereas in Group II (n = 10) the dose was calculated on ideal body weight (IBW). In a control group of 10 normal weight female patients (body mass index 20-24), the dose of cisatracurium was based on RBW. Neuromuscular transmission was monitored using acceleromyography of the adductor pollicis, and anesthesia was induced and maintained with remifentanil and propofol. Onset time was comparable between Group I and the control group (132 s versus 135 s; P = ns). The duration 25% was longer in Group I than in the control group (74.6 min versus 59.1 min; P = 0.01) and in the control group compared with Group II (45.0 min; P = 0.016). In conclusion, the duration of action of cisatracurium was prolonged in morbidly obese patients when dosed according to RBW compared with a control group of normal weight patients. Duration was also prolonged in the control group patients compared with morbidly obese patients to whom the drug was administered on the basis of IBW.
The ability of the isolated lung tissue to take up glucose and to release lactate is potentially similar to that of other body tissues. Nonetheless, when lung lactate exchange was assess in vivo in normal humans, no measurable lactate production could be detected. Lung lactate production may become clinically evident in disease states especially in the patients with acute lung injury or with acute respiratory distress syndrome. Potential mechanisms of lactate production by the injured lung may include not only the onset of anaerobic metabolism in hypoxic zones, but also direct cytokine effects on pulmonary cells and an accelerated glucose metabolism in both the parenchymal and the inflammatory cells infiltrating lung tissue. In addition, as skeletal muscle, lung tissue may show metabolic adaptations in response to systemic mediators and may contribute to the systemic metabolic response to severe illness even in the absence of direct tissue abnormalities.
OBJECTIVE: In mechanically ventilated patients a high fraction of the pressure can be dissipated to overcome the viscoelastic components of the respiratory system. Recently it was demonstrated that sigh improved oxygenation in mechanically ventilated ARDS patients. We evaluated if, in acute lung injury (ALI) patients, the sigh can be used to measure the respiratory viscoelastic properties. METHODS: Ten consecutive normal subjects undergoing general anaesthesia for minor abdominal surgery and ten ALI patients admitted to the ICU, were studied. Three sighs were administered every minute during the measurement period. The viscoelastic constants (E2, R2 and tau2) were determined by (i) a series of end-inflation airway occlusions (multiple breath method, MBM) and (ii) fitting the time course of the slow decay in pressure during end inspiratory pause of the sigh (sigh method, SM). The results were compared by means of the limits of agreement as modified for small sample sizes. RESULTS: Viscoelastic parameters were similar to those obtained in other studies. In normal subjects the mean differences (+/- SEM) of tau2, R2, and E2 given by the SM and the MBM were 0 +/- 0.04 s, 0.37 +/- 0.20 cmH2O L(-1) s, and 0.21 +/- 0.26 cmH2O L(-1), respectively. The mean differences (+/- SEM) of tau2, R2, and E2 in ALI patients were 0.02 +/- 0.02 s, 0.45 +/- 0.31 cmH2O L(-1) s, 0.34 +/- 0.36 cmH2O L(-1), respectively. No lack of agreement could be detected between the two methods in all variables in normal subjects and ALI patients. CONCLUSIONS: The long inflation time characteristic of the sigh allowed the determination of the viscoelastic constants by means of a simpler and faster method. Moreover it does not require very small tidal volumes, which can increase reabsorption atelectasis in ALI patients and can improve alveolar recruitment and oxygenation in these patients.
Anesthetic management of super-obese patients is inferred from evidence which has been based on obese or morbidly obese patients. We present the perioperative management and monitoring of a 44-year-old 232-kg patient (BMI 70) admitted for laparoscopic gastric bypass surgery. Awake fiberoptic endotracheal intubation preceded induction with propofol and rocuronium. Anesthesia was maintained with desflurane and remifentanil. Desflurane was titrated on BIS values, whereas remifentanil was based on hemodynamic monitoring (invasive arterial pressure and HemoSonic). Rocuronium was administered based on ideal body weight and recovery of twitch tension. Safe and rapid extubation in the operating theatre was made possible by the use of short-acting agents coupled with continuous intraoperative monitoring. Recovery in the post-anesthesia care unit was uneventful, pain was managed with meperidine, and after 5 hours the patient was discharged to the surgical ward. Oxygen therapy and SpO2 monitoring were continued overnight. No desaturation episodes were recorded. Pain was managed with I.V. drip of ketorolac and tramadole.