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The number of patients affected by cardiovascular disease admitted to internal medicine and geriatric wards is expanding due to the increasing prevalence of cardiovascular disease in the ageing population. This contributes to a growing demand for cardiology consult visits, with requests for perioperative risk stratification for non-cardiac surgery or endoscopy, and general clinical management. This document was jointly drafted by the Cardiology and Anesthesiology departments, medical and surgical departments, and endoscopy services of the Azienda Ospedaliero-Universitaria "Ospedali Riuniti" in Trieste (Italy). It addresses critical issues such as antiplatelet and anticoagulant therapy in non-cardiac surgery, electric device management, and prophylaxis of bacterial endocarditis. It provides general guidelines and appropriateness criteria, prompted by the Joint Commission International and approved by the Hospital Guidelines Committee. It provides a basis for periodic educational meetings, and will be periodically updated. Periodic audits will monitor its application, and critical and controversial points, in order to promote quality of health care, organizational efficiency, and appropriateness.

The authors describe a case of a drug-associated hyperammonemia, central pontine myelinolysis and coma occurring in a patient with Sjögren's syndrome chronically treated with valproic acid for an underlying psychotic disorder. The possible differential diagnoses are reviewed and discussed.

Aim: The aim of this study was the assessment of the efficacy of recombinant human activated protein C (rhAPC) in septic patients., Methods: A continuous observational prospective study on ICU patients with severe sepsis and septic shock was carried out. Applying the inclusion criteria of a national trial on the use of rhAPC, 15 patients (12 males and 3 females) were enrolled, mean age was 65.9 (SD 9.6), APACHE II score was > or =25. The following variables were assessed on 7 time-points (T1-T7): overall SOFA score; organ-specific SOFA score; APACHE II score; PCR, APTT, INR, fibrinogen, platelet count. Wilcoxon's statistical test and Spearman's correlation test (rho coefficient) between the SOFA and APACHE II scores were used. Test results with a P value below 0.05 were deemed significant., Results: A significant correlation was identified between the APACHE II and SOFA scores. No significant change was found in Friedman's test and the respiratory, haematological and hepatic SOFA score, whereas cardiovascular, renal and neurological SOFA scores showed a significant trend between the ranks at the 7 time-points (chi2=14; df=6; P=0.029). During rhAPC treatment Friedman's test showed significant changes of PCR values over the 7 time-points (chi2=19.2; df=6; P=0.02). Wilcoxon's test indicated a significant decrease in the values recorded during the T2-T6 period. On day 28, 12 of the 15 patients originally enrolled were still alive. Mortality rate was therefore 20% (CI 95%)., Conclusions: RhAPC is the first biological agent approved for the treatment of severe sepsis and septic shock. Our experience is confined to patients with severe sepsis and septic shock, and some severity indexes showed a modulation of the inflammatory processes and haemostatic balance, 2 factors which play a key role in the evolution of sepsis and organ dysfunction.

In recent years the problem of infection has become increasingly significant, especially in intensive care hospital wards such as Intensive Care Units (ICU), emergency medicine, surgery and critically ill patient care departments. Sepsis is a complex, multifactorial syndrome that can develop into conditions of different severity, described as severe sepsis or septic shock. In these conditions the triggering event may coincide with the functional impairment of one or more vital organs or systems, thus leading to poorer prognosis in patients with overt signs of sepsis or systemic inflammation syndromes. The available data are quite alarming, as most prevention and treatment is performed empirically and requires considerable human and technological resources. Clinical signs are often misleading and, in some circumstances, it may be difficult or even impossible to identify the source of the infection which might otherwise be removed relatively simply, using proper antimicrobial treatment or a less invasive surgical removal of the area from which the infection originates based on needle-guided radiology. In addition, the complex pathophysiological mechanisms involved can be an obstacle to gaining a full understanding of the various biohumoral interactions or mediators action mechanisms. It may not be easy to enroll patients belonging to homogeneous groups in terms of age, underlining disease, immune profile or genetic predisposition, although the use of specific severity indexes has proved helpful also to establish the prognosis. Although the interpretation of generalised inflammation as a warning sign also in the absence of clear signs of infection or a state of overt inflammation has to rely largely on simple intuition, it has helped to drive experimental and clinical research work towards the investigation of interaction between different factors such as infection and sepsis, or inflammation and coagulation. An additional useful tool is the possibility of modulating the endothelial response which may support the process of disseminated thrombosis typical of sepsis evolution. In this context the improvement of standards of care can shed light on the efficacy of different treatments.

Aim: The aim of this study was to evaluate if the currently available clinical data and the time elapsing from the diagnosis to the administration of IgM and IgA-enriched immunoglobulins can predict the outcome of patients with severe sepsis and septic shock not responding to the current treatments., Methods: All patients with these diagnoses, who did not respond to the standard treatment from August 1999 to September 2002, were retrospectively enrolled in the study. The variables evaluated included: (a) SAPS II and age at admission; (b) body temperature, mean arterial pressure, PaO2/FIO2 ratio, creatinine, blood white cell count on the day before the administration of the IgM and IgA-enriched immuno-globulins; (c) sequential organ failure assessment (SOFA) score before and during the treatment; (d) time elapsing between the diagnosis and the treatment; (e) outcome., Results: Overall, 22 patients have been enrolled (17 M, 5 F, age 54.3+/-14.5 years). Eleven (50%) survived. None of the variables measured was different among survivors and nonsurvivors. Only the time elapsing from the diagnosis of severe sepsis and septic shock and the beginning of the treatment significantly differed among survivors and nonsurvivors (2.72 +/- 1.49 days vs 7.45 +/- 3.41 days respectively, p<0.005)., Conclusion: In patients with severe sepsis and septic shock the currently available clinical variables and severity score are not valuable in identifying those patients who could take the maximal advantage from the administration of the IgM and IgA-enriched immunoglobulins. Thus, their time of administration plays a major role in the treatment of septic patients unresponding to the conventional treatment.

Purpose: To evaluate the reliability of chest radiograph (CR) and abdominal ultrasonography (US) performed in the Emergency Room (ER) in identifying life-threatening thoracic or abdominal lesions in a group of severely injured patients, who developed arterial hypotension immediately after a trauma., Materials and Methods: The results of all abdominal US and CX performed in the ER in severe blunt trauma patients, with on-the-scene systolic blood pressure 90 mmHg, from November 2000 to November 2002, were analysed. When these initial investigations failed to identify a possible cause of hypotension, a computed tomography (CT) of the chest and abdomen was obtained., Results: Overall, 54 patients were studied; twenty-two patients (40.8%) were hypotensive both on accident scene and on the arrival at the ER and 32 (59.2%) were hypotensive on accident scene, but not in the ER. Forty-five patients had an US in the ER, in 3 patients it was inconclusive, whereas 2 other patients died before the confirmatory investigations could be performed. Among the remaining 40 patients, 11 had a hemoperitoneum (HP) hat was diagnosed by US in 7 cases and missed in 4. Twenty-nine patients had no HP and their US was negative in 24 cases and positive in 5; the US had a sensibility of 63.6% and a specificity of 82.8% The CR was obtained in the ER in 39 patients and it was able to identify 6 pneumothoraces (PNX) out of 20 and 2 hemothoraces (HT) out of 17; the sensitivity for PNX and HT was 30.0% and 11.8%, respectively. One patient with an aortic dissection had a normal CX., Conclusions: Both CX and US are not reliable to identify possible PNX, HT and HP in hypotensive trauma patients and can delay the treatment of life-threatening conditions. In these patients, a CT of the torso is warranted.

The aim of the study was the early identification of patients with acute pancreatitis who subsequently developed critical complications. All patients admitted to a surgical ward for acute pancreatitis were recruited into the study. The severity of acute pancreatitis was assessed using Ranson and Balthazar scores. Patients transferred to the intensive care unit (Group A) were matched with patients with the same scores who did not require intensive care treatment (Group B). Several clinical and biochemical variables were compared between the two groups. A total of 221 patients were recruited (110 m, 121 f; mean age: 60.6 years; range: 17-94 years). Group A included 13 patients (7 m, 6 f; mean age: 59.6 +/- 13.5 years; range: 35-76), whereas Group B included 27 patients (11 m, 16 f; mean age 60.8 +/- 5.5 years; range: 44-93). Only glycaemia, pH, white cell count and body mass index differed between the two groups. The mortality rates were 31% in Group A and 7.4% in Group B, respectively (P<0.005) In the logistic regression analysis, only body mass index continued to show a significant difference. In this population of patients with acute pancreatitis, only body mass index proved capable of identifying patients at risk of critical complications.

Treatment of acute respiratory failure is still a hot issue in intensive care everyday practice: in the last few years high frequency ventilation techniques have been employed as a therapy for adult respiratory distress syndrome (ARDS) and acute respiratory failure (ARF). We applied high frequency percussive ventilation (HFPV) to 3 patients affected by ARDS or ARF, who did not improve after 24 hours of conventional mechanical ventilation (CMV). All our patient underwent 12 hours of HFPV, and showed an improvement of both respiratory exchange and radiological imaging. Even if the pathogenesis of ARF was quite different, in all patient we registered a good response and no complications.

In recent years, the usefulness of high frequency ventilation (HFV) has been clinically reassessed as an alternative to conventional mechanical ventilation (CMV). HFV has often been combined with or in some cases even completely replaced CMV in the attempt to reduce iatrogenic injury. High frequency percussive ventilation (HFPV) is a specific mode of HFV that has been successfully applied in the treatment of acute respiratory failure after smoke inhalation; it has also been more widely used in pediatric than in adult patients. This article gives an introduction to and a description of the basic principles of HFPV, a mode of ventilation which we found particularly versatile and reliable in our preliminary clinical experience with the maneuver.

The authors describe the case of a 75-year-old man admitted to our intensive care unit due to coma and respiratory failure; the history revealed a chronic renal failure due to an ANCA+ arteritis; subsequently, he developed a thrombotic thrombocytopenic purpura which was treated with plasma exchange. During his clinical course the patient developed polymicrobial and fungine sepsis and ultimately died. The autopsy demonstrated a severe cytomegalovirus endocarditis, which is extremely uncommon in non-immunodepressed patients as those receiving a solid-organ transplantation.

The occurrence of a Descending Necrotizing Mediastinistis (DNM) usually is a consequence of oropharyngeal infections, which ultimately invade the mediastinum via the cervical fasciae. The clinical course is rapid and often fatal, and is associated with severe systemic symptoms, including fever and hypotension. In these cases, an aggressive surgical approach associated with an appropriate antibiotic treatment is mandatory. Personal experience in the treatment of DNM is presented and a review of the current literature is made; moreover an operative algorhythm is presented.

Leptospirosis is a world-wide diffused anthropozoonosis due to many strains of Leptospira. Initial symptoms may be mild, although in many cases severe systemic symptoms, including high fever, hypotension, etc. may be present since the beginning. In these latter circumstances, the diagnosis of leptospirosis can be very difficult because of the complexity of clinical picture especially when the history is lacking or incomplete. A case report of a 45 year-old man admitted to the hospital after severe jaundice and fever of unknown origin associated to altered mental status, renal failure and hypoxemia is presented. Because of the presence of septic shock and severe respiratory failure, the patient was transferred to the intensive care unit. The diagnostic hypothesis, based on clinical history, was confirmed by laboratory tests (leptospiral IgM antibodies detection). Therapeutical approach with the use of selected antibiotics (penicillin 24,000,000 U for day) and therapy of septic shock led to improvement of the patient's clinical conditions who was then transferred to a regular medical ward.

Goal of the Study: To evaluate the use of the laryngeal mask during general anesthesia., Study Design: We prospectively studied patients undergoing surgery with general anesthesia in spontaneous breathing., Environment: Urologic and general surgical ward, with standard monitoring equipment., Patients: We studied consecutively 100 patients (ASA 1-3, 80 males, 20 females, age 64 +/- 15 years, range 19-98 years); 59 patients had a preexisting cardiopulmonary or metabolic disease. Monitoring included ECG, the arterial pressure (noninvasive), the CO2 capnography (EtCO2), the pulsossimetry (SpO2), the respiratory rate (RR) and the tidal volume/kg (TVi). The double product (DP = heart rate X systolic arterial pressure) was used as an index of cardiac stress. These parameters were recorded at 10-minute intervals throughout the procedure., Results: The heart rate, the systolic arterial pressure remained stable during the anesthesia, whereas the DP significantly decreased at t10, t20, t30 and t40. The EtCO2 decreased slightly (from 41 +/- 6 to a 36 +/- 4 mmHg; p.n.s.), SpO2 did not change (from 97 +/- 2% to 96 +/- 2%; p:n.s.). The RR significantly increased at t30 and t40 and the TVi significantly increased during the first hour. No relevant complications have been reported., Conclusions: Anesthesia with laryngeal mask was not associated with any detrimental cardiovascular and respiratory effect.

The authors reports the case of a patient with quadriplegia associated with respiratory failure. A few days before, a paralysis of the oculomotor nerves appeared, which rapidly spreads in cranio-caudal fashion. The occurrence of a similar symptomatology in a patients' relative addressed the diagnosis toward a possible Clostridium botulinum intoxication. Other possible differential diagnoses are reviewed and discussed.

The authors report the case of a patient who developed irreversible cardiovascular collapse during a laparoscopic cholecystectomy. The abrupt onset of shock and the rapid deterioration of the hemodynamic conditions prevented a thorough diagnostic workup. Possible differential diagnoses of hypotension occurring during laparoscopic procedures are reviewed and discussed.

The case of a patient with postpartum pituitary failure associated with primitive adrenal failure, jaundice and sepsis is described. Radiologic findings, which initially suggested a pituitary necrosis, were normal two months after the admission. Diagnostic and therapeutic approaches are reviewed and discussed.

After a survey of conventional and modern therapeutic strategies in pulmonary edema, a simple clinical approach to the management of this cardiac emergency is suggested. The central role of chlorpromazine, as a vasodilator drug, is also stressed.

Mortality rate among patients with septic, oliguric, multiple organ failure is high. Conventional hemodialysis has often detrimental effects on critically ill patients. Continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVH/D) and continuous arteriovenous hemodialysis associated with sequential plasmapheresis (CAVHP/D) could reduce mortality in septic (hypercatabolic, oliguric) ARDS induced MOF patients. These techniques are simple and can be managed without superspecialized personnel.