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Background In this prospective observational study, we evaluated the effects of fluid bolus (FB) on venous-to-arterial carbon dioxide tension (PvaCO2) in 42 adult critically ill patients with pre-infusion PvaCO2 > 6 mmHg. Results FB caused a decrease in PvaCO2, from 8.7 [7.6−10.9] mmHg to 6.9 [5.8−8.6] mmHg (p < 0.01). PvaCO2 decreased independently of pre-infusion cardiac index and PvaCO2 changes during FB were not correlated with changes in central venous oxygen saturation (ScvO2) whatever pre-infusion CI. Pre-infusion levels of PvaCO2 were inversely correlated with decreases in PvaCO2 during FB and a pre-infusion PvaCO2 value < 7.7 mmHg could exclude a decrease in PvaCO2 during FB (AUC: 0.79, 95%CI 0.64–0.93; Sensitivity, 91%; Specificity, 55%; p < 0.01). Conclusions Fluid bolus decreased abnormal PvaCO2 levels independently of pre-infusion CI. Low baseline PvaCO2 values suggest that a positive response to FB is unlikely., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer. Methods: This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer. Results: Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60–1.72 and HR 0.87, 95% CI 0.49–1.54) and TLDs (HR 0.81, 95% CI 0.33–1.99 and HR 0.70, 95% CI 0.27–1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58–3.15 and 1.66, 95% CI 1.28–2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups. Conclusions: The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This, SCOPUS: ar.j, info:eu-repo/semantics/published

Toxic epidermal necrolysis (TEN), also known as the Stevens-Johnson Syndrome (SJS), is defined as severe, lifethreatening mucocutaneous reactions, predominantly drug induced, but also associated with infectious diseases. Clinical manifestations consist of erythematous cutaneous lesions, with blister formation and epidermal detachment as a consequence of massive keratinocytes apoptosis. Gastrointestinal involvement by SJS and TEN has been rarely reported. There are many cases with upper esophageal, oropharynx, and anus manifestations, intestinal manifestations are rare and associated with a very high mortality. A 25-year-old man was admitted to our Hospital in April 2015 with diagnosis of TEN, complicated by septic shock and watery diarrhea. Diarrheal symptoms soon started, and an infectious etiology was excluded. Re-epithelialization of the skin started after 3 weeks after admission but diarrheic symptoms persisted. The esophagogastroduodenoscopy (EGDS) showed early hyperemia of duodenum with mucosal edema and bleeding; the same types of lesions were found at the colonoscopy. Histological exams showed no signs of CMV, but granular modifications, compatible with an inflammatory bowel disease. Mesalazine and corticoids was initiated. Few days after, the patient evacuated, in diarrheic episodes, "stripes" of fibrinous material measuring in total more than 2 m. Control colonoscopy showed a colon without haustrations, an erosive mucosa, but no signs of ulcers or pseudo membranes; the ileal mucosa was equally erosive. We also performed capsule endoscopy, to estimate the damage in the small intestine. The structure of the intestinal mucosa appeared to be completely altered, with signs of desquamation and traces of blood, but no evidence of ulcers or active bleeding. During the next 4 months, his skin lesions improved and almost completely recovered, even if some scarring and depigmentation was left. But great daily volumes of watery diarrhea (3 to 5 L/day) persisted along, SCOPUS: ar.j, info:eu-repo/semantics/published

Introduction: We investigated the association between cerebral perfusion perturbations in sepsis with possible cognitive decline (CD) after patients’ discharge from the intensive care unit (ICU). Methods: We studied 28 patients with sepsis and Lawton’s Instrumental Activities of Daily Living scale (IADL) scores ≥5 who were discharged from a university ICU institution. We evaluated cerebral circulatory parameters (pulsatility index (PI) and cerebral blood flow index (CBFi) was calculated based on the measured velocity of the middle cerebral artery. Use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) test was performed daily, and either the Mini Mental State Examination test (MMSE) or Clock Drawing test was performed at ICU discharge. CD was categorized as persistent coma, positive CAM-ICU test at discharge, MMSE <24, or an abnormal Clock test. Results: Patients had a median pre-ICU IADL score of 6.3 (95% CI 5.9–6.7). Fourteen patients (50%) had CD at discharge. Two were in persistent coma despite sepsis resolution. Information recall was the most affected mental function of the other 12 patients. Only on the first day, patients with CD had higher PI and lower CBFi compared to those without CD (2.2 ± 0.7 vs. 1.4 ± 0.5, p = 0.02; 363 ± 170 vs. 499 ± 133, p = 0.03, respectively). Multivariable analysis revealed delirium, but not PI, as an independent prognostic factor for CD (OR: 29.62, 95%CI 1.91–458.01, p = 0.01). Conclusion: Delirium, but not cerebral perfusion alterations, is an independent risk factor for cognitive impairment in septic patients who were discharged from the ICU., SCOPUS: ar.j, info:eu-repo/semantics/published

We report a rare case of fulminant congestive heart failure with fatal outcome in a 21-year-old girl with systemic lupus erythematosus (SLE). A young woman was admitted in the intensive care unit for pericardial tamponade associated with disseminated coagulopathy and refractory shock secondary to multiple coronary aneurysms. Post-mortem examination revealed significant multiple coronary lesions with aneurysms of the interventricular and right coronary arteries, responsible of muscular necrosis, thrombosis of the coronary sinus, and significant pericardial infiltration with hemorrhagic fluid. We describe a refractory cardiac failure with extensive coronary artery involvements, which is very uncommon in young patients with SLE: few cases have been previously described in the literature. We report a rare case of fulminant congestive heart failure with fatal outcome in a young woman with SLE related to extensive coronary involvements., SCOPUS: ar.j, info:eu-repo/semantics/published

Transcranial Doppler can detect cerebral perfusion alteration in septic patients. We correlate static Transcranial Doppler findings with clinical signs of sepsis-associated encephalopathy., Journal Article, SCOPUS: ar.j, info:eu-repo/semantics/published

SCOPUS: le.j, info:eu-repo/semantics/published

Objectives: To determine the safety and efficacy of recombinant thrombomodulin (ART-123) in patients with suspected sepsis-associated disseminated intravascular coagulation. design: Phase 2b, international, multicenter, double-blind, randomized, placebo-controlled, parallel group, screening trial. setting: Two hundred and thirty-three ICUs in 17 countries. patients: All adult patients admitted with sepsis and suspected disseminated intravascular coagulation as assessed using a modified International Society on Thrombosis and Hemostasis score. interventions: Patients were randomized to receive IV ART-123 (0.06 mg/kg/d) for 6 days or placebo, in addition to standard of care. The primary endpoint was reduction in mortality. Secondary endpoints included reversal of overt disseminated intravascular coagulation and reduction in disease severity. Measurements and main results: A total of 750 patients were randomized, nine of whom did not receive the allocated treatment so that 371 patients received ART-123 and 370 received placebo. There were no meaningful differences between the two groups in any of the baseline variables. Twenty-eight-day mortality was 17.8% in the ART-123 group and 21.6% in the placebo group (Cochran-Mantel-Haenszel two-sided p value of 0.273 in favor of ART-123, which met the predefined statistical test for evidence suggestive of efficacy). There were no statistically significant differences in event-free and alive days between the two groups. d-dimer, prothrombin fragment F1.2 and TATc concentrations were lower in the ART-123 group than in the placebo group. There were no differences between the two groups in organ function, inflammatory markers, bleeding or thrombotic events or in the development of new infections. In post hoc analyses, greatest benefit from ART-123 was seen in patients with at least one organ system dysfunction and an international normalized ratio greater than 1.4 at baseline. conclusions: ART-123 is a safe intervention in critical, SCOPUS: ar.j, info:eu-repo/semantics/published

Objective: The aim of this study was to assess the correlation between plasma citrulline and Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, survival, inflammation (C-reactive protein [CRP]), inotrope use, serum levels of prealbumin and albumin, and renal failure in the critically ill patient. Methods: This prospective observational singlecenter controlled study included 91 adult patients over a 2-year period. Inclusion criteria were patients staying in the intensive care unit for >48 hours. Patients renal status was categorized as those with a glomerular filtration rate (GFR) >60 mL/min without renal support, a GFR >60 mL/min with renal support, a GFR <60 mL/min without renal support, and a GFR <60 mL/min with renal support. Plasma citrulline concentrations were categorized into 3 groups: low (015 μmol/L), medium (1635 μmol/L), and high (>36 ?mol/L). The relationship between the recorded parameters and these different cut-off values of plasma citrulline concentrations was analyzed. Results: Ninety-one patients (34% female and 66% male) with a mean (SD) age of 69.3 (11.9) years, a mean (SD) body mass index of 24.8 (5.34) kg/m2, a mean (SD) APACHE II score of 22.4 (7.92), a mean (SD) SOFA score of 8 (4.4), and a mean (SD) plasma citrulline of 21.7 (13.1) μmol/L were enrolled. Only patients with intestinal dysfunction had low plasma citrulline level <15 μmol/L (P = .014). No correlations between serum levels of CRP, albumin, or prealbumin; renal failure; inotrope use; SOFA score; and APACHE II score were found with plasma citrulline level. Conclusion: Low plasma citrulline levels in patients correlate well with intestinal dysfunction. (Nutr Clin Pract. 2012;27:527-532) © 2012 American Society for Parenteral and Enteral Nutrition., SCOPUS: ar.j, info:eu-repo/semantics/published

SCOPUS: le.j, info:eu-repo/semantics/published

A novel approach to increasing erythropoietin (EPO) using oxygen (O2) (the 'normobaric oxygen paradox') has been reported in healthy volunteers. We investigated whether the EPO increase is sufficient to induce erythropoiesis by comparing two protocols of O2 administration., Journal Article, SCOPUS: ar.j, info:eu-repo/semantics/published

A 47-year-old woman with Kearns-Sayre syndrome (KSS) and an implanted pacemaker for complete heart block was admitted to the intensive care unit following a cardiac arrest due to ventricular tachycardia (torsade de pointes) in the setting of QT prolongation. Complete heart blocks and ventricular tachycardia are implicated as mechanisms of sudden deaths in KSS; such patients may require pacemaker implantation and implantation of an automatic implantable cardioverter-defibrillator., Journal Article, SCOPUS: ar.j, info:eu-repo/semantics/published

INTRODUCTION: Chlamydophila pneumoniae is a respiratory pathogen known to infect the upper and lower respiratory tracts. Infection severity can range from sub-clinical pulmonary infection to acute respiratory distress syndrome. CASE PRESENTATION: A previously healthy 62-year-old Caucasian man was admitted to our hospital for acute respiratory failure. Serum samples obtained every week starting from the day of admission showed clear-cut seroconversion for C. pneumoniae antibodies. All other cultures obtained during the first days of hospitalization were negative. Despite maximal ventilatory support (high positive end expiratory pressure, fraction of inspired oxygen of 1.0, nitric oxide inhalation, neuromuscular blocking agents and prone positioning), our patient remained severely hypoxemic, which led us to initiate an extracorporeal membrane oxygenation treatment. Extracorporeal membrane oxygenation and hemodiafiltration were withdrawn on day 12. Our patient was extubated on day 18 and discharged from our Intensive Care Unit on day 20. He went home a month later. CONCLUSION: We describe the first published case of acute respiratory distress syndrome due to C. pneumoniae infection successfully treated by extracorporeal membrane oxygenation, a very useful tool in this syndrome. A quick and specific method for the definite diagnosis of Chlamydophila infection should be developed., JOURNAL ARTICLE, SCOPUS: re.j, info:eu-repo/semantics/published