Early ECMO overcomes primary graft dysfunction after heart transplant

Introduction

Primary graft dysfunction (PGD) is the main cause of early mortality after heart transplantation. Despite affecting approximately 7–8% of all recipients, the etiology and optimal treatment of this condition remains unknown. Extracorporeal membrane oxygenation (ECMO) is a key treatment modality, however optimal timing of initiation has not been established.

Methods

A single-institution retrospective study was conducted. Between January 2003 and October 2019 a total of 13 recipients experienced PGD treated with ECMO. At the beginning of 2016, our institution adopted an early ECMO policy, with PGD patients placed on ECMO prior to leaving the OR at the time of transplant. Patients were stratified into pre-2016 (n=5) and post-2016 (n=8) cohorts. Outcomes including duration of support, ICU and total hospital stay, Ejection Fraction (EF), need for vasoactive or inotropic medication, in-hospital survival, 1-year survival, and complications were analyzed.

Results

Among the pre-2016 and post-2016 cohorts there was no difference in duration of ECMO, ICU stay, and total hospital stay. The average time from release of cross-clamp to initiation of ECMO was 8.04 vs 3.05 hrs in each cohort, respectively (p=0.02). In all patients, ECMO resulted in a reduction in the need for vasopressors and inotropes as assessed by the vasoactive inotrope score. LVEF normalized within the first 5 days of therapy for all patients and was sustained after decannulation. Complication rates among cohorts were similar with respect to bleeding, stroke, infection, and need for permanent dialysis. When compared to the post-2016 cohort, the pre-2016 cohort demonstrated significantly worse in-hospital (75% vs 100%, p=0.04) and 1-year (69% vs 100%, p=0.02) survival.

Conclusions

Early initiation of ECMO results in decreased mortality for PGD after heart transplant without an increased risk of complications.

Funding Acknowledgement

Type of funding source: None

The value of transcranial Doppler sonography with a transorbital approach in the confirmation of cerebral circulatory arrest

OBJECTIVE

Transcranial Doppler sonography (TCD) provides accurate confirmation of cerebral circulatory arrest (CCA) in brain death (BD), but is not feasible in patients with absent temporal bone windows. We added the transorbital approach in the TCD protocol for the diagnosis of CCA and compared findings with angiography. Furthermore, we evaluated whether reporting the angiographic and sonographic confirmation of CCA to relatives of brain-dead patients improves their comprehension and satisfaction with the medical information.

PATIENTS AND METHODS

Eighty-two clinically brain-dead patients underwent 4-vessel angiography, TCD of the basilar and middle cerebral arteries, and transorbital Doppler sonography (TOD) of the internal carotid arteries. Relatives were randomly allocated to 41 in whom BD was presented as a clinical diagnosis (group A) and to 41 in whom BD was presented as a clinical diagnosis confirmed by TCD and angiography (group B). Comprehension and satisfaction of the relatives were assessed using an interview and a questionnaire.

RESULTS

Both angiography and TCD verified CCA in all cases (k = 1). In 11 patients with failure of the transtemporal approach, CCA was confirmed by the transorbital recordings. The addition of TOD enabled 15.5% more cases of CCA to be diagnosed by TCD. Group B exhibited improved comprehension and satisfaction rates (P < .05).

CONCLUSIONS

The addition of TOD increases the efficacy of TCD in confirming CCA in BD. Reporting confirmation of CCA to families of brain-dead patients may improve their comprehension and satisfaction with the provided medical information.

Cardiovascular ultrasound in detecting central venous catheter thrombosis in the intensive care unit: splenectomy and antiphospholipid syndrome

Venous thrombosis of the upper extremities is becoming increasingly prevalent in the intensive care unit as a result of chronic in-dwelling central venous catheters. We report two rare cases in which combined transoesophageal echocardiography and vascular ultrasound examination aided in the identification of catheter-related thrombosis in two patients suffering from splenectomy-induced thrombocytosis and antiphospholipid syndrome respectively.

Candidemia in immunocompromised and immunocompetent critically ill patients: a prospective comparative study

The purpose of this study was to compare the risk factors, clinical manifestations, and outcome of candidemia in immunocompromised (IC) and nonimmunocompromised (NIC) critically ill patients. Data were collected prospectively over a 2-year period (02/2000–01/2002) from patients in a 25-bed, medical–surgical intensive care unit (ICU). Eligible for participation in this study were patients who developed candidemia during their ICU stay. Patients under antifungal therapy and with a confirmed systemic fungal infection prior to the diagnosis of candidemia were excluded. Cultures of blood, urine, and stool were performed for all patients in the study, and all patients underwent endoscopy/biopsy of the esophagus for detection of Candida. Smears and/or scrapings of oropharyngeal and esophageal lesions were examined for hyphae and/or pseudohyphae and were also cultured for yeasts. During the study period, 1,627 patients were hospitalized in the ICU, 57% for primary medical reasons and 43% for surgical reasons. After application of the study’s inclusion and exclusion criteria, 24 patients with candidemia (9 IC and 15 NIC) were analyzed. Total parenteral nutrition was more common in IC than in NIC patients (9/9 [100%] vs 8/15 [53%], p = 0.02). Oropharyngeal candidiasis was detected in 5 of 9 (55.5%) IC patients and in 1 of 15 (6.5%) NIC patients (p = 0.015). Esophageal candidiasis was also more common in IC than in NIC patients (4/9 [44%] vs 0/15 [0%], p = 0.012). Among the 9 IC patients, all except 2 died, resulting in a crude mortality of 78%; among the 15 NIC patients, 9 died, resulting in a crude mortality of 60% (p > 0.05). Autopsy was performed in two IC and in six NIC patients, with disseminated candidiasis found in one IC patient. Oropharyngeal and esophageal candidiasis are frequent in IC patients with candidemia. In contrast, this coexistence is rare in NIC critically ill patients with Candida bloodstream infections. A high mortality was noted in both IC and NIC critically ill patients with candidemia.

Transorbital sonographic monitoring of optic nerve diameter in patients with severe brain injury

OBJECTIVE

We investigated whether alterations in the optic nerve diameter (OND) correlated with brain computed tomography (CT) imaging results among patients with brain injury and whether monitoring of OND could predict brain death.

PATIENTS AND METHODS

We enrolled 54 patients with brain injury (Glasgow Coma Scale < 8) and 53 controls. OND measurements were performed 3 mm posterior to the papillae by means of transorbital sonography. The severity of the injury was classified according to a semiquantitative CT neuroimaging scale (1 to 4). All patients underwent 3 repeated evaluations of OND combined with synchronous CT scans.

RESULTS

Twenty-two patients progressed to brain death, while 32 patients showed gradual clinical improvement. Upon admission, the patients showed significantly increased OND (4.84 +/- 1.2 mm) compared with the controls (3.49 +/- 1.1 mm; P < .001). The median intraobserver variation of OND was 0.2 mm (95% confidence intervals [CI]: 0.1-0.7). The median interobserver variation of OND was 0.3 mm (95% CI: 0.1-0.9). Alterations in the OND were significantly correlated with the neuroimaging scale on 3 repeated evaluations: r = .65, r = .70, and r = .73 (all P < .001). An OND greater than 5.9 mm (specificity = 65% and sensitivity = 74%; P < .01) and a 2.5 mm increased OND between repeated measurements (specificity = 70% and sensitivity = 81%; P < .01) were associated with a poor prognosis.

CONCLUSIONS

Alterations in OND strongly correlated with neuroimaging results among patients with brain injury. However, monitoring of OND exhibited a low predictive value for brain death.

Candiduria in critically ill patients: an early candidemia marker when coupled with multiple blood specimens PCR assays?

BACKGROUND/AIMS

Can repeated blood PCR assays in critically ill patients with culture-confirmed candiduria help in the early detection of candidemia?

METHODOLOGY

Urine samples were obtained on the day of admission and if negative were repeated on the 5th ICU day. Upon laboratory confirmation of candiduria, preemptive antifungal therapy was commenced. Whole blood samples were tested simultaneously with conventional cultures and PCR repeated twice weekly for two weeks.

RESULTS

In ICU patients with candiduria, preemptive antifungal therapy resulted in candiduria clearance and clinical improvement in 94% of them. Candida DNAemia (detected in 64 out of 136 repeated PCR assays) persisted for 1 or 2 weeks in a significant number of patients. Even after multiple positive PCR assays from each individual candiduric patient, the specificity and positive predictive value of the assay in the early detection of candidemia were low (negative predictive value was 100%). No differences were detected on demographics among patients with or without candiduria. The correlations (PCR with culture) with kappa test presented a poor agreement (K = 0.103, Kmin= -0679, Kmax = 0.103).

CONCLUSIONS

PCR in the blood should not be used in early diagnosis of (but it could help in excluding) candidemia, in ICU patients with candiduria.

Post-surgical meningitis due to multiresistant Acinetobacter baumannii. Effective treatment with intravenous and/or intraventricular colistin and therapeutic dilemmas

Post-surgical meningitis and/or ventriculitis caused by Gram-negative bacteria may be difficult to treat due to the emergence of multiresistant strains. Two patients with multiresistant Acinetobacter baumannii central nervous system infection, successfully treated with either intravenous and/or intraventricular colistin are presented. Unresolved issues such as dose and duration of intraventricular colistin are discussed.

Surfactant administration in severe inhalation injury: case report

Inhalation injury is one of the main causes of death in patients with severe burns. Administration of exogenous surfactant appears promising for the treatment of acute respiratory failure. We report our clinical experience with this approach. A 35 yr-old man was admitted to our burns unit after an industrial accident. He had sustained a 60% total body surface area full-thickness burn combined with severe inhalation injury. Fiberoptic bronchoscopy confirmed the diagnosis, demonstrating severe blisters and ulcers of the bronchial mucosa. Refractory hypoxaemia (PaO (2)/FiO (2)56 mm Hg, where PaO (2)is oxygen tension in arterial blood and FiO (2)is the fraction of inspired oxygen) was treated with optimal mechanical ventilatory support; additionally, an initial dose of natural bovine surfactant (Alveofact) of 50 mg/kg body weight was administered by intrabronchial instillation on day 3 postburn. A significant improvement in oxygenation was observed 12 h after administration (from 56 mm Hg initially to 194 mm Hg), followed by an improvement in dynamic compliance (from 26 ml/cm H (2)O initially to 41 ml/cm H (2)O) and inspiratory resistance (from 14 cm H (2)O/lps initially to 11 cm H (2)O/lps). The same dose of surfactant was repeated 48 h later to prevent potential deterioration, resulting in maintenance of gas exchange and lung mechanics at the above levels. No complication associated with the surfactant administration was observed. However, the patient died on day 9 post-burn owing to extrapulmonary causes. Our results demonstrate a significant improvement in gas exchange and lung mechanics in a burn patient with severe inhalation injury after repeated administration of exogenous surfactant. Further study is needed in order to elucidate the clinical impact of surfactant administration and the complications associated with its use in cases of inhalation injury.

Comparison between transcranial color Doppler ultrasonography and angiography in the confirmation of brain death

OBJECTIVE

Cerebral blood flow tests have increasingly been advocated for the confirmation of brain death (BD). Angiography has been considered the gold standard in the diagnosis of BD but is invasive. We validated transcranial color Doppler ultrasonography (TCD) to confirm BD by comparing it to angiography.

PATIENTS AND METHODS

Forty patients experienced the clinical diagnosis of brain death due to head injury in 19 cases (47.5%), cerebral hemorrhage in 11 (27.5%), subarachnoid hemorrhage in 7 (17.5%), and cerebral infarction in 3 (7.5%). Blood pressure, heart rate, SPO2, and PCO2 were monitored throughout the study. Patients were excluded if episodes of hypoxia, arrhythmia, and hypotension occurred during examinations, or if the TCD was not technically feasible.

RESULTS

Both angiography and TCD confirmed BD in all patients. The agreement between the above methods to confirm BD was 100%. Angiography showed the absence of filling of intracranial arteries, while TCD revealed: (1) brief systolic forward flow or systolic spikes and diastolic reversed flow (50%); (2) brief systolic forward flow or systolic spikes and no diastolic flow (25%); (3) no demonstrable flow in a patient in whom flow had been clearly documented on a previous TCD examination (12.5%). Five patients required repeated TCD examinations, because of initial detection of a diastolic to-and-fro flow pattern. BD was confirmed by TCD in the above patients after 30 hours of clinical BD.

CONCLUSION

TCD was a sensitive tool to diagnose BD, affording a reliable alternative examination to standard angiography.

Pharmacogenomics of adrenoceptors

Adrenoceptors (ARs) consist of nine subtypes (alpha(1A)-, alpha(1B)-, alpha(1D)-, beta(1)-, beta(2)-, beta(3)-, alpha(2A)-, alpha(2B)- and alpha(2C)-AR), which are involved in a wide spectrum of physiological functions and are the site of action for a considerable percentage of currently prescribed therapeutics. With the exception of alpha(1D), all AR subtypes are polymorphic with genetic variations in the coding and non-coding regions. This review discusses the biochemical consequences of these genetic variations and their impact in receptor function, disease pathophysiology, and drug response. Pharmacogenomic principles that have been discovered are also discussed.

Colistin forKlebsiella pneumoniae–Associated Sepsis

Klebsiella pneumoniae that was resistant to all available antibiotics (minimum inhibitory concentration of imipenem, 32 microg/mL), including carbapenems, was isolated from blood samples obtained from a 48-year-old patient in the intensive care unit. The patient developed septic shock, which was successfully treated with colistin, the only antibiotic with activity against this multidrug-resistant strain.

Traumatic tricuspid insufficiency: a case report with a review of the literature

Traumatic tricuspid insufficiency, a rare complication of blunt chest trauma, has been reported with increasing frequency during the last 40 years. Automobile accidents are the leading cause of traumatic tricuspid valve regurgitation. The most frequently reported injury is chordal rupture, followed by rupture of the anterior papillary muscle and leaflet tear, primarily of the anterior leaflet. In the acute phase of the injury, the traumatic lesion may go undetected. In the chronic phase many patients remain asymptomatic and others exhibit symptoms and signs of moderate to severe right heart failure. Clinically overt right heart failure has been the traditional indication for surgery, which usually consisted of tricuspid valve replacement. More recently, a more aggressive strategy, with surgical repair of the valve performed before deterioration of the right ventricular function occurs, has been advocated.

Severe accidents due to windsurfing in the Aegean Sea

Windsurfing is a popular sport and has recently become an Olympic event. As an open-air water activity that requires the participant to be in perfect physical condition, windsurfers may be prone to accidents when certain basic rules or procedures are violated. The current study monitored severe injuries due to windsurfing over a period of 12 months in the Aegean Sea in Greece. Our study revealed 22 cases of severe accidents due to windsurfing, with a wide range of injuries including head injuries, spinal cord injuries, and severe fractures of the extremities. Prolonged hospitalization, severe disability and two deaths occurred as consequences of these accidents. The study examined the characteristics of these patients and the possible risk factors and conditions associated with the accidents. We also focused on the most common types of injuries and reviewed the mechanisms that may provoke them. Water sports and particularly windsurfing represent a major challenge for the emergency medical system, especially in the Aegean Sea. Hundreds of islands, kilometres of isolated coasts, millions of tourists, an extended summer period and rapidly changing weather create conditions that constantly test the efficacy of the emergency services. The development of an appropriate infrastructure and maximum control of the risk factors causing these accidents could reduce the morbidity and mortality that, unfortunately but rather predictably, accompany this popular summer activity.

Central venous and mixed venous oxygen saturation in critically ill patients

BACKGROUND

Although mixed venous O2 saturation (SvO2) accurately indicates the balance of O2 supply/demand and provides an index of tissue oxygenation, the use of a pulmonary artery (PA) catheter is associated with significant costs, risks and complications. Central venous O2 saturation (ScvO2), obtained in a less risky and costly manner, can be an attractive alternative to SvO2.

OBJECTIVES

To investigate whether the values of ScvO2 and SvO2 are well correlated and interchangeable in the evaluation of critically ill ICU patients and to create an equation that could estimate SvO2 from ScvO2.

METHODS

Sixty-one mechanically ventilated patients were catheterized upon admission and ScvO2 and SvO2 values were simultaneously measured in the lower part of the superior vena cava and PA respectively.

RESULTS

SvO2 was 68.6 +/- 1.2% (mean +/- SEM) and ScvO2 was 69.4 +/- 1.1%. The difference is statistically significant (p < 0.03). The correlation coefficient r is 0.945 for the total population, 0.937 and 0.950 in surgical and medical patients, respectively. In 90.2% of patients the difference was <5%. When regression analysis was performed, among 11 models tested, power model [SvO2 = b0(ScvO2)b1] best described the relationship between the two parameters (R2 = 0.917).

CONCLUSIONS

ScvO2 and SvO2 are closely related and are interchangeable for the initial evaluation of critically ill patients even if cardiac indices are different. SvO2 can be estimated with great accuracy by ScvO2 in 92% of the patients using a power model.

Early plasmapheresis in patients with thrombotic thrombocytopenic purpura

OBJECTIVES

To investigate the relationship of thrombotic thrombocytopenic purpura to adult respiratory distress syndrome (ARDS) and study the responses of thrombotic thrombocytopenic purpura patients to early plasmapheresis.

DESIGN

Case series.

SETTING

ICU of a university hospital.

PATIENTS

Twenty-four consecutive patients with thrombotic thrombocytopenic purpura, with various periods of time (1 to 18 days) having elapsed since the onset of this condition. Patients ranged in age from 17 to 66 yrs.

INTERVENTIONS

Plasmapheresis, using intermittent flow separators, was instituted soon after the patients' ICU admission. The retinoscopic findings on admission and the relationship of Pao2 to platelet counts before and after plasmapheresis therapy were recorded. Antiplatelet agents were given to the survivors to prevent relapses.

MEASUREMENTS AND MAIN RESULTS

Eighteen patients survived and six died. Plasmapheresis was administered for a range of 1 to 5 days (mean 3) and 3 to 18 days (mean 9.8) in survivors and nonsurvivors, respectively (p less than .001). Four patients with confluent fundus hemorrhages died and seven without these fundoscopic findings had easily controlled disease. Increases in Pao2 paralleled increases in platelet counts after plasmapheresis (p less than .001) in this small series of patients. Three of 18 discharged survivors relapsed over a period of 3 to 56 months of follow-up.

CONCLUSIONS

Early introduction of plasmapheresis in thrombotic thrombocytopenic purpura seems to increase the survival rate and to halt the development of ARDS. Fundus findings may be a prognostic factor in thrombotic thrombocytopenic purpura. The antiplatelet agents seem to be efficacious in the prevention of relapses.

Risk factors for candidemia in cancer patients: a case-control study

Risk factors for candidemia were analyzed in a case-control study of 30 cancer patients with candidemia and 58 controls. In a univariate analysis, previous surgery, neutropenia, central catheterization, chemotherapy, specific antibiotic treatments, and peripheral cultures positive for Candida spp. were associated with a significantly increased risk of candidemia. In a multivariate logistic model, the significant risk factors for candidemia were positive peripheral cultures for Candida spp. (P = 0.02), central catheterization (P = 0.03), and neutropenia (P = 0.05). These results should help to identify cancer patients with a high risk of candidemia, who should be given early systemic antifungal therapy.

[Human cryptosporidiosis: a propos of 4 cases]

Cryptosporidiae are ubiquitous protozoan belonging to the coccidiae family which parasite many wild and domestic animals bowels. Man gets infested by ingestion oocysts. The parasite complete cycle takes place on the surface of intestinal epithelial cells microvillosities. Human cases that we described occurred among patients presenting (or not) with acquired or congenital immunity depression. Diarrhea is the main symptom. Diagnosis is based on parasitological stool examination and pathological study of intestinal biopsies. At the present time no specific treatment is known and only the immunity deficit correction can possibly cure cryptosporidiosis.

[Malaria caused by multi-resistant Plasmodium falciparum contracted in Tanzania]

In a severe case of malaria, the chemosensitivity of a Plasmodium falciparum strain from a traveller to Tanzania who underwent chemoprophylaxis treatment with chloroquine (600 mg weekly) was evaluated in vitro. In the 28 hours maturation assay and a 72 hours proliferation assay, the strain proved to be highly resistant to chloroquine and to have a reduced sensibility to the sulfadoxin - pyrimethamin association.