Transpulmonary lactate gradient after hypothermic cardiopulmonary bypass

Objective: Several studies demonstrated that the lungs could produce lactate in patients with acute lung injury (ALI). Because after cardiopulmonary bypass (CPB) some patients develop ALI, the effect of CPB on pulmonary lactate release was investigated. Design: Prospective observational clinical study. Setting: Twenty-beds, surgical ICU at a university hospital. Patients: Sixteen deeply sedated, ventilated and post-cardiac surgery patients, all equipped with a pulmonary artery catheter. Measurements and results: Lactate concentration was measured using a lactate analyser in simultaneously drawn arterial (A) and mixed venous (V) blood samples. Three measurements per patients were taken at 30-min interval, after body temperature reached 37°C. Concomitantly, measurements of cardiac output were also obtained. Pulmonary lactate release was calculated as the product of transpulmonary A-V lactate and cardiac index. The mean cardiopulmonary bypass duration was 100±44min (SD), and the aortic cross-clamping time was 71±33min. After CPB, lactate release was 0.136±0.210mmol/min m−2. These values were not correlated with cardiopulmonary bypass duration. Conclusion: The present study shows that in patients receiving mechanical ventilation after CPB, the lung is a source of lactate production. This pulmonary release was not dependent on cardiopulmonary bypass duratio

La «ripugnanza per il "bel gesto"»: il rifiuto e la solitudine di Edoardo Ruffini - The «repugnance for the "beau geste"»: Edoardo Ruffini’s refusal and solitude

Converging with his father Francesco’s decision, in November 1931 Edoardo Ruffini refused to take the oath of loyalty that the Fascist regime had imposed on all Italian university professors. Thirty years old, having just been transferred to the University of Perugia to teach History of Italian Law, he was the youngest of the professors who chose not to take the oath. The story of his refusal, and of what followed, also contributes to a better understanding of the phase of transition of Italian society to post-fascism and democracy

A nationwide survey of intensive care unit discharge practices

Objective: To describe intensive care unit (ICU) discharge practices, examine factors associated with physicians' discharge decisions, and explore ICU and hospital characteristics and clinical determinants associated with the discharge process. Design: Survey in adult ICUs affiliated with the Swiss Society of Intensive Care Medicine. Interventions: Questionnaire inquiring about ICU structure and organization mailed to 73 medical directors. Level of monitoring, intravenous medications, and physiological variables were proposed as elements of discharge decision. Five clinical situations were presented with request to assign a discharge disposition. Measurements and results: Fifty-five ICUs participated, representing 75% of adult Swiss ICUs. Responsibility for patient management was assigned in 91% to the ICU team directing patient care. Only 22% of responding centers used written discharge guidelines. One-half of the respondents considered at least 10 of 15 proposed criteria to decide patient discharge. ICUs in central referral hospitals used fewer criteria than community and private hospitals. The availability of intermediate care units was significantly greater in university hospitals. The ICU director's level of experience was not associated with the number of criteria used. In the five clinical scenarios there was wide variation in discharge decision. Conclusions: Our data indicate that there is marked heterogeneity in ICUs discharge practices, and that discharge decisions may be influenced by institutional factors. University teaching hospitals had more intermediate care facilities available. Written discharge guidelines were not widely use

La fiducia testamentaria prima dei codici

SOMMARIO: 1. Il calco romano. – 2. Sviluppi medievali. – 3. La tutela giudiziaria della fiducia. – 4. La fiducia è un contratto. – 5. Sviluppi moderni. – 6. Appendice di fonti

Is it now time to promote mixed enteral and parenteral nutrition for the critically ill patient?

Background: Intensive care outcome measured by morbidity and mortality is altered in the severely malnourished ICU patient, and nutritional support of the critically ill is accepted as astandard of care. Current recommendations suggest starting enteral feeding as soon as possible whenever the gastrointestinal tract is functioning. The disadvantage of enteral support is that inadequate energy and protein intake can occur. The present commentary focuses on some recent findings regarding the nutritional support of critically ill patients and proposes to promote mixed nutrition support by enteral nutrition (EN), and by parenteral nutrition (PN) whenever EN is insufficient. Recent findings: An increasing nutrition deficit during along ICU stay is associated with increased morbidity (increased infection rate or impaired wound healing). Evidence shows that EN can result in underfeeding and that nutrition goals are reached only after 5-7days. Contrary to former beliefs, recent meta-analyses of studies in the ICU showed that PN is not related to excess mortality but may even be associated with improved survival. Conclusions: Optimising the increased substrate requirement for the critically ill by initiating timely nutrition support and ensuring tight glycaemic control with insulin is now considered central for improvedintensive care outcomes. Supplemental PN combined with EN could be an effective alternative to achieve 100% of energy and protein targets at day4, when EN alone fails to achieve goals greater than 60% by day3. Whether such combined nutrition support provides additional benefit on overall outcome has to be ascertained in further studie

Cardioplegia and ventricular late potentials in cardiac surgical patients

Background and objective: Ventricular late potentials (LP) recording with signal-averaged electrocar- diogram allow identifying patients at risk of sudden death and ventricular tachycardia. Cardiac surgery with cardiopulmonary bypass (CPB) could predispose to the development of myocardial ischemia related to imperfect cardioplegia. To the best of our knowledge, no study investigated the protection of cardioplegia and CPB regarding the occurrence of LP in patients without previous myocardial infarction and undergoing cardiac surgery. Methods: In 61 elective patients scheduled for cardiac surgery involving CPB, signal-averaged electrocar- diogram was performed the day before and 24-48h after the surgery. The electrodes were positioned according to Frank's orthogonal derivations. Twenty five patients were excluded because of poor quality signals, leaving 36 patients (age, 64 ± 14) available for the analyses. An abnormal signal-averaged electrocardiogram was considered when ≥2 of the recorded indexes were present. McNemar's tests were performed on the dichotomized values to investigate differences in pre-post scores. Results: The mean CPB duration was of 110 ± 57min. Patients scheduled for cardiac surgery do not exhibited LP after CPB (no significant difference in pre-post CPB scores, P=NS). The probability of a patient with a negative score transitioning to a positive score was 0.23 (P=NS). Conclusions: The present study in cardiac surgical patients suggests that cardioplegia associated to CPB has no significant impact on the occurrence of LP, irrespective of surgery performe