Showing papers by "Massimo Antonelli published in 2000"

Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score.

Abstract: Objectives: To describe risk factors for the development of acute renal failure (ARF) in a population of intensive care unit (ICU) patients, and the association of ARF with multiple organ failure (MOF) and outcome using the sequential organ failure assessment (SOFA) score. Design: Prospective, multicenter, observational cohort analysis. Setting: Forty ICUs in 16 countries. Patients: All patients admitted to one of the participating ICUs in May 1995, except those who stayed in the ICU for less than 48 h after uncomplicated surgery, were included. After the exclusion of 38 patients with a history of chronic renal failure requiring renal replacement therapy, a total of 1411 patients were studied. Measurements and results: Of the patients, 348 (24.7 %) developed ARF, as diagnosed by a serum creatinine of 300 μmol/l (3.5 mg/dl) or more and/or a urine output of less than 500 ml/day. The most important risk factors for the development of ARF present on admission were acute circulatory or respiratory failure; age more than 65 years, presence of infection, past history of chronic heart failure (CHF), lymphoma or leukemia, or cirrhosis. ARF patients developed MOF earlier than non-ARF patients (median 24 vs 48 h after ICU admission, p < 0.05). ARF patients older than 65 years with a past history of CHF or with any organ failure on admission were most likely to develop MOF. ICU mortality was 3 times higher in ARF than in other patients (42.8 % vs 14.0 %, p < 0.01). Oliguric ARF was an independent risk factor for overall mortality as determined by a multivariate regression analysis (OR = 1.59 [CI 95 %: 1.23–2.06], p < 0.01). Infection increased the risk of death associated with all factors. Factors that increased the ICU mortality of ARF patients were a past history of hematologic malignancy, age more than 65 years, the number of failing organs on admission and the presence of acute cardiovascular failure. Conclusion: In ICU patients, the most important risk factors for ARF or mortality from ARF are often present on admission. During the ICU stay, other organ failures (especially cardiovascular) are important risk factors. Oliguric ARF was an independent risk factor for ICU mortality, and infection increased the contribution to mortality by other factors. The severity of circulatory shock was the most important factor influencing outcome in ARF patients.

Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial.

Abstract: ContextNoninvasive ventilation (NIV) has been associated with lower rates of endotracheal intubation in populations of patients with acute respiratory failure.ObjectiveTo compare NIV with standard treatment using supplemental oxygen administration to avoid endotracheal intubation in recipients of solid organ transplantation with acute hypoxemic respiratory failure.Design and SettingProspective randomized study conducted at a 14-bed, general intensive care unit of a university hospital.PatientsOf 238 patients who underwent solid organ transplantation from December 1995 to October 1997, 51 were treated for acute respiratory failure. Of these, 40 were eligible and 20 were randomized to each group.InterventionNoninvasive ventilation vs standard treatment with supplemental oxygen administration.Main Outcome MeasuresThe need for endotracheal intubation and mechanical ventilation at any time during the study, complications not present on admission, duration of ventilatory assistance, length of hospital stay, and intensive care unit mortality.ResultsThe 2 groups were similar at study entry. Within the first hour of treatment, 14 patients (70%) in the NIV group, and 5 patients (25%) in the standard treatment group improved their ratio of the PaO2 to the fraction of inspired oxygen (FIO2). Over time, a sustained improvement in PaO2 to FIO2 was noted in 12 patients (60%) in the NIV group, and in 5 patients (25%) randomized to standard treatment (P = .03). The use of NIV was associated with a significant reduction in the rate of endotracheal intubation (20% vs 70%; P = .002), rate of fatal complications (20% vs 50%; P = .05), length of stay in the intensive care unit by survivors (mean [SD] days, 5.5 [3] vs 9 [4]; P = .03), and intensive care unit mortality (20% vs 50%; P = .05). Hospital mortality did not differ.ConclusionsThese results indicate that transplantation programs should consider NIV in the treatment of selected recipients of transplantation with acute respiratory failure.

Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial.

Abstract: ContextContinuous positive airway pressure (CPAP) is widely used in the belief that it may reduce the need for intubation and mechanical ventilation in patients with acute hypoxemic respiratory insufficiency.ObjectiveTo compare the physiologic effects and the clinical efficacy of CPAP vs standard oxygen therapy in patients with acute hypoxemic, nonhypercapnic respiratory insufficiency.Design, Setting, and PatientsRandomized, concealed, and unblinded trial of 123 consecutive adult patients who were admitted to 6 intensive care units between September 1997 and January 1999 with a PaO2/FIO2 ratio of 300 mm Hg or less due to bilateral pulmonary edema (n = 102 with acute lung injury and n = 21 with cardiac disease).InterventionsPatients were randomly assigned to receive oxygen therapy alone (n = 61) or oxygen therapy plus CPAP (n = 62).Main Outcome MeasuresImprovement in PaO2/FIO2 ratio, rate of endotracheal intubation at any time during the study, adverse events, length of hospital stay, mortality, and duration of ventilatory assistance, compared between the CPAP and standard treatment groups.ResultsAmong the CPAP vs standard therapy groups, respectively, causes of respiratory failure (pneumonia, 54% and 55%), presence of cardiac disease (33% and 35%), severity at admission, and hypoxemia (median [5th-95th percentile] PaO2/FIO2 ratio, 140 [59-288] mm Hg vs 148 [62-283] mm Hg; P = .43) were similarly distributed. After 1 hour of treatment, subjective responses to treatment (P<.001) and median (5th-95th percentile) PaO2/FIO2 ratios were greater with CPAP (203 [45-431] mm Hg vs 151 [73-482] mm Hg; P = .02). No further difference in respiratory indices was observed between the groups. Treatment with CPAP failed to reduce the endotracheal intubation rate (21 [34%] vs 24 [39%] in the standard therapy group; P = .53), hospital mortality (19 [31%] vs 18 [30%]; P = .89), or median (5th-95th percentile) intensive care unit length of stay (6.5 [1-57] days vs 6.0 [1-36] days; P = .43). A higher number of adverse events occurred with CPAP treatment (18 vs 6; P = .01).ConclusionIn this study, despite early physiologic improvement, CPAP neither reduced the need for intubation nor improved outcomes in patients with acute hypoxemic, nonhypercapnic respiratory insufficiency primarily due to acute lung injury.

Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation

Abstract: CONTEXT Noninvasive ventilation (NIV) has been associated with lower rates of endotracheal intubation in populations of patients with acute respiratory failure. OBJECTIVE To compare NIV with standard treatment using supplemental oxygen administration to avoid endotracheal intubation in recipients of solid organ transplantation with acute hypoxemic respiratory failure. DESIGN AND SETTING Prospective randomized study conducted at a 14-bed, general intensive care unit of a university hospital. PATIENTS Of 238 patients who underwent solid organ transplantation from December 1995 to October 1997, 51 were treated for acute respiratory failure. Of these, 40 were eligible and 20 were randomized to each group. INTERVENTION Noninvasive ventilation vs standard treatment with supplemental oxygen administration. MAIN OUTCOME MEASURES The need for endotracheal intubation and mechanical ventilation at any time during the study, complications not present on admission, duration of ventilatory assistance, length of hospital stay, and intensive care unit mortality. RESULTS The 2 groups were similar at study entry. Within the first hour of treatment, 14 patients (70%) in the NIV group, and 5 patients (25%) in the standard treatment group improved their ratio of the PaO2 to the fraction of inspired oxygen (FIO2). Over time, a sustained improvement in PaO2 to FIO2 was noted in 12 patients (60%) in the NIV group, and in 5 patients (25%) randomized to standard treatment (P = .03). The use of NIV was associated with a significant reduction in the rate of endotracheal intubation (20% vs 70%; P = .002), rate of fatal complications (20% vs 50%; P = .05), length of stay in the intensive care unit by survivors (mean [SD] days, 5.5 [3] vs 9 [4]; P = .03), and intensive care unit mortality (20% vs 50%; P = .05). Hospital mortality did not differ. CONCLUSIONS These results indicate that transplantation programs should consider NIV in the treatment of selected recipients of transplantation with acute respiratory failure.

Noninvasive positive pressure ventilation as treatment for acute respiratory failure in critically ill patients

Abstract: Our current state of knowledge on noninvasive positive pressure ventilation (NPPV) and technical aspects are discussed in the present review. In patients with chronic obstructive pulmonary disease, NPPV can be considered a valid therapeutic option to prevent endotracheal intubation. Evidence suggests that, before eventual endotracheal intubation, NPPV should be considered as first-line intervention in the early phases of acute exacerbation of chronic obstructive pulmonary disease. Small randomized and non-randomized studies on the application of NPPV in patients with acute hypoxaemic respiratory failure showed promising results, with reduction in complications such as sinusitis and ventilator-associated pneumonia, and in the duration of intensive care unit stay. The conventional use of NPPV in hypoxaemic acute respiratory failure still remains controversial, however. Large randomized studies are still needed before extensive clinical application in this condition.

Noninvasive ventilation in intensive care unit patients

Abstract: Current knowledge regarding noninvasive ventilation (NIV) and some technical aspects of the subject are discussed. In patients with chronic obstructive pulmonary disease, NIV can prevent endotracheal intubation and reduce mortality. A trial of NIV could be recommended in the early phases of acute exacerbation of chronic obstructive pulmonary disease, before eventual intubation. Some promising preliminary results propose noninvasive ventilation as a possible first line intervention for acute hypoxemic respiratory failure. However, the use of noninvasive ventilation in patients with acute respiratory failure still remains controversial. Large randomized multicenter studies are still needed before extensive clinical application of NIV is used in patients with acute hypoxemic respiratory failure.

Corticosteroids in the Acute Respiratory Distress Syndrome

Abstract: Corticosteroids are currently used for primary and secondary adrenal insufficiency, but many medical conditions benefit from their use in view of their anti-inflammatory and immunosuppressive activity Several mechanisms are involved in the anti-inflammatory action of glucocorticoids, and many remain to be elucidated

[Home mechanical ventilation: the extra-hospital phase].

Abstract: Home mechanical ventilation is the choice option, when there are no contraindications of medical or socio-economic order, in all cases of impossible complete weaning from ventilatory support. Easy to use, reliable and size limited positive pressure ventilators lead to a spread diffusion of this technique. In the patient/ventilator interface, tracheostomy is the golden choice for patient with great reduction in spontaneous ventilatory ability. For all other patients, perfectioning of non-invasive access (nasal and oral nasal mask) represent an effective progress. Major limitations in home ventilation are still, up to present, the lack of multidisciplinary structures able to give territorial assistance. Home ventilation therapy in the experience of the Policlinico Universtitario "La Sapienza", Rome is presented.

Gas conditioning in artificial respiration

Abstract: The authors review the main systems used in the clinical setting to condition inspiratory gases during mechanical ventilation. More in details, the functional principles of hot water humidifiers and heat and moisture exchangers are described.

Search for charged Higgs bosons in $e^+ e^-$ collisions at energies up to $\sqrt{s}$ = 189 GeV

Abstract: The data collected at centre-of-mass energies of 188.6 GeV by ALEPH at LEP, corresponding to an integrated luminosity of 176.2 pb-1, are analysed in a search for pair-produced charged Higgs bosons H+/-. Three analyses are employed to select the taunutaunu, taunucs and cscs final states. No evidence for a signal is found. Upper limits are set on the production cross section as a function of the branching fraction BR(H+ to tau nu) and of the mass M(H+), assuming that the sum of the branching ratios is equal to one. In the framework of a two-Higgs-doublet model, charged Higgs bosons with masses below 65.4 GeV/c2 are excluded at 95% confidence level independently of the decay mode.

Non invasive ventilation in the treatment of FUdr-induced lesional pulmonary oedema.

Abstract: 2-deoxy-5-fluorouridine, also known as floxuridine (FUdr) is a fluoropyridine antimetabolite, used in the treatment of metastatic renal cell carcinoma. We report the first case of lesional pulmonary oedema developed after receiving Fudr, recently treated in our unit. The patient refused endotracheal intubation, and was successfully treated associating noninvasive ventilation (NIV) with full-face mask to steroid treatment. The authors conclude that mechanical ventilation via face-mask can be an effective, comfortable, dignified method of support for patients with end-stage disease and acute respiratory failure.

Use of Corticosteroids in the Severely Ill Patient

Abstract: Besides primary and secondary adrenal insufficiency, many medical conditions benefit from the use of corticosteroids because of their anti-inflammatory and immunosuppressive activity. Several mechanisms are involved in the suppression of inflammation by the glucocorticoids, and many remain to be elucidated. Glucocorticoids inhibit the recruitment of leukocytes and monocyte-macrophages into affected areas and the synthesis of a great variety of chemotactic substances and other factors that mediate increased capillary permeability, vasodilatation, and contraction of various nonvascular smooth muscles. All natural and synthetic glucocorticoids act by binding a specific cytoplasmic glucocorticoid receptor. The complex glucocorticoid receptor has the ability to enter the nucleus of the cell and bind specific sites of DNA and control transcription of glucocorticoid-regulated genes. At present the list of substances whose synthesis or release is inhibited by glucocorticoids includes arachidonic acid and its metabolites (prostaglandins and leukotrienes), platelet activating factor (PAF), the nitric-oxide pathway, tumor necrosis factor (TNF) and many interleukins. Glucocorticoids can thus control the synthesis or release of substances involved in onset and evolution of inflammation [1–7].