We developed a protocol to procure lungs from uncontrolled donors after circulatory determination of death (NCT02061462). Subjects with cardiovascular collapse, treated on scene by a resuscitation team and transferred to the emergency room, are considered potential donors once declared dead. Exclusion criteria include unwitnessed collapse, no-flow period of >15 min and low flow >60 min. After death, lung preservation with recruitment maneuvers, continuous positive airway pressure, and protective mechanical ventilation is applied to the donor. After procurement, ex vivo lung perfusion (EVLP) is performed. From November 2014, 10 subjects were considered potential donors; one of these underwent the full process of procurement, EVLP, and transplantation. The donor was a 46-year-old male who died because of thoracic aortic dissection. Lungs were procured 4 h and 48 min after death, and deemed suitable for transplantation after EVLP. Lungs were then offered to a rapidly deteriorating recipient with cystic fibrosis (lung allocation score [LAS] 46) who consented to the transplant in this experimental setting. Six months after transplantation, the recipient is in good condition (forced expiratory volume in 1 s 85%) with no signs of rejection. This protocol allowed procurement of lungs from an uncontrolled donor after circulatory determination of death following an extended period of warm ischemia.

BACKGROUND:Refractory septic shock (RSS) requiring major vasopressor support is associated with high mortality, especially in Gram-negative infections. The study aim was to describe hemodynamics, organ failure, and clinical outcomes in high-dose vasopressor therapy (HDVT) RSS patients treated with Polymyxin B hemoperfusion (PMX-HP) as rescue therapy.METHODS:We retrospectively analyzed 52 patients, unresponsive to conventional therapy, treated with two sessions of PMX-HP requiring HDVT (norepinephrine and/or epinephrine requirement (NEP+EP) ≥ 0.5 µg/kg/min), ≥ 2 organ failures, and suspected/confirmed Gram-negative infection from any source.RESULTS:At baseline, mean arterial pressure (MAP) was 80 ± 13 mmHg and NEP + EP requirement was 1.11 ± 0.56 µg/kg/min. After two PMX-HP sessions, at 72 h, MAP significantly increased and NEP + EP requirement decreased respectively by 12% and 76%. Pulmonary and renal function also improved significantly. Thirty patients (58%) showed a ≥ 50% reduction in NEP + EP dose within only 24 h after the first PMX-HP session (early responders), and 22 did not or died from irreversible shock in the same time frame (early non-responders). The 30-day hospital mortality was 29%; it was 16% in early responders and 45% in early non-responders. On multivariate analysis, SAPS II score, vasopressin, and central venous pressure significantly affected 30-day hospital mortality.CONCLUSION:This is the first study describing the use of PMX-HP as a rescue therapy in RSS patients with HDVT and MOF. Our results suggest a possible role for PMX-HP in improving hemodynamics, organ function, and mortality in RSS, with a 30-day survival of up to 70%.

Dipartimento di Anestesia, Terapia Intensiva e SubIntensiva e Terapia del Dolore. Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milano; Universita degli studi di Milano, Milano, Italy; AO San Gerardo Monza; AO Ospedale Civile di Legnano; AO Istituti Ospitalieri di Cremona; AO S. Antonio Abate, Gallarate; AO di Desio e Vimercate; AO S.Anna, Como; AO Papa Giovanni XII Bergamo; Ospedale San Raffaele, Milano; AO Fatebenefratelli e Oftalmico; AO Ospedale di Circolo di Melegnano; Ospedale di Circolo e Fondazione Macchi, Varese; Ospedale Niguarda Ca’ Granda, Milano; AO Manzoni, Lecco; AO Spedali Civili di Brescia; Nord Italian Transplant program (NITp); Cooordinatore Prelievi Regione Lombardia.

Sepsis accounts for a very high mortality. The Surviving Sepsis Campaign recommends a first 6 hours resuscitative bundle to improve patient outcome. Despite this, the bundle is poorly performed because of several organizational and cultural barriers. In recognition of this, we guess that an Educational and Organizational Intervention out of the ICUs could impact on septic patient outcome. In order to test our hypothesis we carried out, in 12 hospitals, a pre-intervention survey of the human and organizational resources (HOR) available in the management of septic patients. The aim is to seek any barrier potentially affecting correct Guidelines implementation.

Introduction. The feasibility and utility of a lung donor score that has been recently proposed was tested among a pool of lung donors referred to the Nord Italia Transplant program (NITp) organ procurement organization.Material and Methods. Each lung donor was assigned an Oto score including, age, smoking history, chest X-ray, secretions and ratio of arterial oxygen tension to inspired oxygen fraction (PaO2/FiO(2)). Based on clinical compromise, each variable received a score between 0 and 3, except for PaO2/FiO(2), which was scored between 0 and 6 given its overall relevance.Results. Throughout 2010, 201 multiorgan donors were initially considered to be potential lung donors. Among these, 59 (29.4%) eventually yielded 67 lung transplantations (named "Used group"). Among the 142 (70.6%) refused lungs, 28 were not used due to logistic or medical problems ("general exclusion" group, GE) and 114, because of poor lung function ("lung exclusion" group, LE). Median lung donor scores were 1 (range, 0 to 3), 4 (range, 2.5 to 6.5), and 7 (range, 5 to 9) in the Used, GE, and LE groups, respectively (one-way analysis of variance, P < .001). Some donors with Oto scores <= 7 worsened over time so that the score had significantly increased by the time of organ retrieval. Overall, subjects who died after lung transplantation were characterized by higher lung donor scores, (2 [1-4] versus 0.5 [0-3], P = .003).Conclusion. Our analysis suggested that the use of a donor score as a dynamic tool over the donation process was of great utility to describe and analyze a pool of lung donors.

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Intensive Care Medicine

We designed this study to compare the performance in cardiac output (CO) monitoring capabilities of two devices in refractory septic shock patients (RSS Pts): non-invasive transthoracic bioreactance (NICOM) and pulse contour analysis (PICCO PC) coupled to transpulmonary thermodilution (PICCOTD).

NICOM (Cheetah) is a new non-invasive cardiac output (CO) monitor based on bioreactance. We tested the agreement of NICOM vs LiDCO™ plus in terms of absolute CO values and of the ability to track changes after therapeutic intervention in critically ill patients.

In Italy, like everywhere in the world, the organ shortage for transplantation is a real problem. It is well known that lung donors (LD) are particularly difficult to procure and that management of the organ do not care during the diagnosis of cerebral death represents a difficult challenge. In this context, the salvage of the so-called "marginal donors" may increase the pool of donors, favoring organ retrieval. To increase lung procurement, the intensivist must recognize "marginal donors," optimizing organ selection and function. The aim of our study was to review LD procured in 2008, as identified by the unrestricted criteria, of the Nord Italian Transplant program Center (NITp). Particularly, the age and habits of donors and the presence of a parenchyma contusion were not sufficient per se to exclude donation. We revisited lung ventilation and monitoring modalities during cerebral death before retrieval. In 2008, the application of enlarged criteria for LD enabled us to collect 21 LD, namely 33% of all cerebral deaths, versus 13% in 2007. Seeking to maintain good gas exchange and lung function, we implemented a safe ventilation program avoided high peak pressures, and fluid therapy properly guided by the cardiac index and extravascular lung water index monitoring. Specific actions to improve LD procurement may help cope with the organ-donor shortage. Although our series was small, our results were encouraging; they underline the necessity to continuously review donor criteria and care, allowing good donor/recipient matching.

The aim of the present study was to evaluate the clinical utility of endotoxin activity (EAA) measurement in critically ill septic shock (SS) patients.

An epidemiologic evaluation of trauma-related deaths in trauma centers reveals that the majority of patients die within 6 hours from exsanguination, whereas secondary brain injuries predominate between 6 and 24 hours. Late deaths remain attributable to sepsis and pulmonary embolism,1-3 while early deaths are due in part to multiple bleeding injuries or to a set of complex and untreatable injuries, mainly of the liver and pelvis. Before trauma systems existed, these patients died at the scene of the trauma, whereas since the establishment of the trauma system, they die in emergency or operating rooms. Another subset of early deaths result from severe bleeding injuries, which could be prevented if recognized early. For instance, if a 70 kg adult had a blood volume of 70 mL/kg (5 L), hypotension (systolic blood pressure [SBP]<90 mmHg) would usually occur after a one third-loss of blood volume, and death would follow with a 50% loss. A patient bleeding at a rate of 25 mL/min will become hypotensive within one hour and die within two hours, while a patient bleeding at a rate of 100 mL/min will be hypotensive within 15 minutes and die within 30 minutes. These considerations indicate a narrow window of opportunity for targeting fluid resuscitation. Moreover, increases in blood pressure before surgical hemostasis have been shown to disrupt clotting and increase bleeding, a fact that has been confirmed by a number of animal and human studies on uncontrolled hemorrhage. Furthermore, oxygen must be delivered to vital organs (brain, heart) to prevent death during hemorrhage. In summary, several constraints account for the differences in fluid use, timing of infusions, and determinations of whether to administer fluids at all.

BACKGROUND:The aim of this study was to prove the existence of a direct relationship between the comprehensive strategy of trauma management and an enhancement in outcome. Tests were carried out on the impact of the Niguarda Trauma Team System on mortality rates due to severe trauma.METHODS:The epidemiological data was retrospectively reviewed along with, the severity scores: Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Revised Trauma Score (RTS), Probability of survival (Ps) and the outcome of severe trauma admitted to Niguarda hospital between October 2002 and September 2005. All data were collected from the Trauma Registry of the Niguarda Hospital. Two subsequent periods of 20 and 16 months were compared.RESULTS:Nine hundred forty-two severe traumas (94.05% blunt trauma) were recorded with an overtriage rate of 36.09%. Most patients were admitted for bone and muscular injuries (52.22%). Excluding the patients who were overtriaged, there were 129 patients who died. Comparing the two periods, the Authors observed a significant reduction in mortality from 22.56% to 19.75%, mainly related to a decrease in early mortality due to hemodynamic instability. Central nervous system injury was the main cause of death (65%). Average hospital stay significantly decreased from 17.01+/-12.07 days to 14.97+/-10.34 days.CONCLUSION:Introducing a comprehensive strategy of severe trauma management, the Niguarda Trauma Team System had a significant impact on mortality rates and hospital stay.

The aim of the study was to evaluate the clinical impact of polymyxin-B hemoperfusion (HP-PMX) as adjuvant therapy versus conventional treatment in septic shock (SS) patients with high endotoxemia.

AIM:Massive haemorrhage after trauma is a big challenge for care-givers, being a leading cause of early in-hospital mortality. Surgical bleeding may be easily controlled with several techniques. Otherwise, consumptive coagulopathy is often extremely difficult to stop. An adjunctive strategy to treat traumatic coagulopathic bleeding is recombinant activated factor VII (rFVIIa) (NovoSeven, Novo Nordisk A/S, Bagsvaerd, Denmark). METHODS:All major trauma victims haemodinamically unstable (systolic blood pressure < 90 mmHg or > 90 mmHg with massive infusions or vasopressors) admitted to the Emergency Department of the Niguarda Ca' Granda Hospital in Milan from October 2002 to September 2005 were reviewed. Mechanical bleeding was controlled with interventional techniques when indicated. Blood derivatives were administrated to maintain haemoglobin> 7 g/dL, INR < 1.5, fibrinogen > 1 and platelet count > 50 x 109. Off-label administration of rFVIIa was performed in the last year in any coagulopathic salvageable patient when all other strategies failed to control bleeding. RESULTS:Major trauma were 942, mean age 32.49+/-18.44 years, 94% blunt trauma, 25.13% haemodynamically unstable. Deaths occurred in 17.02% of cases before any procedure. Emergency invasive treatments were performed in 72.34% of cases. Infusions restored haemodynamic stability in 10.63% of patients. In average 9.4+/-4.1 units of red blood cells were transfused in unstable patients. rFVIIa (dosing 60-100 mg/kg) was administrated in 12 patients. Mortality occurred in 33.33% of cases. The principal cause of death was brain injury. A femoral artery thrombosis was observed in a mangled leg. No other adverse effects due to rFVIIa were documented. CONCLUSIONS:Off-label administration of rFVIIa was able to reverse life-threatening bleeding not manageable with standard strategies in our series of major trauma patients without systemic adverse effects.

Levati, A.; Moretti, M. P.; Meregalli, S.; Orsini, C.; Vesconi, S.; Facco, E. Author Information