Biomedical subjects
R Cantieni
Publications and source records attributed to R Cantieni.
[Fatal central pulmonary embolism under heparin therapy: white-clot syndrome].
A 75-year old female underwent coronary angiography for chest pain. Significant proximal stenosis of the left coronary artery was found. During the waiting time for bypass surgery, intravenous heparin treatment was established for several days because of recurrent unstable angina pectoris. 10 days after coronary angiography an acute event with chest pain, hypotension, tachycardia and a new right bundle branch block suspect for myocardial infarction occurred, which was treated with rt-PA. Fever, persistent hypotension, acute progressive renal failure and thrombocytopenia suggested septic shock, and the patient was transferred to our hospital. A pulmonary artery catheter could not be advanced beyond the main stem of the pulmonary artery. The patient died suddenly 24 hours later from acute right ventricular failure. Autopsy demonstrated multiple white clots in both pulmonary arteries. The histological finding of clots rich in leukocytes and fibrin was compatible with the diagnosis of heparin-induced thrombosis-thrombocytopenia or white clot syndrome. Heparin-induced thrombocytopenia may occur after about 5 days of treatment. Two distinct types have been described. The first type occurs in up to 25% of patients receiving heparin and is a result of temporary platelet aggregation, margination and peripheral sequestration. The less common second type of thrombocytopenia is thought to be mediated by a heparin-dependent IgG antibody inducing platelet aggregation and may be associated with thromboembolic events leading to the white clot syndrome, which is rarely reported in the literature. In these cases heparin should be stopped immediately and replaced by oral anticoagulation. Other therapies such as low molecular weight heparin, synthetic heparinoids, hirudin, fibrinolytic agents, plasmapheresis and intravenous immunoglobulins are discussed. Monitoring of the platelet count every 5 days in patients receiving heparin for any extended period should become standard medical practice to avoid potential fatal complications.
Acute colonic pseudoobstruction (Ogilvie's syndrome) in two patients receiving high dose clonidine for delirium tremens.
We describe two cases of severe colonic pseudo-obstruction (Ogilvie's Syndrome) after high dose clonidine i.v. infusions for delirium tremens. The first symptoms occurred 36 h and 5 days, respectively, after institution of therapy. The diagnosis of colonic pseudo-obstruction (CPO) was confirmed during emergency laparotomy in both cases. While other known risk factors may have been present, we propose that clonidine had a major parasympatholytic effect on the large bowel of these patients and was therefore responsible, either alone or in combination with these other factors, for the development of CPO. We conclude that the therapy of delirium tremens with high i.v. doses of clonidine carries the risk of provoking severe CPO, especially when other contributing factors are present. While therapy of the alcohol withdrawal syndrome with clonidine appears to be an attractive alternative to conventional treatment, ICU physicians should be alerted to this potentially serious complication.
Late outcome of percutaneous dilatational tracheostomy in intensive care patients.
OBJECTIVE: Percutaneous dilatational tracheostomy is increasingly practiced in intensive care units and has a low incidence of early complications. The late effects of this procedure are still poorly known and were the focus of this study. DESIGN: Prospective descriptive clinical study. SETTING: Interdisciplinary intensive care unit in a 300-bed teaching hospital. PATIENTS: A consecutive group of critically ill patients who underwent percutaneous tracheostomy between Nov. 90 and March 93, surviving at least 2 months after decannulation. MEASUREMENTS AND RESULTS: There were 17 patients fulfilling the inclusion criteria and 16 of them were seen and examined. The follow-up protocol required a formal standardized patient interview, a physical examination of the stoma site and a fiberoptic laryngotracheoscopy. Results of these sub-tests and overall outcome rating were standardized and expressed as good, moderate or poor. Subjective rating was good in all patients. All denied suffering from any side effects of their tracheostomy. Clinical examination revealed neither stridor nor hoarseness in any of the patients. Most of the scars were whitish and less than 1 cm in length, a few were sunken in, none had adhesions. In 15 patients the clinical result was good and in one, moderate (whitish, sunken-in scar, longer than 2 cm). Ten patients underwent tracheoscopy, while 6 did not. There were no signs of significant stenosis or tracheomalacia. In 8 patients with minor findings results were scored as good, while 2 were classified as moderate (combination of swelling and scar formation of a string-like membrane). The overall rating was good in 13 patients (81%) and moderate in 3 patients (19%). There were no poor outcomes. CONCLUSIONS: Late outcome of percutaneous dilatational tracheostomy in critically ill patients is mostly good. Pending further studies, the use of this technique in intensive care units appears justified.
Traumatic or septic aortic regurgitation: diagnosis by oesophageal echocardiography.
Severe aortic regurgitation was discovered in a young man 21 days after blunt chest trauma and after a prolonged febrile state with positive blood cultures. Using transoesophageal echocardiography (TEE), it was possible to make the differential diagnosis between traumatic rupture and endocarditis as the cause of valvular insufficiency. The use of TEE in the initial evaluation of severe thoracic trauma with an unclear clinical picture is recommended. This method is easy to use at the bedside and gives precise information on the aortic valve and the ascending aorta.
Five years' follow-up of severely injured ICU patients.
We conducted a 5-year follow-up study of a group of 461 consecutive trauma patients treated in our Intensive Care Unit from 1980 to 1983. The entry criteria (initial survival and severe injury: ISS greater than or equal to 18) were fulfilled by 233 patients with a mean ISS of 29.3 and mean age of 35.6 years. Data on prehospital care, type and timing of surgery, and hospital and ICU stay were recorded during hospital discharge. The protocol strictly asked for a personal interview and a physical examination. Mailed questionnaires or phone interviews were not allowed. The areas of medical sequelae, aftercare, missed injuries, occupation, insurance, social integration, economics, legal aspects, and traffic involvement were covered. We were able to gather final information from 223 (95.6%) of the 233 cases. Forty-three patients (18.4%) died in the hospital, 13 patients (5.6%) died later, and 167 (76.5%) were eventually seen. Only 10 patients (4.4%) were lost to follow-up. Outcome was judged using the Glasgow Outcome Scale (GOS), which was compared with a GOS value given prospectively at the time of hospital discharge. Eighty-nine percent of the survivors were healthy or slightly disabled (GOS 5 and 4), 9% were severely disabled, and only 2% were in a persistent vegetative state. Outcome after 5 years was better than tentatively prognosed at the time of hospital discharge. Ninety-one patients with severe head injuries (AIS 4-5) were additionally tested using the Mini Mental State instrument. This test revealed normal mental functions in 77% and dementia, mostly of a minor degree, in 23% of the head-injured patients. Almost all the early deaths and two thirds of the late deaths were related to severe head injury. Seventy-nine percent of the survivors were working after 5 years. During the post-trauma period, patients experienced reduced social well-being and also changed professional and recreational activities. There appears to be extensive room for improvement in the posthospital recovery phase. We conclude that survivors of critical trauma have a very good chance, after 5 years, of regaining a high quality of life. All efforts at improving trauma survival and quality of trauma care are therefore worthwhile and deserve high priority.