RESUMEN
AIMS: In this work, the survival and mortality data of 54 consecutive patients admitted to the Intensive Care Unit (ICU) and suffering from severe respiratory insufficiency imputable to viral SARS - CoV - 2 infection were analyzed and shared, after a critical review of the evidence in order to optimize the most dedicated clinical and treatment strategy, for a future 'targeted' management in the care of the possible return flu outbreak. METHODS: At our Emergency Department of the Crema Hospital, from the beginning of the pandemic until the end of June 2020, 54 consecutive patients admitted to ICU suffering from severe acute respiratory infection (SARI) and severe respiratory distress (ARDS) attributable to viral SARS - CoV - 2 infection were recruited. The recruitment criterion was based on refractory hypoxia, general condition and clinical impairment, comorbidities and CT images. The incoming parameters of the blood chemistry and radiology investigations and the timing of the gold - tracheal intubation were compared. Medical therapy was based on the application of shared protocols. RESULTS: The onset of symptoms was varyng, i.e. within the range of 1-14 days. The average time from the admission to the emergency room to the admission to intensive care was approximately 120 h. The average number of days of hospitalization in the ICU was 28 days. With a majority of male patients, the most significant age group was between 60 and 69 years. There were 21 deaths and, compared to the survivors, the deceased ones were older at an average age of about 67 years (vs an average age of the survivors of about 59 years). From the available data entering the ICU, the surviving patients presented average better values of oximetry and blood gas analysis, with a lower average dosage of D-Dimer than the deceased. Ones with a presence of bilateral pneumonia in all patients, the worsening of the ARDS occurred in 31 patients. 9 out of 25 patients early intubated died, while 12 out of 23 patients died when intubation was performed after 24 h of non-invasive ventilation. The presence of multiple comorbidities was shown in 17 of 28 patients and revealed an additional adverse prognostic factor. Also, more than one complication in the same patient were detected; after respiratory worsening, renal failure was more frequently found in 16 patients. Some particular complications such as lesions induced by ventilation with barotrauma mechanism (VILI), ischemic heart disease and the appearance of central and peripheral neurological events were detected too. CONSIDERATIONS: SARS - CoV - 2 disease is caused by a new coronavirus that has its main route of transmission through respiratory droplets and close contact, resulting in a sudden onset of the clinical syndrome with acute respiratory infection (SARI) and severe respiratory distress (ARDS). But it can also appear with other symptoms such as gastrointestinal or neurological events, as to be considered as a disease with multisystem phenotype. This pathology evolves towards a serious form of systemic disease from an acute lung damage to venous and arterial thromboembolic complications and multi-organ failure, mostly associated with high mortality. All patients received empirical or targeted antibiotic therapy for prevention and control of infections of potential pathogens, together with low molecular weight heparin therapy. The majority of patients was subjected to the off - label protocol with antivirals and hydroxychloroquine therapy, we used cortisone support therapy under surveillance and in 3 cases the protocol with anti - IL6 monoclonal antibody (Tolicizumab). In a simplified classification of the tomographic examination of the chest, mostly 3D and 2C lesions were found in the deceased patients with a prevalence of severe and moderate forms, whilst in the survivors the distribution appears with a prevalence of medium and moderate forms. Among the intubated patients, 21 patients, all suffering from worsening ARDS, died whilst there was no mortality in patients subjected to non-invasive ventilation it so. The heterogeneity of the respiratory syndromes and the presence of multiple comorbidities represent an unfortunate prognostic factor. Among the complications, besides the respiratory worsening, renal failure, liver failure and the state of sepsis were most frequently found; less frequent complications were lesions induced by ventilation with a barotrauma mechanism, ischemic heart disease, the appearance of central neurological events of sensory alterations, meningo - encephalitis and cerebral hemorrhage, and peripheral neurological events with polyneuro - myopathies. Mechanical ventilation can adversely affect the prognosis due to lung damage induced, protective ventilation remains the necessary treatment during severe hypoxia in patients with SARS - CoV - 2. The essential prerequisite remains the search for optimal 'customized' values since conditions can vary from patient to patient and, in the same patient, during different times of ventilation. CONCLUSIONS: In these extraordinary circumstances, our reality was among the most affected and was able to hold the impact thanks to the immediate great response set in place by the operators, although it costed us an effort especially the one to try to guarantee a high quality level of assistance and care compared to the huge wave of patients in seriously bad conditions. Further research on this heterogeneous pathology and data sharing could help identify a more dedicated clinical decision-making and treatment pathway that, together with a resource planning, would allow us to better face any new disease outbreak.
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COVID-19/terapia , Cuidados Críticos/métodos , Hospitalización/estadística & datos numéricos , Unidades de Cuidados Intensivos , Pandemias , Respiración Artificial/métodos , SARS-CoV-2 , Adulto , Anciano , Anciano de 80 o más Años , COVID-19/epidemiología , Femenino , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
AIM: The authors analyse clinical cases of penetrating thoracic, abdominal, perineal and anorectal injury and describe the traumatic event and type of lesion, the principles of surgical treatment, the complication rate and follow up. MATERIALS AND METHODS: In the last 24 months, we analyzed 10 consecutive cases of penetrating thoracic and abdominal wounds [stab wound (n=7), with evisceration (n=4), gunshot wound (n=1)], and penetrating perineal and anorectal wounds (impalement n=4). In addition, we report an unusual case of neck injury from a stab wound. All the patients underwent emergency surgery for the lesions reported. RESULTS: In 7 cases of perforating vulnerant thoracoabdominal trauma from stab wounds there was hemoperitoneum due to bleeding from the abdominal wall (n=3), the omentum (n=1), the vena cava (n=1) and the liver (n=2). Evisceration of the omentum was observed in 4 cases. In 2 cases laparoscopy was performed. In one case laparotomy and thoracoscopy was performed. In a patient with an abdominoperineal gunshot wound, exploration was extraperitoneal. The 4 cases of perineal and anorectal impalement were treated with primary reconstruction, while in one case a laparotomy was needed to suture the rectum and fashion a temporary colostomy. In one case of anorectal injury rehabilitation resulted in a gradual improvement of fecal continence, while in the patient with the colostomy follow up at 2 months was scheduled to plan colostomy closure. CONCLUSIONS: Based on the our clinical experience and the literature, in penetrating abdominal trauma laparotomy may be required if patients are hemodynamically unstable (or in hemorrhagic shock), in patients with evisceration and peritonitis, or for exploration of penetrating thoracoabdominal and epigastric lesions. In anterior injuries of the abdominal wall from gunshot or stab wounds, laparotomy is indicated when there is peritoneal violation and significant intraperitoneal damage. In patients with actively bleeding wounds of the abdominal wall muscles minimal laparotomy is often necessary for control of hemorrhage and abdominal wall reconstruction to avoid herniation. If patients are asymptomatic, in cases of anterior lesions the indications for diagnostic laparoscopy are uncertain. Selective conservative treatment is reserved for asymptomatic patients who are hemodynamically stable. Further controlled studies are needed. Early surgery for perineal and anorectal trauma, and also for complex injuries, is the gold standard for treatment.
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Traumatismos Abdominales/cirugía , Canal Anal/lesiones , Canal Anal/cirugía , Tratamiento de Urgencia , Perineo/lesiones , Perineo/cirugía , Recto/lesiones , Recto/cirugía , Traumatismos Torácicos/cirugía , Heridas por Arma de Fuego/cirugía , Heridas Punzantes/cirugía , Adulto , Colostomía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Violencia , Adulto JovenRESUMEN
Splenic vessel aneurysm is often a casual pathology during strumental imaging or laparotomy. The first cause for the formation of the aneurysm is a vessel primitive degenerative pathology of the medium wall, or idiopathic cystic medionecrosis, that to develop in aneurysmatic dissection. In the early diagnosis, in the selective patients, resulted indicate an endovascular therapy, while in emergency the laparotomy is a gold strandard for reduction morbility and mortality. In this paper, the Authors described a rare case of rupture of the lienal vessel aneurysm in Erdheim disease, and reported clinical features, indications and procedures for better treatment.
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Aneurisma Roto/etiología , Aneurisma/etiología , Aneurisma/cirugía , Enfermedad de Erdheim-Chester/complicaciones , Esplenectomía , Arteria Esplénica , Enfermedades del Bazo/etiología , Adulto , Aneurisma/diagnóstico , Aneurisma Roto/diagnóstico , Aneurisma Roto/cirugía , Humanos , Masculino , Pancreatectomía/métodos , Rotura Espontánea , Enfermedades del Bazo/diagnóstico , Enfermedades del Bazo/cirugía , Resultado del Tratamiento , Procedimientos Quirúrgicos VascularesRESUMEN
The Authors report on an extremely rare case of anal Masson's tumour and has described clinical and histological considerations. Is important the surgical resection of the lesion because this tumour is similar to angiosarcoma.
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Neoplasias del Ano , Hemangioendotelioma , Neoplasias del Ano/patología , Hemangioendotelioma/patología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The AA report on 12 cases of intestinal infarction for acute mesenteric ischemia (IMA) in critical patients observed in the last 2 years. In this work some clinical data, blood tests and strumental considerations are described. IMA is a vascular emergency with severe prognosis and high rate morbidity and mortality, often correlated to a diagnostic delay. The discrepancy between symptoms and clinical objectivity must suggest the suspect, especially in patients with cardiac pathology, short lasting diarrhoea, bowel hemorrhage or only abdominal pain rebel to the analgesics; with the laboratory indexes and strumental data it can be carried out an early diagnosis and then begin the more opportune therapeutical treatment. The increase of blood sugar together to the triad leucocytosis--haemoconcentration and metabolic acidosis, in previously non diabetic patients, confirm the suspect of IMA in the very initial phases of this pathology.
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Colon/irrigación sanguínea , Íleon/irrigación sanguínea , Infarto/diagnóstico , Acidosis/sangre , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Diagnóstico Precoz , Femenino , Hematócrito , Humanos , Infarto/sangre , Infarto/etiología , Infarto/mortalidad , Infarto/cirugía , Isquemia/sangre , Isquemia/complicaciones , Isquemia/diagnóstico , Isquemia/mortalidad , Isquemia/cirugía , Leucocitosis/sangre , Masculino , Isquemia Mesentérica , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Enfermedades Vasculares/sangre , Enfermedades Vasculares/complicaciones , Enfermedades Vasculares/diagnóstico , Enfermedades Vasculares/mortalidad , Enfermedades Vasculares/cirugíaRESUMEN
The AA report some considerations on the treatment and surgical approach during acute mesenteric ischemia (IMA) focusing some indications for a timely and suitable therapeutic approach. In the last 2 years, they treated 12 cases of IMA in critical patients. Early identification allows avoiding advanced phases of the intestinal infarct/bowel necrosis; in this phase the multidisciplinary approach for the hemodynamic stabilization is a priority, together with rianimatory support and surgery operation. The preservation of the intestinal vitality is essential to avoid the need of bowel resections or at least a major one. A suitable treatment permits a better survival and improvement of the quality of life. Surgical timing requires the intervention within 12 hours since the beginning of the symptoms to be more efficacious.
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Isquemia/cirugía , Mesenterio/irrigación sanguínea , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The Authors report on a rare case of diverticular disease complicated by a sigmoid- vaginal fistula with personal considerations based on a review of literature. A 75 year old patient becomes to our observation suffering the lost of smelly vaginal secretions without fever or abdominalgia. In anamnesis hysterectomy cholecystectomy appendectomy and visceral adhesions lysis. Colonoscopy RX barium enema, gynaecological examination, vaginal buffer show diverticulis of colon sigma with sigmoid-vaginal fistula. After laparotomy, visceral adhesions lysis, it was done sigmoid- vaginal fistula resection with healing. Diverticular disease is a XX century pathology with incidence (for some authors) of 50% of population. Symptomatic forms affect 30-50% of patients (variable percentage based on age); the 1% of these need surgery. The colonic anatomical-functional disorder is the principal cause of diverticular disease that recognize the main localization in colon-sigma. Diverticulitis with pericolic inflammation are frequent complications; possible evolutions are local tamponed peritonitis, mechanical intestinal occlusion, hemorrhage from colonic wall and fistulas. Sigmoid-vaginal fistula is the most frequent in women previously treated with laparohysterectomy. The colonoscopy and RX barium enema are gold standard for instrumental diagnosis; the vaginography is diriment, urography excludes urological diseases. The surgical treatment is the fistula resection, with or without colonic resection. In consideration of the necessity of conservative surgery and on the basis of this case, the authors suggest, if it's possible, the simple fistula resection, although the literature report an high number of relapses.
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Diverticulosis del Colon/complicaciones , Fístula Intestinal/cirugía , Enfermedades del Sigmoide/complicaciones , Enfermedades del Sigmoide/cirugía , Fístula Vaginal/cirugía , Anciano , Colonoscopía , Diverticulosis del Colon/diagnóstico , Femenino , Humanos , Fístula Intestinal/complicaciones , Fístula Intestinal/diagnóstico por imagen , Laparotomía , Radiografía , Enfermedades del Sigmoide/diagnóstico , Resultado del Tratamiento , Fístula Vaginal/complicaciones , Fístula Vaginal/diagnóstico por imagenRESUMEN
The insertion of the nasogastric tube is one of the procedure that produces the most discomfort for the patients and practitioners. The AA, with the make use of their clinical experience and the data of the literature, report some personal reflections about the management of the nasogastric tube. The AA also analyse some variables (choice of the tube, approach to the patient, insertion of the tube, examination of the position, fixation and removal) that can influence on discomfort of the patient. The choice of the most right SNG is an important moment for the correct insertion; an effect we need to adjust the material and diameter of the tube to the prearranged use. The common practice demonstrates that the collaboration with the patient, obtained by "direct" and "indirect" strategies, gives more possibilities to immediately success of this procedure. The literature explains that it is possible to decrease the discomfort with topical anesthesia; still there are some points of view to clarify. From analyse of the different methods to check the position of SNG, the pH test of the aspirating fluid is the best solution. Once examination of right placement, we need to fix in different points (at least two). From personal experience the removal of SNG is better tolerate that the insertion because the patient is more conscious to be on the mend. The principal recommendation is to abstain from insertion of SNG if it is not closely necessary!
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Intubación Gastrointestinal/métodos , HumanosRESUMEN
The AA report on a case of intestinal carcinoid tumour. The characters of these tumours to permit a specific clinical and therapeutic approach.
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Tumor Carcinoide , Neoplasias del Íleon , Anciano de 80 o más Años , Tumor Carcinoide/patología , Tumor Carcinoide/cirugía , Colecistectomía , Femenino , Cálculos Biliares/diagnóstico , Cálculos Biliares/cirugía , Humanos , Neoplasias del Íleon/patología , Neoplasias del Íleon/cirugía , Hallazgos IncidentalesRESUMEN
The authors report a case of Amyand's hernia and describe the pathophysiology, the diagnosis and the therapy in occurrence of this surgical condition.