In a heterogeneous ICU population, an abnormal microvascular flow index was present in 17% of patients. This was not associated with mortality. However, in patients with tachycardia, an abnormal microvascular flow index was independently associated with an increased risk of hospital death.

Recombinant activated factor VII (rFVIIa) has been used at different doses in cardiac surgery patients. We tested the efficacy of small-dose rFVIIa in patients with intractable bleeding after cardiac surgery. The study group comprised 15 cardiac surgery patients with intractable bleeding treated with small-dose (1.2 mg) rFVIIa as a slow IV bolus at the end of complete step-by step transfusion protocol. Fifteen matched patients undergoing the same transfusion protocol in the pre-rFVIIa era represented the control group. Blood loss at the end of the transfusion protocol was a primary outcome. Median, 25th-75th 24-h blood loss percentiles were 1685 (1590-1770) mL versus 3170 (2700-3850) mL in study group and controls, respectively (P = 0.0004). Transfused red blood cells, fresh-frozen plasma, and platelets in the study group and controls were as follows: 7 (4-8) U versus 18 (12-21) U (P = 0.001); 7.5 (6-11) U versus 11 (9-15) U (P = 0.003); 0 (0-4) U versus 9 (6-13) U (P = 0.001). In addition, significant improvements of prothrombin time (P = 0.015), international normalized ratio (P = 0.006), activated partial prothrombin time (P = 0.01), and platelet count (P = 0.003) were detected in the study group versus controls. Finally, patients receiving rFVIIa showed a reduced intensive care unit length of stay (chi2 = 15.9, P = 0.0001) and had infrequent surgical re-exploration (chi2 = 16.2,P < 0.0001). Small-dose rFVIIa showed satisfactory results in cardiac patients with intractable bleeding. Further randomized studies are necessary to confirm our findings.

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BackgroundExtracorporeal membrane oxygenation (ECMO) supplies systemic blood perfusion and gas exchange in patients with cardiopulmonary failure. The current literature lacks of papers reporting the possible risks of microembolism among the complications of this treatment.In this study we present our preliminary experience on brain blood flow velocity and emboli detection through the transcranial Doppler monitoring during ECMO.MethodsSix patients suffering of heart failure, four after cardiac surgery and two after cardiopulmonary resuscitation were treated with ECMO and submitted to transcranial doppler monitoring to accomplish the neurophysiological evaluation for coma.Four patients had a full extracorporeal flow supply while in the remaining two patients the support was maintained 50% in respect to normal demand.All patients had a bilateral transcranial brain blood flow monitoring for 15 minutes during the first clinical evaluation.ResultsMicroembolic signals were detected only in patients with the full extracorporeal blood flow supply due to air embolism.ConclusionsWe established that the microembolic load depends on gas embolism from the central venous lines and on the level of blood flow assistance.The gas microemboli that enter in the blood circulation and in the extracorporeal circuits are not removed by the membrane oxygenator filter.Maximum care is required in drugs and fluid infusion of this kind of patients as a possible source of microemboli. This harmful phenomenon may be overcome adding an air filter device to the intravenous catheters.

BackgroundMildly elevated lactate levels (i.e., 1–2 mmol/L) are increasingly recognized as a prognostic finding in critically ill patients. One of several possible underlying mechanisms, microcirculatory dysfunction, can be assessed at the bedside using sublingual direct in vivo microscopy. We aimed to evaluate the association between relative hyperlactatemia, microcirculatory flow, and outcome.MethodsThis study was a predefined subanalysis of a multicenter international point prevalence study on microcirculatory flow abnormalities, the Microcirculatory Shock Occurrence in Acutely ill Patients (microSOAP). Microcirculatory flow abnormalities were assessed with sidestream dark-field imaging. Abnormal microcirculatory flow was defined as a microvascular flow index (MFI) < 2.6. MFI is a semiquantitative score ranging from 0 (no flow) to 3 (continuous flow). Associations between microcirculatory flow abnormalities, single-spot lactate measurements, and outcome were analyzed.ResultsIn 338 of 501 patients, lactate levels were available. For this substudy, all 257 patients with lactate levels ≤ 2 mmol/L (median [IQR] 1.04 [0.80–1.40] mmol/L) were included. Crude ICU mortality increased with each lactate quartile. In a multivariable analysis, a lactate level > 1.5 mmol/L was independently associated with a MFI < 2.6 (OR 2.5, 95% CI 1.1–5.7, P = 0.027).ConclusionsIn a heterogeneous ICU population, a single-spot mildly elevated lactate level (even within the reference range) was independently associated with increased mortality and microvascular flow abnormalities. In vivo microscopy of the microcirculation may be helpful in discriminating between flow- and non-flow-related causes of mildly elevated lactate levels.Trial registrationClinicalTrials.gov, NCT01179243. Registered on August 3, 2010.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1842-7) contains supplementary material, which is available to authorized users.

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This report emphasizes that transplant-acquired WNV neuroinvasive disease can be particularly severe. We suggest that pre-procurement screening of organ donors by testing blood with both WNV IgM capture ELISA and a sensitive nucleic acid testing should be adopted during the transmission season in the present Italian epidemiological setting.

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