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Objective: Extracorporeal membrane oxygenation (ECMO) support has been suggested to improve the survival rate in patients with refractory in- and out-of-hospital cardiac arrest (IHCA and OHCA). The aim of our study is to report our experience with ECMO in these patients. Design: Retrospective, single-centre, observational study. Patients: From January 2006 to February 2011 we studied 42 patients (31 males) with refractory cardiac arrest. Measurement and main results: ECMO implantation was successful in 38 (90%) of the 42 patients. ECMO support was positioned: three times (8%) in the operating room, six (16%) in the cardiac surgery intensive care unit, 21 (55%) in the emergency room, five (13%) in the catheterisation laboratory and three (8%) in the general ward. A total of 14 IHCA (58%) and three OHCA (16%) patients were weaned from ECMO (. p

Defensive medicine takes place when healthcare personnel modify their behaviour with the aim of reducing their exposure to legal challenges from patients. The phenomenon is directly related to the significant growth in medical malpractice litigation over recent years. This article presents the results of two research surveys aimed at measuring the extent of defensive behaviours on the part of doctors in Italy and at understanding the reasons for them. The first study (the National Study (NS) was conducted in respect of a nation-wide sample of general practitioners, while the second (the Local Study (LS) was conducted in respect of two groups of specialists (surgeons and anaesthetists) in a regional hospital. 77.9% of the general practitioners interviewed for the NS (responses were received from 37% of the 1000 GPs to whom the questionnaire was sent) declared that they had practiced at least one form of defensive medicine during the previous working month. The figure for the LS was 83.3%. This article discusses the factors, such as the blame culture and the increase in medical malpractice litigation, that may lead to defensive behaviours and result in negative effects both in terms of costs and patient safety. A clear need emerges for a different approach to the problem of medical error - at a cultural, organizational and legal level - just as in the case of other organizations subject to high risk. The deterrent of punishment does not increase the reliability of such organizations, nor does it improve the level of safety in them.

A case of a 76-year-old woman with a history of ischemic heart disease and chronic mitral valve regurgitation is presented. Her preoperative transthoracic echocardiogram (TTE) showed moderate-to-severe mitral regurgitation, moderate tricuspid regurgitation with pulmonary hypertension (pulmonary artery pressure 50 mmHg), and moderately depressed left ventricular systolic function (ejection fraction 43%). She underwent elective surgery for coronary artery bypass grafting and valve repair. She received a left internal thoracic artery graft to the left anterior descending artery, an annuloplasty ring (Carpentier Physio size 28 mm; Edwards Lifesciences, Irvine, CA) plus a quadrangular resection of the posterior leaflet of the mitral valve, and an annuloplasty ring (Edwards Mc3 size 32 mm) to the tricuspid valve. Routine surgery was performed, with closure of the pericardium and placement of 2 mediastinal and 2 pleural drains. The intraoperative course was uneventful. At the end of surgery, she was transferred to the intensive care unit in stable condition with dopamine and nitrates. In the subsequent hours, her hemodynamics showed an adequate systolic arterial pressure (110 mmHg), normal-to-high heart rate (95 beats/min), and central venous pressure (13 mmHg). Metabolic acidosis, with elevated blood lactate, and gas exchange impairment developed. A pulmonary artery catheter was placed, which revealed a severely reduced cardiac index (1.3 L/min/m2) and mixed venous oxygen saturation (43%); pulmonary artery occlusion pressure (13 mmHg) and pulmonary arterial pressure (32/10 mmHg) were both normal. Central venous pressure values were confirmed as previously assessed from the central venous catheter (13 mmHg). A TTE was performed; it confirmed the reduced systolic function of the left ventricle, no mitral valve regurgitation, mild residual tricuspid regurgitation, and no evidence of pericardial effusion. Because of the unclear hemodynamic data interpretation, a TEE was obtained that revealed a large clot (3.5 5.2 cm) localized in the pericardial cavity around the right atrium at the base of the heart (Fig 1). This caused a localized pericardial tamponade, partially obliterating the right atrium during diastole. The patient went back to the operating room to undergo a surgical revision and hemostasis of the pericardial space. The presence of a large clot (250 mL) was confirmed, and prompt evacuation led to an immediate improvement in hemodynamic function. The patient was transferred back to the intensive care unit in stable condition and subsequently recovered uneventfully.

bdominal compartment syn-drome (ACS) is a clinical entitycomprising a series of patho-physiological changes inducedby abdominal pressure elevations that in-volve both abdominal and extra-abdomi-nal organs and systems. Abdominal hy-pertension is the common final pathwayof various pathologies, either chronic oracute. Severe abdominal trauma and rup-tured abdominal aortic aneurysms arethe most common causes of abdominalhypertension (1). A comprehensive re-view of ACS has recently been published(2). The abdominal consequences of anelevated intra-abdominal pressure (IAP)include a reduction in splanchnic andhepatic blood flow and an increase inrenal venous pressure (3) with renalblood flow redistribution and oliguria.Moreover, elevated IAP produces compres-sion of the inferior cava and dislocation ofthe diaphragm toward the thoracic cavity.Cardiovascular consequences (4) include areduction in cardiac index and stroke vol-ume, resulting from both a decreased ve-nous return and an increase in systemicvascular resistance. Central venous pres-sure and pulmonary artery occlusion pres-sure seem to increase mainly as a result ofraised intrathoracic pressure. Elevated IAPinfluences respiratory system mechanicsthrough the elevation of the diaphragm,which causes a reduction in respiratorycompliance, increased airway pressure, andhypoventilation (1).The first reports (5–8) on this syn-drome focused mainly on its surgical im-plications. Over the last decade, withmore widespread use of laparoscopic sur-gical techniques, there has been a re-newed interest in ACS (9–11). The pro-posed use of laparoscopy for emergencyabdominal evaluations in traumatized pa-tients, associated with the knowledgethat abdominal trauma frequently coex-ists with head injury, led Josephs et al.(12) to test the effects of increased IAP onintracranial pressure (ICP) in animals.Under experimental conditions, a pneu-moperitoneum caused a rise in ICP,which was greater in animals with preex-isting intracranial hypertension. ElevatedIAP may also detrimentally affect ICP inhumans, as described in two case reports(13, 14) in trauma patients and duringlaparoscopy. Animal studies (15, 16) sub-sequently confirmed these first observa-tions and reported not only an increase inICP but also reductions in cerebral per-fusion pressure (CPP). Moreover, thesestudies determined that the ICP increasecould be avoided by performing a thora-cotomy or a pericardiopleurotomy.Therefore, with elevated IAP, an intactthorax seems to be essential to cause anincreased ICP. These data suggest that anintrathoracic pressure increase couldlead to cerebral venous outflow impair-ment, which in turn increases cerebralblood volume and, subsequently, the ob-served rise in ICP. Severe abdominaltrauma may be associated with head in-jury in .40% of patients with abdominaltrauma (17). In a recent 3-month na-tional survey (18) on head trauma victimsin Italy, the presence of associated severeabdominal complications was reported in6.7% of the patients admitted to the in

ICP monitoring is part of intensive care management of subarachnoid hemorrhage patients (SAH). However, patterns of ICP and their relationship with cerebral ischemia or quality of outcome have not yet been clearly defined.