Classifying pain in transoral endoscopic thyroidectomy

PURPOSES

Knowledge of visual analog scale (VAS) pain assessment for transoral endoscopic thyroidectomy vestibular approach (TOETVA) is limited. The purpose of this analysis was to classify the postoperative discomfort scores in patients undergoing TOETVA compared to open thyroidectomy.

METHODS

Observational clinical study of patients who underwent thyroidectomy by VAS pain assessment from September 2016 to March 2017. Patients were stratified into two groups: patients eligible for TOETVA (Group TOETVA) and non-candidates for endoscopic intervention (open thyroidectomy approach-OTA). VAS was recorded in the recovery room, at 24 h, + 2, + 5, + 15, + 30, + 90 days, and 6 months after surgery. Pain assessment was stratified in VAS-lower lip, VAS-chin, VAS-jaw, VAS-anterior neck, VAS-cervical/back, VAS-swallowing, VAS-brushing, VAS-speaking, and VAS-shaving. Secondary outcome assessed were analgesic rescue dose, morbidity, operative notes, hospital stay, and histopathology.

RESULTS

41 TOETVA and 45 OTA constituted the analysis. There were differences between the TOETVA and OTA for age, gland volume, mean nodule diameter, coexistence thyroiditis, bilateral procedures, and use of drain. Operative time was longer in TOETVA. Results indicated that TOETVA was associated with reduced neck, cervical back, and swallowing VAS scores in the 24 h after surgery. Conversely, jaw and brushing teeth resulted in higher VAS score in TOETVA group. OTA patients never experienced lower lip or chin pain. The use of rescue analgesics did not differ between the two groups.

CONCLUSIONS

VAS was used to measure treatment outcome in TOETVA. VAS scores achieved overall a minimal clinical importance difference from the two procedures. There appears to be both a short- and long-term different range of interpretations of pain between TOETVA and OTA.

Navigator® and SmartPilot® View are helpful in guiding anesthesia and reducing anesthetic drug dosing

BACKGROUND

The recently introduced Navigator® (GE Healthcare, Helsinki, Finland) and SmartPilot® View (Dräger Medical, Lübeck, Germany) show the concentrations and predicted effects of combined anesthetic drugs, and should facilitate more precisely their titration. Our aim was to evaluate if Navigator® or SmartPilot® View guided anesthesia was associated with a good quality of analgesia, depth of hypnosis and may reduce anesthetic requirements.

METHODS

We performed a prospective non-randomized study. Sixty ASA I-II patients undergoing balanced general anesthesia for abdominal and plastic surgery were enrolled. Patients were divided in 4 groups. Group 1 (N. 15) and group 3 (N. 15) were cases in whom anesthesia was performed with standard monitoring plus the aid of Navigator® (Nav) or SmartPilot® View (SPV) display. Group 2 (N. 15) and group 4 (N. 15) were controls in whom anesthesia was performed with standard monitoring (heart rate, NIBP, SpO2, end-tidal CO2, end-expired sevoflurane concentration, train of four, Bispectral Index [Aspect Medical Systems, Natick, MA, USA] or Entropy [GE Healthcare]). Patients' vital parameters and end-expired sevoflurane concentration were recorded during anesthesia.

RESULTS

All patients recovered uneventfully and showed hemodynamic stability. End-tidal sevoflurane concentrations values [median (min-max)], during maintenance of anesthesia, were significantly (P<0.05) lower in SPV [1.1% (0.8-1.5)] and Nav [1%(0.8-1.8)] groups compared to SPV-control group [1.5%(1-2.5)] and Nav-control group [1.5%(0.8-2)]. BIS and entropy values were respectively higher in the SPV group [53 (46-57)] compared to the control group [43 (37-51)] (P<0.05) and Nav group [53 (43-60)] compared to the control group [41 (35-51)] (P<0.05). No significant differences in Remifentanil dosing were observed in the four groups.

CONCLUSION

Navigator® and SmartPilot® View may be of clinical use in monitoring adequacy of anesthesia. Both displays can optimize the administration and monitoring of anesthetic drugs during general anesthesia and may reduce the consumption of volatile anesthetic agents.

Coagulopathy induced by acidosis, hypothermia and hypocalcaemia in severe bleeding

Acidosis, hypothermia and hypocalcaemia are determinants for morbidity and mortality during massive hemorrhages. However, precise pathological mechanisms of these environmental factors and their potential additive or synergistic anticoagulant and/or antiplatelet effects are not fully elucidated and are at least in part controversial. Best available evidences from experimental trials indicate that acidosis and hypothermia progressively impair platelet aggregability and clot formation. Considering the cell-based model of coagulation physiology, hypothermia predominantly prolongs the initiation phase, while acidosis prolongs the propagation phase of thrombin generation. Acidosis increases fibrinogen breakdown while hypothermia impairs its synthesis. Acidosis and hypothermia have additive effects. The effect of hypocalcaemia on coagulopathy is less investigated but it appears that below the cut-off of 0.9 mmol/L, several enzymatic steps in the plasmatic coagulation system are blocked while above that cut-off effects remain without clinical sequalae. The impact of environmental factor on hemostasis is underestimated in clinical practice due to our current practice of using routine coagulation laboratory tests such as partial thromboplastin time or prothrombin time, which are performed at standardized test temperature, after pH correction, and upon recalcification. Temperature-adjustments are feasible in viscoelastic point-of-care tests such as thrombelastography and thromboelastometry which may permit quantification of hypothermia-induced coagulopathy. Rewarming hypothermic bleeding patients is highly recommended because it improves patient outcome. Despite the absence of high-quality evidence, calcium supplementation is clinical routine in bleeding management. Buffer administration may not reverse acidosis-induced coagulopathy but may be essential for the efficacy of coagulation factor concentrates such as recombinant activated factor VII.

S100B induces the release of pro-inflammatory cytokines in alveolar type I-like cells

S100B, a 21kDa cytosolic calcium-binding protein of the EF-hand type, present in high abundance in the brain, stimulates inflammatory responses in different cellular types inside and outside the central nervous system. Most of extracellular S100B effects are mediated by Receptor for Advanced Glycation End-products (RAGE). RAGE is highly expressed in lung by Alveolar Type-I (AT-I) cells and its activation contributes to ALI/ARDS pathogenesis. In this in-vitro study, we tested the hypothesis that S100B stimulates an ATI-derived cell line (R3/1) to secrete inflammatory mediators involved in lung inflammation. Our main result is that S100B stimulates R3/1 cells to secrete TNF-alpha and IL-6 (well-known pro-inflammatory cytokines in lung inflammation and neurogenic pulmonary edema), but not sICAM-1, CINC-1 or CINC-3. Soluble RAGE (sRAGE) reduced S100B-dependent secretion of TNF-alpha but did not decrease S100B-dependent secretion of IL-6. Moreover, in absence of S100B, sRAGE enhanced IL-6 release. This study demonstrates that in vitro S100B dose-dependently stimulated R3/1 cells, to enhance the secretion of TNF-alpha and IL-6; S100B pro-inflammatory activity might be mediated at least in part by RAGE. Besides acting as decoy receptor, sRAGE could have pro-inflammatory properties.

Terlipressin in brain-death donors

BACKGROUND

Metabolic management of brain-death organ donors includes correction of the hormonal perturbations that occur after cerebral death and impair circulatory function. Vasopressin is a hormone secreted by the posterior pituitary gland, which contributes to maintain systemic blood pressure by regulating urine secretion and small arteriole tonus. During brain death, the pituitary gland is damaged and hormone secretion rapidly ceases. Low-dose vasopressin increases systemic blood pressure and decreases the need for catecholamines in brain-dead organ donors but it is not available in many countries. Terlipressin is a synthetic analog of vasopressin characterized by greater selectivity for the V1 receptor than vasopressin. To date, the efficacy of terlipressin as a pressor agent in humans has been reported in a few studies.

METHOD

Pharmacology and literature about the use of terlipressin in shock and in particularly in neurogenic shock following brain death is summarized and our personal experience is reported.

RESULTS AND CONCLUSION

Terlipressin is helpful in controlling severe hypotension; its use allowed to reduce the infusion rate of norepinephrine about 50% in two of three brain-death organ donors, but there are not yet enough data to define its therapeutic range and incidence of collateral effects on the grafts.

Toll-like receptor kinetics in septic shock patients: a preliminary study

The aim of this study is to evaluate some inflammatory parameter changes in septic shock patients and their possible correlation with clinical outcome, in particular when continuous veno-venous hemofiltration (CVVH) treatment is required. Considering the objective difficulty in enrolling this kind of patient, a preliminary study was initiated on seventeen septic shock patients admitted to a medical and surgical ICU. The mRNA expression of Toll-like receptor (TLR)-1, TLR-2, TLR-4, TLR-5, TLR-9, TNFα, IL-8 and IL-1β was assessed, the plasmatic concentrations of IL-18, IL-2, IL-10 and TNFα were measured on the day of sepsis diagnosis and after 72 h. In those patients who developed acute renal failure unresponsive to medical treatment and who underwent CVVH treatment the same parameters were measured every 24 h during CVVH and after completion of the treatment. On sepsis diagnosis, gene expression of TLRs was up-regulated compared to the housekeeping gene in all the patients. After 72 h, in 35% of the patients a down-regulation of these genes was found compared to day 1, but it was not associated with a reduction of cytokine serum levels or improved clinical signs, better outcome or reduced mortality. After high volume hemofiltration treatment, cytokine serum levels and TLR expression were not significantly modified. In conclusion, considering the not numerous number of cases, from our preliminary study, we cannot certainly correlate TLR over-expression in septic shock patients with severity or outcome scores.

Prognostic differences between VAP from Acinetobacter baumanii and VAP from other microorganisms

Nosocomial infection, in particular pneumonia, is an important risk factor for hospital mortality and morbidity. Acinetobacter baumanii is a common multi-resistant microorganism responsible of Ventilator Associated Pneumonia (VAP). Currently Colistin is a rescue therapy for this pathogen. The purpose of this retrospective study is to compare the outcome of VAP caused by Acinetobacter baumanii and VAP from other microorganisms in critical patients. Comorbidity, prognostic scores, mortality and eradication frequency did not turn out significantly different between the two study groups. Colistin safety was tested.

Persistence of carbapenem-resistant Acinetobacter baumannii strains in an Italian intensive care unit during a forty-six month study period

The aims of this study were to analyze carbapenem-resistance Acinetobacter baumannii isolates (CRAB) and their molecular epidemiology in an ICU of Southern Italy. Clinical outcomes and therapeutic management of patients are also described. The study was performed from January 2007 to October 2010. The presence of carbapenemases was determined by PCR. Strains were typed by PFGE. All A. baumannii isolates were carbapenem-resistant with imipenem MIC≥16 μg/mL. Molecular characterization showed the occurrence of a predominant clone. The most frequent infection by CRAB was ventilator-associated pneumonia; colistin was the drug of choice for this infection. The therapy was safe in all cases except in one where therapy was suspended due to the onset of acute renal failure. We documented the presence of CRAB in this ICU, besides the occurrence of a predominant clone, over all the study period. Despite the infection control procedures used, intra-facility A. baumannii transmission is evident as well as the significant capacity for long-term survival in the hospital environment.

Aneurysmal subarachnoid haemorrhage in pregnancy: a case series

Pregnancy is a recognized risk factor for aneurysmal subarachnoid hemorrhage (SAH). Headache is very frequent in normal pregnancy and it is a common sign shared between several intracranial diseases. We present a case series of 10 women in the third trimester of pregnancy admitted to our intensive care unit (ICU) with neurological signs and symptoms. 4 of these patients were diagnosed with SAH. Data in this study suggest that a timely diagnosis and an appropriate treatment is crucial for mother and baby.

ITalian Observational Study of the management of mild-to-moderate Post-Operative Pain (ITOSPOP)

BACKGROUND

The multicenter observational ITalian Observational Study on the management of mild-to-moderate PostOperative Pain (ITOSPOP) was carried out in 24 hospitals to describe current postoperative pain management in Italy and the intensity of pain experienced by patients during the first 48 hours after surgery.

METHODS

Adult patients, after surgery expected to result in mild-moderate postoperative pain, underwent six evaluations. The primary endpoint was the level of organization and standardization of postoperative pain management. Secondary objectives included the intensity of postoperative pain, and an assessment of incident pain, postoperative analgesic and concomitant treatment administration.

RESULTS

Only 16.7% hospitals had an acute pain service and 41.7% hospitals applied a standardized protocol for postoperative pain management. The majority (>60%) of the 1952 patients monitored underwent all six assessments, >70% of which were performed by a physician. The proportion of patients with moderate pain decreased during the study period, but almost 10% of patients still experienced moderate pain at study end. Mild pain was reported by 50% of the patients for the entire study duration. At the final assessment, 5% of patients still presented with incident pain frequently interfering with daily activities. Most patients were treated with analgesics, but 20% of patients did not receive any pain medications despite experiencing pain.

CONCLUSION

The level of organization and standardization of postoperative pain management in Italian hospitals remains low. Postoperative analgesic treatment remained suboptimal and almost two-thirds of patients continued to experience pain.

Respiratory failure presenting in H1N1 influenza with Legionnaires disease: two case reports

Introduction

Media sensationalism on the H1N1 outbreak may have influenced decisional processes and clinical diagnosis.

Case Presentation

We report two cases of patients who presented in 2009 with coexisting H1N1 virus and Legionella infections: a 69-year-old Caucasian man and a 71-year-old Caucasian woman. In our cases all the signs and symptoms, including vomiting, progressive respiratory disease leading to respiratory failure, refractory hypoxemia, leukopenia, lymphopenia, thrombocytopenia, and elevated levels of creatine kinase and hepatic aminotransferases, were consistent with critical illness due to 2009 H1N1 virus infection. Other infectious disorders may mimic H1N1 viral infection especially Legionnaires' disease. Because the swine flu H1N1 pandemic occurred in Autumn in Italy, Legionnaires disease was to be highly suspected since the peak incidence usually occurs in early fall. We do think that our immediate suspicion of Legionella infection based on clinical history and X-ray abnormalities was fundamental for a successful resolution.

Conclusion

Our two case reports suggest that patients with H1N1 should be screened for Legionella, which is not currently common practice. This is particularly important since the signs and symptoms of both infections are similar.

Neurogenic pulmonary edema in subarachnoid hemorrage

Aneurysmal subarachnoid hemorrhage (SAH), in addition to the direct effects of the initial hemorrhage and secondary neurological complications, predisposes to medical complications. The proportion of deaths caused by non-neurological medical complications (cardiac, pulmonary, gastrointestinal, renal, hematological) equals that from neurological complications. In particular, pulmonary complications are responsible for 50% of all deaths from medical complications. Neurogenic pulmonary edema (NPE) is an increase of interstitial and alveolar fluid occurring as direct consequence of any acute central nervous system injury. Two different pathogenetic mechanisms of NPE have been hypothesized: i) hemodynamic (an increase of pulmonary vascular pressure due to an α-adrenergic response produces hydrostatic edema) and ii) inflammatory mechanism (brain cytokines and chemokines determinates an increase in the permeability of pulmonary capillaries causing exudative edema). Recent studies postulate that both mechanisms may be implicated in the pathogenesis of NPE. Brain injury is known to determine increased levels of S100B, a Ca- binding protein, in cerebrospinal fluid and in blood. Moreover, amine precursor uptake and decarboxylation (APUD) cells located in the respiratory tract produce and release S100B. This protein may contribute to the pathogenesis of NPE binding RAGE receptors in alveolar epithelial type I pneumocytes and amplifying the immune and inflammatory response causing lung injury. S100B can be the link between the brain and the lung and may be among the multiple pathological pathways that determine the development of pulmonary edema after bleeding.

Update on transfusion solutions during surgery: review of hydroxyethyl starches 130/0.4

OBJECTIVES

Restoration of circulation is crucial in the surgical patient management. Colloids and crystalloids are widely used for blood volume therapy. We reviewed recent trials to evaluate efficacy and safety of hydroxyethyl starch (HES) 130/0.4 during surgery.

MATERIAL AND METHODS

A subjective, not systematic, review of literature was performed. Papers were searched to answer questions about efficacy of HES, its impact on coagulation and inflammation and its effects on pulmonary mechanics and renal function.

CONCLUSIONS

HES 130/0.4 is effective for volume therapy and is less expensive than human albumin. Its effects on coagulation and renal function are manageable; it may ameliorate pulmonary permeability and reduce inflammation.

Different patterns of lung recruitment maneuvers in primary acute respiratory distress syndrome: effects on oxygenation and central hemodynamics

BACKGROUND

The aim of this study was to test if different recruitment maneuver (RM) patterns, that achieve the same maximum pressure for the same length of time in humans, have a similar efficacy on alveolar recruitment, intrathoracic vascular pressures and flows, and on cardiac function and ventricular filling.

METHODS

Forty patients were randomly allocated to undergo different RM patterns: sustained inflation (SI) or pressure controlled ventilation (PCV). The RM methods tested are as follows: SI was achieved by raising peak inspiratory pressure to 45 cmH(2)O and sustaining it for 40 seconds. The PCV was set to obtain a 45 cmH(2)O peak inspiratory pressure for 2 minutes, I:E 1:2, PEEP 16 RR 8/min. During the study period, patients were mechanically ventilated to obtain a volume of 6 mL/kg, FiO(2) 0.7, PEEP 14, RR 14, Pplateau < or =30 cmH(2)O according to the ARDSnet trial. All patients were sedated and paralyzed during the study period. All patients were given i.v. norepinephrine. Heart rate, pulse oxymetry, blood pressure, pulmonary artery catheter data (C.I., PVRI, MPAP, PAOP, SvO(2), CVP), and arterial and right heart side venous blood gas analysis data (ph, PaO(2), PaCO(2), SatO(2), HCO(3)(-), SvO(2)) were recorded before and immediately after the lung recruitment maneuver. The static compliance of the respiratory system (CRS) was recorded. Echocardiographic spot evaluations before and after RM were obtained in all cases.

RESULTS

Central venous pressure increased during RM. Mean pulmonary artery pressure, pulmonary capillary wedge pressure and pulmonary vascular resistance index were reduced during PCV RM compared to SI RM (P<0.05). The right ventricle stroke work index decreased to a major extent during PCV RM (P<0.05). The P/F ratio was significantly increased after PCV RM compared to SI RM (P<0.05). PaCO(2) levels were similar in the two groups. Compared to baseline, the Qs/Qt decreased significantly after the PCV recruitment maneuver. Ventricular end-diastolic and end-systolic areas decreased during both RM protocols, but they were decreased to a greater extent after SI RM than after PCV RM (P<0.05). The eccentricity index increased from baseline after the SI RM (P<0.05).

CONCLUSION

Given its comparable, or even superior, performance over the SI RM, we favor the PCV technique over the time-honored SI maneuver.

Thrombin antithrombin complex and IL-18 serum levels in stroke patients

The complex picture of inflammation and coagulation alterations comes to life in acute stroke phases. Increasing evidence points to a strong interaction and extensive crosstalk between the inflammation and coagulation systems: the interest towards this relationship has increased since recent experimental research showed that the early administration of antithrombin III (ATIII) decreases the volume of ischemia in mice and might be neuroprotective, playing an antiinflammatory role.

We aimed to establish the extent of the relationship among markers of inflammation (S100B and IL-18) and procoagulant and fibrinolytic markers (ATIII, thrombin-antithrombin III complex (TAT), Fibrin Degradation Products (FDP), D-dimer) in 13 comatose patients affected by focal cerebral ischemia.

Plasma levels of TAT, D-dimer and FDP, IL18 and S100B were increased. IL-18 and S100B high serum levels in ischemic patients suggest an early activation of the inflammatory cascade in acute ischemic injury.

The basic principles of the interaction between inflammatory and coagulation systems are revised, from the perspective that simultaneous modulation of both coagulation and inflammation, rather than specific therapies aimed at one of these systems could be more successful in stroke therapy.

Relationship between A-line Autoregressive Index, Spectral Entropy and steady state predicted site-effect effective concentrations at 05-50-95 of propofol at different clinical endpoints

AIM

Target controlled infusion intravenous anesthesia is a growing phenomenon. Nowadays, many anesthesiologists feel the need to monitor depth of anesthesia during total intravenous anesthesia, even though it is not a standard technique worldwide. Spectral Entropy (SE) is a relatively new depth of anesthesia index. The aim of this study was to investigate whether predicted site-effect propofol concentrations, A-line Autoregressive Index (AAI) and SE values are useful for predicting loss of verbal contact (LVC) and loss of consciousness (LOC) during steady-state conditions.

METHODS

Forty-four patients scheduled for elective major abdominal surgery were recruited. All patients were unpremedicated. A target controlled infusion of propofol was administered using Schnider's pharmacokinetic model. The initial propofol infusion provided a site-effect concentration of 1.0 mcg mL-1, and was increased stepwise by 1.0 mcg mL-1 every 4 minutes until the concentration reached 6.0 mcg mL-1. A 4 minute interval was chosen to assure that steady state site-effect concentrations were obtained. AAI, SE and propofol site-effect concentrations were recorded when LVC occurred and also when LOC occurred. Population values for predicted site-effect concentrations at the clinical endpoints were estimated and correlated with AAI and SE values.

RESULTS

In our study for LOC the effect-site concentration to include 90% of patients was 5.85 ?mcg mL-1 (5.70-5.90) and 3.4 mcg mL-1 (3.24-3.60) for LVC. In this study, 90% of patients lost verbal contact at an AAI value of 68 (64.6-71.4) and an SE value of 68.2 (66.2-70.2). LOC occurred in 90% of patients at an AAI value of 39.2 (37.2-41.1) and an SE value of 40.2 (38.1-41.3).

CONCLUSIONS

LOC and LVC occur within a defined range of predicted site-effect concentrations. More emphasis should be given to site-effect concentrations. SE and AAI have similar values at different endpoints and similar correlation with Ceprop. AAI and SE are both useful tools in predicting both LVC and LOC.

Typing of Pseudomonas aeruginosa isolated from patients with VAP in an intensive care unit

Aim of this study was to characterize isolates of Pseudomonas aeruginosa responsible for ventilator-associated pneumonia (VAP) in patients admitted to an ICU in order to evaluate a possible strain clonality. The study was performed from October 2004 to June 2005 in one Southern Italy ICU and 29 patients suspected of having VAP were enrolled. The etiology of VAP was established by quantitative cultures of endotracheal aspirations. Molecular characterization was carried out by PFGE. P. aeruginosa was responsible for 51% of all cases of VAP (15/29) and 12/15 strains were multi-drug resistant. High mortality (44.8%) was connected to this pathogen and evidence of strain clonality was found. The early identification of strain clonality and the application of infection control procedures are necessary to avoid the spread of pathogens such as P. aeruginosa involved in nosocomial infections.

Do you think my ICU will benefit from an electronic medical record system?

In many Hospitals, Intensive Care Units (ICUs) are the most technologically advanced areas since the Intensive Care physicians deal with a massive quantity of data and information, because of the critical status of their patients each day. An electronic medical record (EMR) is a computer-base patient record optimized to support ambulatory settings and ward activities. An EMR may provide the physician with all the necessary information clearly gathered and stored and satisfy the need for more direct integration of the different information. Even if the installation of an EMR is a positive signal of modernity, it may represent a useless investment with minor effects on the clinical staff improvement and on the risk reduction, because of mayor failures in the installation planning, integration in the hospital system, personnel education. Definitions, advantages and limitation, implementation strategies and objectives of an ICU EMR system are reviewed.

The use of erythtropoietin in cerebral diseases

Global and focal cerebral ischemia is followed by a secondary damage characterized by oxidative stress, excitotoxicity, inflammation and apoptosis. Erythropoietin (EPO) exerts antiapoptotic, anti-inflammatory, antioxidative, angiogenetic and neurotrophic properties. Its potential therapeutic role has been demonstrated in several animal models of cerebral ischemia and also in a clinical trial of ischemic stroke, so it could be considered an ideal compound for neuroprotection in ischemic stroke and in cardiac arrest. Intracerebral hemorrhage (ICH) is the least treatable form of stroke; the mechanisms involved in the secondary brain injury include hematoma mass effect, neuronal apoptosis and necrosis, inflammation. It has been demonstrated in an experimental ICH that EPO intervenes in the inflammatory process, reduces brain water content, hemorrhage volume and hemispheric atrophy, promotes cell survival, preserves cerebral blood flow, has antiapoptotic protective function against oxidative stress and excitotoxic damage. EPO can attenuate acute vasoconstriction and prevent brain ischemic damage in subarachnoid hemorrhage. The neuroprotective function of EPO has been studied also in traumatic brain injury: it reduces the inflammation and improves cognitive and motor deficits. The authors review some of the physiological actions of EPO in the physiopathology of ischemic and hemorrhagic stroke, subarachnoid hemorrhage and brain trauma, and its potential usefulness in the brain injured patient management.

Antithrombin reduces ischemic volume, ameliorates neurologic deficits, and prolongs animal survival in both transient and permanent focal ischemia

BACKGROUND AND PURPOSE

Antithrombin (AT), a glycoprotein belonging to the serpin family, blocks thrombin formation and activity at several steps. Thrombin, beside its relevant role in the coagulation cascade, exerts neurodetrimental effects through the activation of a family of protease-activated receptors, which can be implicated in stroke pathophysiology. The aims of the present study were to evaluate whether AT could reduce brain damage, ameliorate neurologic deficits, and prolong animal survival.

METHODS

Two different doses of AT (10 and 30 IU/kg IP) were administered 3 hours, 6 hours, or 3 and 6 hours after an ischemic insult to mice and rats subjected to either transient or permanent focal ischemia. Ischemic volume was evaluated 24 hours or 7 days after the ischemic insult. Neurologic deficits were also scored.

RESULTS

In mice, 10 or 30 IU/kg AT administered twice, at 3 and 6 hours after transient ischemia, and 30 IU/kg AT administered 3 hours only after transient ischemia substantially reduced total ischemic volume, significantly improved neurologic deficits evaluated 24 hours after the insult, and prolonged animal survival. In rats, the same doses given at the same time intervals significantly reduced ischemic volume, evaluated 24 hours after permanent ischemia.

CONCLUSIONS

These results indicate that AT remarkably reduces infarct volume, ameliorates neurologic deficit scores, and prolongs animal survival in 2 rodent models of brain ischemia. Taken together, our data suggest that AT, delivered via systemic administration, an easily achievable route of administration and in a clinically useful time window, could represent a new therapeutic strategy to be validated for the clinical treatment of human stroke.

Prognosis of isolated acute post-traumatic subdural haematoma

AIM

Acute subdural haematoma (ASDH) is seldom an isolated lesion and it is difficult to understand the mechanisms which determine the poor prognosis associated to this occurrence. Aim of this study was estimating the outcome of patients with ASDH without any companion lesions by analysing the haematoma volume, its thickness and midline shift.

METHODS

Twenty-eight severely head injured patients (Glasgow Coma Scale, GCS =/<8) with isolated unilateral ASDH admitted in intensive care unit (ICU) were retrospectively studied. The haematoma thickness, the midline shift, the ASDH volume were obtained from the first emergency computerized tomography (CT) scan and analysed by a computer assisted programme (Osiris). Patients' outcome was scored according to the Glasgow Outcome Scale (GOS) 6 months after the event. According to their GOS the patients were further divided in 2 groups (favourable outcome: GOS 4-5, poor outcome: GOS 1-2-3).

RESULTS

Midline shift ranged from 0 to 19.2 mm; we found a larger midline shift in those patients who died and in patients with severe disability or vegetative state 6 months after the trauma.

CONCLUSION

The presence and size of midline shift was a more important determinant of outcome than ASDH volume or its thickness.

Intra-abdominal hypertension is not reliable as an early predictor of mortality in the intensive care unit

AIM

The aim of this study was to assess the prevalence of intra-abdominal hypertension and its prognostic value in critical patients.

METHODS

In an observational study, 56 patients of a multidisciplinary intensive care unit (ICU) of a university hospital, with either surgical (44.6%) or medical (55.4%) diagnoses, were studied. Intra-abdominal pressure was quantified daily by bladder pressure method from the first to the eighth day of hospitalization.

RESULTS

The mean intra-abdominal pressure at admission was 9.97+/-5.26 mmHg; 41% of patients suffered moderate intra-abdominal hypertension (defined as intra-abdominal pressure greater than 11 mmHg) at admission. On day 1 mean intra-abdominal pressure was not significantly different between the patients who died and those who survived (9.69+/-5.06 mmHg vs 10.12+/-5.57 mmHg respectively), but by measuring IAP until day 8 it was possible to distinguish a subgroup of patients who showed a persistently elevated intra-abdominal pressure, developed further complications, later died (12.5+/-4.37 mmHg vs 7.17+/-2.02 mmHg, P=0.022).

CONCLUSION

Intra-abdominal pressure does not have prognostic value at ICU admission, but may predict bad outcomes later during the ICU stay. Intra-abdominal hypertension is a frequent and rarely recognized event in the ICU which can be monitored by the bladder pressure method throughout the period of hospitalization.

Elevated S100B levels do not correlate with the severity of encephalopathy during sepsis

BACKGROUND

Sepsis-associated encephalopathy (SAE) is defined as a diffuse cerebral dysfunction induced by the systemic response to infection without any clinical or laboratory evidence of direct infectious involvement of the central nervous system. The astroglial protein S100B has been used as a marker of severity of brain injury and as a prognostic index in trauma patients and cardiac arrest survivors. We measured S100B serum levels in patients with severe sepsis to investigate if the severity of SAE correlated with an increase in S100B levels.

METHODS

Twenty-one patients, with a diagnosis of severe sepsis, were included in this study. S100B levels were measured at intensive care unit (ICU) admission, 72 h and 7 days after admission. Their association with markers of brain dysfunction such as Glasgow coma scale (GCS), and EEG, and with sepsis-related organ failure assessment score (SOFA) and ICU mortality was investigated.

RESULTS

Fourteen patients had elevated S100B levels. The levels did not correlate with GCS at admission, EEG pattern, or SOFA scores. Also, S100B levels did not differ between patients who recovered neurologically and those who did not (P = 0.62).

CONCLUSIONS

In severe sepsis, an increase in S100B does not allow the physicians to distinguish patients with severe impairment of consciousness from those with milder derangements or to prognosticate neurological recovery.

S100B is not a reliable prognostic index in paediatric TBI

BACKGROUND

As far as paediatric traumatic brain injury is concerned, it is difficult to quantify the extent of the primary insult, to monitor secondary changes and to predict neurological outcomes by means of the currently used diagnostic tools: physical examination, Glasgow Coma Scale (GCS) score and computed tomography. For this reason, several papers focused on the use of biochemical markers (S100B, neuron-specific enolase) to detect and define the severity of brain damage and predict outcome after traumatic head injury or cardiac arrest.

OBJECTIVE

The aim of this paper is measuring the range of S100B serum concentrations in children affected by traumatic brain injury and describing the possible roles of this protein in the reaction to trauma.

METHODS

Fifteen children aged 1-15 years were included in the study. Traumatic brain injury severity was defined by paediatric GCS score as mild (9 patients), moderate (2 patients) or severe (4 patients). Blood samples for S100B serum measurement were taken at emergency department admission and after 48 h.

RESULTS

The serum S100B concentration was higher in the group of severe trauma patients, who scored the lowest on the GCS at admission, and among them, the highest values were reported by the children with concomitant peripheral lesions.

CONCLUSIONS

The role of S100B in paediatric traumatic brain injury has not been clarified yet, and the interpretation of its increase when the head trauma is associated with other injuries needs the understanding of the physiopathological mechanisms that rule its release in the systemic circulation. The levels of S100B in serum after a brain injury could be related to the mechanical discharge from a destroyed blood-brain barrier, or they could be due to the active expression by the brain, as a part of its involvement in the systemic inflammatory reaction. Early increase of this protein is not a reliable prognostic index of neurological outcome after pediatric traumatic brain injury, since even very elevated values are compatible with a complete neurological recovery.

Posterior reversible encephalopathy syndrome in intensive care medicine

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a well-recognized clinico-neuroradiological transient condition. Early recognition is of paramount importance for prompt control of blood pressure or removal of precipitating factors and treatment of epileptic seizures or status epilepticus. Delay in the diagnosis and treatment may in fact results in death or in irreversible neurological sequelae.

DISCUSSION

PRES is characterized by headache, altered mental status, seizures, and visual disturbances and is associated with a number of different causes, most commonly acute hypertension, preeclampsia/eclampsia, and immunosuppressive agents. Clinical symptoms and neuroradiological findings are typically indistinguishable among the cases of PRES, regardless of underlying cause. Magnetic resonance studies typically show edema involving the white matter of cerebral posterior regions, especially parieto-occipital lobes but frontal and temporal lobes, and other encephalic structures may be involved.

CONCLUSIONS

Intensivists and other physicians involved in the evaluation of patients with presumed PRES must be aware of the clinical spectrum of the associated conditions, the diagnostic modalities, and the correct treatment.

Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study

BACKGROUND AND OBJECTIVES

The aim of this prospective, observational study was to evaluate changes in regional cerebral oxygen saturation (rSO2) and incidence of intraoperative cerebral desaturation in a cohort of elderly patients undergoing major abdominal surgery.

METHODS

rSO2 was continuously monitored on the left and right sides of the forehead in 60 patients older than 65 yr (35 males and 25 females; ASA II-III; age: 72 +/- 5 yr; without pre-existing cerebral pathology, and baseline Mini Mental State Examination (MMSE) score >23) undergoing sevoflurane anaesthesia for major abdominal, non-vascular surgery >2 h.

RESULTS

Baseline rSO2 was 63 +/- 8%; cerebral desaturation (rSO2 decrease <75% of baseline or <80% in case of baseline rSO2 <50%) occurred in 16 patients (26%). The MMSE decreased from 28 +/- 1 before surgery to 27 +/- 2 on 7th postoperative day (P = 0.05). A decline in cognitive function (decrease in MMSE score > or = 2 points one week after surgery as compared to baseline value) was observed in six patients without intraoperative cerebral desaturation (13.6%) and six patients who had intraoperative cerebral desaturation (40%) (P = 0.057) (odds ratio: 4.22; CI95%: 1.1-16). Median (range) hospital stay was 14 (5-41) days in patients with an area under the curve of rSO2 <50% (AUCrSO2<50%) >10 min%, and 10 (4-30) days in those with an AUCrSO2<50% <10 min% (P = 0.0005).

CONCLUSIONS

In a population of healthy elderly patients, undergoing non-vascular abdominal surgery cerebral desaturation can occur in up to one in every four patients, and the occurrence of cerebral desaturation is associated with a higher incidence of early postoperative cognitive decline and longer hospital stay.

The effects of hydroxyethyl starch solution in critically ill patients

AIM

In the treatment of the critically ill patients an adequate fluid therapy appears to be essential to optimize hemodynamics and to get a suitable tissue perfusion. In this study we have evaluated the effects of volume replacement, carried out with 2 different solutions: hydroxyethyl starch 6% (HAES) and albumin 20% (HA).

METHODS

Twenty patients suffering from sepsis were recruited and randomized into 2 groups. The first group was treated with hydroxyethyl starch 6% ( HAES treated group), and the second with albumin 20% (HA treated group). The volume of colloids was given to maintain pulmonary capillary wedge pressure (PCWP) between 15 and 18 mmHg. Daily, both hemodynamic parameters and blood gas analyses were monitored.

RESULTS

Groups were homogeneous for age, sex and pathology. During the treatment we observed that cardiac index (CI), right ventricular ejection fraction (RVEF), oxygen consumption index (VO(2)I), oxygen delivery index (DO(2)I), and rate between arterial oxygen pressure and fraction of inspired oxygen (PaO(2)/FiO(2)) were increased significantly only in HAES treated group (P<0.05). APACHE II score decreased significantly only in HAES treated group (P<0.05), contrarily to the HA treated group, in which we observed a non significant increase.

CONCLUSIONS

Since hydroxyethyl starch induced a hemodynamic and clinical improvement, these effects translated into an improvement of sensorium and a reduction of APACHE II score, without causing pulmonary edema, we can conclude that hydroxyethyl starch 6% ws 130,000 dalton ms 0.4 (Voluven) is an effective fluid for resuscitation of hypovolemic patients and represent an attractive alternative to albumin.

Conscious analgosedation for radiofrequency ablation of lung neoplasm

AIM

Radiofrequency ablation (RFA) is a minimally invasive therapy for pulmonary malignant cancers in patients with medical co-morbidities or refusal of surgery. The aim of this study was to evaluate a conscious analgosedation protocol for RFA of lung neoplasm.

METHODS

Ten RFAs were performed. Following analgesic premedication patients underwent local anesthesia (lidocaine 2%) and propofol infusion.

RESULTS

The procedures were always uneventful. Postoperative severe pain was not reported; a deep sedation was required to allow the quick and safe management of RFA.

CONCLUSIONS

Spontaneous breathing sedation is safe in monitored and well-oxygenated patients and may limit the incidence of tension pneumothorax. Postoperative period needs a proper pain control for the first 24 h. Data on the long-term efficacy of lung tumor RFA are not yet available.

Effects of dopamine infusion on forearm blood flow in critical patients

BACKGROUND

In critical care, dopamine is administered by infusion at low doses (<or=3 microg/kg/min) or at high doses (>or=5 microg/kg/min) for assessment of hemodynamics. The present study was conducted to explore the effects of dopamine infusion on the vast microvascular network of skeletal muscle in the early phases of sepsis.

MATERIAL/METHODS

An observational study was performed which included twelve critically ill patients. Patients' response to dopamine infusion (3 microg/kg/min) was studied within 24 hours from admission to the ICU. The forearm blood flow (FBF) and vascular resistance (FVR) were measured by near-infrared spectroscopy (NIRS).

RESULTS

Dopamine did not ameliorate forearm regional oxygenation. The infusion of dopamine caused an increase in MAP, while FBF decreased with the resistance increase (p>0.05).

CONCLUSIONS

NIRS was suitable to measure bedside the vascular resistance and to test the effects of low doses of dopamine on forearm blood flow. A dopamine infusion of 3.0 microg/kg/min caused a reduction in forearm blood flow and an increase in vascular resistance in our patients.

S100B is a sensitive but not specific prognostic index in comatose patients after cardiac arrest

AIM

The aim of this study was to compare serum S100B levels and EEG findings as prognostic indexes in comatose (GCS<8) patients after cardiac arrest.

METHODS

S100B serum levels were assessed 12 h after the event and EEG findings were recorded within 24 h in comatose cardiac arrest survivors. At hospital discharge, patients were divided into groups according the Glasgow-outcome scale (GOS): group 1 with bad neurological outcome and group 2 with good neurological outcome (GOS 4-5). S100B levels and EEG findings were retrospectively tested about their predictive value.

RESULTS

S100B has a very low specificity (37.5%) while S100B sensitivity is 100%. EEG findings specificity is 75% and sensitivity 50%. S100B was not significantly lower in patients who recovered consciousness (10 patients) and there was no significant difference in EEGs findings between group 1 and 2.

CONCLUSIONS

The association of serum S100B levels with EEG might be helpful when used together to formulate outcome in comatose patients within 24 h after cardiac arrest. However, increased levels of S100B 12 h after a cardiac arrest might be expression of a still amendable brain damage.

Incidence of antimicrobial-resistant ventilator associated pneumonia: an eighteen-month survey

AIM

Microbes commonly involved in ventilator associated pneumonia (VAP) are difficult to eradicate: Pseudomonas aeruginosa and Acinetobacter baumannii are often resistant to piperacillin, aztreonam and ceftazidim while Klebsiella pneumoniae and other Enterobacteriaceae are resistant to third generation cephalosporins. Physicians need to tailor their therapeutic approach depending on individual patients and clinical setting, firmly based on local epidemiology. The aim of this study was to assess the incidence of VAP caused by multidrug-resistant bacteria in our ICU.

METHODS

We conducted a retrospective review of all patients mechanically ventilated for longer than 72 h, who developed pneumonia over an eighteen-month period for whom final culture data were available. One-hundred and forty-three patients admitted to a University Hospital medical surgical ICU were included in this survey. VAP was diagnosed by Centers for Disease Control and Prevention criteria and confirmed by mini- bronchoalveolar lavage.

RESULTS

In this study, the incidence of VAP in the period January 1, 2002-June 31, 2003 was very high, accounting for about 20% of all at-risk cases. Multiresistant agents were involved in about 57% of VAP occurring within 7 days of mechanical ventilation, and in 80% of late VAP.

CONCLUSIONS

This study revealed differences in VAP incidence and features among our ICU and literature data, indicating a need for caution when using hospital infection surveillance data for comparisons and choice of therapy. In our setting, with high levels of antibiotic resistance, combined approaches of non-antibiotic using strategies and education programs might be beneficial.

Sepsis and organ dysfunction: an ongoing challenge

In recent years the problem of infection has become increasingly significant, especially in intensive care hospital wards such as Intensive Care Units (ICU), emergency medicine, surgery and critically ill patient care departments. Sepsis is a complex, multifactorial syndrome that can develop into conditions of different severity, described as severe sepsis or septic shock. In these conditions the triggering event may coincide with the functional impairment of one or more vital organs or systems, thus leading to poorer prognosis in patients with overt signs of sepsis or systemic inflammation syndromes. The available data are quite alarming, as most prevention and treatment is performed empirically and requires considerable human and technological resources. Clinical signs are often misleading and, in some circumstances, it may be difficult or even impossible to identify the source of the infection which might otherwise be removed relatively simply, using proper antimicrobial treatment or a less invasive surgical removal of the area from which the infection originates based on needle-guided radiology. In addition, the complex pathophysiological mechanisms involved can be an obstacle to gaining a full understanding of the various biohumoral interactions or mediators action mechanisms. It may not be easy to enroll patients belonging to homogeneous groups in terms of age, underlining disease, immune profile or genetic predisposition, although the use of specific severity indexes has proved helpful also to establish the prognosis. Although the interpretation of generalised inflammation as a warning sign also in the absence of clear signs of infection or a state of overt inflammation has to rely largely on simple intuition, it has helped to drive experimental and clinical research work towards the investigation of interaction between different factors such as infection and sepsis, or inflammation and coagulation. An additional useful tool is the possibility of modulating the endothelial response which may support the process of disseminated thrombosis typical of sepsis evolution. In this context the improvement of standards of care can shed light on the efficacy of different treatments.

Continuous Monitoring of Cerebral Oxygen Saturation in Elderly Patients Undergoing Major Abdominal Surgery Minimizes Brain Exposure to Potential Hypoxia

Elderly patients are more prone than younger patients to develop cerebral desaturation because of the reduced physiologic reserve that accompanies aging. To evaluate whether monitoring cerebral oxygen saturation (rSO(2)) minimizes intraoperative cerebral desaturation, we prospectively monitored rSO(2) in 122 elderly patients undergoing major abdominal surgery with general anesthesia. Patients were randomly allocated to an intervention group (the monitor was visible and rSO(2) was maintained at > or =75% of preinduction values; n = 56) or a control group (the monitor was blinded and anesthesia was managed routinely; n = 66). Cerebral desaturation (rSO(2) reduction <75% of baseline) was observed in 11 patients of the treatment group (20%) and 15 patients of the control group (23%) (P = 0.82). Mean (95% confidence intervals) values of mean rSO(2) were higher (66% [64%-68%]) and the area under the curve below 75% of baseline (AUCrSO2(2)< 75% of baseline) was lower (0.4 min% [0.1-0.8 min%]) in patients of the treatment group than in patients of the control group (61% [59%-63%] and 80 min% [2-144 min%], respectively; P = 0.002 and P = 0.017). When considering only patients developing intraoperative cerebral desaturation, a lower Mini Mental State Elimination (MMSE) score was observed at the seventh postoperative day in the control group (26 [25-30]) than in the treatment group (28 [26-30]) (P = 0.02), with a significant correlation between the AUCrSO(2) < 75% of baseline and postoperative decrease in MMSE score from preoperative values (r(2)= 0.25, P = 0.01). Patients of the control group with intraoperative cerebral desaturation also experienced a longer time to postanesthesia care unit (PACU) discharge (47 min [13-56 min]) and longer hospital stay (24 days [7-53] days) compared with patients of the treatment group (25 min [15-35 min] and 10 days [7-23 days], respectively; P = 0.01 and P = 0.007). Using rSO(2) monitoring to manage anesthesia in elderly patients undergoing major abdominal surgery reduces the potential exposure of the brain to hypoxia; this might be associated with decreased effects on cognitive function and shorter PACU and hospital stay.