Non invasive hemodynamic monitoring for fluids and blood resuscitation during placenta praevia accreta cesarean delivery: a retrospective observational study

BACKGROUND

We carry out a retrospective observational analysis of clinical records of patients with major placenta praevia who underwent cesarean section surgery over a period of 20 months in our hospital. Out of a total of 40 patients, 20 were subjected to Goal-Directed Therapy (GDT) implemented with non-invasive hemodynamic monitoring using the EV1000 ClearSight system (Group I) and 20 to standard hemodynamic monitoring (Group II). Given the risk of conspicuous blood loss, this study evaluate the impact on maternal and fetal health of GDT relative to standard hemodynamic monitoring.

RESULTS

Average total infusion of fluids was 1600 +/- 350 ml. Use of blood products occurred in 29 patients (72,5%), of which 11 had a hysterectomy and 8 were treated with Bakri Balloons. For 2 patients > 1000 mL of concentrated red blood cells were used. When stroke volume index SVI dropped below 35 mL/m2/beat, it responded well to the infusion of at least 2 crystalloid boluses (5 ml/kg) in 7 patients. Cardiac index (CI) increased in 8 patients in concomitance with a reduction in medium arterial pressure (MAP), but the use of ephedrine (10 mg iv) re-established acceptable baseline values. Group I means are higher than Group II means for MAP, lower for RBC usage, end-of-surgery maternal lactates and fetal pH, and for LOS. Statistical analysis determines that the null hypotheses of equalities between Groups I and II can be rejected for all measures apart from MAP at baseline and induction. Proportions of serious complications in Groups I and II are respectively 10% and 32% and Boschloo's test rejects the null of equality of proportions against the alternative hypothesis of lower proportion of occurrence in Group I than in Group II.

CONCLUSIONS

Hypovolemia can lead to vasoconstriction and inadequate perfusion with decreased oxygen delivery to organs and peripheral tissues and ultimately cause organ dysfunction. Despite the small sample size due to the rarity of the pathology, our statistical analysis finds evidence in favor of more favorable clinical outcomes for patients who received GDT implemented with non-invasive hemodynamic monitoring infusion relative to patients who received standard hemodynamic monitoring.

Role of interventional radiology in treating obstetric haemorrhages

PURPOSE

The aim of this study was to evaluate the efficacy and the safety of selective uterine artery embolisation in patients with a high risk of haemorrhage due to obstetric issues.

MATERIALS AND METHODS

We retrospectively reviewed the angiographic examinations of 63 patients (average age ± SD, 32.6 years ± 4.8), affected by an obstetric disease with a high risk of haemorrhage (22 cases of ectopic pregnancy, 41 of postpartum haemorrhage) and treated with an interventional approach. In particular, we considered the rate of second treatment with interventional technique or conservative or radical surgery, the incidence of postprocedural complications, and the absorbed radiation dose.

RESULTS

Immediate technical success, defined as the cessation of active bleeding, was achieved in all cases. Uterine artery embolisation was able alone to control the haemorrhage in 95.24 % of cases. Three patients required a second treatment to achieve haemostasis. No peri- or postprocedural complications were observed. At the 12-month follow-up after embolisation, 22/49 conservatively treated patients were found to be pregnant and successfully completed their pregnancy.

CONCLUSIONS

Selective uterine artery embolisation allows for safe and complete control of haemorrhage in patients with obstetric disease, with a very low incidence of complications and preservation of fertility.

Postoperative pain treatment SIAARTI Recommendations 2010. Short version

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.

Analgesia in PACU: indications, monitoring, complications

The correct treatment of postoperative pain, in the early period immediately following surgery, is founded on the following four principles: 1-correct diagnosis of the source and magnitude of nociception; 2-understanding of the relationship of ongoing nociception and other components of pain including anxiety, ethnocultural components, meaning, prior experience; 3-treatment by establishment and maintenance of drug level at active sites to achieve and maintain analgesia and anxiolysis as appropriate; 4-continued re-evaluation of the therapy and refinement of the approach. The PACU standard of cure requires a strict accordance between intra and postoperative analgesia. It requires "proactive preoperative plan" that includes: preoperative patient evaluation; discussion with a single patient on different treatment options; patient and family education; pre-emptive measures as indicated; intra-operative multimodal analgesia; a correct triage of analgesia, just after initial evaluation of vital parameters in PACU; re-evaluation of analgesia plan, if analgesia is inadequate; a new titration, intravenous or epidural way, in order to achieve a stable VAS < 3; plan a new analgesia scheme or confirm a preoperative plan; control of adverse events, related to analgesia plan (gastric bleeding and/or bleeding of the surgical wound site, NSAIDs-induced renal damage, respiratory depression, delayed canalisation, nausea, vomiting, excessive sedation, difficulty in bladder emptying, itchiness); a transmission of analgesia plan to ward nurses; a control quality for verify at prefixed times patients satisfaction level, analgesia performed, adverse effects percent, analgesia related, plan variations percent.

Monitored anesthesia care and loco-regional anesthesia. Vascular surgery use

Association of locoregional techniques such as deep and superficial cervical block, lumbar epidural and/or peripheral blocks, and conscious sedation with hypnotic drugs (propofol 1-3 mg/kg/h or midazolam 2-4 mg/h) and/or opiates drugs (sufentanil 5-10 mcg or remifentanil 0.05-0.1 mcg/kg/min) is actually, the gold standard for vascular surgery. Our personal experience is based on 328 patients submitted to carotid endarterectomy, aneurysm repair and peripheral surgery.

Elevated plasma free fatty acid concentrations do not modify cardiac repolarization in patients treated by electrolyte-glucose-insulin infusion

Fat emulsion infusion is routinely used as a source of calories and essential fatty acids for critically ill patients who may be at risk for acquired ventricular repolarization alterations due either to drugs or electrolyte disturbances. The aim of this study was to evaluate whether acute elevations of plasma free fatty acid concentrations influence the corrected Q-T interval (Q-Tc), Q-Tc dispersion and sympathetic nervous system activity in patients requiring parenteral nutrition. Thirty hospitalized patients (mean +/- SD: 62 +/- 17 yr of age) requiring total parenteral nutrition received an infusion of 10% (500 ml) triacylglycerol emulsion as a source of calories (450 Kcal); on another occasion, and in random order, the same patients received an infusion of 20% (500 ml) triacylglycerol emulsion (900 Kcal). The infusion lasted 8 h and was preceded by a sc injection of heparin (5,000 U). Infusions of both 10% and 20% triacylglycerol emulsion increased plasma free fatty acid (p<0.00 1) and triacylglycerol (p<0.01) concentrations, and was associated with no significant change in mean BP, heart rate, and plasma catecholamines. At baseline, Q-Tc and Q-Tc dispersion were within the normal range (<440 milliseconds for QTc and <40 ms for QTc-d) and did not show any significant change at any time during infusion of triacylglycerol emulsion at both concentrations. In the setting of a balanced parenteral nutrition, acute elevation of plasma free fatty acid concentrations in critically ill patients do not modify ventricular repolarization.

Sufentanil: an overview of its use for acute pain management

The knowledge of pharmacodynamics and pharmacokinetics of new opioid drugs is necessary so that anaesthesiologists can choose which one to use, considering the patient's pathophysiology, the surgical procedure, and the dose required to obtain the desired effect. Aim of this review was to evaluate relevant trials on perioperative sufentanil in order to design an optimal strategy for administration.

METHODS

Randomised controlled trials on perioperative sufentanil analgesia were identified by Medline research, Embase, Biosis, Scisearch and references mentioned in relevant reviews were hand searched from 1988 to June 2001.

RESULTS

Twenty-four trials were considered eligible; they were divided according to the use of sufentanil in abdominal surgery, paediatric surgery and other types of surgery (orthopaedic, maxillo-facial, thoracotomy, lithotripsy, etc.). It was possible to compare the use of iv and epidural sufentanil, in iv PCA and PCEA, in continuous infusion, alone or in combination with local anaesthetics (various concentrations of ropivacaine, bupivacaine), with clonidine, adrenaline and ketamine.

CONCLUSIONS

Efficacy of sufentanil in perioperative epidural or intravenous analgesia resulted the same or better than other drugs used commonly despite context-sensible half-life advantages. Its association with local anaesthetics or adjuvant drugs prolongs its action and sometimes decreases the side effects. From the examined trials results that sufentanil can be used at very low doses and its association with local anaesthetics, clonidine, ketamine, and adrenaline by epidural, intravenous or intrathecal route for perioperative analgesia (intra and postoperative) and by various types of administration (PCA, PCEA, fixed intervals doses, continuous infusion, etc.).

[Systemic review of trials on the use of tramadol in the treatment of acute and chronic pain]

BACKGROUND

The purpose of the study was to verify the effectiveness of tramadol in the treatment of non-oncologic chronic pain, oncologic chronic pain and postoperative acute pain, applying the principles of meta-analytic analysis to randomized clinical trials (TCR).

METHODS

I: Medline research of the TCR on the question in the period between 1989-1999, II: exclusion of single TCR through the question of Moore and Mcquay; calculation of the relative risk reduction (RRR), of the number needed to treat (NNT), of the odds ratio (OR) and of the typical odds ratio (TOR) of the trials which responded to characteristics of correct randomization and blindness, which expressed citation of the patients excluded from trial, and patients with measurable analgesic effectiveness (number of patients with reduction of the pain intensity 50%).

RESULTS

52 trials extracted from Medline: 10 on the treatment of non-oncologic chronic pain, 36 on the treatment of postoperative acute pain and 6 on the treatment of oncologic chronic pain. Responded fully to requirements: 8 studies (3 for non-oncologic chronic pain, 3 for postoperative acute pain and 2 for oncologic pain). The OR was 0.55 (-0.31/1.41); 0.44 (1.04/1.92) and 0.98 (0.5/1.46); the RRR was 0.26 (-0.19/0.71), 0.38 (0.15/0.61), 0.005 (0.19/0.20) and the NNT 6.6 (6.39/6.81), 5.26 (5.12/5.4), infinity in the 3 trials selected between those that concern the treatment of the nononcologic chronic pain (with TOR: 0.57 and confidence index: 0.23-0.9); the OR was 0.36 (1.06/1.78), 0.78 (-0.08/-1.64) and 1.12 (0.54/1.69); the RRR was 0.26 (-0.18/0.7), 0.07 (-0.2/0.35), -0.01 (-0.09/0.07) and the NNT 4.7 (4.42/4.58), 20 (19.8/20.20), infinity in the trials on the treatment of postoperative acute pain (with TOR: 0.4 and confidence index: -0.6-0.86); the OR was 0.53 (-0.67/1.73), 0.27 (-0.71/1.12); the RRR was 0.19 (-0.33/0.72), 0.35 (0.02/0.68) and the NNT 7.1 (6.78/7.42), 3.57 (3.37/3.76) in those that involved the treatment of oncologic chronic pain (with TOR: 0.49 and confidence index: 0.36-0.8).

CONCLUSIONS

Although the short number of trials which can treated by the metanalytic technique the treatment with tramadol, compared comparison's to drugs (morphine, pentazocine, bupremorphine, etc.) determined a slight improvement in analgesic parameters or at least in analgesic effectiveness.

The relationship between influenza vaccine-induced specific antibody responses and vaccine-induced nonspecific autoantibody responses in healthy older women

The effect of aging on human humoral immunity was investigated by studying in vivo the relationship between influenza specific antibody responses and nonspecific vaccine-induced autoantibody responses in 32 independent, well-nourished older women volunteers (mean age 86 yr, range 74-97) and 23 young women volunteers (mean age 34 yr, range 23-46). Anti-influenza A/Taiwan/1/86(H1N1) antibody titers were determined by a hemagglutination inhibition test (HI-test), and serum anti-dsDNA antibodies were measured by ELISA prior to, 15, and 30 days after influenza vaccination. The mean postvaccination fold increase (FI) of the anti-influenza antibody response was significantly lower in elderly individuals as compared to younger individuals. In contrast, the mean anti-dsDNA autoantibody level measured 30 days after vaccination was significantly increased in older volunteers as compared to younger ones. There was a significant negative correlation between the level of the FI of the anti-influenza antibody response and the anti-dsDNA antibody response (r = -.441, p less than .01). Our results suggest that the altered influenza specific antibody response was associated with an age-related increase in autoimmunity in aging individuals.

In vivo T cell activation, in vitro defective IL-2 secretion, and response to influenza vaccination in elderly women

IL-2 secretion in response to mitogenic stimulation, assayed in vitro, is significantly reduced in circulating T lymphocytes isolated from healthy old people, but the significance of this abnormality and how it relates to in vivo IL-2 secretion remain unclear. We found that IL-2 secretion in response to PHA plus PMA by peripheral blood T cells isolated from 10 out of 32 (31%) healthy old individuals (mean age 86 yr, range 74-97) was significantly decreased compared with results obtained in 23 younger individuals (mean age 34 yr, range 23-46). This IL-2 secretion defect in vitro was reversible after a 3-day incubation in the absence of activators. The 10 healthy old individuals who had defective IL-2 secretion in vitro also showed increased levels of serum IL-2. T cells from 22 healthy old and 22 young individuals, who had normal IL-2 secretion (geometric mean +/- log of 1 SD: 139 +/- 0.3 U/ml and 212 +/- 0.31 U/ml, respectively) in vitro, showed a remarkable transient T cell defect in IL-2 secretion (15 +/- 0.47 U/ml for the old, 54 +/- 0.28 U/ml for the young) 15 days after influenza vaccination. IL-2 secretion became normal again 30 days after vaccination. The T cell-IL-2 activity, expressed as a T cell-IL-2 activity score (calculated as the logarithm of the serum IL-2 U/ml divided by the logarithm of the IL-2 secretion U/ml, in vitro) was significantly increased in elderly non-responders after influenza vaccination (mean +/- 1 SD: 1.4 +/- 0.51) compared with elderly (0.44 +/- 0.13) and younger responders (0.3 +/- 0.2). Our data suggest that in vitro defective IL-2 secretion is a consequence of T cell activation which seems to occur in a significant proportion of healthy elderly individuals and may be clinically relevant inasmuch as it appears to prevent the normal vaccine-induced antibody response.

In vivo T cell activation, in vitro defective IL-2 secretion, and response to influenza vaccination in elderly women

IL-2 secretion in response to mitogenic stimulation, assayed in vitro, is significantly reduced in circulating T lymphocytes isolated from healthy old people, but the significance of this abnormality and how it relates to in vivo IL-2 secretion remain unclear. We found that IL-2 secretion in response to PHA plus PMA by peripheral blood T cells isolated from 10 out of 32 (31%) healthy old individuals (mean age 86 yr, range 74-97) was significantly decreased compared with results obtained in 23 younger individuals (mean age 34 yr, range 23-46). This IL-2 secretion defect in vitro was reversible after a 3-day incubation in the absence of activators. The 10 healthy old individuals who had defective IL-2 secretion in vitro also showed increased levels of serum IL-2. T cells from 22 healthy old and 22 young individuals, who had normal IL-2 secretion (geometric mean +/- log of 1 SD: 139 +/- 0.3 U/ml and 212 +/- 0.31 U/ml, respectively) in vitro, showed a remarkable transient T cell defect in IL-2 secretion (15 +/- 0.47 U/ml for the old, 54 +/- 0.28 U/ml for the young) 15 days after influenza vaccination. IL-2 secretion became normal again 30 days after vaccination. The T cell-IL-2 activity, expressed as a T cell-IL-2 activity score (calculated as the logarithm of the serum IL-2 U/ml divided by the logarithm of the IL-2 secretion U/ml, in vitro) was significantly increased in elderly non-responders after influenza vaccination (mean +/- 1 SD: 1.4 +/- 0.51) compared with elderly (0.44 +/- 0.13) and younger responders (0.3 +/- 0.2). Our data suggest that in vitro defective IL-2 secretion is a consequence of T cell activation which seems to occur in a significant proportion of healthy elderly individuals and may be clinically relevant inasmuch as it appears to prevent the normal vaccine-induced antibody response.