VAC therapy with long term continuous saline infusion for secondary septic peritonitis: A new strategy for the reduction of perioperative risks?

BACKGROUND: The management of a septic peritonitis open abdomen is a serious problem for clinicians. Open surgery is associated with several complications such as bleeding and perforation of the bowel. CASE PRESENTATION: The authors report a case of a 59-years-old female who underwent a sigmoid resection with an latero-terminal (L-T) anastomosis for the perforation of a diverticulum. After a few days the patients developed a new widespread peritonitis. At the emergency re-laparotomy, surgeons found dehiscence of the posterior wall of the anastomosis with fecal contamination. At admission in ICU (Intensive Care Unit) the patient had open abdomen with dehiscence of cutaneous and subcutaneous layers. CONCLUSION: Conservative therapy with antibiotic therapy and use of the Vacuum-Assisted Closure® (VAC) Therapy with a long term continuous saline infusion led to the resolution of the septic shock and to the wound healing.

Delayed fatal diagnosis in atypical rickettsial infectious disease.

We report the case of an 84-year-old man admitted to ICU with symptoms/signs occurring after upper respiratory airways disease. The upper respiratory condition consisting in an uvula oedema required an empiric anti-inflammatory and antibiotic therapy which masked the clinical features usually seen in the case of rickettsial infections, especially cutaneous rash. Although the patient subsequently presented unexplained cardiac and neurological involvement, the starting treatment interfered with the diagnostic process, resulting in a delayed diagnosis. Rickettsia and other conditions related with a possible tick bite have to be considered in the list of differential diagnosis especially in the case of severe systemic or localised disease, particularly when the only suspicious sign is a clinical history indicative of a patient living in poor conditions of hygiene.

Improving patient safety after rigid bronchoscopy in adults: laryngeal mask airway versus face mask - a pilot study.

BACKGROUND: There are still no clear guidelines in the literature on per procedural bronchoscopic management for anesthesiologists, and few relevant datasets are available. To obtain rapid recovery from anesthesia, it is often necessary to keep patients in the recovery room for several hours until they become clinically stable. In this study, we tested the hypothesis that the laryngeal mask airway (LMA) enables better respiratory and hemodynamic recovery than the oxygen face mask (FM) in patients undergoing rigid bronchoscopy. METHODS: Twenty-one patients undergoing elective bronchoscopy of the upper airway were randomized to ventilation assistance with FM or LMA after a rigid bronchoscopy procedure under general anesthesia. The primary endpoint was duration of post-surgical recovery and the secondary endpoints were postoperative hemodynamic and respiratory parameters. Assessment of the study endpoints was performed by an intensive care specialist blinded to the method of ventilation used. The statistical analysis was performed using the Fisher's Exact test for nominal data and the Student's t-test for continuous data. RESULTS: There was no statistically significant difference in post-procedural time between the two groups (P=0.972). The recovery parameters were significantly better in the LMA group than in the FM group, with significantly fewer desaturation, hypotensive, and bradycardic events (P<0.05). CONCLUSION: We conclude that the LMA may be safer and more comfortable than the FM in patients undergoing rigid bronchoscopy.

Influence of positioning on plain levobupivacaine spinal anesthesia in cesarean section.

Background. The behaviour of isobaric levobupivacaine in relation to gravity when used in obstetric spinal anesthesia is unclear. Methods. 46 women with ASA physical status 1 undergoing cesarean section were randomly allocated to 2 groups. Spinal anesthesia with 12.5 mg levobupivacaine was performed in the sitting position in all women. Those in the first group were placed in the supine position immediately after the injection, while those in the second group were asked to remain seated for 2 minutes before assuming the supine position. The sensory block level, the onset of sensory and motor blocks, the regression of the sensory block for 2 dermatomes of the sensory block, the first request for analgesics, and the regression of motor block were recorded. Results. No differences in onset times, sensory level, or Bromage score were observed between the two groups. The time of first analgesic request was earlier in the seated group (supine 131 +/- 42 min, seated 106 +/- 29 min, P = .02). Conclusion. Isobaric levobupivacaine in women at term produces a subarachnoid block the dermatomal level of which does not depend on gravitational forces.

Epidural local anesthetic plus corticosteroid for the treatment of cervical brachial radicular pain: single injection versus continuous infusion.

BACKGROUND: Efficacy of epidural local anesthetics plus steroids for the treatment of cervicobrachial pain is uncertain. METHODS: A prospective study randomized 160 patients with cervicobrachial pain resistant to conventional therapy. Patients were divided into 4 groups on the basis of the time between pain onset and treatment initiation: group A, 40 patients with pain onset 15 to 30 days; group B, 40 patients with pain from 31 to 60 days; group C, 40 patients, 61 to 180 days; and group D, 40 patients with pain >180 days. Patients of each group were randomized to receive an epidural block with bupivacaine and methylprednisolone at intervals of 4 to 5 days (Single injection) or continuous epidural bupivacaine every 6, 12, or 24 hours plus methylprednisolone every 4 to 5 days (Continuos epidural). The maximum duration of treatment (9 blocks in Single injection, and 30 days in Continuos epidural) was dependent on achieving Pain Control (PC) > or =80% [PC is defined by this formulae: (100) (VAS(initial)-VAS(final))/VAS(initial)]. Follow-up at 1 month and 6 months compared PC and the number of pain-free hours of sleep. RESULTS: One hundred forty-one patients completed the study. The 4 groups had similar characteristics. At the 1-month and 6-month follow-up analysis based on the time between pain onset and treatment initiation showed that patients of group D, who received the Continuous epidural treatment, had significantly greater PC and significantly more pain-free hours of sleep compared with similar patients in Single injection. CONCLUSIONS: Therapy with continuous epidural local anesthetic and methylprednisolone provides better control of chronic cervicobrachial pain compared with Single injection. These results are discussed with respect to the possible mechanism of action of the drugs and may relate to the physiopathologic mechanisms associated with neuronal plasticity that result in chronic pain.

Scopolamine prevents dreams during general anesthesia.

BACKGROUND: Dreaming during anesthesia is not a well-understood phenomenon. Anticholinergic drugs are used in anesthesia as premedication, but their use to decrease the incidence of dreams and psychological adverse reactions after anesthesia is not well established. The authors therefore studied the efficacy of intramuscular atropine and scopolamine for the prevention of dreams during general anesthesia with propofol and nitrous oxide. METHODS: Healthy women undergoing minor gynecologic surgery were randomly assigned to receive 2.5 microg/kg scopolamine or 10 microg/kg atropine intramuscularly (n = 50/group). In both groups, anesthesia was induced and maintained with propofol as a 2.5-mg/kg bolus, followed by 12 mg x kg(-1) x h(-1) as a continuous infusion and 70% nitrous oxide in oxygen. Two interviews regarding dreaming activity and characteristics were conducted at 20 min and 6 h after surgery. RESULTS: None of the patients in the scopolamine group and 47% of the patients in the atropine group reported the occurrence of dreams 20 min after recovery. The results were similar at 6 h: 6% of the scopolamine group and 43% of the atropine group reported dream activity. No differences in sedation or anesthetic requirements were found. CONCLUSIONS: Previous studies in animals and humans suggest that dreams are affected by drugs acting on the central cholinergic system. The current results suggest that intramuscular scopolamine prevents dreams or dream recall in healthy young women undergoing short elective surgery with propofol-nitrous oxide anesthesia.

Clonidine treatment for agitation in children after sevoflurane anesthesia.

Clonidine is effective in treating sevoflurane-induced postanesthesia agitation in children. We conducted a study on 169 children to quantify the risk reduction of clonidine agitation in patients admitted to our day-surgery pediatric clinic. Children were randomly allocated to receive clonidine 2 mug/kg or placebo before general anesthesia with sevoflurane that was also supplemented with a regional or central block. An observer blinded to the anesthetic technique assessed recovery variables and the presence of agitation. Pain and discomfort scores were significantly decreased in the clonidine group; the incidence of agitation was reduced by 57% (P = 0.029) and the incidence of severe agitation by 67% (P = 0.064). Relative risks for developing agitation and severe agitation were 0.43 (95% confidence interval, 0.24-0.78) and 0.32 (0.09-1.17), respectively. Clonidine produces a substantial reduction in the risk of postsevoflurane agitation in children.

Apnea during induction of anesthesia with sevoflurane is related to its mode of administration.

PURPOSE: The incidence and duration of apnea during sevoflurane anesthesia have not been fully characterized. We hypothesized that sevoflurane at slowly increasing concentrations reduces incidence and shortens the duration of apnea compared to administration of a highly concentrated anesthetic mixture. METHODS: 131 women were randomly assigned to receive 35% oxygen in air and sevoflurane at: incremental concentrations of 1%, from 1% to 8% (group 1-8%, n = 42); decremental-incremental concentrations of 2%, from 8% to 4% and then from 4% to 8% (group 8-4-8%, n = 36); or fixed concentrations of 8% for induction of anesthesia (group 8%, n = 53). A blinded investigator observed whether and for how long patients stopped breathing. RESULTS: All groups reached 2.5 minimum alveolar concentration of end-tidal sevoflurane. Although apnea was observed in all groups, it was more frequent in the 8% group than in 1 to 8% (68% vs 21%, P < 0.05) or 8 to 4 to 8% groups (68% vs 20%, P < 0.05). Duration of apnea was also more pronounced in the 8% group than in 1 to 8% and 8 to 4 to 8% groups ( 58 +/- 25 s vs 32 +/- 18 sec, P < 0.05 and vs 35 +/- 16 sec, P < 0.05, respectively). CONCLUSIONS: Sevoflurane induces apnea more frequently and for longer duration at a fixed high concentration compared to incremental or decremental-incremental concentrations. Decremental-incremental concentrations offer the additional advantage of a speed of induction similar to that elicited by the 8% concentration.