A randomised controlled trial comparing two popliteal nerve catheter tip positions for postoperative analgesia after day-case hallux valgus repair.

We compared the effect of two different positions of a sciatic nerve catheter within the popliteal fossa on local anaesthetic consumption and postoperative analgesia in patients undergoing day-case hallux valgus repair. Eighty-four patients were randomly allocated to receive a sciatic nerve catheter either between the tibial and peroneal components (sciatic group) or medial to the tibial nerve (tibial group). The primary endpoint was postoperative local anaesthetic consumption, while secondary endpoints were pain scores, number of occasions where sleep was disturbed by pain and incidence of insensate limb and foot drop at 24 h and 48 h postoperatively. Postoperative median (IQR [range]) local anaesthetic consumption was 126 (106-146 [98-180]) ml in the sciatic group versus 125 (114-158 [98-200]) ml in the tibial group (p = 0.103). Insensate limb occurred in 14 patients in the sciatic group versus one patient in the tibial group (p < 0.001), while foot drop was reported by six patients in the sciatic group and none in the tibial group (p = 0.012). Sciatic nerve catheter placement medial to the tibial nerve may be a superior analgesic technique for day-case foot surgery.

A randomised controlled trial of intrathecal blockade versus peripheral nerve blockade for day-case knee arthroscopy.

We allocated 100 patients scheduled for day-case knee arthroscopy to unilateral spinal anaesthesia with 40 mg intrathecal hyperbaric prilocaine or to ultrasound-guided femoral-sciatic nerve blockade with 25 ml mepivacaine 2%, 50 participants each. The median (IQR [range]) time to walk was 285 (240-330 [160-515]) min after intrathecal anaesthesia vs 328 (280-362 [150-435]) min after peripheral nerve blockade, p = 0.007. The median (IQR [range]) time to home discharge was 310 (260-350 [160-520]) min after intrathecal anaesthesia vs 335 (290-395 [190-440]) min after peripheral nerve blockade, p = 0.016. There was no difference in time from anaesthetic preparation to readiness for surgery.

Update on percutaneous mitral valve therapy: clinical results and real life experience.

Mitral regurgitation (MR) is a common valvulopathy worldwide increasing in prevalence. Cardiac surgical intervention, preferable repair, is the standard of care, but a relevant number of patients with severe MR do not undergo surgery because of high peri-operative risk. Percutaneous mitral valve repair with the MitraClip System has evolved as a new tool for the treatment of severe MR. The procedure simulates the surgical edge-to-edge technique, developed by Alfieri in 1991, creating a double orifice valve by a permanent approximation of the two mitral valve leaflets. Several preclinical studies, registries and Food and Drug Administration approved clinical trials (EVEREST, ACCESS-EU) are currently available. The percutaneous approach has been recently studied in a randomized controlled trial, concluding that the device is less effective at reducing MR, when compared with surgery, by associated with a lower adverse event rate. The patients enrolled in this trial had a normal surgical risk and mainly degenerative MR with preserved left ventricular function. On the other hand, results derived from the clinical "real life" experience, show that patients actually treated in Europe present a higher surgical risk profile, more complex mitral valve anatomy and functional MR in the most of cases. Thus these data suggest that MitraClip procedure is feasible and safe in this subgroup of patients that should be excluded from the EVEREST trial due to rigid exclusion criteria. Despite the promising results clinical experience is still small, and no data related the durability are currently available. Therefore, MitraClip device should be reserved now to high risk or inoperable patients.

Effect of recombinant IL-1 beta and recombinant gamma interferon on septic acute lung injury in mice.

The effect of recombinant human interleukin 1B (IL-1B) and recombinant human gamma interferon (IFN-g), when given prophylactically, in a mouse model of septic acute lung injury was studied. Mice were treated with various doses of IL-1B and IFN-g for 3 consecutive days prior to administration of lipopolysaccharide of Escherichia coli (1 mg/kg given intraperitoneally). To determine the histologic changes occurring after prophylactic administration of such cytokines, a scoring system was assessed. A significant reduction of edema and neutrophil accumulation into the lungs of mice was observed, especially at doses of 100 U per mouse and 10,000 U per mouse of IL-1B and IFN-g, respectively. Prophylactic administration of IL-1B or IFN-g caused histologic changes, including marked reduction of edema and neutrophil accumulation in the interstitial and alveolar spaces. Combined prophylactic administration of IL-1B and IFN-g provoked a marked decrease of neutrophil accumulation into the lungs, but was not accompanied by significant reduction of edema or hemorrhage. These results provide evidence for the beneficial role of IL-1B and IFN-g in the abnormality of septic acute lung injury by reducing inflammatory lesions.

The clinical use of 99m-Tc-labeled WBC scintigraphy in critically ill surgical and trauma patients with occult sepsis.

OBJECTIVE: To evaluate the clinical use of radionuclide-labeled white blood cell scintigraphy in the detection of focal sepsis. DESIGN: Prospective clinical study. SETTING: A medical/surgical 12-bed intensive care unit (ICU) in a university hospital. PATIENTS: 26 trauma and surgical patients affected by sepsis of unknown origin were studied. MEASUREMENTS AND RESULTS: After the usual diagnostic approach, patients were submitted to a total body scan by using the patient's leukocytes labeled with technetium-99m (99m-Tc) HMPAO; three scintigraphy were performed within 20 h of tracer injection; the result of scan was completed with all clinical and instrumental data, including ultrasound (US) arnd computed tomography (CT), and the diagnostic efficacy was demonstrated for each patient on discharge from the ICU. The scan was able to detect 20 sites of infection; it was possible to rule out 11 suspected sites; only in two cases was the result considered to be false positive or false negative; in two cases the result was considered to be uncertain. These results show the high sensitivity (95%), specificity (91%) and accuracy (94%) of the method. CONCLUSIONS: In ICU patients with sepsis, nuclear medicine can provide additional data, as the injection of radionuclide-labeled white blood cells (WBCs) allows the imaging of sites of infection. Analysis of our results suggests that scintigraphy with 99m-Tc-labeled WBCs can be considered a useful tool in the detection of the source of infection.

Use of heat and moisture exchanging (HME) filters in mechanically ventilated ICU patients: influence on airway flow-resistance.

OBJECTIVE: To investigate the flow-resistance of a new generation of Heat Moisture Exchanging Filters (HME filters) during 24 h of clinical use. DESIGN: Before-after trial. SETTING: A general Intensive Care Unit of a university hospital. PATIENTS: A consecutive series of 96 patients undergoing mechanical ventilation for respiratory insufficiency of various etiology and severity. METHODS: The characteristics of the secretions collected by tracheal suctioning and the pressure/flow relationship of the HMEs before and after 24 h of clinical use were analyzed. RESULTS: The resistance of the HMEs when dry was 2 hPa/l.s, and it increased to a maximum of 1 hPa/l.s in 83% of the patients after 24 hours; in four patients with particularly heavy secretions HME resistance was 4-5 hPa/l.s. There were no significant modifications of the secretions within the investigation period, excluding, in particular, an increase in density with consequent tracheal tube obstruction. CONCLUSION: The gas conditioning efficiency and design performance of the tested HMEs did not create a significant obstacle to airflow medium term mechanical ventilation; however, these devices should be cautiously used in patients with heavy bronchial secretions.

Body iron status in critically ill patients: significance of serum ferritin.

Serial measurements of blood haemoglobin, serum iron, serum transferrin, total iron-binding capacity, transferrin per cent saturation and serum ferritin were determined in 51 post-operative critically ill patients to investigate body iron status in severely stressed patients. The results showed decreased blood haemoglobin, serum iron, serum transferrin and transferrin saturation compared to an increase in serum ferritin levels. These results indicate that there is inadequate availability of iron to tissues (secondary to rearrangement of body iron to the advantage of the iron storage compartment), which is often present in severely critically ill patients. A positive correlation was found between the initial (ferritin) levels and SAPS (r = 0.41, p less than 0.01). In addition, the increase of ferritin concentration parallels a worsening of the clinical status in severely ill patients. This is due to enhanced release by the macrophage system. From this, we consider serum ferritin as an acute-phase protein and a useful marker of the severity of the clinical status. It appears to be useful in predicting the patient's outcome, but is not reliable in evaluating iron stores in stressed patients.

Effects of high-dose IgG on survival of surgical patients with sepsis scores of 20 or greater.

Sixty-two consecutive septic surgical patients receiving standard multimodal intensive care unit treatment who developed a sepsis score of 20 or greater (day 0) were randomized to receive 0.4 g/kg of either intravenous IgG (29 patients) or human albumin (controls; 33 patients), repeated on days +1 and +5, in a prospective, double-blind, multicenter study. The two groups were similar in age, initial sepsis scores, and acute physiology and chronic health evaluation II score. A significantly lower mortality was recorded in the IgG-treated group (38%) than in controls (67%). Septic shock was the cause of death in 7% of IgG-treated patients and in 33% of controls. The results of this study indicate that high-dose IgG improves survival and decreases death from septic shock in surgical patients with a sepsis score of 20 or greater.

New trends for pain relief in gynaecologic oncology.

In pre-terminal and terminal gynaecological patients with persistent cancer pain, now it is possible to carry out some anthalgic methods associated or not to parenteral administration of non-narcotic or narcotic analgesic, i.e. intrathecal neurolytic injections and epidural narcotic administration. Many favourable results have been obtained by means of single or repeated 7% phenol in glycerine injections to patients with advanced but not terminal cancer affected by somatic and segmental pain or by perineal pain. In order to control more extensive pains, epidural injections of morphine in saline have been employed in preterminal patients. This method appears to be the best answer to many problems complained by the patients: pain, depression, malaise. As a matter of fact, low doses of epidural morphine induce both complete pain relief and sedation or slight drowsiness.

Postoperative bleeding after coronary revascularization. Comparison between tranexamic acid and epsilon-aminocaproic acid.

BACKGROUND: Microvascular bleeding after Cardiopulmonary bypass (CPB) is mainly due to consumption of clotting factors, platelets damage, and hyperfibrinolysis. Aprotinin, the only antifibrinolytic drug effective in preserving platelets, is no longer available; an alternative regimen based on pure antifibrinolytic drugs has been proposed, since hyperfibrinolysis is known to contribute both to clot lysis and platelet dysfunction. In this study the efficacy of two antifibrinolytic drugs, Tranexamic acid (TA) and epsilon-aminocaproic acid (EACA), was tested in patients undergoing cardiopulmonary bypass (CPB), for primary myocardial revascularization. METHODS: Forty-eight consecutive patients were randomized to receive prophylactically equipotent doses of EACA (group A) or TA (Group B). Platelet count, prothrombin time, fibrin digestion products, blood loss and transfusion requirements recorded after 6 and 24 hours from the end of surgery were compared. RESULTS: The two groups were comparable for length of CPB and numbers of grafts; no significant difference was observed in the coagulation parameters considered. Blood losses were less in group B (TA) than in group A (EACA), both at 6 and 24 hours after surgery; homologous blood transfused was also less in group B, but no difference was statistically significant. No adverse effect was observed. CONCLUSIONS: In coronary patients, TA and EACA exhibit the same effects on blood loss and requirements after CPB; either drug can be safely used in cardiac surgery.

Use of intramyometrial injection of prostaglandin F 2 alpha in the management of intractable hemorrhage due to uterine atony.

Prostaglandin F2 alpha, in doses varying from 1 to 5 mg was injected transabdominally, transvaginally or intraabdominally (during caesarean section) into the myometrium in ten patients affected by metrorrhagias not responsive to conventional uterotonic drugs. In all cases but one the result was excellent. Important side effects were observed in only one patient, because of the inadvertent intravascular injection of 5 mg Prostaglandin into the endocervix. An adequate treatment of this patient brought her to complete recovery in a short time. According to our experience, the intramyometrial injection of PGF2 alpha, in doses varying from 1 to 2 mg, is a simple, safe and effective method in the control of severe hemorrhage due to uterine atony not responding to conventional treatment.

[High-frequency ventilation in the newborn infant]. / La ventilazione ad alta frequenza nel neonato.

High-frequency ventilation (HFV), currently under investigation in three categories: high-frequency positive pressure ventilation (HFPPV), high-frequency jet ventilation (HFJV), and high-frequency oscillation (HFO), is a new form of mechanical ventilation that employs small tidal volumes in relation to dead space and extremely rapid rates, ranging from 1 to 40 Hz. It has a number of theoretical advantages when compared with current methods of conventional ventilation, and provides adequate gas exchange using minimal proximal airway pressure with little circulatory interference. Reports of successful application of the principles of the HFV in the treatment of infants with respiratory distress syndrome and particularly those with severe interstitial emphysema have raised hopes that this technique might prevent barotrauma to the lungs and have stimulated physicians and engineers to develop new equipment that might be useful in ventilating small infants. Approximately 80 infants are known to have been treated with HFV, mostly for short periods of time. In some with pulmonary interstitial emphysema, the only means of ventilating the infant have been with HFV. There is evidence that the technique can produce adequate gas exchange in infants, primarily when employed for a short period of time. As more knowledge is gained about the etiology of chronic neonatal lung disorders and as the questions of serious adverse effects of HFV are answered, it seems likely that a controlled, randomized, clinical trial might be needed in the future to determine whether HFV can decrease the incidence of complications such as air leak, lessen the morbidity, shorten the duration of dependency on the ventilator, and decrease the requirement for oxygen.

Ventilación protectora en anestesia general. ¿Algo nuevo? / Protective Ventilation in general anesthesia. Anything new?

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[Hemodynamic aspects of continuous-infusion ketamine anesthesia for visceral surgery in aged patients]. / Aspetti emodinamici dell'anestesia ketaminica in perfusione continua nella chirurgia viscerale dell'età senile.

The results obtained in a haemodynamic study carried out in 9 elderly patients subjected to ketaminic anaesthesia in continuous perfusion for visceral surgery operations are reported and compared with those observed, under the same conditions, in 9 patients aged less than 65. Stress is laid on the stimulating cardiovascular action observed during induction and the lower myocardial reactivity of elderly patients by comparison with younger ones. Mention is also made of the stability of haemodynamic values throughout the period of the operation. There was, however, a tendency to bradycardia and the constant onset of systemic arterial hypotension during the initial period. These are interpreted as phenomena due to the cardiovascular lability of senile age. The effectiveness of ketamine's cardiocirculatory action is, however, a positive factor in the light of the haemodynamic findings obtained during anaesthesia with Althesin and Fentanyl. It is concluded that the anaesthesia technique employed has some positive aspects that make it particularly indicated in states of acute or chronic cardiocirculatory lability, for visceral surgery operations also.

Clinical uses of high frequency jet ventilation in anaesthesia.

Since 1981, high frequency jet ventilation (HFJV) has been used in 300 patients undergoing surgery, most commonly during i.v. general anaesthesia for endoscopy and surgery of the airways: laryngoscopy, bronchoscopy, laryngeal microsurgery and laser surgery (more than 230 patients); repair of tracheal stenosis, tracheal sleeve pneumonectomy and tracheal sleeve lobectomy. HFJV was administered through a narrow injection catheter inserted in the airway, with a second rigid catheter positioned distally to the injector in the airway for gas sampling and measurement of airway pressure. In all subjects gas exchange was satisfactory, even during tracheoplasty and bronchoplasty.

Hemodynamic effects of continuous positive-pressure ventilation and high-frequency jet ventilation with positive end-expiratory pressure in normal dogs.

The hemodynamic effects of high-frequency jet ventilation (HFJV) at 60, 120, 240, and 480 breath/min, and conventional ventilation at 15 breath/min were compared in 6 anesthetized, paralyzed dogs, at 0, 10, and 20 cm H2O of positive end-expiratory pressure (PEEP). On HFJV at the same inspired oxygen, PaCO2, and PEEP levels, hemodynamic function improved significantly. Cardiac output was higher, whereas transmural CVP and pulmonary vascular resistances were lower. The improvement was primarily related to a decrease in mean airway pressure, particularly at higher PEEP levels. When PEEP was applied, hemodynamic function improved even when mean airway pressure was maintained constant. The findings suggest that lung volume was smaller during HFJV, and/or that lung volume changes during each respiratory cycle contributed to differences in venous return and ventricular function.

[Observing an SSU Em 118 dispatch center for continuous quality improvement. The case of SSUEm 118 Varese]. / Una centrale operativa SSU Em 118 a giudizio per verifica e revisione di qualità. Il caso SSU Em 118 Varese.

The present paper highlights quality aspects of the management of an Emergency Health Service Center (SSUEm 118, Varese) in order to identify the corrective measures required in a service that is increasingly close to the citizens real needs and expectations. Data were collected retrospectively on a total 54,301 calls for assistance in the period October 1997-March 1999 from an area covering some 1,300 sq.km with a population of 1,150,000 residents. That resident population was dramatically increased on a daily basis by heavy vehicle traffic particularly on the motorways to the area's many factories and to the Intercontinental Airport Malpensa 2000. The survey employed 7 anaesthetists and resuscitation staff, 14 nurses and 8 Italian Red Cross works from the Emergency Center. The researchers analysed the following phases: call reception and telephone conversation: ambulance dispatch, patient transportation and the alerting of the hospital of destination. The ServFMEA method was used for Quality Control with appropriate dispatch and the conduct and timing of the ambulance service in the Varese SSUEm 118 area. The data collected allowed for a detailed analysis of the accuracy of the information provided over the telephone (over-triage 58%, undertriage 2%), the usefulness of the telephone filter, the colour coding (correct in 40% of cases), pick-up times (5'40" on average) which were related to problems inherent in the ambulance call-out and the way ambulances reached the emergency (BLS 99%, ALS 1%, Air rescue < 1%). It was concluded that Varese SSUEm 118 was effectively and efficiently run in its first 18 months and results were improved as far as they could be given the inadequate funding of the Italian Heatlh Service.

Measurement of the flow-resistive properties of double-lumen bronchial tubes in vitro.

This study measures the resistance to gas flow of different double-lumen bronchial tubes used for separate ventilation of each lung in critically ill patients. Different-sized Robertshaw and Carlens' tubes were studied, as well as a new device that consisted of a cuffed bronchial catheter introduced through a standard tracheal tube. The pressure-flow relationship was curvilinear in all cases. Robertshaw and Carlens' tubes were generally found to have bronchial and tracheal channels with almost similar resistance and offered total resistances similar to those of 7.0-8.0 mm internal diameter tracheal tubes. The new device had a higher resistance than others of equal external diameter. This must be taken into account when its use is recommended for prolonged respiratory support.