Complete neurological recovery after systemic air embolism during endoscopic retrograde cholangiopancreatography.

Systemic air embolisms are a rare but often a fatal complication of endoscopic retrograde cholangiopancreatography (ERCP). Only few cases have been reported in scientific studies. This paper concerns a case of a systemic air embolism that occurred during endoscopic sphincterotomy for gallstone removal in a 79-year-old-woman and discusses possible mechanisms. The basic vital and neurologic signs of the woman deteriorated abruptly towards the end of the procedure. It was believed to be an air embolism and an urgent transthoracic echocardiography was ordered which confirmed the etiological diagnosis. Supportive measures were initiated: she was administered 100% oxygen, she was placed head down, left lateral position and fluid resuscitation was started to increase venous pressure. We considered hyperbaric oxygen therapy for neurological injury but, despite the severe initial presentation, she had a complete clinical recovery with only conservative treatment. Present experience stresses the importance of the awareness of this uncommon complication: a close vigilance of the anesthetists during ERCP is critical to ensure early diagnosis and a timely intervention.

Regional anticoagulation and antiaggregation for CVVH in critically ill patients: a prospective, randomized, controlled pilot study.

BACKGROUND: The aim of this study is to assess the efficacy and clinical safety of regional anticoagulation (heparin pre-filter plus post-filter protamine) plus antiaggregation (pre-filter prostacyclin) [Group 1 (G1)] vs. only systemic heparin anticoagulation without antiaggregation [Group 2 (G2)] in critically ill patients with acute renal failure undergoing continuous veno-venous haemofiltration (CVVH). METHODS: One hundred and ten patients were randomized in a prospective, controlled pilot study. G1 patients received 1000 U/h pre-filter heparin, 10 mg/h post-filter protamine sulphate and 4 ng/kg/min pre-filter prostacyclin, while G2 patients received 1000 U/h pre-filter heparin. The haemofilter transmembrane pressure (TMP) and lifespan, as well as the platelet count were observed 1 h before, and at 6, 12, 18, 24 and 36 h from the beginning of CVVH. RESULTS: Haemofilter TMP remained unchanged in G1 while it increased up to three times in G2 (P=0.0002). The median filter lifespan was 68 h in G1 and 19 h in G2. The rate of spontaneous circuit failure was 24% in G1 and 93% in G2 (P=0.0001). The platelet count was stable over the treatment period in G1 while in G2 it decreased progressively (P=0.0073). CONCLUSION: In critically ill patients suffering from acute renal failure, regional anticoagulation with pre-filter heparin and post-filter protamine plus antiaggregation during CVVH is a simple and safe procedure that prevents increases in filter TMP and increases circuit life time compared with systemic anticoagulation with pre-filter heparin only.

The increase of endothelial progenitor cells in the peripheral blood: a new parameter for detecting onset and severity of sepsis.

Sepsis is a clinical syndrome characterized by non-specific inflammatory response with evidence of profound changes in the function and structure of endothelium. Recent evidence suggests that vascular maintenance, repair and angiogenesis are in part mediated by recruitment from bone marrow (BM) of endothelial progenitor cells (EPCs). In this study we were interested in whether EPCs are increasingly mobilized during sepsis and if this mobilization is associated with sepsis severity. Our flow cytometry data demonstrate that in the CD34+ cell gate the number of EPCs in the blood of patients with sepsis had a four-fold increase (45 +/- 4.5% p < 0.001) compared to healthy controls (12 +/- 3.6%) and that this increase was already evident at 6 hours from diagnosis (40.6 +/- 4.2 percent), reaching its maximum at 72 hours. Also the percentage of cEPCs identified in the patients with sepsis (35 +/- 4.6% of the CD34+ cell) was statistically different (p < 0.001) compared to that found in the blood of patients with severe sepsis (75 +/- 4.9%). In addition, we proved that at six hours after sepsis diagnosis, VEGF, CXCL8 and CXCL12 serum levels were significantly higher in septic patients compared to healthy volunteers 559 +/- 82.14 pg/ml vs 2.9 +/- 0.6 (p < 0.0001), 189.8 +/- 67.3 pg/ml 15 vs 11.9 +/- 1.6 (p = 0.014) and 780.5 +/- 106.5 pg/ml; vs 190.2 +/- 71.4 (p < 0.001). Our data suggest that the cEPC evaluation in peripheral blood, even at early times of diagnosis, in patients with sepsis can be envisaged as a valuable parameter to confirm diagnosis and suggest further prognosis.

Minimally invasive versus traditional chest surgical approach in patients with reduced renal function.

AIM: All surgical access approaches to the chest wall cause a different degree of muscle damage and freeing of substances as myogloblin into the bloodstream thus compromising kidney function. The aim of this study was to evaluate the potential kidney damage in relation to entity of muscle lesions caused by the different surgical approaches. METHODS: The hematic levels of creatine phosphokinase (CPK), myoglobin, lactate dehydrogenase (LDH), creatinine as well as the amount of the diuresis at different intervals of time were taken of 66 patients who underwent a thoracic surgical operation with diverse surgical access approaches. RESULTS: Surgery determines muscle substances to be freed into the bloodstream. Myoglo-blin levels resulted to be correlated to those of CPK (r=0.83; P<0.00005). Although serum levels of myogloblin are not determined as a routine procedure, high levels of CPK must induce to dose myogloblin. The amount of muscle substances freed depend on the width of the surgical access (r=0.7; P<0.00005) and not upon extension (r=0.36; P=0.18) or duration of surgery. (r=0.4; P=0.093). CONCLUSION: In patients with a reduced renal function or affected by kidney failure a minimally invasive or thoracoscopic approach is indicated whenever possible in order to reduce the amount of myogloblin in the bloodstream.

[Use of monofilament prosthesis in inguinal hernia treatment: cost-benefit ratio]. / L'impiego delle protesi in monofilamento nella terapia dell'ernia inguinale: rapporto costo-beneficio.

BACKGROUND: The authors aimed to demonstrate the real advantages in terms of cost and patient comfort of inguinal hernia surgery using monofilament prostheses. METHODS: A retrospective survey was carried out on two groups of patients: the first group, consisting of 1032 patients who underwent inguinal hernia surgery under general anesthetic between 1985 and 1995 at the Institute of General Surgery at the University Polyclinic of Messina, included cases of both emergency and elective surgery that did not use monofilament prosthesis. The second group, consisting of 348 patients operated under local anesthesia between 1996 and 1999 at the IV Division of General Surgery at the University Polyclinic of Messina, included cases of both emergency and elective surgery using tension-free techniques and polypropylene mesh. The numbers of recidivations and complications were compared, together with the relative costs of the methods used in both groups. CONCLUSIONS: In the light of these experimental results, it is clear that the use of biocompatible alloplastic materials in monofilament considerably reduces the risks of recidivation, without no significant increase in the number of dehiscences, infections or postoperative complications. Moreover, there was a striking reduction in costs linked not only to the shorter hospitalisation of patients and the reduced use of painkillers, but also a fall in the number of future hospital admissions owing to recidivation.

An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest.

We describe a case of more than 5 h cardiac arrest in a 60-year-old patient who underwent general anesthesia for a urologic operation. Before extubation, the patient suddenly developed ventricular fibrillation, pulseless ventricular tachycardia and asystole which was immediately treated by advanced life support (ALS) measures. Thirty minutes later seizures developed and were controlled by 200 mg of thiopentone and 10 mg of diazepam. A pattern of ventricular tachycardia, coarse ventricular fibrillation and asystole lasted for nearly 120 min. Termination of resuscitation maneuvers was considered, but long-term life support was continued for 5 h. After this time, peripheral pulses, with a supraventricular tachycardia-like rhythm and regular spontaneous breathing reappeared. Seven hours later, the patient had a Glasgow Coma Scale (GCS) of 5, dilated unresponsive, absence of pupils, and a systolic arterial pressure of 100 mmHg. He was then transferred to intensive care unit (ICU). The morning after, the patient was awake, responded to simple orders, breathing spontaneously, and free from sensomotor deficit. He was, therefore, extubated. Subsequently, other episodes of transitory ST-line upper wave followed by ventricular fibrillation appeared, suggesting Prinzmetal angina. This was successfully treated by percutaneous coronary angioplasty. The first electroencephalogram recorded the day after cardiac arrest showed a mild widespread background slowing. An electroencephalogram 6 days later showed a return to alpha rhythm with only mild theta-wave abnormalities. Four weeks after the first cardiac arrest the patient was discharged. This is an exceptional experience compared with the others reported. We believe that all the efforts must not be given up when such an event occurs during anesthesia and there are optimal conditions for resuscitation maneuvers.

A new surgical model of acute liver failure in the pig: experimental procedure and analysis of liver injury.

In this research, the effects of portocaval shunt plus 70% partial hepatectomy were evaluated in 11 pigs. Hepatic coma and death from progressive liver failure occurred in 5 pigs between 14 and 64 h from surgery, whereas 3 pigs, which also showed symptoms of progressive liver failure, died of presumed gastric hemorrhage between 17 and 19 h after surgery. In 3 pigs, transient liver failure was followed by complete recovery, as judged by clinical, electroencephalographic and biochemical parameters. No case of death occurred among the pigs treated with portocaval shunt alone or 70% partial hepatectomy alone as controls. This new model for acute liver failure is reproducible, seems to be potentially reversible, causes death due to hepatic failure after a time period sufficiently long to allow for the institution of support procedures, is applied to a large animal and lacks relevant biohazard. Therefore, this model may be used to evaluate possible support procedures during acute liver failure.