"Early" and "definitive" taking charge of subjects positive to SARS-CoV2: the experience of an Italian Local Health Authority.

Abstract: During the second covid-19 pandemic wave in November-December 2021 Prevention Departments had to face a hardly-sustainable workload of contact tracing and taking charge of the sars-cov2 positive case and of his or her close contacts. Also laboratories have been stressed in their ability to process timely the extraordinary load of swabs performed. In this context of hazardous delays, the Prevention Department of Belluno (Italy) tested its resilience: a simple and effective method of taking charge was implemented, by initially phoning to the positive case and imposing the isolation measure on him or her and later on proceeding with the conventional contact tracing.

Post-operative analgesia following total knee arthroplasty: comparison of low-dose intrathecal morphine and single-shot ultrasound-guided femoral nerve block: a randomized, single blinded, controlled study.

BACKGROUND AND OBJECTIVES: Total knee arthroplasty often results in marked postoperative pain. A recent meta-analysis supports the use of femoral nerve block or alternatively spinal injection of morphine plus local anaesthetic for post-operative analgesia. On the other hand, the use of intrathecal morphine may be associated with a large number of distressing side effects (itching, urinary retention, nausea and vomiting, delayed respiratory depression). The aim of this study was to compare the effectiveness of femoral nerve block and low dose intrathecal morphine in post-operative analgesia after primary unilateral total knee arthroplasty. MATERIAL AND METHODS: Fifty-two consecutive patients scheduled for primary unilateral total knee arthroplasty were allocated to the intrathecal morphine group (ITM group) or to the femoral nerve block group (FNB group). In ITM group a subarachnoid puncture was performed at the L3-L4 inter-vertebral space with hyperbaric bupivacaine 15 mg plus 100 mcg of preservative-free morphine. Patients allocated to the FNB group received a single-injection ultrasound-assisted femoral nerve block with ropivacaine 0.75% 25 ml before the spinal injection of hyperbaric bupivacaine 15 mg. All patients received postoperative patient-controlled-analgesia (PCA) morphine, using a 1-mg bolus and a 5-minute lockout period. Data were analyzed using Student t test or two-way analysis of variance (ANOVA) for repeated measures with time and treatment as the 2 factors. Post hoc comparisons were performed by Bonferroni test. Statistical significance for all test was a p value < 0.05. RESULTS: Patient characteristics were similar between the 2 groups. We found a statistically significant differences in postoperative pain between the two groups: ITM group had the lower visual analogic pain score (VAS) values. Morphine consumption was lower in the ITM group: average consumption within the first 6 hours was 0.9 mg in IT group compared to 3.1 mg in FNB group; at 12 h 4.2 mg vs 6.3 mg; at 24 h 6.9 mg vs 10.3 mg; at 48 h 9.7 mg vs 13.6 mg. However, the difference in the opiate consumption was not statistically different (p value = 0.06). Thirteen patients in ITM group experienced itching, only 5 in FNB group. We did not find any difference in the two treatment groups in the use of antiemetic and antipruritic medication. No cases of respiratory depression was recorded. CONCLUSIONS: Our results show that low dose of intrathecal morphine may be safe and more efficient than single-shot femoral nerve block for post-operative analgesia after total knee arthroplasty.

Anesthesiological and intensive care considerations in children undergoing extensive cerebral excision procedure for congenital epileptogenic lesions.

INTRODUCTION: Epilepsy is a relatively common condition in childhood with a generally favorable prognosis of the affected population. Nevertheless, a significant minority of the treated children do not respond to the medical treatment so that surgical treatment is necessary. While minor surgical procedures have a negligible incidence of mortality, major ones may carry a significant risk of perioperative complications. The leading cause of mortality is represented by hemorrhagic derangements after high intraoperative and postoperative blood loss, mostly in very young patients. Therefore, restoration of euvolemia, detection and correction of related bleeding disorders represent the major concern for pediatric neuroanesthesiologists and intensivists throughout the perioperative period. The present report is focused on the anesthesia and intensive care management of the surgical epileptic patient. CONCLUSION: Authors recommend that these high-risk procedures should be performed in highly experienced centers where pediatric neurosurgery is performed daily.

[Anesthesia for neurosurgery in children: techniques and monitoring]. / Anestesia in neurochirurgia pediatrica: tecniche e monitoraggio.

Pediatric neuroanesthesia can be seen as a specific branch of anesthesia half way in between pediatric anesthesia and neuroanesthesia. As a matter of fact, we must keep well in mind the peculiarities of the pediatric patient and the different pharmadynamic and pharmacochinetic properties of the anesthetic drugs, particularly in neonates and infants. Other relevant problems are: 1) high complexity of surgical procedures implying a difficult anesthesiological management; 2) complex blood loss management either if we want to apply a blood sparing technique strategy or if we consider the problems related to diagnosis and treatment of coagulative disorders caused by intraoperative massive blood loss; 3) management of patients with latex allergy for the high incidence, in pediatric neuroanesthesia, of patients belonging to high risk groups; 4) need of repeated radiological examinations implying several anesthesiological procedures. In this article aspects related to the anesthesiological techniques and to the hemodynamic and neurophysiological monitoring of pediatric neurosurgical patients were also discussed.

Effects of isoflurane on cardiovascular system and sympathovagal balance in New Zealand white rabbits.

We investigated the effects of isoflurane on the rabbit cardiovascular system at several end-tidal concentrations. Furthermore, because isoflurane has been reported to produce tachycardia while reducing sympathetic nervous activity and baroreflex function, we evaluated whether the chronotropic effects of isoflurane could be due to a vagal withdrawal. ECG, mean arterial pressure (MAP), and heart rate (HR) were obtained in rabbits the conscious, unsedated state and during isoflurane anesthesia by telemetric device. Measurements of pH, oxygen, carbon dioxide, plasma catecholamines, baroreflex sensitivity, and spectral analysis of HR variability were made in nonanesthetized and anesthetized animals. Isoflurane caused an increase in HR at 0.5, 1, and 1.5 minimum alveolar concentration (MAC) and a decrease in systolic and diastolic blood pressure (SBP, DBP) and MAP at 1 and 1.5 MAC. Biochemical analysis showed that isoflurane-mediated cardiovascular effects were not accompanied by any significant changes in plasma norepinephrine (NE) and epinephrine (Epi) levels. Neither were any significant differences in plasma catecholamine levels noted between anesthetized and awake animals. The analysis of spectral components of HR variability and baroreflex function indicated that isoflurane induced a marked reduction in the low- and high-frequency spectral power of HR variability and in baroreflex sensitivity. Tachycardia under isoflurane was suppressed dose dependently by the administration of clonidine or atenolol and was not influenced by bilateral vagotomy. Collectively, our results indicate that cardiovascular effects induced by isoflurane in smaller animals such as rabbits are similar to those observed in humans and other animal species. We showed that isoflurane-induced tachycardia is mainly the result of vagal withdrawal rather than a baroreflex response, even though a marginal role of baroreflex in heart response to higher concentrations of isoflurane cannot be excluded.

Pediatric neuroanesthesia computerized monitoring system.

The authors describe the development of a computerized on-line monitoring system and its application during major pediatric neurosurgical procedures. The system acquires from monitor by serial communication the values of heart rate, systemic pressures, intracranial and central venous pressures, peripheral and central body temperatures and stores all these data on hard-disk. The system allows the collecting of clinical information, and other data concerning the metabolic and hemodynamic perioperative status of the patient. It also calculates in real time many derived parameters and stores all the measured data, the therapeutical administrations and their temporal relationship with the various surgical procedures on disk for statistical evaluation.

Maintenance of unstable kidney donors.

Cerebral death is often associated with haemodynamic changes which include a decrease in cardiac output and peripheral resistance. Brain-death following head injury may also lead to acquired diabetes insipidus with secondary water and electrolyte derangement. It is therefore necessary to prevent and correct these alterations, particularly when long-term maintenance is required, in order to keep kidney function within the normal range. Computerized monitoring of renal function and electrolyte and water derangements has been adopted. In all cases where early data of renal failure or oliguria were present infusions of dopamine and fluids were started. When indicated, the optimal dose of dopamine was calculated using a computerized system to allow drug dosages and the time of haemodynamic derangement to be minimized. When acquired central diabetes insipidus was present and urine output greater than 4 ml kg-1 h-1 desamino-cis-D-arginine vasopressin (DDAVP) was administered.

Nutrition in acute renal failure.

The nutritional value of regimes enriched with branched chain amino acids has been evaluated in 22 adult patients suffering from acute post-traumatic renal failure. The study was carried out for 12 days. The following data were recorded and compared daily: nitrogen balance, daily blood urea nitrogen (BUN), BUN/creatinine ratio, and plasma albumin levels. Also after 6 days of dialysis and nutritional support, the plasma medium molecular weight compounds (uremic toxins) were studied. It was concluded that: (a) the combined use of parenteral and oral nutrition appears most adequate in this type of patient; (b) the nitrogen intake should provide an essential amino acid/total nitrogen ratio of greater than or equal to 4 and a branched chain essential amino acid ratio of greater than or equal to 0.5; and (c) caution is still necessary in interpreting analyses of middle molecular weight compounds in this type of patient.

[Cerebral amino acid metabolism in acute barbiturate poisoning]. / Metabolismo aminoacidico cerebrale nell'intossicazione acuta da barbiturici.

An experimental study on the protein and aminoacid cerebral metabolism in Barbiturate poisoning coma has been carried out. Some significant alterations in central aminoacid pattern have been found. These changes suggested Hypothesis on particular biochemical pathways of brain tissue related to the pathological status. An attempt of correlation between the aminoacid alterations and cerebral energetic need is also reported.

Sodium nitroprusside and intracranial pressure.

The effects of sodium nitroprusside on intracranial pressure were studied in 10 patients, candidates for surgical treatment, prior to anaesthesia. Blood pressure was lowered to at least 50% of its initial value. In all cases, at the beginning of nitroprusside infusion, both the mean and the pulse intracranial pressures increased (mean increase: 83.2% of the initial value). At a certain moment, however, while the blood pressure continued to fall, the mean intracranial pressure did not increase any more; on the contrary, it decreased. On the other hand, in many cases, the pulse intracranial pressure continued to increase. No neurological or EEG changes were observed. The possible changes of cerebral circulation and CSF dynamics underlying the phenomena observed are discussed.

Biochemical changes in neurosurgical patients under critical care treated with mannitol.

A Study was carried out on ten patients undergoing operations for brain tumors, who were treated with mannitol solutions. This caused a significant depletion of serum sodium ion and in an increase of discriminate osmolality (to 60 mosM/kg H2O). A hypothesis about the particular biochemical mechanism, involving the electrolyte and water distribution, is presented.

Brain lactate uptake in coma secondary to acute cerebrovascular accident.

Relative distribution of lactate, pyruvate, and glucose in cerebrospinal fluid, arterial blood, and jugular blood has been determined in patients in status of coma following cerebrovascular accidents and compared with values obtained in patients without CNS disorders. Ratios of lactate/pyruvate and arteriovenous differences were calculated. In the cerebrospinal fluid of these patients a significant increase of lactate concentration and of the lactate/pyruvate ratio was observed.