Tetraplegia following parathyroidectomy in two long-term haemodialysis patients.

We report two cases of postoperative iatrogenic tetraparesis, which occurred in different hospitals after surgery for parathyroidectomy. Both patients were on long-term haemodialysis. The prolonged neck extension usually required by this procedure was probably the main factor involved in the genesis of the spinal cord injury. Spinal abnormalities associated with chronic renal failure may have made these patients more vulnerable. In our opinion, it is advisable to investigate thoroughly any sign of spinal stenosis in patients who undergo any procedure requiring significant neck extension, particularly if on long-term haemodialysis.

[Stewart's approach]. / L'approccio quantitativo di Stewart all'equilibrio acido-base.

The concentration of H + in blood plasma is one of the most finely regulated variables of the human physiology; acute changes of this concentration result in serious cellular and general consequences. An advanced understanding of the acid-base physiology is essential to the management of "acute" patients, and is as important as the exact understanding of the cardiac and pulmonary physiology. Stewart's approach to acid-base balance has come to the identification of three independent variables that regulate pH in blood plasma: carbon dioxide, relative concentration of strong ions, and total weak acid concentrations. All changes in blood pH occur through changes in these three variables.

Multidimensional health-status assessment of chronic hemodialysis patients: the impact on quality of life.

AIM: This study was designed to define impairment of body functions and structures, limitations in activity, restrictions in participation, and health-related quality of life of chronic hemodialysis (HD) patients, in order to assign proper rehabilitation programs. METHODS: Forty-five patients with end-stage renal disease (ESRD) from the Dialysis Unit of the Trescore Balneario's Hospital were enrolled into the study. Clinical characteristics of the disease and Tinetti's test were used to assess impairment of body structures/functions. Limitations in activities were evaluated by functional independence measure (FIM). Marital status, living environment, employment status and recreational activities were questioned; short form-36 (SF-36) was used to measure health-related quality of life. RESULTS: Mean age of the patients (27 male, 18 female) was 63.8+/-11 years. ESRD was mainly caused by glomerulonephritis (22%). Tinetti's test showed that 11% of HD patients could not walk without help. On the day of dialysis the total FIM score of HD patients dropped about 40 points. Only 2 patients (4.5%) were able to live alone and 6 patients (13%) have gone for vacation since they started dialysis treatment. Compared to the general population sample (91.99+/-23.41), HD patients (50.08+/-22.56) scored significantly lower total SF-36 scores (P<0.001). CONCLUSION: HD patients had to face increased limitations in functional independence on the day of dialysis, as well as highly restricted social participation. Preventive and rehabilitative programs including medical management, nursing care and a range of multidisciplinary services can promote quality of life of patients with ESRD on HD.

Transmembrane pressure modulation in high-volume mixed hemodiafiltration to optimize efficiency and minimize protein loss.

The aim of the present study was transmembrane pressure (TMP) modulation in high-volume mixed hemodiafiltration (HDF) to optimize efficiency and minimize protein loss. The optimal flow/pressure conditions in on-line mixed HDF assisted with a feedback control of TMP were defined in this prospective randomized study in order to obtain maximal efficiency in solute removal while minimizing potential side effects. Two different TMP profiles in mixed HDF were compared in 12 unselected patients who underwent two study periods of 2 weeks each in cross-over randomized sequence: (A) constant TMP at around 300 mmHg and (B) profiled TMP, in which TMP was slowly increased from a low initial value to the maximal value. In both procedures, the mean volume exchange was 10.6+/-1.4 l/h. Mean filtration fraction was 53%. Instantaneous beta2-microglobulin (beta2-m) clearance was higher at the start of the session with profiled TMP (207+/-35 vs 194+/-28 ml/min, P<0.005), whereas no differences were found at the end (135+/-19 vs 132+/-19 ml/min). Profiled TMP resulted in a higher mean beta2-m clearance of the session (97.0+/-15.4 vs 87.8+/-18.3 ml/min, P<0.01), in lower albumin loss in the first 30 min (0.62+/-0.14 vs 0.98+/-0.18 g, P<0.0001), and, in the whole session (3.98+/-1.19 vs 5.24+/-0.77 g, P<0.001), in higher dialyzer ultrafiltration coefficients and lower resistance indexes. This study showed that the TMP feedback modulation in mixed HDF was highly effective in maintaining very high ultrafiltration rates and filtration fractions, and minimized potential side effects as a result of the improved preservation of membrane permeability and more favorable dialyzer pressure regimen.

Postpartum cerebral ischaemia after accidental dural puncture and epidural blood patch.

Puerperal women are reported to have a rate of cerebral infarction 13 times greater than non-pregnant females. We report a case of cerebral ischaemia in a 30-yr-old healthy parturient after epidural analgesia for labour, complicated by dural puncture treated with two epidural blood patches. Investigations showed the development of cerebral ischaemia on postpartum day 14. A transcranial Doppler ultrasonography showed vasospasm of the left middle cerebral artery still present at 3-month follow-up. At 1-yr follow-up, the patient had homonymous hemianopsia. We discuss the possible causative mechanism of the cerebral ischaemia in relation to the dural puncture and epidural blood patch.

High-dose aprotinin with gentamicin-vancomycin antibiotic prophylaxis increases blood concentrations of creatinine and cystatin C in patients undergoing coronary artery bypass grafting.

Both aprotinin and gentamicin-vancomycin antibiotic prophylaxis have been used widely in cardiac surgery to prevent bleeding and infections, respectively. As the drugs are excreted almost entirely by glomerular filtration, we investigated their action on renal function when administered either separately or together. To increase consistency, we measured serum concentrations of creatinine and cystatin C, a new marker of glomerular filtration rate, that many recent studies have shown to be more sensitive than serum creatinine. One hundred patients undergoing coronary artery bypass surgery were allocated randomly to one of four groups: group A received antibiotic prophylaxis with cefamandole and no aprotinin; group B received cefamandole and high-dose aprotinin; group C received antibiotic prophylaxis with gentamicin and vancomycin, but no aprotinin; and group D received both high-dose aprotinin and gentamicin-vancomycin antibiotic prophylaxis. Data from 84 patients, for whom data collection was complete, were analysed. In the first week after operation, mean serum concentrations of cystatin C and creatinine either remained constant or decreased slowly in all groups, except for group D. In group D, both markers increased gradually from postoperative day 2 onwards. The increase in cystatin C was significant on postoperative day 5 (from mean 1.02 (SD 0.11) mg litre-1 before operation to 1.35 (0.32) mg litre-1; P < 0.05), reaching a peak on postoperative day 7 (1.45 (0.35) mg litre-1; P < 0.05), while the increase in creatinine concentration was significant on postoperative day 6 (from 1.05 (0.16) mg dl-1 before operation to 1.29 (0.34) mg dl-1; P < 0.05). We conclude that simultaneous administration of high-dose aprotinin and prophylactic use of gentamicin with vancomycin increased serum concentrations of cystatin C and creatinine in the first postoperative week in patients undergoing cardiac surgery.