Effects of two different strategies of fluid administration on inflammatory mediators, plasma electrolytes and acid/base disorders in patients undergoing major abdominal surgery: a randomized double blind study.

BACKGROUND: Administration of normal saline might increase circulating levels of pro-inflammatory cytokines and may cause variation of plasmatic electrolytic and hyperchloremic acidosis, which in turn can impair renal function. Hence the use of balanced solutions could influence the inflammatory cascade triggered by the surgical procedures, the plasmatic electrolyte concentration, the acid-base equilibrium, and the renal function. METHODS: This is a double blind randomized trial. Forty patients undergoing major abdominal surgery (bowel cancer) were allocated in two groups, the balanced solution (BS) group in which the fluids administered were balanced solutions (colloids and crystalloids); and the unbalanced solution (UBS) group in which the fluids administered were unbalanced solutions (colloids and crystalloids). Measurements were performed after anaesthesia induction (T0), at the end of surgery (T1), within 2 h after surgery (T2) and 24 h after the beginning of surgery (T3). The following data were collected: 1) active matrix metalloproteinase 9 (MMP-9) and its tissue inhibitor (TIMP-1), IL-6, IL-8, IL-10; 2) blood gases variables; 3) electrolytes, albumin, total serum protein and the strong ion difference; 4) neutrophil gelatinase-associated lipocalin (NGAL) from urinary sample. RESULTS: The BS group exhibited higher circulating level of IL-10 and TIMP-1 and lower level of active MMP-9. The UBS group experienced hypercloremia, hypocalcemia, hypomagnesemia, worse acid-base equilibrium and higher level of NGAL. CONCLUSIONS: The use of balanced solutions was responsible of less alteration of plasmatic electrolytes, acid-base equilibrium, kidney function and it might be associated with an early anti-inflammatory mechanisms triggering. TRIAL REGISTRATION: ClinicalTrials.gov (Ref: NCT01320891).

Pulmonary function and expiratory flow limitation in acute cervical spinal cord injury.

OBJECTIVE: To identify the nature of the changes of respiratory mechanics in patients with middle cervical spinal cord injury (SCI) and their correlation with posture. DESIGN: Clinical trial. SETTING: Acute SCI unit. PARTICIPANTS: Patients with SCI (N=34) at C4-5 level studied within 6 months of injury. INTERVENTIONS: Patients were assessed by the negative expiratory pressure test, maximal static respiratory pressure test, and standard spirometry. MAIN OUTCOME MEASURES: The following respiratory variables were recorded in both the semirecumbent and supine positions: (1) tidal expiratory flow limitation (TEFL); (2) airway resistances; (3) mouth occlusion pressure developed 0.1 seconds after occluded inspiration at functional residual capacity (P(0.1)); (4) maximal static inspiratory pressure (MIP) and maximal static expiratory pressure (MEP); and (5) spirometric data. RESULTS: TEFL was detected in 32% of the patients in the supine position and in 9% in the semirecumbent position. Airway resistances and P(0.1) were much higher compared with normative values, while MIP and MEP were markedly reduced. The ratio of forced expiratory volume in 1 second to forced vital capacity was less than 70%, while the other spirometric data were reduced up to 30% of predicted values. CONCLUSIONS: Patients with middle cervical SCI can develop TEFL. The presence of TEFL, associated with increased airway resistance, could increase the work of breathing in the presence of a reduced capacity of the respiratory muscles to respond to the increased load. The semirecumbent position and the use of continuous positive airway pressure can be helpful to (1) reduce the extent of TEFL and avoid the opening/closure of the small airways; (2) decrease airway resistance; and (3) maintain the expiratory flow as high as possible, which aids in the removal of secretions.

Health-related quality of life before planned admission to intensive care: memory over three and six months.

BACKGROUND: The validity of Health-Related Quality of Life (HRQOL) recalled by ICU admitted patients have not been published. The aim of this study was to compare the baseline HRQOL measured before surgery and ICU admission with that recalled at 3 and 6 months in a population of patients with planned ICU admission after surgery. METHODS: This prospective study was performed in three Italian centres on patients who had undergone General, Orthopaedic or Urologic surgery. All adult patients with planned ICU admission between October 2007 and July 2008 were considered for enrolment. At hospital admission, the Mini Mental Status Examination and EuroQoL (EQ) questionnaire (referring to the last two weeks) were administered to the patients who consented. Three and six months after ICU admission, the researchers administered by phone the EQ questionnaire and Post-Traumatic Stress Syndrome 14 questions Inventory, asking the patients to rate their HRQOL before surgery and ICU admission. Past medical history demographic and clinical ICU-related variables were collected. STATISTICAL ANALYSIS: Chi-square test and non parametric statistics were used to compare groups of patients. The EQ-5D was transformed in the time trade-off (TTO) to obtain a continuous variable, subsequently analysed using the Intraclass Correlation Coefficient (ICC). RESULTS: Of the 104 patients assessed at baseline and discharged from the hospital, 93 had the EQ administered at 3 months, and 89 at 6 months. The ICC for TTO recalled at 3 months vs pre-ICU TTO was 0.851, and that for TTO recalled at 6 months vs pre-ICU TTO was 0.833. The ICC for the EQ-VAS recalled at 3 months vs pre-ICU EQ-VAS was 0.648, and that for the EQ-VAS recalled at 6 months vs pre-ICU EQ-VAS was 0.580. Forty-two (45%) patients assessed at 3 months gave the same score in all EQ-5D items as at baseline. They underwent mainly orthopaedic surgery (p 0.011), and perceived the severity of their illness as lower (p 0.009) than patients scoring differently at 3 months in comparison with baseline. CONCLUSIONS: The patients with planned ICU admission have a good memory of their health status as measured by EQ-5D in the period preceding surgery and ICU admission, especially at three months.

Admission and discharge of critically ill patients.

PURPOSE OF REVIEW: The intensive care unit (ICU) provides continuous surveillance and specialized care to acutely ill patients. The decisions on patient admission and discharge should be based on common clinical criteria in order to guarantee equity. RECENT FINDINGS: The survival benefit of early admission to intensive care has been demonstrated recently. Sometimes, the number of potential patients may exceed the available beds making triage of the patients necessary. The prioritization model based on the benefit that the patient can have from the admission is the most used. In the case of the outbreak peak of pandemic A H1N1 flu, a triage plan using Sequential Organ Failure Assessment score combined with inclusion and exclusion criteria to complement clinical judgment has been recommended. Nevertheless, studies have shown that this triage could lead to withdrawal of life support in patients who survive. Triage implies refusal of some patients, and refusal rates vary greatly even across the same country. Policies for discharge from intensive care show wide variability influenced by the availability of step-down facilities. SUMMARY: The decisions to admit and discharge patients depend on patient, structure and physician-related variables. Early ICU admission of the critically ill patient is beneficial. Future analysis should also investigate economic parameters.

Is it possible to measure and improve patient satisfaction with anesthesia?

Satisfaction cannot be considered as an objective indicator of the quality of anesthesia care, but it remains the best way to assess the outcome from the point of view of the patient. Patient satisfaction offers the opportunity for evaluating nontechnical aspects of medical care, in particular interpersonal relationships arising from specific episodes of care. Satisfaction is usually defined as the result of the comparison between expectations and perceived outcome. If improving patient satisfaction with anesthesia becomes one of the aims of a health service, anesthetists have to consider that when patients have an improved anesthesia experience, their expectations are exceeded, which in turn increases the expectations for subsequent anesthetics. A continuous quality improvement process is needed to maintain patient satisfaction at the highest level.

Factors predictive of patient satisfaction with anesthesia.

BACKGROUND: In this multicenter prospective study, we identified factors associated with satisfaction with anesthesia in patients staying in hospital at least 24 h after surgery. METHODS: The study was performed in six centers. Inpatients aged more than 18 yr, who underwent a wide range of common surgical procedures, were asked to answer a 10-item instrument to measure patient satisfaction with anesthesia (mean score range, 0-10) and some specific questions, and to rate their perceived health (score, 0-10). Anesthesia staff members were invited to self-compile a Maslach Burnout Inventory. RESULTS: The satisfaction evaluation questionnaire was returned by 1290 patients (mean age, 61 +/- 16 yr; males, 54.4%). The mean global satisfaction score was 8.7 (95% CI: 8.7-8.8), being <9 in 632 (49%) and > or =9 in 658 (51%) patients. The Maslach Burnout Inventory was returned by 55 anesthesiologists and 68 nurses. Multivariate regression identified five variables as significant predictors of a mean global satisfaction of >/=9: 1) having been treated in a service with perioperative nurses specifically dedicated only to anesthesia; 2) having been treated where anesthesia information leaflets were provided preoperatively; 3) having received more than two anesthesiologist visits after surgery; 4) having a perceived health score >8.5; and 5) being older that 70 yr. No relationship was found between staff burnout and patient satisfaction. CONCLUSIONS: Inpatient satisfaction can be improved by an organization in which surgical suite nurses are dedicated only to anesthesia, a written anesthesia information leaflet is given during the preoperative visit and postoperative visits are enhanced.

Influence of different strategies of volume replacement on the activity of matrix metalloproteinases: an in vitro and in vivo study.

BACKGROUND: Excessive production of matrix metalloproteinase 9 (MMP-9) is linked to tissue damage and anastomotic leakage after large bowel surgery. Hence, the aim of this study was to verify whether different strategies of fluids administration can reduce MMP-9 expression. METHODS: In the in vitro experiment, the authors tested the hypothesis of a direct inhibition of MMP-9 by the fluids used perioperatively, i.e., lactated Ringer's solution, 3.4% poligeline, and hydroxyethyl starch 130/0.4. In the in vivo experiment, 36 patients undergoing surgery for colon cancer were randomly assigned to three groups to receive lactated Ringer's solution, poligeline, or hydroxyethyl starch. MMP-9 and tissue inhibitor of metalloproteinases were measured from venous blood samples; the MMP-9/tissue inhibitor of metalloproteinases ratio was calculated as an index of equilibrium between the action of MMP-9 and its inhibition. RESULTS: In the in vitro experiment, the presence of hydroxyethyl starch 130/0.4 in the MMP-9 assay system showed a strong inhibition of the enzymatic activity compared with lactated Ringer's solution. In the in vivo experiment, MMP-9 and tissue inhibitor of metalloproteinases plasma levels did not differ among the three groups at baseline, whereas those levels increased significantly at the end of surgery. At that time, the MMP-9 plasma levels and the MMP-9/tissue inhibitor of metalloproteinases ratio were significantly higher in the lactated Ringer's solution and poligeline groups than in the hydroxyethyl starch group. These results were confirmed 72 h after surgery. CONCLUSIONS: This study demonstrates that hydroxyethyl starch 130/04 decreases the circulating levels of MMP-9 in patients undergoing abdominal surgery.

Predictors of early recovery of health status after intensive care.

OBJECTIVE: To identify factors predictive of good or poor recovery of health status and health-related quality of life (HRQOL) 90 days after admission to an intensive care unit (ICU). DESIGN AND SETTING: Prospective international multicentre study in 19 ICUs participating in the HRQOL substudy of the SAPS 3 project. INTERVENTION: The EuroQol questionnaire (EQ) was administered to discharged ICU patients 90 days after admission. A question to compare present health status with that 3 months before ICU admission (same/better/worse) was added. PATIENTS: Six hundred and eighteen patients who spent >24h in an ICU and survived for 90 days. EQ data and health comparison were available in 559 (90.5%) of them. MEASUREMENTS AND RESULTS: Patients reported their general level of health to be better (33.8%), the same (31.1%), or worse (35.1%) in comparison with baseline. Recovery was considered to be good for answers "better" or "the same". Regression analysis showed that transplantation surgery [odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01-0.63], coronary artery bypass surgery without valvular repair (OR 0.39, 95% CI 0.17-0.92) and being admitted to the ICU from a ward or other location (OR 0.55, 95% CI 0.31-0.95) predicted good recovery of health. Predictors of poor recovery (all present at the time of ICU admission) were unplanned ICU admission, hypothermia, serum creatinine level >or=2mg/dl, pH

Melatonin does not reduce anxiety more than placebo in the elderly undergoing surgery.

Melatonin has been reported to reduce preoperative anxiety. We performed this study to compare preoperative anxiety in elderly patients receiving melatonin (M) or placebo (P). Anxiety was measured in patients aged >65 yr by a numerical rating scale (range, 0-10). Each patient was randomized to receive M 10 mg or P orally: 71 patients were in group P and 67 in group M. The median (quartiles) anxiety level was 5 (2-8) before and 3 (1-7) 90 min after premedication in group M and 5 (3-6) and 3 (1-5) in group P, respectively. M and P reduce anxiety in elderly patients to a similar degree.

Acute effects of hyperoxemia on dyspnoea and respiratory variables during pressure support ventilation.

OBJECTIVE: To evaluate the acute effect of hyperoxemia on the comfort and the respiratory variables in patients undergoing pressure support ventilation (PSV) for acute respiratory failure (ARF). DESIGN AND SETTING: Prospective, observational study performed in the intensive care unit of a university hospital. PATIENTS: Thirteen semirecumbent patients were ventilated in PSV mode, the setting of which was established by the treating physician who was blinded to the study. MEASUREMENTS: The variables measured at different levels (21-80%) of FiO(2) randomly applied were: minute volume (V (E)), respiratory frequency (f) and the pressure develing during the first 100 ms of an occluded breath (P(0.1)). These variables were firstly measured at the level of FiO(2) chosen by the treating physician. Severity of dyspnea was rated using the visual analogue scale 15' after each FiO(2) variation. RESULTS: Modulation of FiO(2) was able to vary significantly the respiratory variables, since a FiO(2) increase was associated with a decrease in dyspnea, P(0.1), f, and V (E). While valuable variations were detected at both lower and higher values of FiO(2) than those established by the treating physician, a significant improvement in the respiratory variables was detected at FiO(2) 60%. The reduction in respiratory drive was statistically related to an amelioration of dyspnea (R(2)=0.89) even at values of FiO(2) higher than 60%. CONCLUSIONS: During PSV the respiratory drive can be heavily modulated by varying the FiO(2) since even at FiO(2) greater than 0.6 dyspnea and respiratory variables continued to improve.

Reporting of unintended events in an intensive care unit: comparison between staff and observer.

BACKGROUND: In order to identify relevant targets for change, it is essential to know the reliability of incident staff reporting. The aim of this study is to compare the incidence and type of unintended events (UE) reported by facilitated Intensive Care Unit (ICU) staff with those recorded concurrently by an observer. METHODS: The study is a prospective data collection performed in two 4-bed multidisciplinary ICUs of a teaching hospital. The format of the UE reporting system was voluntary, facilitated and not necessarily anonymous, and used a structured form with a predetermined list of items. UEs were reported by ICU staff over a period of 4 weeks. The reporting incidence during the first fourteen days was compared with that during the second fourteen. During morning shifts in the second fourteen days, one observer in each ICU recorded any UE seen. The staff was not aware of the observers' study. The incidence of UEs reported by staff was compared with that recorded by the observers. RESULTS: The staff reported 36 UEs in the first fourteen days and 31 in the second.. The incidence of UE detection during morning shifts was significantly higher than during afternoon or night shifts (p < 0.001). Considering only working day morning shifts, the rate of UE reporting by the staff per 100 patient days was 26.9 (CI 95% 16.9-37.0) in the first fourteen day period and 20.3 (CI 95% 10.3-30.4) in the second. The rate of UE detection by the observers was 53.1 per 100 patient days (CI 95% 40.6-65.6), significantly higher (p < 0.001) than that reported concurrently by the staff. There was excellent agreement between staff and observers about the severity of the UEs recorded (Intraclass Correlation Coefficient 0.869). The observers recorded mainly UEs involving Airway/mechanical ventilation and Patient management, and the staff Catheter/Drain/Probe and Medication errors (p = 0.025). CONCLUSION: UE incidence is strongly underreported by staff in comparison with observers. Also the types of UEs reported are different. Invaluable information about incidents in ICU can be obtained in a few days by observer monitoring.

Application of the Italian version of the Intensive Care Unit Memory tool in the clinical setting.

INTRODUCTION: The aims of the present study were to assess patients' memories of their stay in the intensive care unit (ICU) over time, using the Italian version of the ICU Memory (ICUM) tool, and to examine the relationship between memory and duration of ICU stay and infection. PATIENTS AND METHOD: Adult patients consecutively admitted to a four-bed ICU of a university hospital, whose stay in the ICU was at least 3 days, were prospectively studied. The ICUM tool was administered twice: face to face 1 week after ICU discharge to 93 patients (successfully in 87); and by phone after 3 months to 67 patients. Stability of memories over time was analyzed using Kappa statistics. RESULTS: Delusional memories appeared to be the most persistent recollections over time (minimum kappa value = 0.68), followed by feelings (kappa value > 0.7 in three out of six memories) and factual memories (kappa value > 0.7 in three out of 11 memories). The patients without a clear memory of their stay in the ICU reported a greater number of delusional memories than did those with a clear memory. Of patients without infection 35% had one or two delusional memories, and 60% of patients with infection had one to four delusional memories (P = 0.029). CONCLUSION: The ICUM tool is of value in a setting and language different from those in which it was created and used. Delusional memories are the most stable recollections, and are frequently associated both with lack of clear memory of ICU experience and with presence of infection during ICU stay.

Respiratory function after aortic aneurysm repair: a comparison between retroperitoneal and transperitoneal approaches.

OBJECTIVE: Elective abdominal aneurysm repair can be performed by using the transperitoneal or the retroperitoneal approach. The latter has been described as having a better outcome, reducing the impairment of respiratory function or the incidence of lung complications. Hence, the retroperitoneal approach has been proposed for treatment of medically high-risk patients. However, the superiority of one technique or the other in preserving pulmonary function has not been conclusively demonstrated. The aim of this study was to ascertain whether the retroperitoneal and the transperitoneal approaches affect respiratory function differently. DESIGN: A prospective randomized study. SETTING: Two four-bed surgical-medical ICUs of a University hospital. PATIENTS: Twenty-three consecutive patients undergoing abdominal aortic aneurysm repair were randomized to the retroperitoneal (12 patients) and transperitoneal approach (11 patients). They were studied: a). within 30 min the end of surgery; b). 8 h after the end of surgery; and c). during a T-piece tube-weaning trial. MEASUREMENTS: The comparison between the two groups was based on respiratory mechanics, partitioned between lung and chest wall components, basic spirometry, tension-time index of the inspiratory muscle, weaning indexes, and length of stay both in ICU and hospital. RESULTS: The two surgical techniques do not differ in their impact on either respiratory mechanics or inspiratory muscle function or weaning indexes. However, there was a tendency for retroperitoneal patients to stay for less time both in ICU and in the hospital. CONCLUSIONS: During the first 24 h after surgery, the postoperative impairment of respiratory function is independent of the surgical approach.

Respiratory mechanics by least squares fitting in mechanically ventilated patients: application on flow-limited COPD patients.

OBJECTIVE: Although computerized methods of analyzing respiratory system mechanics such as the least squares fitting method have been used in various patient populations, no conclusive data are available in patients with chronic obstructive pulmonary disease (COPD), probably because they may develop expiratory flow limitation (EFL). This suggests that respiratory mechanics be determined only during inspiration. SETTING: Eight-bed multidisciplinary ICU of a teaching hospital. PATIENTS: Eight non-flow-limited postvascular surgery patients and eight flow-limited COPD patients. INTERVENTION: Patients were sedated, paralyzed for diagnostic purposes, and ventilated in volume control ventilation with constant inspiratory flow rate. MEASUREMENTS: Data on resistance, compliance, and dynamic intrinsic positive end-expiratory pressure (PEEPi,dyn) obtained by applying the least squares fitting method during inspiration, expiration, and the overall breathing cycle were compared with those obtained by the traditional method (constant flow, end-inspiratory occlusion method). RESULTS AND CONCLUSION: Our results indicate that (a) the presence of EFL markedly decreases the precision of resistance and compliance values measured by the LSF method, (b) the determination of respiratory variables during inspiration allows the calculation of respiratory mechanics in flow limited COPD patients, and (c) the LSF method is able to detect the presence of PEEPi,dyn if only inspiratory data are used.