[Use of protein C concentrate in adult patients with severe sepsis and septic shock]. / Uso di concentrato di Proteina C nel deficit as-sociato a sepsi grave e shock settico in pazienti adulti.

AIM: The aim of this study is to describe the first experiences on the use of protein C concentrate (PC) in adult patients with severe sepsis and septic shock and clinical contraindications to activated protein C (APC). On the basis of the effectiveness demonstrated by the activated form in sepsis and of the encouraging results expressed in literature of protein C concentrate (PC) mainly about meningococcus fulminating infections, we carried out an observational study on protein C concentrate (PC) with 28-day follow-up and a daily analysis of the hemato-chemical and clinical parameters. Particular attention was paid to the variations in the PC plasma levels, to the modifications of the coagulation system, to the SOFA score as well as to the safety under bleeding risk conditions. METHODS: The study included 7 patients (5 females and 2 males) either with severe sepsis (2). or septic shock (5); one of them had DIC, with PC plasma levels less than 50%. APC could not be administered because of clinical reasons. Patients' mean age was 60.5 years (43-78), the average SAPS II 52.2 (36-72), the pathologies leading to sepsis were lung infections (3). and peritonitis (4). The average time elapsed between the onset of the organ failure and the beginning of treatment with PC was 27.7 hours (12-42). RESULTS: Mortality on day 28 was 42.8% (3 deaths), in all patients the PC plasma levels were brought again to the physiological values. Among the biochemical parameters recorded during the PC infusion, was observed in particular a significant decrease of PDFs, a general rise of the platelet count, and a reduction of the lactic acid levels. No adverse reaction or bleeding complication were seen, even if most of the patients' coagulation was altered or at risk due to neurological problems or repeated surgery. CONCLUSION: In our small number of patients, protein C concentrate has proven to be safe and particularly useful in the control of the coagulopathy triggered and sustained by sepsis.

Tranexamic acid in primary CABG surgery: high vs low dose.

AIM: Prophylactic administration of tranexamic acid decreases bleeding and transfusions after cardiac procedures but it is still unclear what the best dose and the most appropriate timing to get the best results are. METHODS: We enrolled 250 patients scheduled for elective, primary coronary revascularization. They were randomly divided into 2 groups. Group H received tranexamic 30 mg x kg(-1) soon after the induction of anaesthesia and a further same dose was added to the prime solution of cardiopulmonary bypass (CPB). Group L received tranexamic acid 15 mg x kg(-1) after systemic heparinization followed by an infusion of 1 mg x kg(-1) h(-1) till the end of the operation. Transfusions of bank blood products, bleeding in the postoperative period and coagulation profile were recorded. RESULTS: We did not find any difference between the groups either with respect to transfusion requirements or with respect to blood loss. CONCLUSION: For elective, first time coronary artery bypass surgery, both dosages of tranexamic acid are equally effective. Theoretically, it seems safer to administer it when patients are protected from thrombus formation by full heparinization.

Ventriculo-arterial coupling and mechanical efficiency with remifentanil in patients with coronary artery disease.

BACKGROUND: Optimum transfer of energy from the left ventricle to the arterial circulation requires appropriate matching of these mechanical systems. Left ventricular-arterial coupling describes this relationship between the ventricular elastance (Ees) and arterial elastance (Ea). The ratio of these elastances defines the efficiency of myocardium and provides in our study a useful technique for assessment of the actions of remifentanil. The purpose of this study was to evaluate the effects of remifentanil on ventriculo-arterial coupling in cardiac surgery in patients with coronary artery disease. METHODS: Fourteen patients with coronary artery disease, submitted intraoperatively to cardiac anesthesia for myocardial revascularization, were examined prospectively. With the use of transesophageal echocardiography (TEE) and different dicrotic arterial pressures, we determined the ventricle elastance (Ees), the arterial elastance (Ea) and myocardial efficiency before and after administration of a slow-bolus of remifentanil (1 micro kg(-1)). RESULTS: Remifentanil decreases significantly the ventricular elastance (from 6.09 mmHg ml-1 m(-2) to 4.88) (P < 0.05), with a less, but however, significant decrease of arterial elastance (from 3.68 mmHg ml(-1) m(-2) to 3.13) (P < 0.05). Despite causing simultaneous declines, maintains a good myocardial efficiency (0.64-0.68) with no significant difference. CONCLUSION: Although remifentanil depresses ventricular and arterial elastance, preserves a good left ventricular-arterial coupling and mechanical efficiency, despite a little increase of coupling. However, these effects are maintained only during a slow intravenous infusion and are dose-dependent with impairment of coupling, that may contribute to decline in overall cardiovascular performance, at higher anesthetic dose and rapid infusion in patients with a severe myocardial dysfunction.

Role of short latency evoked potentials in the diagnosis of brain death.

OBJECTIVE: The aim of this study is to confirm the effectiveness of auditory brain-stem responses (ABRs) and somatosensory evoked potentials (SEPs) in the diagnosis of brain death (BD). METHODS: ABRs and SEPs were recorded at the same session in 130 BD patients (age range 8-77 years, 81 male and 49 female). Twenty-four cases were submitted to serial recordings from preterminal conditions through BD. RESULTS: ABRs were absent in 92 cases (70.8%), only waves I or I-II were present in 32 cases (24.6%), while in the remaining 6 patients (4.6%) waves V and/or III were still present, excluding the death of the brain-stem. In 4 cases (3.1%) SEPs showed the absence of all components following the cervical N9, preventing the diagnosis of BD. Among 126 cases (96.9%) with preserved cervical N9-N13 SEPs confirmed the absence of brain-stem activity in 122 cases (93.7%), in whom no waves following P11 or P13 were recordable. SEPs excluded the diagnosis of BD in the remaining 4 cases (3.2%) showing preserved P14 and/or N18. In all pre terminal patients the far-field P14-N18 were present, and their disappearance was closely related to the onset of BD. CONCLUSIONS: The combined us of ABRs and SEPs was able to confirm BD in almost all patients, providing an objective confirmation of the diagnosis, and to exclude it in 7 cases, thus improving the reliability of diagnosis.

Quality control of sedation for diagnostic radiological procedures in paediatric patients (waiting for guidelines).

BACKGROUND: The number of children requiring sedation for radiological procedures is increasing. Anaesthesiologists are increasingly involved in giving sedation or general anaesthesia in the rooms of the Radiology Department. This activity is not easy, and can be dangerous. The procedure is often performed on an ambulatory basis, so the child must be alert and discharged rapidly after the procedure. METHODS: We reviewed the medical charts of 488 patients in order to evaluate the incidence of complications during deep sedation for diagnostic radiological procedures. The patients were sedated with intravenous thiopental or propofol, or with oral chloral hydrate. All the patients were breathing spontaneously and received only supplemental O(2). RESULTS: We found only a few cases of complications, immediately treated without any recourse to tracheal intubation: respiratory failure with arterial desaturation to 94%, regurgitation, vomiting and persistent cough. CONCLUSIONS: On the basis of our experience, we believe that deep sedation with endovenous drugs guarantees safety and rapid discharge after the procedure.

[Prognostic systems in intensive care: TRISS, SAPS II, APACHE III]. / Scale prognostiche in terapia intensiva: TRISS, SAPS II, APACHE III.

BACKGROUND: To validate the accuracy of SAPS II, APACHE III and TRISS for the prediction of mortality in Intensive Care Unit (ICU) at polytrauma patients admission. The outcome of multiple trauma patients is often linked to the degree of physiologic dysfunction and to the extension of anatomic lesions, the age of the patient and the lesion mechanism. METHODS: The study population consisted of 93 cases of multiple injured patients hospitalised at the ICU of the Padua hospital from October 1998 to October 1999; the term polytraumatized patient is referred to patients who have multiple lesions of which at least one potentially endangers, immediately or in a short term, their life. These cases were evaluated with the APACHE III, SAPS II, Revised Trauma Score and Injury Severity Score. The predictive power of each system was evaluated by using decision matrix analysis to compare observed and predicted outcome with a decision criterion of 0.50 and 0.40 for risk of hospital death. RESULTS: All trauma score systems under study showed high accuracy rates, above all if they are used with a 40% positive test. CONCLUSIONS: The prognostic scales used in this study showed a good correlation between expected and observed cases, particularly with TRISS and APACHE III systems. The APACHE III system seems to be the most reliable of the different methods analysed. These prognostic systems are seldom or occasionally used in the ICU, in Padua and in the whole of Italy, so Italian data are not suitable to be compared to international ones. Due to urgency, the importance of the evaluation scales is often underestimated, but even if they require time and attention, they surely can be useful in the evaluation of the treatment, and not only of a polytraumatized patient.

Deaths with acute cerebral lesion and heart-beating potential organ donors in the Veneto region.

BACKGROUND: The study was aimed at describing the clinical characteristics of dead patients with acute cerebral lesion and analyzing reasons of the shortage of heart-beating potential organ donors in the Intensive Care Units (ICUs) in the Veneto Region. METHODS: Data have been prospectively recorded in 23 ICUs over six months for deceased patients with acute cerebral lesion (clinical data, death diagnosis) and for any potential organ donor (medical suitability, family interview, organ retrieval). RESULTS: In the ICUs of the Veneto Region in 1998 deceased patients with acute cerebral lesion were 187 per million population (p.m.p.); 317 cases have been studied. Median age was 64 years (range 7-93). Heart-beating death was legally confirmed only in 98/317 cases (31%) against a clinical diagnosis of brain death in 203/317 (64%). Only 82/317 (26%) were considered eligible donors and 48/317 (15%) became real donors (22.8 p.m.p.). Among the remaining 235 cadavers, 105 were over 70 years old. In the group of 130 under 70 years absolute contraindications were present only in 30 and problematical clinical situations were reported in 100. CONCLUSIONS: The number of deaths with acute cerebral lesion represents a sensible index and a key factor for evaluating the potential organ donor pool in small regions and in the single intensive care unit. Collected data demonstrate that in the Veneto Region the efficiency of solid organ retrieval can be improved and that organ donor shortage may depend, beyond family refusal, on clinical and cultural factors that hamper stabilized heart-beating deaths. Most potential donors with age over 70 or problematical clinical situations are preventively excluded by ICUs physicians. To improve organ donation all the patients who die in spite of neuro-intensive treatment should be prevented from circulatory arrest to permit legal declaration of death. Thus more potential organ donors without absolute contraindications could be recovered and time would exist for discussing any problematical situation with experts in organ procurement, particularly in respect to existing urgencies in the waiting list.

Propofol 1% and propofol 2% are equally effective and well tolerated during anaesthesia of patients undergoing elective craniotomy for neurosurgical procedures.

BACKGROUND: The 2% formulation of the intravenous anaesthetic agent, propofol (Diprivan), delivers half the amount of lipid compared with the original 1% formulation. This may provide an acceptable alternative for patients who have an impaired ability to metabolise lipids. METHODS: This study was a multicentre, randomised, open comparison of parallel groups. Seventy-three adult patients undergoing elective craniotomy in neurosurgery were randomised to receive either propofol 1% (10 mg/ml) or propofol 2% (20 mg/ml) for induction and maintenance of anaesthesia. RESULTS: Analysis of induction time (199 s, 1%; 202 s, 2%; p > 0.05) and induction dose (1.13 mg/kg, 1.12 mg/kg; p > 0.05) shows that propofol 1% and propofol 2% are pharmacodynamically equivalent. Both formulations were similar regarding overall administration rates, recovery times, haemodynamic variables and tolerability. Plasma triglyceride levels, were lower in the propofol 2% group compared with the propofol 1% group, and significantly lower (p < 0.05) from 1 to 4 hours after induction. CONCLUSIONS: We conclude that propofol 2% is as effective and as well-tolerated as propofol 1% for anaesthesia and is an acceptable alternative to propofol 1% in patients undergoing elective craniotomy in neurosurgery. The lower lipid load suggests it may be of particular benefit to patients with disorders of lipid metabolism.

Assessment of brain perfusion in coma and comparison between SPECT and CT scan data: preliminary report.

In this study we submitted 24 comatose patients (Glasgow Coma Score <8) to Single Photon Emission Tomography (SPECT) during the clinical course of coma to verify its utility and the relationship between SPECT and CT scan data. SPECT was recorded following i.v. injection of Xe-133 in 17 patients and of Tc-99m-HMPAO or Tc-99m-ECD in the remaining 7. SPECT data recorded during the acute phase of coma did not show a clear correlation between cerebral blood flow (CBF) and outcome. SPECT and CT scan detected abnormalities in the same areas in 6 cases (25%); 6 patients (25%) with focal CT-scan lesions showed no focal CBF alterations in the same regions; conversely, in the remaining 12 cases (50%) SPECT disclosed severe perfusion abnormalities where no lesions were detectable on CT-scan. SPECT allowed us to recognize different regional flow patterns, such as absolute or relative hyperemia or oligoemia, which could not be checked with other means, thus improving patient's management. Apart from cerebral ischemia, there was no relationship between lesions on CT-scan and flow pattern. Our preliminary results suggest that SPECT can improve both the knowledge of patient's neurological conditions and management in comparison to the use of only CT scan.

Auditory and somatosensory evoked potentials in coma following spontaneous cerebral hemorrhage: early prognosis and outcome.

The aim of this study was to check the prognostic power of auditory brain-stem responses (ABRs) and somatosensory evoked potentials (SEPs) in coma following spontaneous cerebral hemorrhage. Seventy patients comatose following subarachnoidal or hypertensive hemorrhage were submitted to ABR and SEP recordings during the acute phase of clinical course. Twenty-one patients survived (30%), two remained vegetative (2.9%) and 47 died (68.1%). The Glasgow Coma Score (GCS) was significantly related to the outcome (P < 0.001), but showed a low sensitivity, since about 50% of patients with GCS = 5-8 died or remained vegetative. ABRs and SEPs showed a much closer correlation with outcome (P < 0.001): their combined use allowed there to be a sensitivity of 96%, a specificity of 90% and a predictive power of 96%; the relative risk of poor outcome in patients with at least one abnormal modality was equal to 223 times the one for patients with normal evoked potentials. Moreover, in surviving patients a significant relationship appeared to exist between abnormalities of SEPs during the acute phase and the severity of disability. Our results confirm the prognostic effectiveness of short latency evoked potentials in cerebral hemorrhage: they are far superior to clinical data, being able to yield a marked decrease of falsely optimistic predictions.

Spinal anesthesia in outpatient knee surgery: 22-gauge versus 25-gauge Sprotte needle.

Spinal anesthesia in day-care surgery is still controversial because of the possibility of postdural puncture headache (PDPH). The use of the Sprotte needle with a conical tip that spreads the dural fibers may reduce the incidence of PDPH. The aim of this study was to compare the 22-gauge and 25-gauge Sprotte needles with respect to PDPH and postoperative complaints in out-patients undergoing arthroscopy. The rate of spinal anesthesia failure and the feasibility of unilateral spinal anesthesia when using a low dose of anesthesia was also verified. For this randomized, prospective study, 234 patients undergoing elective arthroscopy were chosen. Patients were allocated randomly to have spinal anesthesia with either a 22-gauge or 25-gauge Sprotte needle. Dural puncture was performed with the patient in a lateral flexed decubitus position. After the injection of anesthetic solution (0.5-1.2 mL of 1% bupivacaine in 8% glucose) patients remained in the lateral decubitus position for 30 min. The time to regression of analgesia, time of micturition, and all postoperative complaints were recorded. The most frequent side effect was backache (10.2%) with a more frequent incidence in the group using the 22-gauge needle (14.5% and 5.9%, respectively). PDPH was recorded in only one patient (0.8%) in the group using the 22-gauge needle. The failure rate was 0.8%. Unilateral anesthesia was achieved in 88% of 213 patients. Our data indicate that the use of spinal block is a suitable technique in the ambulatory setting, with a low rate of unplanned hospital admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Propofol-fentanyl versus isoflurane-fentanyl anesthesia for coronary artery bypass grafting: effect on myocardial contractility and peripheral hemodynamics.

To avoid intraoperative awareness and postoperative respiratory depression from high-dose opioid anesthesia, propofol (P), or isoflurane (I) has been combined with moderate-dose opioid with varying results. However, the effects of both P and I on myocardial contractility and left ventricular afterload have not been completely quantified. The end-systolic pressure-diameter relationship (ESPDR) of the left ventricle (LV) is a reliable method to quantitatively assess LV contractility because it is relatively independent of changes in preload and incorporates afterload changes. The purpose of this study was to quantify the cardiodynamic effects of propofol-fentanyl (PF) anesthesia in comparison with isoflurane-fentanyl (IF) anesthesia in patients undergoing coronary artery bypass grafting (CABG). Thirty patients with normal or moderately impaired LV function (ejection fraction > or = 40% with LV end-diastolic pressure < or = 18 mmHg, no preoperative akinesia or dyskinesia) undergoing elective CABG were studied. After premedication with flunitrazepam, 2 mg orally, all patients were induced with thiopental, 1 mg/kg, fentanyl, 20 micrograms/kg, and vecuronium, 0.1 mg/kg, and were ventilated with oxygen/air (F(1)O2 0.6). Anesthesia was maintained throughout the procedure with a zero-order intravenous (IV) continuous infusion of P, 3 mg/kg/h (PF group), or with isoflurane inhalation of 0.6% (IF group), supplemented by intermittent boluses (5 micrograms/kg) of fentanyl (up to a total maintenance dose of 30 micrograms/kg). After intubation, a cross-section of the LV was visualized by two-dimensional transesophageal echocardiography and an m-mode echocardiogram was obtained at the maximum anterior-posterior diameter. The radial artery pressure tracing and the ECG were simultaneously recorded with the M mode.(ABSTRACT TRUNCATED AT 250 WORDS)

Multimodality evoked potentials (auditory, somatosensory and motor) in coma.

Auditory brainstem responses (ABRs) have proved to be significantly related to outcome, both in severe head injury and brain hemorrhage. Nevertheless, the usefulness of ABR is limited by the anatomic extent of the investigated pathways. The combined use of ABRs and somatosensory evoked potentials (SEPs) improves the outcome prediction in comparison to the use of only one modality. It mainly decreases the rate of false negatives, since patients with severe hemispheric damage sparing the brain stem may have a poor outcome despite normal ABRs. The use of motor evoked potentials (MEPs) from magnetic transcranial stimulation is also significantly related to outcome: it appears to be far superior to the clinical evaluation of motor responses, while the combined use of MEPs and SEPs gives a new opportunity of checking sensorimotor dysfunction. ABRs and SEPs may also be useful tools in the confirmation of brain death, the kernel of which is the assessment of brainstem death: they allow to check lemniscal pathways, which cannot be properly evaluated by clinical examination, and provide an objective confirmation of absence of brain stem activity.

EEG monitoring of carotid endarterectomy with routine patch-graft angioplasty: an experience in a large series.

Four hundred and thirty-nine carotid endarterectomies (CEAs) with routine use of patchgraft angioplasty were performed in 375 patients; the indwelling shunt was used only in patients showing clamp-related EEG abnormalities. Five patients showed EEG abnormalities just after head positioning, which reversed after removal of head hyperextension; three cases suffered EEG flattening due to severe bradycardia or cardiac arrest before carotid clamping, which promptly reversed after treatment. Clamp-related EEG abnormalities appeared in 106 operations (24.2%) and all reversed after the insertion of the indwelling shunt; patients with occlusion of the contralateral internal carotid artery showed a 68.8% rate of EEG clamp-related changes. The short term follow-up (one month after the operation) showed six minor strokes with complete recovery (1.37%), one intraoperative stroke (0.23%), three delayed major strokes (0.69%) and three neurological deaths (0.69%). The long-term follow-up over an average of 42 months showed a 3.7% rate of relevant neurological complications (ie permanent deficits + death) and a 3.16% rate significant restenosis or occlusion of the operated carotid artery. Our results show that the routine use of EEG monitoring and patch-graft angioplasty allow to perform CEAs with a very high degree of safety, improving the clinical course of the disease.