Wound levobupivacaine continuous infusion for postoperative analgesia in living kidney donors: case-control study.

INTRODUCTION: The objective of this study was to evaluate the efficacy of an analgesic regimen based on levobupivacaine continuous infusion into the surgical wound of living kidney donors (LKDs). PATIENTS AND METHODS: Fifty adult LKDs (mean age, 53.1 +/- 5.3 years; age range, 52-68 years) were retrospectively assigned to a no wound infusion (NWI) group (n = 25) or a wound infusion (WI) group (n = 25). At the end of surgery, patients in the WI group received 10 mg intramuscular morphine; a peridural catheter was placed 10 cm between the intercostal muscles fibers close to the lower rib extremity, and a solution of levobupivacaine, 150 mg/100 mL, was started at 5 ml/h(-1). Patients in the NWI group received intramuscular morphine, 10 mg, every 8 hours; intravenous tramadole, 100 mg, was planned as a rescue drug for incidental pain. Pain was measured using a visual analog scale (VAS) ranging from 1 (no pain) to 10 (maximum pain) in both the basal condition (VASb) and during coughing (VASc) at 1 hour after leaving the operating room and 6, 12, and 24 hours thereafter. RESULTS: At 1, 6, 12, and 24 hours, VASb values in the NWI vs the WI group were 5.2 vs 3.1, 6.8 vs 4.1, 5.8 vs 4.9 (all p < .01), and 5.4 vs 5.1, respectively, and VASc values were 8.2 vs 6.3, 8.8 vs 5.9, 7.1 vs 5.3, and 6.8 vs 5.1 (all p < .01). Mean VAS score was significantly higher between 1 and 6 hours in the NWI group for all VASb measurements vs VASc values. Tramadole consumption was higher in the NWI group than in the WI group. CONCLUSIONS: Continuous wound infusion with 5 mL/h(-1) levobupivacaine, 1.5 mg/mL(-1), resulted in a safe and effective analgesic protocol in LKDs both in the immediate postoperative period and in the first day after surgery, a result that was more effective than a morphine-tramadole regimen. No adverse effects were recorded, which confirmed the safety of the technique. It is probable that better results could be achieved with dedicated administration devices.

Fenoldopam vs dopamine as a nephroprotective strategy during living donor kidney transplantation: preliminary data.

UNLABELLED: Fenoldopam is a selective DA1 agonist with potential nephroprotective capabilities. The aim of this study was to compare the nephroprotective effect of fenoldopam and dopamine during general anesthesia for living donor kidney transplantation. METHODS: Forty donors enrolled in the study received a similar anesthetic and fluid protocol. The patients were randomly divided into group F (receiving 0.1 mg*kg-1*min-1 fenoldopam) versus group D (receiving "renal dose" 3 mg*kg-1*min-1 dopamine). The mean volume of infused fluids, diuresis, and urinary electrolytes (Na, K, Cl) at infusion start and 120 minutes later were studied. RESULTS: Anthropometric parameters, administered anesthetics, mean infused volume, and urine outputs, did not show significant differences between the groups. Statistically significant differences were observed for urinary excretion of sodium, potassium, and chloride after 120 minutes of continuous fenoldopam infusion, with significant variations within groups for sodium only. CONCLUSIONS: Fenoldopam compared with dopamine resulted in better nephroprotective effects. No adverse events were recorded, and side effects were minimal. Further studies are necessary to evaluate these data.

Monolateral dual kidney transplantation from marginal donors.

BACKGROUND: Dual kidney transplantation (DKT) offers a safe way to face the organ shortage with good short-term and medium-term renal function. However, its application is limited by the longer operating time and the risk of surgical complication. This study reviews our results with DKT performed with an ipsilateral technique in terms of graft loss, graft and patient survival rates, and surgical complications. PATIENTS AND METHODS: From January 2002 to March 2006, 23 patients underwent DKT through a monolateral Gibson incision with placement of both kidneys. RESULTS: One primary nonfunction occurred (4%). Delayed graft function was observed in 3 DKT (13.3%). Acute rejection rate was 4.3% (1 patient). All patients are alive at a mean follow-up of 28 months. One-year and 2-year graft survival rates were 100% and 96%, respectively. Mean serum creatinine level at 1-year posttransplantation was 1.3 mg/dL (range, 0.8-2.1 mg/dL). One DKG recipient lost 1 graft, retaining the second normal functioning graft due to ureteral necrosis. The mean hospital stay after transplantation was 15 days (range, 12-34 days). CONCLUSIONS: Monolateral placement in DKT offers the advantage of a single incision, minimizing the surgical risk. Tailored immunosuppression and careful selection of potential recipients, by excluding those with severe cardiopulmonary pathologies, could significantly improve both patient and graft survival in this group of patients.

Voriconazole in the treatment of invasive aspergillosis in kidney transplant recipients.

BACKGROUND: Aspergillosis and other invasive mold infections are severe complications in immunosuppressed patients, and in renal transplant patients it is the most common cause of systemic fungal disease with an incidence ranging from 0.4% to 2.4% with a high mortality of 56% to 100%. We present our experience with voriconazole in a population of kidney transplant recipients with invasive aspergillosis. PATIENTS AND METHODS: From January 2002 to December 2005, 245 kidney transplantations were performed. RESULTS: Four patients (1.6%) presented with clinical and laboratory findings of invasive aspergillosis. Three patients presented with pulmonary aspergillosis, while one patient presented with pulmonary and ocular aspergillosis. All patients underwent a therapy with voriconazole 200 mg twice a day, in combination with caspofungin in one patient. All patients are alive, with no clinical recurrence of aspergillosis at a median follow-up of 13 months. One patient lost her graft due to discontinuation of immunosuppression. CONCLUSIONS: Voriconazole is a potent and well-tolerated antifungal drug that is extremely efficacious in the treatment of invasive aspergillosis in kidney transplant recipients. A careful monitoring of immunosuppressive drugs should be considered to avoid nephrotoxicity.

First Report of Bacterial Stem Rot Caused by Pectobacterium carotovorum subsp. carotovorum and P. carotovorum subsp. atrosepticum on Grafted Eggplant in Italy.

In December 1999, widespread dieback of eggplant (Solanum melongena L., hybrid Mission Bell), grafted onto the interspecific hybrid Beaufort (Lycopersicon esculentum × Lycopersicon hirsutum) and on tomato hybrid Energy, was observed during four rootstock evaluation trials in greenhouses in Sicily, Italy. Dark brown to black, firm but sometimes fissured lesions, 1 to 20 cm long, were observed just above the grafting point. Water-soaked, soft, dark green lesions that turned brown with age were observed on the upper stem. Extensive discoloration of vascular tissues and, in some cases, breakdown of the pith and stem hollowness occurred. Eggplant seedlings, present in the same experimental trials, did not show any symptoms. From symptomatic tissues, numerous bacterial colonies were obtained on nutrient dextrose agar. Bacteria from purified colonies were gram-negative, oxidase-negative, facultatively anaerobic pectolitic on crystal violet pectate agar, which is nonfluorescent on King's B medium. On the basis of biochemical and physiological tests (1), seven of 10 isolates were identified as Pectobacterium carotovorum subsp. carotovorum (Jones 1901) Hauben et al. 1999, comb. nov. (2), and the remaining three were identified as P. carotovorum subsp. atrosepticum (van Hall 1902) Hauben et al. 1999, comb. nov. (2). Four days after prick inoculation of the stems of eggplant and tomato plants, all isolates caused extensive collapse of stems and internal brown discoloration and hollowness, respectively. In a second pathogenicity test, basil leaves of grafted eggplants and eggplant seedlings were either removed or left intact. These plants were then sprayed with bacterial suspensions (108 CFU/ml) of one isolate of each pathogen. Plants were held at 100% relative humidity or in a low-moisture incubator. After 6 days incubation, stem lesions and vascular discoloration, typical of symptoms observed in greenhouses, were observed on plants held at 100% relative humidity. No symptoms were observed in unwounded plants or plants maintained in low relative humidity. Similar symptoms on grafted eggplant have been attributed to physiological disorders (3). To our knowledge, only P. carotovorum subsp. carotovorum has been reported on eggplant as causing fruit rot. References: (1) N. W. Schaad, ed. 1988. Laboratory Guide for Identification of Plant Pathogenic Bacteria, 2nd ed. American Phytopathological Society, St. Paul, MN. (2) L. Hauben et al. Int. J. Syst. Bacteriol. 41:582, 1999. (3) G. Ginoux and H. Laterrot. Rev. Horticole (Paris) 321:49, 1991.

Decreasing the cost of trauma care: a system of secondary inhospital triage.

The financial realities of the current health care arena make it imperative that deliverers of trauma care initiate programs that reduce the cost of trauma. Triage can be one process that attempts to attain this goal. Once patients are assigned to a Level I trauma center, it is possible to triage patients again to complement field triage. A two-tiered, inhospital trauma response system was developed in which different team responses are initiated depending on the patient status. This tiered, in-house response system differs with respect to human and material resources. Personnel, operating room, laboratory work, and protective wear savings account for approximately $1,042 per code patient, yielding an annual $629,404 institutional savings.

Trauma nurse coordinator: three unique roles.

Three nursing positions were created to effectively manage the Trauma Nurse Coordinator (TNC) role and responsibilities: Trauma Director, Clinical Nurse Specialist and Trauma Researcher. By using this innovative approach, the quality of trauma care improved as shown by decreased complication rates, lengths of stay, and trauma costs. In addition, trauma referrals, research and education increased.