Loco-regional thrombolysis in the treatment of cerebral venous and sinus thrombosis: report of two cases.

Although intravenous (i.v.) heparin is widely used as the first line treatment for cerebral venous and sinus thrombosis (CVST), the most appropriate therapy for this disease is still controversial. We report 2 cases of CVST who were successfully treated by means of loco-regional thrombolysis with urokinase. In the first case we chose this treatment instead of i.v. heparin because clinical conditions of the patient appeared critical for life on hospital admission; in the second case loco-regional thrombolysis was performed because a full-dose heparin treatment over 8 days failed to improve the clinical picture of the patient. In the literature, there are no established criteria for the use of loco-regional thrombolysis in CVST. On the basis of our own experience and few previous reports on the matter, we suggest that loco-regional thrombolysis should be considered an appropriate treatment for CVST when patients are at life risk, when an involvement of deep cerebral veins is present or when, after full heparinization, patients are doing poorly clinically.

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.

A prospective, randomized clinical comparison of sevoflurane and halothane in children.

BACKGROUND: The goal of the present multicenter investigation was to compare in a prospective and randomized study the induction, the maintenance and the recovery characteristics of halothane and sevoflurane when used in paediatric patients. METHODS: With the approval of the Ethical Committee and the parental written informed consent, 64 children aged 3-12 years, receiving general anaesthesia for urological, abdominal, and orthopaedic surgery, were studied. After oral flunitrazepam (0.05 mg kg-1), general anaesthesia was randomly induced by either sevoflurane (start: 1%, maximum: 7%, n = 32) or halothane (start: 0.5%, maximum: 4.5%, n = 32) and a 60% N2O in oxygen mixture until the loss of eyelash reflex (induction time). Then the trachea was intubated (if necessary, a muscle relaxant was administrated), and the concentrations of the anaesthetic vapours were adjusted in order to maintain cardiovascular stability until the end of surgery. The following times were recorded: time of extubation, time for having purposeful movements, time of eyes opening and readiness for discharge from the recovery area, as well as the occurrence of untoward events during either induction of, maintenance of, or recovery from anaesthesia. Before surgery and 24 hr after the procedure, blood was collected in order to measure serum creatinine and BUN. RESULTS: No differences in induction time, extubation time, side effects and postoperative renal function were observed between the two groups. Four patients in each group received muscle relaxants to perform intubation (p = NS). When compared to halothane group, children receiving sevoflurane had shorter times of showing purposeful movements (median: 9 min versus 15.5 min, p < 0.005), emergence from anaesthesia (median: 12 min versus 18 min, p < 0.05) and achieving readiness to be discharged (median: 18 min. versus 30 min, p < 0.005). Sevoflurane group also showed a more stable heart rate during the induction period than halothane one (p = 0.05). DISCUSSION: Sevoflurane is as effective as halothane in providing smooth and rapid induction of anaesthesia, while recovery is considerably faster and haemodynamic tolerance is better if compared to halothane; this suggests that sevoflurane could be an useful substitute for halothane in pediatric patients.

Impact of positive end-expiratory pressure on chest wall and lung pressure-volume curve in acute respiratory failure.

To investigate whether chest-wall mechanics could affect the total respiratory system pressure-volume (P-V) curve in patients with acute respiratory failure (ARF), and particularly the lower inflection point (LIP) of the curve, we drew the total respiratory system, lung, and chest-wall P-V curves (P-Vrs, P-VL, and P-VW, respectively) for 13 patients with ARF, using the supersyringe method together with the esophageal balloon technique. Measurements were randomly repeated at four different levels of positive end-expiratory pressure (PEEP) (0, 5, 10, 15 cm H2O) and from each P-V curve we derived starting compliance (Cstart), inflation compliance (Cinf), and end compliance (Cend). With PEEP of 0 cm H2O (ZEEP), an LIP on the P-Vrs curve was observed in all patients (7.5 +/- 3.9 cm H2O); in two patients an LIP was detected only on the P-VL curve (8.6 and 8.7 cm H2O, respectively); whereas in seven patients an LIP was observed only on the P-VW curve (3.4 +/- 1.1 cm H2O). In four patients, an LIP was detected on both the P-VL and P-VW curves (8.5 +/- 3.4 and 2.2 +/- 1.0 cm H2O, respectively). The LIP was abolished by PEEP, suggesting that a volume-related mechanism was responsible for the observed LIP on both the P-VL and P-VW curves. At high levels of PEEP, an upper inflection point (UIP) appeared on the P-Vrs and P-VL curves (11.7 +/- 4.9 cm H2O and 8.9 +/- 4.2 cm H2O above PEEP, respectively) suggesting alveolar overdistension. In general, PaO2 increased with PEEP (from 81.7 +/- 35.5 mm Hg on ZEEP to 120 +/- 43.8 mm Hg on PEEP 15 cm H2O, p < 0.002); however, the increase in PaO2 with PEEP was significant only in patients with an LIP on the P-VL curve (from 70.5 +/- 16.2 mm Hg to 117.5 +/- 50.7 mm Hg, p < 0.002), the changes in PaO2 in patients without an LIP on the P-VL curve not being significant (from 91.3 +/- 45.4 mm Hg to 122.2 +/- 41.1 mm Hg). We conclude that in ventilator-dependent patients with ARF: (1) the chest-wall mechanics can contribute to the LIP observed on the P-Vrs curve; (2) the improvement in PaO2 with PEEP is significant only in patients in whom LIP is on the lung P-V curve and not on the chest wall curve; (3) high levels of PEEP may overdistend the lung, as reflected by the appearance of a UIP; (4) measurement of P-Vrs alone may be misleading as a guide for setting the level of PEEP in some mechanically ventilated patients, at least in the supine position, although it helps to prevent excessive alveolar overdistension by indicating the inflection volume above which UIP may appear.

[Assessment of various new predictive parameters of the outcome of mechanical ventilation weaning]. / Valutazione di alcuni nuovi parametri predittivi dell'esito dello svezzamento dalla ventilazione meccanica.

OBJECTIVE: To evaluate new indexes predicting weaning outcome from mechanical ventilation. EXPERIMENTAL DESIGN: Prospective study with two main end-points: a comparison of weaning indexes between successful and unsuccessful groups and an evaluation of their predicting value. ENVIRONMENT: Surgical-Medical Intensive Care Unit. PATIENTS: Patients ventilated for more than 72 hours and subjected to a weaning trial until spontaneous ventilation. MEASUREMENTS: Traditional weaning parameters [respiratory rate (fsb), expiratory minute volume (Vesb), Maximal Inspiratory Pressure (MIP)] along with the new indexes [fsb/Vtsb) (rate to tidal volume ratio), CROP index (Compliance Rate Oxygenation Pressure), P0.1/MIP, IEQ (Inspiratory Effort Quotient), WI (Weaning Index)] were measured before discontinuation of ventilation support. RESULTS: A statistically significant difference was observed between successful and unsuccessful groups for the following parameters: fsb, MIP, fsb/.Vtsb, CROP, Po.1/MIP and WI while no differences were observed for Vesb and IEQ. The sensitivity and specificity for the new indexes were respectively: fsb/Vtsb: 0.65 and 0.58; CROP: 0.70 and 0.63; P0.1/MIP: 0.85 and 0.36; WI: 0.69 and 0.47. CONCLUSION: A statistically significant difference between successful and unsuccessful groups was observed for some but not all new indexes; the diagnostic accuracy of the new indexes were no better than additional parameters.

Trauma care in Italy: evidence of in-hospital preventable deaths.

The quality of a trauma system can be assessed by the rate of preventable deaths. A random selected sample of 110 trauma patients was examined using both clinical and autopsy data. The assessors were asked the following question: If this patient had sustained the accident in front of the hospital in a normal working day, might death have been prevented? Death was found to be unavoidable in 61 cases, in 25 cases death was classified potentially preventable; 11 cases were classified as clearly preventable death. The main failures of treatment were identified as errors and delays during the first phases of in-hospital assessment and care. An improvement in the pre-hospital phase will be almost useless if the quality of the definitive in-hospital management is not addressed.

Cerebral venous oxygen saturation studied with bilateral samples in the internal jugular veins.

The current literature reports many measurements (arteriovenous oxygen content difference and cerebral metabolic rate of oxygen, etc.) with samples from the internal jugular veins (IJs), obtained from either side of the neck, based on the assumption that a reliable sample of mixed venous blood can be drawn. We compared oxygen saturation in both IJs in 32 patients with head injuries to establish the similarities or discrepancies in the two veins. Both IJs were cannulated with 20-G catheters; in five patients, a fiberoptic catheter was used to obtain a continuous recording of the hemoglobin saturation. Blood samples were taken simultaneously from the two IJs and immediately processed; the total number of samples processed was 342, with an average of 5.34 paired samples from each patient. The mean and the standard deviation of the differences between the saturation of the two IJs were, respectively, 5.32 and 5.15. Fifteen patients showed differences greater than 15% in hemoglobin saturation; three more patients showed differences greater than 10% at some point during the investigation. Ultimately, only eight patients had differences of less than 5%. No relationship was found among the computed tomographic scan data and the pattern of hemoglobin saturation detected. Therefore, we were not able to identify the side more appropriate for monitoring in patients with bilateral, predominantly monolateral, cortical, or deeply located lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical use of cerebral elastance and intracranial dynamics measurements]. / Impiego clinico delle misure di elastanza cerebrale e di dinamica intracranica.

The treatment of Intracranial Pressure (ICP) requires not only the determination of the pressure but also some kind of estimate of the relationship between intracranial volume and actual pressure. The measurement of the Pressure Volume Index (PVI) offers a quantitative assessment of such a relationship, provided that the measurement is safe and accurate. In 98 comatose patients admitted to the Intensive Care Unit for the treatment of head injury or subarachnoid hemorrhage the ICP was continuously recorded using ventricular or subdural catheters. In 68 patients the PVI was measured using the bolus technique every 12 hours; the intracranial dynamics was assessed according to Marmarou's equations. The preliminary part of the work reviewed the methodology: the interobserver variability was studied and the differences between the PVI data obtained through addition or withdrawal of fluid were determined. The data obtained by different observers did not differ substantially, due to the clear establishment of rules for the measurement. The PVI data obtained withdrawing fluid were lower than the data produced adding volume but the mean PVI calculated after 6 bolus changes of the intraventricular volume reached a good correlation coefficient (> 0.8) with all the measurements. After that the clinical use of the PVI was tested. The patients with a PVI lower than 15 ml showed an increased risk of developing intracranial hypertension in the first 72 hours after trauma of SAH. The group of patients with an intracranial compliance lower than 0.5 had a mortality rate of 27.3%, compared with the rate of 14.3% showed by the patients with a greater Compliance.(ABSTRACT TRUNCATED AT 250 WORDS)

Azlocillin versus azlocillin plus amikacin in the treatment of severe infections in intensive care unit patients.

The authors wanted to verify if in clinical practice (Intensive Care Unit patients), the association of azlocillin with an aminoglycoside offers substantial advantages compared to use of azlocillin alone. Their results show that azlocillin alone is potent enough to be used in the treatment of severe infections.

[Anesthesiologic management in scleroderma patients. Presentation of a clinical case]. / Condotta anestesiologica nel paziente sclerodermico. Presentazione di un caso clinico.

The scleroderma (literally, hard skin), or progressive systemic sclerosis (PSS), is a multisystem disease and can present various anaesthetic problems. The anaesthesist should be aware of the difficulty in opening mouth wide enough for laryngoscopy and intubation, the possibility that cardiopulmonary changes may be present and the probability of lesions in oesophagus, bowel, kidneys, skin and joints. In this article the authors describe the anesthetic management of a patient with Thibierge-Weissenbach syndrome (scleroderma with calcinosis cutis) and explore potential problems that should be anticipated by the anesthesiologist.

[The technic of sub-vigil anesthesia in plastic-reconstructive surgery]. / La tecnica di anestesia sub-vigile in chirurgia plastico-ricostruttiva.

The personal experience in plastic-reconstructive surgery with 395 cases of sub-vigil anaesthesia (neuroleptanalgesia + benzodiazepine in 124 patients (group A); ketamine + benzodiazepine in 138 patients (group B); neuroleptanalgesia + ketamine + benzodiazepine in 133 patients (group C) is described by the authors in the present study. They conclude that the sub-vigil anaesthesia is usually free from complications and a very safe, tolerable, expedient technique for plastic surgical procedures; furthermore, the result is good patient acceptance, a stable blood pressure and heart rate.