Brain metastases: surgical versus conservative treatment.

A comparative study on surgical versus conservative brain metastases treatment has been carried out. Patients have been divided in seven groups by means of treatment modalities. Follow-up, has been carried out taking into consideration mean survival time and quality life in particular, evaluated by means of Order's classes. Anaesthesiological management problems were discussed also. From data analysis, it follows that untreated patients, (group 1) had a lower mean survival time than that of the other patients. Thirty days after first evaluation, 85% of these patients had a very poor quality life. Patients who underwent surgery associated to radio and chemotherapy (group 2) have had better recovery of functional autonomy and longest mean survival time. Among these, thirty days after treatment only 3% had a very poor quality life, while 67% had the better quality life. Patients who underwent others treatment modalities had intermediate results.

Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study.

BACKGROUND AND OBJECTIVES: The aim of this prospective, observational study was to evaluate changes in regional cerebral oxygen saturation (rSO2) and incidence of intraoperative cerebral desaturation in a cohort of elderly patients undergoing major abdominal surgery. METHODS: rSO2 was continuously monitored on the left and right sides of the forehead in 60 patients older than 65 yr (35 males and 25 females; ASA II-III; age: 72 +/- 5 yr; without pre-existing cerebral pathology, and baseline Mini Mental State Examination (MMSE) score >23) undergoing sevoflurane anaesthesia for major abdominal, non-vascular surgery >2 h. RESULTS: Baseline rSO2 was 63 +/- 8%; cerebral desaturation (rSO2 decrease <75% of baseline or <80% in case of baseline rSO2 <50%) occurred in 16 patients (26%). The MMSE decreased from 28 +/- 1 before surgery to 27 +/- 2 on 7th postoperative day (P = 0.05). A decline in cognitive function (decrease in MMSE score > or = 2 points one week after surgery as compared to baseline value) was observed in six patients without intraoperative cerebral desaturation (13.6%) and six patients who had intraoperative cerebral desaturation (40%) (P = 0.057) (odds ratio: 4.22; CI95%: 1.1-16). Median (range) hospital stay was 14 (5-41) days in patients with an area under the curve of rSO2 <50% (AUCrSO2<50%) >10 min%, and 10 (4-30) days in those with an AUCrSO2<50% <10 min% (P = 0.0005). CONCLUSIONS: In a population of healthy elderly patients, undergoing non-vascular abdominal surgery cerebral desaturation can occur in up to one in every four patients, and the occurrence of cerebral desaturation is associated with a higher incidence of early postoperative cognitive decline and longer hospital stay.

[Anesthesiologic problems in candidates for delayed surgery]. / Problemi anestesiologici nel paziente candidato alla chirurgia differita.

In preparing and maintaining a proper anaesthetic plan in the patient with subarachnoid haemorrhage undergoing delayed surgery, various concerns occur to the anaesthesist and the intensivist. These problems are related to the intracranic pathology but also to the structural, biochemical and functional changes occurring in a lot of organs and systems. Aim of anaesthetic approach is a correct preoperative evaluation and the maintenance of intracranic and systemic homeostasis. Systemically it is frequent the evidence of electrocardiographic abnormalities, due in same instances to myocardial hypoperfusion, of respiratory dysfunctions, of idroelettrolitic and metabolic changes leading to hypovolemia, hyponatremia and hypokalemia, and of coagulation disorders. With regards to the cerebral homeostasis, it is imperative to prevent rebleeding and vasospasm and the related neurologic damage. It is important the preoperative correction of the systemic dysfunctions, the prevention of the secondary neurologic damage, the stabilization of hemodynamic responses to various noxious stimuli, the provision of a good surgical field, and the achievement of a stable recovery; all these with the help of a proper clinical and instrumental monitoring.

Behavioral and electrocortical effects of beta-endorphin after intracerebral infusion in rats.

In rats with cannulae chronically implanted into specific areas of the brain, the effects of beta-endorphin were studied on behavior and electrocortical activity. It has been shown that analgesia and catatonia were evoked after infusing beta-endorphin into the III cerebral ventricle or into the hypothalamus. On the contrary, beta-endorphin microinjected into the caudate nucleus or into the substantia nigra produced an intense pattern of stereotyped movements, occasional contralateral circling, contralateral myoclonic jerks and asymmetric posture. Stereotyped gnawing, grooming and "wet-dog" syndrome preceded catatonia after intrahypothalamic administration of beta-endorphin. Bilateral (III ventricle) or ipsilateral (hypothalamus, caudate nucleus and substantia nigra) high voltage electrocortical spikes and other ECoG pathological changes accompanied by motor disorders (stereotypies, myoclonic jerks) or without any overt behavioral change were constantly observed. Behavioral and electrocortical changes evoked by beta-endorphin were long-lasting and rapidly reversed by the specific opiate antagonist, naloxone.

[Postoperative pain in shoulder surgery]. / Il dolore postoperatorio nella chirurgia della spalla.

Postoperative shoulder pain should be adequately treated not only because of the high severity of the symptomatology often observed, but also because pain and muscle contraction render impossible an early rehabilitation programme. Regional anaesthesia, by virtue of its beneficial effects on the pathophysiology of pain and its influence on the rehabilitative problems of shoulder surgery, is the most adequate technique for the control of postoperative pain.

Use of acetylcysteine as the life-saving antidote in Amanita phalloides (death cap) poisoning. Case report on 11 patients.

alpha-Amanitin is an amatoxin known to produce deleterious effects on the liver and the kidneys, when circulating in the blood. It is produced by a particular kind of mushroom called amanita phalloides. Therapeutic options employed to treat mushroom intoxication, such as haemodiaperfusion on activated charcoal, high dosages of penicillin G, oral charcoal, etc., very often failed to act properly and liver transplantation (when a graft is available) appeared to be the only solution. In recent years, as suggest by some authors, it has been postulated that the oxidant effects of alpha-amanitin could be counteracted by the use of antioxidants such as silibinin. High dosages of N-acetyl-cysteine (CAS 616-91-1, NAC), already used as antioxidant in paracetamol poisoning, were successfully used in our Intensive Care Unit (ICU) in the treatment of Amanita phalloides poisoning. In the last two years, 11 patients (mean age of 5-72 = 38.5) were treated for Amanita phalloides poisoning of various degrees, with a protocol (haemodiaperfusion on activated charcoal, high dosages of penicillin G, etc.) further comprehending NAC (fluimucil). All the patients recovered successfully but one (bearing precedent liver disease) needed liver transplantation. Daily monitoring of liver enzymes, creatinine, coagulation, LDH, blood and urinary alpha-amanitin were used to screen the progresses of the patients.

A prospective, randomized, double-blind comparison of epidural levobupivacaine 0.5% with epidural ropivacaine 0.75% for lower limb procedures.

BACKGROUND AND OBJECTIVE: This prospective, randomized, observer-blinded study compared onset time and duration of epidural anaesthesia produced by with levobupivacaine and ropivacaine for lower limb surgery. METHODS: ASA I-III adult patients undergoing elective lower limb procedures were randomized to receive epidural levobupivacaine 0.5% 15 mL (n = 30) or epidural ropivacaine 0.75% 15 mL (n = 35). A blinded observer evaluated onset time and regression of motor and sensory block, and intraoperative needs for fentanyl supplementation (0.1 mg intravenously). RESULTS: With levobupivacaine, onset time was 29 +/- 24 min, with ropivacaine it was 25 +/- 22 min (P = 0.41). Complete resolution of motor block required 105 +/- 63 min with levobupivacaine and 95 +/- 48 min with ropivacaine (P = 0.86). The time for regression of sensory block to T12 was 185 +/- 77 min with levobupivacaine and 201 +/- 75 min with ropivacaine (P = 0.46). Analgesic supplementation was required in one patient receiving levobupivacaine (3.5%) and in two patients receiving ropivacaine (5.7%) (P = 0.99). CONCLUSIONS: In adults undergoing lower limb surgery, levobupivacaine 0.5% 15 mL produces an epidural block with the same clinical profile as ropivacaine 0.75% 15 mL.

[Muscular rigidity caused by alfentanil: prevention]. / Rigidità muscolare da alfentanil: prevenzione.

We studied three groups of 30 patients each, undergoing minor orthopaedic surgery, anaesthetized with alfentanil (30 micrograms/kg bolus followed by an infusion of 0.3 micrograms/kg/min), thiopental 3 mg/kg and 70% N2O via facial mask. Patients in group I were treated, three minutes before induction, with vecuronium 0.02 mg/kg i.v., while those in group II were premedicated with diazepam 0.15 mg/kg i.m. 30-45 minutes before induction. Group III served as control. Muscular rigidity was evaluated clinically with a subjective score based on a scale of 0 (no rigidity) to 3 (severe rigidity). Diazepam did not give significant protection from muscular rigidity. Vecuronium administration did not significantly reduced the number of patients who became rigid, but significantly decreased the incidence of severe rigidity (p less than 0.005), the mean rigidity score (p less than 0.05) and the incidence of rigidity at the induction of anaesthesia (p less than 0.0005). We also observed a progressively increasing incidence of rigidity with increasing age (not significantly) and body weight (p less than 0.05 total rigidity, p less than 0.01 severe rigidity).

[Comparison of manual infusion of propofol and target-controlled infusion: effectiveness, safety and acceptability]. / Confronto tra l'infusione manuale di propofol e l'infusione a target controllato: efficacia, sicurezza ed accettabilità.

BACKGROUND: Diprifusor TCI is a newly developed target-controlled system for the infusion of propofol. Purpose of this study is to evaluate the acceptability, efficacy and safety of Diprifusor TCI in comparison with the manually controlled technique. METHODS: This multicentre, randomised, parallel group study was carried out in 160 patients undergoing surgical procedures of 10 min to 4 h duration in 8 centres. In each centre 20 male or female patients, aged > or = 18 years, ASA I-III were randomised to treatment with either Diprifusor TCI (TCI group--80 patients) or manually controlled infusion (MI group--80 patients). Assessments included hemodynamics; adverse events, including accidents, actual or possible; recovery times; anesthetist ratings of quality of induction and maintenance, and of ease of control and use of technique. Ratings were summed up in a global quality score (study end-point). RESULTS: Induction doses were significantly lower (median values 1.4 vs 1.9 mg/kg) and maintenance infusion rate significantly higher (median values 10.2 vs 8.8 mg/kg/h) in the TCI group; anesthetists ratings obtained maximum scores in most patients of either group, but more frequently in the TCI group, with significant differences for ease of control (good 91.2% TCI vs 74.7% IM; adequate 8.8 vs 21.5%; poor 0 vs 3.8%), and of use of technique (good 91.2% TCI vs 60.8% IM; adequate 8.8 vs 39.2%); the global quality score showed a significant advantage for the TCI system (median value 12 vs 11). CONCLUSIONS: The TCI technique is effective and safe, and has a better acceptability than the manually controlled infusion technique.

Azlocillin and the immune response in intensive care.

The authors have followed the course of the immunological cellular and humoral parameters in 12 patients in the Intensive Care Unit at the University Polyclinic of Messina having grave infections of the respiratory apparatus, for which an antibiotic therapy with azlocillin, semisynthetic penicillin was carried out; all this with the aim of pointing out any possible interferences with the already precarious immune system in such patients. The results obtained seem to exclude any immunodepressing activity by the molecule.

Shortening the discharging time after total hip replacement under combined spinal/epidural anesthesia by actively warming the patient during surgery.

BACKGROUND: To compare passive thermal insulation by reflective blankets with forced-air active warming on the efficacy of normothermia maintenance and time for discharging from the recovery room after combined spinal/epidural anesthesia for total hip arthroplasty. DESIGN: Prospective, randomized study. SETTING: Inpatient anesthesia at three University Departments of orthopedic surgery. PATIENTS: 50 ASA physical status I-III patients, who were scheduled for elective total hip arthroplasty. INTERVENTIONS: Patients received combined spinal/epidural anesthesia (CSE) with intrathecal injection of 15 mg of 0.5% hyperbaric bupivacaine. All procedures started 8-10 a.m., and operating room temperature was maintained between 21-23 degrees C, with relative humidity ranging between 40-45%. As warming therapy patients received either passive thermal insulation of the trunk, the two upper limbs and the unoperated lower limb with reflective blankets (group passive, n = 25), or forced-air active warming of the two upper limbs (group active, n = 25). Core temperature was measured before CSE placement (baseline), and then every 30 min until recovery of normothermia. RESULTS: Demographic data, duration of surgery, intraoperative blood losses, and crystalloid infusion were similar in the two groups. Arterial blood pressure decreased in both groups compared with baseline values, while no differences in heart rate were observed during the study. Core temperatures in passive group patients decreased more markedly than in actively warmed patients, with a 1 degree C difference between the two groups at the end of surgery (p < 0.0005). At recovery room entry seven patients in group active (24%) and 16 patients in group passive (64%) showed a core temperature < 36 degrees C (p < 0.01). Achievement of both discharging criteria and normothermia required 32 +/- 18 min in active group and 74 +/- 52 min in passive group (p < 0.0005). CONCLUSIONS: Forced-air cutaneous warming allows the anesthesiologist to maintain normothermia during combined spinal/epidural anesthesia for total hip replacement even if the convective blanket is placed on a relatively small skin surface with reflex vasoconstriction. Maintaining core normothermia decreased the duration of postanesthesia recovery and may, therefore, reduce costs of care.

[Perioperative thermal homeostasis. A duty of the anesthesiologist]. / Omeostasi termica perioperatoria. Un compito dell'anestesista.

Anaesthesia, surgical procedures and operating room temperature can deeply alter the human thermoregulatory system. Unexpected and sometimes serious perioperative complications can occur. Many studies have been carried out in order to describe and evaluate the detrimental effects produced by different anaesthesia procedures (whether by general, regional or integrated anaesthesia) on thermic homeostasis. More recently it has also been reported that perioperative hypothermia significantly affects patients' outcome, increasing intraoperative blood losses, incidence of postoperative wound infection, and hospital stay. Italian anaesthetists have still a poor consideration about intraoperative body temperature monitoring and patients' warming as basic important skills for a better anaesthesiologic patients management. According with the literature, we do believe that this is not a right opinion. The purpose of the present paper would be to point out the most important knowledges concerning thermic homeostasis management, in order to increase anaesthesiologist's awareness in this essential field of patients perioperative care.

[Comparison of a combination of fentanyl and alfentanil with propofol in brief surgery]. / Confronto tra fentanyl e alfentanil in associazione al propofol nella chirurgia di breve durata.

We studied 96 patients undergoing short gynecological procedures. Anaesthesia has been induced with fentanyl 1.5 micrograms/kg (45 patients) or alfentanil micrograms /kg (51 patients) and a hypnotic dose of propofol, and maintained with 70% N2O via facial mask. We observed a better and more rapid control of surgical analgesia with alfentanil, and an earlier recovery of postoperative psychophysical functions. Post-induction apnea has been more frequent and prolonged in the alfentanil group, but no difference in the time necessary to recover an adequate ventilation has been observed between the two groups. Alfentanil anaesthesia determined a more marked intraoperative bradycardia. By virtue of the speed of onset and the short duration of action, alfentanil is a suitable anaesthetic agent for short surgical procedures, particularly in day-stay patients.

[Anesthesia for shoulder surgery. Comparison of anesthesiologic problems and technics]. / L'anestesia per la chirurgia della spalla. Problematiche e tecniche anestesiologiche a confronto.

We evaluated the ability of general, regional (interscalene block) and balanced anaesthesia (interscalene block supplemented by general anaesthesia) to manage the problems of shoulder surgery. Our results show that general anaesthesia is not adequate. Interscalene block provides intra and postoperative analgesia, allows an early realization of the postoperative rehabilitation programme and quickens the recovery of shoulder function. Therefore, interscalene block should routinely be performed. The positions of patient and surgeons cause the main disadvantages of anaesthesia with interscalene block alone, ad the control of airway of sedated patients is difficult and performing general anaesthesia in case of insufficient analgesia may be troublesome. Balanced anaesthesia, as compared to regional block alone, allows a safer control of respiration and an easier control of surgical analgesia.

[Propofol and alfentanil in total intravenous anesthesia]. / Propofol e alfentanil in anestesia endovenosa totale.

We studied 22 patients undergoing total intravenous anaesthesia for both abdominal and superficial surgery. Anaesthesia has been induced and maintained with propofol (1 mg/kg in 20 seconds; 10 mg/kg/h for 10 minutes; 8 mg/kg/h for 10 minutes; 6 mg/kg/h until the end of the operation) and alfentanil (15 mg/kg before the induction and boli of 10-30 mg/kg in the presence of insufficient surgical analgesia). All the patients have been intubated after the administration of vecuronium 0.1 mg/kg, and artificially ventilated with air and oxygen (FiO2 0.4). We observed: 1) haemodynamic stability after the intubation and during surgery; 2) easy control of surgical analgesia; 3) early postoperative recovery, with no correlation with the doses of propofol and alfentanil; 4) absence of postoperative respiratory depression; 5) intraoperative amnesia; 6) low incidence of postoperative side effects. We conclude that, by virtue of the pharmacokinetic characteristics of propofol and alfentanil, most limitations of total intravenous anaesthesia have been overcome.