[Renal transplantation in the North Italy Transplant program (NITp): Organ allocation and results]. / Il trapianto renale nel Nord Italia Transplant program (NITp): assegnazione degli organi e risultati.

Renal transplantation is an effective therapeutic tool for patients with end-stage renal diseases (ESRDs). Data reported in this article summarize the results obtained from 30 years' activity in the North Italy Transplant program (NITp), the first transplant organization in Italy that implemented a donor procurement and organ transplantation network. In the NITp kidney allocation is governed by a computerized algorithm, NITK3, put in place in 1997, aimed at ensuring equity, transparency and traceability during the stages of the allocation decision-making process. The NITp working group has recognized the NITK3 criteria and they are periodically reviewed following the results of the analysis of patients' transplantation odds. The results obtained with the use of the NITK3 algorithm have been very satisfactory: after 6 yrs, a significantly higher percentage of patients at immunological risk (sensitized or waiting for re-transplant), of patients waiting for >3 yrs and of patients with 0-1 HLA A,B,DR mismatches have been transplanted. Moreover, a higher percentage of kidneys were used locally (in a hospital within the procurement area), and this is known to stimulate donor procurement. Finally, we performed a preliminary statistical analysis of transplants carried out from 1998-2002 in 5/16 centers of the NITp area, demonstrating the quality of the NITp program in terms of patient and graft survival, and that donor and recipient age are the variables significantly impacting on transplant results.

A new simple method for percutaneous tracheostomy: controlled rotating dilation. A preliminary report.

OBJECTIVE: To describe and introduce a new technique for percutaneous dilational tracheostomy. DESIGN AND SETTING: Open, observational clinical trial in patients requiring an elective tracheostomy in two intensive care units of university hospitals. PATIENTS: Fifty (25/25) consecutive patients requiring an elective tracheostomy above 18 years of age. INTERVENTIONS: Performance of a percutaneous dilational tracheostomy with a specially designed screw-type dilator, using a thread for the dilation procedure. RESULTS: In 50 consecutive patients the new device allowed a quick and safe dilation procedure without any serious bleeding complications or other relevant procedural-related side effects. CONCLUSIONS: The described new percutaneous dilational tracheostomy device (PercuTwist, Rüsch, Kernen, Germany) represents a single-step method with a high degree of control during dilation. So far, it appears to be a safe, quickly performed procedure with a strikingly low incidence of even small bleeding complications, thus offering an interesting new alternative for the performance of a percutaneous tracheostomy.

When the end is really the end? The extubation in the difficult airway patient.

Difficult airway management remains one of the most important sources of anesthesia related accidents; recent reviews and dedicated guidelines suggest that not only intubation, but extubation too is a critical phase in terms of potential accidents and serious complications. This paper will highlight some fundamental concepts regarding extubation related problems, focusing particularly on epidemiology, risk factors and time course of difficult extubation, suggesting some conceptual points to plan and manage patients in which a difficult extubation might be expected, including parameters and test to be performed to assess and predict such a situation.

Do videolaryngoscopes have a new role in the SIAARTI difficult airway management algorithm?

The rigid standard Macintosh laryngoscope is the instrument used to obtain an adequate view of the larynx in most patients. In cases of unpredicted severe laryngoscopic difficulties, the SIAARTI guidelines suggest waking the patient and using fiberoptic intubation with topical anesthesia. In the last decade, many videolaryngoscopes have been produced and introduced into clinical use. They provide an excellent view of the glottis. Their role in the SIAARTI algorithm for difficult airway management is now better defined. In fact, their use could be suggested in cases of unpredicted severe laryngoscopic difficulty as a step before awakening the patient. Moreover, they could be used in predicted severe intubation difficulty as an alternative to flexible fiberscope.

Algorithms for difficult airway management: a review.

Difficult airway management and maintenance of oxygenation remain the two most challenging tasks for anesthetists, while also being controversial items in terms of clinically based-evidence to support relevant guidelines in the literature. Nevertheless, different expert groups and scientific societies from several countries have published guidelines dedicated to the management of difficult airways. These documents have been demonstrated to be useful in reducing airway management related critical accidents, despite their limited use in litigations and legal issues. The aim of this review is to compare different airway management guidelines published by the United States, United Kingdom, France, Italy, Germany, and Canada while trying to elucidate the main differences, weaknesses, and strengths for identifying critical concepts in the management of difficult airways.

[Anesthesia accidents: accidental esophageal intubation]. / Incidenti in anestesia: l'intubazione esofagea accidentale.

Accidental oesophageal intubation is a common mistake in inexperienced anaesthetists, but unrecognized oesophageal intubation is fortunately a rare event because, in anaesthetic malpractice claims, it frequently resulted in death or brain damage. The connection of these complications with the lack of experience of the anaesthetist and/or the difficult intubation is not so evident in the literature. The precocious detection of tube dislocation depends on the systematic verification of endotracheal tube position after insertion. The paper describes the clinical and instrumental tests used for detecting tracheal or oesophageal intubation. Clinical signs are often unreliable and, between technical tests, capnography is the most reliable of correct tracheal positioning if waves are regular and repeated; when unavailable, the negative pressure aspiration test is a simple and reliable alternative.

Application of the self-inflating bulb to a hollow intubating introducer.

BACKGROUND: The aspiration test, performed by a self-inflating bulb (SIB), is a simple and reliable method to detect an accidental esophageal intubation. The aim of the study, in case of employment of a hollow intubating introducer (HII), was to verify the possibility to directly perform the test with the introducer and its efficacy in allowing the detection of its position. EXPERIMENTAL DESIGN: prospective, randomized study. ENVIRONMENT: operating theater in a university hospital. PATIENTS: adult patients, without evidence of gastro-esophageal or tracheobronchial pathologies, scheduled for elective surgery. INTERVENTIONS: patients were randomized in two groups T (HII was placed in trachea) and E (HII was positioned in the esophagus). Under general anesthesia, a HII was placed in either the trachea or the esophagus. A blinded anesthesiologist connected the SIB to the HII and performed the test twice. MEASUREMENTS: the anesthesiologist inferred the position of the device, based on the re-inflation observed. RESULTS: One hundred subjects were studied. In group E patients, a prompt and complete re-inflation of the bulb was never observed and the anesthesiologist correctly inferred the position of the HII. Occasionally (3.5% of cases), in group T patients, a prevented or incomplete re-inflation of the bulb occurred, leading to an incorrect judgment of the HII position. CONCLUSIONS: The aspiration test with the SIB allows the proper detection of the introducer in esophagus. When used in combination with a HII, both time and local trauma associated with an erroneous, introducer-guided esophageal intubation in case of difficult laryngoscopy may be reduced.

[Injury of the long thoracic nerve after LRA, which etiology? Clinical case]. / Danno del nervo toracico lungo dopo ALR: quale eziologia? Caso clinico.

The long thoracic nerve supplies the serratus magnus muscle. Its injury causes "winging" of the scapula and functional limitation of the upper limb. Such lesion is mostly due to chronic trauma, occasionally iatrogenic. This case report presents a case of serratus magnus muscle paralysis following an anesthetic block of the brachial plexus performed at the time of a minor orthopedic surgery of the wrist, in a young healthy woman who was a tennis player. The observed lesion seemed to have been caused by the anesthetic technique employed, but, at the same time, it is impossible to rule out, in the etiology of the disease, a role of other predisposing factors, such as the intense sport activity above mentioned, or of concurrent factors, such as an incorrect position in the immediate postoperative period.

[Percutaneous tracheostomy: technological development]. / Tracheotomia percutanea. Sviluppo tecnologico.

PDT based on Seldinger's technique is gaining wide acceptance in ICU patients, but the procedure has undergone various modifications during the past thirty years. The ten most known procedures and the target of their innovating content are briefly examined. The incidence of complications desumed from the literature, wide in some cases and limited or absent in others, is also considered. In many cases, the technological modifications of original procedures had two fundamental objectives: to increase it's safety and to reduce the operator-depencence of the procedure. According to the review of the literature (and our experience too) the increasing interest for percutaneous tracheostomy is the justified conclusion of the technological development of some dilatative techniques. With an appropriate training and the continuous endoscopic guidance, it is possible today to perform PDT in critically ill patients of ICU with a very low total complication rate. Even if the comparison between different techniques is not rich enough on prospective randomized studies, the global low rate of hemorrhage complications, of wound infection and of poor cosmetic result are surely demonstrated and probably related to the small skin incision and the tight fitness between tissues and the tracheostomy tube.

[Double-blind study of lysine acetylsalicylate in the control of postoperative pain of somatic origin]. / Studio in doppio cieco dell'acetilsalicilato di lisina nel controllo del dolore post-operatorio di origine somatica.

In 61 patients submitted to subdural anesthesia for orthopedic operations, postoperative somatic pain was treated by double-blind iv injection of lysine acetylsalicylate 1.8 g or placebo randomly. Patients with persistent pain received methadone 10 mg im. No placebo response was obtained; LAS had similar but shorter effects than methadone. No significant side effect was observed.

A randomly amplified polymorphic DNA marker specific for the Bacillus cereus group is diagnostic for Bacillus anthracis.

Aiming to develop a DNA marker specific for Bacillus anthracis and able to discriminate this species from Bacillus cereus, Bacillus thuringiensis, and Bacillus mycoides, we applied the randomly amplified polymorphic DNA (RAPD) fingerprinting technique to a collection of 101 strains of the genus Bacillus, including 61 strains of the B. cereus group. An 838-bp RAPD marker (SG-850) specific for B. cereus, B. thuringiensis, B. anthracis, and B. mycoides was identified. This fragment included a putative (366-nucleotide) open reading frame highly homologous to the ypuA gene of Bacillus subtilis. The restriction analysis of the SG-850 fragment with AluI distinguished B. anthracis from the other species of the B. cereus group.

PCR fingerprinting of whole genomes: the spacers between the 16S and 23S rRNA genes and of intergenic tRNA gene regions reveal a different intraspecific genomic variability of Bacillus cereus and Bacillus licheniformis [corrected].

Genomic diversity in 21 strains of Bacillus cereus and 10 strains of Bacillus licheniformis was investigated by random amplified polymorphic DNA (RAPD) analysis, which samples the whole genome, and by two PCR fingerprinting techniques sampling the hypervariable spacers between the conserved 16S and 23S rRNA genes of the rRNA gene operon (ITS-PCR) and regions between tRNA genes (tDNA-PCR). RAPD analysis showed a remarkable diversity among strains of B. cereus that was not observed with the rRNA and tRNA intergenic-spacer-targeted PCR, where all the strains showed practically identical fingerprints. A wide variability among the B. cereus strains was also observed in the plasmid profiles, suggesting that the genetic diversity within B. cereus species can arise from plasmid transfer. One contribution to the diversity detected by RAPD analysis was determined by the presence of large extrachromosomal elements that were amplified during RAPD analysis as shown by Southern hybridization experiments. In contrast to the strains of B. cereus, the 10 strains of B. licheniformis were grouped into two clusters which were the same with all the methods employed. The 16S rRNA genes were identical in all 10 strains when examined using single strand conformation polymorphism analysis after digestion with Alul and Rsal. From these data we hypothesize two different evolutionary schemes for the two species.

[Proposal of a health education program]. / Proposta di un programma di educazione sanitaria.

Since 1987 at the Spedali Civili of Brescia the problem of anaesthetic gases pollution in operating surgery rooms was managed by means of periodical environmental monitoring and maintenance of the anaesthesiological equipments. The mean nitrous oxide concentrations were generally reduced to values below the limits indicated by the Italian Ministry of Health. On the contrary, a low participation of the operating room personnel was observed in the health surveillance program and this phenomenon is clearly evidenced by the progressive decrease of the number of medical examinations. In order to clarify the usefulness of health surveillance programs and to promote the adoption of "less pollutant" behaviour, a Health Education Program was planned by the Medical Administration, in collaboration with the Occupational Health Service and the Department of Anesthesiology and Intensive Care. This program will be performed at different times, including the administration of a questionnaire, the participation at information meetings, the distribution of brochures and the evaluation of environmental and biological exposure data before and after the education program.