Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet-based process with a final meeting on 28 June 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, the use of pre-operative intra-aortic balloon counterpulsation, and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Endovascular treatment of arterial bleeding in patients with pancreatitis.

PURPOSE: To assess the technical and clinical success of endovascular treatment of arterial bleeding in pancreatitis. MATERIALS AND METHODS: From 1992 to 2005, 28 patients with pancreatitis underwent endovascular treatment of associated arterial lesions. Fifteen patients were affected by acute pancreatitis and 13 by chronic pancreatitis. The diagnosis was obtained according to medical history and clinical and laboratory evidence of disease. Arterial involvement was diagnosed by non-invasive imaging and angiography. After treatment, all patients underwent CT scanning at a minimum of 15, 30 and 90 days. We evaluated the feasibility of embolization and patients' survival at 90 days. RESULTS: Transcatheter embolization was feasible in 26/28 patients (93%). In 2 patients with acute pancreatitis, selective catheterization failed so we could not proceed with the angiographic approach. After treatment, there were 3/26 rebleeds (11.5%), all of whom died within the first week. At 90 days' follow-up, 21/26 patients (81%) were alive. Two of 26 patients (8%) suffered splenic complications. Among the 13 patients with acute pancreatitis, 8 (61.5%) were alive after 90 days. All 13 patients with chronic pancreatitis were alive after 90 days. CONCLUSIONS: Comparing our results with the surgical literature, we found that embolization is less invasive and, at least, as successful as surgery. Thus, it should be considered the first choice in pancreatitis arterial complications.

[Effect of probiotic administration on colic anastomosis healing]. / Influenza della somministrazione di probiotici nella guarigione delle anastomosi coliche.

Colic anastomoses are still affected by a high incidence of leakage. We speculate that a supply of fibres and probiotic bacteria improves the healing of colic anastomoses due to a higher production of short-chain fatty acids. These are known to improve the anastomotic healing of colic sutures. Sixty Lewis rats, weighing from 250 g to 350 g, were divided into 6 groups. Groups A + A1 were fed with a low-fibre diet (less than 0.1%), Groups B + B1 with normal rat chow and groups C + C1 with normal rat chow + Lactobacillus plantarum 299v. Transections and re-anastomosis of the distal colon were performed. Groups A1, B1 and C1 were sacrificed after 3 days, and groups A, B, and C after 7 days. The bursting pressure of colic anastomoses was measured. All data are expressed as mean (+/- S.D.). The pH of the colon contents was evaluated by means of a fine needle plastic electrode only in groups A1, B1 and C1. The results were studied by analysis of variance followed by the Student Newman Keuls test for multiple comparisons (significance level P < 0.05). Three days postoperatively, the pH of the colic lumen was lower in animals fed with a normal diet (pH 7.1 +/- 0.3 without Lp supplementation, 6.5 +/- 0.2 with Lp supplementation) than in animals fed with a low-fibre diet (pH 8.0 +/- 0.3). Bursting pressures were significantly higher in the groups fed with fibre and fibre + Lactobacilli than in animals on a low-fibre diet, both on day 3 and day 7. On the basis of these data there seems to be no support for the belief that a supply of fibre-rich food might impair healing and promote development of anastomotic leakage. On the contrary, short-chain fatty acids and fibres would seem to facilitate the healing of colic anastomoses.

Day surgery: the value of monitored anesthesia care and intraoperative monitoring.

Recently an increasing percentage of patients is receiving care and surgical procedures in Day Surgery (DS), undergoing local or loco-regional anesthesia techniques, to which many patients appear to be rather reluctant and show fear and anxiety. The anesthesiologist can resolve this problem administering i.v. hypnotic and analgesic drugs and adjusting their level to patient's needs and type of surgery. They increase the patient's compliance to DS care and contribute to its diffusion. Nowadays, commonly used drugs permit quick changes of anesthesia depth with a fast and safe recovery but these require an appropriate monitoring in order to prevent and rapidly detect the onset of complications. In this study we analyze the peculiarity of Monitored Anesthesia Care and the appropriate intraoperative monitoring especially regarding the use of pulse oximetry.

[The pre-emptive analgesia in the treatment of postoperative pain]. / La pre-emptive analgesia nel trattamento del dolore post-operatorio.

The term "pre-emptive analgesia" implies the hypothesis that an analgesic treatment, given before nociceptive stimuli reach the Central Nervous System, could prevent or reduce the subsequent pain. The rational basis of this phenomenon, giving rise to much interest in the last years, comes from the finding that noxious stimuli cause wind-up and receptive fields expansion phenomena in the dorsal horn neurons of the spinal cord leading to hyperalgesia. Recently, many clinical trials to verify the existence of a pre-emptive effect regarding the management of postoperative pain by the administration of non steroidal antiinflammatory drugs (NSAIDs), local anesthetics and opioids have been conducted. As regards NSAIDs to date no study demonstrated a pre-emptive effect. Conflicting results emerged from trials employing local anesthetics, opioids or associations of the three classes of drugs. Thus, the "pre-emptive analgesia" represents a very important phenomenon for the basic research, but further trials must investigate its clinical impact.

[Intravenous patient-controlled analgesia (PCA) in the treatment of postoperative pain: rationale and clinical application]. / Patient-Controlled Analgesia (PCA) endovenosa nel trattamento del dolore post-operatorio: razionale ed applicazione clinica.

The clinical use of the patient-controlled analgesia (PCA) represents a further improvement in the treatment of post-operative pain. In this way in success due to inadequate protocols, unpredictability of the drug absorption and variability of the response to one drug or to the same pain patterns between patients can be avoided. This technique allows the patient himself to control the pain without depending upon nurses or physicians for the administration of analgesic drugs. Although the PCA is in use since several years, there are still some unresolved problems which are considered in this paper.

[The neuroendocrine and metabolic response to surgical stress]. / La risposta neuro-endocrina e metabolica allo stress chirurgico.

Surgical stress and post-operative pain evoke complex neuroendocrine and tissue responses aiming at defence from injury and recovery of body integrity. Such a reaction appears to be a real "hormonal storm" which is mainly induced by Sympathetic Nervous System and sympatho-adrenomedullary and hypothalamic-pituitary-adrenal systems activation and, in the periphery, by the release of inflammatory mediators at the site of injury. These substances by means of complex regulatory mechanisms and reciprocal interactions induce significant cardiovascular, metabolic, inflammatory and immunologic changes. However, this response may became excessive and contribute to an increase in postoperative morbidity and mortality. Since pain is a major factor in neuroendocrine response triggered by surgical injury every effort must be made to achieve effective intra and post-operative pain control.

[Treatment of postoperative pain by balanced spinal analgesia]. / Il trattamento del dolore post-operatorio mediante analgesia spinale bilanciata.

Postoperative pain relief has the aim to provide patient subjective comfort, to inhibit neuroendocrine and metabolic responses to surgical injury and to enhance restoration of function by allowing the patient to breathe, cough, move more easily and to begin enteral nutrition. Opioid analgesics, independently from the route of administration, are unable to provide all this. In addition to spinal opioids other drugs, such as local anesthetics, alpha 2-agonists and cholinergic drugs, may produce an antinociceptive effect when administered by spinal route. All these drugs may be administered in combination between them, realising the so called "balanced spinal analgesia". The aim of this study is to analyse the available methods for the evaluation of pharmacological interactions, the types of interaction among different spinal antinociceptive drugs and the role of balanced spinal analgesia in the treatment of postoperative pain. Analysis of the presented data shows that the spinal synergism between opioids-local anesthetics and opioids-alpha 2-agonists can be useful in the treatment of postoperative pain, because these drug combinations are able to provide a satisfactory pain control at low doses with a reduction of the adverse effects. Furthermore, the combined use of opioids-local anesthetics proved to be effective also in abolishing postoperative incident pain and in inhibiting neuroendocrine and metabolic responses to surgical injury. Especially in high risk patients this is related to a better outcome. Finally, even if the synergism between cholinergic drugs with opioids or a2-agonists have been proved, at the moment their use in man by spinal route in the treatment of postoperative pain is not advisable.

[Treatment of pain in advanced-stage intra-abdominal neoplasms]. / Il trattamento del dolore nelle neoplasie endoaddominali in fase avanzata.

Different types of pain are present in far advanced intra-abdominal cancer, sometimes in the same site too. An accurate semeiological analysis of pain is important because different types of pain often differently respond to the available therapeutical tools. In this paper the results and the complications of the most important methods of pain management in far advanced intra-abdominal cancer are examined. Analysis of the data reveals that the association of more methods, pharmacological and non, should be a rule rather than the exception.

[Hemodynamic and metabolic impairment during hepatectomy: effect of continuous dobutamine infusion]. / Alterazioni emodinamiche e metaboliche in corso di intervento di emiepatectomia: effetto dell'infusione continua di dobutamina.

Following surgical liver resection haemodynamic and metabolic impairment, potentially responsible for post-operative hepatic failure may occur. In this prospective, randomized study such impairments and the effect on them of continuous peri-operative infusion of dobutamine were examined. Twelve patients, scheduled for hepatectomy, were divided in two groups: Group I was treated with an infusion of dobutamine 6 micrograms/kg/min from 10 minutes before the induction of anaesthesia till the fifth postoperative hour; Group II was considered as the control group. The main haemodynamic parameters, gastric pHi and serum lactate level were examined. No significant differences were detected in heart rate, parameters of pressure and SvO2. In both groups, during portal clamp, SVR increased while Cl and DO2 decreased with respect to basal and the other intra- and postoperative values. Gastric pHi decreased in both groups after portal clamp. These alterations were significantly lower in the group treated with dobutamine when compared with the control group. Serum lactate level increased in both groups. This increase was lower in Group I. Differences between groups were not statistically significant. In conclusion, during hepatectomy important haemodynamic and metabolic impairments occur. Dobutamine, by reducing such impairments, can be usefully employed in this kind of surgery.

[Management of postoperative pain in stomatology with ibuprofen L-arginine and naproxen]. / Trattamento del dolore postoperatorio in odontostomatologia con ibuprofene L-arginina e naprossene.

BACKGROUND: The aim of this prospective, randomized study is to compare the efficacy and safety of ibuprofen L-arginine and naproxen in the treatment of postoperative dental pain. METHODS: Seventy patients undergoing removal of impacted third molars were randomly allocated to receive 4 hours after surgery a single oral dose of either ibuprofen L-arginine 400 mg or naproxen 550 mg. Ten patients dropped out from the study because they took the study drug before the allowed time. Using a self-rating record, patients rated their pain and its relief for 1 hour after the drug administration. Remedication, if needed, and mean time of remedication were also recorded. RESULTS: A statistically significant reduction in pain scores with respect to the baseline values was recorded 5 minutes and 15 minutes after the drug administration in the ibuprofen L-arginine and in the naproxen-treated group, respectively. The summed pain intensity difference (SPID) over 60 minutes resulted significantly higher in the ibuprofen L-arginine than in the naproxen-treated group. A complete abolition of pain 60 minutes after medication was obtained in 12/28 patients (42.9%) in the ibuprofen L-arginine and in 5/32 patients (15.6%) in the naproxen-treated group, respectively (p = 0.04). Number of patients requiring remedication, mean time of remedication and drug related adverse effects did not significantly differ in the two treatment group. CONCLUSIONS: Global evaluation of the drugs by the patients showed ibuprofen more effective drug than naproxen.

[Is pain therapy just an ethical-behavioral problem?]. / La terapia del dolore è solo un problema etico-compartamentale?

Pain is a subjective sensation caused not only by pathological events which trigger signals perceived as algogenic (sensory component), but also by emotional mechanisms and critical assessments which modify its perception, both quantitatively and qualitatively. Therefore pain is an unique and unrepeatable experience resulting from the interaction of these three components. When faced with a patient suffering pain, it is fundamental to establish the respective quantitative incidences of these three components, in order to define the correct therapy of the pain in its totality. Whereas there are numerous therapies for dealing with the sensory component, the same cannot be said of the emotional and critical elements. We therefore suggest a number of guidelines for tackling the problem and for developing therapeutic strategies. In the literature there are few perspective and randomized studies that may evaluate the real effectiveness of the different treatments; it follows that the tested and accepted by scientific community therapeutical protocols are very few. Only recently some studies that intend to evaluate the different therapeutical strategies in connection with the different algesic syndromes are being published in the most important scientific journals.

Type of fluid in severe sepsis and septic shock.

Fluid resuscitation is an essential aspect of the management of patients with severe sepsis and septic shock, especially in the early stages of disease. Which fluid should be used for this purpose has been a topic of ongoing and sometimes heated debate for many years, yet this is still little evidence to support one fluid over another. Each fluid type has specific adverse effects, and all fluids when given in excess can be detrimental. In this article, we will review the advantages and limitations of the key fluid types currently used for the resuscitation of critically ill patients with sepsis, including the crystalloids (saline solutions and Ringer's lactate), and the colloids (albumin, gelatins, dextrans, and hydroxyethyl starches). We will then briefly summarize the limited evidence to support use of one fluid type over another, and provide general suggestions for fluid use in these patients.

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

BACKGROUND: There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first international consensus conference on this topic. METHODS: The consensus was a continuous international internet-based process with a final meeting on June 28th 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting and ranking. RESULTS: Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, the use of preoperative intra-aortic balloon counterpulsation and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. CONCLUSION: This international consensus conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Celiac block for the treatment of pancreatic pain.

Neurolytic celiac plexus block (NCPB) is commonly performed to relieve pancreatic cancer pain. Since Kappis described the percutaneous NCPB, a number of variations of this technique have been proposed to improve analgesic results and minimize complications. In this article, we review and discuss techniques, results, and complications of NCPB.

Baroreflex and oscillation of heart period at 0.1 Hz studied by alpha-blockade and cross-spectral analysis in healthy humans.

1. Parameters derived from frequency-domain analysis of heart period and blood pressure variability are gaining increasing importance in clinical practice. However, the underlying physiological mechanisms in human subjects are not fully understood. Here we address the question as to whether the low frequency variability (approximately 0.1 Hz) of the heart period may depend on a baroreflex-mediated response to blood pressure oscillations, induced by the alpha-sympathetic drive on the peripheral resistance. 2. Heart period (ECG), finger arterial pressure (Finapres) and respiratory airflow were recorded in eight healthy volunteers in the supine position with metronome respiration at 0.25 Hz. We inhibited the vascular response to the sympathetic vasomotor activity with a peripheral alpha-blocker (urapidil) and maintained mean blood pressure at control levels with angiotensin II. 3. We performed spectral and cross-spectral analysis of heart period (RR) and systolic pressure to quantify the power of low- and high-frequency oscillations, phase shift, coherence and transfer function gain. 4. In control conditions, spectral analysis yielded typical results. In the low-frequency range, cross-spectral analysis showed high coherence (> 0.5) and a negative phase shift (-65.1 +/- 18 deg) between RR and systolic pressure, which indicates a 1-2 s lag in heart period changes in relation to pressure. In the high-frequency region, the phase shift was close to zero, indicating simultaneous fluctuations of RR and systolic pressure. During urapidil + angiotensin II infusion the low-frequency oscillations of both blood pressure and heart period were abolished in five cases. In the remaining three cases they were substantially reduced and lost their typical cross-spectral characteristics. 5. We conclude that in supine rest conditions, the oscillation of RR at low frequency is almost entirely accounted for by a baroreflex mechanism, since it is not produced in the absence of a 0.1 Hz pressure oscillation. 6. The results provide physiological support for the use of non-invasive estimates of the closed-loop baroreflex gain from cross-spectral analysis of blood pressure and heart period variability in the 0.1 Hz range.

The TURP syndrome: importance of expiratory ethanol measurement and high serum levels of glycine.

OBJECTIVE: In a prospective study it was our intention to evaluate the reliability and the predictive value of expiratory ethanol for the early detection of the occurrence of TURP syndrome and emphasize the role of the serum levels of glycine in clinical manifestation. METHODS: We studied 30 patients scheduled for elective traditional transuretral resection of the prostate performed with subarachnoid anesthesia. Serum sodium and glycine concentrations, serum osmolality and end-expiratory ethanol levels were monitored at scheduled intervals. Continuous heart rate and blood pressure monitoring was performed during the perioperative period in the operativing room and, later, in the recovery room. Occurrence of cardiocirculatory, respiratory and neurologic symptoms were recorded. Statistics included Bonferroni's t-test and Fisher's exact test. A decision level plot for end-expiratory ethanol level was performed for the choice of predictivity criterion. RESULTS: In our population we identified three groups of patients: Group I (15 patients) in which no symptom was recorded; Group II (6 patients) in which non-specific anesthesia-related symptoms occurred; Group III (9 patients) in which TURP syndrome of various degree of severity was observed. In this group of patients changes in serum sodium and glycine concentrations, serum osmolality and end-expiratory ethanol levels were significantly different compared with the other two groups. In regard to end-expiratory ethanol levels, we identified a cut-off point at 0.05 mg/ml. In Group III two patients developed transient blindness. These patients had the highest serum glycine concentrations (> 4000 mumol/ml). Mortality was nil. CONCLUSIONS: Our data show the reliability and accuracy of end-expiratory ethanol levels as a predictive test of the occurrence of TURP syndrome. Further, we emphasize the role of serum glycine concentration in the occurrence of neurologic symptoms related to the transurethral resection of the prostate.

Both right and left cervical cordotomies depress sympathetic indexes derived from heart rate variability in humans.

Unilateral percutaneous cervical cordotomy, performed in humans to relieve intractable cancer pain, elicits signs of ipsilateral sympathetic block. In patients undergoing right or left percutaneous cervical cordotomy (9 per group), changes in sympathovagal balance were evaluated by spectral analysis of heart rate to confirm the sympatholytic effect of this surgical procedure and to investigate the lateralization of sympathetic cardiac control. For these purposes, heart rate variability was recorded 1 hour before cordotomy and 24 hours later. Cordotomy significantly depressed the low frequency peak (LF) of heart rate variability and increased the high frequency component (HF), when measured as a percentage of total power. As a consequence, the LF/HF ratio decreased significantly (P =.001), particularly during standing. The effects of right or left cordotomies were not significantly different. In conclusion, in humans unilateral percutaneous cervical cordotomy depresses some sympathetic indexes (LF/total power ratio and LF/HF ratio) derived from heart rate variability, irrespective of side.