Suckling-induced Fos activation and melanin-concentrating hormone immunoreactivity during late lactation.

AIMS: Melanin-concentrating hormone (MCH) is implicated in the control of food intake, body weight regulation and energy homeostasis. Lactation is an important physiological model to study the hypothalamic integration of peripheral sensory signals, such as suckling stimuli and those related to energy balance. MCH can be detected in the medial preoptic area (MPOA), especially around the 19th day of lactation, when this hormone is described as displaying a peak synthesis followed by a decrease after weaning. The physiological significance of this phenomenon is unclear. Therefore, we aimed to investigate hypothalamic changes associated to sensory stimulation by the litter, in special its influence over MCH synthesis. MAIN METHODS: Female Wistar rats (n=56) were euthanized everyday from lactation days 15-21, with or without suckling stimulus (WS and NS groups, respectively). MCH and Fos immunoreactivity were evaluated in the MPOA and lateral and incerto-hypothalamic areas (LHA and IHy). KEY FINDINGS: Suckling stimulus induced Fos synthesis in all regions studied. An increase on the number of suckling-induced Fos-ir neurons could be detected in the LHA after the 18th day. Conversely, the amount of MCH decreased in the MPOA from days 15-21, independent of suckling stimulation. No colocalization between MCH and Fos could be detected in any region analyzed. SIGNIFICANCE: Suckling stimulus is capable of stimulating hypothalamic regions not linked to maternal behavior, possibly to mediate energy balance aspects of lactation. Although dams are hyperphagic before weaning, this behavioral change does not appear to be mediated by MCH.

Respiratory mechanics at different PEEP level during general anesthesia in the elderly: a pilot study.

BACKGROUND: General anesthesia could imply that the closing capacity exceed the functional residual capacity. This phenomenon, associated with a reduction of maximal expiratory flow, could lead to expiratory flow limitation (EFL). The aim of our study was to verify 1) a new method of determining EFL during anesthesia (PEEP test); 2) if anesthesia could be associated with the development of EFL; 3) if the use a small amount of PEEP is able to reverse the possible negative effects of low lung volume ventilation. METHODS: Fifty two patients scheduled for abdominal surgery were prospectively randomized in: 1) group ZEEP, ventilated at PEEP 0 H(2)O and 2) group PEEP ventilated at PEEP 5 cm H2O. The presence of EFL was determined by the negative expiratory pressure (NEP) test the day before surgery and by the PEEP test during surgery. Data of respiratory mechanics were calculated at the beginning and at the end of anesthesia. RESULTS: 1) The PEEP test allows the detection of EFL; 2) anesthesia was associated with EFL: 8 patients developed EFL after induction. At the end of surgery, 7 more patients became flow limited in the group ZEEP, while only 1 in the group PEEP. The group ZEEP exhibited a marked decrease of expiratory flow and a worsening of respiratory mechanics at the end of surgery. CONCLUSION: The PEEP test allowed to verify that EFL during anesthesia is a valuable phenomenon. The use of 5 cmH(2)O of PEEP was helpful to prevent the deterioration of lung mechanics that occurs during surgery.

LMA Supreme™ vs i-gel™--a comparison of insertion success in novices.

Two new supraglottic airway devices, the LMA Supreme™ (LMA) and the i-gel™, offer potential benefits when inserted by inexperienced operators. This study compared the insertion success rate and ventilation profile between the LMA Supreme and the i-gel when inserted by operators without previous airway management expertise. Following a short lecture and manikin training, airway novices were randomly allocated to insert either the LMA Supreme or the i-gel into 80 patients undergoing breast surgery. The primary outcome was first-time success rate, and secondary outcomes were overall success rate, insertion time, airway leak pressure, tidal volume during pressure controlled ventilation at 17 cmH(2)O, and adverse events. First-time insertion success rate was significantly higher for the LMA Supreme than the i-gel (30/39 (77%) vs 22/41 (54%); p = 0.029). Significantly more placement failures occurred with the i-gel (6 vs 0, p = 0.025). Mean (SD) leak pressure (29 (8) vs 23 (11) cmH(2)O, p = 0.007) and expired tidal volume (PCV 17 cmH(2)O) (785 (198) vs 654 (91), p = 0.001) were significantly greater with the LMA Supreme than with the i-gel, respectively. More patients complained of pharyngolaryngeal pain with the LMA Supreme than with the i-gel (17/39 (44%) vs 8/41 (20%); p = 0.053). We found better first time success rate, fewer failures, and a better seal with the LMA Supreme compared with the i-gel, indicating that the LMA Supreme may be preferable for emergency airway use by novices.

West Nile Virus encephalitis in intensive care: a small mosquito, a tremendous danger.

The authors describe two of three cases of West Nile virus (WNV) meningoencephalitis admitted to ICU in Ferrara (south of Po River) underlying the main common features. They focus on the difficulties in diagnosis, with key-points including seasonality (late summer in Italy), unspecific flu-like symptoms at the beginning, as hyperpyrexia, myalgia and asthenia, followed by neurological impairment, and use of steroids in the patient clinical history. Special attention is deserved to the poor outcome at both short and long term.

Validation of SAPS 3 Admission Score and comparison with SAPS II.

BACKGROUND: The objective of this study was to validate the Simplified Acute Physiology Score SAPS 3 Admission Score (SAPS 3) and to compare its fit with that of SAPS II in an independent sample of patients admitted to a single-centre intensive care unit (ICU). METHODS: The data for all adult patients consecutively admitted to an eight-bed ICU of a 700-bed university hospital between 1 January 2006 and 2 September 2007 were collected. SAPS II and SAPS 3 were computed, as well as the predicted hospital mortality. The calibration of SAPS II and SAPS 3, according to the general equation (GE), and equations for Southern Europe and Mediterranean countries (SE&MC), and Central and Western Europe (C&WE), were assessed by the goodness-of-fit Hosmer-Lemeshow H and C statistics. Standardized mortality ratios (SMR) with 95% confidence interval (95% CI) were computed for SAPS II and SAPS 3 equations. RESULTS: Six hundred and eighty-four patients were studied (males 63%). The median age was 73 (quartiles 65-80) years. The fit of SAPS 3 using the C&WE equation (H 13.49, P=0.095; C 12.73, P=0.121) as well as that of SAPS II was acceptable (H 6.02, P=0.644; C12.08, P=0.147), while SAPS 3 GE (H 23.36, P=0.002; C 22.37, P=0.004) and S&MC (H 25.73, P=0.001; C 26.19, P=0.001) did not fit well. SAPS 3 GE, SAPS 3 SE&M Countries and the SAPS II significantly over estimated the mortality. Only 95% CI of SMR for SAPS 3 C&WE included 1 (SMR 0.97; 95% CI 0.89-1.05). CONCLUSION: Each ICU should identify the SAPS 3 equation most suitable for its case mix. The SAPS II model tended to overestimate the mortality.

Emotional and interpersonal factors are most important for patient satisfaction with anaesthesia.

BACKGROUND: Questionnaires to evaluate patient satisfaction with anaesthesia mainly consider physiological aspects. This study was performed to identify the items of value for patients having anaesthesia (pilot phase) and to validate the questionnaire built on these findings in a new group of inpatients. METHODS: In the pilot phase, 100 surgical patients were interviewed and asked whether each of the 23 items selected by a panel of providers was relevant (score 1) and to rank these from 1 (additional score 6) to 5 (additional score 2). The resulting 10-item final instrument was administered to 219 consecutive inpatients by interview, after recent anaesthesia, asking them how much of each item they received (item received) and the level of satisfaction with the same item, using Numerical Rating Scales (range 0-10). RESULTS: In the pilot phase, gender, age, education and surgery did not influence the score enough to change the first 10 rank-ordered items. The 219 patients subsequently studied did not differ from those missing the questionnaire administration. The patients aged less than 55 years showed lower satisfaction scores than those aged 55 years or more (P = 0.019). In all items, except 'feeling anxious/frightened', the item received was significantly associated with the satisfaction reported. 'Kindness/regard of caregivers' together with 'information given by anaesthetist' and 'feeling safe' predicted 47% of the variance in total patient satisfaction. CONCLUSIONS: Inpatients value highly those elements of care that pertain to emotional and interpersonal relationships.

Post-traumatic stress disorder-related symptoms after intensive care.

AIM: To determine the incidence of Post Traumatic Stress Disorder (PTSD) related symptoms in a population of intensive care unit (ICU) admitted patients and the relationship between PTSD-related symptoms and memories of ICU. METHODS: Adults consecutively admitted to an ICU of a University hospital during 1 year, who stayed in the ICU at least 3 days, were prospectively studied. A questionnaire (ICU memory tool) was administered to 84 patients 1 week after ICU discharge and to 63 of them after 3 months. Past medical history and clinical variables present during ICU stay were collected. RESULTS: At the 1st interview, 5 patients (5.9%) did not remember to have been in ICU. Of the remaining 79 patients (males 59.5%, median age 69 years, SAPS II 34, APACHE II 14 and ICU stay 5 days), 4 reported intrusive memories and none panic attacks. The Impact of Events Scale (IES), available in 3 of them, scored in medium/high levels. Only the median number of factual memories reported by the patients with and without intrusive memories was significantly different (4 interquartile range 2-5 vs 8 interquartile range 6-10; p=0.002). The patients with intrusive memories at the 1st interview did not report them at the 2nd interview. Two patients not having panic or intrusive memories at the 1st interview reported PTSD-related symptoms after 3 months. CONCLUSIONS: In a general ICU population, few patients (5%) have PTSD-related symptoms and those who present those symptoms report less factual memories of ICU stay.

The effect of volatile anesthetics on respiratory system resistance in patients with chronic obstructive pulmonary disease.

We examined the effect of isoflurane and sevoflurane on respiratory system resistance (Rmin,rs) in patients with chronic obstructive pulmonary disease (COPD). The diagnosis of COPD rests on the presence of airway obstruction, which is only partially reversible after bronchodilator treatment. Ninety-six consecutive patients undergoing thoracic surgery for peripheral lung cancer were enrolled. They were divided into two groups: preoperative forced expiratory volume in 1 s/forced vital capacity ratio <70% or >70%. Rmin,rs was measured after 5 and 10 min of maintenance anesthesia by using the constant flow/rapid occlusion method. Maintenance of anesthesia was randomized to thiopental 0.30 mg . kg(-1) . min(-1) or 1.1 minimum alveolar anesthetic concentration end-tidal isoflurane or sevoflurane. Eleven patients were excluded: two because anesthesia was erroneously induced with propofol and nine because of an incorrect tube position. Maintenance with thiopental failed to decrease Rmin,rs, whereas both volatile anesthetics were able to decrease Rmin,rs in patients with COPD. The percentage of patients who did not respond to volatile anesthetics was larger in those with COPD as well. In conclusion, we have demonstrated that isoflurane and sevoflurane produce bronchodilation in patients with COPD.

Analgesia, sedation, and memory of intensive care.

PURPOSE: The purpose of this article was to investigate the relationship between analgesia, sedation, and memory of intensive care. PATIENTS AND METHODS: One hundred fifty-two adult, cooperative intensive care unit (ICU) patients were interviewed 6 months after hospital discharge about their memory of intensive care. The patient was considered to be cooperative when he/she was aware of self and environment at the interview. The patients were grouped as follows: A (45 patients) substantially no sedation, B (85) morphine, and C (22) morphine and other sedatives. RESULTS: The patients having no memory of intensive care were 38%, 34%, and 23% respectively, in the three groups. They were less ill, according to SAPS II (P <.05), and had a shorter ICU stay (P <.01). Group C patients were more seriously ill according to SAPS II, duration of mechanical ventilation, and length of stay in ICU and in hospital (P <.001). The incidence of factual, sensation, and emotional memories was not different among the three groups. Females reported at least one emotional memory more frequently than males (odds ratio 4.17; 95% CI 10.97-1.59). CONCLUSIONS: The patients receiving sedatives in the ICU are not comparable with those receiving only opiates or nothing, due to the different clinical condition. The lack of memory of intensive care is present in one third of patients and is influenced more by length of stay in ICU than by the sedation received. Sedation does not influence the incidence of factual, sensation, and emotional memories of ICU admitted patients. Females have higher incidences of emotional memories than males.

Responsiveness to intravenous administration of salbutamol in chronic obstructive pulmonary disease patients with acute respiratory failure.

OBJECTIVE: In chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF), bronchodilating agents administered by inhalation have, in general, little effect on dynamic hyperinflation and concurrent static intrinsic positive end-expiratory pressure (PEEPi,st). Since in COPD the severely obstructed segments of the lung may not be reached by inhaled medication, we reasoned that drug efficiency may be enhanced by intravenous administration of the agent. DESIGN: Physiological study. SETTING: Two four-bed surgical-medical ICUs of a university hospital. PATIENTS: Fourteen COPD patients were studied within 36 h from the onset of ARF. MEASUREMENTS AND RESULTS: Static compliance (Cst,rs), minimal (Rmin,rs) and additional (DeltaRrs) resistance of the respiratory system, and PEEPi,st were measured before and after intravenous administration of salbutamol. All patients had limitation of air flow before and after salbutamol administration. On average, after salbutamol there was a small, though significant, decrease in Rmin,rs (-9%), DeltaRrs (-12%) and PEEPi,st (-8%). CONCLUSION: The changes in resistance and PEEPi,st after intravenous administration of salbutamol were too small to be of clinical significance.

Quality of life before intensive care admission: agreement between patient and relative assessment.

OBJECTIVE: To assess the agreement between patients and relatives concerning the formers' quality of life (QOL) before intensive care unit (ICU) admission. DESIGN: Prospective study involving direct interviews of patients and relatives during ICU stay. SETTING: Two four-bed surgical-medical ICUs in a 960-bed teaching hospital. PATIENTS AND METHODS: A hundred seventy-two adult, co-operative patients consecutively admitted to ICU for more than 24 h, and their relatives were interviewed. The instruments used were two questionnaires suitable for ICU patients: QOL-IT and QOL-SP. Interobserver reproducibility was investigated in 36 patients. RESULTS: Interobserver reproducibility was nearly perfect (weighted Kappa 0.99 for QOL-IT and QOL-SP). Considering global scores, weighted Kappa was 0.78 for QOL-IT and 0.82 for QOL-SP, with the mean difference between patients and relatives lower than 0.3 for both scores but with limits of agreement wider than 4. Among the items, concordance was excellent in the areas of physical activity and social life for both questionnaires. Gender, living together with the patient and the degree of relationship of relatives did not influence the agreement. CONCLUSIONS: The relatives give global scores for both instruments which can be regarded as acceptable substitutes for those given by patients. However, the wide limits of agreement should make investigators cautious in analysing together scores generated by patients and by relatives. The emotional dimension seems to be assessed less accurately by relatives than the physical one.

Validation of two quality of life questionnaires suitable for intensive care patients.

OBJECTIVE: To validate two instruments measuring quality of life (QOL) suitable for patients admitted to the intensive care unit (ICU): QOL-IT and QOL-SP. DESIGN: Prospective study using patient interviews. SETTING: Two four-bed surgical-medical ICUs in a 960-bed teaching hospital. PATIENTS AND METHODS: One hundred seventy-two adult, co-operative patients consecutively admitted to ICU for more than 24 h were interviewed. One year after hospital discharge, 84 survivors were interviewed again. Inter-observer reproducibility was investigated in 36 patients. To validate the instruments, the QOL-IT and QOL-SP scores reported by patients were considered according to the functional limitation evaluated by the interviewer. Moreover, the theoretical prediction that patients with chronic diseases should have a worse QOL before ICU admission than patients with only acute illness was tested. QOL-IT and QOL-SP scores given 1 year after hospital discharge were compared with those recorded at the first interview. RESULTS: Inter-observer reproducibility was excellent. The possible range of QOL-IT is 0-20 and that of QOL-SP 0-29. According to the functional limitation (absent, mild or severe), the median QOL-IT score increased from 3 to 6 to 13 and QOL-SP from 2 to 6 to 12 (p< 0.0001). The patients with chronic diseases gave scores significantly higher than the patients with only acute illness (median QOL-IT 8 versus 3, p< 0.013; QOL-SP 8 versus 4, p< 0.004). The median QOL-IT score changed from 3 to 4 one year after hospital discharge, a difference which is statistically (p< 0.001), but not clinically, significant. The median QOL-SP score was 3 and did not change. CONCLUSIONS: QOL-IT and QOL-SP are instruments able to discriminate between different health states.

[Laryngeal mask vs tracheal tube in pediatric anesthesia in the presence of upper respiratory tract infection]. / Maschera laringea vs tubo orotracheale in anestesia pediatrica nella flogosi delle prime vie aeree.

BACKGROUND: The aim of this report is to assess the incidence of postoperative respiratory complications in patients recently suffering from inflammation of the upper respiratory tract in whom a LMA or an uncuffed orotracheal tube have been used. METHODS: Four hundred patients were enrolled aged 6 months to 12 years undergoing general anaesthesia for elective body surface surgery with insertion of the LMA (group M) or the uncuffed tube (group T). Acute inflammation of the upper airways (URI) was assessed, defined by the presence of at least two of the following symptoms, rhinorrhea, coughing, pharyngodynia, disphony, fever, malaise. The appearance of post-surgical adverse respiratory events (ARE), such as laryngospasm, stridor, disphony, excessive coughing was detected. Patients were divided into four groups in relation to the management of the airway and the presence or otherwise of URI (M URI, M NO URI, T URI, T NO URI). RESULTS: In NO URI patients, the presence of ARE was 9.6% in the M and 36.9% in the T group (p < 0.001); in URI patients, these figures were respectively 31.5% and 73.9% (p < 0.001). CONCLUSIONS: The frequency of ARE increases significantly in URI patients with both LMA and the tracheal tube, but with the former is far lower than with the latter. Despite the appearance of only minor and transient complications, it is confirmed that the tracheal intubation is an additional risk factor as a result of the mechanical airway simulation. In recent URI, it would seem appropriate to avoid tracheal intubation, if possible, preferring the LMA.

Predictors of weaning outcome in chronic obstructive pulmonary disease patients.

Several threshold values for predicting weaning outcome from mechanical ventilation have been proposed. These values, however, have been obtained in nonhomogeneous patient populations. The aim of the present study was to determine the threshold values in chronic obstructive pulmonary disease (COPD) patients and compare them to those reported for nonhomogeneous patient populations. The initial weaning trial included 81 COPD patients. Fifty-three of them underwent a successful weaning trial, whereas 28 failed it. The latter were enrolled into the present investigation, and were restudied during a subsequent successful trial. The weaning indices used were those reported in the literature. The threshold values obtained were within 10% of those reported for a nonhomogeneous patients population only for tidal volume and effective compliance. The classification error was <20% for maximal inspiratory pressure (MIP), occluded inspiratory pressure swing (deltaPI)/MIP, rapid and shallow breathing (respiratory frequency/tidal volume), and compliance, rate, oxygenation, pressure index (CROP), whereas the area under the receiver operating characteristic curves was >0.9 only for deltaPI/MIP and CROP. In conclusion, the threshold values obtained in chronic obstructive pulmonary disease patients who failed the first weaning attempt differed from those previously reported. Although a gold standard weaning index is not available for chronic obstructive pulmonary disease patients, the occluded inspiratory pressure swing/ maximal inspiratory pressure and compliance, rate, oxygenation, pressure index may be candidates for such a role.

[Laryngeal mask vs tracheal intubation during mechanical ventilation in pediatric anesthesia]. / Maschera laringea vs tubo tracheale in ventilazione meccanica in anestesia pediatrica.

AIM: The aim of this study was to evaluate and compare the parameters for mechanical respiration in pediatric patients undergoing controlled ventilation with a laryngeal mask (LM) and an uncuffed orotracheal tube. METHODS: The study examined 100 ASA 1 patients undergoing general anesthesia with myoresolution and mechanical ventilation using a Servo Ventilator 900 (constant flow, 25% insufflation, 10% teleinspiratory pause, tidal volume 10 ml/kg). All patients were divided into 2 groups matched for age and weight. An uncuffed orotracheal tube was used in one group (Group T) and a laryngeal mask (LM) in the other (Group M). The following parameters were measured: peak and pause pressure in the respiratory passage (Paw), total inspiratory resistance (R tot), compliance (C) and air loss expressed as a fraction of inspired volume (Vi-Ve/Vi). The statistical analysis of results was performed using Student's "t"-test and the level of significance was p < 0.05. RESULTS: Peak pressures were comparable in the two groups and were lower than the pressure needed to open the lower esophageal sphincter. These values could be further reduced by the extension of insufflation time achieved by abolishing the teleinspiratory pause included in the study to measure air resistances and compliance. Air losses were also similar in both groups, being respectively 13 and 11%. This means that environmental pollution using LM was not greater than with the uncuffed tube and confirms that, even with the latter, the protection of the airways cannot be regarded as absolute. Total inspiratory resistances were respectively 16.1 cm H2O/l/sec in group T and 15.1 cm H2O/l/sec in group M. This occurred in spite of the fact that the latter showed an in vitro capacity to oppose lower resistances compared to the corresponding tubes given that it was shorter with a larger diameter. Studies using the mechanical model did not include the laryngeal mask--larynx connection which may cause increased resistance owing to the variable position of the epiglottis, although this cannot be identified clinically. CONCLUSIONS: The laryngeal mask allows mechanical ventilation with low pressure in the respiratory passage and reduced air losses compared to the uncuffed tracheal tube. The risk of gastroesophageal insufflation is therefore minimal and artificial ventilation is reliable, if correctly performed. Lower levels of inspiratory resistance might be an advantage in spontaneous breathing owing to the consequent reduction of respiratory effort, but they do not appear to be significantly lower than with the tracheal tube.

Presumptive delayed gas embolism after laparoscopic cholecystectomy.

A 50-year-old woman, with a history of arterial hypertension treated with beta-blocker and Ca-antagonist, presented cardiac arrest 6 hours after elective laparoscopic cholecystectomy. During surgical intervention, arterial hypotension without any respiratory change was observed. Dyspnea, asthenia and anxiety were the clinical signs appearing approximately 2 hours before cardiac arrest. After resuscitation, myocardial infarction, dissecting thoracic aortic aneurysm and major pulmonary thromboembolism were excluded. The signs of increased resistance to the right ventricular outflow and the relevant alteration of coagulation tests, lasting only a few hours, suggested venous gas embolism. Subsequently, the patient presented a cortical blindness, persisting at hospital discharge. The anesthetists should be aware about the complication that we observed after laparoscopic surgery. The least sign of cardiorespiratory instability appearing in the postoperative period must be taken into account and signal the need for increased monitoring.

Validation of severity scoring systems SAPS II and APACHE II in a single-center population.

OBJECTIVE: To validate two severity scoring systems, the Simplified Acute Physiology Score (SAPS II) and Acute Physiology and Chronic Health Evaluation (APACHE II), in a single-center ICU population. DESIGN AND SETTING: Prospective data collection in a two four-bed multidisciplinary ICUs of a teaching hospital. PATIENTS AND METHODS: Data were collected in ICU over 4 years on 1,721 consecutively admitted patients (aged 18 years or older, no transferrals, ICU stay at least 24 h) regarding SAPS II, APACHE II, predicted hospital mortality, and survival upon hospital discharge. RESULTS: At the predicted risk of 0.5, sensitivity was 39.4 % for SAPS II and 31.6 % for APACHE II, specificity 95.6 % and 97.2 %, and correct classification rate 85.6 % and 85.5 %, respectively. The area under the ROC curve was higher than 0.8 for both models. The goodness-of-fit statistic showed no significant difference between observed and predicted hospital mortality (H = 7.62 for SAPS II, H = 3.87 for APACHE II; and C = 9.32 and C = 5.05, respectively). Observed hospital mortality of patients with risk of death higher than 60 % was overpredicted by SAPS II and underpredicted by APACHE II. The observed hospital mortality was significantly higher than that predicted by the models in medical patients and in those admitted from the ward. CONCLUSIONS: This study validates both SAPS II and APACHE II scores in an ICU population comprised mainly of surgical patients. The type of ICU admission and the location in the hospital before ICU admission influence the predictive ability of the models.

Respiratory mechanics during and after anaesthesia for major vascular surgery.

To evaluate the effects of major vascular surgery on respiratory mechanics, 11 patients undergoing general anaesthesia for abdominal aortic surgery were studied. Before aortic cross-clamping, chest wall elastance and resistance both increased (by 126% and 58%, respectively) when surgical retractors were placed. After aortic cross-clamping, lung elastance increased by 29%, accompanied by a decrease in cardiac index (22%) and an increase in pulmonary (17%) and systemic (15%) vascular resistance. After aortic unclamping, lung elastance decreased, although it remained higher than baseline values (by 12%). All cardiovascular variables returned to the values obtained before aortic cross-clamping.