The daily-practiced post-partum hemorrhage management: an Italian multidisciplinary attended protocol.

Postpartum hemorrhage (PPH) is one of the most frequent causes of mortality and morbidity in the obstetric population globally, causing about a quarter of maternal deaths yearly, and is the leading cause of maternal death worldwide. The management of PPH remains a topic of great debate, even in view of new diagnostic and therapeutic possibilities in recent years, for which, however, the body of evidence available thus far is still scarce, as the standard values are lacking. The protocol hereby presented was developed after a literature review and during several meetings of an Italian multidisciplinary task group of specialists adopting a modified Delphi method, and is the result of the synthesis of therapeutic operational protocols for the treatment of PPH applied by the different specialties within the team. This protocol is intended to represent a practical proposal to support clinicians in the management of a particularly complex event that requires the intervention of a multidisciplinary team and the implementation of dedicated management protocols.

Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC).

BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment. METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting. RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness. CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

[Impact of an integrated treatment approach of the severely injured patients (ISS =/> 16) on hospital mortality and quality of care]. / Impatto di un modello di gestione integrata dei pazienti con trauma grave (ISS >/= 16) sulla qualità del trattamento ospedaliero e sulla mortalità ospedaliera.

BACKGROUND: Outcome of severely injured patients is sharply influenced by the level of prehospital and hospital organization. OBJECTIVE: To evaluate the impact of the re-organization of the trauma care process on the quality of care and final outcome of major trauma (ISS =/< 16) victims. SETTING: the Emergency Department (ED) of a 1600 bedded tertiary care hospital. INTERVENTION: a standardized approach to major trauma patients (MT) was implemented: Written protocols were established and trauma teams were organized. All anesthesiologists and trauma surgeons involved in trauma care were enrolled in an educational program including ATLS Courses and the Italian Resuscitation Council Prehospital Trauma Care Course. One of the targets was to assure the early orthopedic stabilization of limb and pelvis fractures. METHODS: Data of all major trauma victims admitted to the ED during 3 comparable periods of time: before (Jan-May 1998), during (Jan-May 1999) and after (Jan-May 2000) the implementation of the process, were retrospectively and prospectively collected and analyzed. RESULTS: MT patients admitted to the hospital increased from 39 in 1998 to 106 in 2000. For similar ISS (30.2 +/- 11.3 in 1998, 29.6 +/- 13.7 in 1999 and 30.5 +/- 12.9 in 2000) hospital mortality dropped from 42% in 1998 to 20.8%. The mean time from hospital admission to surgical orthopedic stabilization was 12 days in 1998, 4.6 in 1999 and 1.3 in 2000. In 2000, 86% of the patients with limbs fractures who required surgical stabilization, were treated within 36 hours from admission vs 11% in 1998. CONCLUSIONS: The implementation of written protocols for trauma care, the organization of trauma teams, educational programs including ATLS and PTC-IRC Courses and a strategy of early stabilization of limb fractures are associated with a dramatic decrease in hospital mortality for major trauma.

Dose-dependence of 4-aminopyridine plasma concentrations and electrophysiological effects in dogs : potential relevance to ionic mechanisms in vivo.

BACKGROUND: Previous investigators have administered 4-aminopyridine (4AP) to dogs to evaluate the role of transient outward current (I(to)) in vivo; however, plasma concentrations of 4AP were not measured, and it is therefore uncertain which cardiac ion channels were blocked at the concentrations achieved. METHODS AND RESULTS: We applied high-performance liquid chromatography to measure 4AP concentrations produced by intravenous 4AP administration to dogs. A previously described dose regimen produced plasma concentrations that increased during the maintenance infusion but never exceeded 250 micromol/L and caused significant mortality. Whole-cell patch-clamp experiments on isolated canine myocytes showed that even the maximum 4AP concentrations achieved in vivo failed to alter ventricular I(to) and had very small effects on atrial I(to); however, concentrations achieved in vivo had a strong inhibitory effect on the dog ultrarapid delayed rectifier (I(Kur.d)), present only in atrial cells. We designed a loading and maintenance infusion regimen to produce stable 4AP plasma concentrations. At concentrations in the range of 25 and 50 micromol/L, 4AP had no effect on ventricular refractory period but increased atrial refractoriness significantly, consistent with the results of voltage clamp studies. CONCLUSIONS: The interpretation of previous studies using intravenous 4AP administration to inhibit I(to) in dogs in vivo needs to be reevaluated in light of the fact that the infusion regimens used produce plasma concentrations that are inadequate to affect ventricular I(to). Our findings also support the concept that selective inhibition of ultrarapid delayed rectifier current can prolong atrial refractory periods without affecting ventricular refractoriness.

[A case of acute nimodipine poisoning. Cardiac and vascular effects]. / Su di un caso di intossicazione acuta da nimopidina. Effetti cardiaci e vascolari.

The authors report a clinical case of acute poisoning after ingestion of nimodipine. The patient, pulseless with a reduced level of consciousness and a third degree AV block, was treated with calcium salts, high doses of dopamine and temporary cardiac pacing. Nimodipine, a nifedipine-like calcium channel blocker, is widely used in cerebrovascular diseases with a low incidence of side effect. No cases of acute poisoning are reported in the literature. The possibility of loss of selectivity at higher doses suggests a cautious use of the drug in patients with alterations of AV conduction.

Activation of brown adipose tissue thermogenesis by chemical stimulation of the hypothalamic supraoptic nucleus.

Glutamate microinjection (1 M, 250 nl) into the hypothalamic supraoptic nucleus (SON) stimulated heat production in brown adipose tissue (BAT) and caused a rapid and sustained increase in interscapular BAT and core temperatures in urethane-anaesthetized rats. This effect was blocked by intraperitoneal pretreatment with a sympathetic ganglionic blocker, chlorisondamine chloride (2.5 mg/kg), or a beta-adrenergic receptor blocker, propranolol (2.5 mg/kg), but not by prior hypophysectomy or intracerebroventricular pretreatment with specific receptor blockers to vasopressin (d(CH2)5[Tyr(Me)2]AVP, 5 micrograms) or oxytocin (d(CH2(5)[Tyr(Me)2,Thr4,Tyr-NH2(9)]OVT, 5 micrograms). The results demonstrate that stimulation of SON cells with glutamate elicits a non-vasopressinergic/non-oxytocinergic neural signal that can bring about a sympathetically-mediated increase in BAT thermogenesis. Heat production in BAT is an important mechanism of thermal protection during cold stimulation, and there is evidence that osmotic stimulation can influence thermoregulation. SON neurons play a major role in osmoregulation via release of the peptide hormones vasopressin and oxytocin. The present results suggest the possibility that apart from releasing peptide hormones for osmoregulation, SON neurons might be involved in mediating the effect of osmotic stimulation on thermoregulatory responses involved in thermal adaptation.

NG-monomethyl-L-arginine co-injection attenuates the thermogenic and hyperthermic effects of E2 prostaglandin microinjection into the anterior hypothalamic preoptic area in rats.

Prostaglandin E2 (PGE2) microinjection (25 ng, 250 nl) into the preoptic area of the anterior hypothalamus (POAH) stimulated heat production in brown adipose tissue (BAT) and increased core temperature in urethane-anesthetized rats. These thermogenic and hyperthermic effects were attenuated by co-injection of NG-monomethyl-L-arginine (NMMA, 25 micrograms), a competitive inhibitor of nitric oxide (NO) production from L-arginine. Inclusion of L-arginine (50 micrograms), though not D-arginine (50 micrograms) reversed the inhibitory effect of NMMA (25 micrograms) on intra-POAH PGE2-induced increases in interscapular BAT (IBAT) and core temperatures. Intra-POAH injection of NMMA (25 micrograms) or L-arginine (50 micrograms) alone had no effect on IBAT and core temperatures. The results suggest that the effect on thermoregulation induced by action of PGE2 in the POAH is modulated by a local L-arginine-dependent and NMMA-sensitive NO-generating system.

[Circadian rhythm of ventilatory parameters of intrinsic asthma in clinical remission]. / Ritmo circadiano dei parametri ventilatori nell'asma primitiva in remissione clinica.

In six subjects with intrinsic asthma in clinical remission, time-structure of ventilatory parameters has been evaluated in order to evaluate: 1) which indexes present statistically significant circadian fluctuations; 2) if phase-shifts occur in comparison with normal subjects. After a period of synchronization of 7 days (L/D: 07.30-23.00; meal timing at 08.00, 13.00 and 20.30) all subjects have been studied by spirometry, flow-volume loop and Raw determination 6 times in a 24-hr period at constant intervals of 4 hrs. The results have been evaluated by macroscopic and microscopic analysis statistical significant fluctuations have been shown in these functional indexes: MEF50, Raw, SRaw, SGaw, FRC and RV; no phase-shifts occurred in comparison with normal subjects. On the contrary a circadian rhythm has not been shown in FVC, FEV1, and PEF. Therefore only the effort-independent test should be used to study correctly the bronchial tone.