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.

Perspectives for use of surfactant in children and adults.

After impressive results in the treatment of respiratory failure in premature babies, natural surfactant has been proposed in lung pathologies involving suspected surfactant deficiency. Apart from bronchiolitis, in which surfactant was used to stabilize small airways and for its possible antiviral action, research was directed towards pneumonia and sepsis, aspiration and chest trauma, which can lead to adult respiratory distress syndrome. Surfactant bronchoalveolar lavage has been used to 'cleanse' lungs, remove inhibitors and provide sufficient functional surfactant. Failure of surfactant therapy can be caused by insufficient dose, delayed administration, excessive inhibition and catabolism, or by type, severity and complexity of the lung disease (multi-organ failure).

A prospective randomized double-blinded controlled study of ropivacaine 0.75% versus bupivacaine 0.5%-mepivacaine 2% for peribulbar anesthesia.

BACKGROUND AND OBJECTIVES: Ropivacaine 1% has recently been used in clinical trials for peribulbar anesthesia. This study aims to compare the safety and the efficacy of ropivacaine 0.75% with that of a 1:1 mixture of bupivacaine 0.5% and mepivacaine 2% for peribulbar anesthesia. METHODS: Two thousand patients undergoing peribulbar anesthesia for elective cataract phacoemulsification were prospectively studied over a 1-year period and randomly assigned to 1 of 2 groups according to the local anesthetic used. One thousand patients were administered peribulbar anesthesia with 9 mL of ropivacaine 0.75% plus 1 mL of hyaluronidase (group R), and 1,000 patients received peribulbar anesthesia with 4 mL of bupivacaine 0.5% plus 4 mL of mepivacaine 2% plus 1 mL of hyaluronidase plus 1 mL of sodium bicarbonate (group BM). Peribulbar anesthesia was always accomplished by the same physician by 2 injections of 5 mL each, with a 25-gauge 25-mm needle. Evaluation was performed by another physician blinded to the technique used and included assessment of pain on local anesthetic injection, ocular and eyelid akinesia, need for top-up injections, onset time and duration of anesthesia, intraoperative analgesia, duration of surgery, hemodynamic parameters, and incidence of perioperative complications. RESULTS: A greater incidence of pain on injection was found in group BM (P<.001). No difference between the groups was found regarding the onset time and the duration of anesthesia. Perioperative analgesia was satisfactory in both groups with no significant difference. Patients in group R showed a reduced need for top-up injection and a better ocular akinesia at 8 and 10 minutes (P<.01). The akinesia of the eyelid was comparable in the 2 groups and complete in all cases at 8 minutes. Cardiac arrhythmias were more frequent in group BM (P<.01). Local complications did not differ between the groups. An increase in mean artierial blood pressure and heart rate was observed in both groups 1 minute after injection of local anesthetic. CONCLUSIONS: Peribulbar anesthesia with ropivacaine provided better ocular akinesia 8 to 10 minutes after block insertion than a bupivacaine-mepivacaine mixture, which reduced the need for top-up injections. Ropivacaine also caused less pain on injection.

Natural surfactant supplementation in ARDS in paediatric age.

OBJECTIVE: To evaluate the effects of natural surfactant supplementation in infants, children and adolescents affected by ARDS from different origins in order to reduce lung barotrauma due to artificial ventilation, improve gas exchange, reduce oxygen toxicity and survival. MATERIALS AND METHODS: Two groups, the first consisting of 22 children, 7 days-24 months, and the second of 8 oncohaematologic patients, 2-16 years, affected by ARDS from sepsis, inhalation syndrome and interstitial pneumonia, candidates for ECMO, were treated intratracheally with 50 mg/kg of natural surfactant. Before treatment all patients had been mechanically ventilated using PEEP levels > or = 8 cm H2O and FiO2 > or = 0.6, for at least 24 hours without any improvement in gas exchange. RESULTS: From 15 mins after surfactant administration a progressive improvement in PaO2 was noted which peaked at 3 hours. In two cases in the first group a worsening in PaO2 occurred starting from 12-18 hours, which needed additional doses. All patients in the second group needed additional doses after 12 h. No significant PaCO2 variations were noted until 24 hours. In all cases the chest X-ray improved at 4 hours and clearing was obtained starting from 24 hours in those cases where an additional dose had not been necessary. Computed Tomography confirmed the improvement in lung pathology. All the children in the first group survived except one HIV-positive child. The oncohaematologic children showed an improvement in PaO2 after each administration of surfactant even though they later died due to their initial disease, except one child. COMMENT: Surfactant efficacy in this study appears to depend on the severity of lung pathology and to be strictly connected with early treatment.

Pulmonary atelectasis during paediatric anaesthesia: CT scan evaluation and effect of positive endexpiratory pressure (PEEP).

The case series consisted of ten children, ranged in age from one to three years (median 1.8 yrs), and in body weight from 10.2 to 13.5 kg (median 11.7 kg), in ASA class 1 or 2, all without lung disease. Having undergone general anaesthesia for cranial or abdominal CT scans, the patients were studied for pulmonary morphology. The first pulmonary CT scan was taken five min after induction of general inhalational anaesthesia; preoxygenation was avoided and an intraoperative FiO2

Evaluation of the efficiency of heat and moisture exchangers during paediatric anaesthesia.

This study evaluates the efficiency of heat and moisture exchangers (HMEs) in allowing adequate humidification and warming during anaesthesia in children. Eighteen paediatric patients undergoing anaesthesia were divided into two groups: group A ten patients: infants up to 10 kg-->Hygrobaby HME; group B 8 patients: children above 10 kg-->Hygroboy HME. The following parameters were evaluated: body temperature (bT), room temperature (rT), fresh gas temperature, HME warm-up time, inspired and expired gases temperature and humidity, conserving efficiency, and duration of anaesthesia. Gas temperatures were recorded by means of a recorder fitted with four thermal probes. Humidity values were mathematically derived. The correlation between efficiency and rT, bT, and fresh gas temperature was computed. In both groups the inspired gases temperatures were below 30 degrees C. Inspired absolute humidity was never more than 28 mgH2O.l(-1). The conserving efficiency was good (0.93 in both groups). A positive correlation was found between efficiency and fresh gas temperature. HMEs did not meet the minimum standards for humidity and heating during anaesthesia in children, although their conserving efficiency was found to be satisfactory.

Porcine-derived surfactant treatment of severe bronchiolitis.

BACKGROUND: It is hypothesized that surfactant treatment helps to improve severe bronchiolitis by restoring surfactant system activity. This study aims to assess the effect of surfactant on gas exchange, peak inspiratory pressure and duration of mechanical ventilation and intensive care unit (ICU) stay in children with severe bronchiolitis. METHODS: Twenty children with bronchiolitis requiring mechanical ventilation were randomly assigned to one of two groups (10 patients each). Group A was treated with continuous positive pressure ventilation (CPPV) plus surfactant. Group B was treated with CPPV only. Porcine-derived surfactant, 50 mg/kg body weight, was instilled into the trachea. Arterial tension of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, arterial tension of carbon dioxide (PaCO2), and peak inspiratory pressure (PIP) were assessed. Heart rate and non-invasive arterial blood pressure were monitored. The duration of CPPV and the length of ICU stay were also recorded. Finally, the incidence of complications and the survival rate were assessed. RESULTS: In group A, the PaO2/FiO2 ratio significantly improved from 1 h and a reduction in PaCO2 was noted from 12 h. A reduction of PIP was observed from 3 h. The duration of CPPV and the length of ICU stay were reduced in group A. No complications were reported in either group and all children survived. CONCLUSIONS: Surfactant treatment of severe bronchiolitis appeared to improve gas exchange, reduce PIP and shorten CPPV and ICU stay. However, these initial results must be confirmed by a larger and more rigorously controlled study.

Comparison of three different humidification systems during prolonged mechanical ventilation.

BACKGROUND: An efficient humidification system is expected to maintain fluid and easily drainable airway secretions. This study aims to compare the efficiency and safety of three humidification systems during prolonged mechanical ventilation. DESIGN: Two-center, prospective, randomized study. METHODS: 45 critically ill patients undergoing mechanical ventilation were included in the study and allocated to receive one of three humidification techniques: 1) Bennett Cascade water-bath humidifier (Bennett group); 2) Fisher & Paykel servocontrolled humidifier (F & P group); 3) HME Hygrobac DAR (HME group). Clinical and experimental observations were conducted for 3 to 7 consecutive days and included: body T degree, room T degree, inspired gas T degree, tracheal T degree, relative and absolute humidity, heat and water loss, airway secretion score, need for endotracheal saline instillation and incidence of ETT occlusion. RESULTS: The HME group showed a lower temperature of inspired gases compared to the F & P group (p < 0.05); it also showed a lower absolute humidity compared to both Bennett and F & P groups (p < 0.05). A better airway secretion score was obtained in Bennett and F & P groups compared to the HME group (p < 0.01). CONCLUSIONS: Passive humidification systems provided low degrees of humidity and temperature and could not maintain good secretions. Active systems appeared to satisfy the recommended standards and to allow fluid and easily drainable secretions.

Perfluorocarbon broncho-alveolar lavage and liquid ventilation versus saline broncho-alveolar lavage in adult guinea pig experimental model of meconium inhalation.

OBJECTIVE: This study compares perfluorocarbon broncho-alveolar lavage (PFC-BAL) with isotonic saline broncho-alveolar lavage (saline-BAL) in an experimental model of meconium aspiration in adult guinea pigs. DESIGN: Prospective controlled experimental study. PATIENTS AND METHODS: Ten male guinea pigs were given 1 ml of human meconium, diluted to 10% in isotonic saline, via tracheostomy and then artificially ventilated. After stabilization, five animals (control group) underwent BAL with 10 ml/ kg isotonic saline solution. After bronchial suctioning, a further BAL with 2 ml/kg saline was performed. The other five animals (study group) underwent BAL with 100 ml/kg of PFC (RIMAR 101). Bronchosuction was effected at 5 min and then a BAL with PFC 2 ml/kg was performed. Both groups received conventional mechanical ventilation during the lavage procedures. Within 20 min all the saline-BAL treated animals died, whereas the PFC-BAL treated animals survived and were then treated with total liquid ventilation (TLV) by gravity. MEASUREMENTS AND RESULTS: After meconium inhalation in both groups, a large alveolar-arterial oxygen difference, hypercarbia, severe acidosis and tachycardia were noticed. In PFC treated animals, an improvement in blood gases was noted and acid-base balance remained stable compared to saline-BAL treated animals. No haemodynamic change was observed during or after PFC-BAL, while during saline-BAL there was evidence of bradycardia, hypotension and respiratory failure, which led to the death of the animals. The histological lung sections in the PFC-BAL group showed evidence of normal alveolar expansion with a minimal presence of meconium debris in the small bronchioles. In saline-BAL treated animals, the lung structure appeared severely compromised with the presence of meconium in bronchioles and alveoli, intra-alveolar oedema and haemorrhagic areas. CONCLUSIONS: This study confirms the detrimental effects of meconium aspiration and the impairment of lung function following saline-BAL. By contrast, PFC-BAL and TLV by gravity seemed to prevent absorption of meconium, facilitate its removal, improve gas exchange and reduce lung barotrauma.

Role of early diagnosis for a noninvasive treatment of pulmonary thromboembolism in leukemic children.

Pulmonary thromboembolism (PTE) in leukemic children undergoing intensive chemotherapy should be promptly recognized so that specific therapy can be started. Our experience with the two cases reported here has led us to propose guidelines for the treatment of initial PTE in a pediatric hematology unit. Two children with leukemia developed PTE, the first during the relapse for acute lymphoblastic leukemia and the second at the onset of acute promyelocytic leukemia. In both cases, the diagnosis of PTE was based on clinical assessment of sudden acute respiratory failure with positive pulmonary perfusional scintigraphy in spite of a negative chest X-ray. The subintensive supervision consisted of instrumental monitoring with the assistance of an intensive care anesthetist. The clinical monitoring was based on the serial registration of respiratory rate, cardiac rate, SaO2 and body temperature. The thrombolytic therapy, together with heparin prophylaxis, was successfully administered in the hematology ward without the need for intensive care support (i.e. mechanical ventilation). The success of the treatment was documented by the criterion of a return to the normal cardiorespiratory parameters a few hours after the start of the thrombolytic treatment. Furthermore, a chest CT scan in case 1 and an arteriography in case 2 confirmed the PTE-related hypoperfusion. On the basis of this experience, the authors point out that in the course of acute respiratory failure in leukemic children, the combination of a negative chest X-ray and a positive pulmonary perfusional scintigraphy (compared whenever possible with ventilatory scintigraphy) in the presence of a negative CT scan could be a reliable diagnostic tool for PTE. This pathology should be treated promptly and with specific therapy to avoid progression to a severe, massive PTE.

[Nipple discharge: indications for surgery]. / La mammella secernente: indicazioni alla chirurgia.

Nipple discharges are related to physiological events or due to benign lesions of the breast. Sometimes they can express mammary cancers. The authors report their experience of the diagnosis and treatment of 1241 patients with secreting breast. They underline the importance of a correct diagnostic protocol to select cases needing surgical treatment.

Gasless laparoscopic resection of hepatocellular carcinoma (HCC) in cirrhosis.

Liver resection by open surgery remains the method of choice for treatment of hepatocellular carcinoma (HCC) in cirrhotic patients with compensated liver function. Laparoscopy for surgical treatment of hepatic diseases is at an early stage. Laparoscopy has been often proposed for diagnosis, staging of hepatic malignancy, treatment of hepatic cyst or benign tumors, but very few laparoscopic treatments of hepatic malignancies have been reported at present and always using conventional CO2 laparoscopy. We describe herein the operative treatment of a single subglissonian HCC of segment III in a child, HCV (hepatitis C virus)-related cirrhosis. A nonanatomical wedge resection was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. The technique, in selected cases, is a simple, safe, and effective surgical method. The gasless technique guarantees a clear vision, it makes possible the continuous suction of smoke and fluids, it allows the use of conventional instruments for classic maneuvers of the liver surgery (Pringle maneuver), and the easy management of suturing. The present case has proved to be another abdominal procedure that can be carried out with all the advantages of gasless minimally invasive surgery.

[Artificial ventilation in children during anesthesia]. / La ventilazione artificiale in età pediatrica durante l'anestesia.

The authors describe the advantages and disadvantages, the indications and benefits on gas exchange as a result of mechanical ventilation during anaesthesia. The two models of ventilation most commonly used have been analyzed: pressure ventilators and volume preset ventilators. The former are used only in cases of short-term anaesthesia or when volume ventilators are not available. Both the most appropriate settings and ventilatory modes have been discussed regarding different paediatric ages. Particular attention has been given to the oxygen concentration in the ventilated gases (oxygen toxicity > 40%) and to barotrauma connected with high peak pressure (> 30 cm H2O). The authors suggest the type and caliber of endotracheal tube and the tidal volume for paediatric ages.

Pulmonary thromboembolism in childhood leukemia: 8-years' experience in a pediatric hematology center.

PURPOSE: To assess the occurrence and possible causes of pulmonary thromboembolism (PTE) in children with hematologic malignancies evaluated in a single pediatric hematology center. PATIENTS AND METHODS: Four hundred fifty-two patients admitted for leukemia in different stages of disease were evaluated whenever they presented with PTE-related acute respiratory failure (ARF). Diagnosis was based on a perfusional lung scan and a digital pulmonary angiography in most cases. When necessary, patients with ARF were transferred to the pediatric intensive care unit (ICU) for cardiorespiratory monitoring and support. Thrombolytic treatment was usually performed with urokinase at a loading dose of 2,000 to 4,560 IU/kg as single bolus followed by 2,000 to 4,530 IU/kg/h for 12 to 42 hours. Before thrombolytic therapy was discontinued, heparin was started at a daily dose of 100 to 500 IU/kg as a continuous infusion and continued for 6 to 26 days. RESULTS: Twelve of 452 children developed 17 PTE episodes, which were resolved completely after appropriate therapy in 15 cases. Univariate analysis showed a statistical correlation between PTE and the diagnosis of acute myeloid leukemia (AML) (P < .001). No major bleeding was observed after thrombolytic treatment. CONCLUSION: Our findings indicate that PTE is not an extremely rare event in children with leukemia and should be ruled out when sudden tachypnea develops in patients with risk factors such as previous tumor lysis, central venous catheter (CVC) malfunction, coagulation abnormalities, and drug-induced pulmonary toxicity. Complete resolution of PTE may be obtained in a high proportion of cases with early diagnosis and proper treatment.