Impact of perioperative haemodynamic monitoring on cardiac morbidity after major vascular surgery in low risk patients. A randomised pilot trial.

OBJECTIVE: to evaluate whether perioperative haemodynamic optimisation influences outcome from infrarenal abdominal aortic aneurysm repair. METHODS: a consecutive series of 100 eligible patients were randomised to either haemodynamic optimisation through the use of a pulmonary artery catheter (CI > 3.0 l/min/sqm, PWP > 10 and <18 mmHg, SVR <1450 dyne/sec/cm(-5), DO(2)> 600 ml/min/sqm) or conventional treatment. RESULTS: there were no differences in terms of in-hospital mortality, cardiovascular morbidity, postoperative renal failure or duration of hospital stay between the groups. CONCLUSIONS: in this study perioperative haemodynamic optimisation was not beneficial.

Not traditional prognostic factors in human conventional renal carcinoma.

The evaluation of know prognostic factors is an essential step of the assessment of the patients affected by primary renal carcinoma. As long as the major biological mechanisms of renal carcinomas remain unknown, it will be impossible to achieve an accurate prognostic judgement. The TNM classification has always been the main source of information. Nevertheless, recently several investigations evaluated the prognostic power of serum and cellular markers. The aim of this study is to identify those markers which show statistical reliability and can be used in the clinical practice. A literature search was performed on MEDLINE to identify potential not traditional prognostic factors for patients with renal cell carcinoma edited from January 1997 through April 2000 using prognosis and clear cell carcinoma and kidney as keywords. We considered also articles cited in references of first selected manuscript. The analysis of serum and cellular prognostic markers does not allow the identification of specific factors, reliable, independent, easy to dose, widely useful and whose informations are repeatable. Currently classical prognostic factors (staging, grading, hystologic type, patient clinical conditions, anaemia, presentation modalities, etc.) represent the only useful elements after surgical time in RCC patients. Among serum prognostic factors, CRP and ferritin play a crucial role. These proteins appear ideal in monitoring the disease over time, due to simple test execution and specimens repeatability. Among RCC molecular markers, proliferation index result promising for their reliability and reproducibility, the easy dosage and high series number tested. Literature data suggest that the ideal marker for renal carcinomas has not been identified yet. However, C-reactive protein, ferritin and the proliferative activity indexes (Ki67 and AgNOR) appear to be, at present, the best prognostic tools. To confirm obtained results and to use biomolecolar markers on a routinary base further studies on wide surgical series will be required. The improvement of technical tool and costs reduction represent also a necessary step toward the identification of efficient prognostic markers in RCC.

["Classic" vs autolubricant catheterization for endovesicular chemotherapy. Preliminary experience]. / Cateterismo "classico" vs autolubrificante per chemioterapia endovescicale. Esperienza preliminare.

AIM: The aim of this study was to evaluate the frequency of urinary tract infections (UTI) after catheterisation for instillation comparing two systems: the "classic" method and the catheterisation using a new autolubricant device: EasiCath Coloplast. METHODS: During the period of endovesical chemotherapy (between 4 and 48 weeks), 22 patients (6 females and 18 males) were studied, aged between 53 and 78 years old. We have performed 139 instillations using Nelaton Ch 14 or 12 type catheters lubricated with gel based on lidocaine, neomicyn and fluocinolone ("classic" method). Instead 135 patients have been treated with autolubricant devices according to the manufacturer's instructions. After 48 hours from instillation, a total of 274 catheterisation have been examined using urine tests and urine culture with antibiogram. We administered a 5-point visual analogic score to the patients weighing the post-instillation dysuria. RESULTS: With "classic" method UTI frequency is 7.19% (10/139). The most common pathogen has been E. coli (7/10). With autolubricant catheters UTI frequency is 2.96 (4/135). Klebsiella, Enterobacter, as well as E. coli (2/4) have been identified as pathogen. All patients with infections have been treated with targeted antibiotics based on the antibiogram. CONCLUSIONS: We have observed the people with autolubricant catheters left more comfort then those undergoing to the "classic" catheterisation. The frequency of post-catheterisation, dysuria was also reduced. Our data show that the new method is safer and easier to handle then the "classic" one. Moreover, common anaesthetic/antibiotic lubricant have important bacteriostatic effects that reduce the BCG viability.

[Ultrasonography-guided identification of the lumbar epidural space]. / Individuazione ecoguidata dello spazio epidurale lombare.

The study was designed to assess the reliability of sonographic evaluation in the prediction of the depth of the lumbar epidural space. Forty males, scheduled for epidural anesthesia for surgical repair of inguinal hernia, were prospectively studied. Patients were placed in a sitting position and sagittal scanning of the lumbar spine was performed with a 5-MHz transducer over the fourth or fifth interspace in order to identify the deeper hyperechogen interface, which represents the landmark between the ligamentum flavum and the epidural space. Ultrasound depth was measured and transducer removed. A Tuohy needle 18 G was then introduced percutaneously according to the standard technique and a rubber slide placed over it, so that it depth of insertion could be accurately measured. The potential for using ultrasounds for prediction of the distance from skin to epidural space was analyzed using a simple linear regression analysis; p values < 0.05 were considered significant. Mean values of ultrasound depth and needle depth were respectively 51 mm (SD 6.3) and 50.9 mm (SD 6.2); the correlation coefficient was 0.99. Ultrasound scanning of the lumbar spine provides an accurate measurement of the depth of the epidural space, which can facilitate the performance of the epidural anaesthesia and may decrease the complication rate, particularly in those patients in which anatomic landmarks are obscured.

[Trazodone versus flunitrazepam in premedication in day-care surgery]. / Trazodone versus flunitrazepam nella premedicazione in regime di ricovero giornaliero.

A prospective single-blind study was conducted to compare flunitrazepam vs trazodone in the premedication of patients undergoing day-case surgery for termination of pregnancy, with particular regard to the degree of preoperative sedation, intraoperative analgesia and postoperative recovery. 86 patients were randomly allocated to receive orally 45 minutes before the surgical procedure either flunitrazepam 2 mg (group F) or trazodone 50 mg (group T). In both groups anaesthesia was achieved by i.v. fentanyl 2.5 micrograms/kg and ketamina 250 micrograms/kg. Patients in group F showed a deeper degree of preoperative sedation. There were no significant differences in intraoperative analgesia and in the immediate arousal time. In the postoperative period, the incidences of emetic symptoms and dizziness were similar in both groups; the incidence of drowsiness was significantly higher in group F at 120 minutes but not at 180 minutes of observation. Psychomotor performance was assessed preoperatively two days before the surgical procedure and 60, 120 and 180 minutes after surgery, using the Toulouse-Pieron test and the reaction time to a luminous stimulus with the aid of a computerized analogic tachystoscope (Neurometer). Trazodone allowed a more rapid recovery of psychomotor performance and it can represent a valid alternative to the use of benzodiazepines in the premedication of day-case surgical patients.