ABSTRACT
BACKGROUND: In Awake Craniotomy (AC), α2-agonists and remifentanil (clonidine and dexmedetomidine) are used in the preoperative phase and throughout the procedure to combine monitored anesthesia care and local anesthesia. The study aims were to specify the key role of α2-agonists administered and to evaluate complication presence/absence in anesthesiologic management. METHODS: 42 patients undergoing AC in 3 different centers in the south of Italy (Foggia, San Giovanni Rotondo, and Bari) were recruited. Our protocol involves analgo-sedation by administering Dexmedetomidine and Remifentanil in continuous intravenous infusion, allowing the patient to be sedated and in comfort but contactable and spontaneously breathing. During pre-surgery, the patient is premedicated with intramuscular clonidine (2 µg/kg). In the operating setting, Dexmedetomidine in infusion and Remifentanil in Target Controlled Infusion for effect are started. At the end of the surgical procedure, the infusion of drugs was suspended. RESULTS: There were no intraoperative side effects. The mean duration of interventions was 240 ± 62 min. The average quantity of Remifentanil and Dexmedetomidine infused during interventions were 4.2 ± 1.3 mg and 1.0 ± 0.3 mg, respectively. No significant side effects were described in the post-operative phase. A total of 86% of patients and 93% of surgeons were totally satisfied. CONCLUSIONS: Synergy between opioid drugs and α2 agonists plays a fundamental role in ensuring procedure success.
ABSTRACT
OBJECTIVE: The purpose of this study was to evaluate the efficiency, in terms of decreasing overall mortality (primary endpoint), of an immunoglobulin M (IgM)-enriched, polyclonal intravenous immunoglobulin preparation (IVIg) (Pentaglobin; Biotest AG, Dreieich, Germany) in the treatment of a group of patients affected by sepsis after cardiac surgery. A secondary endpoint was to evaluate which subgroup, on the basis of the infectious state when the patient enrolled, could benefit the most from the treatment. Another secondary endpoint was the evaluation of an improvement in the severity score or in other variables such as Glasgow Coma Scale; arterial pressure (systolic, average, and diastolic); heart rate; central venous pressure; cardiac index; respiratory rate; PaO(2), F(I)O(2), and the ratio of PaO(2) to F(I)O(2); pH, base excess, and bicarbonate; C reactive protein and leukocytes; platelets, prothrombin time, partial thromboplastin time, fibrinogen, and anti-thrombin III; creatinine; and bilirubin. DESIGN: Retrospective case-controlled study. SETTING: Cardiovascular intensive care unit of a university hospital. PARTICIPANTS: Sixty-six patients who developed sepsis in the postoperative period after cardiac surgery were admitted to the cardiovascular intensive care unit from June 1, 2001, to June 30, 2003: 30 patients (45.5%) had valvular surgery, 18 (27.5%) had myocardial revascularization, 14 (21%) had thoracic aorta surgery, and 4 (6%) had other surgery. INTERVENTIONS: From the 66 patients diagnosed with sepsis, 22 patients (IVIg group) received IgM-enriched immunoglobulins in addition to the conventional therapy, whereas the other 44 patients (control group) were treated only with conventional therapy. The decision as to whether or not to administer the immunoglobulins was made by physicians in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Of the 66 patients, 8 patients (3 from the IVIg group and 5 from the control group) had sepsis, 47 patients (15 from the IVIg group and 32 from the control group) had severe sepsis, and 11 patients had septic shock (4 from the IVIg group and 7 from the control group). The overall mortality rate was 31.8% without significant differences between groups (22.7% IVIg group v 36.4% control group, p = not significant). Among the 47 patients affected by severe sepsis, those from the control group had a mortality rate significantly higher than that of the IVIg group (12/32 [37.5%] v 1/15 [6.6%], p = 0.036 [2-sided Fisher exact test]). The 70-day survival rate was significantly higher in the IVIg group than in the control group (log-rank test, p < 0.04). No significant differences were found between study groups in Acute Physiology and Chronic Health Evaluation II or SOFA scores. CONCLUSIONS: The polyclonal IgM-enriched immunoglobulins did not significantly reduce the mortality rate in the overall study population. However, in the subgroup of patients with severe sepsis, they improved the survival rate significantly.
