Sufentanil-propofol vs remifentanil-propofol during total intravenous anesthesia for neurosurgery. A multicentre study.

BACKGROUND: In a randomised, prospective multi-centre study, we compared the intraoperative and postoperative effects of two opioids: sufentanil and remifentanil, in combination with propofol in two groups of patients undergoing neurosurgery. METHODS: After Local Ethics Committee approval and informed consent obtaining, 69 patients undergoing neurosurgery for supratentorial tumours, between 18 and 75 years of age were randomised to receive either sufentanil or remifentanil in combination with propofol. Intraoperative and postoperative haemodynamic variables, recovery times (time to eye opening and to extubation), the incidence of postoperative respiratory depression, pain, nausea and vomiting were also evaluated. The Short Orientation-Memory-Concentration Test was used to evaluate cognitive function at 15, 45 and 180 min after emergence from anesthesia. RESULTS: There were no significant differences between the groups in the duration of surgery and anesthesia, mean arterial pressure, heart rate, time to eye opening or extubation. The incidence of vomiting, respiratory depression and shivering was similar in both groups. Postoperative pain requiring supplemental analgesics was significantly lower in the sufentanil group (P<0.05). Although there were no significant differences between the groups in postoperative behavioural examinations by Rancho Los Amigos Test, patients anesthetised with sufentanil had significantly better Short Orientation-Memory-Concentration Test values at 15 and 180 min postoperatively (P<0.05). CONCLUSION. We conclude that remifentanil and sufentanil are suitable adjunct to propofol for total intravenous anesthesia (TIVA). Patients receiving sufentanil have reduced analgesic requirements and better cognitive function postoperatively than those who received remifentanil.

An Italian survey of severe head trauma management during extracranial surgery.

BACKGROUND AND OBJECTIVE: Anaesthetic drugs and procedures interfere with secondary brain injury following severe head trauma, yet studies regarding the anaesthetic management of these patients are lacking. We investigated the behaviour of Italian anaesthetists regarding this topic. METHODS: A questionnaire investigating the approach to a patient with severe head trauma requiring an urgent splenectomy for ruptured spleen was sent to 250 Italian anaesthetists. Questions regarded the pre-, intra- and postoperative phases, and concerned the rationale use and availability of specific monitoring systems, and indications for invasive procedures and use of drugs, fluids and blood products. RESULTS: There were 162 (64.8%) responders. Seventy-five percent believed that early tracheal intubation within the emergency room was necessary, while 25% postponed it to the operating room. Basic monitoring was defined as essential by all responders, 147 (90.7%) considered invasive arterial pressure monitoring to be essential. Fifty-seven (84%) anaesthetists working in hospitals without neurosurgical facilities would have transferred the patient after splenectomy. Prophylactic hyperventilation was frequently used (36%). Sixty-eight percent of responders would have preferred in intracranial pressure monitoring inserted before laparotomy, but only 35% actually had this possibility. In case of acute intraoperative arterial hypotension after splenectomy, 54% of the responders advocated the use of blood or blood products to optimize peripheral oxygen transport. CONCLUSIONS: More widespread knowledge of certain areas of severe head trauma management such as early tracheal intubation, avoidance of prophylactic hyperventilation, adequate invasive monitoring, appropriate use of blood products, and timing of transfer to hospitals with neurosurgical facilities is needed.

Differing temporal patterns of onset in subgroups of patients with intracerebral hemorrhage.

BACKGROUND AND PURPOSE: The purpose of this study was to further analyze the temporal patterns of onset of intracerebral hemorrhage (ICH) and to determine whether or not subgroups with specific clinical characteristics exhibit different patterns of onset. METHODS: The daily, weekly, and yearly variations in occurrence of ICH together with the relationship between ICH occurrence and changes in air temperature were evaluated in 1018 patients. Patients were grouped according to the presumed etiology of ICH: hypertensive ICH, secondary ICH, and ICH of undetermined origin. The contribution of demographic and clinical factors to the temporal distributions of ICH was also evaluated. RESULTS: Marked differences in seasonal and diurnal patterns of ICH onset were observed in the different groups. The incidence of hypertensive ICH reflected seasonal and circadian changes in blood pressure, whereas the latter did not seem related to the onset of nonhypertensive ICH. The seasonal pattern was more evident in elderly patients with hypertensive ICH than in younger subjects. No significant weekly variations were observed; however, risk was greater on Monday in the working population. CONCLUSIONS: Our results suggest that the higher incidence of ICH in the colder months is due to the effect of low temperatures on blood pressure and that the clustering of ICH events in the morning is due to the increase in sympathetic tone, and consequent increase in blood pressure, on awakening.

[Cerebral venous angiomas in childhood]. / Angiomi venosi cerebrali nell'infanzia.

Six cases of cerebral venous angioma in children under 8 years of age reported, with respects to their clinical and neuroradiological features. Any attempt of classification is inadequate, due to the protean characteristics of these malformations, wich can be definied - and usually are - upon the base of predominantly angiographic standards, a valuable diagnostic help being provided by the computerized tomographic investigation. The study of cerebral regional blood flow can represent a major instrument when the clinical and morphological aspects of the malformation make an alteration of it suspectable. In the cases we operated on, clinical healing has been obtained; no worsening has been observed in non-operated cases, during a follow-up of 1 to 7 years; only one of our little patients, presenting with an enormous aneurism of Galen's vein, which we regarded as inoperable, died at 9 months of age.

[Clinical aspects of the prognosis of skull and brain injuries. A study of 108 cases]. / Elementi clinici di prognosi nei traumatizzati cranio-encefalici. Studio di 108 case.

An assessment is made of the extent to which age and the degree an seriousness of the initial neurological picture influenced prognosis in a series of 108 subjects with brain injuries treated in the Siena Hospital Intensive Care Unit between 1974 and 1977. Neurological disease was classified according to Posner and Plum. Mortality was 46.2%. In most cases, age tended to exacerbate the neurological syndrome from the outset. It also facilitated the appearance of respiratory sepsis, which aggravated the brian picture in its turn. Age differences, however, seemed to be of lesser prognostic value when the neurological syndrome was very serious from the beginning.

[Dexamethasone-21-phosphate in the treatment of cerebral edema. Evaluation of the effects on diuresis, natremia and natriuria]. / II desametazone-21-fosfato nel trattamento dell'edema cerebrale. Valutazione degli effetti sulla diuresi, natriemia e natriuria.

An evaluation was made of variations in blood and urinary sodium following the administration of 24 mg/day desamethasone-21-phosphate for at least 9 days, starting from admission, as cerebral antioedemigenic therapy in 30 patients with nerve traumas. The changes observed were within normal limits. This absence of interference with the hydro-electrolyte balance is a strong point in favour of the use of the drug in the treatment of cerebral oedema. The exact mechanism of action of this type of glycocorticoid, however, is still unknown.