Time course of proadrenomedullin in the early phase of septic shock. A comparative study with other proinflammatory proteins.

AIM: It has been shown that pro-adrenomedullin is a good marker of the severity of septic shock but there are no data on the early changes in serum pro-adrenomedullin concentrations in patients with shock. METHODS: Twenty-one patients with septic shock and 21 healthy subjects studied as controls. Serum concentrations of pro-adrenomedullin, procalcitonin, ferritin, CRP and IL-6 were determined in all subjects at the initial observation. Patients with septic shock were also studied after 24 and 48 hours. RESULTS: The concentrations of the acute phase proteins were significantly higher in patients with septic shock than in the control subjects during the entire study period (P<0.001). Only procalcitonin significantly decreased on the third day of observation with respect to both the first day (P=0.002) and the second day (P=0.006). Proadrenomedullin (P=0.017) and IL-6 (P=0.001) showed an AUC significantly different from the null hypothesis in differentiating the patients who survived and those who did not. The sensitivity and specificity of pro-adrenomedullin in the assessment of death were 71.4% and 72.7%, respectively, while IL-6 had a sensitivity of 92.9% and a specificity of 60.6%. CONCLUSION: Proadrenomedullin is a reliable prognostic marker in patients with shock; further studies on a more consistent number of septic patients will definitively assess whether proadrenomedullin may replace the current prognostic markers in critically ill patients with shock due to sepsis.

Pain management in peripheral arterial obstructive disease: oral slow-release oxycodone versus epidural l-bupivacaine.

OBJECTIVES: To compare the effectiveness of oral slow-release oxycodone (group OX, n=18) with that of epidural l-bupivacaine (group LRA, n=13) for the control of moderate/severe pain of advanced-stage peripheral arterial obstructive disease (PAOD) patients. DESIGN: Observational and retrospective analysis of advanced stage and hospitalised PAOD patients treated for pain management for at least 7 days prior to surgery or discharged from the hospital without surgery. METHODS: The outcome measures were pain intensity using the visual analogue scale under static, (VASs) and dynamic (VASd) conditions; vital signs, treatment side effects and patient satisfaction. RESULTS: In both groups, pain control was satisfactory and VAS scores median were VASs<3 and VASd<4; under dynamic conditions, pain control was better in the LRA group (p<0.01). Against few and transient side effects, most patients (n=30) found both pain treatments good or excellent. Results should be confirmed by studies with larger samples. CONCLUSIONS: In the perioperative setting, the epidural infusion of local anaesthetics, such as l-bupivacaine, is an effective technique for pain control in PAOD patients; for patients with contraindication for this technique or for non-surgical or outpatients, slow-release oxycodone is suggested as a possible alternative for the control of severe pain in these patients.

Wernicke's encephalopathy and pancreatic encephalopathy after necrotic-hemorrhagic pancreatitis. A case report.

This case report describes a case of acute necrotic-hemorrhagic pancreatitis complicated by Wernicke's encephalopathy (WE) and stresses the importance of a correct dietetic regimen. A 39-year-old Chinese male patient with negative remote pathological anamnesis was hospitalized in the Medical Department with a diagnosis of gallstones. The clinical course was complicated with the onset of acute pancreatitis. Enteral fasting was imposed with intravenous feeding without vitamin supplementation. The progressive worsening of the clinical, radiodiagnostic and laboratory profile combined with deterioration in the state of consciousness promoted, on the 36th day exploratory laparotomy revealed necrotic-hemorrhagic pancreatitis. The patient was, therefore, admitted to the Intensive Care Unit in a deep coma. The recent medical history, neurological examination, and encephalic computed tomography suggested a revealing diagnosis of WE combined with pancreatic encephalopathy.

Major abdominal surgery and postoperative pain control: are protocols enough?

Suitable postoperative pain control (POPC) requires both the application of appropriate pain therapy and the continuous supervision of its therapeutic effects. In our hospital, POPC was, until recently, limited to the first 48 postoperative hours. The purpose of this retrospective study was to assess, the evolution of POPC at the end of the first postoperative 48 hours among major abdominal surgery patients using the Acute Pain Service (APS) database. Further we sought to establish the indications to extend POPC to the entire postoperative period. Regardless of the type of protocol applied after surgery, 79.6% of cases showed pain control was still needed after the 48(th) hour. In about half of the cases, POPC was perpetuated with only the drug category or by dosage modifications, while in roughly one third of the cases we adopted both drug and administration route changes. These changes were made by the APS after a thorough evaluation of the patients' conditions and needs in terms of analgesia. Interestingly, in approximately 5% of cases the surgeon decided to interrupt pain therapy. When applying evidence-based guideline protocols, organizational issues are important as well as a better definition of the APS role in POPC, at least from the timing point of view.

[Thoraco-abdominal aneurysms of type IV]. / Aneurismi toraco-addominali di IV tipo.

AIM OF THE STUDY: Aims of the study were: 1. to evaluate the results of surgical treatment of type IV thoraco-abdominal aneurysms (TAA), with relationship to other types, 2. to evaluate results obtained with an approach different from the traditional thoraco-phreno laparatomy, with specific attention to postoperative respiratory function. MATERIAL AND METHODS: We have retrospectively compared type IV TAA with all other types of thoraco-abdominal aneurysms electively treated between January 1st, 1994 and May 31st, 2003. Data on perioperative mortality, spinal cord ischemia and renal failure (both temporary and permanent) occurring in the first 30 postoperative days were considered. Protection from spinal cord ischemia was accomplished through liquor drainage and prostaglandin E1 (PGE1) infusion. When the aneurysm extension was limited to the celiac axis an extrapleuric access with removal of XI rib was performed. In this subgroup of patients we have considered postoperative recovery time of respiratory function (intubation time, number of days in intensive care unit, postoperative pulmonary complications) postoperative renal failure, perioperative mortality and morbidity. RESULTS: Seventy-eight TAA have been treated in the period of time of the study. Twenty cases were type IV TAA (25.6%) of which 2 due to chronic dissection. Cumulative postoperative mortality has been 19.2%. The single perioperative death in the group of type IV TAA (5%) occurred in post-operative day 15 for multiple organ failure. No spinal cord ischemia occurred in this group. Temporary renal failure occurred in 3 cases (15%) with one case requiring dialysis. In 10 cases (50%) an extrapleuric access with removal of XI rib was performed, with adequate control of the proximal aorta. Postoperative respiratory failure requiring and intubation time longer than 12 hours occurred in 2 cases (20%). In the remaining 8 cases the mean intubation time was 5.3 hours (range 4-8 hrs). Tracheostomy was not necessary in any case. Mean time of intensive care unit stay was 3.5 days (range 0-15 days). CONCLUSION: The appropriate treatment of type IV TAA leads to low mortality and morbidity with results similar to those of pararenal aneurysms rather than those of other TAA forms. Left extrapleuric access when feasible allows faster recovery of a normal respiratory function.

The effect of transient intestinal ischemia on inflammatory parameters.

BACKGROUND AND AIMS: To determine the early biological changes occurring in intestinal ischemia in vivo. PATIENTS AND METHODS: We studied the effects of acute transient intestinal ischemia in 15 patients undergoing elective open surgery for the treatment of abdominal subrenal aortic aneurysm induced by clamping of the aorta at subrenal level and above the branching of the inferior mesenteric artery. Blocking the blood flow results in hypoperfusion of the inferior mesenteric artery and then to rectal mucosal ischemia. RESULTS: With the introduction of a mucosal ischemic period the basal intestinal mucosal pH decreased during ischemia, and showed a rapid increase during reperfusion to the level preceding ischemia. Parameters were evaluated in blood taken from inferior mesenteric vein. A rectal dialysis was put into the rectum to evaluate eicosanoid concentrations in rectal fluid collected before and during clamping and after declamping. Significant enhancement in plasma level of xanthine, a marker for tissue damage, was observed during reperfusion. Interleukin-6 levels were significantly elevated from 11.28+/-3.4 pg/ml (preischemic) to 109+/-85.9 pg/ml (ischemic) and to 189.33+/-120.24 pg/ml (reperfusion); and tromboxane B(2) levels from 141.57+/-51.20 pg/ml preoperation to 473.01+/-319.01 pg/ml during the surgical procedure. CONCLUSION: These observations indicate that even transient ischemia modifies the inflammatory pattern.

[Wash and non-wash system in the perioperative recovery of blood in prosthetic surgery: ultrastructural assessment of corpuscular blood components]. / Sistema wash e non-wash nel recupero perioperatorio del sangue in chirurgia protesica: valutazione ultrastrutturale della parte corpuscolata del sangue.

AIM: The authors aimed to perform an ultrastructural morphological analysis of blood recovered using wash and non-wash systems in patients undergoing full cement-free hip replacement in order to evaluate the integrity of the various blood corpuscle components. EXPERIMENTAL PROTOCOL: An open prospective study in patients undergoing full cement-free hip replacement at the Orthopedics Division of S. Orsola-Malpighi Policlinico in Bologna. Materials of S. Orsola-Malpighi Policlinico in Bologna. MATERIALS AND METHODS: Blood recovered postoperatively using a non-wash system was studied in 6 patients. In a further 3 patients perioperatively recovered blood was studied after washing using Cell Saver Haemolite 2 before reinfusion. Red globules, white globules and plaelets were isolated from blood collected using these two different recovery systems and analysed by SEM. RESULTS: Study of the ultrastructural morphology of various corpusculated blood fractions. DISCUSSION AND CONCLUSIONS: From the data in our possession it appears that the ultrastructural morphology of the various corpuscle components of blood in subjects undergoing postoperative recovery is better preserved using a non-wash system. There was no sign of "polluting" material in terms of adipose cells or free bone fragments in either group.

Intensive care units as a source of methicillin-resistant Staphylococcus aureus.

Over a 12 month period, 209 isolates of methicillin resistant Staphylococcus aureus (MRSA) were obtained in 39 patients admitted to an ICU. In 23 patients MRSA was the major pathogen, producing either pneumonia, bacteremia or wound infection. In eight patients death was directly related to the MRSA infection. This study suggests an increasing occurrence of MRSA infections in ICU and the need to adopt control measures.