C-reactive protein but not procalcitonin may predict antibiotic response and outcome in infections following major abdominal surgery.

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann-Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann-Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.

Remifentanil-TCI and propofol-TCI for conscious sedation during fibreoptic intubation in the acromegalic patient.

BACKGROUND AND OBJECTIVE: To evaluate the use of remifentanil-propofol administered as target-controlled infusion during awake fibreoptic intubation for anticipated difficult tracheal intubation in acromegalic patients. METHOD: In all, 20 consecutive acromegalic patients underwent elective endonasal endoscopic transsphenoidal pituitary surgery. After premedication with midazolam 0.03 mg kg(-1), initially a target-controlled infusion of remifentanil 1.0 ng mL(-1) and propofol 1.5 microg mL(-1) was started. The fibreoptic intubation was performed by the same physician experienced with the fibreoptic technique. During the fibreoptic procedure the target concentrations of remifentanil and propofol ranged between 1.0 and 5.0 ng mL(-1), and between 1.5 and 3.5 microg mL(-1), respectively. Changes in heart rate and mean arterial pressure were recorded during airway manipulation, during tracheal intubation, and at 1 and 3 min after. On the first postoperative day, patient recall and level of discomfort during fibreoptic intubation were evaluated. RESULTS: Endotracheal intubation was efficaciously and quickly secured in all patients. A significant increase in mean arterial pressure and heart rate was recorded only during tracheal intubation (P < 0.05). Oxygenation was sufficient and no bradypnea or apnoea was recorded. All patients later described their anaesthetic experience as satisfactory. During fibreoptic intubation, remifentanil (ng mL(-1)) and propofol (microg mL(-1)) mean effect-site concentrations were 3.2 +/- 0.3 and 2.0 +/- 1.0, respectively. CONCLUSION: Remifentanil and propofol target-controlled infusion provided satisfactory conscious sedation allowing for successful oral fibreoptic intubation in acromegalic patients with no recall.

Clinical comparison of remifentanil-sevoflurane vs. remifentanil-propofol for endoscopic endonasal transphenoidal surgery.

BACKGROUND: Endoscopic endonasal transphenoidal surgery has been recently proposed as a minimally invasive procedure for the treatment of pituitary adenomas. The main objective of the anaesthesiologist is to induce sufficient haemodynamic control together with rapid recovery at the end of surgery. The aim of this study was to examine recovery profile, surgical operative conditions and haemodynamic differences using remifentanil infusion with either propofol target controlled infusion system or sevoflurane. METHOD: Forty-four adult patients were enrolled in a prospective, randomized, single-blind, two-group study: Group P received propofol target controlled infusion system and remifentanil; Group S received sevoflurane and remifentanil for maintenance of anaesthesia. RESULTS: No statistically significant differences between the two groups with regards to the haemodynamic changes, operative conditions as assessed by a four-step bleeding score (0-3), were obtained. Recovery times were considerably shorter after remifentanil-sevoflurane in comparison with remifentanil-propofol target controlled infusion system group (7.4 vs. 12.8 min, P < 0.01). CONCLUSION: This study demonstrates that sevoflurane-remifentanil gives a faster recovery and equivalent intraoperative status compared with propofol target controlled infusion system with remifentanil for the endoscopic endonasal transphenoidal approach.

Sevelamer worsens metabolic acidosis in hemodialysis patients.

BACKGROUND: Sevelamer hydrochloride, a major phosphate binder for patients on maintenance hemodialysis (MHD) is associated with reduced serum bicarbonate concentration due to hydrochloric acid release in the gut and to the binding of short chain fatty acids in the large intestine. Since metabolic acidosis can be deleterious, a study was devised to compare the time course of serum bicarbonate concentration during treatment with sevelamer hydrochloride or calcium carbonate. METHODS: Sixteen well nourished patients on MHD who were in excellent clinical conditions and achieving target levels for blood pressure (BP) and hemoglobin (Hb), while on a protein intake of 1.1g/kg body weight (bw), were enrolled in the study. After a 2-week washout period, the patients were divided into two groups, each consisting of eight patients, and randomized either to 24 weeks of sevelamer followed by 24 weeks of calcium carbonate (group A) or to 24 weeks of calcium carbonate followed by 24 weeks of sevelamer (group B). Protein intake, n-protein catabolic rate (nPCR), serum concentrations of calcium, phosphate, calcium x phosphate (Ca x P) product, bicarbonate, intact parathyroid hormone (iPTH) and albumin were monitored. Time course changes in serum bicarbonate concentrations in relation to short and long dialytic intervals (48 vs. 72 hr) were also investigated. RESULTS: Both sevelamer and calcium carbonate effectively controlled serum phosphate and the Ca x P product. During calcium carbonate treatment plasma phosphate concentrations were significantly below those of patients on sevelamer. Plasma bicarbonate concentration fell within target DOQI values during calcium carbonate administration both in group A and in group B, a goal which was not achieved under sevelamer administration. After a long dialytic interval in patients on sevelamer, serum bicarbonate concentration averaged 17.3 +/- 1.1 mEq/L, whereas it averaged 21.1 +/- 0.7 mEq/L in patients on calcium carbonate (p<0.01). Finally, a 24-week sevelamer administration caused a statistically significant (p<0.05) reduction (0.8 g/dL) in serum albumin concentration, without affecting iPTH. Taken together, these results indicate that sevelamer worsens metabolic acidosis, which needs to be corrected.

Acid-base balance in heart failure.

In end-stage heart failure, various acid-base disorders can be discovered due to the renal loss of hydrogen ions and hydrogen ion movements into cells, the reduction of the effective circulating volume, hypoxemia and renal failure. This justifies the occurrence of metabolic alkalosis, metabolic acidosis, respiratory alkalosis, as well as respiratory acidosis alone or in combination. Several studies have been published on the acid-base state in heart failure. In a 1951 study, Squires et al analyzed the distribution of body fluid in congestive heart failure by taking into consideration the abnormalities in serum electrolyte concentration and in acid-base equilibrium. A recent study by Milionis et al, analyzed 86 patients with congestive heart failure receiving conventional treatment; the majority of these patients exhibited hypokalemia, hyponatremia, hypocalcemia and hypophosphatemia. Disorders in acid-base balance were noted in 37.2% of patients. In a recent study, 70 patients with severe congestive heart failure before heart transplantation showed high-normal pH, slightly reduced pCO 2 and a slight loss of hydrogen ions. After heart transplantation, stability of blood pH and hydrogen ion concentrations was found. In contrast, bicarbonate and pCO 2 increased significantly. The data led us to formulate the diagnosis of a mixed acid-base disorder that includes respiratory alkalosis and metabolic alkalosis before heart transplantation. In heart failure, the presence of acid-base imbalance associated with the activation of mechanisms that lead to salt and water retention reveals evidence concerning the pivotal role of the kidney in determining the outcome of these patients.

Monitored anesthesia care and loco-regional anesthesia. Vascular surgery use.

Association of locoregional techniques such as deep and superficial cervical block, lumbar epidural and/or peripheral blocks, and conscious sedation with hypnotic drugs (propofol 1-3 mg/kg/h or midazolam 2-4 mg/h) and/or opiates drugs (sufentanil 5-10 mcg or remifentanil 0.05-0.1 mcg/kg/min) is actually, the gold standard for vascular surgery. Our personal experience is based on 328 patients submitted to carotid endarterectomy, aneurysm repair and peripheral surgery.

Paradox of circulating advanced glycation end product concentrations in patients with congestive heart failure and after heart transplantation.

OBJECTIVES: To analyse circulating concentrations of advanced glycation end products (AGEs) in patients with severe congestive heart failure (CHF) and after heart transplantation; to identify the potential contribution of kidney function to plasma AGE concentrations; and to determine whether AGE concentrations and parameters of oxidative stress are interrelated. METHODS AND RESULTS: Circulating N(epsilon)-(carboxymethyl)lysine (CML) and AGE associated fluorescence (AGE-Fl), lipid peroxidation, and glomerular filtration rate (GFR) were measured in a cross sectional study of 22 patients with advanced CHF, 30 heart transplant recipients, and 20 healthy controls. Compared with the controls, the CHF patients had decreased CML (mean (SEM) 467.8 (20.0) ng/ml v 369.3 (22.3) ng/ml, p < 0.01), AGE-Fl (mean (SEM) 302.2 (13.3) arbitrary units v 204.9 (15.7) arbitrary units, p < 0.01), and GFR (p < 0.01). CML was positively related to decreased total protein and serum albumin and negatively to body mass index (p < 0.01). In contrast, in the heart transplant group, impaired GFR was associated with a notable rise of both CML (mean (SEM) 876.1 (53.1) ng/ml, p < 0.01) and AGE-Fl (mean (SEM) 385.6 (26.1) arbitrary units, p < 0.01). A positive relation between CML and serum albumin (r = 0.394, p < 0.05) and lipofuscin (r = 0.651, p < 0.01) was found. CONCLUSIONS: The contrasting concentration of CML and AGE-Fl between patients with CHF and after heart transplantation in the presence of decreased GFR and oxidative stress are explained by lowered plasma proteins in CHF and higher concentrations in heart transplant recipients. In heart transplant recipients, in addition to myocardial inflammatory processes, immunosuppression may be important for enhanced formation of AGEs.

Remifentanil for intraoperative analgesia during the endoscopic surgical treatment of pituitary lesions.

AIM: The authors have evaluated remifentanil for intraoperative analgesia in endonasal endoscopic surgery for pituitary lesions. EXPERIMENTAL DESIGN: a perspective, randomized and comparative study between remifentanil and fentanyl for intraoperative analgesia was performed in an operating room of the neurosurgical department at University. Sixty patients of both sexes were studied and randomly divided into 2 groups. Patients were premedicated with fentanyl 0.15 microg.kg(-1) and atropine 0.01 microg.kg(-1) (group F) or with atro-pine and remifentanil 0.25 microg.kg(-1) min-1 (group R); induction was with propofol 2.0 microg.kg(-1) and maintenance with titrated infusion of propofol and for intraoperative analgesia, fentanyl as bolus injection of 1.0-1.5 microg.kg(-1) (group F) or a titrated infusion of remifentanil (group R). The following parameters were studied: MAP, HR, bleeding, awakening times, adverse effects and VAS. RESULTS: Much more stable hemodynamic parameters during surgery in patients treated with remifentanil; labetalol was administered in 10% of patients in group F; no significant differences as regards the adverse effects and VAS. Faster awakening time was obtained in the remifentanil group as compared with the fentanyl group. CONCLUSIONS: Remifentanil analgesia (mean dose of 0.37 microg.kg(-1).min-1) in patients undergoing endonasal endoscopic surgery of the sellar region provides a more efficacious cardiocirculatory control with reduced bleeding and faster psychosensorial recovery.

Level of hydration and renal function in healthy humans.

BACKGROUND: High hydration is commonly used in renal studies to improve the completeness of urine collection. The renal effects of hydration are not well defined. METHODS: Renal function was studied under fasting conditions (baseline) and after a meat meal (2 g of protein/kg body weight) in 12 healthy adults on a low and high hydration regimen of 0.5 and 4 mL of oral water per kg body weight/30 min, respectively. RESULTS: Urine flow, urinary and plasma Na, K, urea, and osmolality were stably different on low and high hydration regimens. At baseline, there were significant or borderline significant correlations of plasma and urine osmolality with glomerular filtration rate (GFR; inulin clearance) only in the low hydration regimen. GFR was higher in the low than the high hydration regimen at all time points. The difference was significant at baseline (19.2%) and at 90 to 180 minutes after the meal (14.4%). After the meal, GFR increased significantly over baseline values only in the high hydration regimen (30.0% at peak time). Urinary excretion of Na, urea, and osmoles was lower in the low than the high hydration regimen at all time points: The difference was significant for Na (at baseline) and osmoles (all time points). Urinary K excretion was not different in the two regimens. After the meal, there were significant increases in urinary excretion of Na (in the low hydration regimen) and urea (90 to 180 min after the meal). CONCLUSIONS: In fasting adults, high hydration lowered GFR and increased natriuresis. After a meat meal, GFR increased only in the high hydration regimen and natriuresis only in the low hydration regimen. Hydration affects GFR and natriuresis under fasting conditions and after a meat meal.

Nephrotic edema.

This article starts with a concise synopsis of the history of edema. The role of underfilling, overflow, antidiuretic hormone, and acquaporins is subsequently discussed. Emphasis is given to the use of diuretics in edematous patients. The role and risks of albumin infusion are illustrated. The new hypothesis of pulse reverse osmosis is discussed. The final section deals with the measurement of colloid osmotic pressure in the clinical setting.

Bioelectrical impedance analysis in heart transplantation: early and late changes.

The objectives of this study were to perform bioelectrical impedance analysis before and after heart transplantation with comparison to healthy subjects. Eight patients (7 men, 1 woman) before (day 0) and after transplantation (day 3, 7, 12, 15, and 180) and 24 healthy controls, matched for sex, age, and body mass were studied. Data collection included bioelectrical impedance analysis (resistance, reactance, and estimates of body water), clinical, and laboratory measurements. Compared with controls, patients had at baseline significantly higher reactance, not significantly different resistance, body weight, total body water, and intra- to extracellular water ratio. After surgery, for reactance, there was an acute decrease followed by a slow, progressive increase up to normal level by day 15. Resistance and body weight did not significantly change; the intra- to extracellular water ratio significantly decreased with stable total body water. Changes in reactance are the main effects induced on bioelectrical impedance by heart transplantation. Acutely, there is a large decrease which likely reflects changes both in water distribution and in cell membrane function. The late changes more likely reflect the shift of body water from the extra- to the intracellular space with stable total body water.

Renal tubular function by lithium clearance in liver cirrhosis.

Increased tubule sodium reabsorption has been largely suspected in liver cirrhosis (LC), however studies in humans have produced contrasting results. Therefore to ascertain the entity of renal sodium handling in LC this study was devised. A total of 13 patients with child A LC were studied along with 26 age-sex matched healthy controls (HC). Patients and controls were kept on daily Na-intake of 100 mmol for at last 1 week, by measuring glomerular filtration rate (GFR; inulin) and lithium clearance. We have calculated (1) C(Li); (2) the absolute reabsorption of isotonic fluid in the proximal tubule (APR) as GFR - C(LI); (3) the fractional proximal sodium reabsorption (FPRNa) as 1 - (C(Li)/GFR); (4) the absolute distal reabsorption of sodium (ADRNa) as (C(LI) - C(Na)) x P(Na;) and (5) the fractional distal sodium reabsorption (FDRNa) as (C(LI) - C(Na))/C(Li). GFR was significantly lower in LC (P<.001), C(Li) was significantly higher in LC than in HC (P<.001). APRNa and FPRNa were reduced in LC (P<.0001). ADRNa was higher in LC than in HC (P<.001). No difference was found for FDRNa. In conclusion, lithium clearance discloses an increase sodium reabsorption in distal tubule in humans with LC.

Glomerular filtration rate in severely overweight normotensive humans.

The study examined whether indexing glomerular filtration rate (GFR) for body surface area is appropriate for people who are severely overweight. Twenty normotensive adult men who were severely overweight but without microalbuminuria were enrolled into this study. The control group consisted of 20 healthy subjects matched for age, sex, and height. GFR was determined by measuring insulin with the continuous-infusion method. The clearance of endogenous creatinine was also measured after two daily urine collections. Renal plasma flow (RPF) was measured by p-aminohippurate clearance using the continuous-infusion method. Lean body weight was measured by impedentiometry. Adjusting for body surface area (in 1.73 m(2)) caused a significant reduction in GFR (P < 0.0001) in overweight humans (84.1 +/- 2.32 versus 109.6 +/- 3.07 mL/min/1.73 m(2)). The difference disappeared when GFR/height criteria were adopted. No difference between obese and healthy controls occurred after adjusting for lean body weight. Data for creatinine clearance paralleled those with insulin clearance; a significant reduction (P < 0.001) occurred after indexing for basal surface area, which disappeared after correction for height, as well as for lean body weight.

Body impedance studies in end-stage heart failure.

This study adds another category of patients to those amenable to body impedance analysis (BIA). BIA measurements were obtained for the first time in 23 male patients with end-stage heart failure who were waiting for heart transplantation, and the data were compared with those obtained in 69 healthy controls matched for age, sex, height and weight. The data indicate that in end-stage heart failure there is an increased reactance (p<0.01) and an altered intracellular water/extracellular water ratio (p<0.03) due to the increased intracellular water (p<0.01) and decreased extracellular water (p<0.01).

Renal reserve is normal in patients with dilative cardiomyopathy waiting for heart transplantation.

Renal reserve was explored by means of an oral protein load (2 g/kg body weight) under the form of cooked red meat in a group of 9 patients with end-stage heart failure (ESHF), class III of the New York Heart Association receiving loop diuretics and angiotensin-converting enzyme (ACE) inhibitors, and in a group of 18 healthy controls (HC) matched for age, gender, and height under an identical dietary regimen providing 40 cal/kg per day, 1 g/kg body weight of protein per day, Na 120 mmol/day, and K 50 mmol/day. Baseline glomerular filtration rate averaged 109.5+/-9.89 ml/min x 1.73 m2 in HC and 71.9+/-8.8 ml/min x 1.73 m2 in ESHF. Renal plasma flow averaged 540+/-27 ml/min x 1.73 m2 in HC and 235+/-47 ml/min x 1.73 m2 in ESHF. The filtration fraction was significantly higher in ESHF (p<0.01). Renal reserve averaged 26.03+/-3.28 ml/min x 1.73 m2 in HC and 27.2+/-7.12 ml/min x 1.73 m2 (not significant). Renal reserve averaged 123.9+/-2.9% in HC and 137.3+/-6.68% in ESHF (not significant). The filtration capacity was significantly higher in HC (p<0.001). The data point to a normalcy of renal reserve in ESHF which may depend on the chronic use of ACE inhibitors.

[Competitive new generation myorelaxants in pediatric neuroanesthesia]. / I miorilassanti competitivi di nuova generazione in neuroanestesia pediatrica.

Two groups of 50 children were included in a study to examine the use of atracurium and vecuronium. In both groups, newborns and infants showed a shorter onset time and a longer clinical duration of the first dose of the neuromuscular blocking drug. The duration of subsequent doses in the various age groups was not significantly different. Atracurium and vecuronium both have a short recovery index, good cardiovascular stability and do not interfere with ICP. The Authors emphasise the importance of monitoring the use of neuromuscular blocking drugs.

[New anesthetics and myorelaxants. The behavior of intracranial pressure in pediatrics]. / Nuovi anestetici e miorilassanti. Il comportamento della PIC in pediatria.

The authors, following a report on cerebral physiology in childhood, report their experience of ICP and the administration of new drugs in anaesthesiologic practice. The effects of isoflurane, propofol, atracurium, vecuronium on ICP are reported.

[Severe head trauma in the pediatric patient. Our experience]. / Il trauma cranioencefalico grave nel paziente pediatrico. Nostra esperienza.

A retrospective study in a pediatric population of 324 severe head trauma patients hospitalized at Santobone Children's Hospital has been carried out; diagnostic investigations and therapeutic aspects are stressed on the baw of pathophysiological features of such patients.