Parenteral nutrition in ventilated patients with chronic obstructive pulmonary disease: long chain vs medium chain triglycerides.

AIM: The aim of this study was to assess the usefulness of a lipid formulation containing a physical mixture of medium (MCT) and long chain triglycerides (LCT) compared with a long chain triglycerides emulsion in patients affected by chronic obstructive pulmonary disease with acute respiratory failure. METHODS: Twenty-four patients requiring mechanical ventilation were randomly selected in 2 groups and received total parenteral nutrition. Twelve patients received a MCT/LCT emulsion (50:50), the others used a 100% LCT emulsion. Nutritional status, metabolic rate, time of ventilatory support and weaning were evaluated. RESULTS: Both groups showed an improvement of all nutritional parameters evaluated; oxygen uptake, carbon dioxide output and respiratory gas exchange ratio were similar in both groups. The duration of mechanical ventilation was not significantly different; however, the time of weaning in the MCT/LCT group was significantly shorter. The longer weaning time in the LCT group patients could be related to vasoactive intermediates deriving from long chain fatty acids. The T-cell subsets, which were evaluated for both groups, showed a significant decrease of T helper-T suppressor ratio in the LCT group. CONCLUSION: MCT/LCT emulsion is an effective lipid supplementation and should be considered the therapy of choice in COPD patients; however, the relationship between lipid emulsions administered and length of weaning requires further investigations.

[Use of remifentanil in ambulatory obstetric-gynecologic surgery. A dose-effect study]. / Uso del remifentanil in chirurgia ambulatoriale ostetrico-ginecologica. Studio dose-effetto.

BACKGROUND: Remifentanil, a recently commercialised opioid, is characterised by a predictable and non cumulative effect which vanishes rapidly without determining side effects in the long term. These characteristics make remifentanil an ideal opioid in continuous infusion for the ambulatory surgery setting. Aim of this study was to assess the ideal dose of remifentanil, administered in bolus before propofol, in patients undergoing uterine curettage and assisted by mask ventilation in 100% oxygen. METHODS: Sixty patients, ASA status I-II, scheduled for uterine curettage, were divided into three study groups according to the bolus dose of remifentanil received before the induction agent: group A (n = 20) 1 microgram/kg; group B (n = 20) 2 micrograms/kg; group C (n = 20) 2 micrograms/kg. All patients were assisted by 100% oxygen ventilation with facial mask. During surgery the following were recorded: time to spontaneous ventilation (in case of post induction apnea); incidence of somatic and autonomic responses to surgical stress (treated with remifentanil in bolus). At the end of surgery the times to response to simple verbal commands, to discharge from the recovery room (by Aldrete score every 5') and to discharge from hospital (by PADSS score every 30') were registered. RESULTS: All patients presented post-induction apnea with a significantly more rapid return to spontaneous ventilation in group A. Six patients of group A responded to surgical stress while in groups B and C there was no need for supplementary boluses (p < 0.05). Five patients of group C were treated with atropine for bradycardia, in four of group C it was necessary to administer succinylcholine for thoracic rigidity. No significant differences regarding the anesthesia recovery times were observed. All patients were discharged from the recovery room after 10' from the end of surgery. Overall, the qualification for discharge from hospital was obtained at the second PADSS score control, except for one group A patient who incurred in metrorrhagia. CONCLUSIONS: The administration in bolus of remifentanil, before the inducing agent, permits short-term surgery in ambulatory surgery settings thanks to the rapid recovery of vital functions. Compared to the other doses, the 1.5 micrograms/kg dose guaranteed a good control over surgical stress without influencing the speed of awakening and without determining uncomfortable side effects.

Intra-articular buprenorphine after knee arthroscopy. A randomised, prospective, double-blind study.

BACKGROUND: Demonstration of peripheral opioid receptors in inflamed synovia supports the concept of peripheral opioid analgesia. The aim of this study was to evaluate the analgesic effect of intra-articular administration of buprenorphine after knee arthroscopy. METHODS: In a double-blind randomised trial, 48 patients were assigned to four groups: group A patients received buprenorphine 100 micrograms i.a. and NaCl 0.9% i.m., group B patients received bupivacaine 0.25% 50 mg i.a. and NaCl 0.9% i.m., group C patients received NaCl 0.9% i.a. and buprenorphine 100 micrograms i.m., and group D patients received NaCl 0.9% i.a. and NaCl 0.9% i.m. Intensity of postoperative pain was evaluated by VAS at recovery (T0) and 1, 3, 6, 12, 24 h after operation (T1, T2, T3, T4, T5), at rest and during passive 10 degrees knee flexion. Total analgesic requirements and side effects related to study drugs were recorded. RESULTS: The VAS scores were significantly higher in groups C and D than in group A and B patients. The differences were significant at T0, T1, T2 and T3. At T1, group C and D patients had greater analgesic requirement than groups A and B. No patients developed side effects. CONCLUSION: Intra-articular buprenorphine and i.a. bupivacaine, both produced equally good postoperative pain control and allowed a significant reduction of analgesic requirement after knee arthroscopy.

[Oral premedication with clonidine as an alternative in dental practice. The effects on the pain threshold, blood pressure and salivary flow]. / La premedicazione orale con clonidina come alternativa nella pratica odontoiatrica. Effetti sulla soglia del dolore, pressione sanguigna e flusso salivare.

BACKGROUND: Clonidine, an alpha 2-adrenoceptor agonist, has been recently shown to be effective in conscious sedation because of its analgesic and sedative properties, having also proven to be active in reducing neuroendocrine responses to stressful stimuli perioperatively. The current study was designed to investigate the efficacy of 150 micrograms oral clonidine as a premedicant in dentistry. METHODS: In a prospective, randomized, double-blind controlled clinical trial, 40 patients, aged 16-64 yr, undergoing conservative, or prosthetic, or dental surgery procedures, received placebo (n = 20) or 150 micrograms of oral clonidine (n = 20) 90 min before the estimated time of induction of local anesthesia. A blinded observer recorded: salivary flow, systolic and diastolic blood pressure each 30 min lasting 2-3 hours, as well as the degree of pain and sedation intra and postoperatively. RESULTS: Clonidine produced significant salivary flow reduction (p < 0.001) and sedation (p < 0.001) as well as significant difference in postoperative pain scores (p < 0.05) compared to placebo. Xerostomia persisted postoperatively in clonidine premedicated patients as compared to those given the placebo (p < 0.01). Systolic blood pressure decreased significantly only after 120 (p < 0.01) and 150 min (p < 0.001) following clonidine pretreatment, but none of the patients were treated for hypotension. 55% of the clonidine treated patients positively evaluated the experience. CONCLUSIONS: These results suggest that a dose of 150 micrograms of clonidine, given orally 90 min preoperatively, is an effective premedication in dentistry, without causing excessive haemodynamic depression and sedation, and moreover confirm that the oral route of administration is very well accepted.

Nutrition support after total laryngectomy.

This study was performed to evaluate the influence of different nutrition supports (enteral vs parenteral) on nutritional status, postoperative complications, and length of hospitalization in patients undergoing total laryngectomy. Forty-eight patients were divided at random into two groups and received enteral nutrition support by percutaneous endoscopic gastrostomy with a casein and soy-based polymeric formula blended with a modular protein (group A) or a balanced formula in total parenteral nutrition given through a subclavian venous catheter (group B). The results show a satisfactory preservation of nutritional status after total laryngectomy and no significant differences in the nutritional parameters between groups fed enterally or parenterally; however, percutaneous endoscopic gastrostomy could avoid many problems related to enteral nutrition support for patients undergoing laryngectomy. This route of administration was well tolerated by all the patients and, moreover, the percutaneous endoscopic gastrostomy-related complications were clinically less significant than those associated with total parenteral nutrition; this fact could explain the longer hospitalization for group B (34 +/- 11 vs 26 +/- 11 days) (p < .05).