[Hemodynamic and respiratory changes during hip and knee arthroplasty. An echocardiographic study]. / Modificazioni emodinamiche e respiratorie in corso di protesi di anca e di ginocchio. Studio ecocardiografico.

BACKGROUND: The "bone cement implantation syndrome" is a rare but severe complication observed especially during the insertion of cemented prostheses in hip and knee replacement surgery. Several mechanisms are involved: effects of methylmethacrilate, embolism of fat, air and bone marrow, and release of tissue thromboplastin during acetabular and femoral reaming. Aim of this study was to detect embolic events, right heart impairment, hemodynamic and respiratory changes during hip and knee replacement surgery. DESIGN: Prospective study, between February-May 2001. ENVIRONMENT: Orthopedic Operative room. PATIENTS: Twenty-one patients who underwent total hip or knee arthroplasty under general anesthesia. Patients were divided in methylmethacrylate cemented prostheses groups (CEM, n=10) and totally uncemented prostheses (NON CEM, n=11). DATA COLLECTION: Standard anesthesia monitoring and omniplane TEE were performed. TEE probe was positioned in order to obtain "inflow-outflow" views of right heart. Measurements were obtained after anesthesia induction (T1), during femoral realing (T2) at prostheses insertion (T3), and at the end of surgery (T4). RESULTS: Hemodynamic and respiratory parameters measured in different phases of surgical procedures were not different within groups and between groups. Fourtheen patients had TEE evidence of emboli, and the phenomenon was more evident in CEM group (Z= -347; p<0.001). During prostheses insertion, a slight, not significant increase in right ventricular dimensions was observed in both groups, without any right ventricular wall kinetic abnormality. No difference was observed between groups. No adverse cardiac or cerebrovascular events in intra- and postoperatory period were observed. CONCLUSIONS: In normal patients total hip or knee arthroplasty is associated with embolic phenomena, without any significant change in systemic and right heart hemodynamics. Insertion of cemented prostheses does not modify hemodynamic profile. It remains to be elucidated if the occurrence of emboli has a critical role in patients with cardiorespiratory disease.

[Respiratory emergencies in the extra-hospital environment]. / Le emergenze respiratorie in ambiente extraospedaliero.

Prehospital care is a fundamental element for the patient's outcome, in the field of medical and surgical emergencies. There are different strategies about it, defined "scoop and run" and "stay and play". The choice among the different strategies, in our opinion, must be well-suited to the underlying pathophysiology of the illness. The best approach to the care of Acute Respiratory Failure is chosen on the ground of the possible and rapid reversibility of the pathology. Nowadays, classical semeiology is integrated by portable devices that allow the real time monitoring of pulse oximetry, electrocardiography, arterial pressure and heart rate, capnometry, blood gas analysis, serum electrolites, etc. Maintenance of airway patency can be achieved by many devices, according to the patient's neurological conditions. In common opinion the early respiratory support reduces patient's stay in hospital and his outcome.