Tetraplejía espástica secundaria a intoxicación por arsénico inorgánico / Spastic quadriplegia secondary to intoxication with inorganic arsenic

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[Monitoring of consciousness with BIS during induction of anesthesia. Which muscle relaxant?]. / Monitoraggio con BIS dello stato di coscienza durante induzione dell'anestesia generale. Quale miorilassante?

The BIS-index data show that an opiate as Fentanyl is advisable with associations Cisatracurium/Propofol or Vecuronium/Propofol. It is possible to use in these cases a drip infusion to avoid the risk of awareness during intubation.

[A case of total spinal block during epidural anaesthesia]. / Un caso di blocco spinale totale durante anestesia peridurale lombare.

Most cases of total spinal block have been reported in the literature. The displacement of the catheter and the consequent dural perforation are the causes in large percentage of the patients (75%). The Authors describe this case for the importance of the causes and outcome of the patient. A 48 years old woman presented for hysterectomy for uterine fibromas. After having individualized the L3-L4 interspace, a test dose of 3 ml carbocaine 2% was injected. After that, the spinal block was obtained using ropivacaine 0.75% (total dose = 10 ml) injecting slowly, in following times, 5+5 ml of anaesthetic solution. The patient, perfectly conscious at first, presented a gradual increase of the difficulty in talking and breathing. Subsequently she showed a complete paralysis with loss of the consciousness, respiratory arrest, bilateral and symmetrical midriasis, as well as total areflexia. Endotracheal tube was placed. After eighty minutes from the end of the administration of the local anesthetic, spontaneous thoracic excursions appeared, even though of moderate ampleness, midriasis reduced. The patient recovered consciousness and sufficiently ventilated; therefore the endotracheal tube was removed.

[Anaesthesiologic problems about hyperthermic intraoperative intraperitoneal chemotherapy]. / Chemioipertermia intraperitoneale intraoperatoria: problematiche anestesiologiche.

The literature considers hyperthermic intraoperative intraperitoneal chemotherapy a safe and effective procedure for peritoneal carcinomatosis, but a technical improvement is necessary. Regional chemotherapy anticipates the "downfall" of tumoral cells in the peritoneum. The Authors considered 5 patients--female, age 27-45 years, ASA 2--operated of peritonectomy in ovaric neoplasia with peritoneal metastasis. The hyperthermic intraoperative intraperitoneal chemotherapy has been made at the end of the surgery with a hot solution (43 degrees C): 3000 ml of dextrose 1.5% with mytomicina C 25 mg e cysplatino 75 mg/m2. We considered variation of emodinamic parametres (blood pressure, central venous pressure, stroke volume, etc.) and biochemical parametres (Na, K, CI-, CO2, etc.). These parametres have been correlated with some complications: fistula, anastomotic leakage, pancreatitis and postoperative bleeding.

Blood lead levels in shopkeepers and car traffic pollution in Liguria, Italy.

A study was conducted into the exposure to atmospheric pollution caused by car traffic by measuring blood lead (PbB) levels in a sample of 657 adult individuals (shopkeepers) all living in Liguria. The mean level of blood lead in all examined individuals was 9.39 micrograms dl-1 (0.45 mumol per liter; C.I. 95%: 9.06-9.75 micrograms dl-1; 0.44-0.47 mumol per liter) with a range between 2.0 and 46.03 micrograms dl-1 (0.10-2.22 mumol per liter). The average Pb values in individuals working in streets with high and very high traffic was 8.30 micrograms dl-1 (0.40 mumol per liter; C.I. 95%: 7.41-9.31 micrograms dl-1; 0.36-0.45 mumol per liter) and 9.98 micrograms dl-1 (0.48 mumol per liter; C.I. 95%: 9.62-10.37 micrograms dl-1; 0.46-0.50 mumol per liter), respectively. These average blood lead levels were statistically greater than the average PbB values of those working in low traffic streets (7.06 micrograms dl-1; 0.34 mumol per liter; C.I. 95%: 6.22-7.94 micrograms dl-1; 0.30-0.38 mumol per liter). The percentile distribution (50th, 90th and 98th P) for all subgroups surveyed has always proved to be below the maximum limits specified by EC Directive No. 77/312.

Dual individualization of intravenous ciprofloxacin in patients with nosocomial lower respiratory tract infections.

Dual individualization is the integration of patient-specific pharmacokinetic parameters with the pharmacodynamics (concentration versus response) of the infecting pathogen. This technique allows description of the time of in vivo bacterial eradication, and allows estimation of optimal dosages using small numbers of seriously ill patients. In an ongoing study, 11 patients with nosocomial lower respiratory tract infections were given 200 mg of intravenous ciprofloxacin every 12 hours. Ten blood samples were taken after the first dose, with additional peaks and troughs measured on Day 4 and at the end of treatment. Bacterial isolates had minimal inhibitory concentrations (MICs) determined by standard microdilution techniques. In the 11 patients, there were 14 bacterial isolates, of which seven were Pseudomonas aeruginosa and the remainder were other pathogens. Ciprofloxacin MICs ranged from 0.008 to 1.0 microgram/ml. The pharmacokinetics of ciprofloxacin in these patients varied with renal function, and average peak serum concentrations ranged from 1.7 to 4.9 micrograms/ml. Eradication of bacteria from tracheal aspirates occurred between Days 1 and 7, except in four patients in whom the organism persisted. Correlations were observed between the day of eradication and the length of time ciprofloxacin concentrations remained above the minimal inhibitory concentration (MIC). Essentially all bacteria with MICs of less than 0.25 were eradicated. Of the non-eradicated bacteria, most had either MICs of more than 0.25, or less than 100 percent time above the MIC. The clinical response was satisfactory. It is concluded that 200 mg of intravenous ciprofloxacin every 12 hours is highly effective for bacteria with MICs less than 0.25 microgram/ml, but higher dosages may be required to eradicate organisms with higher MICs.

Treatment with aztreonam or tobramycin in critical care patients with nosocomial gram-negative pneumonia.

During the course of one year, 47 critical care patients with gram-negative bacillary pneumonia at Millard Fillmore Hospital were randomly assigned to aztreonam or tobramycin therapy (two to one). Of these, 40 were fully evaluable for microbiologic and clinical response. All evaluable patients had gram-negative organisms in tracheal aspirate culture specimens and confirmed susceptibility of the organism to both study drugs. There was no difference between the two groups with respect to the percentage of patients who received concurrent antibiotics for gram-positive organisms. More than 60 percent of the patients received mechanical ventilation. Essentially, all had new lung infiltrates as shown by chest radiography, leukocytosis, recent onset of fever, and increased volume of purulent secretions. Half had multilobar pulmonary infiltrates. Their mean age was 73 years, with none under age 50. Most had chronic obstructive pulmonary disease, congestive heart failure, or both. By the prognostic nutritional index criteria, over 70 percent were nutritionally deficient at entry. The majority of infections were caused by Pseudomonas, Enterobacter, Klebsiella, and Escherichia coli. Aztreonam eradicated 92 percent of the causative gram-negative organisms, compared with 57 percent for tobramycin (p less than 0.05). Aztreonam produced a favorable clinical response (cure or improvement) in 93 percent of patients, compared with 50 percent for tobramycin (p less than 0.05). There were no differences in the minor adverse effects observed in the two treatment groups. Overall, aztreonam was superior to tobramycin for treatment of pneumonia due to susceptible gram-negative bacteria in these critical care patients.

Role for dual individualization with cefmenoxime.

Cefmenoxime concentration/effect relationships were retrospectively explored for gram-negative bacteria isolated from 14 critical care patients treated for nosocomial pneumonia. The effects of cefmenoxime concentrations on in vitro growth kinetics of 21 isolated pathogens were studied using the Abbott MS-2 Research System, from which a dynamic response concentration was derived. Serum pharmacokinetic profiles were obtained in each patient. These data were used to calculate the in vivo total area under the curve over dynamic response concentration and the time that cefmenoxime concentrations exceeded the dynamic response concentration for each bacteria. The same determinations were made in 18 patients prospectively treated, except that dosage was optimized on the basis of previous mathematical relations to achieve bacterial eradication in four days. This method of dosage optimization is termed dual individualization. Serial cultures of infected tissues were evaluated to determine the number of days to the eradication of bacteria, and the pharmacokinetic and pharmacodynamic variables were used to describe the bacteriologic response of the original pathogen isolated in pretreatment culture. Bacterial eradication rates could be described from cefmenoxime pharmacokinetics in the patient and from the relation between concentration and bacterial inhibition. Patients who were prospectively treated using these retrospectively derived relationships had a predictable day of bacterial eradication. This, in turn, was associated with a shorter duration of treatment (p less than 0.05). The success of prospective dual individualization is encouraging and suggests that more precise optimization of antibiotic dosage can yield a predictable rate of bacterial eradication from the infection site.