The last paper from Prof. Antonio Brienza, who recently died, is published herewith. The real val... more The last paper from Prof. Antonio Brienza, who recently died, is published herewith. The real value of one man may only be completely appreciated in the final balance. Starting from nothing, Antonio created Intensive Care in the South of Italy and from there his group had a deep impact on our scientific community. It is difficult to realize, nowadays, the tremendous amount of effort and personal time Antonio had to spend to reach these targets. Remembering gives value to our lives. Antonio is still with us. Thanks, Professor Luciano Gattinoni,
Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in o... more Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m(2) scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (pre...
Background To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS)... more Background To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS) patients with diffuse loss of aeration, the application of the open lung approach (OLA) would improve homogeneity in lung aeration and lung mechanics, without affecting hemodynamics. Methods Patients were ventilated according to the ARDS Network protocol at baseline (pre-OLA). OLA consisted in a recruitment maneuver followed by a decremental positive end-expiratory pressure trial. Respiratory mechanics, gas exchange, electrical impedance tomography (EIT), cardiac index, and stroke volume variation were measured at baseline and 20 min after OLA implementation (post-OLA). Esophageal pressure was used for lung and chest wall elastance partitioning. The tomographic lung image obtained at the fifth intercostal space by EIT was divided in two ventral and two dorsal regions of interest (ROIventral and ROIDorsal). Results Fifteen consecutive patients were studied. The OLA increased arterial oxy...
ABSTRACT Background: In this prospective physiological observational study, we applied a strategy... more ABSTRACT Background: In this prospective physiological observational study, we applied a strategy to estimate the end-expiratory pleural pressure (Ppl,ee) using esophageal manometry to measure the esophageal pressure (Pes) directly. The estimated Ppl,ee was used to assess the end-expiratory transpulmonary pressure (PL,ee), in order to obtain a parameter to target PEEP, thereby minimizing alveolar collapse and resulting hypoxemia at end expiration during normal and one lung ventilation (OLV) in supine and lateral decubitus in Thoracic Surgery. Material and methods: After Ethical Committee approval was obtained, we enrolled patients with age ≥ 18 ys, scheduled for thoracic surgery and OLV with double-lumen tube in lateral decubitus. Exclusion criteria: ASA > III, haemodynamic instability, ARDS. Haemodynamics, gas exchange and respiratory mechanics data were recorded at three time points: two lung ventilation in supine position (T1), two lung ventilation in lateral (T2) and one lung ventilation in lateral position (T3). We applied a factor to correct absolute Pes values to estimate the Ppl,ee, by subtracting the Pes value obtained at the relaxation volume of the respiratory system (Vr) af ter manual disconnection from the ventilator, from the Pes value at the end of an expiratory occlusion. PL,ee was obtained as airway pressure at the end of the expiratory occlusion minus Ppl,ee. Result and discussion: 8 consecutive patients undergoing to thoracic surgery were included. At T1 Ppl,ee was 1.31±0.37 cmH2O, and increased overtime (3.06 ± 0.23 at T2 and 3.87 ± 0.43 at T3; p< 0.01 vs T1), while PL,ee decreased (2.88 ± 0.36 cmH2O at T1, 0.2 ± 0.33 at T2, -0.36 ± 0.47 at T3; p< 0.01 vs T1).Conclusion: Our preliminary results show that the lateral position and the lung exclusion induce an increase in Ppl,ee and a reduction in PL,ee. We need further studies to determine if the estimation of Ppl,ee on the basis of the Vr method could allow PEEP titration to target an PL,ee of 0 cmH2O in order to avoid atelectrauma during thoracic surgery.
International journal of immunopathology and pharmacology
We studied the effects of Propofol, Desflurane, and Sevoflurane on the systemic redox balance in ... more We studied the effects of Propofol, Desflurane, and Sevoflurane on the systemic redox balance in patients undergoing laparohysterectomy. We measured blood concentration of glutathione (GSH), plasma antioxidant capacity (Trolox Equivalent Antioxidant Capacity-TEAC), and lipid peroxidation products (malondialdehyde (aMDA) and 4-hydroxynonenal (aHNE) protein adducts). Sixty patients were randomly placed into three groups of twenty people each. In Group P anesthesia was induced with Propofol 2 mg/kg and maintained with 12-10-8 mg/kg/min; in Groups S and D anesthesia was induced with 3 mg/kg Sodium Thiopental and maintained with 2 percent Sevoflurane and 6 percent Desflurane, respectively. Blood samples were collected prior to induction (T0 bas), 60min and 24h postoperatively (T1 60 and T2 24 h). In Group P, GSH increased on T1 60 and returned to baseline on T24h, while TEAC remained unmodified; in Groups S, GSH and TEAC decreased on T1 60 in Group D, on T1 60 there was a slight decrease...
The "bone cement implantation syndrome" is a rare but severe complication observed espe... more 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. Prospective study, between February-May 2001. Orthopedic Operative room. 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). 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 af...
To evaluate the effects of positive end expiratory pressure (PEEP) on intrathoracic and extrathor... more To evaluate the effects of positive end expiratory pressure (PEEP) on intrathoracic and extrathoracic blood volumes in patients with acute respiratory failure (ARF). In 4 ARF patients, we have measured cardiac output (CI), intrathoracic blood volume (ITBVI), global end-diastolic ventricular volume (GEDVI), pulmonary (PBVI) and total (TBVI) blood volumes, during application of two PEEP levels (0 and 10 cm H2O). These measurements have been performed by PULSION COLD Z-021 system, using the double indicator dilution technique (thermal and dye dilution). PEEP application caused a significant reduction in CI (from 3.8 +/- 0.4 to 2.9 +/- 0.1 1/min/m2) and ITBVI (from 888 +/- 48 to 698 +/- 25 ml/m2). The reduction in intrathoracic blood volume was associated with a significant reduction in GEDVI and PBVI. After PEEP application, there was a significant reduction in TBVI (from 2437 +/- 135 to 1984 +/- 49 ml/m2). PEEP application decreases cardiac index, mainly through a preload reduction, a...
Background: Aim of this prospective study was to evaluate the sensory block quality and hemodynam... more Background: Aim of this prospective study was to evaluate the sensory block quality and hemodynamic effects in patients undergoing urologic surgery under Combined Sequential Spinal Epidural Anesthesia (CSSE). Methods: Fifty patients were included in the study. Inclusion criteria were age ≥ 18 years and surgery scheduled to last ≤ 2 hours. Patients with a history of hypertension, congestive heart failure, any active medication for cardiovascular disease or any other absolute or relative contraindication to spinal anesthesia were excluded from the study. Patients undergoing urologic procedures received CSSE with 4 ml of Levobupivacaine 0.075% intratecally, followed by 10 ml of Levobupivacaine 1.5% epidurally. Sensory block spread was assessed by a pin prick test. Cardiac index (CI), blood pressure (BP), heart rate (HR) and arterial saturation of O 2 (SpO 2) were continuously monitored and recorded. Before discharge, patient's functional status was assessed by the Aldrete Score. Results: CSSE allowed a pain free procedure. The pinprick test score was 1.2 ± 0.7 at the T7 dermatome level. CI, mean BP and HR were stable during the entire procedure. The Aldrete Score was 9.84 ± 0.4. Conclusion: CSSE performed with low doses of local anaesthetics allowed a good sensory block and was associated with good hemodynamic conditions and recovery score.
Intra-abdominal hypertension (IAH) can affect liver hemodynamics but it is not known if has a sig... more Intra-abdominal hypertension (IAH) can affect liver hemodynamics but it is not known if has a significant clinical impact on liver function. The aim of this study was to investigate the relationship between IAH and liver function. A prospective study was performed in 110 adult intensive care unit (ICU) patients. Intra-abdominal pressure (IAP) was measured on admission and every other day, and liver sequential organ failure assessment (SOFA) score was collected whenever IAP was measured. IAH was defined by a IAP Ն 10 mm Hg, and liver dysfunction was defined by a hepatic SOFA score Ն 2. An overall IAH incidence of 56.3% was found (n ϭ 62). Thirty-three patients presented a liver SOFA score Ն 2, with an overall incidence of 30%. Liver SOFA score of the group of patients with abdominal hypertension was higher than in group of patients without abdominal hypertension. (0.8 Ϯ 1.05 vs 0.4 Ϯ 0.7; P Ͻ .05), but IAH and liver dysfunction were not significantly associated (2 ϭ 2.03; P ϭ .15). When the whole sample was divided according to the worst IAP score (IAP Ͻ 10, IAP between 10 and 15, and IAP Ͼ 15), the corresponding liver dysfunction scores in the three groups were 0.35 Ϯ 0.6, 0.74 Ϯ 1, and 1.2 Ϯ 1.3, respectively (P ϭ .01). A strict association between IAH and liver dysfunction was not found. Most likely, low levels of IAH, although able to reduce liver blood flow, are not per se sufficient to produce a real dysfunction; however, a correlation between the degree of IAH and the degree of hyperbilirubinemia exists. IAH does not seem to be an "on-off" phenomenon, but produces liver alterations for increasing levels of its severity.
The aim of this study was to test the effect of a small volume administration of p-hydroxyphenylp... more The aim of this study was to test the effect of a small volume administration of p-hydroxyphenylpyruvate (pHPP) in a rat model of profound hemorrhagic shock and to assess a possible metabolic mechanism of action of the compound. The results obtained show that hemorrhaged rats treated with 2-4% of the estimated blood volume of pHPP survived significantly longer (p,0.001) than rats treated with vehicle. In vitro analysis on cultured EA.hy 926 cells demonstrated that pHPP improved cell growth rate and promoted cell survival under stressing conditions. Moreover, pHPP stimulated mitochondria-related respiration under ATP-synthesizing conditions and exhibited antioxidant activity toward mitochondria-generated reactive oxygen species. The compound effects reported in the in vitro and in vivo analyses were obtained in the same millimolar concentration range. These data disclose pHPP as an efficient energetic substrates-supplier to the mitochondrial respiratory chain as well as an antioxidant supporting the view that the compound warrants further evaluation as a therapeutic agent.
The combination of sedative and analgesic drugs is increasingly being used during minimally invas... more The combination of sedative and analgesic drugs is increasingly being used during minimally invasive surgery. The authors compared the clinical efficacy of two different fentanyl regimens, in combination with midazolam, for sedation analgesia in patients undergoing office-based plastic surgery procedures under local anesthesia. One-hundred patients were randomized into two groups of 50 subjects each. Group F1 received a fentanyl bolus of 0.7 microg/kg before infiltration with local anaesthetics; group F2 received the same bolus plus 0.6 microg/kg fentanyl every 45 minutes. All patients received a midazolam bolus of 0.05 mg/kg plus continuous infusion 0.08 mg/kg per hour. High-quality analgesia was obtained in every group, without significant differences between the two fentanyl regimens. Group F2 was associated with lower intraoperative mean blood pressure and SpO2 values compared with group F1. No differences were detected between the two groups in perioperative side effects or postoperative pain. Higher doses of opioid did not improve the quality of perioperative patient comfort but acted synergistically with the sedative drugs, amplifying the hemodynamic and respiratory side effects.
This study aimed to validate, in situ, proposed mechanisms of bupivacaine citotoxicity pointing t... more This study aimed to validate, in situ, proposed mechanisms of bupivacaine citotoxicity pointing to impairment of the mitochondrial oxidative metabolism. High resolution oxymetry, carried out on a panel of cell cultures, revealed a dual dose-and time-dependent effect of bupivacaine consisting of uncoupling of the mtDl H+-controlled respiratory rates in a cyclosporine A-insensitive manner and further inhibition of the respiratory rates. Intriguingly, a relatively small decrease on the mtDW (about 20 mV) was sufficient to account for both the bupivacaine-and the FCCP-mediated impairment of the oxidative phosphorylation coupling thereby supporting a common protonophoric mechanism of action. The bupivacaineinduced depression of the cell respiration related to specific inhibition of complexes I and III and accompanied with production of reactive oxygen species. Importantly, inhibition of the respiratory chain complexes was prevented by antioxidant treatment and reversed following removal of the anaesthetic thereby suggesting an oxidant-mediated feedback mechanism reinforcing the primary inhibitory action of the anaesthetic.
Hip fractures represent one of the most important causes of morbidity and mortality in elderly pe... more Hip fractures represent one of the most important causes of morbidity and mortality in elderly people. Anxiety and depression affect their quality of life and increase pain severity, and have adverse effects on functional recovery. Recent World Health Organization guidelines emphasize that therapeutic regimes need to be individualized and combined with psychological support. This study was launched with the primary endpoint of assessing if and to what extent client-centered therapy affects the perception of pain, reduces anxiety and depression, and increases the quality of life of elderly patients with hip fracture. Materials and methods: Forty patients were admitted to the Orthopedic and Trauma Surgery ward for hip fracture. Patients were randomly divided into two subgroups: (1) case (group C), had to receive patient-centered counseling throughout the hospitalization; and (2) control (group NC), receiving the analgesic treatment without receiving counseling. Short Form-36-item Health Survey Questionnaire, State-Trait Anxiety Inventory, and Hamilton Rating Scale for Depression scores were recorded before any treatment, at discharge, and after 30 days. Pain levels were evaluated by means of Visual Analog Scale every 12 hours during the hospitalization from the day of surgery until day 5. Results: The hierarchical clustering analysis identified before any treatment were two clusters based on different physical functioning perceptions and role limitations, which were due to physical and emotional problems. Counseling did have a positive impact on quality of life on all patients, but in a more relevant way if patients were low functioning upon admittance to the ward. Anxiety and depression decreased in patients undergoing counseling, and their pain levels were lower than among patients not receiving it. Conclusion: This study reveals that hip fracture patients can be clustered on the basis of Short Form-36 baseline scores. Counseling affects the evolution of mental and physical status in these patients, and the major benefit is reported in patients whose quality of life perception is worse after the trauma. Decreasing anxiety and depression levels, as well as more satisfying pain management, assessed by means of specific tests, confirm the effectiveness of counseling in elderly patients with hip fracture.
The last paper from Prof. Antonio Brienza, who recently died, is published herewith. The real val... more The last paper from Prof. Antonio Brienza, who recently died, is published herewith. The real value of one man may only be completely appreciated in the final balance. Starting from nothing, Antonio created Intensive Care in the South of Italy and from there his group had a deep impact on our scientific community. It is difficult to realize, nowadays, the tremendous amount of effort and personal time Antonio had to spend to reach these targets. Remembering gives value to our lives. Antonio is still with us. Thanks, Professor Luciano Gattinoni,
Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in o... more Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m(2) scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (pre...
Background To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS)... more Background To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS) patients with diffuse loss of aeration, the application of the open lung approach (OLA) would improve homogeneity in lung aeration and lung mechanics, without affecting hemodynamics. Methods Patients were ventilated according to the ARDS Network protocol at baseline (pre-OLA). OLA consisted in a recruitment maneuver followed by a decremental positive end-expiratory pressure trial. Respiratory mechanics, gas exchange, electrical impedance tomography (EIT), cardiac index, and stroke volume variation were measured at baseline and 20 min after OLA implementation (post-OLA). Esophageal pressure was used for lung and chest wall elastance partitioning. The tomographic lung image obtained at the fifth intercostal space by EIT was divided in two ventral and two dorsal regions of interest (ROIventral and ROIDorsal). Results Fifteen consecutive patients were studied. The OLA increased arterial oxy...
ABSTRACT Background: In this prospective physiological observational study, we applied a strategy... more ABSTRACT Background: In this prospective physiological observational study, we applied a strategy to estimate the end-expiratory pleural pressure (Ppl,ee) using esophageal manometry to measure the esophageal pressure (Pes) directly. The estimated Ppl,ee was used to assess the end-expiratory transpulmonary pressure (PL,ee), in order to obtain a parameter to target PEEP, thereby minimizing alveolar collapse and resulting hypoxemia at end expiration during normal and one lung ventilation (OLV) in supine and lateral decubitus in Thoracic Surgery. Material and methods: After Ethical Committee approval was obtained, we enrolled patients with age ≥ 18 ys, scheduled for thoracic surgery and OLV with double-lumen tube in lateral decubitus. Exclusion criteria: ASA > III, haemodynamic instability, ARDS. Haemodynamics, gas exchange and respiratory mechanics data were recorded at three time points: two lung ventilation in supine position (T1), two lung ventilation in lateral (T2) and one lung ventilation in lateral position (T3). We applied a factor to correct absolute Pes values to estimate the Ppl,ee, by subtracting the Pes value obtained at the relaxation volume of the respiratory system (Vr) af ter manual disconnection from the ventilator, from the Pes value at the end of an expiratory occlusion. PL,ee was obtained as airway pressure at the end of the expiratory occlusion minus Ppl,ee. Result and discussion: 8 consecutive patients undergoing to thoracic surgery were included. At T1 Ppl,ee was 1.31±0.37 cmH2O, and increased overtime (3.06 ± 0.23 at T2 and 3.87 ± 0.43 at T3; p< 0.01 vs T1), while PL,ee decreased (2.88 ± 0.36 cmH2O at T1, 0.2 ± 0.33 at T2, -0.36 ± 0.47 at T3; p< 0.01 vs T1).Conclusion: Our preliminary results show that the lateral position and the lung exclusion induce an increase in Ppl,ee and a reduction in PL,ee. We need further studies to determine if the estimation of Ppl,ee on the basis of the Vr method could allow PEEP titration to target an PL,ee of 0 cmH2O in order to avoid atelectrauma during thoracic surgery.
International journal of immunopathology and pharmacology
We studied the effects of Propofol, Desflurane, and Sevoflurane on the systemic redox balance in ... more We studied the effects of Propofol, Desflurane, and Sevoflurane on the systemic redox balance in patients undergoing laparohysterectomy. We measured blood concentration of glutathione (GSH), plasma antioxidant capacity (Trolox Equivalent Antioxidant Capacity-TEAC), and lipid peroxidation products (malondialdehyde (aMDA) and 4-hydroxynonenal (aHNE) protein adducts). Sixty patients were randomly placed into three groups of twenty people each. In Group P anesthesia was induced with Propofol 2 mg/kg and maintained with 12-10-8 mg/kg/min; in Groups S and D anesthesia was induced with 3 mg/kg Sodium Thiopental and maintained with 2 percent Sevoflurane and 6 percent Desflurane, respectively. Blood samples were collected prior to induction (T0 bas), 60min and 24h postoperatively (T1 60 and T2 24 h). In Group P, GSH increased on T1 60 and returned to baseline on T24h, while TEAC remained unmodified; in Groups S, GSH and TEAC decreased on T1 60 in Group D, on T1 60 there was a slight decrease...
The "bone cement implantation syndrome" is a rare but severe complication observed espe... more 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. Prospective study, between February-May 2001. Orthopedic Operative room. 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). 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 af...
To evaluate the effects of positive end expiratory pressure (PEEP) on intrathoracic and extrathor... more To evaluate the effects of positive end expiratory pressure (PEEP) on intrathoracic and extrathoracic blood volumes in patients with acute respiratory failure (ARF). In 4 ARF patients, we have measured cardiac output (CI), intrathoracic blood volume (ITBVI), global end-diastolic ventricular volume (GEDVI), pulmonary (PBVI) and total (TBVI) blood volumes, during application of two PEEP levels (0 and 10 cm H2O). These measurements have been performed by PULSION COLD Z-021 system, using the double indicator dilution technique (thermal and dye dilution). PEEP application caused a significant reduction in CI (from 3.8 +/- 0.4 to 2.9 +/- 0.1 1/min/m2) and ITBVI (from 888 +/- 48 to 698 +/- 25 ml/m2). The reduction in intrathoracic blood volume was associated with a significant reduction in GEDVI and PBVI. After PEEP application, there was a significant reduction in TBVI (from 2437 +/- 135 to 1984 +/- 49 ml/m2). PEEP application decreases cardiac index, mainly through a preload reduction, a...
Background: Aim of this prospective study was to evaluate the sensory block quality and hemodynam... more Background: Aim of this prospective study was to evaluate the sensory block quality and hemodynamic effects in patients undergoing urologic surgery under Combined Sequential Spinal Epidural Anesthesia (CSSE). Methods: Fifty patients were included in the study. Inclusion criteria were age ≥ 18 years and surgery scheduled to last ≤ 2 hours. Patients with a history of hypertension, congestive heart failure, any active medication for cardiovascular disease or any other absolute or relative contraindication to spinal anesthesia were excluded from the study. Patients undergoing urologic procedures received CSSE with 4 ml of Levobupivacaine 0.075% intratecally, followed by 10 ml of Levobupivacaine 1.5% epidurally. Sensory block spread was assessed by a pin prick test. Cardiac index (CI), blood pressure (BP), heart rate (HR) and arterial saturation of O 2 (SpO 2) were continuously monitored and recorded. Before discharge, patient's functional status was assessed by the Aldrete Score. Results: CSSE allowed a pain free procedure. The pinprick test score was 1.2 ± 0.7 at the T7 dermatome level. CI, mean BP and HR were stable during the entire procedure. The Aldrete Score was 9.84 ± 0.4. Conclusion: CSSE performed with low doses of local anaesthetics allowed a good sensory block and was associated with good hemodynamic conditions and recovery score.
Intra-abdominal hypertension (IAH) can affect liver hemodynamics but it is not known if has a sig... more Intra-abdominal hypertension (IAH) can affect liver hemodynamics but it is not known if has a significant clinical impact on liver function. The aim of this study was to investigate the relationship between IAH and liver function. A prospective study was performed in 110 adult intensive care unit (ICU) patients. Intra-abdominal pressure (IAP) was measured on admission and every other day, and liver sequential organ failure assessment (SOFA) score was collected whenever IAP was measured. IAH was defined by a IAP Ն 10 mm Hg, and liver dysfunction was defined by a hepatic SOFA score Ն 2. An overall IAH incidence of 56.3% was found (n ϭ 62). Thirty-three patients presented a liver SOFA score Ն 2, with an overall incidence of 30%. Liver SOFA score of the group of patients with abdominal hypertension was higher than in group of patients without abdominal hypertension. (0.8 Ϯ 1.05 vs 0.4 Ϯ 0.7; P Ͻ .05), but IAH and liver dysfunction were not significantly associated (2 ϭ 2.03; P ϭ .15). When the whole sample was divided according to the worst IAP score (IAP Ͻ 10, IAP between 10 and 15, and IAP Ͼ 15), the corresponding liver dysfunction scores in the three groups were 0.35 Ϯ 0.6, 0.74 Ϯ 1, and 1.2 Ϯ 1.3, respectively (P ϭ .01). A strict association between IAH and liver dysfunction was not found. Most likely, low levels of IAH, although able to reduce liver blood flow, are not per se sufficient to produce a real dysfunction; however, a correlation between the degree of IAH and the degree of hyperbilirubinemia exists. IAH does not seem to be an "on-off" phenomenon, but produces liver alterations for increasing levels of its severity.
The aim of this study was to test the effect of a small volume administration of p-hydroxyphenylp... more The aim of this study was to test the effect of a small volume administration of p-hydroxyphenylpyruvate (pHPP) in a rat model of profound hemorrhagic shock and to assess a possible metabolic mechanism of action of the compound. The results obtained show that hemorrhaged rats treated with 2-4% of the estimated blood volume of pHPP survived significantly longer (p,0.001) than rats treated with vehicle. In vitro analysis on cultured EA.hy 926 cells demonstrated that pHPP improved cell growth rate and promoted cell survival under stressing conditions. Moreover, pHPP stimulated mitochondria-related respiration under ATP-synthesizing conditions and exhibited antioxidant activity toward mitochondria-generated reactive oxygen species. The compound effects reported in the in vitro and in vivo analyses were obtained in the same millimolar concentration range. These data disclose pHPP as an efficient energetic substrates-supplier to the mitochondrial respiratory chain as well as an antioxidant supporting the view that the compound warrants further evaluation as a therapeutic agent.
The combination of sedative and analgesic drugs is increasingly being used during minimally invas... more The combination of sedative and analgesic drugs is increasingly being used during minimally invasive surgery. The authors compared the clinical efficacy of two different fentanyl regimens, in combination with midazolam, for sedation analgesia in patients undergoing office-based plastic surgery procedures under local anesthesia. One-hundred patients were randomized into two groups of 50 subjects each. Group F1 received a fentanyl bolus of 0.7 microg/kg before infiltration with local anaesthetics; group F2 received the same bolus plus 0.6 microg/kg fentanyl every 45 minutes. All patients received a midazolam bolus of 0.05 mg/kg plus continuous infusion 0.08 mg/kg per hour. High-quality analgesia was obtained in every group, without significant differences between the two fentanyl regimens. Group F2 was associated with lower intraoperative mean blood pressure and SpO2 values compared with group F1. No differences were detected between the two groups in perioperative side effects or postoperative pain. Higher doses of opioid did not improve the quality of perioperative patient comfort but acted synergistically with the sedative drugs, amplifying the hemodynamic and respiratory side effects.
This study aimed to validate, in situ, proposed mechanisms of bupivacaine citotoxicity pointing t... more This study aimed to validate, in situ, proposed mechanisms of bupivacaine citotoxicity pointing to impairment of the mitochondrial oxidative metabolism. High resolution oxymetry, carried out on a panel of cell cultures, revealed a dual dose-and time-dependent effect of bupivacaine consisting of uncoupling of the mtDl H+-controlled respiratory rates in a cyclosporine A-insensitive manner and further inhibition of the respiratory rates. Intriguingly, a relatively small decrease on the mtDW (about 20 mV) was sufficient to account for both the bupivacaine-and the FCCP-mediated impairment of the oxidative phosphorylation coupling thereby supporting a common protonophoric mechanism of action. The bupivacaineinduced depression of the cell respiration related to specific inhibition of complexes I and III and accompanied with production of reactive oxygen species. Importantly, inhibition of the respiratory chain complexes was prevented by antioxidant treatment and reversed following removal of the anaesthetic thereby suggesting an oxidant-mediated feedback mechanism reinforcing the primary inhibitory action of the anaesthetic.
Hip fractures represent one of the most important causes of morbidity and mortality in elderly pe... more Hip fractures represent one of the most important causes of morbidity and mortality in elderly people. Anxiety and depression affect their quality of life and increase pain severity, and have adverse effects on functional recovery. Recent World Health Organization guidelines emphasize that therapeutic regimes need to be individualized and combined with psychological support. This study was launched with the primary endpoint of assessing if and to what extent client-centered therapy affects the perception of pain, reduces anxiety and depression, and increases the quality of life of elderly patients with hip fracture. Materials and methods: Forty patients were admitted to the Orthopedic and Trauma Surgery ward for hip fracture. Patients were randomly divided into two subgroups: (1) case (group C), had to receive patient-centered counseling throughout the hospitalization; and (2) control (group NC), receiving the analgesic treatment without receiving counseling. Short Form-36-item Health Survey Questionnaire, State-Trait Anxiety Inventory, and Hamilton Rating Scale for Depression scores were recorded before any treatment, at discharge, and after 30 days. Pain levels were evaluated by means of Visual Analog Scale every 12 hours during the hospitalization from the day of surgery until day 5. Results: The hierarchical clustering analysis identified before any treatment were two clusters based on different physical functioning perceptions and role limitations, which were due to physical and emotional problems. Counseling did have a positive impact on quality of life on all patients, but in a more relevant way if patients were low functioning upon admittance to the ward. Anxiety and depression decreased in patients undergoing counseling, and their pain levels were lower than among patients not receiving it. Conclusion: This study reveals that hip fracture patients can be clustered on the basis of Short Form-36 baseline scores. Counseling affects the evolution of mental and physical status in these patients, and the major benefit is reported in patients whose quality of life perception is worse after the trauma. Decreasing anxiety and depression levels, as well as more satisfying pain management, assessed by means of specific tests, confirm the effectiveness of counseling in elderly patients with hip fracture.
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