Aldo Luzzani

Comparison of procalcitonin and C-reactive protein as markers of sepsis.

OBJECTIVE To compare the clinical informative value of procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations in the detection of infection and sepsis and in the assessment of severity of sepsis. DESIGN Prospective study. SETTING Medicosurgical intensive care unit. PATIENTS Seventy consecutive adult patients who were admitted to the intensive care unit for an expected stay >24 hrs. INTERVENTIONS None. MEASUREMENTS PCT and CRP plasma concentrations were measured daily during the intensive care unit stay. Each patient was examined daily for signs and symptoms of infection and was classified daily in one of the following four categories according to the American College of Chest Physicians/Society of Critical Care Medicine criteria: negative, systemic inflammatory response syndrome, localized infection, and sepsis group (sepsis, severe sepsis, or septic shock). The severity of sepsis-related organ failure was assessed by the sepsis-related organ failure assessment score. MAIN RESULTS A total of 800 patient days were classified into the four categories. The median plasma PCT concentrations in noninfected (systemic inflammatory response syndrome) and localized-infection patient days were 0.4 and 1.4 ng/mL (p <.0001), respectively; the median CRP plasma concentrations were 79.9 and 85.3 mg/L (p =.08), respectively. The area under the receiver operating characteristic curve was 0.756 for PCT (95% confidence interval [CI], 0.675-0.836), compared with 0.580 for CRP (95% CI, 0.488-0.672) (p <.01). The median plasma PCT concentrations in nonseptic (systemic inflammatory response syndrome) and septic (sepsis, severe sepsis, or septic shock) patient days were 0.4 and 3.65 ng/mL (p <.0001), respectively, whereas those for CRP were 79.9 and 115.6 mg/L (p <.0001), respectively. The area under the receiver operating characteristic curve was 0.925 for PCT (95% CI, 0.899-0.952), compared with 0.677 for CRP (95% CI, 0.622-0.733) (p <.0001). The linear correlation between PCT plasma concentrations and the four categories was much stronger than in the case of CRP (Spearmans rho, 0.73 vs. 0.41; p <.05). A rise in sepsis-related organ failure assessment score was related to a higher median value of PCT but not CRP. CONCLUSION PCT is a better marker of sepsis than CRP. The course of PCT shows a closer correlation than that of CRP with the severity of infection and organ dysfunction.

A new approach to the neurolytic block of the coeliac plexus : the transaortic technique

Abstract The present study critically examines the coeliac plexus block techniques hitherto adopted, pointing out the complications involved and stressing the seriousness of the neurological complications due to spread of the neurolytic agent to the sympathetic chain and the lumbar plexus. Contrast enhanced CT scans demonstrate the difficulties involved in confining the neurolytic agent to the anterior, peri‐aortic and precrural regions. The authors report their recent experience with coeliac plexus block by means of a single transaortic needle in 28 patients. In 12 of the patients, the GT scan revealed a spread of the neurolytic agent anterior and lateral to the aorta; on all occasions this spread was anterior to the medial crura of the diaphragm, sometimes extending laterally towards the costovertebral gutter along the ventral surface of the diaphragm. Pain relief was obtained in 93% of the cases and no complications were observed. The transaortic technique is simple, and a control lateral scan provides a characteristic image.

Impact of oligon central venous catheters on catheter colonization and catheter-related bloodstream infection

ObjectiveTo evaluate a new antimicrobial treatment for central venous catheters in comparison with a traditional treatment, by assessing the catheter colonization and catheter-related bloodstream infection rates in two groups of patients. DesignMultiple-center, prospective randomized study. SettingThe medical and surgical departments of ten institutions. PatientsPatients requiring a central venous catheter for medical or surgical pathologies between June 2000 and November 2001. InterventionsPatients in the control group received a conventional benzalkonium-treated double-lumen central venous catheter, while patients in the oligon group received an oligon-treated (polyurethane combined with silver, carbon, and platinum) catheter with the same characteristics. Data collection included demographics, preexisting clinical conditions, main pathology, catheter insertion, and management data. Catheter colonization was defined as the growth of ≥15 colony-forming units in culture of catheter segments by the roll-plate method, or ≥1000 colony-forming units for the sonication method, and catheter-related bloodstream infection was defined as isolation of the same organism from the colonized catheter and from the peripheral blood of a patient with clinical signs of bloodstream infection. Measurements and Main ResultsData were obtained from 545 catheters. Of these, 132 catheters (24.2%) were positive for colonization. Patients in the oligon group demonstrated a lower risk for catheter colonization in the overall population (relative risk, 0.63; 95% confidence interval, 0.46–0.86;p = .003) and in the surgical subgroup (relative risk, 0.5; 95% confidence interval, 0.33–0.76;p = .001). Significant differences between groups were detected for coagulase-negative staphylococci and Gram-negative bacilli colonization rates. Twenty-one patients (3.8%) were positive for catheter-related bloodstream infection, without significant differences between control and oligon groups. ConclusionsOligon treatment is effective in limiting the catheter colonization rate. Due to the limited amount of events, this study lacked the power to detect significant differences in terms of catheter-related bloodstream infection rate.

Results up to death in the treatment of persistent cervico-thoracic (Pancoast) and thoracic malignant pain by unilateral percutaneous cervical cordotomy

&NA; The authors analyse the results up to death in 103 followed‐up patients undergoing unilateral percutaneous cervical cordotomy for persistent cervico‐thoracic malignant pain (45 cases of Pancoast syndrome and 58 cases of thoracic pain associated with lung cancer or metastases). On the basis of epidemiological data, relationships emerge between onset of pain, stage of cancer, patient survival and lasting efficacy of pain relief. Twenty (44%) of 45 patients with Pancoast syndrome were pain‐free up to death as a result of cordotomy alone, while only 13/58 patients (22%) with thoracic pain were pain‐free as a result of cordotomy alone owing to the very high incidence of mirror pain in this group of patients (42/58 patients, 72%) compared to those with Pancoast syndrome (14/45 patients, 31%). The type and intensity of mirror pain, however, were of such a nature in both groups as to be amenable to control with analgesic drugs. In both groups of patients, there was a low incidence of the causes of post‐cordotomy pain recurrence contralateral to the lesion, i.e., deafferentation pain, fading of analgesia and pain above the levels up to which deep pin‐prick analgesia had been obtained. Cordotomy alone or, as necessary, in conjunction with analgesic drugs afforded complete pain control in 34/45 patients (75%) with Pancoast syndrome and in 50/58 patients (86%) with thoracic pain. These data provide evidence of the unique usefulness of the procedure in controlling otherwise intractable persistent cervicothoracic malignant pain, when the technique is correctly performed.

Subarachnoid neurolytic block (L5-S1) and unilateral percutaneous cervical cordotomy in the treatment of pain secondary to pelvic malignant disease.

&NA; The present study deals with the immediate and long‐term results of subarachnoid neurolytic block (L5−S1) with 7.5%, 10% and 15% concentrations of phenol in glycerine and/or unilateral percutaneous cervical cordotomy in 73 patients (follow‐up in 56 patients) suffering from perineal, perineopelvisacral or pelvisacral pain secondary to malignant diseases of the pelvic cavity. Subarachnoid neurolytic block (L5−S1) produced satisfactory, long‐lasting relief of perineal pain when the higher concentrations of phenol (10 and 15%) were used. The only sequela reported was urinary retention. Percutaneous cervical cordotomy used for the treatment of pelvisacral or predominantly unilateral perineal pain gave complete pain relief until death in 76.7% of patients, either alone (36.7%) or in conjunction with pharmacological therapy (40%). Analysis of the data enabled us to establish the respective indications for the two procedures and to identify those cases in which their use may be complementary.

Retrogasserian glycerol injection: a retrospective study of 112 patients.

From 1984 to 1989. 112 patients with typical drug-refractory trigeminal neuralgia were treated by retrogasserian glycerol injection. The present study assesses results and complications after a mean follow-up period of 3.5 years (range 0.1–5.5 years). One hundred and three of 112 patients (91.9%) showed complete pain relief 1 month postoperatively, and at the end of follow-up 80 patients (71.4%) were still enjoying complete pain relief (recurrence rate 20.5%). Abnormal facial sensations were noted in 49 patients, the most common complication being mild hypoesthesia (32% of patients), while paresthesia occurred in 19% of cases and dysesthesia in 3%. The corneal reflex was absent in 3% of patients and reduced in 5%. None of the patients developed anesthesia dolorosa, permanent masseter weakness, neuroparalytic keratitis, or diplopia.

Role of unilateral percutaneous cervical cordotomy in the treatment of neoplastic vertebral pain

&NA; The present study is a long‐term report on 69 patients undergoing unilateral percutaneous cervical cordotomy for vertebral pain due to neoplastic bone metastases. The pain was unilateral or bilateral and was characterised by a chronic and/or an incident component. Seventy‐one per cent (49/69) of the patients benefitted from the operation, obtaining complete, lasting pain relief or a reduced degree of pain, amenable to control by medication with narcotic or non‐narcotic drugs. There was a survival Q(50%) of 5 months (S.E. = 1.6) with no pain and a satisfactory quality of life.

Percutaneous controlled thermocoagulation in the treatment of trigeminal neuralgia.

This study reviews the results and complications of 162 percutaneous thermocoagulations of the gasserian ganglion in 124 patients with typical idiopathic trigeminal neuralgia. The mean duration of follow-up observation was 3.7 years (range. 1–6 years). One hundred eighteen of 124 patients continued to show complete pain relief I month after the operation. and at the end of follow-up observation, 83 of 124 patients (67%) continued to enjoy complete pain relief (recurrence rate, 28.2%). Anesthesia dolorosa occurred in 3% of cases, dysesthesia in, and paresthesia in l7%; neuroparalytic keratitis with permanent reduction of visual acuity was observed in 2% of cases, permanent diplopia in l%, permanent hearing deficit in 3%, and permanent impairment of mastication in 3%. We compare thermocoagulation with other surgical procedures (microvascular decompression, glycerol injection, and percutaneous decompression) used in the treatment of trigeminal neuralgia.