Enrico Giuliani

Analgesia during abdominal aortic aneurysm endovascular repair: remifentanil vs. fentanyl-midazolam--a randomized controlled trial.

Background and objective Endovascular repair offers a less surgically invasive procedure for abdominal aortic aneurysms but nevertheless, still requires analgesic sedative cover to ensure an acceptable level of patient comfort and cardiorespiratory stability. The peculiarity of this kind of operation is that painful stimuli are concentrated in specific moments separated by intervals devoid of pain, so the insurgence of pain can be predicted and prevented with a bolus of analgesic, making a continuous infusion not essential, but potentially useful in achieving a better analgesic stability. The primary objective of the study was pain control measured by Visual Analogue Scale; secondary endpoints were cardiorespiratory stability and an acceptable level of sedation. Methods The sedative analgesic protocols of two groups of randomly allocated patients, undergoing abdominal aortic aneurysm endovascular repair, were compared. The experimental group received remifentanil infusion (0.03–0.1 μg kg−1 min−1) and the control group received intravenous doses of fentanyl and midazolam (1–3 μg kg−1 and 0.05–0.1 mg kg−1, respectively). Results Fifty patients were investigated out of 60 enrolled. There were no relevant differences concerning cardiorespiratory stability and level of sedation, but pain levels were significantly lower in the experimental group: mean Visual Analogue Scale 0.35 ± 0.40 vs. 1.49 ± 0.62 (P < 0.001) and area under the curve 17.48 ± 5.09 vs. 33.05 ± 8.19 (P < 0.001). Conclusion Both techniques were shown to be safe and most importantly effective in offering cardiovascular stability and analgesia for American Society of Anaesthesiologists III–IV patients undergoing endovascular abdominal aortic aneurysm repair. However, remifentanil continuous infusion proved to offer significantly more stable pain control compared with the currently used combination fentanyl–midazolam.

Education in anesthesia: three years of online logbook implementation in an Italian school.

BackgroundThe progress of physicians through residency training in anesthesiology can be monitored using an online logbook. The aim of this investigation was to establish how residents record clinical activities in their computerized web-based logbooks during their first years of anesthesiology training.MethodsFor this retrospective observational trial, the ESSE 3© digital registry of the University of Modena and Reggio Emilia, Italy was used to record all anesthesia-related activities performed by three consecutive year-groups of residents (Groups A, B and C) between 2009 and 2012. The ratio of activities to sessions was chosen as a surrogate measure of compliance.ResultsA total of 41,348 actions were analyzed. The ratio of activities to sessions showed a statistically significant decline for all activities concerning the perioperative management of anesthesia, with a steady reduction from the first to the last year-group (Group A 23.7, Group B 14.1 and Group C 2.2; p = 0.003).ConclusionsAn online activities logbook is a useful tool for recording and assessing the clinical activities undertaken by each resident during residency training in anesthesiology.

Development and validation of a liquid chromatography-tandem mass spectrometric assay for quantitative analyses of triptans in hair

Triptans are specific drugs widely used for acute treatment of migraine, being selective 5HT1B/1D receptor agonists. A proper assumption of triptans is very important for an effective treatment; nevertheless patients often underuse, misuse, overuse or use triptans inconsistently, i.e., not following the prescribed therapy. Drug analysis in hair can represent a powerful tool for monitoring the compliance of the patient to the therapy, since it can greatly increase the time-window of detection compared to analyses in biological fluids, such as plasma or urine. In the present study, a liquid chromatography-tandem mass spectrometric (LC-MS/MS) method has been developed and validated for the quantitative analysis in human hair of five triptans commonly prescribed in Italy: almotriptan (AL), eletriptan (EP), rizatriptan (RIZ), sumatriptan (SUM) and zolmitriptan (ZP). Hair samples were decontaminated and incubated overnight in diluted hydrochloric acid; the extracts were purified by mixed-mode SPE cartridges and analyzed by LC-MS/MS under gradient elution in positive multiple reaction monitoring (MRM) mode. The procedure was fully validated in terms of selectivity, linearity, limit of detection (LOD) and lower limit of quantitation (LLOQ), accuracy, precision, carry-over, recovery, matrix effect and dilution integrity. The method was linear in the range 10-1000pg/mg hair, with R(2) values of at least 0.990; the validated LLOQ values were in the range 5-7pg/mg hair. The method offered satisfactory precision (RSD <10%), accuracy (90-110%) and recovery (>85%) values. The validated procedure was applied on 147 authentic hair samples from subjects being treated in the Headache Centre of Modena University Hospital in order to verify the possibility of monitoring the corresponding hair levels for the taken triptans.

The effect of desflurane on neuronal communication at a central synapse.

Although general anesthetics are thought to modify critical neuronal functions, their impact on neuronal communication has been poorly examined. We have investigated the effect induced by desflurane, a clinically used general anesthetic, on information transfer at the synapse between mossy fibers and granule cells of cerebellum, where this analysis can be carried out extensively. Mutual information values were assessed by measuring the variability of postsynaptic output in relationship to the variability of a given set of presynaptic inputs. Desflurane synchronized granule cell firing and reduced mutual information in response to physiologically relevant mossy fibers patterns. The decrease in spike variability was due to an increased postsynaptic membrane excitability, which made granule cells more prone to elicit action potentials, and to a strengthened synaptic inhibition, which markedly hampered membrane depolarization. These concomitant actions on granule cells firing indicate that desflurane re-shapes the transfer of information between neurons by providing a less informative neurotransmission rather than completely silencing neuronal activity.

Ibuprofen timing for hand surgery in ambulatory care

OBJECTIVE: To evaluate the effect of pre-operative administration of ibuprofen on post-operative pain control vs. early post-operative administration for hand surgery procedures performed under local anaesthesia in ambulatory care. METHODS: Candidates to trigger finger release by De Quervain tenosynovitis and carpal tunnel operation under local anesthesia were enrolled in the study. Group A received 400 mg ibuprofen before the operation and placebo after the procedure; group B received placebo before the operation and ibuprofen 400 mg at the end of the procedure; both groups received ibuprofen 400 mg every 6h thereafter. Visual analogue scale (VAS) was measured at fixed times before and every 6h after surgery, for a total follow-up of 18h. RESULTS: Groups were similar according to age, gender and type of surgery. Median VAS values did not produce any statistical significance, while there was a statistically significant difference on pre-operative and early post-operative VAS values between groups (A -8.53 mm vs. B 3.36 mm, p=0.0085). CONCLUSION: Average pain levels were well controlled by local anesthesia and post-operative ibuprofen analgesia. Pre-operative ibuprofen administration can contribute to improve early pain management. Level of Evidence II, Therapeutic Studies.

Acute myocardial infarction – from territory to definitive treatment in an Italian province

RATIONALE, AIMS AND OBJECTIVES Early reperfusion is the key to therapeutic success in acute myocardial infarction (AMI). The duration of the process is influenced by various factors which in most of the cases are not easily modifiable. The aim of this study is to analyse AMI treatment process duration to identify determining factors. The objective is to better exploit time intervals imposed by spatial distance from the hospital. METHOD One-year data regarding acute coronary syndromes with elevated ST segment for patients presenting to Policlinico teaching hospital (Modena, Italy) have been studied. Patients were divided into two groups for hospital access: A - ambulance access to Policlinico emergency room (ER); B - self-referral to ER. RESULTS A total of 141 patients have undergone percutaneous transluminal coronary angioplasty for AMI at Policlinico, 106 males, 35 females (58.1% males in group A, 82.7% in B, P 0.002), with an average age of 66.09 ± 14.30 years in group A and 60.90 ± 13.47 in B (P 0.047). Mean pre-hospital time for group A was 122.54 ± 130.69 minutes and B 171.49 ± 353.60 (P 0.25), mean hospital time in group A was 196.03 ± 67.66 and B 255.14 ± 113.16 (P<0.001), mean total time in group A was 318.56 ± 146.91 and B 426.63 ± 382.01 (P 0.02). DISCUSSION Data show that group B suffered on average a 108-minute delay from symptoms insurgence to definitive treatment. The duration of hospital time plays more important role in this finding than distance from the medical facility. In fact, on the ambulance a medical crew starts the diagnostic and therapeutic process relieving ER from initial evaluation.

Critical illness in energy metabolism genetic disorder: rhabdomyolysis, acute kidney injury, respiratory arrest

In very long-chain acylCoA dehydrogenase deficiency (VLCAD), the activity of this enzyme is either reduced or absent with the inability to use long-chain fatty acids as energy substrates. A 25-year old male with VLCAD was admitted to the Emergency Department of Policlinico Teaching Hospital (Modena, Italy)for generalized weakness and oliguria, after a period of physical and mental stress and inadequate compliance to a long-chain fatty acid free diet. Laboratory tests were compatible with acute kidney injury. Seventy-two hours after admission, the subject had an episode of chest pain with elevated markers of myocardial necrosis. The rapid deterioration of muscular strength and the subsequent worsening respiratory failure necessitated ventilator support within the local Medical Intensive Care Unit. There, the patient showed a prompt normalization of respiratory parameters and a steady improvement of renal function. An inadequate compliance to lifestyle and dietary restriction in VLCAD may trigger severe and potentially lethal crisis. The in-hospital management of these patients calls for early intensive care admission as their conditions may deteriorate without warning.

Log-book implementation in anaesthesiology residency training: A retrospective analysis

A log-book, to record all work-related activities during clinical residency training, can become part of the teaching/learning process as a way to monitor the working status of trainees not only in order to document their progress, but also in order to identify areas where further training is necessary (Beasley et al. 2011). Such a document could become part of the curriculum vitae that professionals develops throughout their residency and, if properly updated, could also be maintained during their post-specialization working life. A retrospective investigation was carried out at the University of Modena and Reggio Emilia School of Anaesthesiology (Modena, Italy) to compare residents’ recording compliance between computerized and computerized web-based log-books during their first two years of anaesthesiology training and the variation in the degree of detail for the recordings. Data for this retrospective study came from the University of Modena and Reggio Emilia’s database of residency activities for two consecutive academic years. Anaesthesia training activities were grouped into three categories: pre-operative patient assessment, peri-operative management of anaesthesia, post-operative patient follow-up. Compliance was measured as the ratio between activities and log-book entries, the degree of detail as the ratio between specific activities and entries. The data of 10 residents attending the first and the second years at the School of Anaesthesiology were included. There was a statistically significant difference for perioperative management of anaesthesia, where ratio medians were 29.81 in 2009–2010 and 13.03 in 2010–2011, p-value 0.0117. Specific activities/entries ratio medians were 22.00 in 2009–2010 and 13.71 in 2010–2011, p-value 0.0117. Anaesthesiology practice comprises a variety of different activities, so it becomes necessary to keep track of residents’ educational career in a log-book. Users’ compliance, however, represents a limitation to its effectiveness. The development of a computerized, web-based record that guides trainees through the data entry process has the potential for improving not only accuracy but also completeness. A web-based logbook is a flexible, portable tool, and can be accessed and updated from any device that can connect to the Internet, even a smartphone.

Circumflex coronary artery agenesis associated with thoracic great vessels anomalies.

Coronary artery anomalies are identified in approximately 1% of patients who undergo angiography; among these, circumflex branch agenesis represents 0.003%. A 38-year-old woman was brought to our emergency department with clinical findings suggestive of acute myocardial infarction. Absence of circumflex branch was reported during angiography. Further analysis showed great vessel abnormalities: the presence of a left superior vena cava, a left arterial trunk of abnormal origin, and a small cerebral aneurysm. To our knowledge, this is the only reported case with such vascular anomalies.

Response by Twin Italian Hub Hospitals in a Double Seismic Event: A Retrospective Observational Investigation

Abstract Introduction: The objectives of this study were to compare prevalence rates of different pathologies, ambulance system and emergency department management times, and patient survival and hazard ratios for codes 2 and 3 in two hub hospitals in Modena in the 36-month period across the stages of two major earthquakes in short sequence in Northern Italy in 2012. Methods: Clinical records pertaining to the emergency care of patients were analyzed and only those assigned status codes 2 and 3 by ambulance professionals were included (if the assessment was confirmed by emergency department triage). The statistical analysis of data was divided by three time periods studied: before, during/between, and after the earthquakes. Results: Among the 2,278 retained records, there were no statistically significant differences in the prevalence of the main pathologies presented at the two hubs in the studied period. A Cox regression model was used to analyze the survival of patients in the different stages of the emergency; there were no statistically significant differences in the hazard ratios of death before, during, and after the earthquake. The study found a significant increase in emergency department treatment times. Discussion: Redundancies in the Modena medical system were found to have compensated for damaged hospital facilities. In particular, they helped emergency systems reorganize themselves faster in order to bring medical assistance to people during and around seismic events with as a minimal amount of disruption as possible. Conclusion: The Modena medical system was redundant and ensured that disrupted emergency systems were reorganized and put back online while damaged hospital facilities were compensated for/reproduced elsewhere.