F Della Corte

Neurally Adjusted Ventilatory Assist in Preterm Neonates with Acute Respiratory Failure

Background: Neurally adjusted ventilatory assist (NAVA) is a novel mode of ventilation that has been demonstrated to improve infant-ventilator interaction, compared to the conventional modes in retrospective and short-term studies. Objectives: To prospectively evaluate the physiologic effects of NAVA in comparison with pressure-regulated volume control (PRVC) in two nonrandomized 12-hour periods. Methods: We studied 14 consecutive intubated preterm neonates receiving mechanical ventilation for acute respiratory failure. Peak airway pressure (Pawpeak), diaphragm electrical activity (EAdi), tidal volume (VT), mechanical (RRmec) and neural (RRneu) respiratory rates, neural apneas, and the capillary arterialized blood gases were measured. The RRmec-to-RRneu ratio (MNR) and the asynchrony index were also calculated. The amount of fentanyl administered was recorded. Results: Pawpeak and VT were greater in PRVC (p < 0.01). Blood gases and RRmec were not different between modes, while RRneu and the EAdi swings were greater in NAVA (p = 0.02 and p < 0.001, respectively). MNR and the asynchrony index were remarkably lower in NAVA than in PRVC (p = 0.03 and p < 0.001, respectively). 1,841 neural apneas were observed during PRVC, with none in NAVA. Less fentanyl was administered during NAVA, as opposed to PRVC (p < 0.01). Conclusions: In acutely ill preterm neonates, NAVA can be safely and efficiently applied for 12 consecutive hours. Compared to PRVC, NAVA is well tolerated with fewer sedatives.

Thoracic epidural analgesia in post-thoracotomy patients: comparison of three different concentrations of levobupivacaine and sufentanil

BACKGROUND Relative effects of dosage, volume and concentration of local anaesthetics used for postoperative thoracic epidural analgesia are still under debate. In this randomized, prospective, double-blinded study, we evaluated the incidence of side-effects such as changes in arterial pressure, postoperative nausea, vomiting, and pruritus in patients admitted for thoracic surgery during continuous thoracic epidural infusion using levobupivacaine and sufentanil mixture in three different volumes. METHODS We studied 150 patients who underwent thoracotomy with a thoracic epidural catheter placed between T4 and T7. The patients were randomized into three groups which received 10 mg h(-1) of levobupivacaine at three different concentrations (0.5%, 0.25%, and 0.15%), in combination with sufentanil at 2.6 microg h(-1). Haemodynamic effects, pruritus, nausea, vomiting, sensory and motor block, pain score, additional analgesic requirement, sedation, and patient satisfaction were registered immediately after the surgical operation and on the first, second, and third postoperative days. RESULTS We did not detect any differences in the incidence of side-effects such as changes in arterial pressure, and also postoperative nausea, vomiting, and pruritus. The three groups were also similar with regard to patient characteristics, sensory and motor block, pain score, analgesic rescue dose, sedation, and patient satisfaction. CONCLUSIONS The same dose of a mixture of levobupivacaine and sufentanil administered in three different volumes and concentrations during continuous thoracic epidural infusion for thoracotomy provided an equal incidence of adverse haemodynamic effects, nausea, vomiting, or pruritus.

Inhalational Anesthetics in Acute Severe Asthma

Acute severe asthma is characterized by a state of airway inflammation and increased bronchiolar smooth-muscle tone that leads to increased resistance to expiration and lung hyperinflation. Despite the better knowledge of its pathophysiology, the incidence and severity of asthma in the last twenty years is increased worldwide, although with significant age and geographic variation. As a result, the number of patients requiring more intensive medical therapy has also increased. In the most severe cases, often referred to as near-fatal asthma, the institution of mechanical ventilation may be required. Volatile anesthetics have bronchodilator effects on the bronchial smooth muscle. The use of inhalational anesthetic agents for treatment of severe status asthmaticus has been documented in case reports, case series and small uncontrolled studies. Their use may be considered in any mechanically ventilated patients whose severe bronchospasm failed to respond to maximal medical treatment. In the present review article, we aim to provide a brief description of the physio-pathological and clinical features of acute severe asthma, and of the principles of treatment, focusing our attention on the use of the inhalational anesthetics in severe patients requiring mechanical ventilation and not responding to conventional therapy.

Igm-enriched polyclonal immunoglobulins in an experimental model of gram negative pneumonia developing septic shock

Severe pneumonia is a major challenge in the Intensive Care Unit, as it is characterized by high morbidity and mortality. A high rate of patients with pneumonia, in particular ventilator-associated poneumonia, develops septic shock. Although some interesting results have been reported in uncontrolled studies where IgM-enriched human intravenous immunoglobulins were added to the standard treatment of septic shock, a well-conducted clinical trial is missing[1]. Also, physiopathological data supporting such a trial are presently insufficient.

THE MINI-SIGH TEST: A NEW HAEMODYNAMIC TEST OF FLUID RESPONSIVENESS IN ICU PATIENTS UNDERGOING PRESSURE SUPPORT VENTILATION

Dynamic predictors of fluid responsiveness (FR) perform poorly in ICU patients receiving partial ventilatory assistance. Because these modes of partial support are increasingly used, FR dynamic indexes are applicable only in a few ICU patients [1]. To overcome these limitations, novel approaches for testing FR in ICU have been proposed, such as the passive leg raising and the end-expiratory occlusion. These tests, however, may not always be applicable [2]. During controlled mechanical ventilation, Pulse Pressure (PP) and left ventricle stroke volume are coupled; their variations are due to the reduction of right ventricle stroke volume consequent to ventilator insufflation and are either proportional to the tidal volume and closely related to preload dependence.

Introduction to Trauma Care and Improving Performance

Traumatic injury and trauma deaths have been worldwide considered a major health problem [1]. The World Health Organization estimates that 16 000 people die everyday from trauma injuries, and for every person who dies, several thousands more are injured, many of them with permanent sequelae. Injury accounts for 16% of the global burden of disease [2].