Marco Gemma

7.5% hypertonic saline versus 20% mannitol during elective neurosurgical supratentorial procedures.

This prospective randomized clinical study was designed to compare the effects of equal volumes of 7.5% hypertonic saline solution (HS) or 20% mannitol (M) on brain bulk and lumbar cerebrospinal fluid pressure (CSFP) during elective neurosurgical procedures (aneurysm, arteriovenous malformation, or tumor). After informed consent, 50 American Society of Anesthesiologists physical Status I (ASA I) patients were randomly assigned to M (n = 25) or HS (n = 25) groups. Anesthesia protocol was identical for both, and variables monitored included mean arterial blood pressure (MAP), heart rate (HR), central venous pressure (CVP), CSF pressure (CSFP), arterial blood gases (PaCO2 30-35 mm Hg), serum sodium, potassium, and osmolality, and diuresis. The study period started before hypertonic solution administration (T0) and ended at the opening of the dura mater or 60 min after T0. Data were assessed with repeated measures analysis of variance and Student t test with Bonferroni correction (p < or = 0.05). MAP and CVP were the same in the two groups. After treatment, osmolality increased, and the increase at T15 was higher in HS-treated patients [316.6 +/- 9.3 vs. 304.0 +/- 12.0 (SD) mOsmol/kg; p < 0.001]. Sodium decreased after M and increased after HS. During the study, brain bulk was always considered satisfactory. CSFP was not different between M and HS groups and significantly decreased overtime (p = 0.0056) with no difference between treatments. The results of the present study demonstrate that hypertonic saline is as effective as mannitol in reducing the brain bulk and the CSFP during elective neurosurgical procedures under general anesthesia.

Intracranial effects of endotracheal suctioning in the acute phase of head injury.

In patients with head injury, endotracheal suctioning (ETS) is a potentially dangerous procedure, because it can increase intracranial pressure (ICP). The purpose of this prospective nonrandomized study was to evaluate the impact of ETS on intracranial dynamics in the acute phase of head injury. Seventeen patients with severe head injury (Glasgow Coma Score ≤ 8, range 4–8), sedated and mechanically ventilated, were studied during the first week after trauma. Single-pass ETS maneuver (with a 16-French catheter, negative pressure of 100 mm Hg, and duration of less than 30 seconds) was performed 60 seconds after the FiO 2 was increased to 100%. After ETS, FiO 2 was maintained at 100% for another 30 seconds. Before and after ETS, arterial blood gases and jugular oxygen saturation (S j O 2 ), ICP, and mean arterial pressure (MAP) were measured and cerebral perfusion pressure (CPP) was calculated. A total of 131 ETS episodes, which consisted of repeated assessment of each patient, were analyzed. Six patients in 20 cases coughed and/or moved during ETS because of inadequate sedation. After ETS, ICP increased from 20 ± 12 to 22 ± 13 mm Hg in well-sedated patients and from 15 ± 9 to 28 ± 9 mm Hg in patients who coughed and/or moved (mean change, 2 ± 6 versus 13 ± 6 mm Hg, P <.0001). CPP and S j O 2 increased in well-sedated patients (from 78 ± 16 to 83 ± 19 mm Hg, and from 71 ± 10 to 73 ± 13%, respectively) and decreased in patients who reacted to ETS (from 79 ± 14 to 72 ± 14 mm Hg and from 69 ± 7 to 66 ± 9%, respectively), and the differences were significant (mean change, CPP: 5 ± 14 versus -7 ± 15 mm Hg, P =.003; (S j O 2 ) 2 ± 5 vs. −3 ± 5%, P <.0001). In well-sedated patients, endotracheal suctioning caused an increase in ICP, CPP, and S j O 2 without evidence of ischemia. In contrast, in patients who coughed or moved in response to suctioning, there was a slight and significant decrease in CPP and S j O 2 . In the case of patients with head injuries who coughed or moved during endotracheal suctioning, we strongly suggest deepening the level of sedation before completing the procedure to reduce the risk of adverse effects.

A short plasma exchange protocol is effective in severe myasthenia gravis

SummaryPlasma exchange has been reported to be a successful therapeutic procedure for the treatment of severely compromised myasthenic patients, but the optimal regimen in terms of costs or clinical benefit has not so far been determined. We have investigated the efficacy of a short plasmapheresis protocol of two exchanges 1 day apart in a series of 70 patients with severe forms of myasthenia gravis. Patients were evaluated before and 7 days after the first exchange. A positive outcome was observed in 70% of the plasma exchange cycles performed. Disease severity did not seem to be a negative prognostic factor for the efficacy of this short protocol, which was well tolerated by patients. In only 1 case were major side-effects observed. In spite of its short duration, the exchange treatment plus concomitant immunosuppressive drug therapy was not followed by early clinical deterioration.

Electroacupuncture analgesia for colonoscopy: a prospective, randomized, placebo-controlled study

Abstract Objective A study was undertaken to compare the effectiveness of acupuncture in reducing patient’s discomfort and anxiety during colonoscopy with a standard sedation protocol. Methods Thirty patients scheduled to undergo colonoscopy were randomly assigned to receive acupuncture, sham, or no acupuncture. A verbal rating scale was used to measure patient’s pain when the endoscope reached four scheduled positions. Midazolam was administered at baseline and again anytime patients complained of “severe” pain. The amount of midazolam administered was recorded. A verbal rating scale was used to assess patient’s satisfaction with the level of sedation achieved. Results Pain level was lower, although not significantly, in the acupuncture group. Midazolam boluses were required in three patients with acupuncture (30%), eight in the sham group (80%), and nine in the control group (90%) ( p = 0.01). Six patients in the acupuncture group (60%) reported optimum acceptance of colonoscopy compared with only one in the sham group (10%) and none in the control group (0%) ( p = 0.016). Satisfaction scores, assessed 24–72 h after colonoscopy, were extremely high (median score 90 of 100) in the three groups. Conclusions Acupuncture may decrease the demand for sedative drugs during colonoscopy by reducing discomfort and anxiety of the patient and the well-known adverse effects of pharmacologic sedation.

Sedation and monitoring for gastrointestinal endoscopy: A nationwide web survey in Italy

BACKGROUND Best strategy of sedation/analgesia in gastrointestinal (GI) endoscopy is still debated. AIMS OF THE STUDY To evaluate sedation and monitoring practice among Italian gastroenterologists and to assess their opinion about non-anaesthesiologist propofol administration. METHODS A 19-item survey was mailed to all 1192 members of the Italian Society of Digestive Endoscopy (SIED). For each respondent were recorded demographic data, medical specialty, years of practise and practise setting. RESULTS A total of 494 SIED members returned questionnaires, representing a response rate of 41.4%. The most employed sedation pattern was benzodiazepines for oesophagogastroduodenoscopies (EGDS) in 50.8% of procedures, benzodiazepines plus opioids for colonoscopy and enteroscopy in 39.5% and 35.3% of procedures, respectively, propofol for endoscopic retrograde colangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in 42.3% and 35.6% of procedures, respectively. With regard to propofol use, 66% respondents stated that propofol was exclusively administered by anaesthesiologists. However, 76.9% respondents would consider non-anaesthesiologist propofol administration after appropriate training. Pulse oximetry is the most employed system for procedural monitoring. Supplemental O(2) is routinely administered by 39.3% respondents. CONCLUSIONS Use of sedation has become a standard practise during GI endoscopy in Italy. Pattern varies for each type of procedure. Pulse oximetry is the most employed system of monitoring. Administration of propofol is still directed by anaesthesiologists.

Remifentanil Provides Hemodynamic Stability and Faster Awakening Time in Transsphenoidal Surgery

In this prospective study, we evaluated the effects of remifentanil in ASA I–II patients undergoing transsphenoidal surgery. After the induction of anesthesia, patients were randomly allocated to the Isoflurane (n = 22, 60% nitrous oxide, isoflurane up to 2% end-tidal) or Remifentanil group (n = 21, 60% nitrous oxide, 0.5% end-tidal isoflurane, remifentanil up to 2 &mgr;g · kg−1 · min−1). If mean arterial pressure (MAP) increased >80 mm Hg during maximal dosage of isoflurane or remifentanil, labetalol was administered. At the end of anesthesia, extubation and awakening times, respiratory rate, Spo2, MAP, heart rate, and adverse effects were recorded. Hemodynamics and bleeding (minimal, mild, moderate, severe) were not different between groups. Bleeding grade increased with MAP >80 mm Hg (P < 0.001). Labetalol was administered to 20 patients in the Isoflurane group, and 10 patients in the Remifentanil group (P < 0.01). The dose of labetalol was larger in the Isoflurane group (1.0 ± 0.6 versus 0.5 ± 0.7 mg/kg, P < 0.05). Time to extubation did not differ, whereas time to follow commands was shorter in Remifentanil patients (16 ± 8 versus 10 ± 2 min, P < 0.01). No adverse effects occurred in the early postoperative period.

Hypertonic saline fluid therapy following brain stem trauma

Intravenous hypertonic fluid therapy has been proposed to improve secondary ischemic injury after cerebrospinal trauma. We report the case of a 14-year-old boy with vasospasm of the intracranial vertebral arteries and ischemic brain stem damage following head trauma. The patient presented with severe tetraparesis and somatosensory (SSEPs) and brain stem auditory evoked potentials (BAEPs) impairment. The patient was treated with two subsequent hypertonic saline (HS) infusions, 2.7% and 5.4%, respectively, for a period of 48 sp, followed by standard hypervolemic therapy. After the first treatment with 2.7% HS, improvement of SSEPs without neurological improvement was apparent. Relative hypervolemia was subsequently maintained by administration of crystalloids and 20% albumin for 48 h. During standard hypervolemic therapy, no clinical and/or electrophysiological change occurred. The second infusion of 5.4% HS was concomitant with further amelioration of SSEPs and improvement of motor performance. Twelve hours after the second HS infusion, the neurological status returned to preinfusion levels, while SSEPs showed no further changes. BAEPs never changed during fluid therapy. No complication occurred secondary to the infusion of HS. This case report suggests that local improvement of brain stem perfusion following hypertonic fluid therapy accounts for or relevantly contributes to the neurological and SSEPs improvement of the patient.

Prone versus knee-chest position for microdiscectomy: a prospective randomized study of intra-abdominal pressure and intraoperative bleeding.

Study Design. Prospective randomized study. Objectives. To compare two support systems for positioning patients during microdiscectomy (i.e., prone on a modified Relton-Hall spine support vs. knee-chest position on an Andrews-type table) regarding their effects on intra-abdominal pressure and surgical bleeding. Summary of Background Data. Intra-abdominal pressure is an indicator of epidural venous pressure, which affects bleeding during microdiscectomy. The ideal patient’s position during surgery reduces bleeding by minimizing abdominal compression and vertebral venous engorgement. The results of previous studies on the relationship between intra-abdominal pressure and blood loss during spinal surgery are not consistent, and hardly comparable because they used different measurement systems and support frames. Methods. A total of 30 patients with the American Society of Anesthesiologists physical status I or II undergoing elective, single-space lumbar microdiscectomy had their intra-abdominal pressure measured through a urinary bladder catheter, together with airway pressure: (1) supine after anesthesia induction; (2) in prone position (group P) or knee-chest position (group K), according to randomization; or (3) at the end of surgery before repositioning the patient supine. Results. Baseline intra-abdominal pressure did not differ between groups, and intra-abdominal pressure did not vary significantly from baseline in both groups throughout the study. Baseline airway pressure did not differ between groups. Airway pressure was significantly increased from baseline at the recording before incision in group K and at the end of surgery in both groups. Recordings before incision and at the end of surgery differed significantly from one another in both groups. Such airway pressure variations did not differ between groups. Bleeding was significantly more prominent in group K (P = 0.007). No correlation between bleeding and intra-abdominal pressure or airway pressure was found. Conclusions. Intra-abdominal pressure did not differ between prone position on a modified Relton-Hall frame and knee-chest position on an Andrew-type table. Bothpositions provide good conditions for lumbar microdiscectomy.

Functional magnetic resonance imaging (fMRI) in children sedated with propofol or midazolam.

Magnetic resonance imaging (MRI) requires patient immobility and children generally need to be sedated. The ideal sedative agent for functional MRI (fMRI) should only minimally hamper the neurophysiologic effect of the administered sensorial stimulation. This study compares the effect of propofol and midazolam on the fMRI auditory activation pattern in children. Fourteen children in the 3 to 7 year age group without neurologic or auditory deficits were randomly assigned to receive propofol or midazolam for sedation during auditory fMRI. Two patients in the midazolam group were excluded due to positive baseline MRIs. The children were stimulated using a passive listening task. The fMRI signal was modeled using various functions (hemodynamic response function, temporal derivative, and dispersion derivative) to check for the differing temporal characteristics of the signal between the groups. Patients in the propofol group showed activation only in the primary auditory cortex and exhibited a pattern more similar to that of nonsedated adults. Patients in the midazolam group exhibited a more complex pattern, presenting activation areas other than the primary auditory cortex; a delay in the functional response and higher duration variability were also observed. Our sample sizes are too small to derive a conclusive inference. Our preliminary study encourages the hypothesis that propofol is preferable to midazolam to maintain sedation in 3 to 7-year-old children during auditory fMRI because it facilitates the elicitation of a more focused auditory cortical activation pattern with less temporal and spatial dispersion.

Skull base chordomas: clinical outcome in a consecutive series of 45 patients with long-term follow-up and evaluation of clinical and biological prognostic factors

OBJECTIVE Skull base chordomas (SBCs) are rare dysembryogenetic invasive tumors with a variable tendency for recurrence. According to previous studies, the recurrence rate seems to be affected by both clinical variables and tumor biological features. The authors present the results of treatment of SBCs in a large series of patients and investigate the role of 1p36 chromosomal region loss of heterozygosity (LOH) as a prognostic factor. METHODS Between 1990 and 2011, 45 patients were treated for SBCs. The mean follow-up was 76 months (range 1-240 months). An LOH analysis was performed in 27 cases. Survival analysis was performed to determine clinical and biological parameters correlating with clinical outcome. RESULTS The 5- and 10-year overall survival rates were 67% and 57%, respectively. Five- and 10-year progression-free survival rates were 58% and 44%, respectively. Multivariate analysis showed that extent of resection, adjuvant radiation therapy, and absence of rhinopharynx invasion were positive independent predictors of overall survival. The latter 2 variables and a younger patient age were positive independent predictors of progression-free survival. Twenty-one patients showed 1p36 LOH. All events of recurrence and death clustered in the group of patients with 1p36 LOH; however, this biological marker was not statistically significant on multivariate analysis. CONCLUSIONS Resection is the treatment of choice in primary and recurrent SBC. Patient age, rhinopharynx invasion at diagnosis, extent of tumor removal, and postoperative radiation therapy influence SBC prognosis. Genetic analysis, even while showing interesting results, did not reveal 1p36 LOH as an independent predictor of clinical outcome.