Marinella Astuto

The beneficial effects of antioxidant supplementation in enteral feeding in critically ill patients: A prospective, randomized, double-blind, placebo-controlled trial

We investigated whether intervention with antioxidant vitamins C and E in enteral feeding influenced oxidative stress and clinical outcome in critically ill patients. Two-hundred-sixteen patients expected to require at least 10 days of enteral feeding completed the study. One-hundred-five patients received enteral feeding supplemented with antioxidants, and 111 control patients received an isocaloric formula. Plasma lipoper-oxidation (by thiobarbituric acid reactive substances [TBARS] and prostaglandin F2&agr; isoprostane levels), low-density lipoprotein (LDL) oxidizability, and LDL tocopherol content were determined at baseline and at the end of the 10-day period. The clinical 28-day outcome was also assessed. Plasma TBARS and isoprostanes were 5.33 ± 1.26 nM/mL and 312 ± 68 pg/mL, respectively, before treatment and 2.42 ± 0.61 nM/mL and 198 ± 42 pg/mL after intervention (P < 0.01 for both comparisons). Antioxidants improved LDL resistance to oxidative stress by approximately 30% (the lag time before treatment was 87 ±23 min and was 118 ±20 min after treatment; P <0.04). There was a significantly reduced 28-day mortality after antioxidant intervention (45.7% in the antioxidant group and 67.5% in the regular-feeding group; P < 0.05). Isoprostanes may provide a sensitive biochemical marker for dose selection in studies involving antioxidants.

Relative analgesic potencies of levobupivacaine and ropivacaine for caudal anesthesia in children.

BACKGROUND: Comparing relative potency of new local anesthetics, such as levobupivacaine and ropivacaine, by the minimum local analgesic concentration model has not been described for caudal anesthesia. Therefore, we performed a prospective, randomized, double-blind study to determine the minimum local analgesic concentrations of a caudal single shot of ropivacaine and levobupivacaine in children and to describe the upper dose-response curve. METHODS: We performed a two-stage prospective, randomized, double-blind study comparing the dose-response curves of caudal ropivacaine and levobupivacaine in children. In phase 1, 80 boys were randomized to receive either ropivacaine or levobupivacaine. In the second phase a further 32 patients were randomly allocated to receive caudal anesthesia with doses designed to delineate the upper dose-response range (the 50% effective dose [ED50]-ED95 range). RESULTS: There were no significant differences in ED50 values for caudal ropivacaine and levobupivacaine. The ED50 for levobupivacaine estimated from the Dixon Massey method was 0.069% (95% CI 0.056%-0.082%) and for ropivacaine was 0.075% (95% CI 0.058%-0.092%). Estimated by isotonic regression the ED50 and ED95 respectively of levobupivacaine were 0.068 (0.04-0.09) and 0.20% (95% CI 0.16%-0.24%). For ropivacaine ED 50 and ED95 were 0.066 (0.033-0.098) and 0.225% (95% CI 0.21%-0.24%). CONCLUSIONS: In children receiving one minimum alveolar anesthetic concentration of sevoflurane, there were no significant differences in the ED50 for caudal levobupivacaine and ropivacaine. The potency ratio at ED50 was 0.92 and 0.89 at ED95, indicating that caudal levobupivacaine and ropivacaine have a similar potency.

Depth of sedation using Cerebral State Index in infants undergoing spinal anesthesia

Background:  Infants are noted to frequently sleep during spinal anesthesia, with a concomitant fall in Bispectral Index. However, there are suggestions that EEG derived anesthesia depth monitors have inferior performance in infants. The aim of this study was to quantify the degree of sedation during spinal anesthesia in infants using another EEG derived measure of anesthesia effect – the Cerebral State Index (CSI).

Post-rotavirus vaccine intussusception in identical twins: A case report

ABSTRACT The intussusception is one of the most frequent causes of occlusive syndrome in infants and in children.1 The mesenteric lymphadenopathy, wich is very rare post rotavirus vaccination, can cause intussusception,2-5 especially in genetically predisposed individuals.6 There is an association between intussusception and some classes of genotype.7-9 Two infants aged 3 months, vaccinated against rotavirus. After about a week, one of the 2 identical infants presented inconsolable crying, vomiting, loose stools mixed with blood, and was diagnosed with bowel obstruction with intussusception. He was operated in urgency. After a few hours, his brother presented vomiting, and was admitted to our Hospital for suspected intussusception. The controls carried out have confirmed the presence of intussusception that was treated early, before the onset of severe symptoms. The incidence of post rotavirus vaccine intussusception is very low. The determining factor hypothetically might be linked to the presence of a genotype that exposes infants to a greater risk of developing mesenteric lymphadenitis and intussusception. In our case, the diagnosis of intussusception occurred in a twin, which allowed us to recognize early symptoms which accused the brother and schedule the surgery with less urgency. Our experience may want to sensitize families and pediatricians to report cases of intussusception given a theoretical familiar association. The study of the genotype could be decisive for or not to exclude the presence of a risk of invagination, thus avoiding vaccination.

Indicatori di qualità, sicurezza e benchmarking

L’avvento del governo clinico ha sicuramente rivoluzionato il mondo della medicina in tutti i suoi settori, ma ha anche messo in luce la scarsita di informazioni disponibili sulla qualita delle cure quotidianamente erogate dal sistema sanitario. La concomitante riduzione delle risorse disponibili ha fatto si che, in ambito di politica sanitaria, ci si ponesse come target essenziale la possibilita di produrre la migliore qualita delle cure al piu basso costo possibile.

Off-Label Drugs in Pediatric Perioperative Medicine

The drug licensing system was introduced with the aim of ensuring that medicines are marketed only after having been examined for safety, efficacy and quality. So, before a drug is allowed on the market, a favorable balance between beneficial and harmful effects has to be demonstrated. Often this has been established only in adults and once a drug is approved, it may be prescribed by a physician for any population or disease state desired. Many drugs pass through the licensing process without being evaluated in children. The product license often contains statements such as “not recommended for use in children” or “no evidence for use in children.” This usually reflects an absence of data in children rather than a specific reason for the drug not to be used.

Central Venous Cannulation Techniques

Central venous cannulation (CVC) is a commonly performed procedure in anesthesia and intensive care. It facilitates optimal anesthetic and perioperative management particularly the management of high-risk patients and the long-term management of those with chronic underlying diseases. To insert a central venous line means to place a catheter within the thoracic cavity, with the tip terminating in the joint between the right atrium and the superior vena cava (SVC). CVC is important in infants and children because of the need to establish and maintain a vascular access.

Monitoring the Level of Anesthesia and Sedation in Children - An Overview

Anesthesia is a balance between the amount of anesthetic drugs administered and the state of arousal of the patient. A large number of variables can interfere with the conduction of anesthesia, such as age, concomitant disease or therapies, physiological parameters and human variability. Moreover, clinical signs, such as blood pressure and heart rate, are routinely used by anesthesiologists to monitor anesthetic depth, but such methods are unreliable. Furthermore, patient movement in response to noxious stimulation remains an important sign of inadequate anesthetic dosage, but is unreliable and is suppressed by paralysis. As a consequence, an imbalance between anesthetic requirement and anesthetic drug administration is not uncommon. Under-dosing of anesthetic drugs may be caused by equipment failure or error. Conversely, over-dosing of the hypnotic components, leading to an excessive depth of anesthesia, might compromise patient outcome. How can the “depth of anesthesia” be measured and monitored? Several devices tested in adults with promising results have been recently introduced in clinical practice. Much more difficult is monitoring in the pediatric age group and the interpretation of data derived from such monitoring.

Strategy to Manage Pediatric Patients: the Family and the Child

An important responsibility of physicians who care for children is the elimination of anxiety and suffering whenever possible, especially during the preoperative period. It is known that preoperative anxiety in children is associated with adverse postoperative outcomes (i.e. increased incidence of emergence delirium, increased pain) and so an adequate preparation programme should be applied routinely. The strategy to manage the pediatric patient should include the parents to avoid increasing the parents’ anxiety and concomitantly the child’s anxiety.

The Beneficial Effects of Antioxidant Supplementation in Enteral Feeding in Critically Ill Patients: A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial

We investigated whether intervention with antioxidant vitamins C and E in enteral feeding influenced oxidative stress and clinical outcome in critically ill patients. Two-hundred sixteen patients expected to require at least 10 days of enteral feeding completed the study. One-hundred five patients received enteral feeding supplemented with antioxidants, and 111 control patients received an isocaloric formula. Plasma lipoperoxidation (by thiobarbituric acid reactive substances [TBARS] and prostaglandin F2α isoprostane levels), low-density lipoprotein (LDL) oxidizability, and LDL tocopherol content were determined at baseline and at the end of the 10-day period. The clinical 28-day outcome was also assessed. Plasma TBARS and isoprostanes were 5.33 ± 1.26 nM/mL and 312 ± 68 pg/mL, respectively, before treatment and 2.42 ± 0.61 nM/mL and 198± 42 pg/mL after intervention ( p < .01 for both comparisons). Antioxidants improved LDL resistance to oxidative stress by approximately 30% (the lag time before treatment was 87 ± 23 minutes and was 118 ± 20 minutes after treatment; p < .04). There was a significantly reduced 28-day mortality after antioxidant intervention (45.7% in the antioxidant group and 67.5% in the regular-feeding group; p < .05). Isoprostanes may provide a sensitive biochemical marker for dose selection in studies involving antioxidants.