Minerva anestesiologica
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Both malnutrition and the physical injury related to trauma and surgery increase the expression of T-helper 2 (Th2) lymphocytes which cause impaired cell mediated immunity. Activation of the hypothalamic-pituitary-adrenal axis and sympathoadrenal system with the release of cortisol and catecholamines drive the development of Th2 cells. Th2 cytokines result in the accumulation of arginase-1 expressing myeloid-derived suppressor cells in lymphoid tissue. ⋯ Prostaglandin-E2 released following trauma plays a synergetic role with cortisol and catecholamines in driving these pathways. There is now increasing evidence that immunomodulating enteral formulas supplemented with arginine and omega-3 fatty acids can reverse many of the immune mediated changes and decrease the number of adverse outcomes after major surgery and trauma. These immunomodulating enteral formulas should be strongly considered in surgical patients undergoing major surgery and following severe trauma.
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Minerva anestesiologica · Mar 2012
Argatroban anticoagulation for heparin induced thrombocytopenia in patients with ventricular assist devices.
Patients receiving implantation of ventricular assist devices (VAD) suffer a high incidence of heparin induced thrombocytopenia (HIT); the occurrence of this condition is associated with increased complications and worse outcomes. We report our experience in the management of patients who were diagnosed with HIT either before (HITpre) or after (HITpost) implantation of VAD with argatroban, a direct thrombin inhibitor. ⋯ Argatroban anticoagulation is feasible in patients with HIT after VAD implantation, without increasing bleeding risk. Its impact in terms of survival should be reviewed also in the light of the technological improvements of assist devices.
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Minerva anestesiologica · Mar 2012
Case ReportsExtracorporeal carbon dioxyde removal for additional pulmonary resection after pneumonectomy.
Additional pulmonary surgery in a previously pneumonectomized patient requires apnea during surgical manipulation of the surviving lung. We report on a novel approach to manage the intraoperative apnea period, combining apneic oxygenation and minimally invasive, low flow extracorporeal CO2 removal. A 69-year-old man previously submitted to left pneumonectomy was scheduled for wedge resection of a single right upper lobe lesion. ⋯ The intraoperative apnea period lasted 13 minutes. Our approach allowed maintaining normocapnia (PaCO2 38,5 and 40 mmHg before and at the end of the apnea period, respectively), preserving oxygenation (P/F ratio 378, 191, 198 and 200 after 3, 6, 9 and 12 min of apnea, respectively). Our report suggests that the minimally invasive CO2 removal associated with apneic oxygenation is an useful technique for managing anesthesiological situations requiring moderate apnea periods.
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Minerva anestesiologica · Mar 2012
Inhibition of somatosensory evoked potentials during spinal cord stimulation and its possible role in the comprehension of antalgic mechanisms of neurostimulation for neuropathic pain.
Spinal cord stimulation (SCS) has been widely used for pain relief of patients with neuropathic chronic pain, frequently with only partial efficacy. Further advancements probably need a better understanding of SCS mechanisms, yet largely unknown. Aims of this paper were to answer the question if the lumbar SCS inhibits the tibial nerve somatosensory evoked potentials (SEPs) and to discuss the role of lemniscal afferents modulation in the antalgic mechanism of SCS. ⋯ The results obtained in the present study show an inhibitory effect of SCS on SEPs and support the hypothesis that in some forms of neuropathic pain the antalgic effect of SCS could be attributed to the collision of action potentials travelling in opposite direction on peripheral large diameter fibres.
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Minerva anestesiologica · Mar 2012
Clinical TrialInfluence of continuous renal replacement therapy on cardiac output measurement using thermodilution techniques.
Acute renal failure (ARF) ranks among the most frequent complications in critically ill patients and continuous renal replacement therapy (CRRT) is a typical treatment regimen in intensive care patients. Contributing factors to ARF, such as septic shock and hemodynamic instability require extended hemodynamic monitoring, and the simultaneous use of CRRT and cardiac output measurement is common. In view of this, a systematic analysis of the interaction between CRRT and cardiac output measurements by thermodilution is warranted. Cardiac output (CO) is commonly measured with thermodilution-based methods in critically ill patients. The methods are accurate but the measurements are affected by inconstant indicator volumes or changes in blood temperature. Because continuous renal replacement therapy (CRRT) may alter blood volume and temperature, we investigated its effect on thermodilution-based CO measurement. ⋯ Substantial measurement error was only observed immediately after CRRT was switched off or on. Subsequent CO measurements did not depend on the CRRT status. Interrupting CRRT before measuring CO is not generally recommended, however, if interrupted, it is crucial to wait for blood temperature to reach a steady state before initiating the first measurements.