Minerva anestesiologica
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Minerva anestesiologica · Oct 2016
Case ReportsWhole-exome sequencing of a family with local anesthetic resistance.
Local anesthetics (LA) work by blocking sodium conductance through voltage-gated sodium channels. Complete local anesthetic resistance is infrequent, and the cause is unknown. Genetic variation in sodium channels is a potential mechanism for local anesthetic resistance. A patient with a history of inadequate loss of sensation following LA administration underwent an ultrasound-guided brachial plexus nerve block with a complete failure of the block. We hypothesized that LA resistance is due to a variant form of voltage-gated sodium channel. ⋯ We identified a genetic variant that is associated with LA resistance in the gene encoding for Nav1.5. We also demonstrate that Nav1.5 is present in human peripheral nerves to support the plausibility that an abnormal form of the Nav1.5 protein could be responsible for the observed local anesthetic resistance.
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Minerva anestesiologica · Oct 2016
Right ventricle dilation as a prognostic factor in refractory ARDS requiring VV-ECMO.
The aim of this study was to assess the incidence and prognostic role of echocardiographic abnormalities in consecutive patients with refractory acute respiratory distress syndrome (ARDS) before veno-venous extracorporeal membrane oxygenation (VV-ECMO). ⋯ At echocardiography, 25 patients showed normal findings (33.8%), 32 patients exhibited isolated pulmonary hypertension (43.2%) and the remaining 17 patients showed RV dilation and pulmonary hypertension (23%). A reduced LVEF (<50%) was observed in 14 patients (18.9%), while RV dysfunction (as indicated by TAPSE<16 mm) was documented in 21 patients (28.4%). The in-Intensive Care Unit [ICU] mortality rate was 41.8%. At stepwise regression analysis the following variables were independent predictor for in-ICU mortality (when adjusted for TAPSE<16 mm): RV end diastolic area/LV end diastolic area (OR 0.21, 95%CI 0.062-0.709, P=0.012), Body Mass Index (BMI) (OR 0.87, 95%CI 0.802-0.958, P=0.004) CONCLUSIONS: In consecutive patients with refractory ARDS, echocardiographic alterations were common, mainly represented by systolic pulmonary hypertension associated or not with RV dilatation. Moreover, RV dilatation and BMI were independent predictors of in-ICU mortality. On clinical grounds, our findings strongly suggest that echocardiography helps to risk stratifying patients with refractory ARDS requiring VV-ECMO.
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Minerva anestesiologica · Oct 2016
Point-of-care-based protocol with first-line therapy with coagulation factor concentrates is associated with decrease allogenic blood transfusion and costs in cardiovascular surgery: an Italian single-center experience.
Transfusion in patients having cardiac surgery has been associated with increased morbidity, mortality, and costs. This analysis assessed the impact of a rotational thromboelastometry (ROTEM®)- and functional platelet assessment (Multiplate®)-based protocol for bleeding management on perioperative outcomes and costs in patients undergoing cardiac surgery. ⋯ ROTEM-guided bleeding management in patients undergoing cardiac surgery was cost-effective and associated with an increase of administration of coagulation factor concentrates and a decrease of ICU length of stay.
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Minerva anestesiologica · Oct 2016
Hazards of intubation in the ICU: role of nasal high flow oxygen therapy for preoxygenation and apneic oxygenation to prevent desaturation.
Acute respiratory failure is one the most common motives for intensive care unit admission. Although results from recent studies with high flow nasal oxygen have challenged our current management of these patients, a substantial number of them will require invasive mechanical ventilation and tracheal intubation. Life-threatening hypoxemia is the most frequent complication of these intubations. ⋯ Studies comparing high flow oxygen to noninvasive ventilation are ongoing and will help clarify the indications of each technique. This paper aims to show the evidence on the potential high flow nasal oxygen bears to improve preoxygenation for intubation outside the operating room. A practical algorithm to decide which preoxygenation device to use is proposed.