Minerva anestesiologica
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Over the past 15 years, there have been dramatic changes in the management of blunt hepatic trauma, specifically in the imaging techniques, and in the non-operative management. Actually, in more than 80% of blunt hepatic trauma, non operative management is used. In the last 20% the surgical option has to be taken without delay, sometimes in extreme emergency, using the adapted surgical techniques. In this article the author describes the nonoperative management of blunt hepatic trauma: classification, presentation, initial decision, treatment, possible complications and results.
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Since acupuncture provides analgesia it might be expected to reduce the need for conventional anaesthetic drugs during general anaesthesia. In this review we discuss four double blind, placebo controlled studies evaluating acupunture's ability to reduce analgesic or anesthetic requirement. Three studies (from Greif et al., Morioka et al. and Taguchi et al.) examined whether transcutaneous electrical stimulation of some acupuncture points reduces anaesthetic requirement. Kotani et al. tested the hypothesis that preoperative insertion of intradermal needles in the bladder meridian reduces postoperative pain and oppioid requirement. ⋯ none of the first three studies showed that the stimulation of the acupoints produces clinically important reductions in anaesthetic requirement. In contrast, Kotani et al. showed that at least some acupuncture techniques provide substantial postoperative analgesia and significantly reduce opioid requirement.
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In Italy (130,000 new strokes in the general population per year) ischemic stroke is the third cause of death, after cardiovascular disease and neoplastic disease with a prevalence of 6.5%. Different physicians are involved in the emergent evaluation and treatment of the acute ischemic stroke. As other acute events, the initial evaluation must be addressed to assess the patient's airway and breath-ing and cardiocirculatory conditions. ⋯ The goal is to achieve and to maintain an adequate cerebral perfusion by lowering the intracranial pressure (treating the cerebral oedema) and by increasing the mean arterial pressure, with an appropriate volemic expansion and/or with inotropic or vasopressor drugs. The thrombolytic therapy with intravenous recombinant tessutal plasminogen activator (r-TPA) when not specifically contraindicated, is recommended within 3 hours of onset of ischemic stroke. The benefit of intravenous r-TPA for acute ischemic stroke beyond 3 hours from the onset has never been proved.
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Direct costs of critical care are increasing more than in other health care sectors. Tools are needed to evaluate adequacy of ICU admission in order to have a proper allocation of ICU resources. ⋯ Despite the difficulties imposed by he rigid nurses' work organization in Italy, a daily data collection about level of care, severity of illness, workload utilization could provide, together with standard administrative indexes, the necessary framework to assess and to improve adequacy of ICU admission.
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Corticosteroids were proposed to treat patients with severe sepsis as early as 1940. A summary of all available randomized controlled trials performed between 1966 and 1993 was provided in two systematic review that recommended to abandon the use of high dose coricosteroids to treat patients with severe infection. Nonetheless, a doubt still persist regarding the efficacy of a strategy of replacement therapy in cathecolamines-dependent shock. ⋯ The authors found a significant reduction in 28-day mortality in patient with occult renal insufficiency. In sum, short course with high doses of corticosteroids should not be given in severe sepsis, except for specific entitles like severe typhoid fever, pneumocystis carinii pneumonia in AIDS or bacterial meningitis in children. The rational for a replacement therapy with hydrocortisone in catecholamines-dependent septic shock grows stronger.