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G Citerio

Publications and source records attributed to G Citerio.

At least 37 records · Page 2Linked to original sources
PubMed2002

[Role of assisted breathing in severe traumatic brain injury].

BACKGROUND: Based on available data, there is no definite clinical research describing option, timing and effects of assisted as opposed to controlled ventilation to successfully treat acute severely brain-injured patients. This study demonstrates pressure support ventilation as a possible alternative to controlled ventilation in the acute phase of brain injury. We illustrated which factors influenced the shift from total (CPPV) to partial ventilatory support (PS-SIGH) and the consequences of assisted ventilation on cerebral hemodynamics. METHODS: a) EXPERIMENTAL DESIGN: Retrospective, cohort study. b) SETTING: Adult intensive care unit of a university hospital. c) Patients population: Forty-two severe head-trauma victims (GCS </= 8). d) Measures and interventions: Ventilation modalities and parameters, systemic and cerebral hemodynamics [Intracranial pressure (ICP), cerebral perfusion pressure (CPP), jugular bulb oxygen saturation (SjvO(2))] data were collected daily and described. RESULTS: Controlled ventilation was the main ventilatory support during the very first moment of brain trauma. Percentage of patients ventilated with pressure support increased progressively (37.5% on day 2) and was the dominant method of ventilation on the fourth day. Worst neurologic condition and more elevated ICP were associated to controlled ventilation. Carbon dioxide partial pressure was higher in PS-SIGH, however, it was not correlated with significantly elevated ICP. CONCLUSIONS: In traumatic brain injured patients, ICP and CPP monitoring, together with neurological examination are the main factors influencing the selection of ventilatory assistance. It is evident from these data that assisted ventilation is a feasible and safe alternative to controlled ventilation even in the acute phase of trauma if intracranial parameters are continuously monitored and controlled.

Adult↗
PubMed2002

[Steroids in acute spinal cord injury. An unproven standard of care].

Since 1990s, methylprednisolone has become a widely prescribed therapy for improving the outcome of acute spinal cord injured victims and has considered a standard of care based. This have been claimed on the results of two randomized controlled trials (NASCIS II and III), even if the studies failed to demonstrate improvements due to methylprednisolone administration in any of the a priori hypothesis tested. Although, post hoc analyses were carefully constructed for evidencing minimal benefits of the steroid therapy in subgroups of patients and were publicized worldwide, these presumed benefit have been extended to all acute spinal cord injured patients. Further analyses of the papers, devoid of the participation of the authors, performed by external reviewers and evidence-based experts, failed to demonstrate clinically significant treatment effects. For this reason and for the consideration that high dose methylprednisolone could be harmful to the patients, the use of methylprednisolone in acute spinal cord injury cannot be recommended and cannot be considered a standard of care.

Anti-Inflammatory Agents↗
PubMed2001

Induced abdominal compartment syndrome increases intracranial pressure in neurotrauma patients: a prospective study.

OBJECTIVE: To evaluate the effect of a stepwise increase in intra-abdominal pressure (IAP) on intracranial pressure (ICP) and to further define the pressure transmission characteristics of different body compartments. DESIGN: A prospective, nonrandomized study. SETTING: A multidisciplinary intensive care unit at a university medical center. PATIENTS: Fifteen patients with moderate-to-severe head injury. INTERVENTIONS: All patients were studied after the initial stabilization and resolution of intracranial hypertension. Measurements were carried out before and 20 mins after IAP was increased by positioning a soft, 15-L water bag on the patient's abdomen. MEASUREMENTS AND MAIN RESULTS: Placing weights upon the abdomen generated a significant increase in IAP, which rose from 4.7 +/- 2.9 to 15.5 +/- 4.1 mm Hg (p <.001). The rise in IAP caused concomitant and rapid increases in central venous pressure (from 6.2 +/- 2.4 to 10.4 +/- 2.9 mm Hg; p <.001), internal jugular pressure (from 11.9 +/- 3.2 to 14.3 +/- 2.4 mm Hg; p <.001), and ICP (from 12.0 +/- 4.2 to 15.5 +/- 4.4 mm Hg; p <.001). Thoracic transmural pressure, calculated as the difference between central venous pressure and esophageal pressure, remained constant during the protocol. Respiratory system compliance decreased from 58.9 +/- 9.8 to 44.9 +/- 9.4 mL/cm H2O (p <.001) in all patients because of decreased chest wall compliance. The mean arterial pressure increased from 94 +/- 11 to 100 +/- 13 mm Hg (p <.01), which allowed the maintenance of a stable cerebral perfusion pressure (82.4 +/- 10.3 vs. 84.7 +/- 11.5 mm Hg; p = NS) despite the ICP increase. CONCLUSIONS: Increased IAP causes a significant rise in ICP in head trauma patients. This effect seems to be the result of an increase in intrathoracic pressure, which causes a functional obstruction to cerebral venous outflow. Routine assessment of IAP may help clinicians to identify remediable causes of increased ICP. Caution should be used when applying laparoscopic techniques in neurotrauma patients.

Abdomen↗
PubMed2000

Multi-centre assessment of the Spiegelberg compliance monitor: preliminary results.

Acute brain injury states (e.g. head injury, subarachnoid haemorrhage) show clear inverse relationships of ICP vs compliance, with ICP instability at times of lower compliance states. Variance in compliance values is large in hydrocephalus where ICP is relatively lower and compliance higher. Nonetheless, early experience shows that compliance data influence decisions on CSF diversion treatments. Future work will focus on the ability of intracranial compliance to predict ensuing ICP instability and methodological refinement for monitoring patients who have higher compliance states.

Brain↗
PubMed2000

Control of fever by continuous, low-dose diclofenac sodium infusion in acute cerebral damage patients.

OBJECTIVES: The aim of this study was to assess the efficacy and safety of low doses of diclofenac sodium (DCF) in attaining normothermia with minimal major side effects in patients with acute cerebral damage. The study was designed to verify the adequate, prolonged antipyretic action of DCF infusion, to quantify its haemodynamic and cerebral impact and to assess any negative effect on renal and liver function. DESIGN: Retrospective, cohort study on prospectively collected data. SETTING: Intensive care unit (ICU) of a university hospital. PATIENT POPULATION: Five patients with subarachnoid haemorrhage and seven severe head-trauma victims with febrile illness of various infectious origin. INTERVENTIONS: Continuous i.v. infusion of a low dose (0.04 mg/kg/h) of DCF for 48 h. MEASUREMENTS AND RESULTS: Systemic and cerebral haemodynamic data were collected at 4 h intervals for 8 h before diclofenac infusion and 48 h after. Renal and liver functions were monitored. Normothermia, defined as external temperature < 37.5 degrees Celsius (degrees C), was achieved in all cases. Intracranial pressure was significantly lowered and mean arterial pressure was unaffected, so cerebral perfusion pressure rose after DCF. Hepatic and renal function were not altered in the 48 h post DCF. Mean urinary output was preserved at high flow and was not influenced by DCF. CONCLUSIONS: Continuous infusion of low-dose DCF attained normothermia without any major cerebral or systemic side effects. Renal and liver functions were unaffected. Once normothermia was achieved, intracranial and cerebral perfusion pressure improved.

Acute Disease↗
PubMed2000

Neuro-Link, a computer-assisted database for head injury in intensive care.

Reliable information is vital for clinical trials, so we developed a database, for head trauma victims admitted to neuro-intensive care units (NICU). This database, first step in a sequential project, comprises 176 selected fields mainly focused on the early post-traumatic phase and has a user-friendly computerized interface. The software was tested for a trimester in 18 Italian neuro-intensive care units. The paper describes the main features of the database, the results of a three months' data collection test, its limitations and its potential improvements. A description of the database fields and a brief summary of the 282 patients included so far are also presented.

Adolescent↗
PubMed2000

Guidelines for the treatment of adults with severe head trauma (part I). Initial assessment; evaluation and pre-hospital treatment; current criteria for hospital admission; systemic and cerebral monitoring.

If pragmatic recommendations for treatment of severely head-injured patients could really be applied, they would probably have a considerable impact in terms of reduction in mortality and disability. Since 1995 a Group of Italian Neurointensivists and Neurosurgeons belonging to the Italian Societies of Neurosurgery (SINch) and Anesthesiology & Intensive Care (SIAARTI) has produced this first part of recommendations that are completed by Medical treatment (Part II) and Surgical treatment criteria (Part III). These recommendations reflect a multidisciplinary consent but are based on scientific evidence, when available, and take origin mainly from expert opinions and the current clinical and organizational situation. For this aspect they differ from other American and European guidelines, which are strictly based on criteria of proven efficacy. These recommendations aim at providing a practical reference for all those dealing with severe head injuries from first-aid to intensive care units, setting out the minimal goals of management to be reached throughout the country. For these reasons they need continual critical review and updating. Main clinical aims are: 1) to prevent secondary cerebral damage by continuous and meticulous maintenance of systemic homeostasis 2) to standardize methods of neurological evaluation and CT scan classification and scheduling; 3) to give simple indications for systemic and cerebral monitoring 4) to pragmatically discuss the organizational scenarios and specify the minimal safe clinical approach when patients are treated in non-specialized settings. Briefly, smooth tracheal intubation and ventilation in all comatose patients, administration of rapidly metabolized sedative and analgesic drugs to permit frequent neurological evaluation, restoration of volemia and systolic blood pressure above 110 mm Hg, oxygen saturation >95% and normocapnia, are all recommended from the very early treatment and transport. Homogeneity of language, reliable and correctly tested Glasgow Coma Score and pupillary reflexes, and a simple CT scan classification are recommended to improve communications and clinical decisions in the multidisciplinary setting of management. In comatose patients, cerebral perfusion pressure, intracranial pressure and oxygen jugular saturation must be monitored according to specific criteria, which are described. Therapy with hyperventilation and mannitol should be used only in case of clinical deterioration and uncal herniation. This therapy could be useful to gain time to reach neurosurgery. The aim of these recommendations is to achieve safer management of severely brain injured patients, immediate diagnosis of clinical deterioration and successful identification and treatment of surgical lesions. The impact of these guidelines requires further verification.

Adult↗
PubMed2000

Guidelines for the treatment of adults with severe head trauma (part II). Criteria for medical treatment.

Since 1995 a Group of Italian Neurointensivists and Neurosurgeons belonging to the Italian Societies of Neurosurgery (SINch) and Anesthesia & Intensive Care (SIAARTI) has produced some recommendations for treatment of adults with severe head trauma. They have been published in 3 parts: Part I (Initial assessment, Evaluation and pre-hospital treatment, Criteria for hospital admission, Systemic and cerebral monitoring), Part II (Medical treatment) and Part III (Surgical treatment criteria). These recommendations reflect a multidisciplinary consent and are mostly based on expert opinion. The main aim is to provide a practical reference for all those dealing with severe head injuries from first-aid to intensive care units, setting out the minimal goals of management to be reached throughout the Country. These recommendations need a continuous critical review and updating. Medical treatment is aimed at preventing or minimizing secondary brain damage following acute brain injury, provided that surgical masses have been promptly identified and removed. In order to assure cerebral perfusion, systemic hemodynamics and respiratory exchanges should be normal. Volemia is crucial, and mean arterial pressure should remain above 90 mmHg. Good general intensive care, including gastroprotection, water-electrolyte balance, infection control, nutrition and physiotherapy, is assumed as the basis for brain-oriented therapy. Intracranial hypertension requires an approach based on various steps. First, factors that can directly rise intracranial pressure (ICP) such as venous outflow obstruction, fever, pain etc. should be checked and corrected. Second, Mannitol, CSF withdrawal, sedation and moderate hyperventilation should be applied. This can be done by targeting specific problems with specific treatment (which is possible when the cause of ICP rise is known) or in a step-wise approach, by using less aggressive interventions before than more aggressive ones, with a higher risk of complications. Third, extreme treatment, such as barbiturates, should be reserved to cases with refractory intracranial hypertension. The main goal of ICP treatment is not simply ICP reduction, but the maintenance of adequate cerebral perfusion pressure.

Adult↗
PubMed2000

Guidelines for the treatment of adults with severe head trauma (part III). Criteria for surgical treatment.

The Guidelines of the surgical management of severe head injury in adults, as evolved by the Neurotraumatology Group of the Italian Neurosurgery Society and the Italian Society for Anaesthesia, Analgesia, Reanimation and Intensive Care are presented and briefly discussed. Guidelines presented here are of a pragmatic nature, based on consensus and expert opinion. Aspects pertaining to specific indications to surgery and/or to the possibility of conservative management of different traumatic intracranial lesions are highlighted. The importance of surgery in preventing secondary insults to the traumatised brain is emphasised.

Adult↗
PubMed1999

[What kind of monitoring of intracranial pressure].

Intracranial pressure monitoring is an essential element of severe head injury monitoring. In the Italian reality, this monitoring still has not become diffusely utilised. In this paper are analysed, using the available data obtained from the Neurolink database, the information from the more advanced Italian neurotrauma centres. Only 50% of the patients, in which monitoring is indicated, are monitored. Synthetically will be reviewed the indications to the monitoring, the advantages offers from such procedure, the modalities of monitoring considering also the economic impact and the risks legacies to the procedure.

Craniocerebral Trauma↗
PubMed1999

[What will jugular bulb oxygen saturation monitoring tell?].

Global cerebral oxygenation can be measured by means of a catheter introduced in the internal jugular vein and placed retrograde in the jugular bulb. The measure of oxygen saturation sampled from the jugular vein (SjvO2) depends on cerebral metabolism and blood flow. This parameter describes the relative balance between oxygen delivery to the brain and oxygen consumption by the brain. SjvO2 remains normal until cerebral blood flow is proportional to cerebral metabolic demands. Any disturbances that increase cerebral metabolism and/or diminishes cerebral oxygen supply determines a reduction of SjvO2. Correspondingly, a decrease of oxygen consumption and/or an increase of oxygen supply may induce an increase of SjvO2. Therefore, SjvO2 is a useful monitor to assess the adequacy of cerebral circulation in patients with neurologic illness, allowing detection of state of hypoperfusion. Monitoring cerebral oximetry in comatose patients is of great importance in order to prevent, detect, control and understand secondary brain insults and damage which are mainly ischemic/hypoxic in nature. Although SjvO2 was shown to be highly sensitive in the presence of global hypoxia or ischemia, the occurrence of focal ischemia may still go undetected. Besides this, elevated SjvO2 should not be universally interpreted as hyperaemia. Instead, the presence of an elevated SjvO2 is a heterogeneous condition. Increased SjvO2 may be alarming prognostic indicators that carry important implications for comatose patients management.

Blood Gas Analysis↗
PubMed1998

Jugular saturation (SjvO2) monitoring in subarachnoid hemorrhage (SAH).

Jugular saturation (SjvO2) monitoring was performed in 26 SAH patients to evaluate the incidence of normal (0.56-0.74) and pathological SjvO2 values in this population and to describe its time course in the first 12 days. We also attempt to quantify the influence of systemic and cerebral hemodynamics on SjvO2 and to assess the relationship between cerebral injury volume measured on CT scan and SjvO2. Mean SjvO2 was 0.66 +/- 0.07 (354 samples, median 0.67, range 0.43-0.89). 73% of the observations (259/354) were in the normal range. On serial measurements, we identified only 37/354 (10%) desaturation episodes (D.E.). ICP was significantly higher during low SjvO2 observation (p = 0.008). No statistical differences were noted regarding the influence of MAP, CPP, PaCO2, PaO2 on SjvO2 but during D.E., lower PaCO2 and CPP were more frequently observed. CT scan lesions > 25 ml were associated initially with lower SjvO2 values and with higher values at second CT.

Adult↗
PubMed1998

[Cerebral blood flow in subarachnoid hemorrhage].

Cerebral blood flow (CBF) following subarachnoid haemorrhage varies according to the time of sampling, with regard to the time of bleeding, to clinical conditions of patients and to any possible occurrence of vasospasm. CBF is proportionally reduced upon clinical conditions, involves the totality of patients and represents a diffuse bilateral phenomenon, not dependent on the location of the aneurysm. Following events, such as vasospasm, may deteriorate haemodynamic conditions, especially when unstable. Thus, CBF monitoring is necessary and useful in these patients. The evaluation of this parameter, according to the metabolic demands, appears rather fundamental. Besides, during the first two weeks, all the available therapeutic strategies have to employed in order to achieve the best optimization of the CBF so as to avoid the occurrence or at least minimising the extent of ischemic cerebral lesions.

Cerebrovascular Circulation↗
PubMed1998

[Surgical versus endovascular treatment in cerebral aneurysm. The opinion of a neurosurgeon].

The high risk of rebleeding of ruptured aneurysms imposes the need of their early exclusion from arterial circulation. The onset of endovascular technique of embolization gives a new chance, making, time by time, necessary the choice for the best treatment. The advantages and limits of surgical option are well known and consolidated. The results of endovascular technique are similar in the acute phase, but it lacks an adequate follow up and a clear definition of some technical knowledges. Clinical and anatomical data and a serious analysis of specific technical difficulties of both methods must condition the choice of treatment. Present experience allows us to give sure indications only for certain cases, whereas final landmarks are indisposable in many other situations. However, the team discussion between the neurosurgeon, the neuroradiologist and the neuroreanimator must be the crucial point of the decisional way in every single case.

Embolization, Therapeutic↗
PubMed1998

[The use of jugular saturation in monitoring patients with subarachnoid hemorrhage ].

We evaluated the usefulness of monitoring jugular saturation (SjO2) in subarachnoid haemorrhage patients. SjO2 is an index of the global ratio between cerebral blood flow and metabolism. Low SjO2 identified global cerebral flow reduction, as due to low cerebral perfusion pressures or hypocapnia, but not regional ischemic phenomena related to vasospasm.

Adult↗
PubMed1997

Incidence of asymptomatic berry aneurysms among patients undergoing carotid endarterectomy.

BACKGROUND: Scattered reports of literature suggest the hypothesis that patients suffering from a severe stenosis of extracranial carotid artery may present an increased rate of intracranial berry aneurysms caused by the hemodynamic stress on the side opposite to the stenosis, namely on physiological shunts. However, this hypothesis has never been verified upon a large and homogeneous series focused on the argument. MATERIALS AND METHODS: We reviewed a consecutive series of 405 patients submitted to carotid endarterectomy for stenosis greater or equal to 70%. RESULTS: Thirteen aneurysm were found in 11 patients (2.6%). Our patients showed a slight increase of incidence regards to general population (1%), maybe due to the large number of aged patients among our subpopulation. Preoperative TCD evaluation showed the presence of increased flow velocities in the physiological shunts, namely the anterior cerebral artery and the anterior communicating artery, in 65% of the patients, and angiography confirmed the redistribution of intracranial circulation. Nevertheless, according to aneurysm location, no statistically significant correlation (0.3 < p < 0.4) was found between the presence of an aneurysm and the values of velocity in these arteries. CONCLUSIONS: As regards the etiology of berry aneurysms, these data suggest that increased hemodynamic stress per se is not sufficient to cause the origin of berry aneurysms. Maybe, a role is possible only if either congenital, or acquired and age-related factor, peculiar of cerebral arteries, coexist.

Aged↗