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Biomedical subjects

P Pietropaoli

Publications and source records attributed to P Pietropaoli.

At least 19 recordsLinked to original sources
PubMed2006

Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study.

BACKGROUND AND OBJECTIVES: The aim of this prospective, observational study was to evaluate changes in regional cerebral oxygen saturation (rSO2) and incidence of intraoperative cerebral desaturation in a cohort of elderly patients undergoing major abdominal surgery. METHODS: rSO2 was continuously monitored on the left and right sides of the forehead in 60 patients older than 65 yr (35 males and 25 females; ASA II-III; age: 72 +/- 5 yr; without pre-existing cerebral pathology, and baseline Mini Mental State Examination (MMSE) score >23) undergoing sevoflurane anaesthesia for major abdominal, non-vascular surgery >2 h. RESULTS: Baseline rSO2 was 63 +/- 8%; cerebral desaturation (rSO2 decrease <75% of baseline or <80% in case of baseline rSO2 <50%) occurred in 16 patients (26%). The MMSE decreased from 28 +/- 1 before surgery to 27 +/- 2 on 7th postoperative day (P = 0.05). A decline in cognitive function (decrease in MMSE score > or = 2 points one week after surgery as compared to baseline value) was observed in six patients without intraoperative cerebral desaturation (13.6%) and six patients who had intraoperative cerebral desaturation (40%) (P = 0.057) (odds ratio: 4.22; CI95%: 1.1-16). Median (range) hospital stay was 14 (5-41) days in patients with an area under the curve of rSO2 <50% (AUCrSO2<50%) >10 min%, and 10 (4-30) days in those with an AUCrSO2<50% <10 min% (P = 0.0005). CONCLUSIONS: In a population of healthy elderly patients, undergoing non-vascular abdominal surgery cerebral desaturation can occur in up to one in every four patients, and the occurrence of cerebral desaturation is associated with a higher incidence of early postoperative cognitive decline and longer hospital stay.

Abdomen↗
PubMed2006

Preconditioning effects of levosimendan in coronary artery bypass grafting--a pilot study.

BACKGROUND: The calcium sensitizer levosimendan protects against myocardial ischaemia and reperfusion injury in animal models. METHODS: The present pilot study investigated whether a short infusion before coronary artery bypass grafting (CABG) would protect the myocardium and improve postoperative haemodynamics. Twenty-four patients with stable angina undergoing elective CABG surgery were randomized to receive either placebo or levosimendan (24 microg kg(-1)) infused i.v. over a 10 min period just before placing the patient on cardiopulmonary bypass. RESULTS: Perioperative haemodynamic variables, concentrations of cardiac troponin I over the 48 h postoperative period, and clinical outcomes were assessed. There were no adverse effects related to levosimendan. Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.05) and a higher cardiac index (P<0.05). CONCLUSION: Patients receiving a short infusion of levosimendan before CABG showed evidence of less myocardial damage, suggestive of a preconditioning effect. Larger outcome studies are thus indicated to confirm benefit.

Aged↗
PubMed2006

Extracorporeal circulation with low systemic heparinization during lung transplantation.

BACKGROUND: Some lung transplantation (LT) recipients suffer from pulmonary hypertension and right ventricular dysfunction or failure requiring extracorporeal circulation (ECC) to avoid catastrophic complications during surgery. The extracorporeal support usually requires systemic heparinization which is potentially associated with important side effects. We performed eight LT using preheparinized ECC circuits and an oxygenator associated with a lower level of systemic heparinization without evidence of perioperative complications. PATIENTS AND METHODS: From May 2002 to May 2005, 8 patients (5 men and 3 women) of mean age 22.5 +/- 9.5 years underwent bilateral sequential lung transplantation (BSLT) for cystic fibrosis (n = 6) or idiopathic pulmonary fibrosis (n = 2). All procedures were performed with ECC through a femoro-femoral veno-arterial bypass with preheparinized circuits and an oxygenator. RESULTS: No intraoperative mortality occurred. The mean ECC time was 147.8 +/- 31.3 minutes and the mean heparin administered was 3525 +/- 969.16 UI. No coagulopathy or thrombotic events were observed perioperatively. CONCLUSIONS: Our study confirmed the efficacy and safety of prehepanized circuits and oxygenator for femoro-femoral veno-arterial bypass during LT for patients with severe pulmonary hypertension requiring ECC.

Adult↗
PubMed2005

Caudal additives for postoperative pain management in children: S(+)-ketamine and neostigmine.

BACKGROUND: The aim of the present pilot study was to compare the analgesic efficacy of S(+)-ketamine either alone or in combination with neostigmine for caudal blockade in pediatric surgery. METHODS: A total of 40 children were randomly assigned to receive after induction of general anesthesia either caudal S(+)-ketamine 1 mg.kg(-1) (group K, n = 20) or caudal S (+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1) (group KN, n = 20). Anesthesia was maintained with sevoflurane and a laryngeal mask airway (LMA), no additional analgesics were administered. Postoperative pain and sedation were assessed by the Children's Hospital of Eastern Ontario Pain Score and Ramsay scale for 24 h. RESULTS: No statistical difference in duration of analgesia and sedation was found. Mean duration of postoperative analgesia was 18 +/- 9.4 h in group K and 21.8 +/- 6.7 h in group KN. There was a significantly higher incidence of postoperative vomiting after administration of caudal ketamine with neostigmine (30% group KN Vs 0% group K; P < 0.05). CONCLUSIONS: This pilot study demonstrates equianalgesic effects on postoperative pain relief in children with both caudal S(+)-ketamine 1 mg.kg(-1) and caudal S(+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1). Further studies are required to confirm adoption of caudal neostigmine into routine clinical practice.

Analgesics↗
PubMed2005

Haemodynamic modifications after unilateral subarachnoid anaesthesia evaluated with transthoracic echocardiography.

AIM: The aim of the study is the evaluation through transthoracic echocardiography of the haemodynamic modifications due to unilateral subarachnoid anaesthesia with bupivacaine 0.5% given for orthopaedic surgery. METHODS: In this prospective study, at the University Hospital Orthopedics surgical theater, 20 patients underwent orthopaedic surgery on the lower limbs. Unilateral spinal block was performed with hyperbaric bupivacaine 0.5%, 8 mg after a fluid challenge with saline solution 0.9%. Transthoracic echocardiography was performed and cardiac output was calculated from the left ventricular outflow tract (LVOT) with a recently validated technique. Cardiac output, stroke volume, ejection fraction, heart rate, mean arterial pressure were evaluated. These parameters were obtained before anaesthesia (t1), 5 minutes after anaesthesia (t2) and 16 minutes after anaesthesia (t3). RESULTS: Systolic, mean and diastolic arterial pressures after 5 min and 16 min from anaesthesia significantly decreased if compared to basal time (p<0.05 and p<0.001 respectively) while cardiac index (p<0.001) and ejection fraction (p<0.05) decreased only after 16 min from subarachnoid anaesthesia. CONCLUSION: Despite the fluid challenge we can not prevent a significant fall in the blood pressure and a decrease of the left ventricular function calculated with the decrease of cardiac output and of the left ventricular ejection fraction.

Adult↗
PubMed2004

A new and feasible model for predicting operative risk.

BACKGROUND: Although the POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity) score can be used to calculate operative risk, its complexity makes its use unfeasible in the immediate clinical setting. The aim of this study was to create a new model, based on ASA status, to predict mortality. METHODS: Data were collected in two hospitals. All types of surgery were included except for cardiac surgery and Caesarean delivery. Age, sex and preoperative information, including the presence of cardiocirculatory and/or lung disease, renal failure, diabetes mellitus, hepatic disease, cancer, Glasgow Coma Score, ASA grade, surgical diagnosis, severity of the procedure and type of surgery (elective, urgent or emergency), were recorded for each patient. The model was developed using a data set incorporating data from 1936 surgical patients, and validated using data from a further 1849 patients. Forward stepwise logistic regression was used to build the model. Goodness of fit was examined using the Hosmer-Lemeshow test and receiver operating characteristic (ROC) curve analyses were performed on both data sets to test calibration and discrimination. In the validation data set, the new model was compared with POSSUM and P-POSSUM for both calibration and discrimination, and with ASA alone to compare discrimination. RESULTS: The following variables were included in the new model: ASA status, age, type of surgery (elective, urgent, emergency) and degree of surgery (minor, moderate or major). Calibration and discrimination of the new model were good in both development and validation data sets. This new model was better calibrated in the validation data set (Hosmer-Lemeshow goodness-of-fit test: chi(2)=6.8017, P=0.7440) than either P-POSSUM (chi(2)=14.4643, P=0.1528) or POSSUM, which was not calibrated (chi(2)=31.8147, P=0.0004). POSSUM and P-POSSUM had better discrimination than the new model, although this was not statistically significant. Comparing the two ROC curves, the new model had better discrimination than ASA alone (difference between areas, 0.077, SE 0.034, 95% confidence interval 0.012-0.143, P=0.021). CONCLUSIONS: This new, ASA status-based model is simple to use and can be performed routinely in the operating room to predict operative risk for both elective and emergency surgery.

Adolescent↗
PubMed2004

Caudal analgesia in children: S(+)-ketamine vs S(+)-ketamine plus clonidine.

BACKGROUND: The aim of this study was to evaluate postoperative analgesia provided by caudal S(+)-ketamine and S(+)-ketamine plus clonidine without local anesthetic. METHODS: Forty-four children aged 1-5 years consecutively scheduled for inguinal hernia repair, hydrocele repair or orchidopexy were randomly assigned to receive a caudal injection of either S(+)-ketamine 1 mg x kg(-1) (group K) or S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) (group KC). Postoperative analgesia and sedation were evaluated by CHEOPS and Ramsay scale from emergence from general anesthesia for 24 h. RESULTS: No statistical difference was observed between study groups with respect to pain and sedation assessment. A slight trend toward a reduced requirement for rescue analgesia in group KC was observed, although not statistically significant. CONCLUSIONS: Caudal S(+)-ketamine 1 mg x kg(-1) and S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) are safe and provide effective postoperative analgesia in children without adverse effects.

Adrenergic alpha-Agonists↗
PubMed2004

Fenoldopam mesylate and renal function in patients undergoing liver transplantation: a randomized, controlled pilot trial.

To test the relative effects on serum creatinine (CRE), blood urea nitrogen (BUN), and urine output of small-dose dopamine and fenoldopam in patients undergoing liver transplantation, we randomized 43 patients to 1 of 2 continuous infusions over 48 h, starting with anesthesia induction: fenoldopam, 0.1 microg . kg(-1) . min(-1) or dopamine, 2 microg . kg(-1) . min(-1). We used predetermined hemodynamic and intravascular volume goals (intrathoracic blood volume index 800-1000 mL/m(2), extravascular lung water index <7 mL/kg) to manage patients with an algorithm for use of mannitol and furosemide to maintain urine output >1 mL . kg(-1) . h(-1). At postoperative day 3, the median CRE increase was 0.2 mg/dL (interquartile range [IQR] -0.2-0.5) with fenoldopam and 0.5 mg/dL (IQR 0.3-0.9, P = 0.004) in the dopamine group. The BUN increase was median 2 mg/dL (IQR -2-8) versus 8.5 mg/dL (IQR 5-12, P = 0.01), respectively, with fenoldopam versus dopamine. Urine output was similar; however, significantly fewer fenoldopam patients required furosemide compared with dopamine patients (median 1 [IQR 0-3] versus 3 [IQR 2-4], respectively, P = 0.003). The hemodynamic effects of dopamine and fenoldopam were similar. Compared with dopamine, in the setting of liver transplantation, fenoldopam is associated with better CRE and BUN values.

Acute Kidney Injury↗
PubMed2003

Effects of remifentanil on human heart electrical system. A transesophageal pacing electrophysiological study.

AIM: Previous studies have shown that the administration of remifentanil (a micro-agonist opioid) is often accompanied by bradyarrhythmias preventable or manageable by parasympatholytic drugs. The aim of this paper is to evaluate if these negative chronotropic effects are exclusively due to an increased parasympathetic activity or to a direct action of remifentanil on heart conduction fibres. METHODS: A transesophageal pacing electrophysiological study on 40 healthy subjects scheduled for orthopaedic surgical treatment under general anaesthesia has been carried out. We determined either the correct sinus recovery time or the occurrence of Wencke-bach atrio-ventricular block in the awake state and, again, during remifentanil administration. RESULTS: In all patients either a significant depression of sino-atrial automatism or a decrease of atrio-ventricular node conduction reserve was noticed. In 2 cases, in particular, a sinus arrest and a junctional rhythm, respectively, both spontaneously recovered were observed. CONCLUSION. Atropine normalized all parameters, confirming that remifentanil-associated hypokinetic cardiac phenomena are exclusively vagally mediated.

Adult↗
PubMed2003

To verify four 5-year-old mathematical models to predict the outcome of ICU patients.

AIM: The aim of this study is to verify calibration and discrimination after 5 years in the case mix of patients admitted to the Intensive Care Unit (ICU) during the year 2000. In this way we want to perform a quality control of our ICU in order to justify the increased amount of money spent for intensive care. METHODS: A prospective study has been made on the 357 patients admitted to the ICU during the year 2000. The Apache II score was calculated within the first 24 hours and, depending on the length of stay in the ICU, on the 5(th), 10(th) and 15(th) day after ICU admission. On the basis of the 4 mathematical models death risk has been calculated for each of the 4 times. The Hosmer-Lemeshow test was performed for calibration and ROC curves for discrimination, always for each of the 4 mathematical models. RESULTS: The 1(st) model, at 24 hours from ICU admission, showed a bad calibration (p=0.000088), while the ROC curve was 0.744+/-0.32. Also the 2(nd) model, at the 5(th) day from admission, showed a bad calibration (p=0.000588), with ROC curve of 0.827+/-0.04. The 3(rd) model (10(th) day), was well calibrated (p=0.112247) and discriminating (ROC=0.888 +/-0.04). Finally the models at 15 days showed again a bad calibration (p=0.001422) but a very good discrimination (area=0.906+/-0.06). CONCLUSION: Developing mathematical models to predict mortality within ICUs can be useful to assess quality of care, even if these models should not be the only ICU quality controls, but must be accompanied by other indicators, looking at quality of life of the patients after ICU discharge.

Critical Care↗
PubMed2002

Preload and haemodynamic assessment during liver transplantation: a comparison between the pulmonary artery catheter and transpulmonary indicator dilution techniques.

BACKGROUND AND OBJECTIVE: Liver transplantation is characterized by several changes in intravascular blood volume due to vasodilatation based on neurohumoral mediators, intraoperative bleeding and anaesthesia technique effects. Today, with the transpulmonary indicator dilution technique, cardiac index (CIart) can be evaluated and preload assessed in terms of the intrathoracic blood volume index (ITBVI). The aim was to analyse in patients undergoing liver transplantation two preload variables, pulmonary artery occlusion pressure (PAOP) and ITBVI with respect to cardiac index (CIpa) and stroke volume index (SVIpa), the correlation between ITBVI and PAOP, and secondary the relationship between the changes (delta) of ITBVI and PAOP and the changes of CIpa and SVIpa, and the relationships between deltaITBVI and deltaPAOP. The reproducibility and precision of all CIart and CIpa measurements were also evaluated. METHODS: A prospective study was performed in 60 patients monitored with a pulmonary artery catheter and with the PiCCO system. The variables were evaluated with a linear regression model. RESULTS: Linear regression analysis between ITBVI-CIpa and ITBVI-SVIpa were r2 = 0.47 (P < 0.0001) and r2 = 0.55 (P < 0.0001) respectively, while PAOP poorly correlated to CIpa (r2 = 0.02), SVIpa (r2 = 0.015) and ITBVI (r2 = 0.002). Only changes in ITBVI were correlated with changes in CIpa (delta1, r2 = 0.37; delta2, r2 = 0.32), and SVIpa (delta1, r2 = 0.60; delta2, r2 = 0.47). The mean bias between CIart and CIpa was 0.13 L min(-1) m(-2) (2 SD = 1.04L min(-1) m(-2)) (r2 = 0.86, P < 0.0001). CONCLUSIONS: In comparison with PAOP, ITBVI seems a more reliable indicator of cardiac preload in patients undergoing liver transplantation.

Adult↗
PubMed2002

Continuous and intermittent cardiac output measurement: pulmonary artery catheter versus aortic transpulmonary technique.

BACKGROUND: Cardiac output (CO) can be measured intermittently by bolus thermodilution methods in the pulmonary artery (COpa) or in the aorta (COart). A continuous thermodilution method (CCO) and a method for continuous estimation using the arterial pulse wave (PCCO) are also available. METHODS: We compared two methods of intermittent CO measurements in patients during liver transplantation: COpa, regarded as the current clinical standard, and an aortic transpulmonary thermodilution technique (COart) performed with the PiCCO system. We also compared CCO and PCCO. Measurements were made in 62 patients at three stages: after the induction of anaesthesia, after caval clamping phase, and at the end of surgery. We used Bland-Altman and correlation analysis. RESULTS: We found close agreement between the techniques. Mean bias between COart and COpa and PCCO and CCO was 0.15 (2SD of differences between methods=1.74) litre min(-1) and -0.03 (1.75) litre min(-1), respectively. Mean bias between CCO and COpa and PCCO and COpa was 0.02 (1.48) litre min(-1) and 0.04 (1.69) litre min(-1), respectively. CONCLUSIONS: Measurement with the aortic transpulmonary thermodilution technique gives continuous and intermittent values that agree with the pulmonary thermodilution method.

Adult↗
PubMed2002

Transesophageal Doppler ultrasonography evaluation of hemodynamic changes during videolaparoscopic cholecystectomy.

BACKGROUND: The aim of this study was to assess the changes of hemodynamic and oxyphoretic parameters induced by pneumoperitoneum in a series of patients undergoing laparoscopic cholecystectomy, by using the transesophageal Doppler ultrasonography (TEDU). METHODS DESIGN: prospective study. SETTING: a medico-surgical intensive care unit of an University Hospital. PATIENTS: 11 patients who underwent laparoscopic cholecystectomy because of gallbladder stones. INTERVENTIONS: a central venous line, a radial artery line were placed before the induction of anesthesia. End expiratory CO2 (EtCO2) was monitored by using a capnometer (Dräger, Germany). Cardiac output (CO) was measured using the transesophageal Doppler system Abbott ODM II (Abbott Critical Care Systems, Ireland), which was positioned in the esophagus after stabilization of anesthesia. MEASUREMENTS: hemodynamic parameters, including CO, central venous pressure, mean arterial pressure, measurement of EtCO2 and arterial and central venous samples were performed: after reaching a stable anesthesia but before any surgical manipulation (T0); after induction of pneumoperitoneum (T1); 15 min after T1 (T2); 30 min after T1 (T3). RESULTS: SVR increased significantly at T1 and T2 compared to T0; PaCO2 and PvCO2 at T2 and T3. HR and MAP increased significantly at T1, and CVP significantly at all the times. CONCLUSIONS: Laparoscopic surgery is a mini-invasive technique of increasing success among both surgeons and patients. The widening of candidate patients raises the question of eligibility for individuals with known cardiopulmonary disease. In these patients, only a careful and thorough anesthesiologic monitoring allows the prompt identification and treatment of any relevant hemodynamic and/or ventilatory changes.

Adult↗
PubMed2002

Post-thoracotomy analgesia: epidural vs intravenous morphine continuous infusion.

BACKGROUND: We compared thoracic morphine epidural analgesia (TEA) and I.V. analgesia (IVA) with morphine, in respect to the time to extubation, the quality of postoperative analgesia, side effects, complications, postoperative hospital length of stay in patients having thoracotomy lung resection. METHODS: We prospectively studied 563 consecutive patients, undergoing thoracotomy (lobectomy, bilobectomy or pneumonectomy), randomized in two groups: TEA 286 patients and IVA 277 patients. In the epidural group, before the induction of anesthesia, continuous infusion of 15 mg of morphine in 250 mL of normal saline at 5 mL/h was started. In the IVA group a continuous infusion of 30 mg of morphine associated with 180 mg ketorolac in 250 mL of normal saline at 5 mL/h was started before the induction of anesthesia. The pain degree was evaluated on an analogic scale by Keele modified at 1 (end of anesthesia) 6, 12, 24, and 48 postoperative hours, at rest and after movements. Data obtained were analysed by means of the analysis of variance for repeated measures. RESULTS: The time from the end of surgery to tracheal extubation was similar in both groups. Significantly lower numeric verbal pain scores at rest and after movements were found in the epidural group (p<0.001). Postop complications, nausea and vomiting were higher in the IVA group (p<0.05). Postoperative mean hospital length of stay was 9+/-4 days in TEA and 11+/-4 in the IVA group (p<0.05). CONCLUSIONS: In our study the epidural root was superior in terms of analgesia, side effects, length of stay and postoperative complications after thoracotomy.

Analgesia, Epidural↗
PubMed2002

Transesophageal atrial pacing in the management of re-entry supraventricular tachyarrhythmias occurring during general anesthesia.

BACKGROUND: Supraventricular tachyarrhythmias (SVTs) represent an intraoperative risk factor that should be always prevented/managed. The commonly used anti-arrhythmic drugs are accompanied by intrinsic hazards, such as pro-arrhythmic and toxic effects or unpredictable onset and duration of action. We underline the therapeutic use of transesophageal atrial pacing (TAP) for the interruption of particular re-entry SVTs occurred during surgical procedures in general anaesthesia. METHODS: Our study was carried out in 25 patients characterized by a personal clinical history of transient tachyarrhythmic episodes, subjected to general anaesthesia obtained by midazolam, propofol, N2O e O2, sevoflurane, fentanil and vecuronium bromide. We used TAP bursts of 3-5 sec, their minimal pacing rate being equivalent to the tachyarrhythmia cycle length, with an impulse intensity ranging from 18 to 25 mA. In such conditions, the re-entry was interrupted by the induction of refractoriness of the wave-front that sustained the underlying arrhythmogenic circuit. RESULTS: During the study, the following arrhythmias occurred in 7 out of all patients: 1 type I atrial flutter, 3 nodal tachycardias, 1 antidromic and 2 orthodromic atrioventricular tachycardias, respectively. TAP assured either atrial capture or prompt suppression of arrhythmias in all cases. Low intensity impulses did not ever allow ventricular capture. CONCLUSIONS: TAP can be considered as a valid therapeutic device for the management of re-entry SVTs occurred during general anaesthesia, resulting it effective, safe and easy-practicable.

Anesthesia, General↗