Minerva anestesiologica
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Minerva anestesiologica · May 2003
Review[Prevention of hypotension in spinal anaesthesia carried out for caesarean section].
After describing the most commonly applied obstetric indications for caesarean section and the respective percentages reported in countries that are comparable with Italy in terms of health care standards, the clinical reasons and requirements on the basis of which it is considered that spinal anaesthesia is first choice compared to general anaesthesia in obstetrical surgery are outlined. This evidence is confirmed by the spinal anaesthesia/general anaesthesia ratio encountered in the major national and international Obstetric Hospitals. Maternal hypotension remains the most frequent and clinically important complication consequent on spinal anaesthesia in pregnant women at term. ⋯ It is pointed out that certain procedures have become part of standard practice but their effectiveness has not yet been confirmed while others are not only ineffective but also expose mother and foetus to potential complications. For others again the jury is still out on their real effectiveness. Finally, the techniques that are currently considered to be effective and shared by the majority of authors are described and these must therefore be included in the procedural protocols regarding spinal anaesthesia for caesarean section.
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Ketamine is an NMDA receptors antagonist, with a potent anaesthetic effect. NMDA receptors are involved in nociceptive modulation, in the wind-up phenomenon, in peripheral receptive fields expansion, in primary and secondary hyperalgesia, in neuronal plasticity. Ketamine effects are well-known: it produces a state of "dissociative anaesthesia", amnesia, and, at the same time, it mantains the respiratory drive effective and supports the sistemic arterial blood pressure. ⋯ The suggested doses are: Epidural or caudal route (as an ajuvant for local anaesthetic agents, in the treatment of postoperative pain): 0.5 mg/kg. Sedative/analgesic effect (for algesic procedures): 1-2 mg/kg i.v. Continuous infusion (intensive care unit): 0.5 mg/kg/h, with a range from 20-30 microg/kg/min to 80 microg/kg/min, depending on the age of the patient.
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Microcirculatory alterations have been widely described in experimental models of sepsis, however the microcirculation have long been neglected in septic patients as traditional techniques do not allow the visualisation of the microcirculation. The Orthogonal Polarization Spectral (OPS) imaging technique allows the direct visualisation of the microcirculation at the bedside. A selected review of the articles on the microcirculation in patients with sepsis using the OPS imaging technique, is made. ⋯ The severity of these alterations is more pronounced in non survivors than in survivors, and is related with the development of multiple organ failure. These alterations can be reversed by vasodilators, either topically applied or administered intravenously. Microvascular blood flow alterations are frequently observed in patients with sepsis and can have major pathophysiological implications.
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Minerva anestesiologica · May 2003
Review[Antithrombin: prospects in clinical practice. Sespsi: anticoagulant or anti-inflammatory agents?].
Sepsis and septic shock represent a frequent cause of mortality in Intensive Care Units, despite of the progress in antibiotic therapy and in the hemodynamic and respiratory support. The most frequent cause of death is the Multi Organ Dysfunction Syndrome (MODS), which is the clinical manifestation of the irreversibile damage of the microvascular bed. During sepsis and septic shock both activation of coagulation /fibrinolysis and release of mediators of inflammation contribute to the pathogenesis of disseminated intravascular coagulation (DIC); in particular the formation of fibrin in the microvascular bed is the pathological substrate of the clinical development of MODS. ⋯ AT has a double function: anticoagulant and anti-inflammatory. The most important mechanism responsible of the anti-inflammatory properties of AT is the binding to the glycosaminoglycans of the endothelial cells and the consequent release of prostacyclin. During sepsis and septic shock, treatment with AT was able, especially in animal models but also in clinical studies, to decrease plasma levels of mediators of inflammation and in some case to preserve organ failure and to reduce mortality.