Minerva anestesiologica
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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
ReviewNew approaches for the prevention of airway infection in ventilated patients. Lessons learned from laboratory animal studies at the National Institutes of Health.
Despite early diagnosis and appropriate antibiotic therapy, ventilator-associated pneumonia (VAP) remains the leading cause of death from hospital-acquired infection in ventilator-dependent patients. Strategies to prevent bacterial colonization of the trachea and lungs are the key to decrease mortality, hospital length of stay, and cost. ⋯ Aspiration may occur during 1) intubation, 2) mechanical ventilation through leakage around the tracheal tube cuff, 3) suctioning of the tracheal tube when bacteria can detach from the biofilm within the tube, or 4) areosolization of bacterial biofilm during mechanical ventilation through the tracheal tube or the ventilator circuit biofilm. From experimental studies in sheep, we drew 3 relevant conclusions: 1) The tracheal tube and neck should be oriented horizontal/below horizontal to prevent aspiration of colonized secretions and subsequent bacterial colonization of the lower respiratory tract. 2) Continuous aspiration of subglottic secretions (CASS) can lower bacterial colonization of the respiratory tract, but at the price of severe tracheal mucosal damage at the level of the suction port. 3) Coating the interior of the tracheal tube with bactericidal agents can prevent bacterial colonization of the tube surface and of the entire respiratory circuit, during 24 hours of mechanical ventilation.
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The aim of the paper is to review the literature concerning 4 unanswered or debatable questions concerning the practice of regional anesthesia in pediatric patients. The published material concerning the 4 selected topics is reviewed, namely importance of ropivacaine, preoperative coagulation screening tests, hemodynamic stability following neuraxial blocks and prevention/treatment of post-dural puncture headache. Of the 4 questions considered in this article, 3 can be reasonably answered in a consensual way. ⋯ Preoperative coagulation screening tests are not necessary, even not useful in children when clinical history is not suggestive of coagulation disorders, with the notable exception of neonates and prematurely born infants less than 45 weeks of post-conceptual age. The long established hemodynamic stability following neuraxial blocks results from well equilibrated compensatory mechanisms which may not be functional in children with preoperative hemodynamic instability or anomalies of the regional blood flow distribution. Finally, even though the post-dural puncture headache is not frequent in children, its management still remains difficult and no definitive recommendation can be currently made in case of inadvertent dural puncture during an attempted epidural anesthesia in children.
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Minerva anestesiologica · May 2003
ReviewPostanaesthetic shivering. Epidemiology, pathophysiology and approaches to prevention and management.
Postanaesthetic shivering is one of the leading causes of discomfort for patients recovering from general anesthesia. During EMG records, the distinguishing factor from shivering in fully awake patients is the existence of clonus similar to that recorded in patients with spinal cord transection. They coexist with the classic waxing and waning signals associated with cutaneous vasoconstriction (thermoregulatory shivering). ⋯ Prevention mainly entails preventing hypothermia by actively rewarming the patient. Postoperative skin surface rewarming is a way of obtaining the threshold shivering temperature while raising the skin temperature and improving the patient's comfort. However, it is less efficient than certain drugs such as meperidine, nefopam or tramadol, which act by reducing the shivering threshold temperature.
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Minerva anestesiologica · May 2003
ReviewMechanical and infectious complications of central venous catheters.
Central venous catheters (CVC) are an important tool in the operation room and intensive care unit. The application of CVC is associated with both mechanical and infectious complications. Knowledge and recognition of risk factors and implementation of strict guidelines will help to reduce the number and severity of complications. Catheter-related factors, patient-related factors, selection of the site of puncture and catheter use and care related factors, all play a contributive role in the risk on complications.