Minerva anestesiologica
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Defibrillation as soon as possible is the mainstay of modern emergency system in the treatment of sudden cardiac death. The emergency medical system (EMS) should be integrated with first responders in the community trained to use the semiautomatic external defibrillators (AED). Piacenza Progetto Vita is a European project of early defibrillation through lay first responders integrated within the EMS. ⋯ Survival from sudden cardiac arrest significantly increased (from 3.3% to 10.5%, p<0.01). In particular in the group of patients treated by first responders survival from ventricular fibrillation was 44.1% vs 21.2% of EMS treated group (p < 0.05). A simple training for the use of AED without cardiopulmonary resuscitation training increased survival and created a group of competent AED operator integrated within the EMS.
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Minerva anestesiologica · May 2003
Review Comparative StudyPost-operative epidural versus intravenous patient-controlled analgesia.
Patient-controlled analgesia techniques have opened a new dimension to individualize patient's need for analgesia, in the treatment of acute post-operative pain. These techniques can be used intravenously, in the epidural space, and into peripheral nerve sheets. There is a common consensus that intravenous patient-controlled analgesia should not have a continuous infusion while epidural patient-controlled analgesia (PCEA) should be programmed with a continuous infusion. ⋯ The continuous epidural infusion of opioids has the advantages of fewer fluctuations in cerebrospinal fluid concentrations of drug, but it is necessary to administer a loading bolus, to overcome the fact that it takes several hours to provide adequate analgesia. The advantages of epidural versus intravenous patient-controlled analgesia are represented by better analgesia and a reduced opioids requirement, while the advantages when compared to epidural continuous infusion are: increased efficiency, self-adjustment by the patient, higher patient satisfaction, less sedation, and lower opioids dosage. The clinical advantages of PCEA may outweigh the greater cost and invasiveness of this technique.
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Minerva anestesiologica · May 2003
ReviewGuidelines on anticoagulants and the use of locoregional anesthesia.
Growing numbers of patients are treated with hemostasis altering drugs, as thromboembolic diseases are a major cause of mortality in our western society. The insertion of epidural or subarachnoidal needles and/or catheters in such patients carries the inherent risk of the development of a compressing vertebral canal hematoma. This is especially true in patients treated with thrombolytic agents or oral anticoagulants. ⋯ The available data do not allow making firm recommendations on the safe use of major neuraxial blocks. In contrast, the isolated use of acetyl-salicylic acid or non-steroidal anti-inflammatory drugs is no longer considered contraindicated, but their combination with of heparin remains controversial. Intraoperative heparinization, perioperative thromboprophylactic use of unfractionated heparin or low molecular weight heparins are possible if: 1) a minimum time interval between the regional anesthetic block and the administration of the previous or next dose of anticoagulant is respected and; 2) the specified dose limitations of the heparin compound used are not exceeded; and 3) indwelling catheters are removed only after the disappearance of any remaining anticoagulant effect.
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Minerva anestesiologica · May 2003
Review[Emergencies in cardiac surgery: prophylaxis or correction?].
Management of coagulation during cardiac surgery is always challenging for the anesthesiologist, even in elective operations. The strict linkage between coagulation and inflammation is amplified during cardiopulmonary bypass due to the contact of the blood with the foreign surfaces. In emergencies, coagulative derangement could be worse but the cardiocirculatory instability and parenchimal failure often overcome the attention to this problem.
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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.