Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo
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Monaldi Arch Chest Dis · Jul 2017
Postoperative delirium: A preventable complication in the elderly surgical patient.
Postoperative delirium (POD) is an acute organic cerebral disturbance of consciousness and attention in combination with additional cognitive symptoms. It usually develops shortly after surgery and lasts for some hours up to some days. It worsens clinical outcomes, prolongs the hospital stay and leads to negative trajectories of cognitive, emotional and functional outcomes up to month if not years after surgery. ⋯ Offering optimal and safe care for an elderly surgery patient requires a team based approach. Strategies for reducing POD incidence include early detection of risk factors, adaptation of surgical and anaesthesiologic techniques, avoiding certain drugs, optimisation of haemostasis, continuously monitoring of the patients' cognitive status as well as early mobilization and careful management of eventual early signs of POD. If POD is prevented, it's negative trajectories may be likewise anticipated.
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Monaldi Arch Chest Dis · Jul 2017
Comparative StudyCurrent multivariate risk scores in patients undergoing non-cardiac surgery.
Several indexes to predict perioperative cardiovascular risk have been proposed overtime. The most widely used is the Revised Cardiac Risk Index (RCRI) developed by Lee since 1999. It predicts major cardiac outcomes from five independent clinical determinants: history of ischemic heart disease, history of cardiovascular disease, heart failure, insulin-dependent diabetes mellitus, and chronic renal failure (i.e. serum creatinine >2 mg/dl). ⋯ The AUROC curves showed higher accuracy as compared to the RCRI score both in the derivation than in the validation cohort (AUROC= 0.872 ± 0.028 vs 0.807 ± 0.037). Thus, many risk indices are available nowadays. Despite the latest European guidelines recommended them for risk stratification (class I, level of evidence B), their use in clinical practice is still scarce.
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Over the past few decades, the progressive aging of the population combined with the resulting increase in cardiovascular disease and the marked improvement of technologies applied to surgery justify the marked increase of the elderly patients requiring cardiovascular surgery. This claims a highly skilled perioperative management, which should be aimed at treating cardiac disease without increasing risk of hospitalization-related harmful events. Current preoperative assessment for cardiac surgery, such as the European System for Cardiac Operative Risk Evaluation II (EUROSCORE II) and the Society of Thoracic Surgeons (STS) risk score, are limited in their ability to predict perioperative outcomes in older patients. This is because patients' chronological age should not be considered as the only tool to identify the surgical risk. ⋯ Therefore, further research is needed in order not only to identify a unique, fast and easy to use tool aimed to recognize frailty syndrome, but chiefly resulting able to give us information about the effectiveness of focused preoperative interventions. Finally, we need to have scientific data on the role that surgical, percutaneous and transcatheter procedures have on outcome in elderly patients in terms of perioperative mortality, postoperative quality of life and regarding the possible reversibility of frailty. Cardiovascular surgery is to date a "moving target", due to changing face of patients and changing face of technical requirements and perioperative management should reflect such changes.
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Monaldi Arch Chest Dis · Jul 2017
Case ReportsGradually worsening dyspnea and dry cough in an elderly patient.
Primary tracheal chondrosarcomas are an extremely rare condition that affect adult of all ages, 24% being more that 70 years old. The progression may be slow, with symptoms that may continue up to 72 months before diagnosis is made. The clinical manifestations, that include a combination of nonproductive cough, wheezing, and dyspnea without hemoptysis often leads to misdiagnosis of asthma or chronic obstructive pulmonary disease. We report a case of an 87-year-old male, a Medical Doctor, with such a history, in whom a diagnosis of a tracheal chondrosarcoma was finally performed, 12 months after the first manifestation of the disease.
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Monaldi Arch Chest Dis · Jul 2017
Endobronchial ultrasound-guided transbronchial needle aspiration under conscious sedation with meperidine and midazolam.
Endobronchial Ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is usually performed under general anesthesia or deep sedation with drugs such as Propofol that, at least in Italy, can be administered only by an anesthesiologist. Aim of the study was to assess conscious sedation feasibility, safety and tolerability using Meperidine and Midazolam as administered by Pulmonologist and relevant impact on the efficiency of the sampling procedures. All patients undergoing EBUS-TBNA from February 2013 to July 2014 were examined retrospectively. ⋯ A 27% cost reduction was calculated. EBUS-TBNA under conscious sedation using Meperidine and Midazolam prescribed and administered by pulmonologist without the Anesthesiologist assistance, revealed to be a safe, well tolerated and cost saving procedure. The efficiency of sampling was good, apart from a relatively low diagnostic yield due to different expertise of operators.