Severe hypernatremia as a predictor of mortality after percutaneous endoscopic gastrostomy (PEG) placement

BACKGROUND

Percutaneous endoscopic gastrostomy is the preferred option for providing enteral nutrition, allowing for an improvement in survival and quality of life.

AIM

To evaluate risk factors for early and delayed mortality after gastrostomy placement.

METHODS

A single-center retrospective analysis of a prospectively-collected database including all patients undergoing gastrostomy placement for enteral nutrition was performed. Two operators performed all the procedures according to the most recent guidelines.

RESULTS

Analysis included data on 438 patients [178 male; 80.5 (72-86) year-old]. Indications for PEG were stroke (34.0%), dementia (31.3%), neurodegenerative disorders (18.5%), coma (9.1%) and cancer (7.1%). No periprocedural adverse events was observed. Mean survival was 14.6±3.4months; 1-month and 3-month mortality rates were 4.0% and 8.1%, respectively. Severe hypernatremia (≥150mmol/L) was independently related to 1-month mortality (odds ratio 25.4; P<0.0001), while C-reactive protein level>4.3mg/dL was independently related to 3-month mortality (odds ratio 5.3; P=0.003). Kaplan-Meier and Cox-regression analysis identified male gender (hazard ratio 2.32; P=0.0002), severe hypernatremia (hazard ratio 4.3; P<0.0001), C-reactive protein>4.3mg/dL (hazard ratio 3.5; P=0.0014), leukocytosis (hazard ratio 1.97; P=0.0036) and presence of underlying malignancy (hazard ratio 2.4; P=0.0013) as independent risk factors for long-term mortality.

DISCUSSION

Presence of severe hypernatremia and increased C-reactive protein levels were strongly correlated with early and delayed mortality in our population. Studies are necessary to understand whether correcting underlying dehydration and inflammation further improves patients' outcomes.

The role of embolization for hemangiomas

We retrospectively studied 31 patients with painful bone (15 patients) and soft-tissue (16 patients) hemangiomas treated with 39 embolizations using N-2-butyl cyanoacrylate from 2003 to 2010. The mean tumor size before embolization was 6 cm for bone and 7 cm for soft-tissue hemangiomas. The technique of embolization was the same for bone and soft-tissue lesions. Preoperative embolization was done in six patients, while the remaining patients had embolization as only treatment. The mean follow-up was 47 months (11-89 months). The clinical and imaging effect of treatment was evaluated at follow-up with a pain score scale, tumor size, and ossification. In four patients, embolization was not feasible because of the inability to catheterize and low blood flow of the feeding vessels. Nine patients with bone and 10 with soft-tissue hemangiomas experienced complete pain relief. Four patients with bone and four with soft-tissue hemangiomas experienced recurrence of pain and were treated with repeat embolization. Re-recurrences were not observed in any of the patients with soft-tissue hemangiomas until the period of this study. Ossification and tumor size reduction were higher for bone hemangiomas. Embolization-related complications were more common for soft-tissue hemangiomas.

Shortening the discharging time after total hip replacement under combined spinal/epidural anesthesia by actively warming the patient during surgery

BACKGROUND

To compare passive thermal insulation by reflective blankets with forced-air active warming on the efficacy of normothermia maintenance and time for discharging from the recovery room after combined spinal/epidural anesthesia for total hip arthroplasty.

METHODS

DESIGN

Prospective, randomized study.

SETTING

Inpatient anesthesia at three University Departments of orthopedic surgery.

PATIENTS

50 ASA physical status I-III patients, who were scheduled for elective total hip arthroplasty.

INTERVENTIONS

Patients received combined spinal/epidural anesthesia (CSE) with intrathecal injection of 15 mg of 0.5% hyperbaric bupivacaine. All procedures started 8-10 a.m., and operating room temperature was maintained between 21-23 degrees C, with relative humidity ranging between 40-45%. As warming therapy patients received either passive thermal insulation of the trunk, the two upper limbs and the unoperated lower limb with reflective blankets (group passive, n = 25), or forced-air active warming of the two upper limbs (group active, n = 25). Core temperature was measured before CSE placement (baseline), and then every 30 min until recovery of normothermia.

RESULTS

Demographic data, duration of surgery, intraoperative blood losses, and crystalloid infusion were similar in the two groups. Arterial blood pressure decreased in both groups compared with baseline values, while no differences in heart rate were observed during the study. Core temperatures in passive group patients decreased more markedly than in actively warmed patients, with a 1 degree C difference between the two groups at the end of surgery (p < 0.0005). At recovery room entry seven patients in group active (24%) and 16 patients in group passive (64%) showed a core temperature < 36 degrees C (p < 0.01). Achievement of both discharging criteria and normothermia required 32 +/- 18 min in active group and 74 +/- 52 min in passive group (p < 0.0005).

CONCLUSIONS

Forced-air cutaneous warming allows the anesthesiologist to maintain normothermia during combined spinal/epidural anesthesia for total hip replacement even if the convective blanket is placed on a relatively small skin surface with reflex vasoconstriction. Maintaining core normothermia decreased the duration of postanesthesia recovery and may, therefore, reduce costs of care.

[Wash and non-wash system in the perioperative recovery of blood in prosthetic surgery: ultrastructural assessment of corpuscular blood components]

AIM

The authors aimed to perform an ultrastructural morphological analysis of blood recovered using wash and non-wash systems in patients undergoing full cement-free hip replacement in order to evaluate the integrity of the various blood corpuscle components.

EXPERIMENTAL PROTOCOL

An open prospective study in patients undergoing full cement-free hip replacement at the Orthopedics Division of S. Orsola-Malpighi Policlinico in Bologna. Materials of S. Orsola-Malpighi Policlinico in Bologna.

MATERIALS AND METHODS

Blood recovered postoperatively using a non-wash system was studied in 6 patients. In a further 3 patients perioperatively recovered blood was studied after washing using Cell Saver Haemolite 2 before reinfusion. Red globules, white globules and plaelets were isolated from blood collected using these two different recovery systems and analysed by SEM.

RESULTS

Study of the ultrastructural morphology of various corpusculated blood fractions.

DISCUSSION AND CONCLUSIONS

From the data in our possession it appears that the ultrastructural morphology of the various corpuscle components of blood in subjects undergoing postoperative recovery is better preserved using a non-wash system. There was no sign of "polluting" material in terms of adipose cells or free bone fragments in either group.

[Paravertebral block of the lumbar plexus. Variations of the original technic]

After studying a hundred or so abdominal CT scans carried out at L5 level and having verified that the interfascial compartment between the quadrate muscle of the lumbi and the psoas muscle is relatively fixed (1.8-2.3 cm), it is proposed to utilise this datum (introduction of the 2 cm) needle after contact with the transverse apophysis of L5) to identify the psoas compartment which contains most of the nerves making up the lumbar plexus. Study of the series and results obtained confirm the value and simplicity of the proposed technique.