Major trauma critical pathway: preliminary results from the monitoring system in the regional network and in a hub center in Rome metropolitan area

OBJECTIVE

The aim of this study is to collect the two years' data regarding the Integrated Trauma Management System (SIAT) by capturing the activity of its three Hubs in the Italian Lazio Region and test the performance of one of the Hubs' (Fondazione Policlinico Universitario A. Gemelli - IRCCS, FPG -IRCCS) Major Trauma Clinical Pathway's (MTCP) monitoring system, introducing the preliminary results through volume, process and outcome indicators.

MATERIALS AND METHODS

A retrospective analysis on SIAT was conducted on years 2016 to 2018, by collecting outcome and timeliness indicators through the Lazio Informative System whereas the MTCP was monitored through set of indicators from the FPG - IRCCS Informative System belonging to randomly selected clinical records of the established period.

RESULTS

Hubs managed 11.3% of the 998,240 patients admitted in SIAT. All patients eligible for MTCP were "Flagged", and 83% underwent a CT within 2 hours; intra-hospital mortality was 13% whereas readmission rates 16.9%.

CONCLUSIONS

SIAT converges the most severe patients to its Hubs. The MTCP monitoring system was able to measure a total of 9 out of 13 indicators from the original panel. This research may serve as a departing point to conduct a pre-post analysis on the performance of the MTCP.

Thromboelastography clot strength profiles and effect of systemic anticoagulation in COVID-19 acute respiratory distress syndrome: a prospective, observational study

OBJECTIVE

Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) infection may yield a hypercoagulable state with fibrinolysis impairment. We conducted a single-center observational study with the aim of analyzing the coagulation patterns of intensive care unit (ICU) COVID-19 patients with both standard laboratory and viscoelastic tests. The presence of coagulopathy at the onset of the infection and after seven days of systemic anticoagulant therapy was investigated.

PATIENTS AND METHODS

Forty consecutive SARS-CoV-2 patients, admitted to the ICU of a University hospital in Italy between 29th February and 30th March 2020 were enrolled in the study, providing they fulfilled the acute respiratory distress syndrome criteria. They received full-dose anticoagulation, including Enoxaparin 0.5 mg·kg-1 subcutaneously twice a day, unfractionated Heparin 7500 units subcutaneously three times daily, or low-intensity Heparin infusion. Thromboelastographic (TEG) and laboratory parameters were measured at admission and after seven days.

RESULTS

At baseline, patients showed elevated fibrinogen activity [rTEG-Ang 80.5° (78.7 to 81.5); TEG-ACT 78.5 sec (69.2 to 87.9)] and an increase in the maximum amplitude of clot strength [FF-MA 42.2 mm (30.9 to 49.2)]. No alterations in time of the enzymatic phase of coagulation [CKH-K and CKH-R, 1.1 min (0.85 to 1.3) and 6.6 min (5.2 to 7.5), respectively] were observed. Absent lysis of the clot at 30 minutes (LY30) was observed in all the studied population. Standard coagulation parameters were within the physiological range: [INR 1.09 (1.01 to 1.20), aPTT 34.5 sec (29.7 to 42.2), antithrombin 97.5% (89.5 to 115)]. However, plasma fibrinogen [512.5 mg·dl-1 (303.5 to 605)], and D-dimer levels [1752.5 ng·ml-1 (698.5 to 4434.5)], were persistently increased above the reference range. After seven days of full-dose anticoagulation, average TEG parameters were not different from baseline (rTEG-Ang p = 0.13, TEG-ACT p = 0.58, FF-MA p = 0.24, CK-R p = 0.19, CKH-R p  = 0.35), and a persistent increase in white blood cell count, platelet count and D-dimer was observed (white blood cell count p < 0.01, neutrophil count p = 0.02, lymphocyte count p < 0.01, platelet count p = 0.13 < 0.01, D-dimer levels p= 0.02).

CONCLUSIONS

SARS-CoV-2 patients with acute respiratory distress syndrome show elevated fibrinogen activity, high D-dimer levels and maximum amplitude of clot strength. Platelet count, fibrinogen, and standard coagulation tests do not indicate a disseminated intravascular coagulation. At seven days, thromboelastographic abnormalities persist despite full-dose anticoagulation.

Iron, zinc and aluminium ferritin content of hemodialysis hyperferritinemic patients: comparison with other hyperferritinemic clinical conditions and normoferritinemic blood donors

The present study describes the specific content of ferritin iron, zinc and aluminium in four different groups: 1) hemodialysis hyperferritinemic patients; 2) septic patients; 3) iron overloaded patients with hematologic diseases; and 4) blood donors. In all four groups high levels of aluminium and zinc were found in addition to those of iron. However, the sum of the ferritin ions of the control group is significantly higher than that of the other three groups. Furthermore, while ferritin of hemodialysis patients has the same molecular ratio of metal ions as control group (high Al content vs. Fe and Zn), a lower Al/Fe ratio is found both in septic and hematological patients. The results of the present paper might help to explain the high percentage of hyperferritinemia found in hemodialysis patients also in presence of low transferrin saturation and in absence of inflammatory markers. Moreover, the high content of ions other than iron in the ferritin core leads us to believe that ferritin is not only an iron storage protein but rather a regulator of redox active ions.

Good neurological recovery after cardiopulmonary resuscitation and thrombolysis in two old patients with pulmonary embolism

The use of thrombolysis as an emergency treatment for cardiac arrest (CA) due to massive pulmonary embolism (MPE) has been described. However, there are no reports of successful treatment of MPE-associated CA in patients over 77 years of age. We report two cases of successful cardiopulmonary resuscitation for an MPE-associated CA in two very old women (87 and 86 years of age). In both cases, typical signs of MPE were documented using emergency echocardiography, which showed an acute right ventricle enlargement and a paradoxical movement of the interventricular septum. Emergency thrombolysis was administered during resuscitation, which lasted 45 and 21 min, respectively. Despite old age and prolonged resuscitation efforts, both patients had good neurological recovery and one of them was alive and neurologically intact 1 year later. Thrombolysis is a potentially useful therapy in MPE-associated CA. A good neurological outcome can be obtained even in very old patients and after prolonged resuscitation.

Balanced anestesia versus total intravenous anestesia for kidney transplantation

AIM

An ideal anesthetic regimen for kidney transplantation should be able to assure haemodynamic stability to obtain an optimal graft reperfusion. The aim of this study was to compare 2 regimens of anesthesia for patients submitted to kidney transplantation.

METHODS

We studied 40 patients: 20 subjects (Group A) received balanced anesthesia with thiopental, fentanyl and isoflurane, to the others 20 (Group B), a total intravenous anesthesia (TIVA) with propofol and remifentanyl was given. In both groups muscle relaxation was obtained with a bolus of cisatracurium followed by a continuous infusion. We performed standard clinical, invasive blood pressure and central venous pressure monitoring. Hemodyna-mic data have been collected at standard times. During the postoperative period we evaluated the recovery (Aldrete Score) in the recovery room and the analgesia (VAS) at 1, 6, 24 h after the end of surgery.

RESULTS

The trend of hemodynamic parameters did not show statistically significant differences between the 2 groups. We observed statistically significant differences concerning the quality of the recovery and the postoperative analgesia. The recovery in group B was faster than in group A, but in group A the pain control was better than in group B at least during the first postoperative hour.

CONCLUSIONS

For their pharmacokinetic properties, propofol, remifentanyl and cisatracurium allow to obtain a good control of the hemodynamic parameters and a fast and safe recovery of consciousness. Total intravenous anesthesia regimen seems to be an alternative to the balanced anesthesia for patients undergoing kidney transplantation.

Efficacy and safety of continuous intravenous infusion of remifentanil in preterm infants undergoing laser therapy in retinopathy of prematurity: clinical experience

BACKGROUND

Preterm infants often require surgery. As experimental evidence suggests that premature infants may experience pain and this could even result in fatal complications, the anaesthesiologist must face problems related to lowbirth weight, high risk of hypothermia, concomitant pulmonary disease and metabolic and receptor immaturity. Recently remifentanil has been considered an optimal analgesic drug in a preterm infant undergoing mechanical ventilation and frequent surgical manoeuvres, but no clinical studies have been reported in the literature. The aim of our study was to evaluate the efficacy of a continuous intravenous infusion of remifentanil in premature infants undergoing laser therapy for retinopathy of prematurity (ROP).

METHODS

Six premature infants with ROP were scheduled for laser therapy. The procedure was performed in the neonatal intensive care unit. Transcutaneous carbon dioxide, pulse oximetry, respiratory rate, ECG and noninvasive blood pressure were continuously monitored. Infusion of remifentanil started with a dose of 0.75-1 microg x kg-1x min-1, 1 h before surgery. A midazolam bolus dose (0.20 mg x kg-1) was administered and the remifentanil infusion was increased to 3-5 microg x kg-1x min-1 taking into account haemodynamic and respiratory changes or spontaneous movements.

RESULTS

Increased dosage was necessary only for 10 min during the procedure. No changes in temperature and ventilatory settings were observed and after 2 h from the surgical procedure the preterm infants were back to their preoperative status.

CONCLUSIONS

A continuous infusion of remifentanil allowed optimal control of surgical stress and a return to preoperative status and ventilatory settings without side-effects.

Comparison of positive end-expiratory pressure with reverse Trendelenburg position in morbidly obese patients undergoing bariatric surgery: effects on hemodynamics and pulmonary gas exchange

BACKGROUND

Anesthetized morbidly obese patients often exhibit impaired pulmonary gas exchanges, mostly because of a reduction in functional residual capacity. At present, several approaches are suggested to ventilate these patients.

METHODS

The efficiency of positive end-expiratory pressure (PEEP) and reverse Trendelenburg position (RTP) were compared in order to improve oxygenation in 20 morbidly obese patients undergoing bariatric surgery.

RESULTS

Both PEEP and RTP determined a significant decrease in alveolar-arterial oxygen difference and an increase in total respiratory compliance (Ctot). RTP resulted in lower airway pressures than PEEP with similar improvements in Ctot and oxygenation. Concerning hemodynamic parameters, cardiac output (CO) significantly decreased with both PEEP and RTP.

CONCLUSIONS

RTP and PEEP can be considered adequate ventilatory settings for morbidly obese patients, without any significant difference with regard to gas exchange improvement. However, the decrease in CO may partially counteract the beneficial effects on oxygenation of these ventilatory settings.

Effects of low-dose alfentanil administration on central respiratory drive and respiratory pattern in spontaneously breathing ASA 1 patients

The aim of this study was to assess the short-term effects of the administration of low doses of alfentanil on respiratory drive and respiratory pattern. We studied 17 ASA I patients scheduled for minor surgery or endoscopic procedures. During spontaneous ventilation, Respiratory Rate, Tidal Volume, Total Respiratory Cycle, Inspiratory and Expiratory Time, Mean Inspiratory Flow, P0.1, S(a)O(2) and EtCO(2) were all measured. The inspired oxygen concentration was 21% and measurements were made at baseline, 5 min (T1), 10 min (T2) and 15 min (T3) following an intravenous bolus injection 10 microg.kg(-1) alfentanil. The administration of alfentanil produced a significant (p < 0.05) reduction in S(a)O(2), minute volume and P0.1. In ASA I spontaneously breathing patients, the pre-operative administration of low doses of alfentanil can initially reduce the respiratory centre activity leading to a reduction in minute volume and S(a)O(2). We therefore recommend careful monitoring of cardio-respiratory function in ASA I patients, following the administration of alfentanil.

[Computerized multiple-choice questions: an efficacious method of evaluation in medical instruction?]

To evaluate the efficacy of Multiple Choice Questions (MCQ) as an evaluation tool in medical education, were analyzed the responses to 80 MCQ delivered by 300 physicians working in emergency departments and following a course on Basic and Advanced Life Support. Pre- and post-test were administered using a dedicated computer application running on PC. Students' scores were high and demonstrated both course and test validity. More than 95% of the students used the computer application without interface difficulties. However, some limits of MCQ were individuated: first, misinterpretation of some questions, especially when two or more similar answers were presented; from the other side, the student's personal experiences during the course practice could influence student's responses bringing him to different conclusions on respect to the instructor. These difficulties should be kept in mind in the development of a MCQ session, and students should have the possibility to give to the instructor a feedback of problems encountered during the course. This is especially important when MCQ are the sole evaluation technique.