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Objective: Deprescribing, i.e. the suspension of drugs whose existing or potential harms outweigh the benefits in the context of care for the individual patient, is an increasingly frequently encountered topic in various congresses today. This issue becomes predominant especially in patients with chronic pathologies with a life expectancy of less than a year, in whom the goal of the treatments passes from healing to caring. Currently there are few validated deprescribing tools, one of these is certainly the STOPPFrail, currently available in its second version. Therefore, we decided to provide for the translation into Italian, to make the description for the elderly patient with limited life expectation more applicable., Methods: For the translation, we used the method expressed by the European organisation for research and treatment of cancer (Eortc), using forward-backward translation and a Pilot Testing to verify the clarity and comprehensibility of the translation itself., Results: We interviewed 15 experts, of whom 13 responded and completed the evaluation, without bringing to light any unclear sections or sources of misunderstanding., Conclusions: STOPPFrail2 can be a valid deprescribing tool in the elderly with limited life expectancy; the Italian version can help the physicians in the therapeutic appropriateness in this time of life where it is necessary to focus on the quality of life and on the ethical aspect of the choices, as well as being of help in a "cost-opportunity" logic.

In patients on hemodialysis, the reduced alkali urinary loss makes metabolic acidosis less severe. Unexpected is the large occurrence of respiratory alkalosis and acidosis. During the therapy, the convective/diffusive inward fluxes of CO2 and bicarbonate and the loss of organic anions affect acid-base homeostasis. In bicarbonate-dialysis, the neutralization of acids by bicarbonate and gain of gaseous CO from the dialysate cause an increase of CO2 content in the body water, which requires an increase in lung ventilation (>10%) to prevent hypercapnia. In on-line hemodiafiltration, the infusate drags additional CO2 into bloodstream, while in acetate - free biofiltration the dialysate is CO2 - free and this prevents any addition of CO2. Bicarbonate and acetate diffuse into extracellular fluid according to their bath-to-blood concentration gradients. The initially large bicarbonate flux decreases rapidly because of the rapid increase in blood concentration. The smallest acetate flux is instead constant with time providing a constant source of alkali. Rapid alkalinization elicits H+ mobilization that consumes most of the bicarbonate added. Some H+ are originated by back-titration of body buffers, but others are originated by new organic acid production, a maladaptive event that wastes metabolic energy. In addition, organic anions diffuse into dialysate causing a substantial increase in net acid production. A novel dialysis protocol prescribes a low initial bath bicarbonate concentration and a stepwise increase during the therapy. Such a staircase protocol ensures a smoother increase of blood bicarbonate concentration avoiding the initial rapid growth and reducing the rate of organic acid production, thus making the treatment more effective., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

In bicarbonate-dialysis the dialysate is acid, thus allowing salts to remain in their soluble form, as a result of the chemical reaction of bicarbonate with any acid that yields carbon dioxide (CO2). The residual anion, commonly acetate or more rarely citrate, reaches the patients' bloodstream. CO2 also spreads to the patients and ventilation needs therefore to be increased to avoid hypercapnia. In addition, during on-line haemodiafiltration in post-dilution mode, the dialysate - in the form of infusate - carries CO2 (and acetate) to the patient, bypassing the filtering membrane. On the contrary, in Acetate-Free Biofiltration (AFB) the dialysate is free of acid and, uniquely, is also a CO2-free bath. Despite the infusion of bicarbonate in post-dilution mode, the blood coming back from the extracorporeal circuit does not carry any burden of CO2. As a result, AFB is the recommended renal replacement therapy for patients affected by lung disease and those with CO2 retention (respiratory acidosis). Patients with some degree of ventilatory dysfunction may in fact experience acute hypercapnia (acidosis by dialysate) at the beginning of the treatment if bicarbonate-dialysis or on-line HDF is performed (and regardless of whether acetate-containing or citrate-containing bath is employed). Acidosis by dialysate is characterized by respiratory symptoms first and by haemodynamic instability later, which make it look very similar to acetate intolerance. To discriminate between these two conditions, blood gas analysis is mandatory. The presence of hypercapnia can be revealed by using the Very Simple Formula (expected pCO2 = bicarbonate + 15), thus identifying those patients that may take the most advantage of AFB., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

The hemodialysis might interfere with patients hemodynamic, as the technique allows a sophisticated game with extra and intravascular fluids. As the cardiocirculatory response could sometimes be unpredictable, it is interesting to collect valuable information by reaching a deep understanding of the tissue metabolism which is mirrored by the blood gas analysis of variations in arterial and central venous blood samples. Particularly interesting are the time course variations of the central venous hemoglobin saturation (ScvO2), which are directly related to the patient with O2-demand as well as to the O2-Delivery (DO2). The ScvO2 is determined by four parameters (cardiac output, Hb concentration, arterial Hb saturation and O2 consumption): If the fluids subtraction during dialysis was about to determine an occult hypoperfusion, the ScvO2 reduction would be a timely warning sign to be considered. Moreover, while the normal veno-arterial PCO2 difference is 2-4 mmHg, whenever a mismatch between O2-demand and DO2arise, a larger v-aPCO2 difference should be observed.

We report a rare case of hand pain acutely experienced after arteriovenous placement with vascular derangement playing an etiopathogenetic key role and misleading neurological features due to a painless and misunderstood carpal tunnel syndrome. It cannot be explained by any well-defined pathophysiologic mechanism underlying the hand pain syndrome of hemodialysis patient. It is worth to note that the pain spontaneously relieved within few weeks in accordance with the time of transient tissue hypoxia triggered by fistula construction. In conclusion, an accurate neurological examination is mandatory in planning phase of vascular access, especially in the presence of special features or risk factors. Nevertheless, we would like to stress that the nephrologists must keep in mind that the wide range of ischemic damage caused by the arteriovenous fistula includes not only necrotic damage but also transient tissue hypoxia. The latter can spontaneously regress within few weeks, so that any deferrable decision must be postponed for at least thirty days.

The acid-base abnormalities in uremic patients on hemodialysis are well known. There is less awareness of the fact that during bicarbonate dialysis patients are simultaneously exposed to the four fundamental acid-base disorders. Attempts at compensation involving the respiratory system persist in the hours following hemodialysis. Furthermore, several landmark publications in addition to more recent papers clearly show that bicarbonate HD is only able to compensate for uremic acidosis through the elimination of surplus CO2 from dialysate via the lungs. The artificial kidney and lungs of the patient work together to ensure the efficiency of hemodialysis. Dialysate is a more acidic solution than the patient's blood and contains, in addition to oxygen and bicarbonate, at least twice the CO2 concentration of blood. The high dialysance of CO2 allows for its rapid diffusion from the dialysate to the blood compartment and can be a clinically relevant issue in patients with co-morbidities, especially respiratory disease. In such circumstances, hemodialysis may cause iatrogenic respiratory acidosis which, if not recognized, can require ventilatory assistance and advanced life support. Checking for such problems in a real life setting, such as an outpatient hemodialysis unit, is an important part of the nephrologists day-to-day work.

The use of pulse oximetry can improve the management of critical events and daily clinical problems in a haemodialysis unit. Blood oxygen saturation using pulse oximetry (SpO2), the so-called 'fifth vital sign', can be determined together with noninvasive blood pressure measurement, before haemodialysis treatment or when, during treatment, a patient's condition suddenly worsens. The pulse oximeter provides useful information on pulse rate and on heart rhythm. It can be considered a diagnostic first step for dyspnoea because normal-high values rule out interstitial pulmonary fluid. It is also a useful screening for blood gas analysis, providing confirmation of arterial blood from an arteriovenous fistula sample. It can indicate when oxygen therapy should be initiated and provides monitoring. Finally, it can be used to explore pulse blood flow distal to the arteriovenous fistula.

Aim: The aim of this study was to evaluate the analgesic effects of remifentanyl on mechanically ventilated newborns., Methods: Eighteen newborns, mechanically ventilated, were submitted to continuous infusion of R. A pain scale was used to evaluate comfort during mechanical ventilation. Data were collected at T0, T1, Tn, T ext, T post-ext; statistical analysis was performed by Student's t test and Pearson coefficient., Results: Mean R infusion time was 66.94+/-22.24 h, with mean dose of R 0.146+/-0.038 gamma/kg/min. Mean time to reach comfort was 20+/-13.11 h with a mean infusion of R equal to 0.173+/-0.146 gamma/kg/min; R was 0.18+/-0.039 gamma/kg/min on pressure controlled ventilation and R was 0.09+/- 0.045 gamma/kg/min on assisted ventilation. Statistically significant was considered the decrease in HR as well as the increase of SpO2 at T0 vs 30 min after infusion., Conclusion: No adverse effects were observed during and after infusion.

Aim: Hemodynamic monitoring is an important step in the management of critically ill children despite the difficulty in measuring preload indices continuously. The aim of the study was to analyze cardiac output parameters and preload indices after acute changes in mean airway pressure and volemia., Methods: Twenty-three children treated at our unit were enrolled in a prospective non randomized cohort study. Respiration was supported by controlled mechanical ventilation with positive expiratory-end pressure (PEEP), peak inspiratory pressure <20 cm H(2)O and mean airway pressure <10 cm H(2)O, and hemodynamic monitoring using the PiCCO system. Hemodynamic parameters were measured at T0 (base line), T(1) (after an increase in PEEP of 5 cm H(2)O for 10 min), and T(2) (after fluid challenge). The statistical analysis (BMPD New System software package) comprised comparison of changes at T(0) vs T(1), T(1) vs T(2) and T(0) vs T(2), construction of 3 correlation matrices and multiple linear regression analysis., Results: Sixty-nine hemodynamic parameters were measured in the 23 patients. A comparison between T(0) and T(1) showed no significant changes; differences between T(0) and T(2) were found for cardiac index (CI), (p=0.003); between T(0) and T(2) significant differences were found for CI (p=0.0015), intrathoracic blood volume index (ITBVI) (p=0.04) and stroke volume index (SVI) (p=0.06). The analysis of the correlation matrices yielded ITBVI with CI (p=0.0006), ITBVI with SVI (p=1 x 10(-5)), CI with SVI (p=0.002); a significant correlation between CI and extravascular lung water index (EVLWI) was found only at T(1). Multiple linear regression analysis showed that ITBVI and SVI were predictive for variance of CI at each time point., Conclusion: ITBVI measured by a volumetric monitoring system such as the PiCCO may be considered a sensitive preload indicator also in critically ill children.

The objective of this paper was to examine the major anaesthetic problems during transthoracic endoscopic sympathectomy without artificial pneumothorax and to present our experience of 16 cases suffering from Raynaud's disease. For the perioperative management we used a double lumen endo-bronchial tube and balanced anaesthesia (intravenous agents plus isoflurane). Arterial pressure, heart rate, ECG, end-tidal carbon dioxide concentration, SatO2, blood gases and peak inspiratory pressures were monitored. The results showed that no significant changes in these parameters occurred during surgery. Since hypoxaemia is the main problem of the thoracoscopic sympathectomy the A.A. emphasize the necessity to ensure a correct ventilation as well as a haemodynamic stability throughout the procedure. The combination of balanced anaesthesia and double lumen endobronchial intubation seems an advisable method when no artificial pnx is instituted. A close monitoring of the circulatory and respiratory systems is imperative.