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Summary Arterial carbon dioxide partial pressure measurements using the NBP-75® microstream capnometer were compared with direct PaCO2 values in patients who were (a) not intubated and spontaneously breathing, and (b) patients receiving intermittent positive pressure ventilation of the lungs and endotracheal anaesthesia. Twenty ASA physical status I–III patients, undergoing general anaesthesia for orthopaedic or vascular surgery were included in a prospective crossover study. After a 20-min equilibration period following the induction of general anaesthesia, arterial blood was drawn from an indwelling radial catheter, while the end-tidal carbon dioxide partial pressure was measured at the angle between the tracheal tube and the ventilation circuit using a microstream capnometer (NBP-75®, Nellcor Puritan Bennett, Plesanton, CA, USA) with an aspiration flow rate of 30 mL min-1. Patients were extubated at the end of surgery and transferred to the postanaesthesia care unit, where end-tidal carbon dioxide was sampled through a nasal cannula (Nasal FilterLine, Nellcor, Plesanton, CA, USA) and measured using the same microstream capnometer. In each patient six measurements were performed, three during mechanical ventilation and three during spontaneous breathing. A good correlation between arterial and end-tidal carbon dioxide partial pressure was observed both during mechanical ventilation (r = 0.59; P = 0.0005) and spontaneous breathing (r = 0.41; P = 0.001); while no differences in the arterial to end-tidal carbon dioxide tension difference were observed when patients were intubated and mechanically ventilated (7.3 ± 4 mmHg; CI95: 6.3–8.4) compared to values measured during spontaneous breathing in the postanesthesia care unit, after patients had been awakened and extubated (6.5 ± 4.8 mmHg; CI95: 5.2–7.8) (P = 0.311). The mean difference between the arterial to... [ABSTRACT FROM AUTHOR]

Results of 33 simultaneous pancreas and kidney transplantations performed at the San Raffaele Hospital, Milan, Italy are presented. In 26 cases segmental neoprene duct-injected grafts were transplanted and in seven cases, duodenopancreatic bladder-drained grafts. Five-year patient, kidney and pancreas survival were respectively, 89%,72% and 58%. Five-year survival in patients with technically successful pancreas transplants was 73%. Thrombosis occured in 20% of cases. Mortality was 6% and overall morbidity 76%. Surgical complications were present in 51% of cases. [ABSTRACT FROM AUTHOR]

Background: To compare surgical tracheostomy (ST) versus percutaneous dilatational tracheostomy (PDT) in terms of complication rates. In particular we specifically studied the late tracheal complications of both methods by means of endoscopic controls of patients up to 6 months after the procedures., Design: prospective-randomized clinical study., Setting: University-affiliated tertiary care referral hospital., Patients: 50 consecutive translaryngeally intubated patients with respiratory failure were randomized to undergo either ST (25 patients) or endoscopic guided PDT (25 patients)., Results: ST was performed in 41+/-14 min versus 14+/-6 min for PDT (p<0.0001). There was no procedure-related death. In the ST group there were no intraoperative complications. In the PDT group 2 intraoperative complications (minor hemorrhages) were observed. In the ST group 9 early postoperative complications occurred: one minor bleeding, 7 stomal infections and one accidental decannulation. In the PDT group only one early postoperative complication (minor bleeding) occurred. Early postoperative complication rates were 36% for ST and 4% for PDT. In the ST group there were no late tracheal complications. In the PDT group 2 late tracheal complications (one segmental malacia and one stenosis at the level of the stoma) were observed., Conclusions: This study confirms that PDT is a simpler and quicker procedure than ST and that it has a lower rate of early postoperative complications. Late tracheal complications were more frequent, although the difference was not statistically-significant, in the PDT group. Further investigations of long-term outcome following PDT are therefore necessary.

Background: To evaluate the end tidal carbon dioxide estimation in nonintubated, spontaneously breathing patients using either conventional sidestream or microstream capnometers., Methods: Patients received a regional anesthesia technique, while the end tidal carbon dioxide partial pressure (EtCO2) was sampled through a nasal cannula (Nasal FilterLine, Nellcor, Plesanton, CA, USA) and measured using either a conventional sidestream capnometer with a 200 ml.min-1 aspiration flow rate, or a microstream capnometer (NBP-75, Nellcor Puritan Bennett, Plesanton, CA, USA) with an aspiration flow rate of 30 ml.min-1. After a 20 min period with stable hemodynamic variables (systolic arterial blood pressure within +/- 20% from baseline values), the EtCO2 was randomly recorded using one of the two capnometer while arterial blood was simultaneously drawn from the radial artery and analyzed for measurement of arterial CO2 partial pressure. Afterwards the nasal cannula was connected to the other capnometer and the procedure repeated. Both the capnometer and arterial blood gas analyzer were calibrated before each studied patient according to the manufacturer instructions. The same procedure was repeated at least two times in each patient., Results: A total of 120 pairs of EtCO2 and PaCO2 measurements were drawn from 30 adults (age: 69 +/- 5 years; weight: 70 +/- 10 kg; height: 160 +/- 10 cm): 60 using the conventional sidestream capnometer and 60 with the microstream one. The median arterial to end tidal CO2 tension difference was 4.4 mmHg (range: 0.28 mmHg) with the microstream capnometer and 7 mm Hg (range: 0-22 mmHg) with the conventional capnometer (p = 0.02)., Conclusion: The microstream capnometer provides a more accurate end tidal CO2 partial pressure measurement in nonintubated, spontaneously breathing patients than conventional sidestream capnometers, allowing for adequate monitoring of the respiratory function in nonintubated patients.

Purpose: To evaluate the effectiveness of cervical plexus block performed with ropivacaine 0.75% or 1%, or mepivacaine 2%., Methods: In a prospective, randomized, double-blind study, 60 patients received deep cervical plexus block with 0.2 ml x kg(-1) divided among C2-C4 injections using ropivacaine 0.75% and 1% or mepivacaine 2%. A blinded observer recorded loss of pin-prick sensation every minute in the C2-C4 dermatomes until readiness for surgery. Then, a superficial cervical block was performed with 0.15 ml x kg(-1) lidocaine 1%. The need for intraoperative supplemental analgesia and degree of pain and time of first postoperative pain medication were also recorded., Results: General anesthesia was not required to complete surgery in any case. No differences in the need for intraoperative supplemental analgesia was observed (7, 6, and 9 patients with ropivacaine 0.75% and 1% or mepivacaine 2%, respectively). Readiness to surgery required 15 (10-25) min with ropivacaine 0.75%, 18 (8-20) min with ropivacaine 1%, and 15 (5-20) min with mepivacaine 2% (P = NS); while patients asked for first postoperative pain medication after 10 (4-13) hr and 9 (6.5 - 11) hr with ropivacaine 0.75% and 1% compared with 5 (0-8) hr with mepivacaine 2% (P<0.05)., Conclusion: Ropivacaine 0.75% or 1% are appropriate choices when performing cervical plexus anesthesia for carotid endarterectomy, providing nerve block characteristics similar to those of mepivacaine 2%, but with the advantage of longer postoperative pain relief.

Background: To compare early and late complications after either conventional surgical or percutaneous dilatational tracheostomy., Design: Prospective, randomized study., Setting: General intensive care unit and neuro-surgical intensive care unit in a university hospital., Patients: 50 consecutive patients, requiring tracheostomy for prolonged mechanical ventilation., Interventions and Measurements: Patients were randomly allocated to receive either surgical (surgical group, n = 25) or percutaneous dilatational tracheostomy (percutaneous group, n = 25). Occurrence of perioperative complication were carefully evaluated during ICU stay. Late complications were evaluated with both physical and endoscopic examination at 1, 3 to 6 months after tracheostomy., Results: All surgical and percutaneous tracheostomies were successfully completed and no deaths directly related to the tracheostomy procedures were reported. Completion of the procedure required 41 +/- 14 min in the surgical group and 14 +/- 6 min in the percutaneous one (p < 0.0001). The incidence of early perioperative complications was higher in the surgical group (36%) than in percutaneous one (12%), (p < 0.05). The endoscopic follow-up demonstrated one segmental malacia and one stenosis of the trachea in the percutaneous group only (p = n.s.). Skin repair was better after percutaneous tracheostomy than in the surgical group (p < 0.01)., Conclusions: In experienced hands, percutaneous dilatational tracheostomy is as safe and effective as the conventional surgical tracheostomy. The percutaneous technique is less time-consuming and has a lower rate of early infectious complications with better cosmetic results than the surgical technique.

The case of a 32-year-old woman admitted to Hospital for diabetic coma (GCS 8), with arterial blood pH below usually reported vital range, is described. After First Aid admittance an arterial blood gas analysis adjusted for patient's temperature showed PaO2 10.77 kPa, PaCO2 7.8 kPa, pH 6.52, HCO3 5 mmol/L, BE-34.9. A significant increase of lactate and butyrate concentration was also found. The patient was intubated and breathing was assisted for a 60 hour period after ICU admission, while acidemia was treated by THAM and bicarbonate associated to potassium i.v. infusion (infusions were titrated on acid-base and electrolyte concentration direct monitoring). After progressive neurological and biochemical improvement, 7 days after ICU admission the patient was moved to an Internal Medicine department. This case demonstrated that during diabetic ketoacidosis, despite very low pH (below reported vital range), an invasive intensive treatment could give complete cure without neurological sequelae.

Objective: To evaluate the usefulness of the modified Harris-Benedict formula predicting Energy Expenditure (EE) in pressure support ventilated, critically ill patient., Setting: The intensive care unit (ICU) of a teaching hospital., Patients: Fiftyfive patients admitted to ICU for acute respiratory failure, requiring mechanical ventilation., Measurements and Results: After 12 hours at rest, EE was measured using indirect calorimetry (Datex-Deltatrac, with method exclusions - ICEE), and calculated using modified Harris-Benedict formula (MHBEE) (with correction for "hospital activity" and "stress factor") to calculate the bias between calculated and measured EE. Patients were divided into three groups on the basis of nutritional stress: A) non surgical/non septic patients (n = 10), B) complicated surgical patients (n = 21), C) severe infectious/multiple trauma patients (n = 24). In each group, a good correlation between calculated and measured EE was found [A) r = 0.809, p = 0.0046; B) r = 0.753 p = 0.0001; C) r = 0.711, p = 0.0001]. The bias (+/- SEM) was: A 175.1 (+/- 82) kcal/day, B 324.5 (+/- 64.5) kcal/day, C 366.7 (+/- 62.9) kcal/day. The mean difference value seems to be increased in the more stressed patients but these differences did not reach statistical significance (p = 0.23). A single correction factor for the original Harris-Benedict formula (OHBEE) was also calculated (ICEE/OHBEE) on each studied group: A) 1.20 (+/- 0.04), B) 1.28 (+/- 0.03), C) 1.50 (+/- 0.04) (p = 0.0001)., Conclusions: The use of both "stress" and "activity" correction factors seems to be excessive in pressure support ventilated ICU patients. A single correction factor, proportional to the intensity of the illness, should be used in mechanically ventilated patients. Compared to the original Harris-Benedict formula, we found an EE increment of about 20%, 30%, and 50% respectively in non-septic/non-complicated, surgical complicated, and multiple trauma/septic patients.

Pancreas and kidney transplantation is performed in uremic IDDM patients to cure end-stage renal failure and diabetes. Seventy-two simultaneous kidney-pancreas transplantations were performed at our Institution between July 1985 and November 1994. All transplants were performed using heart-beating cadaver donors. The first 25 patients received 26 segmental pancreas according to Dubernard (KPS), whereas the last 46 patients received a whole, bladder-drained pancrea according to Sollinger (KPW). Mean pancreas cold and warm ischemia times were 294 +/- 14 and 44 +/- 2 minutes, respectively, in the KPS group and 660 +/- 37 and 40 +/- 8 minutes, respectively, in the KPW group. Twelve (48%) KPS patients and 19 (41%) KPW patients had postoperative pancreas surgical complications: vascular thrombosis led to graft failure in 5 KPS patients (20%) and 2 KPW patients (4%) (p = 0.01). Pancreatic fistula, hemorrhagic complications, and duodenum-bladder leakage were the surgical complications observed more frequently. Six KPS patients (24%) and 8 KPW patients (17%) underwent reintervention as a consequence of surgical complications. Fifteen KPS patients (60%) and 30 KPW patients (65%) experienced an acute kidney rejection episode, which was steroid-resistant in 14 KPW and 2 KPS patients. The actuarial survival rates for simultaneous kidney-pancreas recipients at one and 4 years were 92% and 84%, respectively, for KPS recipients, and 95% and 88%, respectively, for KPW patients. Kidney actuarial survival rates at one and 4 years were 96% and 76% respectively, for group KPS, and 93% and 89%, respectively, for KPW patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The role played by chest radiograph and CT scan in diagnosis of pneumothorax is analyzed in a retrospective study based on two years of activity in Intensive Care Unit. The sensibility of traditional chest radiography was 75% while the sensibility of CT scan resulted higher (87.5%). In the authors opinion, when pneumothorax is suspected, particularly in patients with polytrauma, CT scan of the chest is mandatory unless patient's conditions or logistic difficulties related with transport of the patient contraindicate it.

It is well known that the presence of a tumour may be accompanied by production and release into the serum of a substantial number of protein and/or hormonal substances. Only relatively recently, however, have investigators begun to identify which of these supposed markers may actually be clinically useful. A picture is thus gradually emerging of a number of markers (in actual fact only very few) which are already clinically useful, as well as others which are clinically promising and numerous markers which require more thorough clinical evaluation. Prominent among those already in clinical use is undoubtedly CEA. Carcinoembryonic antigen (CEA) is a glycoprotein isolated for the first time by Gold and Friedman in 1965. Very recently, sensitive radioimmune and immuno-enzymatic assays have made it possible to determine serum levels lower than 3 ng/ml. Though high plasma levels of CEA do not indicate the presence of a tumour with certainty, very high levels are, however, to some extent indicative of its existence. In view of the fact that CEA possesses neither the sensitivity nor the specificity to be able to diagnose the presence or otherwise of a tumour, its use is generally recommended when formulating a prognosis or for monitoring surgical and/or medical therapy (chemotherapy and radiotherapy) in asymptomatic patients. We therefore carried out tests in 357 patients on file as having undergone surgery for neoplasms of the colon-rectum-anus, monitored in our colostomy outpatients' department, which was started up in 1980. 188 of these patients had already been submitted to CEA assay prior to surgery. The data are analyzed in relation to the site, stage and grade of differentiation of the neoplasm, the supposed radicality of the operation and the period of follow-up in these patients.