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Background: General anesthesia may be a risk factor for post-operative cognitive impairment, which could be counteracted by neuroprotective compounds. The aims of this study were to determine cognitive functions impaired by general anesthesia and to test blueberry juice as a neuroprotective agent against neuropsychological dysfunctions induced by general anesthesia., Methods: Twenty-six patients undergoing elective major surgery were randomized into two groups, receiving either 500 mL/day of blueberry juice within 14 preoperative days (G1) or to a control group (G0). Neuropsychological tests were performed around 20 days before surgery (T0), as well as both three hours (T1) and 24 hours (T2) after surgery. All the scores were statistically analyzed to find significant differences between groups and within the three times., Results: The control (G0) group showed a significant decrease in the performance in the Prose Memory Test (P<0.001), the Attentional Matrices Test (P<0.01), and the Trail Making Test Part B (P<0.01) after general anesthesia. Significant differences were reported in the Prose Memory test, T0 versus T1 (P<0.01), T0 versus T2 (P<0.001); in the Trail Making Test Part B, T0 versus T2 (P<0.01); and the Attentional Matrices test, and T0 versus T2 (P<0.001). The G1 group did not show any decrease in the performance of the three tests., Conclusions: General anesthesia induces a short-term impairment of verbal memory and selective and divided attention. Blueberry compounds may prevent these neuropsychological deficits through a neuroprotective action in patients undergoing general anesthesia.

Background: Sugammadex is the first of a new class of selective relaxant binding drugs developed for the rapid and complete reversal of neuromuscular blockade (NMB) induced by the aminosteroid neuromuscular blocking drugs rocuronium and vecuronium. Neuromuscular blocking drugs block the transmission from the peripheral nerve to the muscle units, with reduction and disappearance of the evoked electromyographic activity. Usually, neuromuscular monitoring for the investigational reversal drug is performed by calibrated acceleromyography. The efficacy of sugammadex in reversing profound and "deep" residual rocuronium-induced NMB using myogenic motor evoked potentials (mMEPs) monitoring was evaluated., Methods: In this prospective trial, 30 consenting patients undergoing propofol-remifentanil anesthesia for spine surgery were enrolled and divided into two groups: Group 1, reversal of profound NMB (sugammadex 16 mg/Kg, 3 minutes after rocuronium 1.2 mg/Kg) and Group 2, reversal of "deep" residual NMB (sugammadex 4 mg/Kg, 15 minutes after rocuronium 0.6 mg/Kg). Myogenic MEPs registrations of upper and lower limbs and the diaphragm were performed, as well as TOF monitoring., Results: After injection of 4 mg/Kg of sugammadex, the means of recovery time of the basal mMEPs amplitudes (diaphragm, and lower limbs and upper limbs) were 124±9.6, 143±163, 151±207 sec, respectively whereas after 16 mg/Kg of sugammadex the times were 109±13.8, 124±0.6, and 135±14.1 sec. Times to TOF ratio 0.9 were 114±75 and 186±105 sec in Group 1 and 2, respectively. No serious adverse effects related to sugammadex and to electrical stimulation were reported. No reoccurrence of neuromuscular block was observed., Conclusion: Neurophysiological monitoring using mMEPs confirmed that sugammadex provided a complete recovery from profound and "deep" residual rocuronium-induced neuromuscular blockade.

Acute kidney injury (AKI) is an independent risk factor for mortality in critically ill patients whose epidemiology has been made unclear in the past by the use of different definitions across various studies. The RIFLE consensus definition has provided a unifying definition for AKI leading to large retrospective studies in different countries. The present study is a prospective observational multicenter study designed to prospectively evaluate all incident admissions in 10 Intensive Care Units (ICUs) in Italy and the relevant epidemiology of AKI. A simple user-friendly web-based data collection tool was created with the scope to serve for this study and to facilitate future multicenter collaborative efforts. We enrolled 601 consecutive patients into the study; 25 patients with End-Stage Renal Disease were excluded leaving 576 patients for analysis. The median age was 66 (IQR 53-76) years, 59.4% were male, while median SAPS II and APACHE II scores were 43 (IQR 35-54) and 18 (IQR 13-24), respectively. The most common diagnostic categories for ICU admission were: respiratory (27.4%), followed by neurologic (17%), trauma (14.4%), and cardiovascular (12.1%). Crude ICU and hospital mortality were 21.7% and median ICU length of stay was 5 days (IQR 3, 14). Of 576 patients, 246 patients (42.7%) had AKI within 24 hours of ICU admission while 133 developed new AKI later during their ICU stay. RIFLE-initial class was Risk in 205 patients (54.1%), Injury in 99 (26.1%) and Failure in 75 (19.8%). Progression of AKI to a worse RIFLE class was seen in 114 patients (30.8% of AKI patients). AKI patients were older, with higher frequency of common risk factors. 116 AKI patients (30.6%) fulfilled criteria for sepsis during their ICU stay, compared to 33 (16.7%) of non-AKI patients (P<0.001). 48 patients (8.3%) were treated with renal replacement therapy (RRT) in the ICU. Patients were started on RRT a median of 2 (IQR 0-6) days after ICU admission. Among AKI patients, they were started on RRT a median of 1 (IQR 0-4) days after fulfilling criteria for AKI. Median duration of RRT was 5 (IQR 2-10) day. AKI patients had a higher crude ICU mortality (28.8% vs. non-AKI 8.1%, P<0.001) and longer ICU length of stay (median 7 days vs. 3 days [non-AKI], P<0.001). Crude ICU mortality and ICU length of stay increased with greater severity of AKI. Two hundred twenty five patients (59.4% of AKI patients) had complete recovery of renal function, with a SCr at time of ICU discharge which was ≤120% of baseline; an additional 51 AKI patients (13.5%) had partial renal recovery, while 103 (27.2%) had not recovered renal function at the time of death or ICU discharge. Septic patients had more severe AKI, and were more likely to receive RRT with less frequency of renal function recovery. Patients with sepsis had higher ICU mortality and longer ICU stay. The study confirms previous analyses describing RIFLE as an optimal classification system to stage AKI severity. AKI is indeed a deadly complication for ICU patients where the level of severity correlated with mortality and length of stay. The tool developed for data collection resulted user friendly and easy to implement. Some of its features including a RIFLE class alert system, may help the treating physician to collect systematically AKI data in the ICU and possibly may guide specific decision on the institution of renal replacement therapy.

Background: In the developing rodent brain, exposure to volatile anesthetics causes widespread neuronal apoptosis in several regions of the brain. Increasing evidence points to a possible neuroprotective role for the anesthetic gas xenon, following neuronal injury. To address this gap in understanding, we explored the transcriptional consequences of xenon in the brains of postnatal day 7 (P7) rats exposed to xenon compared to those of air-breathing animals, with particular emphasis on the mRNA transcript levels of Akt and c-Jun N-terminal kinase kinase 1 (JNKK1), which are important for cell survival and the activation of extrinsic neuroapoptotic pathways, respectively., Methods: P7 Sprague/Dawley rats were exposed to air (75% nitrogen, 25% oxygen) or xenon (75% xenon, 25% oxygen) for 120 min (N=6/group). Forebrains were harvested for reverse transcription polymerase chain reaction, which enabled quantification of Akt and JNKK1 mRNA transcripts. Suppression subtractive hybridization was used to explore the "genetic signature" of xenon exposure., Results: Compared to control air-breathing animals, xenon-breathing rats exhibited a 0.7-fold decrease in Akt mRNA expression (P<0.01) and a 1.6-fold increase in JNKK1 mRNA levels (P<0.05)., Conclusion: The concomitant decrease in the Akt mRNA expression level and increase in the JNKK1 mRNA transcript level provide evidence that xenon has a neuroapoptotic effect in the developing rodent forebrain. Given these results, further study into the paradoxical neuroprotective and neuroapoptotic effects of xenon is warranted.

Aim: Animal studies suggest that neuronal cell death often results from anesthetic administration during synaptogenesis. Volatile anesthetics are strongly involved in triggering neuronal apoptosis, whereas other inhalational agents (xenon) demonstrate protective effects. Nitrous oxide (N2O) has modest pro-apoptotic effects on its own and potent, synergistic toxic effects when combined with volatile agents. Recent findings suggest that, during periods of rapid brain development, the enhanced neurodegeneration triggered by anesthetic drugs may be caused by a compensatory increase in intracellular free calcium, a potent activator of neuronal nitric oxide synthase (nNOS). Anesthesia-induced neuro-apoptosis is also activated via the intrinsic and the extrinsic apoptotic pathways because both pathways involve p53, a key regulatory gene. The molecular events related to neuronal cell apoptosis are not completely understood. To gain further insight into the events underlying neuro-apoptosis, we analyzed the transcriptional consequences of N2O exposure on nNOS, iNOS and p53 mRNA levels., Methods: The study used 2 groups of postnatal day seven Sprague/Dawley rats (N=6 each) that were exposed for 120 minutes to air (75% N2, 25% O2) or N2O (75% N2O, 25% O2; this N2O concentration is commonly used to induce anesthesia and has been demonstrated to trigger neurodegeneration in postnatal day seven rats). Total RNA was isolated from each brain and expression analyses on iNOS and nNOS transcripts were performed using relative Real-Time C-reactive protein PCR (using G3PDH as a housekeeping gene). A semi-quantitative RT-PCR analysis was performed on the p53 transcript (using Ciclophylin A as a housekeeping gene)., Results: Statistical analysis (REST 2005) revealed a significant, 11-fold up-regulation (P=0.026) of the nNOS transcript but no significant changes in iNOS transcription. The p53 mRNA was up-regulated almost 2-fold (P=0.0002; Student's t-Test; GraphPad Prism 4.00) in N2O-treated samples relative to room-air samples., Conclusion: Our preliminary data show that N2O induced a selective increase in nNOS and p53 transcription. These new findings provide evidence of pro-apoptotic action by N2O and may shed new insight on its toxic effects; however, further investigations are necessary.

Background: To survey current anaesthesiology practice in Italy., Methods: We submitted to 1260 Italian anaesthesiologists in 12 different regional places a structured form aimed at surveying their common work practice. Our sample consisted of anaesthesiologists, age 26-63, with 1-35 years of professional practice. We believe that our sample represents about 7-10% of Italian anaesthesiologists, reflecting a global number of 600,000 procedures performed during 2000. The results have been analyzed by an Excel spreadsheet and they are reported as mean of the percentage of use declared in the case of drugs, and as percentage of the responses in the case of procedure and monitoring systems used. Furthermore we divided our sample population according to two criteria: principal place of work (general operating rooms (OR), subspecialty ORs, ICU) and years of anaesthesiology practice (<5>). The results have been crossmatched within and between the subgroups., Results: The survey showed a composite state of anaesthesia practice in Italy. The main differences are between the youngest and the oldest anaesthesiologists and between the anaesthesiologists working mainly in the ICU and in the ORs., Conclusions: Italian anaesthesia practice is still a very composite reality.

Unlabelled: Acute pain treatment after surgery or trauma, when inadequate, contributes to increased morbidity and prolonged in hospital stay. Acute postoperative pain management can be realised by application of treatment protocols and the regular assessment of the patients clinical conditions. The aim of the ACUTE PAIN SERVICE (APS) is to plan postoperative treatment. According to our experience, besides providing assistance, the APS elaborates results and intervenes through regular audits to improve quality. This system is further enriched through collection of information obtained through an anonymous questionnaire compiled by the patients about forty eight hours after surgery. The questions are expressed such to outline a judgement about patients' satisfaction towards the services supplied by the agency., Objective: Evaluation of effectiveness of pain treatment and level of postoperative wellbeing through continuous observation of the patient., Methods: a retrospective study on about 4400 consecutive patients arriving at the APS in the last 2 years of activity, who have been evaluated at fixed moments using various indicators (VAS at rest/activity, PONV and other discomforts)., Results: Follow-up of the patients showed that: - pain relief, when reached, does not conform well-being; - for certain symptoms of discomfort, specific protocols are necessary; - there are correlations between type of surgery, type of anaesthesia and discomfort, which may be reducible through the right attitude in behaviour and therapy; - antalgic therapy itself can cause several side-effects. The solution of the discomfort problem gets close to the concept of perioperative medicine in which APS action goes beyond pain, towards a more complete pain management.

Superficial cervical plexus block in association with laryngeal mask for the airways control has improved the postoperative outcome, in comparison with a previous group in general anaesthesia, performed by the same equipment. The local anaesthetic infiltration as a preemptive analgesia give us good evidences in pain control. The laryngeal mask contributes to a good surgical field and avoid the neck hypertension.

Objective: To evaluate the cerebral blood flow parameters assessed by transcranial Doppler during aortic cross-clamping and unclamping in patients undergoing abdominal aortic aneurysmectomy., Methods: Invasive intraoperative monitoring of mean arterial pressure (MAP) and PaCO2, and right middle cerebral artery (RMCA) monitoring of blood flow parameters (mean velocity "Vm" and pulsatility index "PI") by transcranial Doppler were performed as well as evaluation of the four parameters during these subsequent periods: pre-cross-clamping, pre-unclamping, unclamping and 1-5-10-20 minutes after abdominal aortic unclamping., Results: No significative changes of MAP, PaCO2, Vm and PI were noticed during the aortic cross-clamping period (77.5 +/- 18.5 SD minutes). During aortic unclamping Vm and MAP decreased (64 +/- 20 vs 52 +/- 20 cm/sec, p < 0.05, and 101 +/- 8 vs 80 +/- 15 mmHg, p < 0.01, respectively). At the 1th post-unclamping minute there was an increase from pre-unclamping values of Vm (75 +/- 20 cm/sec, p < 0.05) and PaCO2 (42 +/- 1.5 vs 36 +/- 2 mmHg, p < 0.05), with persistent reduction of MAP (92 +/- mmHg, p < 0.05), even more evident at the 5th post-unclamping minute (Vm = 93 +/- 25 cm/sec; PaCO2 = 46 +/- 1.2 mmHg, p < 0.001, and MAP returned to pre-unclamping value), in which there was also a decrease of PI (0.65 +/- 0.16 vs 0.78 +/- 0.2, p < 0.05). At the 10th minute Vm (83 +/- 24 cm/sec, p < 0.02) and PaCO2 (41 +/- 1.5 mmHg, p < 0.05) increments were present together with persistent reduction of PI (0.69 +/- 0.17, p < 0.05), while at the 20th post-unclamping minute also Vm, PaCO2 and PI returned to their pre-unclamping values., Conclusions: The Vm decrease at aortic unclamping might correlate with the acute changes in MAP (blood steal hypovolemia) and is likely due to an inadequate cerebral autoregulatory response to abrupt MAP changes. The arterial CO2 increase after aortic unclamping could lead to a dilation of cerebral arterioles and a rise of CBF (increase of Vm and decrease of PI). Transcranial Doppler is a simple and reliable technique for the monitoring of cerebral blood flow parameters and seems to be quite suitable for the recognition and the quantification of changes in these parameters induced by surgical manoeuvres able to produce hemodynamic instability.

Objective: To investigate the venous-arterial PCO2 gradient, and the mixed venous blood acid-base status together with the oxygen transport variables in a group of acutely ill postsurgical patients., Design: Retrospective, descriptive study of hemodynamic and acid-base data collected immediately after the patients' admission to the Postsurgical Intensive Care Unit., Setting: Eight-bed, Postsurgical Intensive Care Unit in a University Hospital., Patients: A total of one hundred and one postsurgical patients (87 male, 14 female; 14 to 86 years)., Interventions: None immediately before the first measurement., Measurements and Main Results: Hemodynamic, oxygen transport variables, and arterial and mixed venous acid-base status measurements obtained immediately after the admission to the Postsurgical Intensive Care Unit. The venous-arterial PCO2 gradient was elevated (> 6 torr) in 23 patients and normal (< or = 6 torr) in 78 patients (respectively 9.1 +/- 3.3 vs 4.4 +/- 1.0 torr, p < 0.001). Patients with an increased venous-arterial PCO2 gradient had a higher arterial-venous pH gradient (0.05 +/- 0.03 vs 0.03 +/- 0.01 Unit, p < 0.001) and mixed venous PCO2 (47.5 +/- 8.0 vs 42.1 +/- 5.6 torr, p < 0.001). These patients had a lower cardiac index, oxygen delivery, mixed venous oxygen saturation, and a higher oxygen extraction index than the patients with normal venous-arterial PCO2 and pH gradients. For all the measurements, there was an inverse non linear significant relation between oxygen delivery, venous-arterial PCO2 (r = 0.74, p < 0.001) and pH (r = 0.57, p < 0.01) gradients., Conclusions: This study suggests that in acutely ill postoperative patients increased venous-arterial PCO2 and pH gradients are directly and principally related to the reduction in blood flow and are both suggestive of low-flow state.

Objective: To investigate if there were differences between bench central oxygen saturation (ScvO2) and mixed venous oxygen saturation (SvO2) in a group of acutely ill postsurgical patients., Design: A prospective comparative study of two sampling sites., Setting: Postsurgical ICU at a University Hospital., Patients: 39 acutely ill postsurgical patients, requiring perioperative invasive hemodynamic monitoring, studied during their stay in a postsurgical ICU., Interventions: Routine care for acutely ill postsurgical patients., Measurements and Main Results: Blood was simultaneously sampled, according to the clinical course, both from the distal and central port of a pulmonary artery catheter (n = 296 each). Oxygen saturation and blood gas analysis were immediately measured with a CO-oxymeter and a blood gas analyzer. We investigated the relationship and the agreement between the two measures. To assess if bench ScVO2 could give information on time related variations of bench SvO2 we evaluated the absolute sequential changes of the two measures during the period of observation, by analyzing the relationship and the agreement of their absolute changes (n = 1817). There was a significant difference between bench SvO2 and bench ScvO2 (71.8 +/- 8.2 vs 72.7 +/- 8.6% mean +/- SD, p < 0.001). The relationship between the two measures showed a significant correlation (r = 0.90, p < 0.001, and SEE 3.8%). The bias was -0.93 +/- 3.8%, and the limits of agreement were +6.6 and -8.5%. The changes in bench ScvO2 correlated with the respective changes in bench SvO2 (r = 0.86, p < 0.001, and SEE 4.4%). The bias was 0.79 +/- 4.7% and the limits of agreement were +9.4 and -7.8%., Conclusions: SvO2 cannot be predicted well from bench ScvO2, nor changes in ScO2 can be predicted wel from changes in bench ScvO2. Therefore, in this category of patients, the clinical usefulness of monitoring bench ScvO2 is strongly limited and we must still rely on the SvO2.

Aim: To evaluate the effect of noradrenaline infusion in a case of hyperdynamic septic shock refractory to volume loading, dopamine and dobutamine, on hemodynamic parameters, oxygen transport, lactate and pyruvate levels., Design: Description of a clinical case., Setting: Postsurgical Intensive Care Unit in a University Hospital., Patient: A 48-year-old woman with symptoms of peritonitis due to Enterobacter Agglomerans and refractory hyperdynamic septic shock., Interventions: Administration of noradrenaline in doses ranging from 0.03 to 0.14 micrograms/kg/min., Measurements and Results: Before and after noradrenaline infusion the following were evaluated: hemodynamic (parameters) and oxygen transport acid-base status, arterial blood levels of lactate and pyruvate, and lactate/pyruvate ratio. During the administration of noradrenaline an increase was observed over time in oxygen consumption (from 110 +/- 16 to 164 +/- 19 mL/min/m2; p < 0.01), peripheral vascular resistance (from 509 +/- 95 to 1172 +/- 384 dynes.sec.cm-5, p < 0.01) and the oxygen extraction index (from 12.9 +/- 2.1 to 21.2 +/- 2.9%, p < 0.01), together with reduced lactate (from 24.4 +/- 1.5 to 4.9 +/- 5.1 mmol/L) and pyruvate levels (from 945 +/- 62 to 357 +/- 174 mumol/L; p < 0.01) and a reduced lactate/pyruvate ratio (from 26.2 +/- 1.2 to 11.8 +/- 5.9, p < 0.01). No significant increases were found in cardiac output and oxygen delivery., Conclusions: In the case observed here the infusion of noradrenaline induced an increase in oxygen consumption and the oxygen extraction index associated with a reduction in the lactate/pyruvate ratio and the normalisation of the acid-base status. These changes were not associated with an increase in oxygen which remained delivery > or = 600 mL/min/m2.