To evaluate the utility of serial measurements of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) to detect acute cardiac dysfunction during weaning failure in difficult to wean patients with chronic obstructive pulmonary... more
To evaluate the utility of serial measurements of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) to detect acute cardiac dysfunction during weaning failure in difficult to wean patients with chronic obstructive pulmonary disease. Prospective observational cohort study. A 14-bed general intensive care unit in a university hospital. Nineteen patients mechanically ventilated for chronic obstructive pulmonary disease exacerbation who were difficult to wean. None. Cardiac and hemodynamic variables, arterial and central venous blood gas, breathing pattern, respiratory mechanics, indexes of oxygen cost of breathing, and plasma levels of NT-proBNP were measured and analyzed immediately before (baseline) and at the end of a spontaneous breathing trial. Eight of 19 patients (42%) were identified with acute cardiac dysfunction at the end of the weaning trial. Baseline NT-proBNP levels were significantly higher (median 5000, interquartile range 4218 pg/mL) in these patients than in patients without evidence of acute cardiac dysfunction (median 1705, interquartile range 3491 pg/mL). Plasma levels of NT-proBNP increased significantly at the end of the spontaneous breathing trial only in patients with acute cardiac dysfunction (median 12,733, interquartile range 16,456 pg/mL, p < .05). The elevation in NT-proBNP at the end of the weaning trial had a good diagnostic performance in detecting acute cardiac dysfunction, as estimated by area under the receiver operating characteristic curve analysis (area under the curve 0.909, se 0.077, 95% confidence interval 0.69-0.98; p < .0001, cutoff = 184.7 pg/mL). Serial measurements of NT-proBNP plasma levels provided a noninvasive manner to detect acute cardiac dysfunction during an unsuccessful weaning trial in difficult to wean patients with chronic obstructive pulmonary disease. The utility of this test as a complement of the standard clinical monitoring of the weaning trial deserves further investigation.
Research Interests: Nursing, Cardiology, Medicine, Linear models, Critical Care, and 15 moreCritical Care Medicine, Electrocardiography, Heart Failure, Humans, Internal Medicine, Female, Male, Clinical Sciences, Aged, Middle Aged, Chronic obstructive pulmonary disease, Blood gas analysis, Oxygen Consumption, Brain Natriuretic Peptide, and Acute Disease
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Dynamic hyperinflation and intrinsic positive end-expiratory pressure (PEEPi) are observed in patients with chronic obstructive pulmonary disease (COPD) and flow limitation. Several reports suggest that PEEP levels approaching PEEPi... more
Dynamic hyperinflation and intrinsic positive end-expiratory pressure (PEEPi) are observed in patients with chronic obstructive pulmonary disease (COPD) and flow limitation. Several reports suggest that PEEP levels approaching PEEPi reduce inspiratory load due to PEEPi, without further hyperinflation. Hence PEEP should not increase intrathoracic pressure or affect hemodynamics and gas exchange. To verify this hypothesis, the effects of PEEP (0 to 15 cm H2O) on respiratory mechanics, hemodynamics, and gas exchange were studied in nine COPD patients during controlled mechanical ventilation. PEEP levels approaching PEEPi (9.8 +/- 0.5 cm H2O) did not affect the expiratory flow/volume relationship, confirming the presence of flow limitation. PEEP levels of 5 and 10 cm H2O did not change lung volume and PEEPi in the respiratory system (PEEPtot,rs) and chest wall (PEEPtot,cw) or affect hemodynamics and gas exchange. When applied PEEP overcame PEEPi, changes in lung volume and the expiratory flow/volume relationship were observed. PEEPtot,rs and PEEPtot,cw also increased. Under these circumstances, PEEP increased static elastance in both the respiratory system and the chest wall, reducing cardiac index and affecting hemodynamics and gas exchange. Our data show that in mechanically ventilated COPD patients with PEEPi due to flow limitation, PEEP levels exceeding the 85% of PEEPi (Pcrit) caused further hyperinflation and compromised hemodynamics and gas exchange.
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Research Interests: Chemistry, Free Radicals, Medicine, Bioenergetics, Biological Sciences, and 15 moreIschemia Reperfusion Injury, Ischemia, Animals, Physical sciences, Lipid peroxidation, Hydrogen Peroxide, Mitochondrial dysfunction, Rats, Oxygen, Oxygen Consumption, Biochemistry and cell biology, Cardiolipin, Mitochondrion, Complex I, and Mitochondrial ROS
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Airways humidification during mechanical ventilation (MV) can be performed by means of heat and moisture exchangers (HME). Good performance of selected hygroscopic HME was shown in terms of tracheal temperature and humidity control and... more
Airways humidification during mechanical ventilation (MV) can be performed by means of heat and moisture exchangers (HME). Good performance of selected hygroscopic HME was shown in terms of tracheal temperature and humidity control and low tube obstruction rates. However, few data are available on their effects on tracheobronchial ciliated cells. The purpose of this study was to evaluate the effects of 2 different HME on ciliated cell during MV. Twenty consecutive patients undergoing elective surgery lasting <4 h were randomly assigned to be treated with Rusch (Group 1) or Mediflux (Group 2) hygroscopic HME. The morphology of tracheobronchial ciliated cells was evaluated from cytologic smears of endotracheal aspirate. Smears were prepared by using the thin-prep processor, stained using the Papanicolau method and examined in triplicate: recognizable respiratory cells were graded on a six-point scale, according to the normal appearance of cilia, cytoplasm and nucleus. In Group 1, 1...
Research Interests: Medicine, Prospective studies, Humans, Female, Pubmed, and 8 moreMale, Aged, Middle Aged, Adult, Trachea, Humidity, Cilia, and Respiration Artificial
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Research Interests: Medicine, Prospective studies, Humans, Hemodynamics, INTENSIVE CARE, and 15 moreFemale, Male, Anesthesia, Lung, Clinical Sciences, Intensive Care Unit, Middle Aged, Adult, Mechanical Ventilation, Intensive Care Medicine, Barotrauma, Lung Injury, Mean Airway Pressure, Prospective Study, and Hemothorax
Conflicting data are available on the relative contribution of the chest wall (cw) to the intrinsic positive end-expiratory pressure of the total respiratory system (PEEPi,rs) in patients with chronic obstructive pulmonary disease (COPD).... more
Conflicting data are available on the relative contribution of the chest wall (cw) to the intrinsic positive end-expiratory pressure of the total respiratory system (PEEPi,rs) in patients with chronic obstructive pulmonary disease (COPD). In order to assess the chest wall and lung contribution to the elastic properties of the respiratory system in COPD patients during acute ventilatory failure, using the "interrupter technique", static inflation volume-pressure (V-P) curves of the total respiratory system (rs), lung (L) and cw were obtained in seven mechanically-ventilated COPD patients during application of zero end-expiratory pressure (ZEEP) and different levels (0-15 cmH2O) of PEEP. On ZEEP, PEEPi,rs was present in all patients (range 10.5-13.1 cmH2O), to which PEEPi,cw and PEEPi,L contributed 17 +/- 2 and 83 +/- 1%, respectively. The static V-P curves of the rs, L, and cw on ZEEP were concave toward the horizontal axis, indicating that elastance increased with inflatin...
Research Interests: Cardiology, Medicine, Humans, COPD, Female, and 15 moreMale, Regression Analysis, European, Aged, Middle Aged, Analysis of Variance, Mechanical Ventilation, Chronic obstructive pulmonary disease, Elastic Properties, Elastic tissue, Respiratory function tests, Respiratory insufficiency, Critical value, Medical and Health Sciences, and European Respiratory Society
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Research Interests: Artificial Intelligence, Medicine, Linear models, Animals, Lung Diseases, and 14 moreClinical Sciences, Air Pressure, Respiratory System, Swine, Mechanical Ventilation, Reproducibility of Results, Lung Volume Measurements, Artificial Neural Network, Neurosciences, Respiratory Mechanics, Computer Science Neural Networks, Tidal volume, artificial ventilation, and Respiration Artificial
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Diltiazem is a dihydropyridinic calcium-antagonist which acts an arterial muscle, producing an increase in vascular capacity. We administered it intraoperatively in 2 patients subjected to kidney transplantation, to asses the maximal... more
Diltiazem is a dihydropyridinic calcium-antagonist which acts an arterial muscle, producing an increase in vascular capacity. We administered it intraoperatively in 2 patients subjected to kidney transplantation, to asses the maximal vascular reserve of the transplanted organ. After 2' and 10' from administration of Diltiazem, Color Doppler Ultrasound showed a 30% increase in mean flow in the renal artery and 13% reduction in the intraparenchymal resistance rates with respect to the basal parameters. Systemic arterious pressure remained unchanged. This result was associated with an improvement in the perfusion of the transplanted organ.
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For monitoring of vecuronium profound neuromuscular blockade post-tetanic count (PTC) following tetanic stimulation at frequency of 50 and 100 Hz was employed in 25 ASA I-II patients submitted to elective surgery, to evaluate the... more
For monitoring of vecuronium profound neuromuscular blockade post-tetanic count (PTC) following tetanic stimulation at frequency of 50 and 100 Hz was employed in 25 ASA I-II patients submitted to elective surgery, to evaluate the differences between the two patterns of stimulation and the possible clinical utility of the latter pattern of stimulation. The drugs employed for anaesthesia were: diazepam 0.15 mg kg-1 in premedication, thiopental 4-5 mg kg-1 for induction, suxamethonium 1.5 mg kg-1 for tracheal intubation. Anaesthesia was maintained with N2 + O2 (2:1). Analgesia was obtained with fentanyl at usual doses, and muscular relaxation with vecuronium. The ulnar nerve was stimulated at the wrist with Digistim III Plus and the responses evaluated by tactile method. The pattern of stimulation used was a cyclic one, as described by Howardy Hansen et al. The first dose of vecuronium (0.06 mg kg-1) was administered at recovery from suxamethonium (clinically evaluated) and the other d...
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The objective of this study was to compare patient-ventilator interaction during pressure-support ventilation (PSV) and proportional-assist ventilation (PAV) in the course of increased ventilatory requirement obtained by adding a dead... more
The objective of this study was to compare patient-ventilator interaction during pressure-support ventilation (PSV) and proportional-assist ventilation (PAV) in the course of increased ventilatory requirement obtained by adding a dead space in 12 patients on weaning from mechanical ventilation. With PSV, the level of unloading was provided by setting the inspiratory pressure at 20 and 10 cmH2O, whereas with PAV the level of unloading was at 80 and 40% of the elastic and resistive load. Hypercapnia increased (P < 0.001) tidal swing of esophageal pressure and pressure-time product per breath at both levels of PSV and PAV. During PSV, application of dead space increased ventilation (VE) during PSV (67 +/- 4 and 145 +/- 5% during 20 and 10 cmH2O PSV, respectively, P < 0.001). This was due to a relevant increase in respiratory rate (48 +/- 4 and 103 +/- 5% during 20 and 10 cmH2O PSV, respectively, P < 0.001), whereas the increase in tidal volume (VT) played a small role (13 +/- ...
Research Interests: Carbon Dioxide, Medicine, Biological Sciences, Humans, Applied, and 15 moreFemale, Male, Anesthesia, Applied Physiology, Aged, Middle Aged, Adult, Mechanical Ventilation, Respiratory Mechanics, Hypercapnia, Respiratory Rate, Airway resistance, Respiratory function tests, Medical and Health Sciences, and Dead Space
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Subjects in spinal anaesthesia have been reported to show a decrease in the level of alertness, even when they have not received any sedative drugs. of this study is to verify, in caesarean delivery if the bupivacaine subarachnoid... more
Subjects in spinal anaesthesia have been reported to show a decrease in the level of alertness, even when they have not received any sedative drugs. of this study is to verify, in caesarean delivery if the bupivacaine subarachnoid anaesthesia, with or without intrathecal fentanyl dose, produces a sedative effect, to define the entity and to identify the mechanism that most likely causes it. The clinical investigation is divided into Part I (non-randomized trial) and Part II (randomized trial) and is set in the University hospital's delivery-unit. Part I: 45 pregnant women were recruited and enrolled in 3 groups: women having natural delivery (n=15), women receiving caesarean delivery with subarachnoid anaesthesia (n=15) and with general anaesthesia (n=15). Self-rating depression scale (SDS), self-rating anxiety scale (SAS), state anxiety inventory (SAI) and trait anxiety inventory (TAI) psychometric tests were patient-completed for pre-delivery anxiety evaluation. Part II: 23 pr...
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The mechanics of respiration affects the left ventricular preload in acting on the pulmonary circulation. It also affects the left afterload, heart rate, and contractility by eliciting reflexes from cardiopulmonary afferents. The... more
The mechanics of respiration affects the left ventricular preload in acting on the pulmonary circulation. It also affects the left afterload, heart rate, and contractility by eliciting reflexes from cardiopulmonary afferents. The consequent changes in the circulation are further modified by reflexes from aortic and carotid baroreceptors. Mechanical ventilation with positive end-expiratory pressure (PEEP) is a technique that strongly affects the mechanics of respiration. It is applied to patients with acute respiratory failure to recruit collapsed alveoli. Despite improvement in arterial oxygenation, the use of PEEP causes a decrease in the cardiac output and arterial pressure. This is due to a reduction in the left ventricular preload, which depends on the decrease in the venous return, increase in the right ventricle afterload, and the leftward displacement of the interventricular septum [1–3]. The integrated effect of mechanical and neural interactions on aortic and ventricular hemodynamics has been studied in this paper during the application of PEEP on anesthetized dogs.
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Research Interests: Cardiology, Humans, Internal Medicine, Hemodynamics, Female, and 15 moreMale, European, Aged, Indexation, Linear Regression, Ejection Fraction, Coronary artery bypass surgery, Left Ventricular Function, Cardiopulmonary bypass, Cardiac function, Cardiac output, Left Ventricular, High risk, Cardiovascular medicine and haematology, and Coronary Artery Bypass
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Melatonin, a well-known antioxidant, has been shown to protect against ischemia-reperfusion myocardial damage. Mitochondrial permeability transition pore (MPTP) opening is an important event in cardiomyocyte cell death occurring during... more
Melatonin, a well-known antioxidant, has been shown to protect against ischemia-reperfusion myocardial damage. Mitochondrial permeability transition pore (MPTP) opening is an important event in cardiomyocyte cell death occurring during ischemia-reperfusion and therefore a possible target for cardioprotection. In the present study, we tested the hypothesis that melatonin could protect heart against ischemia-reperfusion injury by inhibiting MPTP opening. Isolated perfused rat hearts were subjected to global ischemia and reperfusion in the presence or absence of melatonin in a Langerdoff apparatus. Melatonin treatment significantly improves the functional recovery of Langerdoff hearts on reperfusion, reduces the infarct size, and decreases necrotic damage as shown by the reduced release of lactate dehydrogenase. Mitochondria isolated from melatonin-treated hearts are less sensitive than mitochondria from reperfused hearts to MPTP opening as demonstrated by their higher resistance to Ca...
Research Interests: Calcium, Medicine, Ischemia Reperfusion Injury, Melatonin, Antioxidants, and 15 moreIschemia, Animals, Male, Heart rate, American, Perfusion, Cyclosporine, Medical Physiology, Lipid peroxidation, Myocardial Infarction, Myocardium, Necrosis, Mitochondrial Permeability Transition Pore, NAD, and In Vitro Techniques
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The incorporation of microprocessors into the design of ventilators has produced a confounding array of products, each with its own peculiar features and modes of operation. This confusion has been compounded in the medical literature... more
The incorporation of microprocessors into the design of ventilators has produced a confounding array of products, each with its own peculiar features and modes of operation. This confusion has been compounded in the medical literature with unproved statements favouring one new device or mode of ventilation over another. We believe that physicians concerned with the ventilatory management of patients with respiratory failure must base their approach on physiologic principles and an understanding of patient-ventilator interactions [1].
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Research Interests: Carbon Dioxide, Medicine, Humans, INTENSIVE CARE, Female, and 15 moreMale, Acute Lung Injury, Brain injury, Clinical Sciences, Aged, Middle Aged, Adult, Intensive Care Medicine, Flow Velocity, Intervention study, Lung Volume Measurements, Intracranial Hypertension, Intracranial Pressure, Middle Cerebral Artery, and Brain injuries
ABSTRACT
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BACKGROUND An overview of the validity of transesophageal echocardiography (TEE) in patients suspected to have traumatic aortic injury (TAI). METHODS Computerized bibliographic search of trials from 1994 to 2002 evaluating the use of TEE... more
BACKGROUND An overview of the validity of transesophageal echocardiography (TEE) in patients suspected to have traumatic aortic injury (TAI). METHODS Computerized bibliographic search of trials from 1994 to 2002 evaluating the use of TEE to confirm the diagnosis of TAI. Seven relevant studies out of 204 were identified, involving 758 patients. The accuracy of TEE was analyzed by constructing summary receiver-operating characteristic (sROC) curves and computing areas under the sROC curve. RESULTS No prospective randomized trial was found. Although accuracy varied greatly, summary ROC curve found that TEE enjoyed a high diagnostic performance. Some study characteristics can affect accuracy. CONCLUSIONS Our findings seems to indicate that TEE is a valuable tool for diagnosing TAI, and its use as first-line evaluation of such patients can be supported; however, given the lack of randomized trials, no standard of care can be drawn from the present overview: future studies should look at ...
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Can Expiratory Electrical Diaphragmatic Activity Guide Setting Of Positive End-Expiratory Pressure During Spontaneous Breathing In Acute Respiratory Failure?
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Computed tomography (CT), together with image analysis technologies, enable the construction of regional volume (VREG) and local transpulmonary pressure (PTP,REG) maps of the lung. Purpose of this study is to assess the distribution of... more
Computed tomography (CT), together with image analysis technologies, enable the construction of regional volume (VREG) and local transpulmonary pressure (PTP,REG) maps of the lung. Purpose of this study is to assess the distribution of VREG vs PTP,REG along the gravitational axis in healthy (HL) and experimental acute lung injury conditions (eALI) at various positive end-expiratory pressures (PEEPs) and inflation volumes. Mechanically ventilated pigs underwent inspiratory hold maneuvers at increasing volumes simultaneously with lung CT scans. eALI was induced via the iv administration of oleic acid. We computed voxel-level VREG vs PTP,REG curves into eleven isogravitational planes by applying polynomial regressions. Via F-test, we determined that VREG vs PTP,REG curves derived from different anatomical planes (p-values&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1.4E-3), exposed to different PEEPs (p-values&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1.5E-5) or subtending different lung status (p-values&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;3E-3) were statistically different (except for two cases of adjacent planes). Lung parenchyma exhibits different elastic behaviors based on its position and the density of superimposed tissue which can increase during lung injury.
Research Interests: Gravitation, Elasticity, Hemodynamics, Animals, Regression Analysis, and 12 moreAcute Lung Injury, Medical Physiology, Lung, Pressure, Swine, Oleic Acid, Lung Volume Measurements, X ray Computed Tomography, Breath Holding, Neurosciences, Pulmonary Gas Exchange, and Cardiovascular medicine and haematology
Currently, evidence-based medicine indicates that epidural analgesia (EA) labor is not associated with cesarean and instrumental delivery for dystocia. This evidence was obtained from clinical investigations of variability in clinical... more
Currently, evidence-based medicine indicates that epidural analgesia (EA) labor is not associated with cesarean and instrumental delivery for dystocia. This evidence was obtained from clinical investigations of variability in clinical labor management. An optimized balance between anesthesiological and obstetric practice is vitally important for securing spontaneous delivery. The total dose of local anesthetic for EA may be associated with operative delivery when there is a lack of obstetric care standardization and co-interventions reducing unintended EA effects. Furthermore, combining local anesthetic low dose and opioid low dose may produce a new balance with obstetric management. Physiological and pharmacological knowledge together with recent clinical findings suggest that combined opioid-local anesthetic low dose EA causes minimal negative effects on labor progress and is effective and safe in terms of maternal and neonatal outcome. Internal communication between obstetricians...
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ABSTRACT