Noninvasive ventilation in the treatment of acute respiratory failure induced by all-trans retinoic acid (retinoic acid syndrome) in children with acute promyelocytic leukemia.

Purpose: To evaluate the feasibility of noninvasive ventilation through a nasal mask in the treatment of acute respiratory failure induced by all-trans retinoic acid. Design: Observational, nonrandomized report of two cases. Setting: Intensive care unit in a university hospital. Patients: Two pediatric patients (an 11-yr-old male and a 12-yr-old female) affected by acute promyelocytic leukemia. Interventions: Pressure support ventilation was delivered via a nasal mask by means of a bilevel positive pressure ventilator (Respironics, Murrysville, PA). Measurements and Main Results: We evaluated the effects of the bilevel positive pressure ventilator on blood gas analysis, respiratory rate, hemodynamics, patient tolerance, complications, and outcome. Patients showed an improvement of blood gas analysis and respiratory rate after 3–6 hrs of noninvasive ventilation. The nasal mask was well tolerated by the two patients. No complications were observed. Patients were discharged from the intensive care unit in stable clinical conditions after 3–4 days. Conclusions: Noninvasive ventilation by a nasal mask can offer effective ventilatory support and improve gas exchange in the treatment of acute respiratory failure in pediatric hematologic patients. In addition, noninvasive ventilation may decrease the risk of life-threatening complications associated with endotracheal intubation and conventional mechanical ventilation in patients with hematologic malignancies

Safety and efficacy of transdermal buprenorphine and transdermal fentanyl in the treatment of neuropathic pain in AIDS patients.

BACKGROUND: Multifactor neuropathic pain is one of the most frequent symptoms in AIDS patients and analgesic treatment is primarily based on the use of drug combination of opioids, tricyclic antidepressants and antiepileptics. However, the chronic use of opioids in AIDS patients presents a risk due to the immunosuppressive action of these drugs. Until now, buprenorphine has been regarded as one of the safest opioid analgesics for the treatment of patients with compromised immune systems. To assess the suitability of transdermal fentanyl for the treatment of neuropathic pain in AIDS patients, the present study compares the efficacy, tolerability and the immunosuppressive effects of transdermal buprenorphine vs. fentanyl. METHODS: Forty advanced AIDS patients (28 male and 12 female) with chronic peripheral neuropathic pain were enrolled onto this clinical trial. Neuropathic pain was assessed for its constituent types of pain (burning, stabbing and shooting), its overall intensity and allodynia; scores were awarded using the Neuropathic Pain Scale, expressed as 10 item VAS scores. RESULTS: Both treatment groups showed statistically significant reductions in each of the individual types of neuropathic pain and allodynia (P<0.05; 95% CI: -14.7, -3.1) and significant improvements in Karnofsky Performance Status (P<0.05; mean value, 69; range: 40-90). Both buprenorphine and fentanyl were well tolerated. Neither buprenorphine nor fentanyl affected CD4+ or CD8+levels and both treatments, but particularly buprenorphine group, resulted in more stable CD4+ concentrations. CONCLUSION: The high efficacy, tolerability and patient compliance of both buprenorphine and fentanyl make both these two opioids valid therapeutic options for the treatment of neuropathic pain in patients with AIDS

Caudal analgesia in children: S(+)-ketamine vs S(+)-ketamine plus clonidine

Background: The aim of this study was to evaluate postoperative analgesia provided by caudal S(+)-ketamine and S(+)-ketamine plus clonidine without local anesthetic. Methods: Forty-four children aged 1-5 years consecutively scheduled for inguinal hernia repair, hydrocele repair or orchidopexy were randomly assigned to receive a caudal injection of either S(+)-ketamine 1 mg.kg(-1) (group K) or S(+)-ketamine 0.5 mg.kg(-1) plus clonidine 1 mug.kg(-1) (group KC). Postoperative analgesia and sedation were evaluated by CHEOPS and Ramsay scale from emergence from general anesthesia for 24 h. Results: No statistical difference was observed between study groups with respect to pain and sedation assessment. A slight trend toward a reduced requirement for rescue analgesia in group KC was observed, although not statistically significant. Conclusions: Caudal S(+)-ketamine 1 mg.kg(-1) and S(+)-ketamine 0.5 mg.kg(-1) plus clonidine 1 mug.kg(-1) are safe and provide effective postoperative analgesia in children without adverse effects

Total intravenous anesthesia using remifentanil in extracorporeal shock wave lithotripsy (ESWL). Comparison of two dosages: a randomized clinical trial.

BACKGROUND: Extracorporeal Shock Wave Lithotripsy is usually performed in day surgery setting, consequently people who undergo to this procedure need a safe and fast recovery. Conscious sedation with remifentanil can relieve from pain and keep patients in touch with anaesthesiologists. Few publications tell about infusion rates administered to perform this procedure7. The aim of this study is to assess which is the most appropriate infusion rate. METHODS: Patients were randomly assigned to two groups. Two different infusion rates were compared: 0,05 mcg/kg/min, GROUP A (N.=114), vs. 0.1 µg/kg/min, GROUP B (N.=114). Patients' vital signs, additional analgesic requests, PONV (postoperative nausea and vomiting) and other side effects were registered. The deepness of sedation and patient's satisfaction were evaluated referring to Obsever's Assessment of Alertness and Sedation scale (O/ASS) and using a Likert's scale respectively. Pain intensity was assessed with a 11-points VAS (visual analogue scale). Differences between groups were analyzed using Student t test for independent variables. The χ2 test was used to analyze categorical variables. RESULTS: The study enrolled 228 patients and assigned them to two groups (N.=114). No significant differences were found regarding Likert's scale values (P=0.20), additional analgesic request (P=0.30) and mean VAS values (P>0.05) between the two groups. The difference between the two groups about PONV, hypotension, oxygen desaturation and respiratory depression was statistically significant (P<0.05), as a matter of fact in group A these side effects occurred less frequently. The fifth degree of O/ASS was estimated in about 1.61±0.19 min and 2.987±0.20 min in group A and in group B respectively (P<0.05). CONCLUSION: According with previous results remifentanil at the infusion rate of 0.05 µg/kg/min provides an effective analgesia, causing a lower incidence of side effect than 0.1 µg/kg/min, granting a fast and safe recovery