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OBJECTIVE: Carbon monoxide is produced by the incomplete combustion of organic fuel. In the United States, it is responsible for about 500 deaths annually. Increased carboxyhemoglobin concentration and hypoxia disrupt cardiac myocyte integrity and cause dysrhythmias, acute cardiac failure and coronary artery disease. We described a case of a patient with CO-poisoning and ST elevation at ECG precordial leads who developed severe transient heart failure. CASE PRESENTATION: A 57-year-old man was admitted to the emergency department for acute carbon monoxide poisoning that led to respiratory and cardiac failure. The electrocardiogram showed ST elevation in precordial leads, but the coronary angiography was normal. The patient was successfully treated and discharged. Three days later he was readmitted for similar symptoms and subsequently died. We hypothesize that the ECG findings were related to transient coronary vasospasm due to CO poisoning and that acute respiratory and cardiac failure related to carbon monoxide toxicity caused death. CONCLUSIONS: The management of patients poisoned by carbon monoxide requires early identification and intensive treatment and a careful evaluation of the home environment prior to discharge. ST elevation in such patients may be related to coronary vasospasm.

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OBJECTIVE: Critical illnesses are a significant public health issue because of their high rate of mortality, the increasing use of the Intensive Care Units and the resulting healthcare cost that is about 80 billion of dollars per year. Their mortality is about 12% whereas sepsis mortality reaches 30-40%. The only instruments currently used against sepsis are early diagnosis and antibiotic therapies, but the mortality rate can also be decreased through an improvement of the patient's nutrition. The aim of this paper is to summarize the effects of vitamins A, B, C and E on the balance between pro-oxidants and anti-oxidants in the critical care setting to confirm "a beneficial care enhancing". MATERIALS AND METHODS: The peer-reviewed articles analyzed were selected from PubMed databases using the keywords "critical care", "intensive care", "critical illness", "sepsis", "nutritional deficiency", "vitamins", "oxidative stress", "infection", and "surgery". Among the 654 papers identified, 160 articles were selected after title and abstract examination, removal of duplicates and of the studies on pediatric population. Finally, only the 92 articles relating to vitamins A, C, E and the B complex were analyzed. RESULTS: The use of vitamins decreased morbidity and mortality in perioperative period and critically ill patients, especially in ICU. Among the most encouraging results, we found that the use of vitamins, both as monotherapy and in vitamins combinations, play a crucial role in the redox balance. Vitamins, especially vitamins A, C, E and the B complex, could help prevent oxidative damage through the breakdown of the oxidizing chemical chain reaction. CONCLUSIONS: Even if the results of the studies are sometimes discordant or inconclusive, the current opinion is that the supplementation of one or more of these vitamins in critically ill patients may improve their clinical outcome, positively affecting the morbidity and the mortality. Further, randomized studies are required to deeply understand the potentiality of a vitamin supplementation therapy and develop homogeneous and standardized protocols to be adopted in every critical care scenario.

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BACKGROUND: Intravenous fluids and vasopressors are used for managing spinal-induced hypotension during cesarean delivery, but the choice of vasopressor and the type and timing of fluid administration remain controversial. METHODS: We conducted an electronic survey of all members of the Society for Obstetric Anesthesia and Perinatology between February and March 2007 to determine their preferences for preventing and treating spinal-induced hypotension with respect to fluid and vasopressor administration. RESULTS: The response rate was 292/746 (39%). Fifty percent worked in academic institutions and 56% had >50% of their clinical responsibility to obstetric anesthesia. For prophylaxis, 35% used fluid preloading, 30% fluid preloading with vasopressors, and 12% fluid co-loading with vasopressors. Of those using vasopressors for prophylaxis, 32% used ephedrine, 26% used phenylephrine, and 33% based their choice on heart rate. For treatment, 32% used ephedrine, 23% used phenylephrine, and 41% used either agent based on heart rate. Anesthesiologists in academic practice were less likely to use fluid preloading only (P=0.028) and more likely to use fluid co-loading and vasopressors (P=0.003). They were also more likely to administer phenylephrine for prophylaxis compared with those in private practice (P=0.042). CONCLUSION: Significant variations in practice exist in the prevention and treatment of spinal-induced hypotension. Fluid preloading and the prophylaxis and treatment of hypotension with ephedrine continue to be common practices.

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Hemorrhage and thrombosis are major causes of maternal mortality. This case discusses the management of a woman with placenta percreta complicated by intraoperative pulmonary embolism. A 39-year-old gravida 3 with two previous cesarean deliveries presented at 34 weeks of gestation with an antepartum hemorrhage. Magnetic resonance imaging confirmed placenta percreta. The multidisciplinary group including obstetricians, gynecological oncologists, interventional radiologists and anesthesiologists developed a delivery plan. Cesarean delivery was performed with internal iliac artery occlusion and embolization catheters in place. After the uterine incision our patient experienced acute hypotension and hypoxia associated with a drop in the end-tidal carbon dioxide and sinus tachycardia. She was resuscitated and the uterus closed with the placenta in situ. Postoperatively, uterine bleeding was arrested by immediate uterine artery embolization. With initiation of embolization, hypotension and hypoxia recurred. Oxygenation and hemodynamics slowly improved, the case continued and the patient was extubated uneventfully at the end of the procedure. Computed tomography revealed multiple pulmonary emboli. The patient was anticoagulated with low-molecular-weight heparin and returned six weeks later for hysterectomy. Placenta percreta with invasion into the bladder can be catastrophic if not recognized before delivery. The chronology of events suggests that this may have been amniotic fluid emboli. An intact placenta with abnormal architecture, such as placenta percreta, may increase the risk of amniotic fluid embolus. The clinical findings and co-existing filling defects on computed tomography may represent a spectrum of amniotic fluid embolism syndrome.

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We present a case of a patient who received nitrous oxide on two occasions within a period of 8 weeks and who subsequently developed a diffuse myelopathy, characterized by upper extremity paresis, lower extremity paraplegia and neurogenic bladder. Laboratory testing revealed hyperhomocysteinaemia and low levels of vitamin B(12). Because of this uncommon clinical presentation, we analysed the patient's DNA, and found a polymorphism in the MTHFR gene that is associated with the thermolabile isoform of the 5,10-methylenetetrahydrofolate reductase enzyme, which explained the myelopathy experienced by the patient after being exposed to nitrous oxide. Soon after initiating supplementary therapy with folic acid and vitamin B(12), the neurological symptoms subsided.

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We report two cases of Caesarean section in patients with Marfan's syndrome where continuous subarachnoid anaesthesia failed to provide an adequate surgical block. This was possibly because of dural ectasia, which was confirmed by a computed tomography scan in both cases.

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Focus has changed from the immediate postpartum condition to the more long-term outcome of the neonate with respect to the use of epidural analgesia in labour. Anaesthesiologists have been slow to respond to the demand for this information. Newer analgesic agents and techniques may offer some advantage to the neonate; however, extensive study is still needed.

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PURPOSE: To evaluate the efficacy of ropivacaine 0.25% when administered epidurally for relief of labour pain and to compare it with bupivacaine 0.25%. METHODS: In a multicentre investigation, 60 ASA I and II labouring women were randomized in a double-blind fashion to receive either bupivacaine 0.25% or ropivacaine 0.25% administered epidurally by intermittent top-up for labour analgesia. Using a standardized technique, epidural analgesia was initiated after the woman received 10-15 ml-kg.1 crystalloid solution. Maternal blood pressure, heart rate, analgesia sensory level, degree of motor block and visual analogue pain scores were measured by the research nurse prior to, and at regular intervals, following the administration of analgesia. Total dose of local anaesthetic administered, duration of labour, mode of delivery, and maternal and fetal/neonatal side effects were noted. The fetus/neonate was assessed by the research nurse using the fetal heart rate tracing, Apgar scores at delivery and neonatal neurobehavioural assessments at 2 and 24 hr postnatally. Maternal and investigators' satisfaction with the analgesia achieved was assessed after delivery. RESULTS: No differences were found between the two agents in any of the variables studied. CONCLUSION: Ropivacaine 0.25%, when administered epidurally by intermittent top-ups for labour analgesia, was equally efficacious as bupivacaine 0.25%.

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