Abstract Background context Currently, treatment for patients diagnosed with noncomplicated (ie, known infectious agent, no neurologic compromise, and preserved spinal stability) pyogenic ...spondylodiscitis (PS) is based on intravenous antibiotics and rigid brace immobilization. Since January 2010, we started offering our patients percutaneous posterior screw-rod instrumentation as an alternative approach to rigid bracing. Supposed benefits of posterior percutaneous instrumentation over rigid bracing are earlier free mobilization, increased comfort, and faster recovery. Purpose To evaluate safety and effectiveness of posterior percutaneous spinal instrumentation for single-level PS and compare clinical and quality-of-life outcomes with standard thoracolumbosacral orthosis (TLSO) rigid bracing. Study design/Setting Retrospective observational cohort study. Patient sample Twenty-seven patients consecutively diagnosed with single-level noncomplicated lower thoracic or lumbar PS from January 2010 to December 2011. Outcome measures Healing rate, healing time, and changes in segmental kyphosis Cobb angle were compared in the two treatment groups. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count at regular time points until complete healing were also obtained. Self-report measures included Visual Analog Scale (VAS), Short-Form 12 (SF-12), and EuroQol five-dimension (EQ-5D) questionnaires. Methods At enrollment, patients were offered to choose between 24/7 TLSO rigid bracing for 3 to 4 months and bridging posterior percutaneous screw-rod instrumentation followed by soft bracing for 4 weeks after surgery. All patients underwent antibiotic therapy accordingly to isolated infectious agents. Patients were seen in the clinic at 1, 3, 6, and 9 months, and ESR, CRP, complete blood count, VAS, SF-12, and EQ-5D questionnaires were obtained. Segmental kyphosis was measured at diagnosis and at 9 months follow-up. Two-way repeated-measures analysis of variance was used to assess group and time differences across time points. Results Fifteen patients chose conservative treatment, whereas 12 patients chose surgical treatment. Complete infection healing was achieved in all patients with no significant differences in healing time (p<.366). C-reactive protein and ESR levels decreased in both groups accordingly with positive response to therapy with no significant differences. Surgically treated patients had significantly lower VAS scores at 1 month (2.76±0.80 vs. 5.20±1.21, p<.001) and 3 months (2.31±0.54 vs. 2.85±0.54, p<.016) post-diagnosis over TLSO patients. Moreover, surgery patients also showed steeper and statistically significant improvements in SF-12 scores over TLSO patients at 1, 3, and 6 months post-diagnosis (p<.012); no significant differences were detected at the other time points. EuroQol five-dimension index was significantly higher in surgery patients at 1 month (0.764±0.043 vs. 0.458±0.197, p<.001) and 3 months (0.890±0.116 vs. 0.688±0.142, p<.001); no significant changes were observed in segmental pre- and posttreatment kyphosis between the two groups. No instrumentation-related complications were observed in any patient. Conclusions Posterior percutaneous spinal instrumentation is a safe, feasible, and effective procedure in relieving pain, preventing deformity, and neurologic compromise in patients affected by noncomplicated lower thoracic (T9–T12) or lumbar PS. Posterior instrumentation did not offer any advantage in healing time over TLSO rigid bracing because infection clearance is strongly dependent on proper antibiotic therapy. Nevertheless, surgical stabilization was associated with faster recovery, lower pain scores, and improved quality of life compared with TLSO conservative treatment at 1, 3, and 6 months after treatment.
Background The hypothesis that fenoldopam mesylate, by increasing renal flow, could reduce renal damage in patients undergoing cardiac surgery with cardiopulmonary bypass has gained great interest. ...The aim of the current study was to quantify the relationship of the increase of the renal blood flow as a function of the fenoldopam dose in these patients and to evaluate renal flow distribution within the renal parenchyma using Doppler. Methods Twenty-five patients admitted to cardiac surgery have been enrolled. We used the Doppler technique to measure renal blood flow at the level of the renal, segmental, interlobar, and interlobular arteries. We calculated both the resistive and pulsatility indexes in all the renal segments. Moreover, we calculated echographically all the variables of preload, afterload, and cardiac index. Measurements were performed at baseline and after the infusion of fenoldopam mesylate at the doses of 0.05, 0.1, 0.2, and 0.3 μg · kg−1 · min−1. Results Fenoldopam infusion at doses more than 0.1 μg · kg−1 · min−1 significantly increases blood flow in all renal compartments, thus improving the resistive and pulsatility indexes starting at a dose of 0.1 μg · kg−1 · min−1 . The highest renal flow increase is observed with 0.3 μg · kg−1 · min−1 . Fenoldopam seems to increase the renal flow directed to the most external kidney areas. Systemic hemodynamically significant changes are observed only in patients receiving doses more than 0.1 μg · kg−1 · min−1. Conclusions In hemodynamically stable patients undergoing cardiac surgery with preserved renal function, fenoldopam shows a pharmacodynamic dose-dependent profile: it significantly increases renal flow and reduces the resistances of the renal circulation starting at a dose of 0.1 μg · kg−1 · min−1.
Objective The purpose of this study was to evaluate the effect of 0.1 μg/kg/min of fenoldopam mesylate on renal flow and central hemodynamics measured by echocardiography in hemodynamically stable ...patients with preserved renal function undergoing cardiac surgery. Design Experimental observational study. Setting Single-institutional community hospital study. Participants Thirty patients undergoing cardiac surgery. Intervention Fenoldopam mesylate infusion (0.1 μg/kg/min) in patients undergoing cardiopulmonary bypass. Measurements and Main Results Doppler measurements of renal blood flow and echocardiographic hemodynamic determinations after Doppler echocardiography measured flux velocities of the main, segmental, and interlobar and interlobular right renal arteries. The authors calculated the resistive index of all the renal segments studied. Moreover, the authors measured the flux of the main renal artery and its diameter as well as the main hemodynamic variables. All the measurements were performed in the intensive care unit setting at baseline and 20 minutes after the infusion of 0.1 μg/kg/min of fenoldopam mesylate. Fenoldopam mesylate infusion significantly increased blood flow in all renal compartments, thus improving the resistive index. The study showed that fenoldopam mesylate infusion does not induce any significant change of the heart rate or arterial pressure, cardiac output, preload, or wall stress. Conclusions In hemodynamically stable cardiac surgery patients with preserved renal function, an infusion of 0.1 μg/kg/min of fenoldopam mesylate has no influence on systemic hemodynamics while increasing renal blood flow.
Objectives To measure the effects of fenoldopam mesylate infusion on splanchnic blood flow in patients undergoing myocardial revascularization with cardiopulmonary bypass. Design An experimental ...observational study. Setting A single-institution community hospital. Participants Eighteen patients undergoing on-pump coronary artery bypass graft surgery. Interventions Fenoldopam mesylate infusion (0.1 μg/kg/min). Measurements and Main Results Blood flow through the celiac artery, superior mesenteric artery, portal vein and hepatic artery were assessed by means of Doppler measurements. The main hemodynamic variables were measured using echocardiography. The infusion of fenoldopam significantly increased the blood flow through both celiac and superior mesenteric arteries by decreasing vascular resistance. The percentage of cardiac output directed to these 2 vessels increased significantly; the increase through the superior mesenteric artery was greater compared with the celiac artery. Portal vein and hepatic artery blood flow also consistently increased. No significant variations were observed with respect to hemodynamic variables. Conclusions The infusion of fenoldopam increased the flow through the celiac artery and superior mesenteric artery; the effect was higher for the latter. These changes did not affect the hemodynamic variables.
