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Abstract Background In the last decades, several adjunctive treatments have been proposed to reduce mortality in septic shock patients. Unfortunately, mortality due to sepsis and septic shock remains elevated and NO trials evaluating adjunctive therapies were able to demonstrate any clear benefit. In light of the lack of evidence and conflicting results from previous studies, in this multidisciplinary consensus, the authors considered the rational, recent investigations and potential clinical benefits of targeted adjunctive therapies. Methods A panel of multidisciplinary experts defined clinical phenotypes, treatments and outcomes of greater interest in the field of adjunctive therapies for sepsis and septic shock. After an extensive systematic literature review, the appropriateness of each treatment for each clinical phenotype was determined using the modified RAND/UCLA appropriateness method. Results The consensus identified two distinct clinical phenotypes: patients with overwhelming shock and patients with immune paralysis. Six different adjunctive treatments were considered the most frequently used and promising: (i) corticosteroids, (ii) blood purification, (iii) immunoglobulins, (iv) granulocyte/monocyte colony-stimulating factor and (v) specific immune therapy (i.e. interferon-gamma, IL7 and AntiPD1). Agreement was achieved in 70% of the 25 clinical questions. Conclusions Although clinical evidence is lacking, adjunctive therapies are often employed in the treatment of sepsis. To address this gap in knowledge, a panel of national experts has provided a structured consensus on the appropriate use of these treatments in clinical practice.

BackgroundThis phenomenological-hermeneutic study is about the experiences of physicians in the Oncology Intensive Care Unit of the Careggi University Hospital, in Florence. The Oncology Intensive Care Unit is a place of great emotional impact and can be create stressful situations. The emotional labor can lead to the development of cynicism, depersonalization and emotional exhaustion. The objective of the study was to learn about and come into contact with the experiences of operators who operate in a highly specialized and critical context.MethodA semi-structured interview was conducted on 11 physicians in the Oncology Intensive Care Unit of careggi hospital. The interviews were transcribed and subjected to content analysis using the phenomenological-hermeneutic method. The results concerning the emotional involvement of doctors were placed in three macro categories: difficulties, what helps and needs.ResultsThe interviews highlight the difficulty doctors have in coming into contact with the potentially deadly disease and a further aggravating element appears to be the identification with the patient himself. This condition of difficulty can lead doctors to commit medical errors or to reduce the quality of care.ConclusionThe results that emerged provide a more detailed understanding of the landscape of emotional reactions of working with the cancer patient in the intensive care unit. In light of the high emotional burden and the inherent possibility of developing burnout in this target population of health care workers, knowing the main critical issues and needs reported may facilitate a more effective tailored intervention.

Abstract Background The intraoperative period is often characterized by hemodynamic instability, and intraoperative hypotension is a common complication. The optimal mean arterial pressure (MAP) target in hypertensive patients is still not clear. We hereby describe the protocol and detailed statistical analysis plan for the high versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: the HISTAP randomized clinical trial. The HISTAP trial aims at addressing whether the use of a higher intraoperative MAP target in high-risk hypertensive surgical patients scheduled for elective abdominal surgery would improve postoperative outcomes, as compared to the standard and recommended perioperative MAP, by using a composite outcome including a 30-day mortality from surgical intervention and at least one major organ dysfunction or new onset of sepsis and septic shock occurring 7 days after surgery. Methods The HISTAP trial is an investigator-initiated, pragmatic, parallel-grouped, randomized, stratified, analyst-blinded trial with adequate allocation sequence generation, and allocation concealment. We will allocate 636 patients to a MAP target ≥ 80 mmHg (treatment group) or to a MAP target ≥65 mmHg (control group). The primary outcome is a composite outcome including a 30-day mortality from the operation and major organ complications. Secondary outcomes are mortality at 30 days, intensive care unit (ICU) length of stay, ICU readmission, Sequential Organ Failure Assessment (SOFA) scores recorded up to postoperative day 7, overall intraoperative fluid balance, vasopressors use, and the need for reoperation. An unadjusted χ 2 test will be used for the primary outcome analysis. A Cox proportional hazards model will be used to adjust the association between the primary outcome and baseline covariates. Conclusions The HISTAP trial results will provide important evidence to guide clinicians’ choice regarding the intraoperative MAP target in high-risk hypertensive patients scheduled for elective abdominal surgery.

Abstract Background The role of β-blockers in the critically ill has been studied, and data on the protective effects of these drugs on critically ill patients have been repeatedly reported in the literature over the last two decades. However, consensus and guidelines by scientific societies on the use of β-blockers in critically ill patients are still lacking. The purpose of this document is to support the clinical decision-making process regarding the use of β-blockers in critically ill patients. The recipients of this document are physicians, nurses, healthcare personnel, and other professionals involved in the patient’s care process. Methods The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects underlying the use of β-blockers in critically ill adult patients. The methodology followed by the experts during this process was in line with principles of modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales in the form of informative text. The overall list of statements was subjected to blind votes for consensus. Results The literature search suggests that adrenergic stress and increased heart rate in critically ill patients are associated with organ dysfunction and increased mortality. Heart rate control thus seems to be critical in the management of the critically ill patient, requiring careful clinical evaluation aimed at both the differential diagnosis to treat secondary tachycardia and the treatment of rhythm disturbance. In addition, the use of β-blockers for the treatment of persistent tachycardia may be considered in patients with septic shock once hypovolemia has been ruled out. Intravenous application should be the preferred route of administration. Conclusion β-blockers protective effects in critically ill patients have been repeatedly reported in the literature. Their use in the acute treatment of increased heart rate requires understanding of the pathophysiology and careful differential diagnosis, as all causes of tachycardia should be ruled out and addressed first.

Abstract Renal replacement therapies (RRT) are essential to support critically ill patients with severe acute kidney injury (AKI), providing control of solutes, fluid balance and acid–base status. To maintain the patency of the extracorporeal circuit, minimizing downtime periods and blood losses due to filter clotting, an effective anticoagulation strategy is required. Regional citrate anticoagulation (RCA) has been introduced in clinical practice for continuous RRT (CRRT) in the early 1990s and has had a progressively wider acceptance in parallel to the development of simplified systems and safe protocols. Main guidelines on AKI support the use of RCA as the first line anticoagulation strategy during CRRT in patients without contraindications to citrate and regardless of the patient’s bleeding risk. Experts from the SIAARTI-SIN joint commission have prepared this position statement which discusses the use of RCA in different RRT modalities also in combination with other extracorporeal organ support systems. Furthermore, advise is provided on potential limitations to the use of RCA in high-risk patients with particular attention to the need for a rigorous monitoring in complex clinical settings. Finally, the main findings about the prospective of optimization of RRT solutions aimed at preventing electrolyte derangements during RCA are discussed in detail.

Abstract Adult and pediatric palliative care (PC) share common aims and ethical principles but differ in many organizational and practical aspects. The aim of this narrative review is to analyze these differences and focus on which key aspects of pediatric palliative care could integrate adult services for a better care of suffering patients. Interventions which are peculiar of pediatric PC respect to adult PC include: an earlier referral to the PC service to identify the needs and plan the interventions at an earlier stage of the disease; consequently, a more systematic cooperation with the disease-specific physicians to reduce the burden of treatments; a better integration with the community and the social surroundings of the patients, to prevent social isolation and preserve their social role; a more dynamic organization of the PC services, to give patients the chance of being stabilized at in-hospital or residential settings and subsequently discharged and cared at home whenever possible and desired; the implementation of respite care for adults, to help the families coping with the burden of the disease of their beloved and promote the home-based PC. This review underlines the relevance of some key-aspects of pediatric PC that can be beneficial also within PC of adults. Its findings give the chance for a more dynamic and modern organization of adult PC services and may serve as a basis of future research for new interventions.

Abstract Critical care ultrasonography (US) is widely used by intensivists managing critically ill patients to accurately and rapidly assess different clinical scenarios, which include pneumothorax, pleural effusion, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis. Basic and advanced critical care ultrasonographic skills are routinely used to supplement physical examination of critically ill patients, to determine the etiology of critical illness and to guide subsequent therapy. European guidelines now recommend the use of US for a number of practical procedures commonly performed in critical care. Full training and competence acquisition are essential before significant therapeutic decisions are made based on the US assessment. However, there are no universally accepted learning pathways and methodological standards for the acquisition of these skills. Therefore, in this review, we aim to provide a methodological approach of the head to toe ultrasonographic evaluation of critically ill patients considering different districts and clinical applications.

Abstract Background An amplified and/or prolonged surgical stress response might overcome the organs’ functional reserve, thus leading to postoperative complications. The aim of this systematic literature review is to underline how specific psychological interventions may contribute to improve surgical outcomes through the positive modulation of the surgical stress response in surgical patients. Methods We conducted a comprehensive literature search in the Cochrane Register of Controlled Trials, PubMed, EMBASE, Scopus, PsycINFO, and CINAHL databases. Only studies published in English from Jan 2000 to Apr 2022 and reporting pain and/or anxiety among outcome measures were included in the review. The following psychological interventions were considered: (1) relaxation techniques, (2) cognitive-behavioral therapies, (3) mindfulness, (4) narrative medicine, (5) hypnosis, and (6) coping strategies. Results Among 3167 records identified in the literature, 5 papers were considered eligible for inclusion in this review because reporting the effects that psychological features have on neurochemical signaling during perioperative metabolic adaptation and those metabolic and clinical effects that the psychological interventions had on the observed population. Conclusion Our findings confirm that psychological interventions may contribute to improve surgical outcomes via the positive influence on patients’ metabolic surgical stress response. A multidisciplinary approach integrating physical and non-physical therapies can be considered a good strategy to successfully improve surgical outcomes in the perioperative period.

Abstract Background Since the appearance of the first report on postoperative cognitive impairment in 1955, the number of papers focusing on perioperative neurocognitive disorders (PND) has constantly increased, both in the field of basic science and clinical research. A critical comprehensive review may explore the perception of how noteworthy PND is for physicians and clinical researchers. The aim of this systematic review is to describe how the clinical papers published to date with PND as primary or secondary outcome have changed over time in terms of editorial characteristics. Results A literature search was performed on PubMed, Embase, CINAHL, Cochrane, Scopus, and Web of Science databases, up to March 2021. Human prospective or retrospective clinical studies in which incidence, risk factors, treatments, or outcomes associated with PND are described among primary or secondary outcomes were included. A total of 2109 articles were considered. Conclusions The bibliometric analysis suggests a stable increase in attention towards PND, particularly in general surgery adult-elderly patients, and underlines the importance for the clinicians not to underestimate this specific field.

Abstract We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.

Introduction Previous studies demonstrated that the implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guideline-based bundle, consisting of different supportive measures in patients at high risk for acute kidney injury (AKI), might reduce rate and severity of AKI after surgery. However, the effects of the care bundle in broader population of patients undergoing surgery require confirmation.Methods and analysis The BigpAK-2 trial is an international, randomised, controlled, multicentre trial. The trial aims to enrol 1302 patients undergoing major surgery who are subsequently admitted to the intensive care or high dependency unit and are at high-risk for postoperative AKI as identified by urinary biomarkers (tissue inhibitor of metalloproteinases 2*insulin like growth factor binding protein 7 (TIMP-2)*IGFBP7)). Eligible patients will be randomised to receive either standard of care (control) or a KDIGO-based AKI care bundle (intervention). The primary endpoint is the incidence of moderate or severe AKI (stage 2 or 3) within 72 hours after surgery, according to the KDIGO 2012 criteria. Secondary endpoints include adherence to the KDIGO care bundle, occurrence and severity of any stage of AKI, change in biomarker values during 12 hours after initial measurement of (TIMP-2)*(IGFBP7), number of free days of mechanical ventilation and vasopressors, need for renal replacement therapy (RRT), duration of RRT, renal recovery, 30-day and 60-day mortality, intensive care unit length-of-stay and hospital length-of-stay and major adverse kidney events. An add-on study will investigate blood and urine samples from recruited patients for immunological functions and kidney damage.Ethics and dissemination The BigpAK-2 trial was approved by the Ethics Committee of the Medical Faculty of the University of Münster and subsequently by the corresponding Ethics Committee of the participating sites. A study amendment was approved subsequently. In the UK, the trial was adopted as an NIHR portfolio study. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and will guide patient care and further research.Trial registration number NCT04647396.

Abstract Background Goal-directed therapy (GDT) aims to assure tissue perfusion, by optimizing doses and timing of fluids, inotropes, and vasopressors, through monitoring of cardiac output and other basic hemodynamic parameters. Several meta-analyses confirm that GDT can reduce postoperative complications. However, all recent evidences focused on high-risk patients and on major abdominal surgery. Objectives The aim of the present meta-analysis is to investigate the effect of GDT on postoperative complications (defined as number of patients with a least one postoperative complication) in different kind of surgical procedures. Data sources Randomized controlled trials (RCTs) on perioperative GDT in adult surgical patients were included. The primary outcome measure was complications, defined as number of patients with at least one postoperative complication. A subgroup-analysis was performed considering the kind of surgery: major abdominal (including also major vascular), only vascular, only orthopedic surgery. and so on. Study appraisal and synthesis methods Meta-analytic techniques (analysis software RevMan, version 5.3.5, Cochrane Collaboration, Oxford, England, UK) were used to combine studies using odds ratios (ORs) and 95% confidence intervals (CIs). Results In 52 RCTs, 6325 patients were enrolled. Of these, 3162 were randomized to perioperative GDT and 3153 were randomized to control. In the overall population, 2836 patients developed at least one complication: 1278 (40%) were randomized to perioperative GDT, and 1558 (49%) were randomized to control. Pooled OR was 0.60 and 95% CI was 0.49–0.72. The sensitivity analysis confirmed the main result. The analysis enrolling major abdominal patients showed a significant result (OR 0.72, 95% CI 0.59–0.87, p = 0.0007, 31 RCTs, 4203 patients), both in high- and low-risk patients. A significant effect was observed in those RCTs enrolling exclusively orthopedic procedures (OR 0.53, 95% CI 0.35–0.80, p = 0.002, 7 RCTs, 650 patients. Also neurosurgical procedures seemed to benefit from GDT (OR 0.40, 95% CI 0.21–0.78, p = 0.008, 2 RCTs, 208 patients). In both major abdominal and orthopedic surgery, a strategy adopting fluids and inotropes yielded significant results. The total volume of fluid was not significantly different between the GDT and the control group. Conclusions and implications of key findings The present meta-analysis, within the limits of the existing data, the clinical and statistical heterogeneity, suggests that GDT can reduce postoperative complication rate. Moreover, the beneficial effect of GDT on postoperative morbidity is significant on major abdominal, orthopedic and neurosurgical procedures. Several well-designed RCTs are needed to further explore the effect of GDT in different kind of surgeries.

Abstract Background Since late 2019, a severe acute respiratory syndrome, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread with overwhelming speed causing over 214 million confirmed infections and more than 4.5 million deaths worldwide. In this framework, Italy had the second highest number of SARS-CoV-2 infections worldwide, and the largest number of deaths. A global effort of both the scientific community and governments has been undertaken to stem the pandemic. The aim of this paper is to perform a narrative review of the Italian contribution to the scientific literature regarding intensive care management of patients suffering from COVID-19, being one of the first western countries to face an outbreak of SARS-CoV-2 infection. Main body We performed a narrative review of the literature, dedicating particular attention and a dedicated paragraph to ventilatory support management, chest imaging findings, biomarkers, possible pharmacological interventions, bacterial superinfections, prognosis and non-clinical key aspects such as communication and interaction with relatives. Conclusions Many colleagues, nurses and patients died leaving their families alone. To all of them, we send our thoughts and dedicate these pages.

Abstract Background The role of intravenous immunoglobulins (IVIG) during sepsis is controversial, as different trials on IVIG have observed inconsistent survival benefits. We aimed to elucidate the possible association and clinical significance between circulating levels of immunoglobulins. Methods In a subset of 956 patients with severe sepsis and septic shock of the multicentre, open-label RCT ALBIOS, venous blood samples were serially collected 1, 2, and 7 days after enrolment (or at ICU discharge, whichever came first). IgA, IgG and IgM concentrations were assayed in all patients on day 1 and in a subgroup of 150 patients on days 2 and 7. Ig concentrations were measured employing a turbidimetric assay, OSR61171 system. Results IgA on day 1 had a significant predictive value for both 28-day and 90-day mortality (28-day mortality, HR: 1.50 (95% CI 1.18–1.92); 90-day mortality, HR: 1.54 (95% CI 1.25–1.91)). IgG, but not IgM, on day 1 showed similar results for 28-day (HR 1.83 (95% CI 1.33–2.51) and 90-day mortality HR: 1.66 (95% CI 1.23–2.25)). In addition, lower levels of IgG but not of IgA and IgM, at day 1 were associated with significantly higher risk of secondary infections (533 [406–772] vs 600 [452–842] mg/dL, median [Q1–Q3], p = 0.007). Conclusions In the largest cohort study of patients with severe sepsis or septic shock, we found that high levels of IgA and IgG on the first day of diagnosis were associated with a decreased 90-day survival. No association was found between IgM levels and survival. As such, the assessment of endogenous immunoglobulins could be a useful tool to identify septic patients at high risk of mortality. Trial registration #NCT00707122, Clinicaltrial.gov, registered 30 June 2008

Abstract An accurate assessment of preoperative risk may improve use of hospital resources and reduce morbidity and mortality in high-risk surgical patients. This study aims at implementing an automated surgical risk calculator based on Artificial Neural Network technology to identify patients at risk for postoperative complications. We developed the new SUMPOT based on risk factors previously used in other scoring systems and tested it in a cohort of 560 surgical patients undergoing elective or emergency procedures and subsequently admitted to intensive care units, high-dependency units or standard wards. The whole dataset was divided into a training set, to train the predictive model, and a testing set, to assess generalization performance. The effectiveness of the Artificial Neural Network is a measure of the accuracy in detecting those patients who will develop postoperative complications. A total of 560 surgical patients entered the analysis. Among them, 77 patients (13.7%) suffered from one or more postoperative complications (PoCs), while 483 patients (86.3%) did not. The trained Artificial Neural Network returned an average classification accuracy of 90% in the testing set. Specifically, classification accuracy was 90.2% in the control group (46 patients out of 51 were correctly classified) and 88.9% in the PoC group (8 patients out of 9 were correctly classified). The Artificial Neural Network showed good performance in predicting presence/absence of postoperative complications, suggesting its potential value for perioperative management of surgical patients. Further clinical studies are required to confirm its applicability in routine clinical practice.

Fetal gastrointestinal motility (FGM) was suggested as useful to assess fetal maturity. Our study aimed to quantify FGM in relation to days before parturition (DBP), maternal size, and sex ratio of pups. During the last ten days of pregnancy, 23 clinically healthy pregnant bitches of 16 different breeds ranging in age from 2 to 9 years and body weight from 3.5 to 56.8 kg were monitored twice. The fetal intestine was observed in longitudinal and transversal scan on 3 of the most caudal fetuses in both uterine horns. Gestational age was counted backward from parturition day. The number of fetuses showing FGM was recorded in time in I (−11/−5 DBP) and II (−4/0 DBP). A Mann–Whitney test was performed to analyze variations of FGM% in relation to time and parity. A Kruskal–Wallis test was performed to identify variations of FGM% in relation to maternal size and sex ratio. Statistical significance was set at α = 0.05. A total of 147 FGM observations on 50 ultrasonographic monitoring points were performed. The FGM% was higher during time II compared to time I (median: 33%, range 0–100% vs. 100%, range 33–100%; P < 0.0001). FGM% was higher in small compared to large size bitches (median: 100%, range 67–100% vs. 67%, range 0–100%; P = 0.01). FGM% was not affected by parity and sex ratio. As previously reported, a significant increase in FGM% was observed in the last five DBP. FGM observation may be influenced by the maternal size, with easier evaluation in small size bitches, as well as ultrasound equipment and positioning.

Background: Deslorelin implant use in cats is a medical alternative to surgical sterilization, and due to its prolonged efficacy, its use has shown growing interest in the veterinary community. In the case of breeding facilities, its removal is often requested for the early restoration of testicular function. As anti-Müllerian hormones (AMH) in males is dependent of testosterone secretion, its assay may determine the restoration of testicular steroid secretion. An average of 3 weeks has been already described for tomcats’ testicular function resumption after implant removal, but information about AMH concentrations in deslorelin-treated tomcats is lacking. Methods: Fourteen tomcats were treated for temporary suppression of fertility with a 4.7 mg deslorelin implant, which was surgically removed after 3, 6 or 9 months (n = 6, 4 and 4 tomcats, respectively). A general clinical and reproductive check with a gonadorelin stimulation test for testosterone determination was performed before deslorelin implant administration. After implant removal, tomcats’ testicles were ultrasonographically checked for volume determination every 1-2 weeks with observation of the glans penis (presence or absence of spikes) and blood collection to assay both testosterone and AMH concentrations. Results: AMH concentrations increased significantly during the deslorelin treatment from 20.95 ± 4.97 ng/mL to 82.41 ± 14.59 ng/mL (p < 0.05). Following implant removal, AMH concentrations progressively decreased to pre-treatment levels, with a value of 28.42 ± 7.98 ng/mL on the third week post-removal where testosterone secretion was again detected. Conclusions: Even if a big variability of AMH concentrations exists between male individuals, resumption of tomcats’ testicular function following a deslorelin treatment can be determined by AMH assay.

Abstract Background Postoperative acute kidney injury (PO-AKI) is a leading cause of short- and long-term morbidity and mortality, as well as progression to chronic kidney disease (CKD). The aim of this study was to explore the physicians’ attitude toward the use of perioperative serum creatinine (sCr) for the identification of patients at risk for PO-AKI and long-term CKD. We also evaluated the incidence and risk factors associated with PO-AKI and renal function deterioration in patients undergoing major surgery for malignant disease. Methods Adult oncological patients who underwent major abdominal surgery from November 2016 to February 2017 were considered for this single-centre, observational retrospective study. Routinely available sCr values were used to define AKI in the first three postoperative days. Long-term kidney dysfunction (LT-KDys) was defined as a reduction in the estimated glomerular filtration rate by more than 10 ml/min/m2 at 12 months postoperatively. A questionnaire was administered to 125 physicians caring for the enrolled patients to collect information on local attitudes regarding the use of sCr perioperatively and its relationship with PO-AKI. Results A total of 423 patients were observed. sCr was not available in 59 patients (13.9%); the remaining 364 (86.1%) had at least one sCr value measured to allow for detection of postoperative kidney impairment. Among these, PO-AKI was diagnosed in 8.2% of cases. Of the 334 patients who had a sCr result available at 12-month follow-up, 56 (16.8%) developed LT-KDys. Data on long-term kidney function were not available for 21% of patients. Interestingly, 33 of 423 patients (7.8%) did not have a sCr result available in the immediate postoperative period or long term. All the physicians who participated in the survey (83 out of 125) recognised that postoperative assessment of sCr is required after major oncological abdominal surgery, particularly in those patients at high risk for PO-AKI and LT-KDys. Conclusion PO-AKI after major surgery for malignant disease is common, but clinical practice of measuring sCr is variable. As a result, the exact incidence of PO-AKI and long-term renal prognosis are unclear, including in high-risk patients. Trial registration ClinicalTrials.gov , NCT04341974 .

Abstract Background Chronic pain after breast surgery (CPBS) has a disabling impact on postoperative health status. Mainly because of the lack of a clear definition, inconsistency does exist in the literature concerning both the actual incidence and the risk factors associated to CPBS. The aim of this prospective, observational study is to describe the incidence of and risk factors for CPBS, according to the definition provided by the IASP taskforce. The impact of CPBS on patients’ function and quality of life is also described. Methods Women aged 18+ undergoing oncological or reconstructive breast surgery from Jan until Apr 2018 at the Breast Unit of Careggi Hospital (Florence, Italy) were prospectively observed. Postoperative pain was measured at 0 h, 3 h, 6 h, 12 h, 24 h, 48 h, and 3 months (CPBS) after surgery. Preoperative, intraoperative, and postoperative factors were compared in CPBS and No-CPBS groups through multivariate logistic regression analysis. Results Among the 307 patients considered in this study, the incidence of CPBS was 28% [95% CI 23.1–33.4%]. Results from the logistic regression analysis suggest that axillary surgery (OR [95% CI], 2.99 [1.13–7.87], p = 0.03), preoperative use of pain medications (OR [95% CI], 2.04 [1.20–3.46], p = 0.01), and higher dynamic NRS values at 6 h postoperatively (OR [95% CI], 1.28 [1.05–1.55], p = 0.01) were all independent predictors for CPBS. Conclusions Chronic pain after breast surgery is a frequent complication. In our cohort, long-term use of analgesics for pre-existing chronic pain, axillary surgery, and higher dynamic NRS values at 6 h postoperatively were all factors associated with increased risk of developing CPBS. The possibility to early detect persistent pain, particularly in those patients at high risk for CPBS, might help physicians to more effectively prevent pain chronicisation. Trial registration ClinicalTrials.gov registration NCT04309929 .

Background and AimThe novel coronavirus disease 2019 remains challenging. A large number of hospitalized patients are at a high risk of developing AKI. For this reason, we conducted a nationwide survey to assess the incidence and management of AKI in critically ill patients affected by the SARS-CoV-2 infection.MethodsThis is a multicenter, observational, nationwide online survey, involving the Italian Society of Nephrology and the critical care units in Italy, developed in partnership between the scientific societies such as SIN and SIAARTI. Invitations to participate were distributed through emails and social networks. Data were collected for a period of 1 week during the COVID-19 pandemic.ResultsA total of 141 responses were collected in the SIN–SIAARTI survey: 54.6% from intensivists and 44.6% from nephrologists. About 19,000 cases of COVID-19 infection have been recorded in hospitalized patients; among these cases, 7.3% had a confirmed acute kidney injury (AKI), of which 82.2% were managed in ICUs. Only 43% of clinicians routinely used the international KDIGO criteria. Renal replacement therapy (RRT) was performed in 628 patients with continuous techniques used most frequently, and oliguria was the most common indication (74.05%). Early initiation was preferred, and RRT was contraindicated in the case of therapeutic withdrawal or in the presence of severe comorbidities or hemodynamic instability. Regional anticoagulation with citrate was the most common choice. About 41.04% of the interviewed physicians never used extracorporeal blood purification therapies (EBPTs) for inflammatory cytokine or endotoxin removal. Moreover, 4.33% of interviewed clinicians used these techniques only in the presence of AKI, whereas 24.63% adopted them even in the absence of AKI. Nephrologists made more use of EBPT, especially in the presence of AKI. HVHF was never used in 58.54% of respondents, but HCO membranes and adsorbents were used in more than 50% of cases.ConclusionThis joint SIN–SIAARTI survey at the Italian Society of Nephrology and the critical care units in Italy showed that, during the COVID-19 pandemic, there was an underestimation of AKI based on the “non-use” of common diagnostic criteria, especially by intensivists. Similarly, the use of specific types of RRT and, in particular, blood purification therapies for immune modulation and organ support strongly differed between centers, suggesting the need for the development of standardized clinical guidelines.

Abstract Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria. Results Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery). Conclusions These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Abstract A maladaptive response to surgical stress might lead to postoperative complications. A multidisciplinary approach aimed at controlling the surgical stress response may reduce procedural complications and improve patients’ quality of life in the short and long term. Several studies suggest that psychological interventions may interact with the pathophysiology of surgical stress response, potentially influencing wound repair, innate and adaptive immunity, inflammation, perception of pain, and patients’ mood. The aim of this systematic review is to summarise the effects of perioperative psychological interventions on surgical pain and/or anxiety in adult patients scheduled for elective general abdominal and/or urologic surgery. We conducted a systematic review of controlled clinical trials and observational studies involving psychological interventions for adult patients scheduled for elective general abdominal and/or urologic surgery. Only studies reporting pain and/or anxiety among outcome measures were included in the systematic review. The following psychological interventions were considered: (1) relaxation techniques, (2) cognitive-behavioural therapies, (3) mindfulness, (4) narrative medicine, (5) hypnosis and (6) coping strategies. We examined 2174 papers. Among these, 9 studies were considered eligible for inclusion in this systematic review (1126 patients cumulatively): 8 are randomised controlled trials and 1 is an observational prospective pre/post study. Psychological characteristics widely influence the pathophysiological mechanisms underlying the neuroendocrine and inflammatory response to surgical stress, potentially interfering with surgical outcomes. Psychological interventions are technically feasible and realistically applicable perioperatively during abdominal and/or urologic surgery; they influence the pathophysiological mechanisms underlying maladaptive surgical stress response and might have positive effects on patients’ surgical outcomes, such as pain and anxiety.

Abstract Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Abstract Background Systemic inflammation in COVID-19 often leads to multiple organ failure, including acute kidney injury (AKI). Renal replacement therapy (RRT) in combination with sequential extracorporeal blood purification therapies (EBP) might support renal function, attenuate systemic inflammation, and prevent or mitigate multiple organ dysfunctions in COVID-19. Aim Describe overtime variations of clinical and biochemical features of critically ill patients with COVID-19 treated with EBP with a hemodiafilter characterized by enhanced cytokine adsorption properties. Methods An observational prospective study assessing the outcome of patients with COVID-19 admitted to the ICU (February to April 2020) treated with EBP according to local practice. Main endpoints included overtime variation of IL-6 and multiorgan function-scores, mortality, and occurrence of technical complications or adverse events. Results The study evaluated 37 patients. Median baseline IL-6 was 1230 pg/ml (IQR 895) and decreased overtime (p

Abstract Arterial blood pressure (BP) is a fundamental cardiovascular variable, is routinely measured in perioperative and intensive care medicine, and has a significant impact on patient management. The clinical reference method for BP monitoring in high-risk surgical patients and critically ill patients is continuous invasive BP measurement using an arterial catheter. A key prerequisite for correct invasive BP monitoring using an arterial catheter is an in-depth understanding of the measurement principle, of BP waveform quality criteria, and of common pitfalls that can falsify BP readings. Here, we describe how to place an arterial catheter, correctly measure BP, and identify and solve common pitfalls. We focus on 5 important steps, namely (1) how to choose the catheter insertion site, (2) how to choose the type of arterial catheter, (3) how to place the arterial catheter, (4) how to level and zero the transducer, and (5) how to check the quality of the BP waveform.

Abstract Background The “END-of-Life ScorING-System” (ENDING-S) was previously developed to identify patients at high-risk of dying in the ICU and to facilitate a practical integration between palliative and intensive care. The aim of this study is to prospectively validate ENDING-S in a cohort of long-term critical care patients. Materials and methods Adult long-term ICU patients (with a length-of-stay> 4 days) were considered for this prospective multicenter observational study. ENDING-S and SOFA score were calculated daily and evaluated against the patient’s ICU outcome. The predictive properties were evaluated through a receiver operating characteristic (ROC) analysis. Results Two hundred twenty patients were enrolled for this study. Among these, 21.46% died during the ICU stay. ENDING-S correctly predicted the ICU outcome in 71.4% of patients. Sensitivity, specificity, positive and negative predictive values associated with the previously identified ENDING-S cut-off of 11.5 were 68.1, 72.3, 60 and 89.3%, respectively. ROC-AUC for outcome prediction was 0.79 for ENDING-S and 0.88 for SOFA in this cohort. Conclusions ENDING-S, while not as accurately as in the pilot study, demonstrated acceptable discrimination properties in identifying long-term ICU patients at very high-risk of dying. ENDING-S may be a useful tool aimed at facilitating a practical integration between palliative, end-of-life and intensive care. Trial registration Clinicaltrials.gov Identifier: NCT02875912 ; First registration August 4, 2016.

Abstract This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Background: Identifying acute kidney injury (AKI) within few hours of onset is certainly helpful. However, early prediction of a long-term eGFR decline may be an even more important goal. Our aim was to identify and compare serum [creatinine, kineticGFR, cystatin C, neutrophil gelatinase–associated lipocalin (NGAL)] and urinary (NephroCheck, NGAL, proteinuria, albuminuria, acantocytes at urinary sediment) predictors of AKI that might efficiently predict long-term GFR decline after robotic Nephron-Spearing Surgery (rNSS). Methods: Monocentric prospective observational study. Patients scheduled for rNSS for suspected localized Renal Cell Carcinoma from May 2017 to October 2017 were enrolled. Samples were collected preoperatively and postoperatively (timepoints: 4 h, 10 h, 24 h, 48 h), while kidney function was re-assessed up to 24 months. Results: 38 patients were included; 16 (42%) developed clinical AKI. The eGFR decline at 24 months was more pronounced after postoperative AKI (−20.75 vs. −7.20, p < 0.0001). KineticGFR at 4 h (p = 0.008) and NephroCheck at 10 h (p = 0.001) were, at multivariable linear regression analysis, efficient predictors of post-operative AKI and long-term eGFR decline if compared to creatinine (R2 0.33 vs. 0.04). Conclusions: NephroCheck and kineticGFR have emerged as promising noninvasive, accurate, and early biomarkers of postoperative AKI and long-term GFR decline after rNSS. Combining NephroCheck and kineticGFR in clinical practice would allow to identify high risk of postoperative AKI and long-term GFR decline as early as 10 h after surgery.

Deslorelin is currently registered for the induction of temporary infertility in male dogs, male cats, male ferrets, and also prepubertal female dogs, but research has shown its usefulness for other conditions requiring chronic treatment. This paper presents six cases of dogs chronically treated with deslorelin for indications such as benign prostatic hyperplasia, control of fertility, abnormal reproductive behavior and urinary incontinence. All animals were in good health during treatment. Treatment duration was 2–9 years. No short-term side effects were observed except for flare-up reactions, which were observed only in 1/4 intact males. Two dogs developed a neoplasia: a spayed bitch treated for urinary incontinence developed a pituitary carcinoma, and an intact male dog implanted for control of fertility developed a bladder carcinoma. While the pituitary carcinoma seems unlikely to be related to deslorelin, the bladder carcinoma could be due to the neutered condition of the dog (which was treated for 9 years) as urinary tract neoplasia is more common in dogs following gonadectomy. Chronic treatment with deslorelin is regarded as safe when an animal is being treated for life. The possibility that a pause in the treatment might be helpful for the animal should be investigated.

Abstract Background Assessment of fluid responsiveness is problematic in intensive care unit (ICU) patients, in particular for those undergoing modes of partial support, such as pressure support ventilation (PSV). We propose a new test, based on application of a ventilator-generated sigh, to predict fluid responsiveness in ICU patients undergoing PSV. Methods This was a prospective bi-centric interventional study conducted in two general ICUs. In 40 critically ill patients with a stable ventilatory PSV pattern and requiring volume expansion (VE), we assessed the variations in arterial systolic pressure (SAP), pulse pressure (PP) and stroke volume index (SVI) consequent to random application of 4-s sighs at three different inspiratory pressures. A radial arterial signal was directed to the MOSTCARE™ pulse contour hemodynamic monitoring system for hemodynamic measurements. Data obtained during sigh tests were recorded beat by beat, while all the hemodynamic parameters were averaged over 30 s for the remaining period of the study protocol. VE consisted of 500 mL of crystalloids over 10 min. A patient was considered a responder if a VE-induced increase in cardiac index (CI) ≥ 15% was observed. Results The slopes for SAP, SVI and PP of were all significantly different between responders and non-responders (p

Introduction: Severe acute kidney injury is a common finding in the Pediatric Intensive Care Unit (PICU), however, Continuous Renal Replacement Therapy (CRRT) is rarely applied in this setting. This study aims to describe our experience in the rate of application of CRRT, patients' clinical characteristics at admission and CRRT initiation, CRRT prescription, predictors of circuit clotting, short- and long-term outcomes.Methods: A 6-year single center retrospective study in a tertiary PICU.Results: Twenty-eight critically ill patients aged 0 to 18 years received CRRT between January 2012 and December 2017 (1.4% of all patients admitted to PICU). Complete clinical and CRRT technical information were available for 23/28 patients for a total of 101 CRRT sessions. CRRT was started, on average, 40 h (20–160) after PICU admission, mostly because of fluid overload. Continuous veno-venous hemodiafiltration and systemic heparinization were applied in 83.2 and 71.3% of sessions, respectively. Fifty-nine sessions (58.4%) were complicated by circuit clotting. At multivariate Cox-regression analysis, vascular access caliber larger than 8 Fr [HR 0.37 (0.19–0.72), p = 0.004] and regional citrate anticoagulation strategy [HR 0.14 (0.03–0.60), p = 0.008] were independent protective factors for clotting. PICU mortality rate was 42.8%, and six survivors developed chronic kidney disease (CKD), within an average follow up of 3.5 years.Conclusions: CRRT is uncommonly applied in our PICU, mostly within 2 days after admission and because of fluid overload. Larger vascular access and citrate anticoagulation are independent protective factors for circuit clotting. Patients' PICU mortality rate is high and survival often complicated by CKD development.

Abstract Background There is no consensus on which lung-protective strategies should be used in cardiac surgery patients. Sparse and small randomized clinical and animal trials suggest that maintaining mechanical ventilation during cardiopulmonary bypass is protective on the lungs. Unfortunately, such evidence is weak as it comes from surrogate and minor clinical endpoints mainly limited to elective coronary surgery. According to the available data in the academic literature, an unquestionable standardized strategy of lung protection during cardiopulmonary bypass cannot be recommended. The purpose of the CPBVENT study is to investigate the effectiveness of different strategies of mechanical ventilation during cardiopulmonary bypass on postoperative pulmonary function and complications. Methods/design The CPBVENT study is a single-blind, multicenter, randomized controlled trial. We are going to enroll 870 patients undergoing elective cardiac surgery with planned use of cardiopulmonary bypass. Patients will be randomized into three groups: (1) no mechanical ventilation during cardiopulmonary bypass, (2) continuous positive airway pressure of 5 cmH2O during cardiopulmonary bypass, (3) respiratory rate of 5 acts/min with a tidal volume of 2–3 ml/Kg of ideal body weight and positive end-expiratory pressure of 3–5 cmH2O during cardiopulmonary bypass. The primary endpoint will be the incidence of a PaO2/FiO2 ratio

Deslorelin implants have been used to produce a reversible sterilization in several species. In cats, the prolonged duration (12–15 months in tomcats and 18–22 months in queen) is often too much for cat breeders who request early implant removal. The interval between implant removal and resumption of reproductive function in cats has never been investigated. Eighteen tomcats received a 4.7 mg deslorelin implant placed in the periumbilical area and surgically removed during all seasons of the year after 3, 6, or 9 months (n = 6, 6, and 6 cats, respectively). Following implant removal, all cats received a clinical exam every two weeks, including testicular ultrasonographic measurement, observation of penile spikes, and blood collection for serum testosterone assay. Restoration of serum testosterone secretion occurred after 23 ± 6, 23 ± 6, and 22 ± 7 days in the 3-, 6-, and 9-month groups, respectively. Restoration of testicular function was confirmed by histology in 13/15 cats undergoing orchiectomy at the end of the study while the owners of the remaining two cats opted to maintain their animals intact. Removal of a 4.7 mg deslorelin implant after 3, 6, or 9 months is followed by resumption of serum testosterone secretion after about 3 weeks independent of age or season.

An amendment to this paper has been published and can be accessed via the original article.

Elective gonadectomy in the dog is a topic of interest for clinicians, pet-owners, and society. Although canine prostatic neoplasia (CPN) has a low incidence (0.35%), reports of an increased risk for castrated dogs attract attention and cause concern in pet-owners. Our aim is to provide professionals and non-professionals with a detailed description of this possible side effect of gonadectomy in the dog. The mean age at diagnosis of CPN ranges from 8.5 to 11.2 years. Medium to large size breeds are more frequently affected. Symptoms and findings of non-invasive examinations are not pathognomonic, therefore, cytological or histological examinations are needed for diagnosis. Overall, the incidence of metastasis reaches up to 80%, yet lung metastasis reportedly has no negative impact on median survival time (MST). It has been reported that castrated males have a significantly higher MST than intact males. Differences in inclusion criteria for studied populations make a comparison of studies difficult. Citation of odds ratios without consideration of the context of the reference may result in premature conclusions. We conclude that elective gonadectomy of adult male dogs under six years of age cannot be excluded from the veterinary practice due to concern of causing CPN until clear and strong evidence is available.

In the literature, the term “inoperable” mainly refers to two specific clinical aspects: cancer staging and technical difficulty/impossibility in performing. In light of this clarification, the statement “the patient cannot be anesthetized” has no medical foundation. On the contrary, the physicians have to carefully stratify the perioperative risk and optimize the patients’ preoperative clinical status. In order to perform a precise risk stratification, the European Society of Cardiology and the European Society of Anaesthesiology have joined and published the guidelines for the perioperative cardiovascular management of patients scheduled to undergo non-cardiac surgery. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) represents the most complete and accurate prediction tool so far. It includes 21 preoperative factors relating to demographics, comorbidities and procedures able to predict outcomes based on preoperative risk factors such as death, cardiac complications, pneumonia, and acute kidney injury. The present article will address aspects related to common aspects concerning modifiable and non-modifiable that should be addressed in every patient to whom elective surgery has been scheduled.

BACKGROUND:Continuous veno-venous hemodialysis with high cut-off membranes (HCO-CVVHD) removes inflammatory mediators involved in organ dysfunction during sepsis. The aim of the present study was to assess the variations in SOFA score and identify early predictors of short-term mortality in a cohort of patients with septic shock, treated with HCO-CVVHD for acute kidney injury (AKI). METHODS:An observational prospective multicenter cohort study was conducted in four mixed medical-surgical ICUs. Thirty-eight patients with septic shock and AKI (KDIGO stage≥1) treated with HCO-CVVHD have been included in this study. Patients were divided into Survivors and non-Survivors according to mortality observed at 72nd hr of treatment. The variation of SOFA scores and clinical/biochemical parameters were described over time for the entire population and specifically for Survivors and non-Survivors. Similarly, circulating inflammatory mediators (as IL-6, TNF-a and IL-10) were described over time. A logistic regression analysis was used to identify the baseline clinical and biochemical parameters associated with 72 hrs-ICU mortality. RESULTS:Overall, the mean SOFA score was 12±3 at baseline, 10.9±3 at 6hrs, 9.8±3 at 12hrs, 8.9±3.3 at 24 hrs, and 8±3.5 at 48 hrs after HCO-CVVHD initiation; and 6.5±2.7 at 24 hrs and 6.6±3 at 48 hrs after HCO-CVVHD discontinuation. In the multivariate regression analysis, baseline serum lactate levels and AKI stage independently correlated with short-term mortality during HCO-CVVHD. A significant reduction was observed in circulating levels of TNFα and IL-6 among Survivors. CONCLUSIONS:SOFA score significantly decreased early after initiation of HCO-CVVHD in patients with septic AKI. Baseline lactate levels and the AKI stage resulted to be associated to 72 hrs-ICU-mortality.

During the last few years, due to medical and surgical evolution, patients with increasingly severe diseases causing multiorgan dysfunction are frequently admitted to intensive care units. Therapeutic options, when organ failure occurs, are frequently nonspecific and mostly directed towards supporting vital function. In these scenarios, the kidneys are almost always involved and, therefore, renal replacement therapies have become a common routine practice in critically ill patients with acute kidney injury. Recent technological improvement has led to the production of safe, versatile and efficient dialysis machines. In addition, emerging evidence may allow better individualization of treatment with tailored prescription depending on the patients’ clinical picture (e.g. sepsis, fluid overload, pediatric). The aim of the present review is to give a general overview of current practice in renal replacement therapies for critically ill patients. The main clinical aspects, including dose prescription, modality of dialysis delivery, anticoagulation strategies and timing will be addressed. In addition, some technical issues on physical principles governing blood purification, filters characteristics, and vascular access, will be covered. Finally, a section on current standard nomenclature of renal replacement therapy is devoted to clarify the “Tower of Babel” of critical care nephrology.

INTRODUCTION:The kidneys play a crucial role in the regulation of electrolytes and acid-base homeostasis. Urinary Strong Ion Difference (SIDu = NaU + KU-ClU) represents an important aspect of renal acid-base regulation. We evaluated the role of SIDu as a marker of renal dysfunction in critically ill patients. MATERIALS AND METHODS:Patients admitted to the Medical Intensive Care Unit with a diagnosis of AKI for whom concomitant urinary samples available for SIDu calculation were retrospectively reviewed and staged according to KDIGO criteria for 3 days from inclusion. Patients were classified as Recovered (R-AKI) or Persistent-AKI (P-AKI) whether they exited KDIGO criteria within the 3-day observation period or not. A control group with normal renal function and normal serum acid-base and electrolytes was prospectively recruited in order to identify reference SIDu values. RESULTS:One-hundred-and-forty-three patients with a diagnosis of AKI were included: 77 with R-AKI, and 66 with P-AKI. Thirty-six controls were recruited. Patients with P-AKI had more severe renal dysfunction and higher mortality than patients with R-AKI (SCr 2.23(IQR:1.68-3.45) and 1.81(IQR1.5-2.5) mg/dl respectively, p

Incontinência urinária (IU) pode ocorrer após castração de cadelas, quando há diminuição nos níveis circulantes de hormônios esteroides e aumento nos de gonadotrofinas, além de alteração funcional no esfíncter uretral. Para determinar a ocorrência da IU em cadelas castradas no Hospital Veterinário da Universidade Anhembi-Morumbi, os prontuários de cadelas esterilizadas no período 2002-2009 foram analisados de agosto de 2010 a março de 2011. Foi feito contato telefônico com os proprietários para investigar um possível desenvolvimento de IU após a castração. Nesse período, foram contatados osproprietários de 227 cadelas. Destas, 73 (32,2%) vieram a óbito sem sintoma de IU pós-castração, 146 (64,3%) não apresentaram IU e oito (3,5%) desenvolveram IU no período de 3,8 ± 1,6 anos após castração.