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Resumo Justificativa e objetivo O bloqueio do plano do eretor da espinha e uma tecnica valida para fornecer analgesia em cirurgias combinadas, toracica e abdominal, de modo simultâneo. Relato de caso Um paciente foi submetido a esofagectomia aberta seguida de esofagogastroplastia reconstrutiva, mas recusou analgesia peridural toracica; uma analgesia multimodal com o bloqueio dos multiplos segmentos do eretor da espinha foi entao planejada. Tres cateteres foram colocados no plano do eretor da espinha (T5 e T10 no lado direito e T9 no lado esquerdo) para analgesia continua antes da cirurgia. Durante as primeiras 48 horas, nao houve queixa de dor na area toracica, mas varias vezes o paciente relatou sentir uma dor bem localizada no epigastrio, mas nunca localizada em qualquer outro quadrante abdominal. Discussao O bloqueio do plano do eretor da espinha e uma tecnica valida para fornecer analgesia de modo simultâneo em cirurgias combinadas – toracica e abdominal – e pode ser uma estrategia opcional tambem valida nos casos em que o uso de analgesia peridural for contraindicado.

Background: There is an increased interest in methods of objective cardiac output measurement in pediatric cardiac surgery. Several techniques are available, but have limitations, among the new technologies pressure recording analytical method with MostCare (MostCare-PRAM), a minimally invasive hemodynamic monitoring system, represents a novel arterial pulse contour method that does not require calibration. For this reason, we compared the MostCare-PRAM vs the Fick method for estimation of cardiac output. Methods: We studied prospectively 13 pediatric patients who underwent cardiac surgery and compared intraoperatively Cardiac Index (CI) measured with the MostCare-PRAM with the CI measured with the Fick method. We also measured Cardiac Cycle Efficiency (CCE) and maximal arterial pressure/time ratio (dp/dt max) and compared with Fick method. Results: The data showed good agreement between CI Fick and CI MostCare-PRAM (r = 0.93 and R2= 0.86; p < 0.0001) and also between CCE (r = 0.82 and R2 = 0.67; p < 0.001) and dp/dt (r = 0.84; R2 = 0.81; p < 0.001) with CI measured with Fick method. Conclusion: In pediatric patients submitted to cardiac surgery, the MostCare-PRAM seems to estimate CI with a good level of agreement with the Fick method measurements.

Study objective Sugammadex has been introduced for reversal of neuromuscular blockade (NMB) induced by rocuronium (or vecuronium). Although its efficacy and safety have been established, data are conflicting as to whether it accelerates discharge to the surgical ward compared with neostigmine, which is traditionally used for reversing NMB. The object of this systematic review and meta-analysis was to review the research comparing sugammadex and neostigmine in the context of patient discharge after general anesthesia. Design Systematic review and meta-analysis. Setting University medical hospital. Patients Five-hundred eighteen patients from six studies were included. Methods A comprehensive search was conducted using PubMed, Web of Science, Google Scholar, and Cochrane Library electronic databases to identify randomized controlled trials written in English. Two reviewers independently selected the studies, extracted data regarding postoperative discharge, and assessed the trials' methodological quality and evidence level. Postoperative discharge time was determined from the operating room (OR) to the postanesthesia care unit (PACU) and from the PACU to the surgical ward. This study was conducted using PRISMA methodology. Measurements Time to discharge after NMB reversal with sugammadex or neostigmine. Main results Compared with neostigmine, sugammadex was associated with a significantly faster discharge from the OR to the PACU (mean difference [MD]=22.14min, 95% CI (14.62, 29.67), P 2 =0%) and from the PACU to the surgical ward (MD=16.95min, 95% CI (0.23, 33.67), P =0.0469, I 2 =98.4%). Similarly, discharge-readiness was shorter for sugammadex than for neostigmine from the OR to the PACU (MD=5.58min, 95% CI (3.03, 8.14), P ≤0.0001, I 2 =0%). However, discharge-readiness was similar in both groups for patients moving from the PACU to the surgical ward (MD=−1.10min, 95% CI (−5.69, 3.50), P =0.6394, I 2 =25.3%). Conclusions Results from this meta-analysis suggest that sugammadex accelerates postoperative discharge of patients after general anesthesia compared with neostigmine.

Purpose: Noninvasive ventilation (NIV) may facilitate withdrawal of invasive mechanical ventilation (i-MV) and shorten intensive care unit (ICU) length of stay (LOS) in hypercapnic patients, while data are lacking on hypoxemic patients. We aim to determine whether NIV after early extubation reduces the duration of i-MV and ICU LOS in patients recovering from hypoxemic acute respiratory failure. Methods: Highly selected non-hypercapnic hypoxemic patients were randomly assigned to receive NIV after early orstandard extubation. Co-primary end points were duration of i-MV and ICU LOS. Secondary end points were treatment failure, severe events (hemorrhagic, septic, cardiac, renal or neurologic episodes, pneumothorax or pulmonary embolism), ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT), tracheotomy, percent of patients receiving sedation after study enrollment, hospital LOS, and ICU and hospital mortality. Results: We enrolled 130 consecutive patients, 65 treatments and 65 controls. Duration of i-MV was shorter in the treatment group than for controls [4.0 (3.0–7.0) vs. 5.5 (4.0–9.0) days, respectively, p = 0.004], while ICU LOS was not significantly different [8.0 (6.0–12.0) vs. 9.0 (6.5–12.5) days, respectively (p = 0.259)]. Incidence of VAT or VAP (9% vs. 25%, p = 0.019), rate of patients requiring infusion of sedatives after enrollment (57% vs. 85%, p = 0.001), and hospital LOS, 20 (13–32) vs. 27(18–39) days (p = 0.043) were all significantly reduced in the treatment group compared with controls. There were no significant differences in ICU and hospital mortality or in the number of treatment failures, severe events, and tracheostomies. Conclusions: In highly selected hypoxemic patients, early extubation followed by immediate NIV application reduced the days spent on invasive ventilation without affecting ICU LOS.

Background Microparticles (MP) have been largely studied as potential biomarkers in septic shock (SS) though their biological and clinical relevance is still unclear. This case-control study describes the trend of various MP subtypes during SS to evaluate their possible association with severity of illness and sepsis-related complications (disseminated intravascular coagulation [DIC] and acute kidney injury [AKI]). Methods Forty patients admitted to the Intensive Care Unit with SS and 40 matched healthy volunteers were recruited. AnnexinV+, E-selectin+, thrombomodulin (TM+), leukocyte-derived (CD45+, CD36+) and platelet-derived MP (PMP-expressed as PMP/platelets ratio) were measured by flow-cytometry at baseline, on day 1, 3 and 7 after diagnosis. Severity of illness was assessed by Sequential Organ Failure Assessment Score, duration of vasoactive support and mechanical ventilation. Sepsis-related complications were considered. Results Overall, septic patients showed higher levels of all MP considered compared to controls. TM+MP were significantly lower in more severe sepsis, while CD36+MP and PMP/platelets ratio were significantly increased in patients requiring longer vasoactive support and mechanical ventilation. As for sepsis-related complications, a higher PMP/platelets ratio in patients who developed DIC and increased E-selectin+MP in subjects who developed AKI were observed. PMP/platelets ratio at baseline was significantly associated with longer vasoactive support (OR=1.59 [1.05-2.42]), longer mechanical ventilation (OR=1.6 [1.06-2.42]) and DIC occurrence (OR=1.45 [1.08-1.96]). Conclusions A global response through extra-vesiculation of endothelial cells, leukocytes and platelets during the early stages of SS was confirmed. The cellular activation was detected until day 3 after diagnosis. PMP/platelets ratio at diagnosis may be useful to evaluate SS severity and DIC occurrence.

Background and objective: Erector spinae plane block is a valid technique to provide simultaneously analgesia for combined thoracic and abdominal surgery. Case report: A patient underwent open esophagectomy followed by reconstructive esophagogastroplasty but refused thoracic epidural analgesia; a multi-modal analgesia with a multiple erector spinae plane block was then planned. Three erector spinae plane catheters (T5 and T10 on the right side and T9 on the left side) for continuous analgesia were placed before surgery. During the first 48 h pain was never reported in the thoracic area but the patient reported multiple times to feel a pain well localized in epigastrium, but never localized in any other abdominal quadrant. Discussion: Erector spinae plane block is a valid technique to provide analgesia simultaneously for combined thoracic and abdominal surgery and could be a valid alternative strategy if the use of epidural analgesia is contraindicated. Resumo: Justificativa e objetivo: O bloqueio do plano do eretor da espinha é uma técnica válida para fornecer analgesia em cirurgias combinadas, torácica e abdominal, de modo simultâneo. Relato de caso: Um paciente foi submetido à esofagectomia aberta seguida de esofagogastroplastia reconstrutiva, mas recusou analgesia peridural torácica; uma analgesia multimodal com o bloqueio dos múltiplos segmentos do eretor da espinha foi então planejada. Três cateteres foram colocados no plano do eretor da espinha (T5 e T10 no lado direito e T9 no lado esquerdo) para analgesia contínua antes da cirurgia. Durante as primeiras 48 horas, não houve queixa de dor na área torácica, mas várias vezes o paciente relatou sentir uma dor bem localizada no epigástrio, mas nunca localizada em nenhum outro quadrante abdominal. Discussão: O bloqueio do plano do eretor da espinha é uma técnica válida para fornecer analgesia de modo simultâneo em cirurgias combinadas — torácica e abdominal — e pode ser uma estratégia alternativa também válida nos casos em que o uso de analgesia peridural for contraindicado. Keywords: Erector spinae plane block, Regional anesthesia, Esophagectomy, Palavras-chave: Bloqueio do plano do eretor da espinha, Anestesia regional, Esofagectomia

Sugammadex has been introduced for reversal of rocuronium (or vecuronium)-induced neuromuscular blockade (NMB). Although its efficacy has been established, data are conflicting whether it is safer than neostigmine traditionally used for reversing NMB.Meta-analysis of data about effectiveness and safety of sugammadex compared to neostigmine for reversing NMB in adults was performed using the PRISMA methodology.University medical hospital.A comprehensive search was conducted using PubMed, Web of Science, and Cochrane Library electronic databases to identify English-language randomized controlled trials. Two reviewers independently selected the trials; extracted data on reversal times, incomplete reversals of NMB, and adverse events (AEs); and assessed the trials' methodological quality and evidence level. Only AEs that were related to study drug by a blinded safety assessor were considered for meta-analysis.A total of 1384 patients from 13 articles were included in this meta-analysis.Compared to neostigmine, sugammadex was faster in reversing NMB (P.0001) and more likely to be associated with higher train-of-four ratio values at extubation (mean difference, 0.18; 95% confidence interval [CI], 0.14-0.22; P.0001) and lower risk of postoperative residual curarization after extubation (odds ratio [OR], 0.05; 95% CI, 0.01-0.43; P=.0068). Compared to neostigmine, sugammadex was associated with a significantly lower likelihood of global AEs (OR, 0.47; 95% CI, 0.34-0.66; P.0001), respiratory AEs (OR, 0.36; 95% CI, 0.14-0.95; P=.0386), cardiovascular AEs (OR, 0.23; 95% CI, 0.08-0.61; P=.0036), and postoperative weakness (OR, 0.45; 95% CI, 0.21-0.97; P=.0409). Sugammadex and neostigmine were associated with a similar likelihood of postoperative nausea and vomiting (OR, 1.23; 95% CI, 0.70-2.15; P=.4719), pain (OR, 1.06; 95% CI, 0.15-7.36; P=.9559), neurologic AEs (OR, 1.47; 95% CI, 0.52-4.17; P=.4699), general AEs (OR, 0.75; 95% CI, 0.47-1.21; P=.2448), and changes in laboratory tests' values (OR, 0.57; 95% CI, 0.18-1.78; P=.3368).Results from this meta-analysis suggest that sugammadex is superior to neostigmine, as it reverses NMB faster and more reliably, with a lower risk of AEs.

Perioperative noninvasive ventilation (NIV) has been proposed to reduce postoperative morbidity and improve perioperative outcomes in patients undergoing general anesthesia. Whether it is advantageous to apply NIV just before and after general anesthesia in obese patients has not been yet established.To perform a qualitative review and meta-analysis to assess the effectiveness and tolerability of perioperative NIV in obese patients.All studies in English language performed in clinical setting that compared the application of NIV with standard care just before and after induction of general anesthesia in obese adults (body mass index [BMI]≥35 kg/m(2)) were included. Data on oxygenation, respiratory function, complications, and outcomes were extracted.Twenty-nine articles were selected and used in the qualitative review. Eleven studies including 768 patients were used for subsequent meta-analyses. Compared with standard preoxygenation, NIV was associated with a significant improvement in oxygenation (P.0001) before tracheal intubation. Benefits in oxygenation (P.0001), clearance of carbon dioxide (P.0001), and pulmonary function testing (P.0001) after general anesthesia were observed with NIV compared with standard care. Postoperatively, NIV was associated with a decreased risk of respiratory complications (relative risk [RR] = .33; 95% confidence interval [CI] .16-.66; P = .002), but not of reintubation after tracheal extubation (RR = .41; 95% CI .09-1.82]; P = .3657) and unplanned intensive care unit admission (RR = .43; 95% CI .16-1.15; P = .0937). NIV-related complications in obese patients were mainly due to intolerance and ranged from 7% to 28% of cases. NIV-related anastomotic leakage and adverse events were not reported.Results from this review and meta-analysis suggest that NIV is well tolerated and effective in improving perioperative care in obese patients. The application of NIV before and after general anesthesia should be considered and promoted in relevant cases.

Michele Carron, Fabio Baratto, Francesco Zarantonello, Carlo Ori Department of Medicine, Anesthesiology and Intensive Care, University of Padova, Padova, Italy Objective: The aim of the study is to evaluate the clinical and economic impact of introducing a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen for neuromuscular block (NMB) management. Methods: We conducted a retrospective analysis of clinical outcomes and cost-effectiveness in five operating rooms at University Hospital of Padova. A clinical outcome evaluation after sugammadex administration as first-choice reversal drug in selected patients (rocuronium–sugammadex) and as rescue therapy after neostigmine reversal (rocuronium–neostigmine–sugammadex) compared to control was performed. A cost-analysis of NMB management accompanying the introduction of a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen was carried out. To such purpose, two periods were compared: 2011–2012, without sugammadex available; 2013–2014, with sugammadex available. A subsequent analysis was performed to evaluate if sugammadex replacing neostigmine as first choice reversal drug is cost-effective. Results: The introduction of a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen reduced the average cost of NMB management by 36%, from €20.8/case to €13.3/case. Patients receiving sugammadex as a first-choice reversal drug (3%) exhibited significantly better train-of-four ratios at extubation (P

Ulderico Freo, Maurizio Furnari, Carlo Ori Anesthesiology and Intensive Care Unit, Department of Medicine – DIMED, Padua University, Padua, Italy Background: Pain is a common and undertreated non-motor symptom in patients with Parkinson’s disease (PD). Opioids have been seldom used in PD because they could worsen cognitive and motor functions. Objective: We aimed to assess efficacy and tolerability of tapentadol in PD patients. Methods: We retrospectively reviewed 21 PD patients treated with tapentadol extended release (ER) for chronic pain. Patients were evaluated before treatment and at 3 and 6 months during treatment for pain intensity (current, 24-hour average, and minimum and worst) with a 0–10 Numerical Rating Scale and the painDETECT questionnaire; for motor symptom severity with the Unified PD Rating Scale part III and the Hoehn and Yahr scale; for cognitive functions with Mini-Mental Status Examination, Corsi’s Block-Tapping test, Digit Span test, Digit-Symbol Substitution test, FAS test, Rey’s Auditory Verbal Learning test, Trail-Making test A and B and the 9-Hole Peg test; for anxiety and depression with the Hospital Anxiety and Depression Scale; and for the quality of life with the Short Form-12. Data were analyzed by 1-way analysis of variance and paired t-test, and by Friedman’s and Wilcoxon’s tests. Statistical significance was taken in all cases as P

Leptin has shown positive effects on respiratory function in experimental settings. The role of leptin on perioperative respiratory function in morbidly obese patients has not been established. We performed a retrospective analysis of morbidly obese patients undergoing laparoscopic sleeve gastrectomy. Fasting serum leptin and interleukin (IL)-6 were measured preoperatively, and arterial blood gases were obtained pre- and postoperatively. Outcome variables were arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), and differences in PaO2 and PaCO2 between pre- and postoperative values (ΔPaO2, ΔPaCO2; postoperative minus preoperative). Patients with lower (

Orthotopic lung transplantation in rats has been developed as a model to study organ dysfunction, but available tools for monitoring the graft function are limited. In this study, lung ultrasound (LUS) is proposed as a new non-invasive monitoring tool in awake rodents.LUS was applied to native and graft lung of six rats after left orthotopic transplantation. Rats were monitored with LUS while awake, patterns identified, images evaluated with a scoring system, intra- and inter-rater agreement was assessed and examination times analyzed.A total of 78 clips were recorded. The median quality score of LUS was 3.66/4 for left hemithorax and 3.71/4 for native right side. The intra-rater agreement was 0.53 and 0.65 and the inter-rater agreement was 0.61 (P0.01). Median time to complete the examination was 233.0 seconds (IQR 142) for both lungs, lowered from 254.0 seconds (IQR 129.5) (first trimester of study) to 205.5 seconds (IQR 88.5) (second trimester of the study). Significant findings on LUS were confirmed on pathological examination.LUS in awake rodents without shaving has been shown to be both feasible and safe and the images collected were of good quality and comparable to those obtained in anesthetized rats without bristles.

Background The relationship between ventilator-associated pneumonia (VAP) and mortality varies from study to study, and its entity is uncertain due a considerable variation in the attributable mortality. The aim of this study was to evaluate the relationship between VAP frequency and mortality in a cohort of mechanically ventilated patients. Methods A multicenter prospective observational study was conducted in 21 Intensive Care Units (ICUs). The patients were recruited from 2008 to 2010 within randomly selected periods. 842 patients of 2595 admitted, met the eligibility criteria and were enrolled in the study. The study's primary outcome was death by any cause in one of the ICUs. We modelled VAP occurrence as a time-dependent covariate and fitted a competing risk analysis model. We estimated the attributable mortality of VAP as the population-attributable fraction of ICU mortality. Results A total of 121 patients developed VAP (14.4%), for an incidence rate of 15.7 cases per 1000 ventilator days; of the 175 patients (20.8%) who died during the study period, 31 (25.6%) had VAP. The ICU mortality rate in the patients who developed VAP was 22.6 per 1000 ventilator days (95% CI: 15.9-32.1). We estimated an attributable mortality of 8.4%. Conclusions In 8.4% of cases, VAP was the leading cause of death in our study. This indicates that the patients died more frequently with VAP rather than because of it.

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Introduction: Extracorporeal membrane oxygenation (ECMO) is considered a reliable technique in lung transplantation requiring cardiorespiratory support. However, the impact of this technology on blood product transfusion rate and outcomes compared to off-pump lung transplantation has been rarely investigated. Methods: Between January 2012 and June 2015, 52 elective adult lung transplants were performed at our institution. Of these, 15 recipients required intraoperative venoarterial extracorporeal support and 37 did not. We compared blood product consumption and other outcome variables between the 2 groups. Results: We found comparable in-hospital (86.7% vs 97.3%, P = .14) and 6-month (86.7% vs 91.9%, P = .56) survival between patients with and without extracorporeal support, respectively. Survival at 30 days was lower in the ECMO group (86.7% vs 100%, P = .02). Although patients who underwent ECMO received more intraoperative transfusions, postoperative transfusion rate was similar between the 2 groups. The ECMO group experienced longer mechanical ventilation (median 3 vs 2 days, P = .02) and intensive care unit stay (median 7 vs 5 days, P = .02), besides more cardiogenic shock and deep vein thrombosis. However, we observed no difference in other major and minor in-hospital complications and 6-month complications. Conclusions: In our experience, despite the higher need for intraoperative transfusions, lung transplantation performed with ECMO support is comparable to the off-pump procedure as to short-term survival and outcomes.

Local anesthetic systemic toxicity (LAST) occurrence may cross several medical specialties. In 2010, the American Society of Regional Anesthesia and Pain Medicine (ASRA) published the first algorithm on LAST management, introducing the use of lipid emulsion (ILE) treatment. In the present study, we retrieved the cases of LAST published between ASRA guidelines dissemination and March 2014. We analyzed the reported clinical manifestations of LAST, characteristics of affected patients, onset time of toxicity, and clinical setting. We also focused on the treatment measures that were applied in the different cases, especially on the use of ILE and adherence to ASRA recommendations. Despite the limits of a review of case reports, the present study calls attention to the insidious nature of LAST, especially its atypical manifestations, and shows that ILE may currently be underadministered in daily clinical practice, especially in nonanesthesiology practice.

Laryngeal mask (LM) and inhaled anesthesia combination is often deemed unsuitable. Actually the evolution of surgical procedures towards minimal invasiveness, the search of improved productivity, and the contemporary need for patient safety and faster recovery, push the anesthetists to get interested in their use in the daily practice. An Expert Panel composed by anesthetists coming from university and tertiary hospitals undertook to write an experts' opinion on the correct management of LM and desflurane in adult patients, with a view to issuing a simple operative protocol for their combined intraoperative usage. Main operative steps have been defined, which, if appropriately implemented, would successfully achieve safety objectives. Two aspects are considered crucial, first the educational role of Universities and Medical Schools to structure a systematic approach to the theoretical and practical teaching of the use of LM with desflurane; second an appropriate training for improving the skills in the use of LM also for more complicated patients.

Critically ill obese patients are at increased risk of severe hypoxemia during intubation. Preoxygenation consists in enhancing the patient’s oxygen reserve to avoid this complication and should be routinely applied in clinical practice. Correctly positioning the patient or using specific techniques might provide additional time before hypoxemia develops.

Sugammadex, which is used to reverse rocuronium-induced neuromuscular blockade, has a limited and transient effect on activated partial thromboplastin time and prothrombin time. However, no data are available on the effects of sugammadex on coagulation in morbidly obese patients, as assessed by rotational thromboelastometry (ROTEM®).Sixty patients received sugammadex 2 mg/kg or 4 mg/kg to reverse moderate or deep rocuronium-induced neuromuscular blockade (N.=30/group) at the end of surgery under desflurane anesthesia. Arterial blood samples were collected before and 3 min and 30 min after sugammadex administration for ROTEM® analysis, including measurements of clotting time (CT), clot formation time, α angle, and maximum clot firmness in INTEM, EXTEM, and FIBTEM assays. Major and minor bleeding events were also monitored during the postoperative period.Sugammadex 2 and 4 mg/kg has a limited and transient (30 min) effect on INTEM CTs of 7.7% (P=0.04) and 10.7% (P0.0001), respectively. There were no relevant effects on other ROTEM® parameters. A multivariate analysis indicated a significant effect of total sugammadex dose (250, 250-500,500 mg) on the INTEM CT (P=0.002). A regression analysis showed a positive relationship between sugammadex dose and INTEM CT value at 3 min after administration (coefficient = 0.052 s; 95% CI: 0.005-0.098 s; P=0.03). No major or minor bleeding events were observed in either group during the postoperative period.Sugammadex produces a slight effect on coagulation in morbidly obese patients, without increasing the risk for postoperative bleeding.

The incidence and prevalence of obesity continues to increase globally. Physicians will therefore provide care for an increasing number of obese patients in their clinical practice. Optimal management of these patients is required to minimize the risk of perioperative complications that increase morbidity and mortality. Obesity affects the respiratory function. It is generally associated with reduced lung volume with increased atelectasis, decreased lung and chest wall compliance, increased airway resistance, and moderate to severe hypoxemia. These physiologic alterations are generally more pronounced in obesity complicated by obstructive sleep apnea syndrome or obesity hypoventilation syndrome. Anesthesia and surgery can profoundly impair respiratory function, increasing the risk of postoperative respiratory complications and acute respiratory failure. Certain comorbidities associated with obesity (e.g., metabolic syndrome, obstructive sleep apnea, pulmonary disease) further increase the risk of perioperative complications. Non-invasive ventilation (NIV) is emerging as an important strategy to minimize perioperative complications. It may ameliorate obesity-related comorbidities, counteract upper airway obstruction, reduce hypoventilation and atelectasis, improve gas exchange and respiratory function, relieve dyspnea, and decrease breathing effort in obese patients in the perioperative period. Thus, NIV may lower the risk of acute respiratory failure after bariatric surgery. Selecting the appropriate interface and type of NIV is fundamental for increasing the likelihood of NIV success in such high-risk patients. NIV is a safe therapy, which should be considered in the perioperative period to help optimize the management of obese patients undergoing bariatric surgery and improve their postoperative course.

Background General anaesthesia should prevent patients from experiencing surgery, defined as connected consciousness. The isolated forearm technique (IFT) is the current gold standard for connected consciousness monitoring. We evaluated the efficacy of different anaesthesia regimens in preventing IFT responses. Methods We conducted a systematic review with meta-analysis of studies evaluating IFT in adults. Proportions of IFT-positive patients were compared for inhalational versus intravenous anaesthesia and anaesthesia brain monitor (ABM)-guided versus non-ABM-guided. Results Of 1131 patients in 22 studies, 393 (34.8%) had an IFT response during induction or maintenance. IFT-positive patients were less frequent during induction (19.7% [95% CI, 17.5–22.1]) than during maintenance (31.2% [95% CI, 27.8–34.8]). Proportions of IFT-positive patients during induction and maintenance were similar for inhalational (0.51 [95% CI, 0.38–0.65]) and intravenous (0.52 [95% CI, 0.26–0.77]) anaesthesia, but during maintenance were lower with inhalational (0.18 [95% CI, 0.08–0.38]) than with intravenous (0.48 [95% CI, 0.24–0.73]) anaesthesia. Proportions of IFT-positive patients during induction and maintenance were not significantly different for ABM-guided (0.64 [95% CI, 0.39–0.83]) and non-ABM-guided (0.48 [95% CI, 0.34–0.62]) anaesthesia but during maintenance were lower with non-ABM-guided (0.19 [95% CI, 0.09–0.37]) than with ABM-guided (0.57 [95% CI, 0.34–0.77]). Proportions of IFT-positive patients decreased significantly with increasing age and premedication use. Of the 34 anaesthesia regimens, 16 were inadequate. Studies had low methodological quality (only seven randomised controlled trials) and significant heterogeneity. Conclusions Standard general anaesthesia regimens might not prevent connected consciousness. More accurate anaesthesia brain monitor methodology to reduce the likelihood of connected consciousness is desirable.

The measurement of cardiac output (CO) may be useful to improve the assessment of hemodynamics during simulated scenarios. The purpose of this study was to evaluate the feasibility of introducing an uncalibrated pulse contour device (MostCare, Vytech, Vygon, Padova, Italy) into the simulation environment. MostCare device was plugged to a clinical monitor and connected to the METI human patient simulator (HPS) to obtain a continuous arterial waveform analysis and CO calculation. In six different simulated clinical scenarios (baseline, ventricular failure, vasoplegic shock, hypertensive crisis, hypovolemic shock and aortic stenosis), the HPS-CO and the MostCare-CO were simultaneously recorded. The level of concordance between the two methods was assessed by the Bland and Altman analysis. 150-paired CO values were obtained. The HPS-CO values ranged from 2.3 to 6.6 L min−1 and the MostCare-CO values from 2.8 to 6.4 L min−1. The mean difference between HPS-CO and MostCare-CO was − 0.3 L min−1 and the limits of agreement were − 1.5 and 0.9 L min−1. The percentage of error was 23%. A good correlation between HPS-CO and MostCare-CO was observed in each scenario of the study (r = 0.88). Although MostCare-CO tended to underestimate the CO over the study period, good agreements were found between the two methods. Therefore, a pulse contour device can be integrated into the simulation environment, offering the opportunity to create new simulated clinical settings.

Water samples (0-200 m) were collected in a coastal area of the Ross Sea in January 2014 to evaluate the physical and biological forcing on the carbonate system at the mesoscale (distance between stations of 5-10 km). Remote sensing supported the determination of the sampling strategy and helped positioning each sampling station. Total alkalinity, pH, dissolved oxygen, phytoplankton pigments and composition were investigated in combination with measurements of temperature, salinity and current speed. Total inorganic carbon, sea water CO2 partial pressure and the saturation state (0) for calcite and aragonite were calculated from the measured total alkalinity and pH. In addition, continuous measurements of atmospheric CO2 concentration were completed. LADCP measurements revealed the presence of a significant change in current speed and direction that corresponded to a clearly defined front characterized by gradients in both temperature and salinity. Phytoplankton biomass was relatively high at all stations and the highest values of chlorophyll-a were found between 20 to 50 m, with the dominant taxonomic group being haptophyceae. The carbonate system properties in surface waters exhibited mesoscale variability with a horizontal length scale of about 10 km. Sea-ice melt, through the input of low salinity water, results in a dilution of the total alkalinity and inorganic carbon, but our observations suggest that phytoplankton activity was the major forcing of the distribution of the carbonate system variables. Higher CO3- ,Omega and pH in the surface layer were found where the highest values of chlorophyll-a were observed. The calculated Delta pCO(2) pattern follows both MODIS data and in situ chlorophyll-a measurements, and the estimated CO2 fluxes ranged from -0.5 +/- 0.4 to -31.0 +/- 6.4 mmol m(-2) d(-1). The large range observed in the fluxes is due to both the spatial variability of sea water pCO(2) and to the episodic winds experienced. (C) 2015 Elsevier B.V. All rights reserved.

Compromised liver function, as a consequence of acute liver insufficiency or severe chronic liver disease may be associated with various neurological syndromes, which involve both central and peripheral nervous system. Acute and severe hyperammoniemia inducing cellular metabolic alterations, prolonged state of "neuroinflammation", activation of brain microglia, accumulation of manganese and ammonia, and systemic inflammation are the main causative factors of brain damage in liver failure. The most widely recognized neurological complications of serious hepatocellular failure include hepatic encephalopathy, diffuse cerebral edema, Wilson disease, hepatic myelopathy, acquired hepatocerebral degeneration, cirrhosis-related Parkinsonism and osmotic demyelination syndrome. Neurological disorders affecting liver transplant candidates while in the waiting list may not only significantly influence preoperative morbidity and even mortality, but also represent important predictive factors for post-transplant neurological manifestations. Careful pre-transplant neurological evaluation is essential to define severity and distribution of the neurological impairment, to identify the abnormalities still responsive to current treatment, and to potentially predict the inherent post-operative prognosis. The preferred specific indices of neurological pre-transplant assessment may vary among centers, however, even with the aid of the current biochemical, neurophysiological, neuropsychological and neuroimaging diagnostic tools, the correct diagnosis and differential diagnosis of various syndromes may be difficult. In this article the relevant pathophysiological and clinical aspects of the most frequent brain and peripheral nervous system diseases affecting liver transplant candidates with acute or advanced chronic liver failure are briefly reported. The practical diagnostic findings useful for the preoperative assessment and treatment, as well as the expected neurological evolution after liver transplantation are also evaluated.

Objectives Improved congenital heart defect (CHD) operations have reduced operative mortality to 3%. The major concern is now long-term neurological outcomes. We measured plasma glial fibrillary acidic protein (GFAP), an early marker of brain injury, during different phases of cardiopulmonary bypass (CPB), to correlate the increase of GFAP to clinical parameters or specific operative phases. Methods We performed a prospective, single-centre, observational study in children undergoing cardiac operations. We studied 69 children with CHD and biventricular heart physiology: 26 had tetralogy of Fallot; 17 transposition of the great arteries; and 26 ventricular/atrial septal defects with or without associated arch defects. GFAP levels were measured by ELISA at different stages of CPB. We recorded clinical and surgical parameters and applied multivariable and logistic regressions to assess which parameters were independent predictors of variations in plasma GFAP. Results GFAP increased during CPB and peaked at the end of rewarming. Multivariable regression showed degree of hypothermia as the only significant independent predictor of GFAP increase, adjusted for age, prematurity, type of CHD, cyanosis, aortic cross-clamp time, haemodilution, neurological risk time interval and rewarming rate. Temperature nadir and neurological risk time interval were significant independent predictors of a GFAP value > 0.46 ng/ml. Conclusions Hypothermia degree during CPB is correlated with GFAP plasma increase in children with biventricular heart defects undergoing surgical repair. Rewarming is the most critical CPB phase for GFAP increase. The implication of high plasma GFAP is still under evaluation. Follow-up studies are ongoing to assess the reliability of GFAP as a marker of brain injury and/or as a predictor of neurodevelopmental abnormalities.

Background Although post–liver transplantation pain is not as severe as expected from the size of the surgical incision, optimal pain control becomes crucial to aid compliance with the ventilator, improve respiratory function, and facilitate an early weaning from mechanical ventilation. Methods Because the majority of analgesics are primarily metabolized and excreted by the hepatobiliary system, a poor recovery of graft function will result in a decrease in clearance and reduced elimination of the drug. On the other hand, if the liver is working well, the metabolism of analgesics improves significantly with minimal accumulation. Morphine-based analgesia has been associated with a higher risk of sedation and respiratory depression compared with major abdominal surgical procedures. Fentanyl and sufentanil in continuous intravenous infusion may be preferred in the presence of hemodynamic instability or bronchospasm. Sufentanil produces shorter-lasting respiratory depression and long-lasting analgesia than does fentanyl. Results The provision of potent continuous analgesia, independent of the duration of infusion, and the unique pharmacokinetics, not significantly affected by the functional status of the graft, make remifentanil appropriate for the majority of liver-transplanted patients. Unlike for patients with very severe pain after major abdominal surgery, liver transplant recipients usually benefit from tramadol, either in repeated intravenous boluses or continuous intravenous infusion. Paracetamol has been included as adjuvant (or sole agent, rarely) in the analgesic treatment of mild to moderate postoperative pain. The combination treatment (paracetamol plus tramadol) is a reasonable, safe option with improved analgesia and concurrent reduction in the incidence of some opioid-related side effects. Conclusions Frequent review of the patient's response is mandatory when potent opioids are used because dose-dependent respiratory depression is a serious and potentially life-threatening adverse effect. The benefits provided by epidural analgesia in this particular setting should be weighed against the risks because in the presence of markedly deranged perioperative blood clotting, the development of epidural hematoma represents a disastrous complication.

The effectiveness of noninvasive positive pressure ventilation delivered by helmet (H-NPPV) as a weaning approach in patients with acute respiratory failure is unclear.We randomly and evenly assigned 64 patients intubated for acute respiratory failure to conventional weaning with invasive mechanical ventilation (IMV) or H-NPPV. The primary end point was a reduction in IMV duration by 6 days between the 2 groups. Secondary end points were the occurrence of ventilator-associated pneumonia and major complications, duration of mechanical ventilation and weaning, intensive care unit and hospital length of stay, and survival.The mean duration of IMV was significantly reduced in the H-NPPV group compared with the IMV group (P.0001), without significant difference in duration of weaning (P=.26) and total ventilatory support (P=.45). In the H-NPPV group, the incidence of major complications was less than the IMV group (P=.032). Compared with the H-NPPV group, the IMV group was associated with a greater incidence of VAP (P=.018) and an increased risk of nosocomial pneumonia (P=.049). The mortality rate was similar between the groups, with no significant difference in overall intensive care unit (P=.47) or hospital length of stay (P=.37).H-NPPV was well tolerated and effective in patients who were difficult to wean.

During the 2011–2012 hemispheric voyage of the M/V Italica from Italy to the Atlantic Ocean, southern Indian Ocean, New Zealand and Antarctica, atmospheric CO2 concentrations were continuously recorded and 52 air samples collected in 4-L Pyrex flasks for the measurement of the δ13C of atmospheric CO2. In the case of CO2 concentrations, new data include the following: 1) in the Adriatic, between Ravenna and Otranto, CO2 was never measured in order to avoid the expected heavy contribution from industrial plants; the 2011 measurements fully confirm this contribution; 2) in the Atlantic, along the Moroccan coast, high values of up to 415 ppmv were recorded, apparently due to considerable industrial development in Morocco; 3) minor CO2 concentrations were also recorded along other sections of the African coast north of the Equator, whereas relatively low constant values were recorded south of the Equator; 4) in the southern Indian Ocean, CO2 concentrations were measured almost along a parallel, yielding homogeneous values not much higher than the mean values recorded at NOAA stations in nearby areas. With only one exception, the δ13C values were systematically less negative than −9‰ (VPDB), the mean values for the three oceanic sections being the following: Atlantic Ocean −8.64 ± 0.20‰; Indian Ocean −8.54 ± 0.06‰; New Zealand to Antarctica −8.49 ± 0.02‰. A small but progressive increase in δ13C values with increasing latitude was in good agreement with the expected trend. The homogeneity of such values between New Zealand and Antarctica was remarkable, as these samples had been collected in particularly rough oceanic conditions with high winds. In spite of these particular environmental conditions these values were very close to those of samples collected in the same area in 2009 and 2010 in conditions of calm sea and low wind. This similarity contrasts sharply with the theory and models of air-sea gas exchange.

In our study, we evaluated the analgesic effect and plasma level time course of subanesthetic doses of intraoperative S(+)-ketamine administered by continuous epidural infusion for postthoracotomic pain.A study population of 140 patients undergoing thoracic surgery was randomly assigned to either S(+)-ketamine or ropivacaine by continuous epidural infusion. The outcome measures were as follows: (a) intraoperative fentanyl requirements; (b) postoperative pain intensity; and (c) postoperative rescue analgesics.Intraoperative fentanyl consumption was significantly lower (median of difference: -58.6 μg; 95% confidence interval [CI], -97.2 to -19.6 μg; P = 0.0032) in patients in the ketamine group than those in the ropivacaine group. Postoperative visual analog scale scores were significantly lower in the ketamine group than in controls (Wilcoxon-Mann-Whitney odds at 24 hours = 6.25; 95% CI, 4.07 to 1.97; P0.0001). Rescue analgesics were required more frequently in controls than in the ketamine group (percentage difference: 58.6%; 95% CI, 43.3% to 69.6%; P0.0001). The mean plasma level of ketamine declined rapidly during continuous epidural infusion and decayed slowly after it had stopped.Our data show that epidural infusion of subanesthetic doses of S(+)-ketamine during thoracic surgery provides better postoperative analgesia than epidural ropivacaine.

Summary Non-invasive ventilation (NIV) has become a common treatment for acute and chronic respiratory failure. In comparison with conventional invasive mechanical ventilation, NIV has the advantages of reducing patient discomfort, procedural complications, and mortality. However, NIV is associated with frequent uncomfortable or even life-threatening adverse effects, and patients should be thoroughly screened beforehand to reduce potential severe complications. We performed a detailed review of the relevant medical literature for NIV complications. All major NIV complications are potentially life-threatening and can occur in any patient, but are strongly correlated with the degree of pulmonary and cardiovascular involvement. Minor complications can be related to specific structural features of NIV interfaces or to variable airflow patterns. This extensive review of the literature shows that careful selection of patients and interfaces, proper setting of ventilator modalities, and close monitoring of patients from the start can greatly reduce NIV complications.

Background: General anesthetics induce apoptotic neurodegeneration in the developing mammalian brain. General anesthesia (GA) also causes significant disturbances in mitochondrial morphogenesis during intense synaptogenesis. Mitochondria are dynamic organelles that undergo remodeling via fusion and fission. The fine balance between these two opposing processes determines mitochondrial morphometric properties, allowing for their regeneration and enabling normal functioning. As mitochondria are exquisitely sensitive to anesthesia-induced damage, we examined how GA affects mitochondrial fusion/fission. Methods: Seven-day-old rat pups received anesthesia containing a sedative dose of midazolam followed by a combined nitrous oxide and isoflurane anesthesia for 6 h. Results: GA causes 30% upregulation of reactive oxygen species (n = 3–5 pups/group), accompanied by a 2-fold downregulation of an important scavenging enzyme, superoxide dismutase (n = 6 pups/group). Reactive oxygen species upregulation is associated with impaired mitochondrial fission/fusion balance, leading to excessive mitochondrial fission. The imbalance between fission and fusion is due to acute sequestration of the main fission protein, dynamin-related protein 1, from the cytoplasm to mitochondria, and its oligomerization on the outer mitochondrial membrane. These are necessary steps in the formation of the ring-like structures that are required for mitochondrial fission. The fission is further promoted by GA-induced 40% downregulation of cytosolic mitofusin-2, a protein necessary for maintaining the opposing process, mitochondrial fusion (n = 6 pups/group). Conclusions: Early exposure to GA causes acute reactive oxygen species upregulation and disturbs the fine balance between mitochondrial fission and fusion, leading to excessive fission and disturbed mitochondrial morphogenesis. These effects may play a causal role in GA-induced developmental neuroapoptosis.

Neuropathic pain is a common and distressing symptom in thoracic surgical patients. When it consistently presents with measurable sensory changes in a circumscribed area, neuropathic pain can be diagnosed as localized neuropathic pain (LNP).The purpose of this study was to report the efficacy of lidocaine 5% medicated plaster (Lido5%P) in the treatment of LNP in thoracic surgical patients.We retrospectively reviewed the records of sixteen cancer and noncancer thoracic patients treated with Lido5%P for LNP. Patients had been assessed before and during treatment with standardized forms and questionnaires for pain intensity, sleep quality, drug dosages and adverse events.Treatment with Lido5%P yielded a significant and lasting improvement in pain symptomatology. In oncological patients as an add-on therapy, Lido5%P improved pain intensity and sleep quality, and delayed opioid dose escalation. In non-oncological patients as monotherapy or in association with antineuropathic drugs, Lido5%P attenuated LNP. No local or systemic adverse events were recorded.Lido5%P was effective in relieving thoracic LNP, and was well tolerated.