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Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.

Introduction: Minimally invasive aortic valve replacement (MIAVR) requires changes in cannulation strategy and cardiopulmonary bypass (CPB) management when compared to the conventional approach (CAVR). We aimed at evaluating if these differences could influence perfusion-related quality parameters and impair postoperative outcomes. Methods: Overall, 339 consecutive patients underwent MIAVR or CAVR between 2014 and 2020 and were analyzed retrospectively. To account for baseline differences, a propensity-matching analysis was performed, obtaining two groups of 97 patients each. Results: MIAVR group had longer CPB time [107 (95–120) vs 95 (86–105) min, p =.003] than CAVR group. Of note, average pump flow rate index [2.4 (2.2–2.5) vs 2.7 (2.4–2.8) l/min/m2, p =.004] was lower in the MIAVR group. Mean arterial pressure was 73 = 9 mmHg vs 62 = 11 mmHg for the MIAVR and CAVR group, respectively (p <.001). Cell-salvaged blood was most commonly used in the MIAVR group (25.8% vs 11.3%, p =.02). Finally, CPB temperature was 32.8°C (32.1–34.8) for MIAVR group vs 34.9°C (33.2–36.1) for the CAVR group (p =.02). Postoperative complications were similar between groups. Conclusions: In conclusion, despite differences in CPB parameters in patients undergoing CAVR and MIAVR, the incidences of adverse outcomes were similar. However, compared to CAVR, MIAVR was associated with shorter durations of mechanical ventilation and hospital stay as well as less transfusion of blood products.

Objective: Aortic valve disease is more and more common in western countries. While percutaneous approaches should be preferred in older adults, previous reports have shown good outcomes after surgery. Moreover, advantages of minimally invasive approaches may be valuable for octogenarians. We sought to compare outcomes of conventional aortic valve replacement (CAVR) versus minimally invasive aortic valve replacement (MIAVR) in octogenarians. Methods: We retrospectively collected data of 75 consecutive octogenarians who underwent primary, elective, isolated aortic valve surgery through conventional approach (41 patients, group CAVR) or partial upper sternotomy (34 patients, group MIAVR). Results: Mean age was 81.9 ± 0.9 and 82.3 ± 1.1 years in CAVR and MIAVR patients, respectively (P = 0.09). MIAVR patients had lower 24-hour chest drain output (353.4 ± 207.1 vs 501.7 ± 229.9 mL, P < 0.01), shorter mechanical ventilation (9.6 ± 2.4 vs 11.3 ± 2.3 hours, P < 0.01), lower need for blood transfusions (35.3% vs 63.4%, P = 0.02), and shorter hospital stay (6.8 ± 1.6 vs 8.3 ± 4.3 days, P < 0.01). Thirty-day mortality was zero in both groups. Survival at 1, 3, and 5 years was 89.9%, 80%, and 47%, respectively, in the CAVR group, and 93.2%, 82.4%, and 61.8% in the MIAVR group, with no statistically significant differences (log-rank test, P = 0.35). Conclusions: Aortic valve surgery in older patients provided excellent results, as long as appropriate candidates were selected. MIAVR was associated with shorter mechanical ventilation, reduced blood transfusions, and reduced hospitalization length, without affecting perioperative complications or mid-term survival.

This is a case report in which the Anesthetic Management of Patients Undergoing Aortic Dissection Repair With Suspected Severe Acute Respiratory Syndrome Coronavirus Disease 2019 (COVID-19) Infection is reported

BACKGROUND: The partial pressure of carbon dioxide (pCO(2)) gap is the difference between pCO(2) values in the arterial and mixed venous blood; values higher than six mmHg may be predictive of tissue hypoperfusion. It is still doubtful if central venous blood can be used to assess the gap. This study was aimed to compare the values obtained with blood collected from the superior vena cava and the pulmonary artery.METHODS: Data were obtained from a previous study. In 30 patients who underwent on-pump myocardial revascularization, blood samples from a radial artery, the pulmonary artery, and the superior vena cava were collected eight times in the perioperative period. Two-hundred determinations were utilized to calculate the pCO(2) gap from central and mixed venous pCO(2).RESULTS: The pCO(2) gap was 8.7 +/- 2.6 mmHg in the superior vena cava, and 6.0 +/- 2.7 in the pulmonary artery. The difference between the two values fell within a wide interval between -4.1 mmHg and +9.5 mmHg in 95% of cases. pCO(2) values were significantly higher in the superior vena cava than in the pulmonary artery (mean difference 2.7 +/- 2.4 mmHg; P<0.0001), causing a systematic bias between the two estimates; such bias increased during spontaneous breathing (P=0.0249).CONCLUSIONS: pCO(2) values are higher in the superior vena cava than in the pulmonary artery. As a consequence, the pCO(2) gap calculated with the blood taken from the superior vena cava is overestimated, probably because it reflects the pCO(2) arteriovenous difference of the upper part of the body, in particular of the brain.

Background: Management of mechanical ventilation is a key issue in the prevention of postoperative pulmonary complications (PPCs) and the improvement of surgical outcome. This is especially true in cardiac surgery where the use of the cardiopulmonary bypass (CPB) increases the risk of lung injury. In the last years a growing number of studies have shown that protective ventilation has led to excellent results. However, the literature in this regard is lacking in cardiac surgery and there are no univocal guidelines in this sense. The aim of this survey was to investigate the actual clinical practice about ventilation techniques used in the Italian cardiac surgery centers. Methods: A questionnaire of 32-item was sent to 69 Italian cardiac surgery centers, 56 of which return a completed form (81.2%). The questionnaire was assembled by three independent researchers and the final version was e-mailed to all members of the SIAARTI (Italian society of anesthesia resuscitation and intensive care medicine) Study Group on Cardiothoracic and Vascular Anesthesia. The answers were collected using a Google Forms sheet. In case of multiple questionnaires returned from the same center (i.e., different physicians from the same center responded) the head of department was asked to give a definite answer. Furthermore, for the 17 centers who reported multiple questionnaires, no large differences were found between the responses of different doctors belonging to the same center (12.3%±4.2% of discordant answers). Results: Intraoperatively, patients were ventilated with a tidal volume (TV) of 6−8 mL/kg (91.1% of centers), a positive end-expiration pressure of 3−5 cmH 2 O (76.8% of centers) and a fraction of inspired oxygen (FiO 2 ) of 50−80% (60.7% of centers). During the CPB, the “stop ventilation” technique was frequently adopted (73.2%). Before the discharge from the intensive care unit (ICU) non-invasive ventilation (NIV) was never applied in 32.1% of the centers, but it was used in

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INTRODUCTION: Dynamic obstruction of right ventricle outflow tract (RVOTO) is a rare condition that may acutely cause severe heart failure. It has been reported in some hypertrophic cardiomyopathies, after lung transplantation, and in some cases of hemodynamic instability after cardiopulmonary bypass. PRESENTATION OF CASE: We report the case of a 71-year-old man who developed severe hypotension during the induction of general anesthesia for surgical coronary revascularization. Hypotension did not respond to the initial treatment with vasoconstrictors and fluids. RVOTO was suspected during pulmonary artery catheterization because of the difficulty of the catheter tip to move from the right ventricle to the pulmonary artery and, successively, because of the finding of a large gradient between the systolic pressure in the right ventricle and in the pulmonary artery. The diagnosis was confirmed by transesophageal echocardiogram (TEE). Hemodynamics recovered after the infusion of cristalloids, 1L, and the suspension of vasoconstrictors and inotropes. DISCUSSION: This is the first case in which RVOTO was observed during the induction of general anesthesia. Although this is a rare condition, the diagnostic suspect is of outmost importance because treatment is mainly based on fluid administration, and drugs with positive inotropic properties (like most vasoconstrictors) are contraindicated. CONCLUSIONS: RVOTO is an unusual, but possible cause of severe arterial hypotension during general anesthesia induction. TEE is useful for the evaluation of severely hypotensive patients who do not respond to routine treatment with fluids and vasoconstrictors.

BACKGROUND: We organized a training program for oral fiber optic intubation (FOI) under conscious sedation. The efficacy of the program was evaluated by comparing the performances of experts and novices. METHODS: The training procedure was divided into two sessions: a theoretical session on difficult airways, the fiber optic bronchoscope (FOB), remifentanil, topical anesthesia and patient interactions; and a session involving simulations of the FOI technique on dummies. For in vivo FOI, we enrolled patients requiring orotracheal intubation for elective surgery. Electrocardiograms, mean arterial pressure was railroaded over the fiberscope, and tracheal intubati6 and 7) FOIs, respectively, joined the study. To reach ±23 bpm, P=0.02), and RR was decreased (from 16±3 to 12±4 bpm, P<0.05). No differences were recorded between the experts and less-experienced anesthesiologists. The average duration of FOI was 3.3±2.0 min for experts and 4.2±2.4 min for novices (P=0.03). Procedures were successful in both groups, with patients in each group being equally satisfied with the procedures. CONCLUSION: This study highlights the importance of a structured FOI training program, demonstrating that it is possible to learn to perform FOI proficiently by practicing on dummies.

COPYRIGHT 2013 EDIZIONI MINERVA MEDICA Y E A R I N R E V I E W A year in review in Minerva Anestesiologica 2012 D. CHIUMELLO 1, M. ALLEGRI 2, F. CAVALIERE 3, G. DE COSMO 3 G. IOHOM 4, O. LANGERON 5, D. PIETRINI 3, M. ROSSI 6 1Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milano, Italia; 2Department of Surgical Clinical Diagnostic and Pediatric Science, Pain fterapy Service, University of Pavia-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; 3Istituto di Anestesia e Rianimazione, Università Cattolica Sacro Cuore, Policlinico “A. Gemelli”, Roma, Italia; 4Department of Anesthesia and Intensive Care Medicine, Cork University Hospital and University College Cork, Wilton, Cork, Ireland; 5Department of Anesthesiology and Intensive Care, Hôpital de la Pitié-Salpêtrière, Paris, France; 6Dipartimento di Anestesia, Terapia Intensiva e Terapia del Dolore, Centro di ricerche e formazione ad Alta Tecnologica nelle Scienze Biomediche “San Giovanni Paolo II”, Università Cattolica Sacro Cuore, Campobasso, Italia General anesthesia he analysis of electroencephalogram (EEG) signal is of the outmost importance in the perioperative period. It is indeed useful to evalu- ate the depth of anesthesia, particularly when muscle relaxant are used; to point out early al- terations of cerebral metabolism due to hypoxia or ischemia, such as during carotid surgery; to diagnose seizure disorders; and to titrate drugs in pharmacologically-induced coma.1 Gross EEG abnormalities (absence of electrical activ- ity, burst suppression) are immediately apparent even to non-specialists, but subtle pronounced changes are more difficult to detect. For this rea- son, some computerized systems are now avail- able that process EEG signals and provide anes- thetists with numeric scores informative of the depth of anesthesia.2 As each system is based on its own mathematical algorithm, the usefulness

Introduction. A case of massive facial edema and airway obstruction secondary to an acute sialadenitis is described that occurred a few hours after a neurosurgical procedure performed in the prone position. Literature on this topic is reviewed. Case presentation. A 73-year-old Caucasian woman underwent a right parieto-occipital craniotomy to remove a meningioma. The procedure was performed in the prone position and lasted for 7 hours. One hour after the end of surgery, left submandibular gland swelling was clearly visible and in a few hours, she developed massive facial edema. Imaging (computed tomography and magnetic resonance) showed inflammatory swelling of the submandibular and parotid glands and of the periglandular tissues, undilated excretory ducts, and complete obliteration of the pharynx lumen (pharyngeal mucosa adhered to the endotracheal tube). Analgesics, corticosteroids, and antibiotics were administered. Edema regressed from the 4th postoperative day and the endotracheal tube could be removed on the 7th postoperative day. The patient was discharged from the surgical intensive care unit on the 14th postoperative day and from hospital on the 28th postoperative day. Conclusion. This is the first case report in which acute postoperative sialadenitis caused complete upper airway obstruction: only the presence of a tracheal tube avoided the need for an emergency tracheostomy. Since edema evolves insidiously, we recommend caution when removing the endotracheal tube in patients who are acutely developing postoperative sialadenitis. © 2009 Cavaliere et al; licensee Cases Network Ltd.

Here we report a case of leptospirosis without fever during the late stage of pregnancy in which the initial clinical presentation was more suggestive of a pregnancy-related liver dysfunction rather than an infectious disease. A 32-year-old primipara at 37 week of gestation was hospitalised with a 10-day history of nausea, vomiting, and abdominal pain without fever. Initial routine blood tests showed hyperbilirubinemia, a moderate increase in transaminase levels, severe coagulopathy and an increased creatinine level. On clinical suspicion of pregnancy-related liver dysfunction such as HELLP syndrome (hemolysis, elevated liver enzyme levels, low platelet count) or acute fatty liver of pregnancy (AFLP), emergency caesarean section was performed and a healthy baby was delivered. Postoperatively, the patient was stable, but 5 days later she developed clouding of consciousness, severe jaundice and respiratory failure. At this time, an infectious disease was considered and leptospirosis was confirmed by serological tests. In conjunction with intensive care management, antibiotic therapy was given; the patient was discharged in good condition and her baby did not develop signs of active leptospirosis. While leptospirosis is rare in pregnancy, this is the first report of acute infection without fever mimicking the clinical pattern of HELLP syndrome or AFLP.