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Veno-venous extracorporeal life support (V-V ECLS or V-V ECMO) has been adopted as a rescue support in severe cases of COVID-19 ARDS. Initial reports on the use of V-V ECLS in COVID-19 patients reported very high mortality rates (57%-94%), but subsequent studies showed much lower rates (30%-40%). The aim of this study is to analyze demographic features, clinical course and outcomes of COVID-19 treated with V-V ECLS during the Italian 'third wave', in which the alpha variant was prevalent in the country.Single-center, retrospective observational study conducted at the ECLS referral center of a teaching hospital in Italy from January 1st, 2021 and October 31st, 2021.Between January and October 2021, 18 consecutive adult patients who underwent V-V ECLS for severe ARDS due to COVID-19 were enrolled. Thirteen patients (72.2%) were male, and their median age was 50 years; the median P/F ratio before V-V ECLS initiation was 43 mm Hg (IQR, 40; 56), and the median RESP score was 0.5 (IQR, -2.25; 1.0). The mortality rate at 90 days was 55.6, compared to 55.7% in non-COVID patients in our center (p 0.05); the median duration of ECLS was 29 days (IQR, 11; 32), compared to 10 days (IQR, 8; 15), in non-COVID patients (p = 0.004). Incidence of complications was high.In patients with COVID-19 ARDS receiving V-V ECLS, unadjusted mortality was similar to pre-pandemic V-V ECLS cases, while the duration of ECLS was almost three times longer and with frequent complications. This could be partly explained by the selection of very sick patients at the baseline that evolved to multiorgan failure during the course of ECLS.

International audience; This document represents the first update of the Cardiothoracic and Vascular Anaesthesia Fellowship Curriculum of the European Association of Cardiothoracic Anaesthesiology and Intensive Care. After obtaining feedback from exit interviews with fellows in training, graduate fellows, and program directors, 2 modified online Delphi procedures with questionnaires were conducted. A consensus was reached when two-thirds of responding committee members gave green or yellow ratings on a traffic light system, and >70% indicated strong agreement or agreement on a 5-point Likert scale. The new regulations include the following: (1) more flexibility in the fellows` rotation, as long as the total number of days, rotations, and cases are completed during the training year; (2) recommendation for strict compliance with national working-time guidelines; (3) no extension of fellowship training to compensate for annual and/or sick leave, unless the required minimum number of cases and rotations are not reached; (4) interruption of fellowship training for >12 months is allowed for personal or medical reasons; (5) introduction of a checklist for quantitative assessment of standard clinical skills; (6) recommendations for a uniform structure of exit interviews; (7) possibility of a 1-month training rotation in a postanesthesia care unit instead of an intensive care unit; and (8) provided all other requirements have been met, the allowance of progression from the basic training year to the advanced fellowship training year without first passing the transesophageal echocardiography examination.

En este artículo, los autores revisan el concepto de pubertaz precoz y los factores que pueden influenciar su desarrollo, en especial en las niñas y en el contexto de las medidas de aislamiento social preventivo y obligatorio durante periodos prolongados a causa de la actual pandemia por el SARS-CoV-2.

International audience; Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

Left ventricular assist device is a life-saving option in patients with end-stage left heart failure. It leads to a decrease of pulmonary arterial pressure, wedge pressure and pulmonary vascular resistences. However, a post capillary pulmonary hypertension persists in a significant proportion of patients despite adequate LV unloading. A possible explanation is the pulmonary venous congestion and subsequent decrease in the level of nitric oxide. This observation has led to an increased interest for pulmonary vasodilators, especially phosphodiesterase 5 inhibitors (PD-5 I). They enhance the nitric oxide (NO) signaling through the increase of cyclic guanosine monophosphate availability. Sildenafil allows to tritate down the iNO and succesfully extubated the patient; it has been shown to significantly reduce mPAP and PVR 2-4 weeks after LVAD implantation and to wean from inotropic support within the first 72 hours. However, whereas literature seems to support its use in the immediate postoperative period, there are not enough evidences about their long term use.

SARS-CoV-2 may cause severe respiratory failure due to massive alveolar damage. Currently, no adequate curative therapy for Coronavirus Disease 2019 (COVID-19) disease exists. By considering overall impact of COVID-19 pandemic outbreak, an increased need of extracorporeal membrane oxygenation (ECMO) support becomes evident. We report on our preliminary institutional experience with COVID-19 patients receiving venovenous ECMO support. ASAIO Journal 2020; 66:734-738.

Cardiac surgery is responsible for profound modification in body water distribution, electrolyte plasma concentration, and acid–base balance. Maintaining fluid, electrolyte, and acid–base balance it must be taken into account the alterations due to anaesthesia, the effects of cardiac surgery together with patient’s comorbidities and physiological response to the surgical stress. However the ideal approach to perioperative fluid management in cardiac surgery is still debated. The debate involves the kind of fluid to use (crystalloids vs colloids, colloid vs colloid, balanced vs unbalance solutions) and the amount of fluid to administer (liberal vs restrictive). The goal-directed therapy seems to be the best choice to guide the quantity of fluid infused, potentially impacting on outcomes. Electrolytes are always modified after cardiac surgery. With respect to the past, the benefit of their administration (in particular calcium) has been discussed in literature. In this chapter, the basis of fluid and electrolyte management in cardiac surgery patient is explained, through understanding physiology and pathophysiology.

Inhaled nitric oxide (iNO) therapy as a selective pulmonary vasodilator in cardiac surgery has been one of the most significant pharmacological advances in managing pulmonary hemodynamics and life threatening right ventricular dysfunction and failure. However, this remarkable story has experienced a roller-coaster ride with high hopes and nearly universal demonstration of physiological benefits but disappointing translation of these benefits to harder clinical outcomes. Most of our understanding on the iNO field in cardiac surgery stems from small observational or single centre randomised trials and even the very few multicentre trials fail to ascertain strong evidence base. As a consequence, there are only weak clinical practice guidelines on the field and only European expert opinion for the use of iNO in routine and more specialised cardiac surgery such as heart and lung transplantation and left ventricular assist device (LVAD) insertion. In this review the authors from a specialised cardiac centre in the UK with a very high volume of iNO usage provide detailed information on the early observations leading to the European expert recommendations and reflect on the nature and background of these recommendations. We also provide a summary of the progress in each of the cardiac subspecialties for the last decade and initial survey data on the views of senior anaesthetic and intensive care colleagues on these recommendations. We conclude that the combination of high price tag associated with iNO therapy and lack of substantial clinical evidence is not sustainable on the current field and we are risking loosing this promising therapy from our daily practice. Overcoming the status quo will not be easy as there is not much room for controlled trials in heart transplantation or in the current atmosphere of LVAD implantation. However, we call for international cooperation to conduct definite studies to determine the place of iNO therapy in lung transplantation and high risk mitral surgery. This will require new collaboration between the pharmaceutical companies, national grant agencies and the clinical community. Until these trials are realized we should gather multi-institutional experience from large retrospective studies and prospective data from a new international registry. We must step up international efforts if we wish to maintain the iNO modality in the armamentarium of hemodynamic tools for the perioperative management of our high risk cardiac surgical patients.

Background: Yoga may be an effective method to promote physical fitness, motor skills, strength, and attention to task, mindfulness and stress reduction in children. However, evidence is limited on the feasibility of conducting yoga programs for preschool children in integrated preschools (Early Intervention and Head Start). The purpose of this study is to examine the feasibility and acceptance of a yoga program in an integrated preschool. All preschoolers in this study have or are at risk for developmental delay or disability. Methods: Seventy one (71) pre-schoolers aged 3-5 years participated in a 5 week yoga program. (2 sessions/ week). Thirty-nine (39) pre-schoolers participated in pre and post gross motor measures. Teachers completed pre and post Devereux Early Childhood Assessment Clinical Form (DECA-C) to examine pre-schoolers behavioural concerns. Teachers provided anecdotal feedback on the feasibility and acceptance of the yoga program in the preschool setting. Results: The pre-schoolers improved on two of the five gross motor tests (Stepping Sideways over a Balance Beam: z=- 3.34, p=0.001and Sit-to-Stand (z=-4.29, p=0.001). One significant finding was observed for DECA-C Behavioural Control (z=-2.59, p=0.010). Conclusion: A yoga program may be feasible in the integrated preschools to promote gross motor skills. However, the DECA-C findings indicated that behavioural control (attention, focus, emotions) decreased suggesting that the yoga program may need to be revised to include more social, behavioural and interactive activities. Teachers indicated that students were eager and that they showed improved attention with better transitions among classroom activities.

Cardiac surgery patients may present many alterations of acid–base balance due to cardiac pathology, comorbidities, type and duration of surgery, and CPB. Acid–base status evaluation through Arterious Blood Gas (ABG) is the base for an adequate perioperative treatment. ABG interpretation needs more useful tools than those proposed by the Henderson–Hasselbach approach, such as anion gap, standard base excess, and strong ions difference, in order to identify the underlying acid–base disorders. In this chapter the physiology and pathophysiology of acid–base balance in cardiac patients and their consequence on perioperative management are described; an overview on ABG interpretation and its relation with diagnostic hypothesis and therapeutic management are presented.

Infusion therapy requires the use of a peripheral venous catheter (PVC), whose position can be complicated by phlebitis, defined as an inflammation of the tunica intima of a vein. Inflammation, in turn, may have mechanical, chemical, or bacterial origins [1]. Mechanical phlebitis occurs when the cannula generates friction with the wall of the vein, leading to inflammation. Chemical phlebitis is due to the infusion of fluids and medications, according to their osmolarity or pH [2]. Bacterial phlebitis is due to the presence of infectious bacteria. The main risk factors are: a high number of administrations, inadequate practices during infusion, or a lack of cleanliness of the skin before the cannula is inserted [3,4].

Body water accounts for approximately 60% of body weight; it is mainly distributed in the extracellular and intracellular spaces (ECS and ICS, respectively). The ICS contains nearly 55% of the water, and the ECS 45% (about 15 L in a normal adult). The ECS is further divided into the intravascular space (IVS), the interstitial space (ISS), and the transcellular space (TCS), containing about 15%, 45%, and 40% of ECS water, respectively. The TCS is a functional compartment represented by the amount of fluid and electrolytes continually exchanged (in and out) by cells with the ISS and by the IVS with the ISS.

The choice of a non-blood plasma substitute should be guided by the properties of the targeted fluid space. Ideal IV fluids should be isotonic, should not cause electrolyte imbalance, and should contain metabolizable anions [1]. According to blood tonicity, the infusion of hypotonic or hypertonic solutions will change plasma osmotic pressure, resulting in an abnormal water flow.

In clinical practice, it is important to distinguish whether the fluid imbalance is due to an absolute volume deficit or to a relative volume deficit and/or whether this hypovolemia presents concurrent electrolyte imbalance problems. Absolute volume deficits can be due to massive blood loss or to severe dehydration issues. Relative volume deficits can be due to vasodilatation brought about by sepsis, anesthetic drug effects, or anaphylaxis.

Background The widespread of hallux valgus surgery in a day care setting enhanced the role of regional anaesthesia in the last few years. Sciatic nerve block at popliteal fossa has been shown to provide safe and effective analgesia. Our purpose was to compare the success rate and performance time of popliteal block during resident’s training for regional anaesthesia by using nerve stimulation (NS) or combined nerve stimulation and ultrasound (NS + US). Methods 70 adult patients undergoing hallux valgus surgery were randomly assigned to receive sciatic nerve block at popliteal fossa with US+NS or NS alone with a double injection technique for peroneal and tibial branches, respectively. Two residents experienced with nerve stimulator performed the procedures after a learning phase concerning ultrasonography. A local anaesthetic solution, containing 10 mL of 0.75% ropivacaine and 10 mL of 2% lidocaine was used: 12 mL were infiltrated close the tibial nerve, and 8mL were infiltrated close the common peroneal nerve. Block success rate, sensory block onset time, block performance time were evaluated. Recourse to general anaesthesia was considered as failure. Results No differences were detected in success rate and onset time of sensory block between the two groups (P > 0.05). The time to block tibial nerve and the overall block time were significantly faster in US+NS group (P < 0.05). Conclusions Ultrasound guidance for popliteal nerve block resulted in similar success rate with a faster procedure time when compared with nerve stimulator, thus providing a possible effect on resident education and operating room efficiency.

Perioperative intravenous fluid therapy is a fundamental part of the management of any surgical procedure and a daily challenge for anesthesiologists. While historically it has been quite neglected in clinical practice, in the last few years fluid administration has received suitable interest, following several studies demonstrating its influence on the outcome of perioperative fluid management [1, 2].

AIM: To investigate the molecular events involved in liver regeneration following subtotal hepatectomy (SH) as previous studies have largely focused on partial hepatectomy (PH). METHODS: Male Wistar rats were subjected to 70% PH or 90% SH, respectively, and sacrificed at different times after surgery. Untreated and sham-operated animals served as controls. Serum and liver samples were obtained to investigate liver function, apoptosis (TUNEL assay) and transcription factors (NF-κB, Stat3; ELISA) or cytokines (HGF, TNF-α, IL-6, TGF-α, TGF-β; quantitative RT-PCR) involved in liver regeneration. RESULTS: Serum levels of ALT and AST in animals with 70% PH differed significantly from sham-operated and control animals. We found that the peak concentration 12 h after surgery returned to control levels 7 d after surgery. LDH was increased only at 12 h after 70% PH compared to sham. Bilirubin showed no differences between the sham and 70% resection. After PH, early NF-κB activation was detected 12 h after surgery (313.21 ± 17.22 ng/mL), while there was no activation after SH (125.22 ± 44.36 ng/mL) compared to controls (111.43 ± 32.68 ng/mL) at this time point. In SH, however, NF-κB activation was delayed until 24 h (475.56 ± 144.29 ng/mL). Stat3 activation was similar in both groups. These findings correlated with suppressed and delayed induction of regenerative genes after SH (i.e. TNF-α 24 h postoperatively: 2375 ± 1220 in 70% and 88 ± 31 in 90%; IL-6 12 h postoperatively: 2547 ± 441 in 70% and 173 ± 82 in 90%). TUNEL staining revealed elevated apoptosis rates in SH (0.44% at 24 h; 0.63% at 7 d) compared to PH (0.27% at 24 h; 0.15% at 7 d). CONCLUSION: The molecular events involved in liver regeneration are significantly influenced by the extent of resection as SH leads to suppression and delay of liver regeneration compared to PH, which is associated with delayed activation of NF-κB and suppression of proregenerative cytokines.