Abstracts of the ICARE 2023 77th SIAARTI National Congress

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A1

Sedation may be defined as a drug-induced depression in the level of consciousness. The purpose of sedation and analgesia is to relieve patient anxiety and discomfort, improve the outcome of the examination, and diminish the patient's memory of the event. Inadequate sedation/analgesia is to be avoided at any cost, given it may result in undue patient discomfort or patient injury because of lack of cooperation. In most cases, it can affect the endoscopist’s ability to successfully complete the procedure.

Overall, there is no consensus on optimal depth of sedation or sedative agents, however, when it comes to routine, low-risk and moderate endoscopic procedures the administration of propofol in unintubated patients, termed “monitored anesthesia care (MAC)”, paired with benzodiazepine and/or opioids, is one of the most common sedation methods for GI procedures in North America and Europe. On the other hand, Emergency upper GI endoscopy is often prolonged and complex, performed during high-risk conditions, like acute upper GI hemorrhage, sub-acute bowel obstruction/ileus, food bolus, achalasia, Morbid obesity and SpO2 < 95% with supplemental oxygen. In these patients, the upper GI endoscopy is intrinsically aggravated by the increasing risk for airway compromise and sedation can, in addition, put patients at risk of entry into general anesthesia, rendering them unconscious and potentially incapable of protecting their airway, patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.

Scarce literature can be found providing guidance on the anesthesiologic conduct during upper GI endoscopy in Emergency, and despite the above-mentioned risks, the present retrospective study conducted on 100 patients treated in the Emergency Gastroenterology Unit at AORN Cardarelli aim at demonstrating that deep sedation obtained with the administration of propofol, benzodiazepine and opioids is a safe and viable option when it comes to complex upper GI endoscopy, especially in those patients where the risk-benefit ratio for general anesthesia is not optimal. The present study can address some of the current literature’s shortages on this topic, however further studies are needed to better support these results.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A2

Introduction: Morbidity and mortality of people with disabilities are significantly higher than in the general population, this is due to the difficulty in accessing care. People with disabilities die 20 years earlier than the average of people without disabilities from causes unrelated to the cause of the disability, 30 years earlier in the case of severe intellectual disability.

The difficulty in accessing treatment is often due to the lack of collaboration and low tolerance towards the healthcare environment and for this reason physical restraint has been and is often used to provide services, even non-invasive or minimally invasive. This increases the resistance and fear of patients towards the healthcare environment, with greater difficulties in subsequent accesses.

Since 2000 with the DAMA Project (Disable Advanced Medical Assistance) and since 2017 in Tuscany with the PASS project (Assistance Paths for People with Special Needs) dedicated paths have been created to facilitate access to care for people with disabilities.

Tools: The DAMA-PASS clinic has been active in the ASL Toscana Centro, at the S. Giuseppe hospital in Empoli, managed by a multidisciplinary team made up of anesthesiologists, internists, facilitator nurses, and specialists who are involved case-by-case. The presence of the anesthetist is essential for those patients for whom it is not possible to obtain collaboration in any way except with sedation, absolutely avoiding physical restraint.

With the consent of the legal administrator, non-cooperative patients are subjected to oral sedation in the NORA regimen, this may be necessary for the execution of non-invasive tests or it may be preparatory to obtaining a venous access in order to carry out continuous sedation with intravenous drugs for invasive procedures. Oral sedation is performed with midazolam, mixed with a drink the patient likes, in the range of 0.3 mg/kg to 1.3 mg/kg.

Results: Since 2015 we have taken care of 438 patients (250 males, 188 females). Of these, 164 patients required sedation. Oral sedation involved 64 males (25.5% of the total males) for a total of 103 oral sedations and 21 females (11.2% of the total females) for a total of 28 oral sedations.

The mean midazolam dose used was 0.7 ± 0.2 mg/kg body weight in males, 0.6 ± 0.2 mg/kg body weight in females. We obtained, with an onset of 20-25', a moderate-deep sedation (RASS - 3/ - 5) which allowed the positioning of the venous access and the subsequent procedures without restraint. Complete awakening occurred spontaneously after 60-90' in 50% of the patients, for others flumazenil 0.5-0.8 mg was administered IV.

Side effects are rare: one case of bronchospasm, one case of paradoxical reaction to midazolam and three cases of resistance to midazolam. Only one case required hospitalization for observation.

Conclusions: The DAMAPASS of the San Giuseppe di Empoli hospital has guaranteed the provision of care to patients with specific needs in an appropriate and non-traumatic way, thus restoring the real right to health and dignity.

Oral sedation with midazolam has been shown to be acceptable to the patient, repeatable, predictable, reliable and safe.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A3

BACKGROUND

Patient pain is usually managed with analgesic therapy. However, recent studies have focused on non pharmacological treatments and, among them, virtual reality hypnosis - VRH - (i.e. digital sedation) is an innovative technique that reduces pain and anxiety in clinical practice. During VRH patients wear virtual lens and headphones through which they are conducted in a virtual reality, an immersive virtual experience that combines a 3D video with music, sounds and/or voice. Immersion session follows standard phases of hypnosis. During the induction phase, subjects are over the surface of the sea. They are invited to induce progressive relaxation in their body. The guidance phase brings the subjects slowly under the water. During the deepening phase, subjects follow a soothing underwater experience. The realtering phase brings the subjects progressively back into reality.

MATHERIALS AND METHODS

Our clinical experience has focused on the positioning of implanted vascular devices (PICC, PICC-PORT, FICC-PORT) in oncological adult patients (30 px control) and the combined use of VRH (30 px study).

We have previously collected informed consent, monitored vital parameters (NIPB, HR), and started VRH in the study group during the positioning of the vascular device.

At the end of the procedure we have collected a satisfactory questionnaire reported to the scale of anxiety (Hamilton Scale Anxiety).

We have also timed the procedure in both groups.

RESULTS

We have noticed that patients in the study group have evaluated virtual reality as a pleasant experience, reducing their feeling of anxiety. Vital parameters presented less variability in study group (HR started from 100 HR average to 65 HR average during the surgical procedure), meanwhile in the control group the average HR was 90 during the procedure.

In the study group the time required to carry out the procedure was shorter than control group (30 minutes in study group vs 45 minutes in control group).

CONCLUSIONS

Virtual Reality Hypnosis can improve performance combined with surgical practice, increasing patients’ compliance and reducing time necessary to carry out the procedures, that can help the cut of healthcare costs.

Authors have no conflict of interest

REFERENCES

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A4

Background

Intranasal application of drugs is widely used in pediatric anesthesia, especially for surgical premedication or diagnostic non-painful procedures [1,2]. Midazolam [3,4] and recently Dexmedetomidine [5-6] are most common drugs used as a single intranasal sedative in pediatric population. This retrospective study seeks to evaluate the efficacy and safety of intranasal dexmedetomidine plus midazolam (IN) as a sedatives for diagnostic Magnetic Resonance Imaging (MRI) examinations in children.

Methods

Children 3 to 10 years of age (Table 1), ASA 1-2, undergoing sedation for brain MRI with contrast were enrolled.

A combination of Dexmedetomidine (4 mcg/kg) plus midalozam (0,2 mg/kg) was administered IN before the procedure. The IN cohort (32 children) was matched and compared to a cohort of subjects (44 children) who underwent sedation with IN dexmedetomidine (4mcg/kg) plus endovenous midazolam (0,05-0,1 mg/kg)(EV). MRI was started when subjects reached a deep sedation, according to University of Michigan Sedation Scale (UMSS). We included only good or excellent image quality, with no or almost absent motion artifacts. We evaluated adverse events, i.e. bradycardia, desaturation, nausea, interventions and procedure times. Children were required to have a UMSS of 0 or 1, an Aldrete score > 9 to discharge.

Results

All 32 children of IN group were successfully sedated; there were no significant differences in the rate of observed adverse events/interventions in comparison to the EV cohort (Table 2).

Furthermore, the IN group had a shorter onset time (Table 3) when compared to the EV cohort (p < 0.003), which had a significant effect on procedure and recovery times (p < 0.001).

Conclusions

Total intranasal sedation may be used for children undergoing MRI scans. The IN combination of Dexmedetomidine and Midazolam is a safe and effective form of sedation in pediatric patients showing faster onset and discharge times.

Written informed consent was obtained from the parents of included children.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A5

Local perfusion on the measurement site affects the accuracy of pulse oximetry to estimate arterial hemoglobin oxygen saturation [1]. Using the ratio of pulsatile to non-pulsatile blood flow detected by the probe, the CO-oximeter measures the Perfusion Index (PI) that quantifies local perfusion [2]. Moreover, multi-wave CO-oximetry can estimate arterial partial pressure of oxygen (PaO2) between 100 to 200 mmHg calculating the Oxygen Reserve index (ORi) based on the simultaneous measurement of arterial and venous blood light absorption using a similar technology of traditional pulse oximetry [3,4]. This prospective observational study investigates if changes in PI affect the ability of ORi to estimate PaO2 in anaesthetized dogs.

Thirty anaesthetized and mechanically ventilated dogs undergoing elective procedures were connected to a multi-wave pulse CO-oximeter by a probe wrapped around the tongue to measure ORi and PI. As the pulse signal was judged stable, an arterial blood sample was analysed to obtain the PaO2. The residuals calculated from the regression model that plotted ORi over PaO2 were analysed with a linear regression to investigate the correlation between the PI measured by the device and the PaO2 measured by the blood gas analyser. To identify a range of PI with the strongest correlation between ORi and PaO2, paired measurements, organized according to ascending values of PI, were subset evenly into 4 groups containing 21 paired values (PI1, PI2, PI3, PI4), and the correlation analysis was recalculated for each.

A total of 84 paired measurements were collected, and PaO2 ranged between 72 and 288 mmHg. The median PI value was 1.41 (0.23-3.40). The correlation between ORi and PaO2 was moderate (r=0.69, p<0.001), and the residuals calculated from the regression line moderately correlated with PI (r=0.47, p<0.001). In groups PI1, PI2, PI3 and PI4, the obtained PI ranges were 0.23-0.80, 0.84-1.40, 1.41-1.90, and 2.00-3.40, respectively. No significant differences were observed in PaO2 values among groups (p=0.836). The strongest correlation between ORi and PaO2 was detected in the PI2 (r=0.89, p<0.001), while in PI4, the correlation was not significant (r=0.42, p=0.060).

In anaesthetized healthy dogs, the ability of ORi to estimate the PaO2 correctly was lower if the CO-oximeter displays a PI >2, likely because changes in the pulsatile and non-pulsatile component of lingual blood flow alter the performances of the probe. The value of PI should be taken into consideration if ORi is used to titrate oxygen therapy.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A6

Background

The presence of pain in rabbits leads to increased recovery times, stress, decreased gastrointestinal motility with reduced appetite and fecal output [1]. Composite pain scales, such as CANCRS (Centro Animali Non Convenzionali Rabbit Scale), are useful tools for pain assessment in rabbits [1,2]. NSAIDS such as meloxicam and carprofen have analgesic effects and are commonly used after elective surgical procedures; although meloxicam is a well-tested NSAID in rabbits, carprofen has been evaluated to a lesser extent [3,4]. The aim of this study was the comparison between the post-operative effects of meloxicam and carprofen after ovariectomy in rabbits.

Materials and methods

16 mixed-breed domestic rabbits, undergoing elective ovariectomy, were included in this study and divided in 2 Groups, consisting of 8 subjects each. A signed informed consent was obtained. A mix of ketamine, medetomidine and butorphanol (20, 0.4, and 0.2 mg/kg) was administered IM to obtain anesthesia, and ovariectomy was performed. The NSAIDs were post-operatively administered for three days, SQ SID: Group M, 1 mg/kg meloxicam; Group C, 2 mg/kg carprofen. All rabbits received 5 mg/kg enrofloxacin SQ SID and 1 mg/kg metoclopramide SQ BID for three days.

Rabbits were evaluated using CANCRS at 5 time points (T0: baseline, T1-T4: respectively, 6 h after surgery and at 9 am, 1.30 pm, and 6 pm the day after). Also, time of spontaneous feeding and fecal output after recovery were recorded. Statistical analysis was performed with R (v. 4.3.0), considering a significance level of p<0.05. Anova for repeated measures with Bonferroni post-hoc test was used for the analysis of the CANCRS score over time; Mann-Whitney U test was used for comparisons of CANCRS final scores and for times of spontaneous feeding and fecal output between Groups.

Results

There were no significant differences between Groups in CANCRS final score between groups at any time point (Table 1), and in times of spontaneous feeding and fecal output (both p=0.63) (Table 2).

Conclusions

The absence of differences in final scores between Groups suggests that both NSAIDs had similar effects in alleviating post-operative pain, although maximum time to fecal output was shorter in group C. The greater final score for CANCRS was at T1: however, it was beneath the score indicating pain during rabbit gastrointestinal syndrome. Meloxicam and carprofen are therefore both suitable alternatives for post-surgical pain management in female rabbits undergoing ovariectomy.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A7

Background

Methylphenidate, an inhibitor of dopamine and norepinephrine reuptake transporters, has been suggested to shorten and improve anesthesia recovery [1-3]. In a previous study, we have demonstrated its lack of effect when administered at the end of anesthesia in experimental pigs. The aim of the present research was to evaluate if its administration at extubation would enhance anesthesia recovery.

Materials and methods

Sixteen healthy pigs, 10.0 ± 0.6-week-old (mean ± standard deviation), weighting 28.9 ± 4.7 kg, and of mixed sex (ten females and six castrated males) were included in this experimental, randomized study. A sole propofol infusion was started at a rate of 10 mg/kg/hour and increased by 10 mg/kg/hour every 15 minutes, until reaching an electroencephalographic suppression ratio (SR; as calculated by the SedLine monitor) >80%. Afterwards, propofol was stopped and the pig let recovery. Immediately after extubation, either saline (group SL) or methylphenidate 20 mg/kg (group MP) was administered IV. The following parameters were assessed at baseline, 5 (TP5), 10 (TP10) and 15 (TP15) minutes after methylphenidate administration: heart rate, respiratory rate, diastolic (DAP), mean (MAP) and systolic (SAP) blood pressure, nociceptive withdrawal reflex thresholds, patient state index (PSI), suppression ratio, spectral edge frequency 95% right (SEF r) and left (SEF l). Moreover, time to return of palpebral reflex and jaw tone, and time to return to a PSI of 50, 60, 70 and 80 was calculated. Comparison among groups was performed using the two-way repeated measure ANOVA followed by the Bonferroni test in case of parametric data and the Kruskal-Wallis test followed by the Dunn's Method in case of non-parametric data.

Results

Significantly higher DAP was found at TP5 in group MP compared to group SL (p=0.046). Significantly higher SEF r values were found at TP5 in group MP compared to group SL (p=0.038). No other significant differences were found.

Conclusions

The present research confirms the results of our previous study. No clinically relevant improvements in anesthesia recovery were achieved when administering methylphenidate at extubation in experimental pigs.

Ethical approval (protocol 32015) was obtained from the committee for animal experiments, canton Bern.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A8

Background

Due to the lack of antagonists, recovery from anesthesia relies on drugs clearance. The difficulty of controlling such a delicate phase leads to increased risks for the patient, costs and prolonged recovery. Different than pharmacological antagonization, the inhibitor of dopamine and norepinephrine reuptake transporters methylphenidate has been shown to stimulate arousal pathways [1–3]. The aim of the present study was to evaluate the effect of methylphenidate on anesthesia recovery from propofol in experimental pigs.

Materials and methods

Five healthy pigs, 10.4 ± 0.5-week-old (mean ± standard deviation), weighting 25.8 ± 1.8 kg, and of mixed sex (one female and four castrated males) were included in an experimental, randomized, cross-over study. Each pig was anesthetized three times, ensuring a wash-out period of at least 36 hours. Sole propofol was administered intravenously (IV) to effect until intubation. A continuous IV infusion was simultaneously started at 20 mg/kg/hour and increased every ten minutes by 6 mg/kg/hour, together with an additional IV bolus of 0.5 mg/kg. Once electroencephalographic suppression ratio (as calculated by the SedLine monitor) reached a value between 10% and 30%, propofol was stopped and either saline (group SL), methylphenidate 10 mg/kg (group MP10) or methylphenidate 20 mg/kg (group MP20) was administered IV. The following parameters were assessed at baseline, 5 (TP5), 10 (TP10) and 15 (TP15) minutes after methylphenidate administration: heart rate, respiratory rate, diastolic (DAP), mean (MAP) and systolic (SAP) blood pressure, nociceptive withdrawal reflex thresholds, patient state index (PSI), suppression ratio, and spectral edge frequency 95% right and left. Moreover, time to extubation, time to return of palpebral reflex and jaw tone, and time to return to a PSI of 50, 60, 70 and 80 were calcualted. Comparison among groups was performed using the two-way repeated measure ANOVA followed by the Bonferroni test in case of parametric data and the Kruskal-Wallis test followed by the Dunn's Method in case of non-parametric data.

Results

Significantly higher MAP (p=0.042) was found at TP10, and significantly higher SAP (p=0.049) at TP15 in group MP10 compared to group SL. Significantly longer time was needed in group MP20 compared to group SL (p=0.015) to regain jaw tone, and in group SL compared to group MP10 (p=0.039) to reach a PSI of 80. No other significant differences were found.

Conclusions

Methylphenidate does not shorten or improve anesthesia recovery in experimental pigs. Cardiovascular parameters seem to be only marginally affected.

Ethical approval (protocol 32015) was obtained from the committee for animal experiments, canton Bern.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A9

Introduction

Legionella Pneumophila is one of the most important causes of respiratory infections in humans and it is the cause of about 30% of nosocomial infections.

Anastomotic leakage following the intervention of esophageal resection presents one of the surgical complications with the highest morbidity and mortality.

Case reports

For the past year we have faced a case of anastomotic leakage post esophageal resection, treated through the application of an endoprosthesis esophageal in a patient affected by L. Pneumophila.

The main problem for the anesthetist during this procedure is identifying the most inadequate perioperative management.

In this specific case, the patient, affected by L. Pneumophila, presented a PO2/FiO2 ratio between 100mmHg and 200mmHg, giving rise to a moderate ARDS panel according to Berlin Criteria (Image 1).

For this reason, we decided to use a non-invasive periprocedural ventilation mode, specifically the High Flow Nasal Cannula (HFNC), to reduce the risk of postoperative pulmonary complications due to invasive ventilation through endotracheal intubation (ETI).

The parameters set during the entire procedure remained stable: Flow 60 L/min, FiO2 100%, Temperature 37 °C.

The patient, opportunely mixed with the current type of anesthesiological procedure and immediately after signing the Informed Consensus, is premedicated with intravenous Midazolam 0.05mg/Kg, while sedation is effected with an initial bolus of Propofol at 0.5mg/Kg. Successively, sedation is maintained whit Propofol in continuous infusion at 3.5mg/Kg/h.

The approximate duration of the procedure is 25 minutes. The patient's vital parameters are stable for all the duration of the intervention, with a SpO2 > 95%, and a MAP > 70 mmHg.

After the procedure, the patient is returned to the Intensive Care unit where he has completed the course of antibiotic therapy, with a progressive reduction of the need for oxygen therapy.

Conclusion

Airway management in patients with L. pneumophila can be a problem, aggravated by a series of additional risks related to ETI, such as pulmonary damage from mechanical ventilation, contamination of the ventilator, delayed weaning and an increase in hospital stay days. The use of HFNCs in endoscopic procedures allows to avoid these risks, eliminating the operating field conflict with the surgical procedure and guaranteeing a higher oxygen saturation compared to other oxygenation devices.

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A10

Background

The COVID-19 pandemic led to significant changes in the management of surgical patients. Elective surgery underwent a strong reshaping, whereas urgent and emergency procedures continued.

The aim of this retrospective study was to evaluate postoperative mortality rate and thrombotic events in SARS-CoV-2 positive patients undergoing urgent or emergency surgery.

Materials and Methods

After local Ethic Committee’s approval, we reviewed all records of the SARS-CoV-2 positive patients who underwent urgent or emergency surgical procedures between April 2020 and October 2022 in the emergency department of IRCCS Fondazione Policlinico Universitario Agostino Gemelli of Rome.

We included patients who tested positive for both antigenic and molecular SARS-CoV-2 specimens in the time range that goes from 5 days before to 1 day after surgery.

Postoperative mortality rate and the percentage of thrombotic events were evaluated. Mortality rate was specifically assessed on the first postoperative day, between the second and the fifth postoperative day and after 5 postoperative days.

Surgical procedures are summarized in Table 1.

Results

From April 2020 to October 2022, 6387 patients underwent urgent or emergency surgery, 160 of which reported a positive SARS-CoV-2 test. Our patients’ mean (SD) age was 57 (23) years old.

A total of 40 SARS-CoV-2 positive patients died after surgery so the overall mortality rate was 25%: 16 patients died on the first postoperative day (40%), 11 patients died between the second and fifth postoperative day (28%) and 13 patients died after the fifth postoperative day (13%). Dead patients’ mean (SD) age was 73 (15) years old.

Postoperative thrombotic events occurred in 11 patients (7%).

The distribution of fatality and thrombotic events per year are reported in Figure 1 and Figure 2.

Conclusions

Despite the lack of comparison our study provides evidence of what happened during the pandemic period in a high volume COVID-19 hospital.

SARS-CoV-2 positive patients undergoing urgent or emergency surgical procedures during the pandemic had a high risk of mortality and of postoperative thrombotic events.

Even though the highest distribution of SARS-CoV-2 positive patients occurred in 2022, the mortality rate per year resulted higher in 2020, probably due to a lower sensitivity and specificity of the tests used at the beginning of the pandemic and also to the lockdown condition that significantly reduced access to emergency departments.

The results of this study emphasize the importance of carefully evaluating risks and benefits of performing urgent or emergency surgery in SARS-CoV-2 positive patients and the need to implement strict postoperative monitoring to prevent the complications to which these patients are highly susceptible.

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A11

Background

ERAS guidelines recommend multimodal analgesia strategy for patient undergoing liver surgery and individuate intrathecal opiates as a viable alternative to thoracic epidural analgesia (TEA) with less associated hemodynamic instability [1].

Intrathecal opiates administration reduces the need for systemic opiates that have more undesired side effects, including postoperative nausea and vomiting (PONV), itching and respiratory depression. The use of atropine also seems to contribute to reduction of PONV [2].

Materials and Methods

We conducted an observational retrospective study, including patients over 18 years of age undergoing laparotomic liver surgery. Our objectives were: to compare intrathecal morphine (100-200 mcg) versus TEA and total intravenous analgesia in terms of pain intensity and need for rescue analgesics in the postoperative period; evaluate the incidence of side effects such as PONV, itching and respiratory depression in patients undergoing laparotomic liver surgery after administration of intrathecal morphine.

Data were collected at 0, 3, 6, 12, 24 and 48 hours after surgery. To assess the intensity of pain (static and dynamic) we used the NRS scale, dividing the patients into 4 groups with no (NRS 0), mild (NRS 1-3), moderate (NRS 4-5) and severe pain (NRS>5).

Results

Data from 171 patients were analyzed. Eighty-seven patients received only intravenous analgesia, seventy intrathecal morphine and fourteen TEA.

We found no significant difference in static NRS between the three groups of patients; we recorded significant difference in dynamic NRS between intrathecal opioid group and total intravenous analgesia group, while we didn’t find significant difference in dynamic NRS between intrathecal opioid group and TEA group. There was no significant difference in incidence of side effects (e.g. PONV) between the three groups of patients.

No major complication followed intrathecal morphine administration.

Conclusions

Intrathecal analgesia has shown to be effective in post-operative pain control in the first 24-48 hours after surgery. Dosages of 100-200 mcg of morphine seem to be safe and also it seems that using atropine as adjuvant could be useful to reduce side effects such as PONV.

In conclusion somministration of intrathecal opioid seems to be a valid alternative to TEA and a better analgesia strategy than total intravenous analgesia.

Data were collected from elettronic-database, patients expressed informed consent to data collection in University-hospital

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A12

Background

Opioid administration remains the mainstay of therapy for post-surgical pain; still these drugs have undesired side effects, including postoperative nausea and vomiting (PONV), delayed recovery of bowel function, itching and respiratory depression. Multimodal analgesia is recommended by ERAS guidelines as a strategy to reduce side effects and obtain a better pain control [1]. Spinal analgesia has a high efficacy and relatively low complications [2]. The use of atropine as adjuvant could reduce PONV [3].

Materials and Methods

We conducted an observational retrospective study, including patients over 18 years of age undergoing major abdominal surgery who received intrathecal analgesia with morphine at a dose of 100-200 mcg. Analgesic effects were evaluated by means of the VAS score (NRS scale) for pain intensity and need for rescue analgesics. In addition, the incidence of PONV and respiratory depression were collected.

Data were registered at 0, 3, 6, 12, 24 and 48 hours after surgery. NRS scale was used to divide the patients into 4 groups with no (NRS 0), mild (1-3), moderate (4-5) and severe pain (>5).

Results

Data from 700 patients were analyzed. Graphic 1 and 2 summarize the results on analgesia and Graphic 3 shows the incidence of PONV. No major complications were recorded and 26 patients (3.71%) experienced pruritus.

Conclusions

Intrathecal morphine has shown to be effective in post-operative pain management during the first 48 hours after surgery. Dosages of morphine of 100-200 mcg seem to be safe in terms of respiratory depression.

Data were collected from elettronic-database, patients express informed consent to data collection in University-hospital.

References

Bild vergrößern

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A13

Current pediatric preoperative fasting guidelines have recommended conservative fasting regimes for many years without significant updates in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. The development of a liberal protocol with a strict application may warrant a shorter period of fasting before pediatric surgery. Essentially, we allowed clear fluid fasting within 1 hour, mother's milk within 3 hours, non-human milk and 'light breakfast' within 4 hours and last meal within 6 hours. The aim of this study was to evaluate the actual times of clear fluid fasting in children undergoing surgery in an institution where fasting was standardized according to the recent European guidelines. A retrospective analysis of fasting times according to local monitoring forms was conducted in a 6 months period. The local ethics committee approved the study. Overall 1000 patients were enrolled in the study. Median (interquartile) age was 7 (3-12) years. All surgeries except cardiac were included. The first 421 children were selected as initial protocol application (group START) in the first 2 months after protocol publication and providers training. START children data were compared to the remaining cases in order to verify if adherence to the protocol tended to improve (group APP). Clear fluid fasting was 180 min (110-342) in START group and 160 (96-320) in group APP (p=0.08) (figure 1).

The improvement was slightly more evident when patients scheduled after the first case (i.e., after 9.30 AM) were analyzed: in this case clear fluid fasting was 207 min (120-345) in START group and 180 (105-306) in group APP (p=0.028). There were 84 adverse events (i.e., hypotension/bradycardia at induction and difficulty to achieve venous access) related to preoperative fasting. At logistic regression these events showed a significant association with duration of clear fluids fasting (OR 0.12 95%CI 0.09-0.17; p=0.02) with a median fasting time in children with presence of adverse events of 377 (210-660) minutes vs 170 (100-351) in children without. Our study showed several important information: 1) in an institution were clear fluids fasting is allowed up to 60 minutes before surgery, median times do not tend to decrease below 2-3 hours. This is essentially due to unwillingness of patients and relatives to provide fluids and to the scarce explanation of the involved healthcare providers to consistently explain this aspect to the patients. 2) Interestingly, some tendency to improvement was observed between START and APP. Then, apparently, fasting times are not influenced by the time of scheduled surgery, even if the APP group seemed to improve with respect to START in the subgroup of 'later' cases. 3) Clear fluid fasting is indeed associated with adverse events related to fasting and this further underlines the importance of respecting protocol times. Further monitoring of fasting times will allow us to appraise if the slight trend to improvement in the APP population will achieve a significant value in the next months and if practices to endorse such improvement will need to be considered.

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A14

Background

Postoperative respiratory complications are a major cause of mobidity and mortality during the postoperative period. The PRISM trial investigated the effect of postoperative CPAP via helmet device on PPCs. Although the PRISM trial did not found any statistically significant difference in terms of PPCs [1], CPAP is still widely used in the treatment of respiratory failure during postoperative period. The effect of CPAP via helmet on intra-abdominal pressure still not well investigated.

Materials and Methods

After obtaining informed consent, as a sub-study of the PRISM trial, we enrolled 22 patients that underwent major abdominal surgery and we started CPAP via helmet device according to the PRISM study protocol. We performed arterial BGA and measured intra-bladder pressure through urinary catheter as an indirect measure of intra-abdominal pressure [2]. The measures were obtained before starting CPAP (T0), after 30 minutes (T1) and 4 hours (T2) of CPAP.

Results

All of the patients underwent CPAP via helmet for at least 4 hours. The median level of PEEP administered was 7.5 cmH2O [5-7.625]. At T0, 5 patients (22%) had an IAP equal or grater than 12 cmH2O (cutoff value for defining Intra-abdominal Hypertension [3]). At T1 and T2, 10 (45%) and 12 (55%) patients respectively met the criteria for IAH. 6 patients (27%) with normal IAP values at T0 developed grade 1 or 2 IAH at T1 and/or T2. The mean IAP was 8.57±3.82 at T0, 10.20±4.36 at T1 and 11.16±4.16 at T2. We found a statistically significant increase in the IAP between T0 and T2 (p=0.0012). We found a statistically significant increase in P/F ratio between T1 and T2 (p=0.023) but not between T0 and T1 (p=0.27). No statistically significant variations were found in creatinine levels before and after the CPAP (p=0.48).

Conclusions

IAP was significantly higher after 4 hours of CPAP. In 6 cases, IAP increased from normal values to over 12 cmH2O during CPAP.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A15

Background

Perioperative anxiety is one of the most impacting aspects on the patient's quality of life in the perioperative period. This pilot study, which started on February 7, 2019 and ended on January 29, 2020, has as primary objective to investigate the role of anxiety in the context of general anesthesia during elective abdominal surgery in adult patients, clarifying the correlation between the extent of anxiety state and the level of pain in the postoperative period.

Materials and Methods

This is a prospective, observational, single-centre study. Participants were adults patients undergoing videolaparoscopic cholecystectomy. Informed consent was obtained for each patient. Anxiety before surgery and 1 day postoperatively were measured using the APAIS (Amsterdam Preoperative Anxiety and Information Scale) questionnaire, while pain was investigated by using NRS (Numeric Rating Scale) and VAS (Visual Analogue Scale). Along with these, other clinical variables were recorded (Fig. 1).

Results

31 patients were included in the pilot study, 22 female and 9 male. Mean age was 57 years. An average score of 11.06 on the APAIS scale was observed in the postoperative period versus an average score of 13.38 in the preoperative period, highlighting how patients tended to have less anxiety in the postoperative phase than in the preoperative one. Correlating the APAIS questionnaire score with the postoperative pain by NRS scale and setting a value greater than/equal to 4 as a cut-off, 21 out of 31 patients (67.74%) had an NRS greater than or equal to 4, and of these 15 had an APAIS score greater than or equal to 14 (above the calculated mean); at the opposite, 10 out of 31 patients had an NRS less than or equal to 3, of these 8 had an APAIS score less than or equal to 13 (below the calculated mean).

Conclusions

The results of this study show that highly anxious patients tend to present more pain postoperatively, while moderately anxious patients present less pain postoperatively. It becomes therefore important to create perioperative programs that can not only manage pain in the postoperative phase with the existing pain services but also recognize, investigate, and treat the patient's anxious state preoperatively, in order to create more patient-centered pathways.

In addition, this pilot study may give the basis for further studies to understand the pathophysiological processes that correlate anxiety with pain, such as inflammatory status and/or other perioperative variables.

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A16

Background

Postoperative nausea and vomiting (PONV) is a condition that can occur in the immediate postoperative period up to 24 hours after surgery. PONV is usually a self-limited adverse event, treated without sequelae, but it could lead even to severe complication [1]. This condition is still underestimated but a comprehensive multimodal approach should be indicated facing high-risk patients.

Case report

A 42-years old woman scheduled for elective bilateral breast implant replacement, ASA score I, BMI 23.03, nonsmoker, reported previous episodes of severe PONV following general and neuraxial anesthesia and motion sickness. She was considered a risk 4 based on simplified Apfel score. She refused a loco regional anesthesia, so a multimodal strategy was proposed to reduce the risk of PONV.

In pre-anesthesia, premedication was given iv with ondansetron 4 mg and dexamethasone 4 mg while magnetic beads were positioned on the surface of both ears’ skin, in antiemetic points (Figure 1).

In the operating room, after multiparametric monitoring, general anesthesia was induced with propofol in Target Controlled Infusion (TCI) 3 mcg/ml and remifentanil TCI 2 ng/ml. Intraoperative maintenance was ensured by a bolus of fentanyl 100 mcg, remifentanil TCI (2-3 ng/ml), ketamine 0.8 mg/kg and midazolam 10 mg both in refracted doses. Towards the end of the surgery, acetaminophene 1g, ketorolac 30 mg, and metoclopramide 10 mg were administered. In the emerging phase, remifentanil was discontinued and propofol was reduced to 1 mcg/ml until the patient resumed spontaneous breathing. The patient was successfully extubated and propofol infusion terminated.

The patient stayed under observation for about 45 minutes in the Recovery Room. She wasn’t agitated and denied PONV.

During the 24 hours after surgery, the patient didn't experienced either nausea or vomiting or pain and was in complete well-being for the discharge.

Conclusion

Preventing PONV in high-risk patients should require a multimodal strategy to reach a safe postoperative recovery. In our case we provide a multimodal strategy based on three cornerstones. Total intravenous anesthesia technique with opioid sparing approach is nowadays considered the gold standard technique [2]. The use of pharmacological prevention and homeostasis maintenance during surgery has been proved as effective in reducing emetic stimulus [3]. We add in this case a non-pharmacological approach using acupuncture technique, useful for PONV managing [4]. In view of this multimodal strategy, we hope that in the future acupuncture approach will be more used as well as the pharmacological approach.

Informed consent to publish had been obtained.

References

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A17

Background

The Newborn Infant Parasympathetic Evaluation (NIPE) is a Heart rate variability-based technology, developed in 2015, for assessing pain and comfort in neonates under 2-years-old, including premature infants. It is an adaptation of the Analgesia Nociception Index (ANI), developed for monitoring adults and children > 2 years, during surgery under GA. NIPE estimates HR, HF oscillations (> 0.15 Hz), reflecting parasympathetic activity. The monitor displays 2 values, ranging from 0 to 100: the instant-NIPE (NIPEi) and the mean-NIPE (NIPEm). A decrease in NIPE score is interpreted as indicating an increased stress level, whereas an increase in NIPE score indicates improved comfort. According to the manufacturer, NIPE value <50 is indicative of either discomfort, stress, or pain.

Little is known about the performance of the NIPE in anesthetized neonates and infants.

The aim of this study was to investigate the effectiveness of NIPE in predicting painful stimuli, in newborns undergoing GA, and the impact on the need of postoperative analgesia.

Methods

In this single center, prospective, observational pilot study, 28 infants, aged <15 months and weighting <10Kg were recruited for correction of craniosynostosis. Patients were compared in two groups: the NIPE group received Fentanyl (1-2 mcg/Kg) according to the NIPE value (NIPE score< 50); the Control group received Fentanyl (1-2 mcg/Kg) relying on changes in heart rate and blood pressures, together with other clinical signs such as sweating or movements. The primary endpoint was to investigate the ability of the NIPE and heart rate to detect an insufficient antinociception. The secondary endpoint was the correlation between NIPE values and heart rate and the amount of postoperative analgesia.

Results

For statistical analysis Student’s T test was used for unpaired data. A p=0.05was considered statistically significant. A reduction in the use of fentanyl in the NIPE group is evident, with a mean of 12 mcg versus the 22mcg of the control group (Figure 1).

A wide inter-variability was found in the control group. The Pearson’s chi-square test was used for the secondary objectives. NIPE group showed a tendency to match heart rate values and NIPE value reduction at various times of surgery with no significant statistically difference.

Conclusion

This study provisionally suggests the ability of the NIPE to detect insufficient antinociception and is valuable in reducing the amount of opioids really needed by the infant.

References

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A18

Background. Obstructive sleep apnea syndrome (OSAS) is a frequent pathology: it is estimated that 25% of all patients admitted for elective surgery suffer from OSAS and that more than 80% of them are unaware of it. OSAS is known to be responsible of serious postoperative complications, especially respiratory and cardiovascular, including deaths that are often referred generically to cardiac arrest.1 Guidelines propose decision-making flow charts to manage the most critical aspects of the perioperative path, guiding the screening and identification of patients with suspected OSAS and guiding the planning of pre-, intra- and post-operative care levels.2

Case report. A 35-year-old female with grade I obesity (BMI 35.5) and no other comorbidities underwent videolaparoscopic cholecystectomy. The medical history did not report neither snoring nor daytime sleepiness, and the STOP-Bang questionnaire showed a mild risk for OSAS (score 3).

According to the SIAARTI 2019 OSA screening score, she was classified among patients with a mild risk of OSA (score 1), with a BMI > 35 but with gynoid-type obesity, a neck circumference of 37 cm, and a negative SpO2 test (SPO2 >90% in sitting and supine positions). Moreover, the risk associated with the surgical and anesthetic procedures was moderate (interventional procedure under general anesthesia, score 2). Considering these factors, the risk to be attributed to the patient was to be considered not increased (score 3). After the surgical procedure, the patient was discharged to the ward with SpO2 monitoring, and about 10 minutes after discharge she undergoes cardiocirculatory arrest caused by respiratory arrest. ROSC was obtained rapidly and recovery of consciousness as well, without neurological deficits. On the first postoperative day, episodes of arterial desaturation during sleep were observed, and, in the suspicion of OSAS, pneumologist indicated a polysomnography that confirmed a severe OSAS.

Conclusions. STOP-Bang questionnaire is a good screening tool, but it does not identify all undiagnosed cases of OSAS. Therefore, even in patients at not-increased/low risk for OSAS, the measurement of SpO2 is useful during the post-operative time especially if the risk associated with the surgical and anesthetic procedures is moderate/high. In these situations, the increased levels of analgesia/sedation can have a negative impact on predisposed patients.

Informed consent to publish had been obtained.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A19

BACKGROUND

In morbid obesity, central fat accumulation pushes a significant load on the respiratory system, with decreased of lung volumes, lung/chest wall compliance and increased airways resistance.; all contributing to higher breathing work and shorter safe apnea time.

Obstructive Sleep Apnea [1] affects 2/3 of morbidly obese individuals undergoing bariatric surgery. Perioperative continuous positive airway pressure (CPAP) is advised for moderate/severe OSA to avoid respiratory failure.

Obesity Hypoventilation Syndrome [2] is a respiratory consequence of morbid obesity characterized by alveolar hypoventilation during sleep and wakefulness. It involves an interaction between impaired respiratory mechanics, ventilatory drive and sleep-disordered breathing.

AIM

In our Hospital we currently submit the STOP-BANG questionnaire [3] to all candidates for bariatric surgery, to identify moderate/high risk for OSA in order to direct them to specialistic evaluation and start CPAP treatment. Patients with the clinical features of OHS undergo blood gas analysis: if hypoxemia and hypercapnia (>45mmHg) are present, then CPAP treatment should be considered (Figure 1).

METHODS

Retrospective observational study (Jan. 2021 - Dec. 2022). 156 adult patients enrolled (M 33, F 123), undergoing laparoscopic bariatric surgery. Mean BMI for women: 40.96 (min 31,56; max 54,11), for men: 41.86 (min 32,53; max 53,07). Of these subjects, 70 (45%) had or received a diagnosis of OSA/OHS, and perioperatively used CPAP (Table 1).

RESULTS

No patient receiving perioperative CPAP and undergoing LBS (sleeve gastrectomy) had respiratory complications nor showed respiratory issues during the induction of general anesthesia, and none of them was admitted to ICU for postoperative care due to respiratory insufficiency.

CONCLUSIONS

Based on our experience, we can argue that an adequate perioperative ventilation strategy is useful in patients with OHS/OSA candidates for bariatric surgery [4], also for ERAS (Enhanced Recovery After Surgery) protocol applicability [5]. We should preoperatively investigate these pathologies in order to direct patients to the appropriate treatment to minimize the risk of respiratory failure.

Informed consent for the publication of these clinical data has been obtained from the participants.

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A20

BACKGROUND

As known in the literature, opioids, due to their breath-depressing effect, can be dangerous for obese patients, who often suffer from disorders such as obstructive sleep apnoea (OSA) and hypoventilation syndrome (OHS) [1,2,3].

At recommended doses [4,5], perioperative i.v. lidocaine is considered safe and effective in ensuring adequate pain control in patients undergoing laparoscopic bariatric surgery (LBS), without the aid of opioids [5,6].

AIM

The present observational retrospective study aims to address the feasibility of opioid free anesthesia OFA with i.v. lidocaine, evaluating its safety and effectiveness in LBS.

METHODS

Clinical data of all patients undergoing LBS at L. Galmarini Hospital (Tradate, Italy) between Jan 2021 and Dec 2022 were retrospectively collected. We entrolled 156 adult patients (M 33, F 123). Mean BMI for women: 40.96 (min 31,56; max 54,11), for men: 41.86 (min 32,53; max 53,07).

We tested a protocol of opioid free anesthesia OFA using i.v. lidocaine (Figure 1).

All patients were evaluated in terms of postoperative pain control according to the Numerical Rating Scale (NRS). Adequate control of postoperative pain was considered reached with NRS lower equal to 4 (24/48 hours).

RESULTS

The protocol used ensured adequate anesthesia and pain control.

Of all patients, 3% did not require post-operative analgesia, 21% required i.v. paracetamol only on the first day at a dose of 1 g every 8 hours, the remaining percentage (76%) required i.v. paracetamol 1g every 8 hours and from 1 to 3 doses of i.v. ketorolac, exclusively during the first day (Graphic 1).

No adverse effects related to i.v. lidocaine were noted during the perioperative time.

CONCLUSIONS

Based on our experience and supported by the literature, we can state that the use of i.v. lidocaine in LBS seems to be safe and effective in reducing consumption of opioids, improving quality of recovery [5].

The results obtained (considering the advantages of an opioid free anesthesia OFA, the easy and safe applicability of the protocol, and the reduced adverse effects associated with the use of i.v. lidocaine) encourage further studies.

The opioid sparing effect of systemic i.v. lidocaine could be a significant criterion to better investigate its efficacy for the applicability of ERAS (Enhanced Recovery After Surgery) protocols [7].

Informed consent for the publication of these clinical data has been obtained from the participants.

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A21

CASE REPORT

A 75 years old patient whose characteristics are reported in Table 1 was admitted for a programmed laparotomic radical cystectomy due to bladder cancer.

General anesthesia was obtained with target controlled infusion (TCI) of Propofol with Eleved Model [1], TCI of Remifentanil [2], Midazolam, Ketamine and Rocuronium. Other drugs administered are reported in table 1. The patient remained normothermic and hemodynamically stable, even though due to blood loss > 1 l and anemization he was transfused.

At awakening the patient was extubated and transferred to the intensive care unit (ICU) for postoperative monitoring with optimal haemodynamic, neurological and antalgic control.

A few hours after the admission in ICU he reported a blunt abdominal pain, mainly on the right side, nausea and the exams showed increased amylase levels, urologists excluded any surgical involvement of pancreatic tissue and suspected a transient sphincter of Oddi dysfunction [3]. After one night in ICU he was transferred to the urology ward due to his clinical stability, even though Amylase peaked at 2340 U/l. Two days later abdominal pain increased to severe, with characteristics of peritonism and increased inflammatory markers. An abdomen-thorax CT scan revealed acute pancreatitis (AP) (Figure 1) and he was transferred to ICU. He started a standard treatment for acute pancreatitis and antibiotic therapy [4].

On postoperative day nine, due to general deterioration of clinical conditions and further anemization that required blood transfusion, he underwent an emergency laparotomy, in which propofol was not used as an anesthetic drug, that found a completely necrotic pancreas. The following day he faced a multi organ failure (MOF) which rapidly led to death. Consent to publish the case report was accorded by the family.

Acute pancreatitis (AP) Is a complex and severe disease with a high mortality rate [4]. Propofol, is a common anesthetic drug which is widely used in daily practice for sedations and general anesthesia [5], few cases of Propofol Induced AP have been published, in which the diagnosis has been made excluding more common causes [6].

In fact, Propofol is listed as a possible cause of AP, class Ib, based on the classification of Badalov et al. [7]. Following the scheme proposed by the systematic review by Haffar et al for Propofol induced AP [6] we could confirm that our hypothesis is plausible. He satisfied the American College of Gastroenterology criteria for AP [8,9] and it is classified as severe acute pancreatitis according to the Revised Atlanta Classification with peripancreatic necrotic fluid collection [10]. Marshall score [11] after admission was two and Naranjo et al [12] probability scale for drug adverse reaction was three, meaning that the adverse reaction is possible. Latence according to Badalov et al [7] has been short or intermediate. Exclusion of other plausible causes, timing of pancreatitis symptoms and previous cases in literature support our hypothesis of propofol induced pancreatitis.

Informed consent to publish had been obtained.

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A22

Background

Patent Blue V (PBV) is used in plastic surgery for sentinel lymph node identification in breast cancers and cutaneous melanomas. Other less allergenic molecules are often preferred over this dye. Currently, propelled by the widespread adoption of lymphatic reconstruction techniques, the use of PBV is strongly re-emerging in clinical practice.

Case report

The patient of our clinical case report is a 60-year-old woman (ASA 2, no history of allergies) admitted to the plastic surgery unit of the IRCCS -Regina Elena National Cancer Institute, Rome, undergoing removal of the left breast prosthesis, debridement of homolateral axillary scar tissue and total breast reconstruction with bipedicled deep inferior epigastric perforator (DIEP) and lymph node flaps. During the procedure, approximately 30 minutes after the intradermal injection of 2 ml of 2.5% PBV sodium salt (50 mg) in the right lower limb, the patient experienced a slight reduction in SpO2 (from 100% to 96%), unresponsive to increased inspiratory fraction of oxygen, and methemoglobinemia was detected in blood gas analysis (maximum value 4.5%), which did not require any treatment. Additionally, a generalized bluish skin discoloration and bluish-greenish urine were observed. No significant hemodynamic, respiratory or hemogasanalytic changes were observed during the procedure; therefore, the decision was made to continue with the surgical intervention. At the end of surgery, the patient was transferred conscious, alert, and cooperative to the Intensive Care Unit (ICU) for postoperative monitoring. The postoperative course in ICU was uneventful and the patient was transferred to the plastic surgery department the following day.

Conclusions

The frequency of allergic reactions to PBV has been estimated to be between 0.2% and 2.7% [1]. Preoperative antiallergic prophylaxis does not prevent anaphylactic reactions but it may reduce their severity.

When administering blue dyes, including PVB, the SpO2 value measured by pulse-oximetry may falsely decrease; therefore, in such cases, serial arterial blood gas analysis is recommended to assess any respiratory exchange abnormalities [2]. Blood gas tests may show falsely elevated methemoglobin values when measured by spectrophotometry [3]. False SpO2 values and methemoglobinemia appear to manifest only when their evaluation is performed in the presence of moderate-to-high blood concentrations of blue dyes using the photometric method. Finally, it is worth noting that in a limited number of cases described in the literature, after the administration of Patent Blue V, the appearance of methaemoglobinemia has occurred, which sometimes has also required treatment.

Informed consent to publish had been obtained.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A23

Introduction

We aimed to investigate the positive effects of low-flow sevoflurane anesthesia on the emergence and recovery periods in pediatric patients undergoing adenotonsillectomy.

Material and Methods

The study was performed after obtaining informed consent. Sixty children of ASA I-II aged 2-10 years who were scheduled for adenotonsillectomy were included in the study. Patients were randomly assigned to either low-flow anesthesia or high-flow anesthesia. Heart rate, mean arterial pressure, peripheral oxygen saturation, inspiratory oxygen concentration, end-tidal carbon dioxide, and Bispectral index values of the patients were recorded in the operating room. Spontaneous breathing effort and extubation time were recorded while emergence from anesthesia. Heart rate, mean arterial pressure, peripheral oxygen saturation, pain, and agitation scores were also recorded in the recovery room. The day after surgery, the parents were called to investigate whether the unwanted effects occurred.

Results

Hemodynamic variables were not different between the groups at all times (p> 0.05). There was no difference between the groups in bispectral index values (p> 0.05). Spontaneous respiration time and extubation time were not different between the groups (p> 0.05). Pain and agitation scores were lower in the low flow group (p <0.05). No side effects were observed in any of the groups. Mean arterial pressure and heart rate were similar between groups in our study. However, both of them were decreased during the operation, although they did not drop lower than normal limits. These decreases might have been due to the effect of sevoflurane on cardiorespiratory reflexes, which seemed to be clinically unimportant. Adverse reactions were not detected in any patient in our study indicating that low flow anesthesia does not increase adverse reactions in low flow sevoflurane anesthesia in children.

This study has some limitations. One limitation is the number of participants. Although the numbers are enough to compare groups statistically it would be better if the number of participants had been higher. As we performed routinely in our clinic, we assumed that intravenous paracetamol would be enough for the early postoperative period during which we measured severity of pain which may be another limitation of the study. It could be better if we had planned to give rescue analgesia.

Conclusion

Low flow anesthesia may reduce emergence delirium and postoperative pain even in short-term operations like adenotonsillectomy with no increase in the incidence of adverse events, and with no change in hemodynamic and respiratory parameters in pediatric patients.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A24

Introduction

Face masks are commonly used during the induction phase of pediatric anesthesia. The present study investigated whether the use of a mask in the presence of the parents improved mask acceptance before the slow induction of anesthesia in pediatric patients.

Methods

The study was performed after obtaining informed consent.

This prospective, randomized controlled trial enrolled patients aged 2–10 years who were scheduled to undergo surgery under general anesthesia. Patients were randomly assigned to mask induction with Air/O2/Sevoflurane without the presence of parents (control group) or in the presence of parents (experimental group). The primary outcome was the mask acceptance score, rated on a validated 4-point from 1 point (not afraid; easily accepts the mask) to 4 points (afraid of a mask; crying or struggling). The secondary outcome was heart rate assessed by pulse oximetry in the pediatric ward before transfer to the operating room (OR), at the entrance to the OR, at the patient notification of mask fitting by the anesthesiologist, and after mask fitting.

Results

Seventy-seven patients were accessed for eligibility, with 67 enrolled in the study: 33 in the experimental group and 34 in the control group. Mask acceptance was significantly greater among patients aged 2–3 years in the experimental than in the control group (p < 0.05) (Figure 1).

The mask acceptance score was significantly lower in the experimental than in the control group in patient group 1 (p<0.05)

Conclusions

The use of a mask in the presence of parents can improve acceptance before anesthesia induction with a parental presence in pediatric patients aged 2–3 years.

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A25

Background

Multimodal Prehabilitation (MP) before major upper gastrointestinal surgery has shown to improve preoperative functional capacity (FC) and facilitate surgical recovery [1]. Neoadjuvant therapy (NAT), frequently indicated for these patients, is associated with loss of lean body mass (LBM) and deterioration of FC [2]. This cohort study aims at describing the preliminary experience of the University of Florence MP program recently implemented as standard of care for these patients.

Material and Methods

From May 2022 to May 2023, high-risk patients were referred to the University of Florence MPC, in preparation for their surgery. The six-Minute Walking Test, the Fried physical frailty criteria, Patient-Generated Subjective Global Assessment (PG-SGA), bioimpedentiometry, and the Hospital Anxiety and Depression Scale were used to assess physical, nutritional, and psychological status. A personalized MP program was then prescribed for at least 4 weeks, and patients revaluated before and 30 and 90 days after surgery. MP consisted of medical, functional, nutritional, and psychological optimization, including correction of preoperative anemia, optimization of geriatric conditions, and a smoking cessation interventions.

Results

Sixty-two patients were referred to the MPC. Of these, 24 received the intended surgical intervention. Eighteen patients (75%) received NAT (chemotherapy n=14, chemo-radiation n=4) (Table 1).

MP characteristics and interventions are reported in (Table 2).

Overall, there was a clinically meaningful improvement [3] of preoperative FC (six-minutes waking distance, 6MWD), more pronounced in patients who received NAT (Figure 1).

Similarly, preoperative LBM increased; this improvement was mainly driven by an increment of LBM in patients treated with NAT (Figure 1). Compared to baseline, FC decreased after surgery, but return above baseline 90 days after surgery. In contrast, there was a postoperative loss of LBM up to 90 days after surgery. The proportion of sarcopenic, frailty and malnourished patients after MP decreased (baseline vs preoperative: 29% vs 17%, 21% vs 8%, 92% vs 33%, respectively). However, the proportion of anemic patients increased (Figure 2).

Conclusions

MP improved preoperative FC and LBM in oncologic patients undergoing major upper gastrointestinal surgery. FC was maintained throughout the perioperative period, despite the loss of LBM that persisted up to 90 days after surgery. Moreover, in patients treated with NAT, MP prevented the loss of function and LBM commonly observed after NAT. Finally, MP modified several preoperative risk factors associated with postoperative morbidity, mortality and poor functional recovery.

References

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A26

Background

Rapid sequence induction (RSI) is an anesthesia technique for tracheal intubation in patients at high risk of aspiration of gastric content. As manual ventilation is not recommended in RSI, pre-oxygenation is a fundamental strategy to ensure an adequate period of safe apnea [1]. The current standard for pre-oxygenation entails spontaneous facemask ventilation (FM) delivering a fraction of inspired oxygen (FiO2) of 100% at 15 L/min flow such as to reach an end tidal O2 (EtO2) of at least 90% prior to the administration of induction medications and myorelaxants. The use of High Flow Nasal Oxygen (HFNO) may offer some advantages over the standard technique [2].

Patients and methods

After obtaining informed consent, patients undergoing anesthesia with indication for RSI were randomized for FM or HFNO. Patients belonging to the FM-group were pre-oxygenated with an anesthesia mask for 5 minutes (15 L/min, FiO2 of 1). After the anesthesia induction, the mask was left in place during the apnea time and removed during the intubation. Patients of the HFNO-group were pre-oxygenated for 5 minutes with HFNO at 40 L/min and FiO2 1. Oxygen flow was increased to 70 l/min after the anesthesia induction and the cannula was left in place during the apnea time and the intubation (figure 1).

PaO2, PaCO2, SpO2 and oxygen reserve index (ORi) were measured before, at 5 minutes of pre-oxygenation and immediately after intubation. Apnea time was measured in each patient. The variables considered were compared. For each patient, the variation of PaO2 and PaCO2 during apnea was related to the apnea time to obtain and compare the mean variation per second during apnea of these variables.

Results

We enrolled 50 patients and randomized 25 for each group. There was no difference in the baseline patient characteristics and basal SpO2, PaO2 and PaCO2. Patients in the HFNO group showed a lower decrease in PaO2 during the apnea time (p=0.0009). In a sub-population with apnea time greater than 300 seconds, PaO2 at intubation was significantly higher in the HFNO group (p=0.046) than in FM-group. Differently, there were no differences between the two groups in PaCO2 (table 1-2).

Conclusions

HFNO might increase the safe apnea compared to the standard method for the pre-oxygenation of patients undergoing RSI offering additional safety especially when the intubation procedure needs more time. In addition, ORi can be a useful non-invasive monitoring of the patient oxygen status during RSI. There was no evidence in CO2 clearance under HFNO.

References

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A27

BACKGROUND

Near-infrared spectroscopy (NIRS) is a tool for noninvasive monitoring of regional tissue oxygenation, including splanchnic and cerebral circulation. ¹

This pilot study aims to analyze the effects of surgical hemorrhages and transfusions on regional oxygen saturation (sSO2). This is detected at the splanchnic level in children undergoing corrective surgery for craniostenosis.

The main purpose of this study is to identify timely transfusion indications. 2

The study also aims to evaluate any correlations between sSO2 and metabolic acidosis markers such as lactate and base excess.

MATERIALS AND METHODS

This no profit observational study involves the Catholic University of the Sacred Heart as the sole participating center.

An INVOS oximeter ( Somanetics, Troy, USA) was used for the study.

This instrument emits light at two wavelengths (730 and 810 nm) in order to measure the concentration of oxygenated and deoxygenated hemoglobin in the microcirculation.

The study examines nineteen patients ages less than 15 months, weighing less than 10 kg, undergoing cranioplasty procedures for the correction of primary craniostenosis. All these patients had a postoperative course in the Pediatric Intensive Care Unit (PICU). Patients with known comorbidities and/or suffering from syndromic craniosynostosis (Crouzon syndrome, Pfeiffer syndrome or Apert syndrome) were excluded from the study.

All patients included in the study underwent the same anesthetic protocol. Plasma expanders were used to replace the lost blood volume. Albumin 5 % was administered in boluses at the initial dose of 20 ml/kg, which could be adjusted according to blood loss.

Conversely, concentrated red blood cells were administered when signs and symptoms of hypoperfusion were observed, considering a hemoglobin cutoff value of 7 g/dL.

At the end of the surgery, the patients were transferred to the Pediatric Intensive Care Unit (PICU), for postoperative monitoring and management of the surgical case.

RESULTS

Data were analyzed using the median and quartiles as the distribution was non-normal (non-Gaussian). From the data analysis, a linear regression was performed between the absolute value (a.v.) values of regional oxygen saturation (rSO2) and hemoglobin (Hb), revealing a significant but weak linear relationship (p=0.001, r2=0.15). On the other hand, the correlation between rSO2 and lactate levels and base excess (BE) values was not statistically significant (p value = 0.97).

CONCLUSIONS

NIRS has proven to be a non-invasive method that could provide valid data for the correct management of perioperative anesthesia. In the pediatric field we could have great benefits in terms of blood saving strategies.

REFERENCES

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A28

Background: Prehabilitation (PreHab) refers to individualized preoperative interventions aiming at improving preoperative functional capacity and optimize modifiable risk factors to better overcome surgical stress and better recover to daily activities1. Measuring adherence to a medical intervention is essential for accurately determining its efficacy. It is unclear how adherence to PreHab is currently measured and reported. The aim of this systematic review is to determine how PreHab adherence is measured and reported, and if possible, determine whether high adherence rates are associated with better outcomes.

Materials and methods: PRISMA guidelines for systematic reviews were followed. Medline, Embase, Cochrane Library databases were searched for Randomized Controlled Trial, Clinical Trial, and retrospective studies, from January 1999 to March 2023, and that evaluated PreHab interventions in adult patients awaiting for major or moderate elective surgery. As there is no standardized and unambiguous definition of PreHab, it was decided to search and include trials evaluating any unimodal preoperative intervention including physical exercise, nutritional, and cognitive/psychological support, or multimodal interventions combining at least 2 of the forementioned treatments. Only preoperative treatments that started at least 7 days before surgery were included. Studies aiming at optimizing individual surgical risk factors, such as smoking cessation or anemia were excluded. Included studies were analyzed to investigate 1) how adherence to PreHab interventions was reported and defined 2) the association between adherence to PreHab and preoperative and postoperative outcomes.

Results: Of the 21.313 studies identified from Medline, 246 studies were included for the analysis. PreHab was unimodal in 210 studies (exercise-based PreHab n=127, nutrition-based PreHab n=47, and psychological PreHab n= 36) and multimodal in 36 studies (Table 1).

Different type of prehabilitation interventions were identified (Figure 1).

Overall, adherence to PreHab was reported in 125 of the studies included (50.8%). Of these, 103 (82.4%) defined it. Multimodal PreHab studies that reported adherence to each component of the multimodal intervention prescribed were only 8 (40%); when not entirely reported, adherence to the exercise intervention was the most reported. Parameters used to define adherence were frequency (n=92), intensity/dose (n=1) or duration (n=2) relatively to the PreHab prescription. Sixteen trials used more than 1 of these parameters to define adherence to PreHab (Figure 2).

Due to the high degree of heterogeneity in defining and reporting PreHab adherence it was not possible to assess and establish whether high rates of Prehab adherence are associated with better outcomes.

Conclusions: these preliminary results show that PreHab adherence was not reported in half of the study identified. It was mainly reported describing the frequency of the intervention, relatively to PreHab parameters prescribed. Due to a high degree of heterogeneity defining and reporting PreHab adherence, it was not possible to establish its association with postoperative outcomes. Future studies should better define and report adherence to PreHab, not only describing how frequent the intervention occurred, but also assessing if the intensity/dose and the duration of the intervention are achieved. This will help to better understand the efficacy of PreHab.

References

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A29

Background: Whether a hemodynamic optimization protocol based on dynamic arterial elastance (Eadyn) improves clinical outcomes in patients undergoing major abdominal surgery remains unclear.

Methods: We randomly assigned patients scheduled for major abdominal surgery to Control group (n=23) or Intervention group (n=23) after obtaining written informed consent. We used Hemosphere platform (Edwards Lifesciences, Irvine-California, USA, AcumenIQ sensor) as hemodynamic monitor in both groups. In the Control group, we administered fluids and vasoactive drugs based on Stroke Volume Variation (SVV) and Mean Arterial Pressure (MAP) changes. For the Intervention group, in fluid responders patients, we gave fluid or vasoactive drugs administration according to arterial dynamic Elastance (Eadyn), added to the treatment algorithm. The primary endpoint was the lactate levels at the end of surgery. Secondary endpoints were fluid amount, vasoactive drugs usage and clinical and surgical postoperative complications.

Results: Fourty-six patients were analyzed. No differences beetween the two groups have been noticed in lactate levels at the end of surgery (control group Lac 2.5 mmol/L vs intervention group 2.6 mmol/L p=0.63). The preoperative and intraoperative variables significantly associated with anastomotic leak were: hemodynamic protocol (rho= -0.546; p=0.071), preoperative albumin (rpbi=-0.373; p=0.011), preoperative hemoglobin (rpbi= -0.516; p=0.0001) and total crystalloids amount (rpbi= -0.560; p=0.0001). A logistic regression showed that preoperative hemoglobin (p=0.025) was the only independent predictor of anastomotic leak (Log-Likelihood=-10.01; Likelihood Ratio chi2 =28.14; p<0.0001) (fig. 4). Post-regression receiver operating characteristic analysis (ROC) showed an area under ROC curve of 0.88 and there was a significant association between anastomotic leak and hospital length of stay (rpbi=0.692; p<0.0001).

Conclusions: the addition of arterial dynamic elastance to hemodynamic protocol did not change the lactate levels at the end of major abdominal surgery but it produced a significant effect on fluid balance and vasoactive drugs.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A30

Background

Clevidipine is a new intravenous calcium channel blocker with favourable pharmacokinetic properties approved for perioperative management of hypertension. We described a case of reversible hypoxemia caused by clevidipine-induced pulmonary vasodilatation in a patient who developed hypertension after abdominal surgery. Written informed consent for the publication was obtained by the patient.

Case report

A 62-year-old man was admitted in our ICU after gastrectomy for spontaneous gastric rupture. His medical history revealed systemic artery hypertension in medical treatment. After weaning from mechanical ventilation and extubation, the patient was treated with high-flow nasal cannula for hypoxemia due to postoperative bilateral lung consolidations diagnosed by computerized tomography. The respiratory function gradually improved until reaching a PaO2/FiO2 ratio of 250 mmHg. The following clinical course was complicated by onset of severe hypertension (190/100 mmHg). Because of esophago-jejunal anastomotic leakage, the patient could not assume oral medications, so we decided to start intravenous clevidipine with a prompt control of pressure (140/80 mmHg) at infusion rate of 2 mg/h. However, immediately after initiation of clevidipine’s infusion the patient developed hypoxemia (PaO2/FiO2 ratio of 130 mmHg). The echographic lung examination excluded new causes of hypoxemia (pneumothorax, pulmonary edema) but confirmed bilateral consolidations similar to previous computerized tomography control. A bedside transthoracic echocardiogram did not revealed right heart dilatation or intracardiac shunting. Having ruled out other obvious causes of hypoxemia, we hypothesized that the clevidipine inhibition of hypoxic pulmonary vasoconstriction (an important compensation mechanism in our patient in consideration of his bilateral lung consolidations) magnified pulmonary shunt and it was the probable explanation of sudden hypoxemia. In fact the following discontinuation of the drug infusion promptly resolved hypoxemia and the patient reached a PaO2/FiO2 ratio of 250 mmHg. We reported this case as a suspected adverse drug reaction.

Conclusion

Based on our case report and analogue ones described in literature [1], we suggest that clinicians must be aware of the possibility of hypoxemia during clevidipine infusion. The probable/possible mechanism involved is the shunt due to clevidipine-induced pulmonary vasodilatation like other dihydropyridine calcium channel blockers [2]. We believe that clevidipine infusion should be used carefully in patients with hypoxic pulmonary vasoconstriction.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A31

Background

High-Flow Nasal Cannula Oxygenation (HFNCO) is an open-loop oxygenation system that uses flows of up to 70 L/min of 100% oxygen through the Optiflow THRIVE TM apparatus (Fisher and Paykel Healthcare Ltd, Auckland, New Zealand), increasingly used as an alternative to tracheal intubation in patients undergoing short-term general anesthesia.

The efficacy of HFNCO in apnoic patients undergoing laryngeal surgery is debated: on the one hand it allows minimal manipulation of the airways, it expands the surgical field and it proved to be not inferior to tracheal intubation in maintaining oxygen saturation, on the other, it has been associated with a higher incidence of hypercarbia, acidosis and need for rescue maneuvers of airway management.

Methods

Patients aged 18 to 69 years, American Society of Anaesthesiologists (ASA) status I and II undergoing laryngeal microsurgery under general anesthesia and neuromuscular blockade were randomized to either apnoic oxygenation (THRIVE group) or tracheal intubation (Control group).

Primary aim will be evaluation of changes in frontal cerebral tissue oxygen saturation (SctO 2 ) through Near-Infrared Spectroscopy (NIRS) technology in the two groups. Secondary objectives will be the noninferiority of THRIVE compared to tracheal intubation in term of success rate of the technique. Success rate will be defined as partial pressure of carbon dioxide (PaCO 2) <= 65 mmHg and/or peripheral oxygen saturation (SpO 2 ) >= 94% throughout the procedure in the absence of

adverse events.

Results

First 10 patients of 30 expected at completion of the study were included in this preliminary analysis.

Patients characteristics are listed in Table 1;

no significant differences were observed in both groups. Median (IQR) surgery and anesthesia duration, as well as baseline StcO 2, SpO 2, PaCO 2 and hemodynamic parameters were comparable between the two groups (Table 2).

For the primary outcome StcO 2 values were significantly different and higher in the THRIVE group compared to the Control group, consistently with the higher flows of O 2 received (mixed-effect linear regression model, P < 0.001).

For the secondary outcome, success rate of THRIVE was 60% compared to 100% for tracheal intubation. No patient in both groups showed SpO 2 <= 94%; median (IQR) peak PaCO 2 was 61 (60, 61) mmHg in the THRIVE group compared to 43 (41, 45) mmHg in the Control group. Two (40%) patients reached PaCO 2 levels > 65 mmHg and 100% of patients in the THRIVE group developed transient respiratory acidosis with no hemodynamic instability during surgery compared to none in the Control group.

No patient in both group reported dyspnoea at the end of anesthesia; no complication occurred during hospital stay and all patients were discharged on first postoperative day.

Conclusion

THRIVE oxygenation should be used with cautious monitoring during laryngeal microsurgery under general anesthesia and neuromuscular blockade. THRIVE was successful in maintaining oxygen saturation but incidence of hypercarbia and transient respiratory acidosis were more frequent during HFNCO compared with tracheal intubation.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A32

Background

Acute kidney injury (AKI) is a well-known and frequent complication in elderly patients after major surgery, causing significant morbidity and mortality, as well as increased health care costs. AKI is a frequent complication in elderly surgical population because it presents a reduced renal functional reserve. While preoperative AKI risk factors (hypertension, diabetes mellitus, known chronic kidney disease) and pathophysiological mechanisms of AKI are well understood, the management of perioperative AKI is still a matter of debate because the therapeutic interventions are often implemented late, particularly only after clinical evidence of decreased urine output, elevated serum creatinine levels or decreased glomerular filtration rate. In any case, all the delayed therapeutic approaches act on already existing organ damage.

Materials and methods

This systematic literature review aims to identify relevant literature from 2010 to 2022, published on the English-language PubMed database, gathering quantitative, qualitative and mixed information. The inclusion criteria of the studies examined were based on the collection of AKI prevention strategies to reduce morbidity and mortality in elderly patients undergoing major surgery.

Results

Based on the inclusion criteria, 143 articles were identified including 32 review articles, 18 systematic reviews, 31 randomized trials, 28 meta-analyses, 14 case-control studies, 32 clinical trials of which 18 were multicentres.

The scientific literature reviewed identified preoperative, intraoperative, and postoperative strategies for meaningful prevention of AKI. Among the preoperative ones literature detects:1. evaluation of the pharmacological therapy that the elderly patient takes with particular attention to NSAIDs and ACE inhibitors;2. preoperative fluid therapy plan which must aim at a hydrated and euvolemic patient; 3. encourage patients to drink clear fluids up to 2 hours before induction of general anesthesia. Among the intraoperative strategies, literature detects: 1. goal direct fluid therapy guided by hemodynamic monitoring with study of the patient's reactivity to fluids; 2. hemodynamic stability with MAP > 65 mmHg; 3. use of crystalloids and balanced hydroelectrolyte solutions and reduction of physiological solutions to 0.9%; 4. close monitoring of intraoperative blood glucose, avoiding excessive glycemic variability. Among the postoperative ones:1. postoperative fluid therapy plan with the aim of avoiding postoperative hypotension 2. avoiding the use of contrast media 3. early oral fluid intake 4. function monitoring. Furthermore,the scientific literature has shown that efforts should also be focused on early diagnosis through the use of point of care.

Conclusions

The scientific literature has demonstrated that efforts should be focused on prevention through preoperative, intraoperative and postoperative strategies in association with an early diagnosis of AKI. The KDIGO Care Bundle will be guided by careful monitoring of renal function through the traditional markers of renal function (serum creatinine, eGRF and diuresis),but also through the use of urinary and blood biomarkers which allow for the diagnosis of stress before organ damage has occurred: Insulin-like growth factor binding protein 7 (IGFBP) and tissue inhibitor of metalloproteinase-2 are two urinary biomarkers of cell cycle arrest that can be used to predict risk of developing AKI after major surgery (AKI risk assessment), Proenkephalin A119-159, neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18, proteinCbinding factor and soluble thrombomodulin.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A33

Introduction

Multiorgan oncological patient’s therapeutic pathway needs usually both surgical complex techniques and anesthesiologic and intensive-care support due to provide its effectiveness; in this specific setting, also the choice of a mild-high risk surgical approach could be challenged according to patient’s clinical conditions.

Moreover, current literature lack in evaluation’s score useful for the whole perioperative period’s assessment: this need creation and validation of a new tool, named PERIDIA-score, developed by a multidisciplinary team, from the Cancer Institute Giovanni Paolo II in Bari.

Primary Data acquired from PERIDIA01-study, a retrospective-perspective and still ongoing study, showed the cut-off of 13.5/48 points for complications’ onset (1) with a good sensitivity and specificity; statistical analysis performed on a larger sample strongly confirmed this cut-off and strengthened the idea of its predictivity role in the decision-making process.

Materials and methods

A cohort of 199 patients who underwent elective, non-palliative, turaco-abdominal-peri diaphragmatic-sovramesocolic surgery in the surgical ward of our Institute and who needed Post-Operative ICU care was extracted from the 2018-2019 data collection.

According to previous investigation, a ROC analysis was accomplished to confirm both comprehensive PERIDIA-score’s and PERIDIA-partials’ (PERIDIA pre, intra and post) predictability. The same methodology was also applied to single items for their significance assessment and to the sum of PERIDIA-pre and intra for their complications’ onset predictivity evaluation.

Finally, a multivariate logistic regression was implemented which underlined the most significant items.

Results

Primary results highlighted a quite good score’s predictivity of complications’ occurrence during surgical ward stay (NPV 0.765 and AUC 0.805). Also, the ROC analysis performed on the PERIDIA score in the pre intensive period (expressed as PERIDIA-pre + PERIDIA-intra) showed good predictivity value with a threshold of 12.5/32 points for complications’ onset in post-operative ICU stay (NPV 0.722, AUC 0.749).

Moreover, the multivariate logistic regression performed on this sample confirmed statistical significance of HR and Breathing but underlined Frailty as potentially significant item in predicting complications’ onset instead of Nutritional Status.

Discussion

The overall PERIDIA score showed quite good complications’ predictivity for oncological patient in this surgical setting; therefore, this data could support the score application in clinical practice as a useful evaluation’s tool of the whole care pathway in the specific setting of cancer patient.

Moreover, the predictivity of pre intensive PERIDIA could be focused as a guide to support some clinical choice and to achieve tailored treatments in post-operative ICU.

Thus, future steps of this work require single items’ improvement of each assessment (pre intra and post operative phase) to increase their significance and strengthen the overall score’s predictivity, also suggesting a possible role in the decision-making process not only for peri diaphragmatic sovramesocolic oncological surgery, but also for major oncological surgery pathway.

Ethical Approvement

The study was reviewed and approved by the Ethic Committee of IRCCS Istituto Tumori Giovanni Paolo II- Bari, Italy (Prot. N. 326/CE 30/7/2020).

References

Bild vergrößern

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A34

Background. 83-year-old patient, BMI 31, history of hypertension, hypercholesterolemia, aortic-myocardial disease, mild mitral and aortic insufficiency, chest pain exacerbated efforts for about 8 years, in treatment with Prasugrel and Cardio-Asa, reaches the Emergency Department for angina/dyskinetic symptoms, with diagnosis of NSTEMI. Blood chemistry tests show elevation of specific myocardial enzymes: Troponin T 966 pg/ml, Myoglobin 151 ng/ml. Performs coronarography that highlights severe obstructive, calcific and coronary disease, with critical stenosis of the common trunk, multiple critical stenosis in the proximal and middle anterior descending artery and the first marginal branch. During the stay he presents intestinal obstruction from paralytic ileum on left crural hernia clogged, painful and not reducible manually. The surgical evaluation indicates the treatment in an unavoidable emergency by vascular compression of the loops in prison.

Case Report: The patient arrived in S.O. alert and collaborating, in spontaneous breath, VAS 5. HR 92 b/min, NIBP 145/75 mmHg, spo2 94%. Signed the informed consent, we proceed to Trasversus Abdominis Plane Block (TAP block anterior) to anesthetic dosage, performed by ultrasound with linear probe with ultrasonic needle 100 mm, made difficult by large abdominal meteorism. Fast-acting local anaesthetics (AL) (Mepivacaine 1%, 20 ml) and long-acting anaesthetics (Ropivacaine 5%, 20 ml) were used and 4 mg of dexamethasone and 70 mcg of clonidine were added as adjuvants to increase the duration of the sensory block. Verified the effectiveness of the block with both tactile and pain stimulation, the surgeon proceeds with the repair of crural hernoplasty with open technique. Patient alert and collaborating, in spontaneous eupnoic breath in ambient air enriched in O2 through nasal goggles with FiO2 28%. Hr 84 b/min, NIBP 145/75 mmHg, spo2 97%. VAS 3 despite viscera manipulation and numerous attempts at manual bowel reduction. At the end of the procedure, the patient is returned to UTIC for the rest of the stay.

Conclusions. Because of the patient’s comorbidities both neuroaxial and general anesthesia would have required hospitalization in an intensive/resuscitation environment for the risk of massive intra or post-operative cardiac failure. With the single execution of the TAP block the disconfort of the patient was derisory, tied mostly to the manipulation of the intestinal loops, than to the surgical act itself. At 24 hours from the procedure, the patient was hemodynamic stability, with VAS 1, without request for analgesics in the postoperative stay, treatable abdomen with the presence of peristalsis.

Informed consent to publication was obtained together with consent to the anesthesiology procedure.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A35

INTRODUCTION

G6PD deficiency is estimated to affect approximately 400 million people.

It is a hereditary disease linked to the X chromosome, therefore more frequent in men. In these subjects the first reaction of the pentose phosphate pathway is not carried out efficiently, resulting in a lack of NADPH (Nicotinamide-Adenine-Dinucleotide-Phosphate).

Patients with G6PD deficiency can be very sensitive and vulnerable to oxidative stress caused by ingestion of broad beans, some drugs, infections, metabolic imbalances. with clinical manifestations such as haemolytic anemia in adults and severe jaundice in newborns.

CLINICAL CASE

Patient of 16 years, female, weight 55 kg, affected by favism, with surgical indication for umbilical hernioplasty.

It was decided to practice subarachnoid anesthesia, performed with a 27G Withacre needle at the L2-L3 level, with Ropivacaine 12 mg in a volume of 2.2 ml since general anesthesia in these patients often makes it difficult to identify a haemolytic crisis because symptoms such as hypotension, could be attributed to other causes.

Furthermore drugs such as Isoflurane, Sevoflurane and Bupivacaine are able to inhibit the G6PDH enzyme in vitro as well as Benzodiazepines; for this reason its use is not recommended.

During the operation, the vital parameters were always stable and normal. The surgery was performed with excellent compliance on the part of the little patient and the duration of anesthesia was estimated to be more than two hours. The post-operative course was also free from complications and the patient was discharged from the hospital on the third day.

Upon discharge, the patient was provided with the telephone number to contact the anesthesiologist in case of problems since the haemolytic crisis can occur up to 7 days. after anesthesia.

DISCUSSION AND CONCLUSIONS

The most effective perioperative management strategy is to prevent hemolysis by avoiding general anesthesia and bupivacaine in the subarachnoid if possible. For postoperative pain, it is advisable to use codeine/codeine derivatives, fentanyl and ketamine.

CONFLICTS OF INTEREST

None of the authors have conflicts of interest.

Informed consent to publish had been obtained

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A36

Background

As surgical techniques and pharmacology advance, pain management in orthopedic surgery patients continues to evolve [1]. Multimodal analgesic regimens that target numerous pain pathways may provide the best pain management and reduce opioid use and related side effects [2]. Adjuvants in spinal anesthesia have been used to prolong the quality and duration of its effect, including analgesic one [3,4]. This study aims to prove that intrathecal injections of Midazolam, binding gamma-aminobutyric acid-A (GABAA) receptors in the spinal cord, lead to the potentiation of analgesia.

Materials and methods

This is a retrospective comparative study performed at the Department of Orthopedics and Traumatology of the AOU Federico II in Naples, Italy. Data about patients who underwent spinal anesthesia between September 2022 and April 2023 were retrieved from the department's archive. Inclusion criteria were patients scheduled for elective major orthopedic surgery with spinal anesthesia, aged from 18 years on with a body mass index of 18 – 45 kg/m2 and an American Society of Anesthesiologists physical status classification of I to IV. After obtaining informed consent, patients were clustered into two groups: “Midazolam group” (12 mg Bupivacaine + 150 μg Morphine + 2 mg Midazolam) and “Control group” (12mg Bupivacaine + 150 μg Morphine). In both groups, postoperative pain management included the administration of 1 g intravenous Paracetamol every 8 hours and as rescue analgesia (VAS greater than or equal to 5) 30 mg Ketorolac or, in renal impairment, 10 mg Oxycodone. The study's primary outcome was postoperative pain estimated with Visual Analogue Scale (VAS)[5]. Postoperative pain, itching, nausea, and vomiting were assessed immediately after (T0) the end of the surgery and then after 6 (T6), 12 (T12), 18 (T18), and 24 hours (T24). Furthermore, the level of intraoperative sedation with the Richmond Agitation-Sedation Scale (RASS) were evaluated [6].

Results

In the selected cohort, 20 (57%) patients were included in the Midazolam group (MG) and 15 (43%) patients in the Control group (CG). Average VAS scores were slightly lower in MG (3 at T18) than in CG (4 at T18) (Figure 1). Only 15% of the patients needed rescue analgesia. The level of intraoperative sedation was the same in both groups. The incidence of itching was 30% in both groups, while the incidence of nausea and vomiting was 35% in MG and 40% in CG.

Conclusion

The addition of intrathecal midazolam didn’t lead to statistically significant differences in the management of postoperative pain. The adjuvant neither produce an increase in the level of intraoperative sedation, nor a decrease of the incidence of side effects.

References

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A37

Background: Arthroscopic shoulder surgery often requires the patient in beach chair position. Compared with open techniques, arthroscopy allows smaller incisions, faster recovery, and pain-free muscle contraction, and has cosmetic benefits. During arthroscopic shoulder surgery, clear visibility is essential(1). Various methods have been used to ensure clear visibility during surgery but controlled hypotensive anesthesia is still the most effective method. However, risks associated with reduction in cardiac output and cerebral perfusion which could result in serious cardiovascular events.

Clevidipine is an ultrashort-acting intravenous dihydropyridine that inhibits L-type calcium channels with high clearance, low distribution and a rapid shift to inactive metabolites by blood esterases. It was developed for short-term intravenous control of blood pressure through a selective effect on arterioles(2).

The purpose of our study is to provide the efficacy and safety of clevidipine to maintain controlled hypotension during shoulder arthroscopy in beach chair position in patients undergoing regional anesthesia and sedation.

Materials and Methods: The study is an open label, interventional study. All patients undergoing shoulder arthroscopy are eligible. Informed consent was collected. Interscalenic US-guided brachial plexus block and sedation (Propofol 0.5 mg/Kg/h) are administered. Information regarding clevidipine include the initial infusion rate, the average infusion rate, and the duration of administration. Hemodynamic information include the MAP, HR and NIRS (to evaluate cerebral oxygenation) during clevidipine infusion. Data were collected every 15 minutes.

Results: 8 patients were enrolled, age 52-76 years. Clevidipine infusion was started at 4 ml/h and tritrated until a target MAP of 60-65 mmHg was reached. The average maintenance infusion rate was 6.9 ml/h.

We found a significant reduction in MAP equal to an average of 20 mmHg from baseline, with no significant changes in HR and NIRS.

Intraoperative clevidipine infusion was stopped in 2 patients for excessive hypotension, with resetting of MAP and NIRS to baseline values almost 15 minutes after discontinuation. In one of these there was a significant decrease in NIRS (from 61 to 48), without neurological syntoms.

Conclusion: Clevidipine results effective and safe in maintaining controlled hypotension during shoulder arthroscopy without significant decreases in NIRS. Its haemodinamic profile allows arteriolar vasodilation without action on venous vasculature, thus maintaining cardiac output that is already reduced by the beach chair position. Both the onset and offset of action on MAP are rapid. These are preliminar results since only a few patients are enrolled in the study at this time, so further enrollments are necessary to confirm our data.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A38

Epidural Analgesia (EA) and Paravertebral Block (PVB) are the regional techniques commonly considered as the gold standard for analgesia after abdominal laparotomy, despite of the complexity of the procedures and the high risk of complications.

Therefore, the erector spinae plane block (ESPB) could be a valid alternative. [1]

ESPB is a paraspinal fascial plane block, first described by Forero et al. in 2016.

It’s a relatively easy technique to perform with a lower risk of complications. The spread of the local anesthetic through the connective tissues and towards the spinal nerve roots cranially and caudally from the site of injection provides a multi-dermatomal sensory block. Furthermore, the transforaminal and epidural spread of the local anesthetic during ESP block has been described. It results in a blockage of the dorsal and ventral rami of thoracic and abdominal spinal nerves, thus ensuring both somatic and visceral analgesia and allowing a significant reduction in opioid consumption. [2,3,]

We report a case in which ESPB was successfully used as the only strategy for analgesia in Major Abdominal Laparotomic Surgery.

An 86-years old woman (65Kg;160cm), was scheduled for an open right hemicolectomy whit xifo-pubic incision. Her only comorbid condition were hypertensive heart disease and HBV+.

The patient declined epidural analgesia due to the perceived risks. After a discussion, she agreed to a bilateral ESP blockade.

The ESP block was performed before induction of anesthesia, after institution of IV access, electrocardiogram, invasive blood pressure, pulse-oximetry monitoring, TOF, Entropy and SurgicalPlethIndex (as monitoring of intraoperative pain)

The patient was placed in a sitting position and, using an aseptic technique, a high- frequency (12–15 MHz) linear-array transducer was placed in a longitudinal para- sagittal orientation. A 21G Needle (Pajunk SonoPlex 50mm) was inserted in-plane to the ultrasound beam and in a cranial-to-caudal direction to contact the tip of the T8 transverse process. Twenty milliliters of Ropivacaina 0.5% were injected. This procedure was repeated on the other side.

Anesthesia was induced whit Propofol 130mg, Sufentanil 10mcgr, Rocuronio 50mg and maintained whit Sevoflurane; according to the intraoperative SPImonitoring no more analgesics were needed.

Paracetamol 1g and Morphine 1mg were administered 40 minutes before awakening.

Upon awakening, patient was comfortable and had a numerical rating scale <3 at time 0 and after 6, 12 and 48h.

In summary, this case demonstrates the successful use of Thoracic ESPB for major open abdominal surgery, but more studies need to be conducted.

Informed consent to publish had been obtained.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A39

In recent decades advances in technology and surgery have led to an increase in the number of operations performed in VLS, a new frontier of minimally invasive surgery with high precision that allows to operate with minimal trauma for organs and tissues through small incisions on the anterior abdominal wall; the images are enlarged and projected onto video.

The main problems are hemodynamic and respiratory alterations related to the Pneumoperitoneum and the Trendelemburg position that determine reduction of venous return and GC, risk of arrhythmias and increased airway pressures. These conditions have contraindicated in recent decades the use of neuroaxial anesthesia in laparoscopic procedures, resorting only to AG.

Anesthesiological strategy can make use of different strategies and the choice of technique depends on many factors: type of patient, preference of the anesthesiologist, expected duration of the intervention, preference of the surgical team.

The aim of this study is to evaluate the possibility of performing laparoscopic gynecological surgery under neuroaxial anesthesia and to evaluate the point of view of the anesthesiologist, surgeon and patient. This is a prospective cohort study comprising sixty-six patients undergoing laparoscopic surgery for benign pathology at the Obstetric Clinic of the Federico II University of Naples.

Patients were assigned to Group A (subarachnoid anesthesia) and Group B (general anesthesia). They were invited to participate in the study during preoperative counseling and it was obtained with written informed consent.

The primary outcome assessed was post-operative pain. Secondary outcomes included mobilization, length of postoperative stay, global patients and surgeons satisfaction.

Immediate postoperative pain was significantly lower in Group A, with no significant differences at 24h in the two groups. Secondary outcomes demonstrated early mobilization of patients, a reduction in post-operative pain with reduced use of opioids in the post-operative period, excellent satisfaction of the surgeon and patients in group A and reduction of hospitalization times (ERAS-protocols). In these patients, the VAS score averaged 3 during surgery.

Regional anesthesia has proven to be an effective choice for conducting anesthesia in benign gynecological surgery, reducing the impact of surgical stress, ensuring faster recovery without compromising surgical outcomes.

In addition, during the Sars-Covid19 pandemic, the ALR has allowed us to avoid airway management by offering greater protection to health workers.

Keywords: post-operative pain, loco-regional analgesia, benign gynecological surgery, Sars-Covid19-pandemic, ERAS-protocols

Laparoscopic gynecological surgery under minimally invasive anesthesia: a prospective cohort study. Giampaolino, Della Corte, Mercorio, Bruzzese, Coviello, Grasso, Del Piano, Bifulco

Laparoscopic surgery for benign adnexal conditions under spinal anaesthesia: Towards a multidisciplinary minimally invasive approach. Raimondo et al

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A40

Keywords: Mastectomy, Breast Reconstruction, Regional Block, Amyotrophic lateral sclerosis

Background

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that results in progressive loss of upper and lower motor neurons. Weakness of respiratory muscles, difficulty swallowing and susceptibility to muscle relaxants pose challenges for anesthetists. General anesthetics depress ventilation and swallowing reflexes, thereby increasing the risk of regurgitation and hypoxia. Furthermore, ALS patients are highly sensitive to non-depolarizing muscle relaxants. Intravenous opioids may worsen the breathlessness of these patients. Despite the lack of widespread consensus on the ideal anesthetic approach to ALS patients undergoing major breast surgery, there are few noteworthy anesthetic considerations in this cohort.

Case Report

A 60-year-old female patient was scheduled for skin reducing mastectomy and breast reconstruction for ductal carcinoma in situ. Preoperative evaluation revealed a late-stage disease with speech impairment and mouth incompetence with hypersalivation and dysphagia.

After a careful risk-benefit analysis, involving a multidisciplinary team approach,

the patient successfully underwent the surgical procedure with regional block: pectoserratus block T5 with Ropivacaine 0.375% 30 ml and parasternal block T3 with Ropivacaine 0.375% 6 ml were performed with ultrasound-guided technique, adding Clonidine 150 mcg and Dexamethasone 8 mg to the anesthetic mixture.

Pain control was achieved with 1 g paracetamol three time per day and Ketorolac 30 mg as rescue therapy. The patient maintained VAS < 2. Perioperative course was uneventful and the patient was discharged on the second postoperative day without complications.

Conclusion

Patients with ALS present unique challenges for anesthesia providers. Recent studies highlight the benefit of local-regional techniques, discouraging predictable complications of general anesthesia in patients undergoing oncological surgeries.

The decision to perform anesthesia in this high-risk patient population should be based on analyzing patient’s risks against the potential benefits. In conclusion, the regional block allowed the performance of a safely and successful surgery with high patient satisfaction.

Consent to publish

Informed consent to publish had been obtained.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A41

-introduction

Postoperative pain management of a patient with platelet deficiency undergoing robotic cystectomy may require a challenging multimodal approach due to concerns around the use of antalgic subarachnoid block (contraindicated with PLT <75x103). Therefore, we used a bilateral ESP Block catheter to manage both intra- and post-operative pain.

We collected the data from a single patient with a background of type 2 diabetes mellitus, new onset atrial fibrillation, splenomegaly, and thrombocytopenia due to increased splenic sequestration. Of note, the relevant drug history for the patient in question includes metformin and Edoxaban.

This study adhered to the STROBE Statement and the Declaration of Helsinki. Written informed consent was obtained from all subjects, or their proxies or legal surrogates

-materials and methods

Upon arrival of the patient in the pre-operating room, after having explained to him the chosen technique, ensuring his maximum collaboration, we begin the practical preparation for the execution of an eco-guided bilateral ESP Block. The patient is asked to assume a prone position. The procedure is carried out in a sterile field. The target area is identified by the transverse process (TP). The linear probe is positioned in a longitudinal parasagittal orientation, approximately 3 cm lateral to the spinous processes, allowing visualization of the adjacent transverse processes in a flat approach. After successful identification of the target, an 18-gauge echogenic needle is inserted using a craniocaudal approach. Once the fascial plane has been recognized, 15ml of local anesthetic (LA), such as Levobupivacaine 0.25% + Dexamethasone 4mg are injected bilaterally (T10- T12 level). After the firsts bolus of LA a bilateral Pajunk E-Cath was inserted in the actual targeted space created from the injected LA.

In the operating room, balanced general anesthesia is performed with Propofol 200mg, Rocuronium 50mg, Remifentanil TCI 0.5-1.5 ng/ml, Sevoflurane 2% (MAC 0.8) plus Morphine 2mg (patient weigh: 80kg). Analgesic starter with Paracetamol 1g and Ondansetron 4mg, thirty minutes before the end of the operation.

Data about intra- and post-operative pain from a single patient undergoing robotic cystectomy were analyzed. Intra-operative pain data included invasive IBP and CR. Data were collected prospectively to evaluate the pain medication needed and pain scores at 1, 4, 12 and 24h after surgery. NRS and Likert Scale was used to assess perceived pain.

-results

Our data, albeit limited, demonstrates that recurrent boluses of Levobupivacaine 0,25% 5ml did not affect IBP or CR significantly, and intravenous Remifentanil TCI was needed to manage intra-operative pain. However, in the post-operative course, the patient appears to respond well to our multimodal approach consisting of a bolus of Levobupivacaine 0,25% 5ml, Paracetamol 1g iv, Morphine 2mg iv. In the immediate post-operative recovery, the patient did not require any further analgesia other than the PCA with levobupivacaine 2.5mg/ml at 6 ml/hr.

-conclusions

Bilateral ESP block catheters seem to be an excellent analgesic option for pain management in robotic cystectomy, at least in those patients where antalgic subarachnoid anesthesia is not advisable (Plt <75*103) and/or there is concern regarding opioid use and side effects (1).

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A42

Background

Incidence of Chronic Post-operatory Pain (CPoP) in oncological breast surgery is around 30%¹ , this percentage rises to 45% in patients who undergo axillary lymph node dissection. ICD-11 definition of CPoP includes all patients with persistent or rising pain after surgery or tissue damage that present pain beyond 3 months after healing. Many strategies are proposed to prevent this complication such as Regional Anaesthesia (RA) as a part of Multimodal Analgesia (MA). Poorly managed preoperative anxiety has reportedly slowed the postoperative recovery of breast cancer patients², therefore the need to also treat this aspect.

The aim of the study is to evaluate the incidence of CPoP following the new perioperative multidisciplinary treatment RA-based and secondary to verify the effectiveness in enhancing patients' psychological and physical conditions.

Materials and methods

Patients are recruited at the pre-operatory evaluation with 3 questionnaires: the Quality of Recovery questionnaire (QoR-15 A-B), the Brief Pain Inventory (BPI) and Pain Catastrophizing Scale (PCS). Rest and incident Numeric Pain Rating Scale (rNRS - iNRS) is collected at 2-6-12-24h after surgery and at the time of discharge Qor-15 is proposed. Then, patients are called at 3-6-9-12 months to assess rNRS – iNRS and BPI.

Results

Preliminary data of 21 patients (Table 1), scheduled with a 3 months follow-up, showed that they had good pain control and a high quality of recovery in the first 24 hours following surgery (median rNRS at 24h= 0 IQR=4 and median iNRS at 24h=1 IQR=4) (Table 2).

Pre- and post-surgery QoR results were similar (Median preop-QoR-A=92 IQR=13 to postop=91 IQR=15 and preop-QoR-B=40 IQR=20 to postop=45 IQR=10) suggesting a good pain, anxiety and nausea and vomiting control with a fast recovery (Image 1). MA with RA permitted a low opioid dose during surgery (Remifentanil mean value for conservatory surgery was 364.5±209.1 mcg and reconstructive surgery was 1442± 434.2 mcg). Furthermore, only 1 patient (4,7%) needed morphine after surgery and that was justified by the fact that this patient underwent reconstructive surgery (285 minutes) and bilateral prosthesis positioning. Anxiety and depression were related to pain perception and 75% of the patients who needed rescue therapy (4; 19%) had PCS>10.

CPoP may be also well controlled months following surgery: patients have reported good pain management (rNRS median=0 IQR=1, iNRS median=0 IQR=3, BPIsev median=0 IQR=12) and full recovery of their daily activities (BPIint median=0 IQR=33). 4 patients (19%) at 3 months had CPoP but 75% of them had axillary lymph node dissection.

Conclusions

Despite further studies are needed to confirm these results, a transitional pain service and a RA-based pain management seems to enhance recovery from surgery and reduce the incidence of CPoP.

Trial registration

Current Controlled Trials ID 603-11102022 AN S00049/2022

References

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A43

Abstract

A 63-year-old woman (55 kg, 156 cm, BMI 22.6 kg/m2) was admitted to pneumology ward because of her worsening health conditions due to a known IV stage pleural mesothelioma; cancer had spread to all right lung (total opacity at chest X-rays) leading to a compressive effect on the mediastinal structures (superior vena cava, bronchi and pericardial infiltration) (Fig. 1), central nervous system (focal metastasis at left parietal cortex). Moreover, there was also a widespread peritoneal involvement conditioning a large bowel obstruction requiring an emergency skin level cecostomy. The patient had also a history of L4-S2 epidural abscess and L4-L5 osteomyelitis complicated by multiple right iliopsoas abscesses.

Patient-related anesthesiologic risk of mortality was estimated extremely high (ASA 4, POSSUM score 40.4% of predicted mortality, ACS NSQUIP risk score 20.3% of serious complications, 8.8% of death): considering the intrapulmonary shunt due to the tumoral infiltration, the ventilation management could have been very challenging and the hemodynamic instability generated by anesthetic agents, could have led to a dramatic reduction in pre-load needing a huge fluid administration and vasoactive drugs.

A neuraxial block was considered equally risky because of the infectious contraindication, the possible predicted technical difficulty due to the past spinal osteomyelitis and the hemodynamic effect of intrathecal local anesthetic.

Case reports of awake skin level cecostomy conducted with anesthetic blocks like QLB-1, Rectus sheath or TAP block are described and the authors reported good results in terms of pain management and comfort1,2.

In our case we deemed to perform a combined echo-guided monolateral right thoracic erector spinae plane block plus homolateral T8-T9 paravertebral block that, in our opinion, could assure better visceral and peritoneal analgesic coverage (Fig. 2).

A total of 30 ml of 0.33% Ropivacaine, 20 ml for ESP block and 5 ml for each paravertebral block was used to achieve the anesthesiologic plan, adding a light pharmacological intravenous sedation with Midazolam 1 mg and Remifentanil 300 mcg.

During the procedure no hemodynamic instability was observed, spontaneous breathing was maintained, and patient reported comfort without pain during all the surgical stimulation.

At the end of the surgery the patient has been transferred to a surgical ward and no postoperative complications have been reported.

Our experience, although limited to a single case of awake regional anesthesia skin level cecostomy, confirms the possibility of achieving an adequate anesthetic plan, even in frail patients who seem preferable not to be exposed to the systemic effects of general anesthesia.

Informed consent to publish had been obtained.

References

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A44

BACKGROUND

The Transcatheter Aortic Valve Implantation (TAVI) is a minimally invasive endovascular procedure aimed to replace a stenotic aortic valve by implanting an aortic bio prothesis inside of a sick native aortic valve.

This procedure is generally performed in local anaesthesia trought femoral artery. It’s an alternative to open heart surgery in patients older than 75 years old or in high-risk patients.

Transapical approach is an alternative to transfemoral technique. However trans-subclavian and trans axillary approach play an important role in patients with poor femoral vascular access.

Alternative approaches are usually performed under general anaesthesia.

We propose a case report of a patient undergoing transaxillary TAVI, treated with BRILMA.

CASE REPORT

A 71 years old man was admitted to ER for cardiogenic pulmonary edema and hospitalized in intensive care unit (ICU). The echocardiografic assessment esteblished a severe aortic stenosis. Past medical history: COPD, CAD (FE 30% - 80% RCA obstruction), hypertension.

The Heart Team decided for a transaxillary TAVI and PTCA on RCA.

We optated for a BRILMA due to high anaesthesiologic risk (ASA IV)

Previous mild sedation with dexmedetomidine (0,7 mcg/kg/m), the block was performed in plain with ultrasound technique, inserting the needle caudal-cranially over middle axillary line (IV-VI intercostal space) and placing the needle tip between the serratus muscle’s fascia and external intercostal muscle’s fascia. An anaesthetic mixture containing 25 mL of ropivacaine 0,5% plus 4 mg dexamethasone was used. The access point was infiltrated with an additional dose of 4 ml lidocaine 2%.

During the procedure the RASS was -2/-1 and no pain or adverse events recorded. At the end he was transferred to ICU for postoperative monitoring.

DISCUSSION

Chest wall blocks are usually used for breast cancer surgery. BRILMA, consists of the block of the cutaneous branches (lateral and anterior) from the II to the VI intercostal nerve, along the middle axillary line and which is commonly used for axillary lymphadenectomy.

It’s easy to perform, carried out under ultrasound guidance, since there are no superficial anatomical finds. It allows to observe real time the diffusion of the local anesthetic along the neurovascular plane, ensuring a lower rate of complications and a high success rate.

CONCLUSIONS

BRILMA can be successfully used in minimally invasive endovascular aortic valve surgery, when axillary or transucclavian approach is required, especially in patients at high anesthesiological risks. It represents a valid alternative to general anesthesia and paravertebral thoracic block.

Authors confirm that informed patient consent has been obtained.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A45

Background

Intraoperative hypotension (IOH) is common during anesthesia and associated with postoperative adverse outcomes. The AcumenTM Hypotension Prediction Index (HPI) (Edwards Lifesciences; Irvine, CA, USA) is an innovative algorithm based on arterial waveform that predicts hypotension up to 15 minutes before it occurs(1). The aim of this study is to evaluate the haemodynamic pattern in patients undergoing neuroaxial anesthesia (NA) or peripheral nerve block (PNB) during elective total hip arthroplasty THA.

Materials and methods

Twelve patients, aged >18 years and consensual for the procedure, undergoing THA have been recruited at our centre. A radial arterial line was placed before anesthesia and connected to Hemosphere platform (Edwards Lifesciences). HPI monitoring started immediately. IOH was defined as a mean arterial pressure (MAP) < 65 mmHg for at least 1 minute. The decision to perform NA or the combination of Sciatic nerve block (SNB), Lumbar plexus block (LPB) and lateral Femoral Cutaneous nerve block (LFCNB) was based on the clinical assessment. A value of HPI of 85 and higher was defined as a trigger to initiate treatment with fluids or vasopressors according to hemodynamic parameters measured by Hemosphere.

The collected data analysis was performed using Acumen Analytics software, Edwards Lifesciences.

Results

The mean age of the patients was 80.2 ± 2.6 years. 7 patients had ASA III status. NA was performed in 5 patients and the combination of PNB in 7. Total number of the hypotension events in patients undergoing NA was 13 and the number of patients that experienced the hypotension was 2; one of them had severe hypotension (MAP under 50 mmHg). The average duration of each hypotensive event was 7.28 minutes. The time-weighted average (TWA) of AUT (area under a MAP of 65 mmHg) per patients was 0.69 mmHg. Hypotension events never occurred in patients undergoing combined PNB (Table 1).

Conclusions

In our experience, the hemodynamic management of patients candidate for THA is complex, because of old age and comorbidities (2). Our preliminary results show that patients undergoing combined PNB benefit of hemodynamic stability when compared with patients submitted to NA. This supports the hypothesis that this technique causes less perturbation due to the absence of sympatholysis and the consequential vasoplegia. Further clinical studies are needed to evaluate if the advantage of PNB in terms of hemodynamic stability is confirmed.

Informed consent to publish had been obtained

Reference

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A46

Background

Congenital factor VII (FVII) deficiency is a rare haemorrhagic disorder that causes isolated and prolonged prothrombin time (PT) in the presence of a normal partial thromboplastin time (PTT) [1].

Evidence on the safety of peripheral nerve block (PNB) in patients with coagulopathy is lacking.

We describe the anesthetic management of two high risk patients with FVII deficiency undergoing orthopaedic surgery.

Case report

A 71 year-old female patient, (65 kg, 159 cm, ASA III) with chronic obstructive pulmonary disease, diabetes mellitus, chronic renal failure and a 68 year-old female patient (71 kg, 164 cm, ASA III) with dilated cardiomyopathy, left ventricular systolic dysfunction, and diabetes mellitus were admitted for femoral fracture and humerus fracture respectively. They had no history of pathologic bleeding due to FVII deficiency.

Coagulation studies showed a low FVII activity and a decreased prothrombin activity (PT) with a normal activated partial thromboplastin (APTT).

A first dose of 15 mcg/kg of recombinant form activated FVII (rFVIIa) was given 30 minutes prior to anesthesia.

Anesthesia plan for total hip replacement included lumbar plexus, sciatic, lateral femoral cutaneous and lateral branch of the iliohypogastric nerve blocks, while open reduction and internal fixation of the humerus fracture was managed with ultrasound-guided interscalene and infraclavicular brachial plexus blocks.

No bleeding complications were seen during the surgical procedures and no blood transfusion was required for both.

A second and third dose of rFVIIa were administered 6 and 12 hours after surgery

Coagulation tests were performed every day. Bleeding through the drainage tubes were minimal.

The subsequent course was uneventful, and the patients were discharged on the seventh and fifth

day after surgery respectively.

Conclusion

PNB could be a safe technique in FVII-deficient patients, nevertheless substitution therapy is necessary for anesthestic and surgical procedures to prevent or to manage bleeding episodes.

Written informed consent to publish had been obtained

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A47

Background

We hypothesized an alternative way to perform thoracic paravertebral block. We called this technique thoracic intervertebral foramen (TIF) block. We aimed to verify the spread of dye onto the nervous structures of retropleural space, and into the thoracic paravertebral space (TPVS) and epidural space (ES).

Methods

This is a prospective cadaveric study. Before performing the autopsy, the anesthetic procedure was bilaterally performed at sixth (T6) and at tenth thoracic (T10) vertebra, by using a highfrequency linear-array ultrasound (US) transducer. A Tuohy needle was inserted in-plane to the ultrasound beam in a lateral-to-medial direction gently to contact the spinous process (SP). Subsequently, the needle tip was advanced for 2 mm along with the superior limit of the vertebral pedicle, until losing contact with the bone with 5 ml methylene blue 1% dye (MB) injection. Following, 2 continuous catheter sets were inserted. At the end of the anesthetic procedure, a second US scan of thoracic paravertebral space was performed. A cadaveric dissection was then performed.

Results

We report data from a total of 8 TIF blocks performed in 2 cadavers. In 6 injection sites, we

found dye on both sides of the TPVS and ES, from T4 to T8 and from T9 to T12 levels. In 2 cases, MB was accumulated intramuscularly at T10 level. The ventral rami, the communicating rami, and the

sympathetic trunk (from T4 to T7 and from T8 to T12) were stained by dye in 6 cases. Five intervertebral foramens (IVFs) were filled by dye. The second look US scan documented that in 6 cases, anechoic fluid was found in the TPVS ranging from T4 to T7 and from T8 to T12 levels.

Conclusions

The TIF block achieved a consistent dye spread into the TPVS and ES capturing retropleural organs.

Consent to publish.

Informed consent to publish had been obtained.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A48

Background

Robotic surgery is increasing in various specialties, however, there is still limited knowledge regarding perioperative pain management. Enhanced Recovery After Surgery (ERAS) protocols suggest that quadratus lumborum block (QLB) may be a feasible option for abdominal procedures, although evidence supporting the use of fascial blocks is of low-moderate quality [1]. While Lai et al. has suggested a potential benefit of QLB in robotic-assisted partial nephrectomy (RAPN)[2], conflicting data have emerged from other fields[1,3]. Neuraxial approaches are associated with potential adverse events and have fallen out of recommendations in laparoscopic colorectal surgery since 2012 due to the limited pain caused by less invasive techniques [4].

Therefore, our study aims to evaluate the efficacy of QLB type 3 in providing pain relief, enhancing early recovery, and promoting mobilization.

Materials and methods

We enrolled 11 patients scheduled for abdominal robotic surgery under general anesthesia (two excluded for intraoperative complications). Ultrasound-guided QLB 3 (transmuscular approach) was performed before surgery with ropivacaine 0.375% (Image 1).

Multimodal therapy was administered, consisting of paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs). Pain levels were assessed using the Numerical Rating Scale (NRS) at 2, 6, 12, and 24 hours postoperatively. At 24h, we request patients to complete Quality of Recovery (QoR-15) questionnaire.

Results

Clinic and demographic data are shown in (Table 1).

QLB block was performed before surgery, with ropivacaine 0.375%. NRS scores at rest and during movement are presented in (Table 2).

One patient required 2 mg of morphine and one (with a history of NSAIDs allergy and chronic kidney failure) 100mg of tramadol as rescue therapy. The mean QoR score was 110.89±14.38. Nobody reported nausea following the surgical procedure. Comparing to a group of 22 patients (using chi-square test) receiving intrathecal morphine we found statistically significant difference in terms of nausea (p<0.01), pruritus (p<0.001) and post-operative morphine consumption (p<0.03).

Conclusions

QLB 3 appears to be associated with good pain relief at rest and movement within the first 24 hours post-operatively and may be a useful addition to the multimodal analgesic regimen for a variety of surgeries. We also observed a limited opioid consumption and clinical benefit for nausea and pruritus in comparison to intrathecal analgesia. Data from QoR-15 questionnaire suggest that QLB may be an effective tool to enhance early mobilization, despite the common practice in the department does not allow implementation of these programs.

Our results are encouraging, further research is necessary to confirm preliminary data.

References

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A49

Background

Robotic-assisted laparoscopic surgery revolutionized the surgical management of localized kidney and prostate cancer, offering advantages over traditional open surgery. Robotic surgery offers less discomfort to patients because of smaller keyhole incisions and less tissue retraction and stretching of fascia and muscular fibers. However, optimal postoperative pain management remains crucia [1]. Analgesia techniques such as transversus abdominis plane (TAP) block [2] and intrathecal administration of morphine [3] have shown promise but lack direct comparison in this surgical context.[4] We performed a retrospective pilot trial comparing TAP block and intrathecal analgesia on postoperative pain control after urologic surgery.

Materials and methods

We conducted a retrospective study at Niguarda Hospital in Milan from September 2022 to January 2023, including patients scheduled for major urologic robotic surgery receiving intrathecal analgesia (IA) with morphine or TAP block. Patient demographics, surgical risk assessment (ASA score), and baseline characteristics were recorded. Data on analgesia techniques, rescue analgesia, pain scores, postoperative nausea and vomiting (PONV), and length of hospital stay (LOS) were collected prospectively. Data are reported as median (interquartile range [IQR]) for continuous variables and as frequencies and proportions for categorical variables.

All the analyses were conducted using R Core Team (version 4.3.0).

Results

We analyzed 59 consecutive patients 44 receiving IA and 15 receiving TAP block as regional analgesia. Population baseline characteristics are summarized in Table 1.

Eight patients underwent robotic nephrectomy, eight partial nephrectomy and 43 radical prostatectomy. We found no significative difference between Numeric pain Rating Scale (NRS) at operative room discharge (p=0.12), and during the first (p=0.63) and second postoperative days (p=0.5) (Figure 1).

Also the need of rescue analgesic therapy during the first (p=1) and second (p=0.32) postoperative day. None of the patients receiving TAP block experienced PONV during the first and second postoperative days while, in the IA group, eight and three patients experienced PONV during postoperative day 1 and 2 respectively. Hospital length of stay did not differ between the two groups.

Conclusion

This pilot observational study suggests that both TAP block and IA effectively manage postoperative pain after major robot-assisted urologic surgery. TAP block emerges as a valid alternative to IA due to the comparable effect on postoperative pain without IA related side effects such as PONV, urinary retention, pruritus and respiratory depression. Larger studies are needed to confirm these findings and further optimize pain management in this surgical population.

References

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A50

Background

Septic shock is characterized by an abnormal host response to infection, resulting in multi organ failure and hemodynamic instability. Guidelines recommend fluid resuscitation with 30 mL/kg of crystalloids within the first three hours of diagnosis and administration of norepinephrine to achieve a MAP > 65 mmHg.

Distributive shock is not the only hemodynamic alteration which can occur in septic patients. The catecholamine stress that characterizes the early stages of the disease is an important trigger for the onset of transient and reversible dysfunction of the left ventricle (LV) with symptoms like myocardial infarction, a condition known as Tako-Tsubo Syndrome (TTS).

TTS is a stress-induced (physical or emotional) cardiomyopathy so called for the characteristic ballooning shape that the left ventricular apex presents on echocardiography.

The diagnostic criteria for TTS according to the 'International Expert Consensus Document on TTS' are:

Case Report

After obtaining informed consent, a 56-year-old man with dehiscence of the ileocolic anastomosis post-resection surgery was admitted to our intensive unit care. Septic shock was diagnosed and fluid resuscitation and continuous infusion of norepinephrine at a dosage of 0.2 mcg/kg/min were administered. The patient, connected to mechanical ventilation in IPPV mode, was weaned off at 6 hours after admission. Hemodynamic monitoring was established using Acumen HPI software. Norepinephrine therapy was continued, achieving a MAP of 65 mmHg.

On the second day, there was an elevation of cardiac biomarkers and T wave inversion in all leads on the ECG.

Transthoracic echocardiogram (TTE) showed an ejecton fraction (EF) of 30%, halved compared to that found on the pre-operative TTE, meeting the diagnostic criteria for TTS.

In accordance with guidelines, non-catecholamine inotropic infusion was started with levosimendan (0.1 mcg/kg/min) and short-acting beta-blocker infusion with esmolol (60 mcg/kg/min) to reduce catecholamine-mediated myocardial insult.

Conclusion

In our case report, due to peri-operative management, artificial intelligence-based monitoring, and post-operative pharmacological management according to guidelines, we observed an improvement in EF, a reduced need for vasopressors, and an increase in cardiac output until discharge to the referring department.

Informed consent to publish had been obtained

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A51

Background

Elderly frail patients undergoing surgery are increasing nowadays. Sarcopenia is an objective measurement of frailty and has been identified as a predictor of poor postoperative outcomes. Study objectives are to evaluate the impact of sarcopenia on postoperative outcomes in elderly frail patients undergoing major elective surgery and factors affecting postoperative depletion of skeletal muscle mass in the same patients.

Materials and methods

This retrospective analysis was conducted on prospectively included patients 70 years older or more, undergoing major elective surgery in general surgery, urology, orthopedics at Maggiore della Carità Hospital, Novara, for whom preoperative and postoperative computer tomography (CT) scans were available. Total psoas area (TPA) measured at third lumbar vertebra level was adjusted for height to calculate total psoas index (TPI = TPA/height² [cm²/m²]). Sarcopenia was defined as the lowest sex-specific quartile of TPI. Furthermore, preoperative and postoperative muscle density as Hounsfield Units (HU) was calculated.

Results

Among the 104 patients included from May 2020 to January 2022, 51 patients with preoperative and postoperative CT scans were retrospectively analyzed. Mean age was of 76 (±4) years and 27 (53%) were males. Eighteen patients underwent urologic surgery, 13 upper digestive and 20 lower digestive surgery, with laparoscopic or robotic surgery performed in 31 cases. Surgery was conducted under general balanced anesthesia in all cases and mean anesthesia duration was of 322 (±117) minutes. Thirteen patients were defined as sarcopenic at the preoperative CT scan analysis and mean preoperative TPI was 4.27 (±0.93) cm²/m² in males and 2.96 (±0.85) cm²/m² in females. Baseline muscle density was 55 (±8) HU in males and 50 (±7) HU in females. Postoperative CT was performed in median 8 (5-15) months after surgery, showing an overall decrease of 14% in TPI (absolute decrease of 0.51 (±0.08) cm²/m²) and of 13% in muscle density. TPI reduction was more relevant in males than females, 0.62 (±0.03) cm²/m² (14%) vs 0.38 (±0.06) cm²/m² (12%) respectively. Median hospital length of stay (HLOS) was of 8 (6-13) days, eight patients were admitted to intensive care unit (ICU) after surgery, and 22 experienced some postoperative complications. At univariable regression analysis, preoperative sarcopenia did not influence HLOS, ICU admission and postoperative complications occurrence, while HLOS and ICU admission were significantly associated with postoperative TPI decrease.

Conclusions

Sarcopenia did not affect postoperative outcomes in our cohort, but patients with muscle depletion had longer hospitalization and more ICU admissions.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A52

Background: Postoperative cognitive dysfunction (POCD) occurs in 40% of elderly patients, during post-operative recovery for elective surgery; POCD can be assessed with Montreal Cognitive Assessment score (MoCA) [1,2]. 36-Item Short Form Health Survey (SF-36) and Quality of Recovery (QoR) are two questionnaires to assess the healthy status and recovery quality, respectively.

Methods: This study was a prospective observational trial. We included all over 60 years old patients, hospitalized for at least 3 days, undergoing general anaesthesia combined with spinal anesthesia for elective surgical procedure lasting at least 2 hours. Exclusion criteria were: history of mental or central nervous disorders, severe hypoacusis or visual loss, assumption of psychotropic drugs, impossibility to obtain written consent. Informed consent was obtained from all partecipants in the study. CONOX® were applied on each patient before the induction of anesthesia. Patients were divided in two groups: CONOX® guided group (C-group), in which anesthesia was guided by CONOX®, or routine care group. MoCA and SF-36 were collected: the day before and the day after the surgery; 7 days and 30 days via telephone after surgery; QoR was collected only the day after surgery. POCD is present if the MoCA score of postoperative periods is 1 or more standard deviations less than the baseline [1]. T-student test was used to analyses the difference between the continuous data and a chi-square test was used to analyse the binomial distributions. The statistical significance was set at a p-value<0.05.

Results: We enrolled 13 patients: 7 in C-guided group and 6 in routine care group. Two patients of C-group dropped out at the follow-up and they were excluded from the analysis. No differences were found in the baseline characteristics (Table 1).

No significant statistical difference was found in all scores at day 1, day 7 and day 30 between the two groups (Table 2).

The intraoperative parameter (i.e. heart rate, halogenated consumption, etc.) did not differ between groups (Table 3).

No differences were found in POCD incidence between the groups (Table 4).

Table 4 - Value of standard deviations from baseline for each patient and comparison of incidence of POCD between groups

Conclusions: Conversely to data reported in literature in our population we found no difference in the 2 groups, probably due to a too small sample size. Our data reported an incidence of about 50% of POCD, with no POCD at 30 days in the C-guided group. However, the application of anaesthesia monitoring, such as bispectral index (BIS), reduces the incidence of POCD [3]. More trials are needed to clarify if also CONOX® can reduce the incidence of POCD.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A53

Background: Post-operative delirium (POD) is one of the most insidious complication in elderly and is associated with prolonged mechanical ventilation, increase length of stay (LOS) in hospital, long term neurocognitive impairment and an overall increase mortality. In literature, the incidence POD after major abdominal surgery is 25%. The aim of the study is to assess the incidence of POD in elderly patients undergoing major abdominal surgery; adverse events and risk factors for POD have also been recorded.

Materials and methods: We conducted an observational, prospective, monocentric study. After obtaining appropriate informed consent we enrolled patients aged 60 yrs. or older, scheduled for major abdominal elective surgery from august 2019 to October 2019 at department of Oncological Anaesthesia and Intensive Care of Careggi University Hospital. Five days, 1 – 3 months follow-up were recorded. Confusion Assessment Method (CAM) and the CAM–ICU were used as diagnostic tools for POD assessment.

Results: From the 110 patients enrolled, 11 developed POD with an incidence of 10% (C.I 5,1 – 17,2). No differences between the delirium post-operative Group (PODg) and not-POD group (nPODg) was found in the pre-operative data, except for an older age and a higher value of Charlson Comorbidity Index in PODg. PODg experienced higher incidence of intraoperative burst suppression (60% vs 24%; p<0.05) and prolonged amount of intraoperative hypotension (23,7 min vs 6,3 min; p<0,05). PODg experienced more morphine prescription and longer mobilization times, LOS in ICU and higher incidence of post-operative complications (63% vs 17%; p <0.05). PODg showed a worsening of the Short Blessed Test performance at follow-up.

Conclusions: POD is a serious complication associated with morbidity and poor neurocognitive performance still after discharge, with worsening of patient’s quality of life. In addition, it is important to understand how neurocognitive decline of patients who experienced POD impact on care givers quality of life with physical, psychological, and financial burdens. Within this context a multidisciplinary strategy due to reduce the iatrogenic risk factors that can precipitate the fragile patient's compensation is pivotal.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A54

Keywords

Hip fractures, Geriatrics, Spinal anesthesia, General anesthesia, Perioperative care.

Abstract

Introduction: Hip fractures are common injuries in geriatric population, which often require surgical intervention. The choice between spinal and general anesthesia requires careful consideration of patient's medical condition, surgical procedure, risks, and benefits of each technique. We aimed to investigate the differences in perioperative care and mortality in patients receiving spinal (SA) and general anesthesia (GA) for hip fractures repair.

Methods: This is a retrospective multicentered study conducted in Jordan. Demographic, clinical, preoperative, operative, and postoperative data of geriatric patients (age more than or equal to 65) who underwent surgical fixation for hip fractures under spinal or general anesthesia were collected.

Results: Overall, 1083 patients were included, of whom 485 were males (44.8%) and 598 were females (55.2%). The median age for the study population was 78-year-old. Diabetes mellitus, hypertension, Alzheimer disease and osteoporosis were the most common comorbidities. 674 patients (37.4%) underwent spinal anesthesia, and 410 patients (62.6%) underwent general anesthesia. The median time to surgery in the overall cohort was 2 (4-1) days. Time to surgery was significantly longer in GA than SA (3 (4-2) days GA and 2 (4-1) GA, p = 0.000).

Cefazolin was the most commonly used class of antibiotics, followed by a combination of Cefazolin and Vancomycin. SA group used more antibiotics than GA group (p = 0.000). antegrade intramedullary nailing (IMN) was the most common technique of fixation, followed by hemiarthroplasty. SA group was fixed with IMN technique more than GA ([443 (62.76%) SA and 264 (64.39%) GA], p=0.390).

Cementation was needed more in the SA group ([164 (81.19%)SA and 72 (61.02%) GA], p=0.000).

Postoperatively, opioids were used more frequently in the SA group [424 (62.91%)] more than the GA group [229 (55.85%). p = 0.021].

Overall, 152 patients died after 1-year postoperatively (14.0%) [98 patients (64.5%) in SA and 54 in GA group, 29.6% of them died 1-year postoperatively, 25.7% after 6 months, and 18.4% in the hospital.

Conclusion: To our knowledge no studies have yet indicated the differences between general anesthesia and spinal anesthesia in elderly patients undergoing hip fracture repair. Our study found that spinal and general anesthesia are both commonly used in geriatric patients undergoing surgical fixation for hip fractures. However, SA was associated with shorter time to surgery, higher use of antibiotics, more frequent use of cementation, and more frequent use of opioids postoperatively. The choice between SA and GA should be made carefully based on patient-specific factors, comorbidities, and surgical requirements.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A55

BACKGROUND: Medical progress in the recent years resulted in increased survival of people with chronic organ failures and in longer life expectancy. [1] Since 2017 is possible to express living wills and share plans of care [2]. However, this possibility remains untapped by the majority of people and physicians, as if the “end of life” concept is still a kind of taboo; decisions are delayed longer and longer until it’s no more possible to avoid the conversation [3].

MATERIALS AND METHODS: Retrospective revision of ICU consultancies from 11/01/2022 to 01/31/2023 in a single centre (Lodi Hospital).

RESULTS: We evaluated 182 patients; 22% ended up in a non-indication to ICU admission (“too sick to benefit”); 65% of consultancy requests was received during afternoon or night shifts; 34% was requested from the ED. Mean patients age was 80.3 years; 73% of this was in a very frail condition (dependency from a caregiver or in a nursing home). 26.8% had three or more severe comorbidities. We received one request for “shared decision making” in the absence of an acute necessity and one patient had a living will. We also received 4 doubled “confirmatory” requests.

COMMENTS End-of-life decisions are taken in a situation of acute organ failure (46% respiratory failure in our study) which requires fast decisions that often become irreversible. Almost none of the patients had any living will or planned care in case of acute organ failure, even if affected from chronic diseases. The intensivist is invested with the determining role of decision about completely unknown patients, often alone, quickly, and during understaffed shifts. It seems that other specialists call the intensivist focusing their clinical evaluations more on the single organ failure than on the whole patient condition; this may happen because death may be considered a professional failure, it’s difficult to talk with patients and with shocked, unprepared relatives, or, perhaps, it may represent a sort of self-protection determined by the so-called “defensive medicine”. This condition may generate frustration, increase burnout, and, being a time-consuming activity, it could eventually lead to a disadvantage for people who benefit from ICU care by diverting staff's attention in the absence of a consultancy dedicated specialist. It seems necessary a better application of 219/2017 law; early involvement of “complementary palliative care”; avoidance of “defensive medicine”; a validated and shared decision-making algorithm; education and training in hospitals and general practice. It might also be useful, to take the right time to talk with patients and caregivers, to have a specific, multi-disciplinary outpatient clinic targeted to people with chronic and potentially worsening conditions to promote shared decisions and living wills when not urged by any life-threatening condition.

REFERENCES

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A56

Background

Cardiac patients on antiplatelets or oral anticoagulation undergoing emergency cardiac surgery are at an increased risk of developing perioperative bleeding due to insufficient discontinuation time[1]. Cytosorb (Cytosorbents, Monmouth Junction, NJ) is a blood purification technology that has been demonstrated to remove the antiplatelet P2Y12 receptor inhibitor, Ticagrelor, from the blood.

Case report

A 69 years old male patient, height 180 cm, weight 85 Kg, presented to the emergency room with myocardial infarction. Dual antiplatelet therapy (DAPT) with loading doses of ticagrelor and aspirin was administered. He underwent percutaneous coronary intervention (PCI) with one drug eluting stent (DES) implantation and subsequently developed cardiogenic shock due to papillary muscle rupture. He required multi-organ support and was brought to emergency surgery.

Considering the high risk of bleeding we decided to implement Cytosorb in parallel to the Cardiopulmonary Bypass (CPB).

Preoperative laboratory assays showed a haematocrit of 39,4%, platelet count 348000/L, INR 1, aPTT 32 sec, and fibrinogen 483 mg/dL. Preoperative VerifyNow P2Y12 PRU (Platelet Reactivity Unit) test value was 6, signifying a low platelet reactivity (LPR). Mitral valve replacement and tricuspid repair via right mini-thoracotomy were performed. Aortic cross-clamping time was 83 minutes, CPB time 130 min, and surgical time was 180 min. Haemostasis was obtained through the use of protamine in a 1:1 ratio to initial heparin, fibrinogen 2 gr, and 1 platelet pool. At the end of the surgery the ROTEM test was normal and the PRU test was 9.

Cytosorb was continued in ICU allowing complete free-ticagrelor adsorption (3 hours).

12 hours after surgery (24 hours after DAPT) PRU test was 178 (OPR optimal-platelet-reactivity range for P2Y12 receptor binding drugs), ARU (Aspirin resistance units) test was 478 (optimal range for aspirin therapy) and total chest tube output was 280 ml. On postoperative day 2 the patient was weaned from IABP and aspirin was restarted. Clopidogrel was added to aspirin on postoperative day 5 according to the platelet function tests, without a loading dose.

Patient’s total hospital stay was 19 days including 11 days in CICU. Total number of pRBCs transfused were 3 with only 1 platelet transfusion required. A coronary angiography one month after surgery showed complete DES patency.

Conclusions

Ticagrelor adsorption with Cytosorb during CPB is a safe and effective method to reduce bleeding complications in high-risk bleeding cardiac surgical patients. Careful haemostasis and serial measurements of platelet function permit the simultaneous management of the thrombotic risk.

A formal written consent was acquired from the patient for data publication.

References

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A57

Background

Tachyarrhythmias commonly occur in patients admitted to the Cardiac Intensive Care Unit (ICCU), high risk patients are those septic and undergoing cardiac surgery or major surgery [1,2,3]. Atrial fibrillation (AF) may also result in extended hospital stays and can significantly increase morbidity [4,5]. Compared to other beta-blockers, landiolol is an ultra-short acting beta-blocker with a very high beta1-selectivity, with only marginal effects on blood pressure and myocardial contractility [6,7,8]. In particular, landiolol was effective in rapidly controlling heart rate (HR) and could be used in vasopressor-dependent patients without significant effects on blood pressure or as a bridging treatment for adjunctive oral β-blocker in heart failure (HF) patients [9,10,11].

Case report

The patient was a 66-year-old woman with valvular disease. Fifteen days after cardiac surgery she had an episode of AF with HR increased to 150 bpm and systolic blood pressure (SBP) decreased to 70 mmHg. Continuous crystalloids infusion was increased, and norepinephrine was increased up to 0.2 mcg/kg/min without improving hemodynamics. Therefore, continuous landiolol infusion was started with a rate of 10 mcg/kg/min and was increased to 15 mcg/kg/min in three steps, titrated according to HR response without any significant effect on SBP. Six hours later, the patient converted to sinus rhythm and her SBP increased to 120 mmHg with a MAP>70 mmHg, which led to a reduction of norepinephrine (Figure 1).

Two days later landiolol was stopped and norepinephrine was tapered to 0.05 mcg/kg/min. The patient remained in sinus rhythm and her cardiac output (CO) improved, resulting in decreased norepinephrine demand with a stable MAP>75 mmHg.

Conclusion

In this report, we present a critically ill patient with new-onset AF who was successfully treated with a continuous intravenous administration of landiolol for 48h. Patients admitted to ICCUs often require norepinephrine to maintain adequate blood pressure which may induce the development of supraventricular tachyarrhythmias, like AF, in these patients [12]. Landiolol, compared to other beta-blockers, shows faster pharmacokinetics, higher potency and cardioselectivity (β1/β2-selectivity 255:33) with a less potent negative inotropic effect [13]. Accumulating evidence is supporting the use of ultrashort-acting β1-blockers (like landiolol) suitable for the acute management of supraventricular arrhythmias in ICCU patients, without adverse effects on inotropia and blood pressure [14,15,16,17,18].

References

©Consent to publication collected from the patient's family.

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A58

BACKGROUND

Although substantial advances in diagnosis and surgical techniques, the acute type A aortic dissection remains associated with high morbidity and mortality rates. Postoperative bleeding, several perioperative transfusions and reoperation for bleeding are the most frequent complications for this condition. The dissection itself activates the coagulation system and consumes platelet, clotting factors, and fibrinogen, even before surgery [1-2]. Blood flow through the false lumen is a powerful activator of the hemostatic system even before the operation. This remarkable activation may influence postoperative outcome of AAD patients [3]. In this consumption coagulopathy setting, literature suggests that hemostatic therapy should focus on the rapid and sufficient supplementation of clotting factor and fibrinogen after hypothermic circulatory arrest [4]. In line with the guidelines recommendations, the aim of the study is to manage the patients’ coagulation corrections through Thromboelastographic (TEG) to improve coagulation and outcome.

MATERIALS AND METHODS

Between 2020 and 2022, we enrolled adult patients with age over 18 years, admitted to the Department of Cardiac Surgery (Policlinico of Bari, Italy) for acute type A aortic dissection. We collected all medical, surgical, CPB and TEG perioperative data. TEG was performed at the end of CPB (post protamine) and after coagulation’s correction.

RESULTS

We enrolled 17 patients (10 man and 7 women) with mean age of 66,7 years, undergoing emergency surgery for acute type A aortic dissection. All patients underwent CPB with a mean duration of 224,4 minutes. Nine patients did not receive any transfusion, the remaining received in mean 278,52 ml of Blood red cells. A mean of packed red blood cell (2,5 pool), Platelets (1,4 pool), fresh frozen plasma (2,4 pool) Fibrinogen (1.75 gr), Tranexamic Acid (1,33 gr), Kedcom (1450 UI), Uman Complex (1750 UI) and Factor VII (600 UI) have been used.

CONCLUSIONS

In our brief case series, TEG early confirms the hypocoagulability, related to several factors: dissection, surgical trauma, cardiopulmonary bypass, and hypothermic circulatory arrest. TEG permits the immediate and bedside evaluation of Reaction Time, K, Angle, Maximum Amplitude, Lysis Time and Coagulation Index and their TEG guided correction (Figures. 1-2). The outcome of surgery for acute aortic dissection is improving, but many debates remain as to the optimal treatment and coagulation management.

REFERENCES

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A59

INTRODUCTION

The study of microcirculatory bed gained in recent years an increasing interestfor the evaluation different pathological states, particularly of shock. Furthermore recent studies have demonstrated improvement of the microcirculatory coronaric flow after TAVI. Unfortunately, literature about the correlation between these interventions and systemic microcirculation is still lacking.

PURPOSE

The aim of our study consists in evaluating the possible correlation between sistemic microcirculation (evaluated through the analysis of sublingual microcirculation) and TAVI. Our goal was to investigate if TAVI-related changes in hemodynamic could be associated alsowith modifications of sublingual microcirculatory bed. We tried also to investigate the maintenance or loss of the so-called hemodynamic coherence (concordance between macro and microcirculatory parameters) following TAVI.

METHODS

The analysis of the sublingual microcirculation was made using a CYTOCAM© device, a handheld device which exploits the IDF tecnology to produce a real-time image of the sampled field. Measurements were collected in 3 different moments: T0, before TAVI; T1, immediately after TAVI; T2, 24 hours after. We recorded the following perfusion parameters of microcirculation: TVL, TVD, PPV, PVD. Contextually, lactate values were obtained at T0 and T1. Sample was composed of 28 patients undergone Transfemoral TAVI between November 2023 and February 2023 in the hemodynamic lab of our institution. The group comprehended patients with AS both high flow high gradient and low flow low gradient. All the procedures were performed under moderate sedation. Informed consent was collected before the procedure for each patient.

RESULTS

Analysis of our data showedno statistically significant differencefor all the parameters in the T0-T1 and in the T0-T2 intervals. We recorded a trend in deterioration of microcirculation perfusion immediately after the procedure, not reaching the significance (p>0.05). The only parameter showing an improvement was TVL at 24 hours in low flow low gradient patients (p 0.07, Table 1). We have also seen a tendency of loss of hemodynamic coherence in some patients.

CONCLUSIONS

In our study we have tried to find a correlation between TAVI and microcirculatory bed modification. We havenot found a significant relationship in terms of improvement of the microcirculatory perfusion parameters after TAVI. However, we recorded a tendency of improvement of many parameters in the subpopulation of low flow low gradient patients, which could stimulate future researches.

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A60

Introduction: Left ventricular diastolic dysfunction (LVDD) is associated to weaning failure (1). Spontaneus breathing trial (SBT)-induced central hemodynamic changes monitored by critical care echocardiography (CCE) helps guide weaning of patients at high risk of weaning pulmonary edema (WIPO). Levosimendan improves both LV sistolic and diastolic functions and can be used to optimize cardiac function before of SBT in anticipation of a difficult weaning process in patients with LVDD (2).

Methods: An obese 44-years-old man with known dilated cardiomyopathy arrived at the Emergency Department with a pulseless ventricular tachycardia, treated with electrical shock, followed by rapid ventricular response atrial fibrillation, treated with more 4 shocks and subsequent restoration of sinus rhythm. The patient was intubated and admitted in Intensive Care.

Results: After 72h, a SBT failed because of WIPO. A CCE showed an E/A ratio of 1,37 cm/sec with DT of 145,0 ms , E/e’ 26,57 cm/sec and a left atrial Volume Index of 38ml/m2 identifying a grade II LVDD (3). A chest X-ray revealed perihilar and increased vascular markings. Levosimendan was added to standard therapy. 48h later, a CCE demonstrated an improvement in LVDD (Fig.1): E/A ratio was 1,06 cm/sec; DT 210 msec, E/e’ 10,9 cm/sec. Weaning was successfull on day 5 and patient was discharged on day 7.

Conclusion: A combination of clinical parameters with bedside CCE can not only help in setting up therapy, but also facilitate weaning from ventilation. Use of CCE to study LVDD can help to identify patients who can be difficult to wean off the ventilator. Furthermore, levosimendan can be associated to a better weaning outcome in patients with LVDD through its beneficial effect on cardiac function.

Written informed consent for the publication has been obtained by patient after discharge.

Transmitral pattern during weaning ventilation before and after levosimendan therapy

References

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A61

BACKGROUND

Heparin is the drug of choice for anticoagulation during Carotid Endarterectomy (CEA) required to minimize dangerous thromboembolic events, but in patients with its contraindication, bivalirudin is frequently used as a short half-life direct thrombin inhibitor. In the vascular surgical and endovascular setting the use of the heparin is codified, but there are no defined protocols for the management of bivalirudin during open surgery. The aim of this case report is to define and evaluate the results of TEG guide administration of bivalirudin during these procedures.

CASE PRESENTATION AND TREATMENT

An 87-year-old lady with severe pulmonary hypertension, ASA III, NYHA III, allergic to sodium heparin and to low molecular weight heparins, was scheduled for an elective CEA, after obtaining the informed consent. Approximately 5 months earlier, the same patient underwent percutaneous correction of tricuspid regurgitation with TriClip (Abbott) and the procedure was successfully completed using bivalirudin for anticoagulation. According to body weight and kidney function, the administration of the bolus has been followed by continuous infusion; bivalirudin was also diluted in the surgery washing solutions during CEA. Immediately before carotid occlusion, bivalirudin was administered as a 60 mg bolus followed by a 1,4 mg/Kg/h infusion. Following a team-agreed protocol, the infusion rate was modulated according to the value of the Activated Clotting Time (ACT), double-checked at close intervals and Thromboelastogram (TEG) before, during and in the hours following the procedure (Fig. 1);

(Fig. 2); (Fig. 3). The patient was discharged home in 4 days without significant complications. Bivalirudin provided adequate anticoagulation and good surgical outcome without any adverse effects in this patient.

DISCUSSION and CONCLUSION

Viscoelastic testing provides a rapid picture of whole blood coagulation dynamics and hemostasis that can be reviewed and evaluated bedside. So, this experience supports the utility of TEG to guide the administration of bivalirudin as an alternative to heparin in surgical vascular procedures. Before, during and after CEA, TEG guided the coagulation state of the patient, monitoring the effect of bivalirudin and the function of coagulation system components, to ensure the possibility of targeted corrective action, in case of hemorrhagic complications, until the end of the drug effect.

Informed consent to publish had been obtained

REFERENCE

Bild vergrößern

Bild vergrößern

Bild vergrößern

Journal of Anesthesia, Analgesia and Critical Care 2023, 3(Suppl 1):A62

Background

Variation of inferior vena cava (IVC) is used to predict fluid-responsiveness, but the IVC visualization with standard sagittal approach (SC, subcostal) cannot be always achieved. In such cases, coronal trans-hepatic (TH) window may offer an alternative, but the interchangeability of IVC measurements in SC and TH is not fully established [1, 2]. Further, artificial intelligence (AI) with automated border detection may be of clinical value but it needs validation.

Materials and Methods

We performed a prospective observational validation study in mechanically ventilated patients with pressure-controlled mode. Informed consent was obtained before the assessment. Primary outcome was the IVC distensibility (IVC-DI) in SC and TH imaging, with measurements taken both in M-Mode or with AI software (Figure 1).

We calculated mean bias, limits of agreement (LoA), and intra-class correlation (ICC) coefficient. The study was approved by local ethical committee on 21/03/2022 (Reference protocol: 53/2022/PO).

Results

Thirty-three patients were included. Feasibility rate was 87.9% and 81.8% for SC and TH visualization, respectively. Comparing imaging from the same anatomical site acquired with different modalities (M-Mode vs AI), we found the following IVC-DI differences: 1) SC: mean bias -3.1%, LoA [-20.1;13.9], ICC=0.65; 2) TH: mean bias -2.0%, LoA [-19.3;15.4], ICC=0.65. When comparing the results obtained from the same modality but from different sites (SC vs TH), IVC-DI differences were: 3) M-Mode: mean bias 1.1%, LoA [-6.9;9.1], ICC=0.54; 4) AI: mean bias 2.0%, LoA [-25.7;29.7], ICC=0.32 (Table 1).

Conclusions

In patients mechanically ventilated, AI software shows good accuracy (modest overestimation) and moderate correlation as compared to M-mode assessment of IVC-DI, both for SC and TH windows. However, precision seems suboptimal with wide LoA. The comparison of M-Mode or AI between different sites yields similar results but with weaker correlation.

Trial registration: Reference protocol: 53/2022/PO, approved on 21/03/2022

REFERENCES

Bild vergrößern