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BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation.METHODS: EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing.FINDINGS: Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms.INTERPRETATION: Patient's age, timing of cannulation (FUNDING: None.

The effect of psychopathology on swallowing ability tends to be an overlooked issue in the assessment of dysphagic patients, possibly overshadowed by the given prominence to organic pathologies and the difficulties on the management of these patients. In addition, it should also be kept in mind that a great number of psychotropic drugs can affect swallowing adding problematic clinical issues in this area. Despite this, assessment of dysphagia should be considered as an extremely important issue, due to its impact on basic symptomatology, course of illness and quality of life. This review aims to be an overview of relevant data on psychopathology associated with dysphagia and impairment of swallowing function. An extensive bibliographic search was carried out in different medical databases (PubMed and Psycharticles) to comprehensively identify the most relevant publications available on dysphagia in eating disorders published until December 2020, according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) method. Research articles, either theoretical or empirical-based, published in peer-reviewed journals and in English language, were included. Case reports were also considered in the analysis when it was appropriate for completeness purposes. Titles and abstracts were reviewed according to the eligibility criteria. In total, 260 published studies were identified and 40 were finally selected after removal of duplicates and relevance. Primarily we investigated the correlation between dysphagia and eating disorders, analysing the complex relationship between the two conditions. Then we provided an overview of the assessment of dysphagic symptoms in other psychiatric syndromes. No exclusion criteria or statistical methods were applied nor was an assessment of study-level or outcome-level bias applicable for our purpose. The topic is vast and research bias could not be excluded; moreover, data available are heterogeneous and lacking systematic approach. With this review, the authors want to provide an overview of the most considerable and clinically useful information about the topic, focusing on some key points to disentangle psychiatric components from the complexity of patient with dysphagia. It should be a relevant concern for all clinicians and should be always thoroughly assessed, considered its frequency in clinical practice and its implications in every kind of patients’ morbidity, mortality and quality of life. Special attention should be paid to mentally ill patients, who might display complex and multiple comorbidities, as well as consequences of abnormal eating behaviours, occasionally exacerbated by psychotropic medications. More systematic studies are needed, while it seems clear that a multidisciplinary approach is pivotal in the assessment and management of dysphagic patients. Level I (evidence obtained from at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies).

Several perioperative factors are responsible for the dysregulation or suppression of the immune system with a possible impact on cancer cell growth and the development of new metastasis. These factors have the potential to directly suppress the immune system and activate hypothalamic-pituitary-adrenal axis and the sympathetic nervous system with a consequent further immunosuppressive effect.Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system, inflammatory system, and angiogenesis, with a possible impact on cancer recurrence and long-term outcome. Even if the current data are controversial and contrasting, it is crucial to increase awareness about this topic among healthcare professionals for a future better and conscious choice of anesthetic techniques.In this article, we aimed to provide an overview regarding the relationship between anesthesia and cancer recurrence. We reviewed the effects of surgery, perioperative factors, and anesthetic agents on tumor cell survival and tumor recurrence.

Lung ultrasound (LU) has a multitude of features and capacities that make it a useful medical tool to assist physicians contending with the pandemic spread of novel coronavirus disease-2019 (COVID-19) caused by coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thus, an LU approach to patients with suspected COVID-19 is being implemented worldwide. In noncritical COVID-19 patients, 2 new LU signs have been described and proposed, the “waterfall” and the “light beam” signs. Both signs have been hypothesized to increase the diagnostic accuracy of LU for COVID-19 interstitial pneumonia. In critically ill patients, a distinct pattern of LU changes seems to follow the disease's progression, and this information can be used to guide decisions about when a patient needs to be ventilated, as occurs in other disease states similar to COVID-19. Furthermore, a new algorithm has been published, which enables the automatic detection of B-lines as well as quantification of the percentage of the pleural line associated with lung disease. In COVID-19 patients, a direct involvement of cardiac function has been demonstrated, and ventilator-induced diaphragm dysfunction might be present due to the prolonged mechanical ventilation often involved, as reported for similar diseases. For this reason, cardiac and diaphragm ultrasound evaluation are highly important. Last but not least, due to the thrombotic tendency of COVID-19 patients, particular attention also should be paid to vascular ultrasound. This review is primarily devoted to the study of LU in COVID-19 patients. The authors explain the significance of its “light and shadows,” bearing in mind the context in which LU is being used—the emergency department and the intensive care setting. The use of cardiac, vascular, and diaphragm ultrasound is also discussed, as a comprehensive approach to patient care.

Background To assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard. Methods A prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients. Results As per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p Conclusions The concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Background Diaphragmatic dysfunction is a major factor responsible for weaning failure in patients that underwent prolonged invasive mechanical ventilation for acute severe respiratory failure from COVID-19. This study hypothesizes that ultrasound measured diaphragmatic thickening fraction (DTF) could provide corroborating information for weaning COVID-19 patients from mechanical ventilation. Methods This was an observational, pragmatic, cross-section, multicenter study in 6 Italian intensive care units. DTF was assessed in COVID-19 patients undergoing weaning from mechanical ventilation from 1st March 2020 to 30th June 2021. Primary aim was to evaluate whether DTF is a predictive factor for weaning failure. Results Fifty-seven patients were enrolled, 25 patients failed spontaneous breathing trial (44%). Median length of invasive ventilation was 14 days (IQR 7–22). Median DTF within 24 h since the start of weaning was 28% (IQR 22–39%), RASS score (− 2 vs − 2; p = 0.031); Kelly-Matthay score (2 vs 1; p = 0.002); inspiratory oxygen fraction (0.45 vs 0.40; p = 0.033). PaO2/FiO2 ratio was lower (176 vs 241; p = 0.032) and length of intensive care stay was longer (27 vs 16.5 days; p = 0.025) in patients who failed weaning. The generalized linear regression model did not select any variables that could predict weaning failure. DTF was correlated with pH (RR 1.56 × 1027; p = 0.002); Kelly-Matthay score (RR 353; p 2/FiO2 ratio (RR 1.03; p = 0.05); SAPS2 (RR 0.71; p = 0.005); hospital and ICU length of stay (RR 1.22 and 0.79, respectively; p Conclusions DTF in COVID-19 patients was not predictive of weaning failure from mechanical ventilation, and larger studies are needed to evaluate it in clinical practice further. Registered: ClinicalTrial.gov (NCT05019313, 24 August 2021).

Since the first months of 2020 COVID-19 patients who were seriously ill due to the development of ARDS, required admission to the intensive care unit to ensure potentially life-saving mechanical ventilation and support for vital functions. To cope with this emergency, an extremely rapid reorganization of premises, services and staff, to dedicate an entire intensive care unit exclusively to SARS-CoV-2 patients and increasing the number of beds was essential. The aim of the study was to evaluate the effects of reorganization of the COVID-19 intensive care unit in terms of nursing sensitive outcomes.a retrospective observational study was conducted to compare nursing sensitive outcomes between pre-COVID period and COVID period.Falls (0.0 and 0.4%, respectively), physical restraint (1.8 and 1.1%, respectively), and pressure ulcers (8.0 and 3.0%, respectively) were similar in the COVID and in the pre-COVID group. After adjusting for gender, age, BMI, and number of comorbidities, the incidence of bloodstream infections was significantly higher in the COVID group than in the pre-COVID group. There were no statistically significant differences in the incidence between the two groups regarding other evaluated outcomes.The selected nursing sensitive outcomes maintained similar values in the pre-COVID and COVID patient groups. Healthcare-related infections rate must be considered an important alarm signal of quality of nursing care especially in conditions of excessive workload, stress and the presence of less experienced staff increase.

This study aims to evaluate clinical correlates of psychiatric comorbidity and length of hospitalization in patients admitted in a general hospital emergency medicine setting. Overall, 160 patients hospitalized for different acute medical pathologies were selected consecutively over 12 months. All subjects were evaluated with proper forms to collect data on medical and psychiatric diagnoses. Levels of C-reactive protein were also measured in all patients. Statistical analyses were conducted with univariate, logistic, and multiple linear regressions. Patients with psychiatric comorbidity had significantly longer hospitalization than did patients with no psychiatric diagnoses (days 10.9±9.5 vs. 6.9±4.5, p

Fewer than 100 cases of amiodarone-induced thyrotoxicosis (AIT) managed surgically have been reported worldwide. This study aims to assess the outcome of thyroidectomy under general anesthesia in a relatively large case series. A retrospective analysis of the clinical records of 53 patients who underwent thyroidectomy for AIT between 1995 and 2019 was conducted. There were 48 (90%) males and 5 females with an average age of 63.7 years. Type 1 and 2 AIT were present in 35 (66%) and 18 (34%) of patients, respectively. The mean preoperative ejection fraction (EF) was 45 ± 13%. Salvage surgery was performed in 6 (11%) patients due to decompensating heart failure and/or malignant arrhythmias. 35 (66%) patients underwent urgent surgery due to a predicted late response to medical therapy and/or the need to discontinue it. Elective surgery was performed in the remainder. A considerable improvement in mean EF occurred 12 months post-surgery (44% vs. 49%; p 0.001). The overall survival rate following thyroidectomy was 96% at 12 months, and 83% at 5 years. No survival differences were observed based on systolic function. Cardiac-specific mortality was 11%, and these patients demonstrated a considerably shorter survival post-surgery compared to those who died of a non-cardiac cause (27 ± 18 vs. 77.5 ± 54 months; p 0.05). Total thyroidectomy can be safely performed under general anesthesia despite severe cardiac disease. It considerably improves cardiac function and confers a survival advantage. Therefore, it should be considered early in the treatment plan of select cases.

Purpose The COVID-19 outbreak has led to an increasing number of acute laryngotracheal complications in patients subjected to prolonged mechanical ventilation, but their incidence in the short and mid-term after ICU discharge is still unknown. The main objective of this study is to evaluate the incidence of these complications in a COVID-19 group of patients and to compare these aspects with non-COVID-19 matched controls. Methods In this cohort study, we retrospectively selected patients from November 1 to December 31, 2020, according to specific inclusion and exclusion criteria. The follow-up visits were planned after 6 months from discharge. All patients were subjected to an endoscopic evaluation and completed two questionnaires (VHI-10 score and MDADI score). Results Thirteen men and three women were enrolled in the COVID-19 group while nine men and seven women were included in the control group. The median age was 60 [56–66] years in the COVID-19 group and 64 [58–69] years in the control group. All the patients of the control group showed no laryngotracheal lesions, while five COVID-19 patients had different types of lesions, two located in the vocal folds and three in the trachea. No difference was identified between the two groups regarding the VHI-10 score, while the control group showed a significantly worse MDADI score. Conclusions COVID-19 patients subjected to prolonged invasive ventilation are more likely to develop a laryngotracheal complication in the short and medium term. A rigorous clinical follow-up to allow early identification and management of these complications should be set up after discharge.

PurposeAn increasing number of laryngotracheal complications in mechanically ventilated COVID-19 patients has been reported in the last few months. Many etiopathogenetic hypotheses were proposed but no clear explanation of these complications was identified. In this paper we evaluated the possibility that the tracheal mucosa could be a high viral replication site that could weaken the epithelium itself.MethodsSubjects for the COVID-19 group and the control group were selected retrospectively according to specific criteria. Patients’ basic and clinical data were recorded and analyzed. Tracheal samples of both groups were collected during surgical tracheostomies and then analyzed from a histological and genetic-transcriptional point of view.ResultsFour COVID-19 patients were enrolled in this study and compared with four non-COVID-19 patients. No laryngotracheal complications were identified in both groups. The SARS-CoV-2 was detected in one out of four COVID-19 samples. A subepithelial inflammatory lymphomonocyte infiltrate was observed in all patients but two cases of the COVID-19 group showed vasculitis of small subepithelial vessels associated with foci of coagulative necrosis. Two gene sets (HALLMARK_INFLAMMATORY_RESPONSE and HALLMARK_ESTROGEN_RESPONSE_LATE) were significantly deregulated in COVID-19 patients compared to the control group.ConclusionThe altered inflammatory response of the COVID-19 patients could be another possible explanation of the increasing number of laryngotracheal complications.

Background To produce statements based on the available evidence and an expert consensus (as members of the Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care, SIAARTI) on the use of lung ultrasound for the management of patients with COVID-19 admitted to the intensive care unit. Methods A modified Delphi method was applied by a panel of anesthesiologists and intensive care physicians expert in the use of lung ultrasound in COVID-19 intensive critically ill patients to reach a consensus on ten clinical questions concerning the role of lung ultrasound in the following: COVID-19 diagnosis and monitoring (with and without invasive mechanical ventilation), positive end expiratory pressure titration, the use of prone position, the early diagnosis of pneumothorax- or ventilator-associated pneumonia, the process of weaning from invasive mechanical ventilation, and the need for radiologic chest imaging. Results A total of 20 statements were produced by the panel. Agreement was reached on 18 out of 20 statements (scoring 7–9; “appropriate”) in the first round of voting, while 2 statements required a second round for agreement to be reached. At the end of the two Delphi rounds, the median score for the 20 statements was 8.5 [IQR 8.9], and the agreement percentage was 100%. Conclusion The Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care produced 20 consensus statements on the use of lung ultrasound in COVID-19 patients admitted to the ICU. This expert consensus strongly suggests integrating lung ultrasound findings in the clinical management of critically ill COVID-19 patients.

Positive end-expiratory pressure (PEEP) may affect arterial wave propagation and reflection, thus influencing ventricular loading conditions. The aim of the study was to investigate the hemodynamic variations in arterial wave reflection (i.e., wave reflection time, augmentation index, left ventricular ejection time, diastolic time, SEVR) associated with the application of increasing levels of PEEP in healthy subjects. We conducted a prospective observational study. Study population was selected from students and staff. Pulse contour wave analysis was performed from the right carotid artery during stepwise increase in PEEP levels (from 0 cmH2O, 5 cmH20, 10 cmH2O) with applanation tonometry. Sixty-two healthy volunteers were recruited. There were no significant changes in heart rate, augmentation index (AIx), left ventricular ejection time, Diastolic time (DT) among all of the different steps. A significant increase of time to the inflection point (Ti) was observed during all steps of the study. Diastolic area under the curve (AUC) divided by systolic-AUC (SEVR) increased from baseline to PEEP = 5 cmH2O, and from baseline to PEEP = 10 cmH2O. AIx and Ti were significantly correlated (directly) at the baseline and during PEEP = 10 cmH2O. Ti and DT were significantly correlated at the baseline and during PEEP = 5 cmH2O. In our preliminary results, low levels of PEEP played a role in the interaction between the heart and the vascular system, apparently mediated by a prolongation of the diastolic phase and a reduction in the systolic work of the heart.Clinical trials registration number: NCT03294928, 19/09/2017.

IntroductionIn patients with septic shock, low levels of circulating immunoglobulins are common and their kinetics appear to be related to clinical outcome. The pivotal role of immunoglobulins in the host immune response to infection suggests that additional therapy with polyclonal intravenous immunoglobulins may be a promising option in patients with septic shock. Immunoglobulin preparations enriched with the IgM component have largely been used in sepsis, mostly at standard dosages (250 mg/kg per day), regardless of clinical severity and without any dose adjustment based on immunoglobulin serum titres or other biomarkers. We hypothesised that a personalised dose of IgM enriched preparation based on patient IgM titres and aimed to achieve a specific threshold of IgM titre is more effective in decreasing mortality than a standard dose.Methods and analysisThe study is designed as a multicentre, interventional, randomised, single-blinded, prospective, investigator sponsored, two-armed study. Patients with septic shock and IgM titres Ethics and disseminationThe study protocol was approved by the ethics committees of the coordinating centre (Comitato Etico dell’Area Vasta Emilia Nord) and collaborating centres. The results of the trial will be published within 12 months from the end of the study and the steering committee has the right to present them at public symposia and conferences.Trial registration detailsThe trial protocol and information documents have received a favourable opinion from the Area Vasta Emilia Nord Ethical Committee on 12 September 2019. The trial protocol has been registered on EudraCT (2018-001613-33) on 18 April 2018 and on ClinicalTrials.gov (NCT04182737) on 2 December 2019.

Contains fulltext : 238976.pdf (Publisher’s version ) (Open Access) On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

Anticoagulants are widely used, especially in the elderly, for the prevention and treatment of thromboembolic complications and in high-risk post myocardial infarction. Above all, Vitamin K antagonists (VKAs) are predominantly prescribed in the general population. Unfortunately, due to VKAs intrinsic pharmacodynamic and pharmacokinetic properties (high interindividual variability, food interaction, narrow therapeutic window), routine management of VKAs can be challenging both for the patients and for the clinicians, consequently, the number of patients taking non-vitamin K oral anticoagulants (i.e., direct oral anticoagulants) is increased in the last years. In fact, direct oral anticoagulants (DOACs) have progressively been used owing to their shorter half-lives, rapid onset, and predictable pharmacodynamics.

Purpose: The aim of this study was to evaluate whether measurement of diaphragm thickness by ultrasonography may be a clinically useful noninvasive method for identifying patients at risk of adverse outcomes defined as need of invasive mechanical ventilation or death. Methods: We retrospectively reviewed the records of consecutive of 77 patients with laboratory-confirmed Covid-19 infection admitted to our intermediate care unit in Pisa between March 5 and March 30, 2020, with follow up until hospital discharge or death. Logistic regression was used identify variables potentially associated with adverse outcomes and those PResults: The main findings of this study are that 1) patients who developed adverse outcomes had thinner diaphragm than those who did not (2.0 vs 2.2 mm, p:0.001), 2) DT and lymphocyte count were independent significant predictors of adverse outcomes, with end-expiratory DT being the strongest (-708, OR: 0.492, p: 0.018).Conclusion: Diaphragmatic ultrasound may be a valid tool to evaluate the risk of respiratory failure. Evaluating the need of mechanical ventilation treatment should be based not only on PaO2/FiO2, but on a more comprehensive assessment including DT because if the lungs become less compliant a thinner diaphragm, albeit free of intrinsic abnormality, may become exhausted, thus contributing to severe respiratory failure.

Ten critically ill patients with either bacteremia or ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii, Stenotrophomonas maltophilia, or New Delhi metallo-β-lactamase–producing Klebsiella pneumoniae received cefiderocol. All strains had minimum inhibitory concentration ≤2 μg/mL. Thirty-day clinical success and survival rates were 70% and 90%, respectively. Two patients had a microbiological failure. Future prospective studies are warranted.

Background Peritoneal carcinomatosis (PC) is a common manifestation of many gastrointestinal (GI) malignancies and is an advanced stage that is often associated with disseminated disease. Considerable progress has been made to achieve safe elimination of macroscopic disease using cytoreductive surgery (CRS) and more recently in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of microscopic disease or disease with minimal volume. The aim of this study was to assess the effects of such procedures on the quality of life (QoL), the long-term benefit and the functional status of the treated patients. Patients and methods Data from patients who underwent CRS-HIPEC for peritoneal metastasis (PM) at our center from November 2016 to November 2018 were analyzed retrospectively. The drugs administered were mitomycin and cisplatin. Quality of life (QoL) was assessed using the Euroquol-5D-5L and National Comprehensive Cancer Network Functional Assessment of Cancer Therapy-Breast Cancer Symptom Index v2 questionnaires before CRS-HIPEC, and 1, 3 and 6 months after were administered. Results In our series, the survival efficacy of CRS plus HIPEC was confirmed in the treatment of primary and secondary peritoneal pathologies, particularly in ovarian cancer, although larger studies are needed to investigate its role in the pathology of gastric, colonic and rectal cancer. The QoL data were promising, with essentially stable values between the preoperative and the 1-month follow-up, but with incremental benefits from the second to the third month.

Background: Minimally-invasive video-assisted parathyroidectomy (MIVAP) can be considered as the primary treatment of choice for single parathyroid adenoma. Often, this technique is performed in a day surgery setting and is associated with regional anaesthesia (RA). Many studies have already reported the feasibility and safety of MIVAP in day surgery. Here our focus has been on the patient’s personal experience with these procedures through an assessment of their recovery at home. Methods: We conducted a prospective observational study in the University Hospital of Pisa Day Surgery Unit. Forty-eight patients were enrolled and divided by personal choice of anaesthesia technique: a regional anaesthesia group (RAg) and general anaesthesia group (GAg). Data were extracted from the medical records and three questionnaires: the first was self-compiled at discharge (Q1), while the second (Q2) and the third (Q3) were administered as telephone surveys. Results: None of the patients in RAg reported pain longer than 1 day after discharge, whereas 15% of patients in GAg reported pain relief the third day after discharge (P=0.0065). Discharge in RAg was within 3 hours in 12.5% of patients, within 4 hours in 78.1%, and within 5 hours in 9.4%. Discharge in GAg was within 5 hours in 53.8% and in more than 5 hours in 46.1% (P=0.0027). Conclusions: Patients highly appreciated day-case parathyroidectomy. Furthermore, the association of RA with MIVAP leads to better results than those of general anaesthesia (GA) and MIVAP. Finally, we point out that it is fundamental that the physicians pay attention to what the patients consider important for them; that is, the personal meaning of the hospitalization.

Introduction: So far, only heparin-based anticoagulation has been proposed during polymyxin-B hemoperfusion. However, postsurgical septic patients can be at high risk of bleeding due to either surgical complications or septic coagulation derangement. Consequently, heparin should not represent in some cases the anticoagulation regimen of choice in this type of patients. Methods and results: We present a case series of four postsurgical septic patients treated with polymyxin-B hemoperfusion using regional citrate anticoagulation. All the treatments were performed without complications. During each treatment, there were no episodes of filter clotting, no bleeding, and no metabolic complications for any of the patients. Conclusion: To our knowledge, this is the second published report on the use of citrate anticoagulation during polymyxin-B hemoperfusion. Our case series continued to show that regional citrate anticoagulation regimen is feasible and safe during polymyxin-B hemoperfusion treatment in postsurgical septic patients.

Objectives To evaluate the effects of the reorganisation of an intensive care unit for COVID-19 patients in the context of the SARS-CoV-2 pandemic on wellbeing perceived by nurses. Methods An observational cross-sectional study was conducted to evaluate wellbeing perceived by nurses who during the study were on duty in the COVID-19 intensive care unit. The “Covid-19-Nurse Well-being at Work (NWB) scale” questionnaire consisting of 72 items divided into 13 sections, was validated and used to collect data. Results The level of wellbeing perceived by the nurses was very good (4.77; SD 0.83). Differences in the of level of perceived wellbeing were found for “years of experience” and the various levels of competence. We found a positive correlation between “female gender” and “nurses’ togetherness and collaboration”, a negative correlation between “male gender” and “satisfactory practical organisation of work, and a negative correlation between “work experience” and the overall “level of wellbeing at work. Conclusions The reorganisation had positive effects in terms of wellbeing perceived by the nurses. The factors that contributed mostly to the perception of wellbeing were in the area of “support”, “communication, and “socializing with colleagues”. It is appropriate to consider “gender differences”, “work experience” and “levels of competence” when implementing this type of reorganisation to respond to a pandemic or a health emergency.

Parenchyma-sparing hepatectomy techniques allow a lesser volume resection (3 adjacent segments) for tumors involving the hepatic veins at the hepatocaval confluence, assuring adequate volume of the future liver remnant. We report the ability to perform parenchyma-sparing hepatectomy as planned from the preoperative imaging and the type of vascular intervention used to preserve hepatic outflow.We analyzed 60 consecutive parenchyma-sparing hepatectomies in 54 patients for 7 primary and 53 metastatic tumors (48 colorectal), located in segments I, VII, VIII, or IVa and involving the hepatocaval confluence. Patients had a median of 2 (range: 1-18) lesions with median diameter of 4 cm (range: 1.2-16.5), which were bilateral in 43%.A parenchyma-sparing hepatectomy was performed in all of the 60 cases, only one case required the resection of 3 adjacent segments. In 16 (27%) hepatic veins-resections, the outflow was assured by preservation of the inferior-right-hepatic veins in 3 (5%), of the communicating-veins in 4 (7%), of the middle-hepatic veins in 3 (4%; middle-hepatic veins patch-reconstruction in 2 cases), by polytetrafluoroethylene-grafts in 4 (7%), and by hepatic veins-anastomosis in 2 (3%). In 15 (25%) cases, the hepatic veins were resected tangentially and reconstructed by direct suture venorraphy. In 29 (48%) cases, the hepatic veins were skeletonized from the tumor. Grade IIIb to IV complications occurred in 7%, median hospital-stay was 9 days, and 90-day mortality occurred in one cirrhotic patient. Median overall and disease-free survivals were 72 and 16 months (median follow-up: 34 months).A lesser volume parenchyma-sparing hepatectomy rather than a formal major hepatectomy for tumors involving the hepatocaval confluence can be performed with a low rate of major complications (7%). Parenchyma-sparing hepatectomy should be considered in highly selected patients when evaluating liver resection for tumors involving the hepatocaval confluence based on appropriate and accurate preoperative imaging.

Background Jehovah’s Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah’s Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures. Methods This is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah’s Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure. Results In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah’s Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications. Conclusions Our experience confirms that liver transplantation in selected Jehovah’s Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach.

Jehovah's Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We developed a peri-operative management pathway with strategies toward a transfusion-free environment in the respect of the patients’ religious beliefs. Briefly, our peri-operative multimodal strategy to liver transplantation in Jehovah's Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure. In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest LT program from deceased donors in JW patients that has been reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications. Our experience confirms that liver transplantation in selected Jehovah's Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach

Supplemental Digital Content is available in the text., Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a highly infectious virus transmitted by inhalation of infected matter containing live virus or by exposure from contaminated surfaces. Aerosol-generating procedures (AGPs) create an increased risk of airborne transmission of infection. Tracheal extubation of coronavirus disease 2019 (COVID-19) patients in the intensive care unit (ICU) is a risky AGP procedure owing to the proximity of the staff members to the patients’ mouths and the exposure to airway secretions. We describe the use of a disposable openable mask (Janus Mask, Biomedical Srl, Florence, Italy) that might limit aerosol generation in the periextubation phase of COVID-19 cardiac surgical patients.

Subarachnoid hemorrhage (SAH) represents a medical emergency. Unfortunately, diagnosis can be delay due to cardiogenic abnormalities often associated with SAH. Cardiac manifestations are heterogeneous and common in patients with SAH. This phenomenon has not to be underestimated taking into account the devastating consequences of misdiagnosis and delay in the correct diagnosis and in a specific treatment, with serious and life-threatening consequences. We present a case report of an out of hospital ST elevation in a patient with Glasgow coma score of 6. He was primarily managed as an acute coronary syndrome case. However, coronary angiography was normal. After performing a computed tomography scan, the diagnosis of SAH was made.

Purpose Septic shock involves a dysregulation of the immune response to an infection. This may lead to hemodynamic dysfunction and multiple-organ failure. The main aim of this study was to evaluate the effect of coupled plasma filtration adsorption (CPFA) on the hemodynamic profile in patients with septic shock. Materials and methods We retrospectively analyzed data from 21 adult patients admitted to the intensive care unit with a diagnosis of septic shock, comparing data between pre-CPFA and post-CPFA treatment. They received a maximum of 5 cycles of treatment. Results Coupled plasma filtration adsorption treatment was associated with a significant increase of mean arterial pressure ( P P = .007), and renal improvement. In patients with leukocytosis or leucopenia, the leukocyte count was restored to a reference range of values. Conclusion Treatment with CPFA improves hemodynamic parameters in septic shock patients, ameliorating organ failure.

The evidence suggests that antiplatelet agents (APA) slightly increase the risk of death and disease progression in patients with traumatic brain injury or spontaneous intracranial hemorrhage (ICH). There is little evidence that APA reversal with platelet (PLT) transfusion may improve the outcome. In this systematic review and meta-analysis, our goal was to evaluate the differences in mortality, severe disability, and hematoma expansion related to PLT transfusion. We retrieved randomized or cohort studies comparing adult patients on APA with traumatic brain injury or ICH who were treated with PLT or not. We calculated the standardized risk difference and 95% confidence interval. A random-effects model was applied to analyze the data. The heterogeneity of the retrieved trials was evaluated through the I2 statistic. Our review included 16 clinical trials. We observed a significant difference between the 2 groups only for hematoma expansion: risk difference was –0.10 (10%; 95% confidence interval, –0.14 to –0.05; P

Objective The negative effect of sepsis on the myocardium affects its electric functionality. This study aims to evaluate the incidence of atrial fibrillation (AF) in patients with septic shock, and the mortality rate of patients with AF versus patients that maintained sinus rhythm (SR). Methods This is a one-year observational prospective pilot study. It was conducted at the Department of Anaesthesia and Intensive Care of Pisa University. Patients with septic shock were enrolled in this study. They were divided in two groups based on the occurrence of AF while in the ICU. Data were collected at admission and after 72 hours, and the data consisted of anamnesis, vital parameters, blood results and severity score. Results Out of 27 patients, 9 developed AF during the first 72 hours. At admission and at 72 hours, SOFA was statistically higher in the patients with AF (p=0.012 and p=0.002, respectively). In the AF group, the overall mortality was 66.7%, whereas, it was 11.1% (p=0.006) in the patients with SR. Age, rhythm and noradrenaline dosage were univariate predictors of total mortality. Conclusion In patients with septic shock, AF has a high incidence, and it correlated with a worse outcome. Patients with higher SOFA score are at a greater risk of developing arrhythmia.

BACKGROUND General anesthesia may be a risk factor for post-operative cognitive impairment, which could be counteracted by neuroprotective compounds. The aims of this study were to determine cognitive functions impaired by general anesthesia and to test blueberry juice as a neuroprotective agent against neuropsychological dysfunctions induced by general anesthesia. METHODS Twenty-six patients undergoing elective major surgery were randomized into two groups, receiving either 500 mL/day of blueberry juice within 14 preoperative days (G1) or to a control group (G0). Neuropsychological tests were performed around 20 days before surgery (T0), as well as both three hours (T1) and 24 hours (T2) after surgery. All the scores were statistically analyzed to find significant differences between groups and within the three times. RESULTS The control (G0) group showed a significant decrease in the performance in the Prose Memory Test (P

Light sedation, corresponding to a Richmond Agitation-Sedation Scale between 0 and -1 is a priority of modern critical care practice. Dexmedetomidine, a highly selective, central, α2-adrenoceptor agonist, is increasingly administered in the intensive care units (ICUs) as an effective drug to induce light sedation, analgesia and a quasi-physiological sleep in critically ill patients. Although in general dexmedetomidine is well tolerated, side effects as bradycardia, hypertension, and hypotension may occur. Although a general dosing range is suggested, different ICU patients may require different and highly precise titration that may significantly vary due to neurological status, cardio-respiratory function, base-line blood pressure, heart rate, liver efficiency, age and co-administration of other sedatives. This review analyzes the use of dexmedetomidine in different settings including pediatric, adult, medical and surgical patients starting with some considerations on delirium prevention and sleep quality in critically ill patients and how dexmedetomidine may contribute to these crucial aspects. Dexmedetomidine use in specific sub-populations with unique characteristics will be detailed, with a special attention to a safe use.

Electronic supplementary material The online version of this article ( https://doi.org/10.1007/s00134-019-05737-4 ) contains supplementary material, which is available to authorized users.

BACKGROUND: Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. OBJECTIVE: Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. DESIGN: A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). SETTING: Four hundred and ninety-eight hospitals in 28 European countries. PATIENTS: Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. INTERVENTION: None. MAIN OUTCOME MEASURES: Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. RESULTS: Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. CONCLUSION: In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the procedure was performed., BACKGROUND: Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. OBJECTIVE: Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. DESIGN: A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). SETTING: Four hundred and ninety-eight hospitals in 28 European countries. PATIENTS: Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. INTERVENTION: None. MAIN OUTCOME MEASURES: Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. RESULTS: Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. CONCLUSION: In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the procedure was performed. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01203605.

The noble gas xenon has been known for >50 years in the field of anesthesia with an emerging series of favorable features; several clinical and preclinical studies performed over the last years reveal a renewed interest because they substantially agree on attributing relevant analgesic properties to xenon. The main mechanism of action is the inhibition of N-methyl-D-aspartate receptors of glutamate; it involves the blocking of painful stimuli transmissions from peripheral tissues to the brain and it also avoids the development of pain hypersensitivity. Therefore, this mechanism is responsible for the inhibition of pain transmission at spinal and supraspinal levels, as well as the cortical level. In all these levels of pain pathways, as the development of hyperalgesia is possible, xenon efficacy can also be based on the blocking of these processes. Several forms of pain share such mechanisms in their maintenance, and xenon can be successfully used at low dosages, which have no effects on vital parameters. The literature shows that analgesic features could also emerge outside the field of anesthesia; thus, this could permit xenon to have a larger usage according to local availability.

Background/Aims: The normal lung ultrasound (US) pattern during a regular pregnancy has not been evaluated extensively in the current literature. Pregnancy-related changes in the respiratory tract affect maternal predisposition to several respiratory complications; consequently, it is important to differentiate between a physiologic pattern during pregnancy and a pathologic lung pattern, due to respiratory failure. The goal of our study was to assess the normal US lung pattern in women without known comorbidities in the last weeks of pregnancy. Methods: We conducted a prospective cross-sectional observational pilot study. Chest wall was examined in 8 areas, 1 scan for each area with women in supine position. Results: One hundred fifty parturients were enrolled during the 36th-38th gestational weeks. None of the participants showed pleural effusion, pneumothorax or lung consolidation. None presented an interstitial syndrome US pattern. One hundred thirteen participants out of 150 (75%) showed A-lines in all the regions. The remaining 25% showed 1 or 2 B-lines in at least 3 regions. Only 2 participants showed 2 positive regions also. Conclusions: We found that, in the majority of the women examined, the lung US pattern matches the physiological pattern in non-pregnant patients. Lung US assessment is a feasible and a helpful diagnostic tool during pregnancy.

Anesthesia is able to modulate the balance between proinflammatory and anti-inflammatory cytokine production during surgery. The aim of this study is to assess the effect of three anesthesia approaches, total intravenous anesthesia (TIVA), inhalation anesthesia, and xenon anesthesia, on sieric levels of nitric oxide (NO), IL6, IL10, and TNFα in obese patients undergoing Roux-en-Y laparoscopic gastric bypass. Thirty adult morbidly obese patients (BMI > 35) scheduled for Roux-en-Y laparoscopic gastric bypass were randomly recruited and allocated to TIVA (N = 10), inhalation anesthesia (SEV, N = 10), and xenon anesthesia (XE, N = 10). Exclusion criteria were ASA IV, age 60 years, and Mallampati IV. Opioid dosage and ventilation parameters were standardized. Sieric levels of NO, IL6, IL10, and TNFα were assessed at T0 (before induction of anesthesia), T1 (end of surgery), and T2 (12 h after the end of surgery). We compared the relative cytokine level variations (delta) at T1 and T2 and the cytokine exposure levels calculated as the area under the curve (AUC) between T0 and T2 in the XE and non-XE (SEV + TIVA) groups. At T1, we found a significant ΔIL10 (reduction) and ΔTNFα (reduction) between XE and SEV (p

The aim of this work was to highlight the effects and the possible mechanisms of the action of blueberry polyphenols on the central nervous system (CNS).An analysis was carried out, in a temporal order, of the most important literature about this topic and the results have been correlated with the beneficial and protective effects, mainly concerning the CNS.Over the last 10 years an increasing scientific interest has developed about polyphenols, which are very abundant in blueberries, as they have been seen to produce favourable effects related to neuroprotection and linked to a possible decrease of age-related cognitive and motor decline, as shown by the improvement of such functions in animal models with a supplemented diet. Such effects could not only be explained through a purely antioxidant action but also through more complex mechanisms related to inflammation, genic expression, and regulation of cell survival.Despite the wealth of data from animal studies, there is a relative lack of data concerning human beings, even if some positive results are beginning to emerge. Therefore, blueberry polyphenols could become useful pharmacological agents for various conditions including neurological diseases, but further studies are still necessary to attain this objective.