Search

Intraoperative hypotension (IOH) is associated with increased morbidity and mortality. Hypotension Prediction Index (HPI) is a machine learning derived algorithm that predicts IOH shortly before it occurs. We tested the hypothesis that the application of the HPI in combination with a pre-defined Goal Directed Therapy (GDT) hemodynamic protocol reduces IOH during major gynaecologic oncologic surgery. We enrolled women scheduled for major gynaecologic oncologic surgery under general anesthesia with invasive arterial pressure monitoring. Patients were randomized to a GDT protocol aimed at optimizing stroke volume index (SVI) or hemodynamic management based on HPI guidance in addition to GDT. The primary outcome was the amount of IOH, defined as the timeweighted average (TWA) mean arterial pressure (MAP) Trial registration number: NCT04547491. Date of registration: 10/09/2020.

Intraoperative hypotension (IOH) is common during major surgery and is associated with a poor postoperative outcome. Hypotension Prediction Index (HPI) is an algorithm derived from machine learning that uses the arterial waveform to predict IOH. The aim of this study was to assess the diagnostic ability of HPI working with non-invasive ClearSight system in predicting impending hypotension in patients undergoing major gynaecologic oncologic surgery (GOS). In this retrospective analysis hemodynamic data were downloaded from an Edwards Lifesciences HemoSphere platform and analysed. Receiver operating characteristic curves were constructed to evaluate the performance of HPI working on the ClearSight pressure waveform in predicting hypotensive events, defined as mean arterial pressure 1 min. Sensitivity, specificity, positive predictive value and negative predictive value were computed at a cutpoint (the value which minimizes the difference between sensitivity and specificity). Thirty-one patients undergoing GOS were included in the analysis, 28 of which had complete data set. The HPI predicted hypotensive events with a sensitivity of 0.85 [95% confidence interval (CI) 0.73–0.94] and specificity of 0.85 (95% CI 0.74–0.95) 15 min before the event [area under the curve (AUC) 0.95 (95% CI 0.89–0.99)]; with a sensitivity of 0.82 (95% CI 0.71–0.92) and specificity of 0.83 (95% CI 0.71–0.93) 10 min before the event [AUC 0.9 (95% CI 0.83–0.97)]; and with a sensitivity of 0.86 (95% CI 0.78–0.93) and specificity 0.86 (95% CI 0.77–0.94) 5 min before the event [AUC 0.93 (95% CI 0.89–0.97)]. HPI provides accurate and continuous prediction of impending IOH before its occurrence in patients undergoing GOS in general anesthesia. Supplementary Information The online version contains supplementary material available at 10.1007/s10877-021-00763-4.

BACKGROUND: Severe perineal lacerations are rare obstetric complications in high-income countries, yet, their prevention is crucial due to their long-term consequences on woman digestive function, sexual-mental health and wellbeing. This study aims study to assess the incidence of obstetric anal sphincter injuries at a single institution over a period of ten years and identifying women more at risk by evaluating the relationship between antenatal and intrapartum risk factors and severe perineal tears. METHODS: This was an observational retrospective cohort study carried out at a University Teaching Hospital in Italy in the period 2009-2019 using a prospectively maintained database. The study cohort included all women with singleton pregnancy at term who delivered by vaginal delivery in cephalic presentation. Two stages comprised the data analysis: a propensity score matching and a stepwise univariate and multivariate logistic regression. A secondary analysis was performed to further evaluate the effect of parity, epidural anaesthesia and duration of second stage.RESULTS: Of 41,440 patients screened for eligibility, 22,156 women met the inclusion criteria. Among them, obstetric anal sphincter injuries occurred in 81 (0.4%) cases: 51 (0.3%) after spontaneous delivery and 30 (0.5%) after vacuum delivery. There was an increased odd of severe lacerations for nulliparous women delivering by vacuum delivery (aOR 2.85, 95% CI 1.19,6.81; p=0.019), with reciprocal reduction in multiparous women with spontaneous vaginal delivery (aOR 0.35, 95% CI 0.15,0.84; p=0.019), Epidural anaesthesia and episiotomy were associated with a lower incidence of obstetric anal sphincter injuries (aOR 0.54, 95% CI 0.33, 0.86; p=0.011; (aOR 0.20, 95% 0.11, 0.36; p

Background Left uterine displacement (LUD) has been questioned as an effective strategy to prevent aortocaval compression after spinal anesthesia (SA) for cesarean delivery (CD). We tested if LUD has a significant impact on cardiac output (CO) in patients undergoing CD under SA during continuous non-invasive hemodynamic monitoring with Clearsight. Methods Forty-six patients were included in the final analysis. We considered 4 timepoints of 5 min each: T1 = baseline with LUD; T2 = baseline without LUD; T3 = after SA with LUD; T4 = after SA without LUD. LUD was then repositioned for CD. The primary outcome was to assess if CO decreased from T3 to T4 of at least 1.0 L/min. We also compared CO between T1 and T2 and other hemodynamic variables: mean, systolic and diastolic blood pressure (respectively MAP, SAP and DAP), heart rate (HR), stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), contractility (dP/dt), dynamic arterial elastance (Eadyn) at the different timepoints. Data on fetal Apgar scores and umbilical arterial and venous pH were collected. Results CO did not vary from T3 to T4 (CO mean difference -0.02 L/min [95% CI -0.88 to 0.82; P = 1). No significant variation was registered for any variable at any timepoint. Conclusions LUD did not show a significant impact on CO during continuous hemodynamic monitoring after SA for CD. Trial registration (retrospectively registered on 03/12/2021) NCT05143684.

Background Arterial hypotension is common after spinal anesthesia (SA) for cesarean delivery (CD), and to date, there is no definitive method to predict it. The hypotension prediction index (HPI) is an algorithm that uses the arterial waveform to predict early phases of intraoperative hypotension. The aims of this study were to assess the diagnostic ability of HPI working with arterial waveforms detected by ClearSight system in predicting impending hypotension in awake patients, and the agreement of pressure values recorded by ClearSight with conventional noninvasive blood pressure (NIBP) monitoring in patients undergoing CD under SA. Methods In this retrospective analysis of pregnant patients scheduled for elective CD under SA, continuous hemodynamic data measured with the ClearSight monitor until delivery were downloaded from an Edwards Lifesciences HemoSphere platform and analyzed. Receiver operating characteristic (ROC) curves were constructed to evaluate the performance of HPI algorithm working on the ClearSight pressure waveform in predicting hypotensive events, defined as mean arterial pressure (MAP) 1 minute. The sensitivity, specificity, positive predictive value, and negative predictive value were computed at the optimal cutpoint, selected as the value that minimizes the difference between sensitivity and specificity. ClearSight MAP values were compared to NIBP MAP values by linear regression and Bland-Altman analysis corrected for repeated measurements. Results Fifty patients undergoing CD were included in the analysis. Hypotension occurred in 23 patients (48%). Among patients experiencing hypotension, the HPI disclosed 71 alerts. The HPI predicted hypotensive events with a sensitivity of 83% (95% confidence interval [CI], 69-97) and specificity of 83% (95% CI, 70-95) at 3 minutes before the event (area under the curve [AUC] 0.913 [95% CI, 0.837-0.99]); with a sensitivity of 97% (95% CI, 92-100) and specificity of 97% (95% CI, 92-100) at 2 minutes before the event (AUC 0.995 [95% CI, 0.979-1.0]); and with a sensitivity of 100% (95% CI, 100-100) and specificity 100% (95% CI, 100-100) 1 minute before the event (AUC 1.0 [95% CI, 1.0-1.0]). A total of 2280 paired NIBP MAP and ClearSight MAP values were assessed. The mean of the differences between the ClearSight and NIBP assessed using Bland-Altman analysis (±standard deviation [SD]; 95% limits of agreement with respective 95% CI) was -0.97 mm Hg (±4.8; -10.5 [-10.8 to -10.1] to 8.5 [8.1-8.8]). Conclusions HPI provides an accurate real time and continuous prediction of impending intraoperative hypotension before its occurrence in awake patients under SA. We found acceptable agreement between ClearSight MAP and NIBP MAP.

Background: Lumbar epidural analgesia (EA) is the most commonly used method for reducing labour pain, but its impact on the duration of the second stage of labour and on neonatal and maternal outcomes remains a matter of debate. Our aim was to examine whether EA affected the course and the outcomes of labour among patients divided according to the Robson-10 group classification system. Methods: Patients of Robson’s classes 1, 2a, 3, and 4a were divided into either the EA group or the non-epidural analgesia (NEA) group. A propensity score-matching analysis was performed to balance the intergroup differences. The primary goal was to analyse the duration of the second stage of labour. The secondary goals were to evaluate neonatal and maternal outcomes. Results: In total, 21,808 cases were analysed. The second stage of labour for all groups was prolonged using EA (p < 0.05) without statistically significant differences in neonatal outcomes. EA resulted in a lower rate of episiotomies in nulliparous patients, with a higher rate of operative vaginal deliveries (OVD) (p < 0.05) and Caesarean sections (CS) (p < 0.05) in some classes. Conclusions: EA prolonged the duration of labour without affecting neonatal outcomes and reduced the rate of episiotomies, but also increased the rate of OVDs.

Labor and delivery, while perceived as gratifying and joyful, are nonetheless among the most painful events women can experience in life. Treating pain is nowadays one of the essential elements in assisting women during labor. Epidural analgesia is the best option to ensure the optimal control of pain for the mother without compromising the wellbeing of the fetus. The main contraindications to neuraxial analgesia techniques include patient refusal, known bleeding diathesis or abnormal coagulation tests, elevated intracranial pressure (particularly in the presence of an intracranial space occupying lesion), severe aortic or mitralic valve stenosis and infections at the puncture site [1]. There are many pathogens responsible for cutaneous infections at the dorsal-lumbar level, yeasts of the Malassetia genus being the most commonly implicated. Malassetia Globulosa is the predominant species in the Tinea Versicolor infection [2,3]. Also implicated are M. Sympodialis, M. Furfur and others as well [4]. These fungi are normal components of the cutaneous flora but the transformation from yeasts to micelia can lead to the pathology. The cause for this occurrence is still unknown, yet there are a few contributing factors leading to this infection that affects mostly adolescents and young adults; these are genetic predisposition [5], heat and humidity, immunosuppression, contraceptives, pregnancy and malnutrition. It manifests with characteristic hypo- or hyper-pigmented spots alongside the trunk, the neck, and the face. The majority of the times infection is entirely superficial but cases of meningitis and Central Nervous System (CNS) infections from hematogenous spread have been reported [6,7]. The literature supports with data that adequate antiseptic preparation of the skin effectively prevents meningitis occurrence after epidural puncture [8]; other cases are reported where a small incision of the skin allows for a safer passage of the needle directly in the subcutis without going thnrough the corneal layer.

Background Previous studies have reported a greater frequency of sensitization to latex in the female population and a higher incidence of anaphylactic reactions to latex during cesarean section. In this study, the authors investigated the prevalence of latex sensitization in obstetric patients compared with nonpregnant subjects. Methods Two hundred ninety-four healthy pregnant women who were at term with a singleton fetus and scheduled for caesarean section (group A) were compared with 294 healthy nulliparous women with childbirth potential undergoing gynecologic surgery (group B). Before surgery, patients completed a questionnaire, and venous blood samples were collected to measure specific immunoglobulin E serum concentrations with a fluorescent enzyme immunoassay test. Skin-prick tests were performed if adverse reactions occurred during surgery. Latex allergy was diagnosed on the basis of immunoglobulin E results and/or positive skin-prick tests. Results The prevalence of latex sensitization was higher in group A than in group B (15/294, 5.1% vs. 5/294, 1.7%; P < 0.05). A significant difference in specific immunoglobulin E serum concentration was noted between pregnant and nonpregnant patients who had a positive fluorescent enzyme immunoassay test (median serum concentration: 1.93 kilounits/l; interquartile range = 2.28 vs. 0.78 kilounits/l; interquartile range = 1.07; P less than 0.05). Two patients in group A experienced an anaphylactic reaction to latex. Statistical analysis disclosed no association between latex sensitization and accepted risk factor for latex allergy. Conclusions The authors report a higher prevalence of latex sensitization in the obstetric population than in nonpregnant subjects undergoing gynecologic surgery.

The number of women with major congenital heart defects reaching reproductive age is likely increasing. We herein describe the anesthetic management of a 33-year-old woman at 37 gestational weeks with a history of Glenn surgery who was undergoing an urgent cesarean section due to pathological cardiotocography. Combined spinal-epidural anesthesia was the most suitable technique for urgent cesarean section in our patient with a single ventricle and phasic flow in the pulmonary artery because it provided rapid-onset anesthesia with negligible hemodynamic effects.

Recently, photoactive proteins have gained a lot of attention due to their incorporation into bioinspired (photo)electrochemical- and solar cells. This paper describes the measurement of the asymmetry of current transport of self-assembled monolayers (SAMs) of the entire photosystem I (PSI) protein complex (not the isolated reaction center, RCI), on two different "director SAMs" supported by ultra-flat Au substrates. The director SAMs induce the preferential orientation of PSI, which manifest as asymmetry in tunneling charge-transport. We measured the oriented SAMs of PSI using eutectic Ga-In (EGaIn), a large-area technique, and conducting probe atomic force microscopy (CP-AFM), a single-complex technique, and determined that the transport properties are comparable. By varying the temperatures at which the measurements were performed we found that there is no measurable dependence of the current on temperature from ±0.1 V to ±1.0 V bias, thus we suggest tunneling as the mechanism for transport; there are no thermally-activated (e.g., hopping) processes. Therefore, it's likely that relaxation in the electron transport chain is not responsible for the asymmetry in the conductance of SAMs of PSI complexes in these junctions, which we ascribe instead to the presence of a large, net dipole moment present in PSI.

Background The transversus abdominis plane (TAP) block is a regional anesthesia technique that effectively reduces the pain intensity and use of analgesia in abdominal surgery. The aim of this study was to determine the utility of the ultrasound-guided TAP block in improving the efficacy of the ultrasound-guided ilioinguinal/iliohypogastric nerve (IIN/IHN) block for intraoperative anesthesia and postoperative pain control in day-case inguinal hernia repair (IHR). Methods We conducted a descriptive study of patients undergoing elective primary unilateral open IHR. Fifty-nine patients were divided into two groups according to the anesthetic technique used: ultrasound-guided TAP block plus ultrasound-guided IIN/IHN block (TAP group) vs. ultrasound-guided IIN/IHN block alone (IIN/IHN group). The outcome measures were the adequacy of anesthesia during surgery and postoperative analgesia. Results Four patients (12.5%) in the TAP group and 10 patients (37.0%) in the IIN/IHN group experienced inadequate anesthesia and needed systemic sedation (P < 0.05). No significant differences in additional local anesthetic volume were found between the two groups. Patients in the TAP group reported lower pain scores at the end of surgery (0.4 ± 0.8 vs. 2.1 ± 2.5, P < 0.01), at 2 hours after surgery (0.8 ± 1.3 vs. 3.0 ± 2.2, P < 0.01), at discharge (1.4 ± 1.2 vs. 4.3 ± 2.2, P < 0.01), and at 24 hours (1.5 ± 1.1 vs. 4.5 ± 2.3, P < 0.01). Conclusions The combination of the TAP and IIN/IHN blocks is associated with better intraoperative anesthesia and lower postoperative pain scores compared with the IIN/IHN block alone.

Background. We retrospectively investigated the incidence and risk factors for transfusion-related acute lung injury (TRALI) among patients transfused for post-partum hemorrhage (PPH). Methods. We identified a series of 71 consecutive patients with PPH requiring the urgent transfusion of three or more red blood cell (RBC) units, with or without fresh frozen plasma (FFP) and platelet (PLT) transfusion. Clinical records were then retrieved and examined for respiratory distress events. According to the 2004 consensus definition, cases of new-onset hypoxemia within 6 hours after transfusion, with bilateral pulmonary changes in the absence of cardiogenic pulmonary edema were identified as TRALI; if an alternative risk factor for acute lung injury was present, possible TRALI was diagnosed.Results. Thirteen cases of TRALI and 1 case of possible TRALI were identified (overall incidence 19.7%). At univariate analysis, patients with TRALI received higher number of RBC, PLT and FFP units and had a longer post-partum hospitalization. Among several pregnancy-related diseases (including hypertensive disorders, anemia, intrahepatic cholestasis, gestational diabetes) and various pre-existing comorbidities, only gestational hypertension and pre-eclampsia significantly increased the risk to develop TRALI (p = 0.006). At multivariate analysis, including both transfusion- and patient-related risk factors, pregnancy-related hypertensive disorders were confirmed to be the only predictors for TRALI, with an odds ratio of 27.7 ( 95% CI 1.27-604.3, p=0.034).Conclusions. Patients suffering from PPH represent a high-risk population for TRALI. In particular, patients with gestational hypertension and pre-eclampsia have the highest risk, particularly if they are not receiving anti-hypertensive therapy. A careful monitoring of these patients after transfusions is therefore recommended.

Previous studies have reported a greater frequency of sensitization to latex in the female population and a higher incidence of anaphylactic reactions to latex during cesarean section. In this study, the authors investigated the prevalence of latex sensitization in obstetric patients compared with nonpregnant subjects.Two hundred ninety-four healthy pregnant women who were at term with a singleton fetus and scheduled for caesarean section (group A) were compared with 294 healthy nulliparous women with childbirth potential undergoing gynecologic surgery (group B). Before surgery, patients completed a questionnaire, and venous blood samples were collected to measure specific immunoglobulin E serum concentrations with a fluorescent enzyme immunoassay test. Skin-prick tests were performed if adverse reactions occurred during surgery. Latex allergy was diagnosed on the basis of immunoglobulin E results and/or positive skin-prick tests.The prevalence of latex sensitization was higher in group A than in group B (15/294, 5.1% vs. 5/294, 1.7%; P0.05). A significant difference in specific immunoglobulin E serum concentration was noted between pregnant and nonpregnant patients who had a positive fluorescent enzyme immunoassay test (median serum concentration: 1.93 kilounits/l; interquartile range = 2.28 vs. 0.78 kilounits/l; interquartile range = 1.07; P less than 0.05). Two patients in group A experienced an anaphylactic reaction to latex. Statistical analysis disclosed no association between latex sensitization and accepted risk factor for latex allergy.The authors report a higher prevalence of latex sensitization in the obstetric population than in nonpregnant subjects undergoing gynecologic surgery.

Hemovigilance studies report that from 6.7% to 15% of overall transfusion-related acute lung injury (TRALI) events occur among obstetrics-gynecological patients (Chapman et al, 2009, Transfusion, 49:440; Ozier et al, 2011, Transfusion, 51: 2102). Severe postpartum hemorrhage (sPPH, i.e. the blood loss in excess of 1000 ml), complicates from 1 to 5% of all deliveries and requires massive transfusion, which is a well acknowledged TRALI risk factor. In this retrospective study we evaluate the incidence and risk factors for TRALI among patients with sPPH. We identified in the blood bank database EmoNet those patients admitted to the delivery room of our hospital from January 2005 to December 2011, necessitating the urgent transfusion of a minimum of 3 red blood cell (RBC) units, with or without fresh frozen plasma (FFP) and platelet (PLT) concentrates. Clinical records of identified patients were then retrieved and demographics, clinical and obstetric data and laboratory and radiological findings were collected. Two anesthesiologists blinded to all information of transfused units independently examined clinical records. Suspected or possible TRALI were diagnosed according to the 2004 consensus criteria; (Kleinman et al. 2004; Transfusion 44: 1774; Toy et al. 2005; Crit Care Med 33:721). In total 71 patients received at least 3 RBC units for sPPH; suspected or possible TRALI was identified in 14 cases (overall incidence 21,6%). The 2 patients with possible TRALI had pneumonia and pulmonary embolism, respectively. On the whole, patients with TRALI were more frequently admitted to the intensive care unit and had a longer hospitalization (p=0.021 and p=0.001, respectively). At univariate analysis, patients with TRALI received a higher number of RBC (p=0,008), PLT (p =0,008,) and FFP units (p =0,034). No difference were found between TRALI and no TRALI groups according to the number of PLT and FFP units from female donors, the storage time of RBC and PLT units or the number of transfused RBC units with a storage time longer than 14 days. Relatively to patient-related factors, TRALI was not associated with age or smoke habit, or with the presence of co-morbidities pre-existing to pregnancy. In contrast, the presence of pregnancy-related hypertensive disorders (PR-HD, including gestational hypertension and preeclampsia /eclampsia) (8 patients, p=0.006) was an important risk factor for TRALI. The poor adverse role was confirmed also in gestational hypertension (6 patients, p=0.012 ) or preeclampsia/eclampsia (4 patients, p=0.022) separately evaluated. In a multivariate model combining both transfusion- and patient-related factors with significance level equal or inferior to 10% at univariate analysis, only PR-HD, gestational hypertension and preeclampsia/eclampsia maintained their significance. In particular, we found that the odds ratio for TRALI was 15.98 (95% IC 2.5-103.5, p=0.004) in PR-HD in total, 24.8 (95% IC 2.5 - 248.4, p=0.006) in gestational hypertension and 33.8 (95% IC 2.2-484.1, p=0.011) in preeclampsia/eclampsia. The strong association between PR-HD and TRALI has never been reported before and it is probably due to the widespread endothelial cell activation occurring in PR-HD. These results impose a careful observation when PR-HD patients receive transfusions. The study was supported by the “Gruppo Donatori Sangue, Francesco Olgiati” Disclosures: No relevant conflicts of interest to declare.