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Proper management of obese patients requires a team vision and appropriate behaviors by all health care providers in hospital. Specialist competencies are fundamental, as are specific clinical pathways and good clinical practices designed to deal with patients whose Body Mass Index (BMI) is ≥30 kg/m2. Standards of care for bariatric and non-bariatric surgery and for the critical care management of this population exist but are not well defined nor clearly followed in every hospital. Thus every anesthesiologist is likely to deal with this challenging population. Obesity is a multisystem, chronic, proinflammatory disorder. Unfortunately many countries are facing a marked increase in the obese population, defined as "globesity". Obesity presents an added risk in hospital, leading health care organizations to call for action to avoid adverse events and preventable complications. Periprocedural assessment and critical care strategies designed specifically for obese patients are crucial for reducing morbidity and mortality during surgery and in emergency settings, critical care and other particular settings (e.g., obstetrics). Specific care is needed for airway management, as are proactive strategies to reduce the risk of cardiovascular, endocrine, metabolic and infective complications; any effort can be fruitful, including special attention to the science of human factors. The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving other national scientific societies to increase risk awareness, define the best multidisciplinary approach for treating obese patients in election and emergency, and enable every hospital to provide appropriate levels of care and good clinical practices. The Obesity Project Task Force, a section of the SIAARTI Airway Management Study Group, used a formal consensus process to identify a series of notes, alerts and statements, to be adopted as bundles, to define appropriate clinical pathways for hospitalized obese patients. The consensus, approved by the Task Force and endorsed by several European scientific societies actively operating in this field, is presented herein.

Objectives: To assess the performance of the Pediatric Index of Mortality (PIM) 2 score in Italian pediatric intensive care units (PICUs). Design: Prospective, observational, multicenter, 1-year study. Setting: Eighteen medical-surgical PICUs. Patients: Consecutive patients (3266) aged 0-16 years admitted between 1 March 2004 and 28 February 2005. Interventions: None. Measurements and main results: To assess the performance of the PIM2 score, discrimination and calibration measures were applied to all children admitted to the 18 PICUs, in the entire population and in different groups divided for deciles of risk, age and admission diagnosis. There was good discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.89 (95% CI 0.86-0.91) and good calibration of the scoring system [non-significant differences between observed and predicted deaths when the population was stratified according to deciles of risk (chi(2) 9.86; 8 df, p = 0.26) for the whole population]. Conclusions: The PIM2 score performed well in this sample of the Italian pediatric intensive care population. It may need to be reassessed in the injury and postoperative groups in larger studies.

Background. Congenital diaphragmatic hernia (CDH) still has a high mortality despite advanced assistance techniques. The aim of this study is to verify the validity of fve respiratory and blood-gas-derived indices in defining presurgical stabilization: the oxygenation index (OI), the alveolar-arterial O2 gradient (A-aDO2), the arterial-alveolar O2 tension ratio (a/AO2), the arterial pH and the PaCO2. Methods. The study involved 73 neonates with CDH where the accuracy of stabilization was assessed through the survival percentage and the contemporary behaviour of mean arterial pressure (MAP), ductal shunting, urine output and lactate levels. The trend of the indices was compared in two groups (stable/ft for surgery vs unstable/unfit for surgery) at five times (PICU admission, 6, 12, 24 hours after admission, assessment of clinical stabilization). Results. Fifty-fve neonates were defined stabilized on the basis of the indices and underwent surgery with a 100% survival rate; 18 patients died before surgery, having never achieved clinical stabilization. MAP, ductal shunting, urine output and lactate levels were normal in the stabilized patients and altered in the non stabilized. Of the fve parameters considered, all three oxygenation-linked indices (OI, A-aDO2, a/AO2) are very powerful, whereas pH and PaCO2 appears valid but more tardive. Their progressive improvement (OI0.50, PaCO27.35) defined presurgical stabilization, thus allowing CDH surgical correction. Conclusion. The study confirms the validity of these indices as a guide to the treatment of neonates with CDH, showing a good reliability in identifying presurgical stabilization

Cancer remains a major death cause in children, though outcomes have considerably improved over the past decades (1-3). Outcomes for children diagnosed with cancer have changed since ’70 from 80% mortality to 80% survival (2), while children with solid tumors 5-year survival has been reported as 67%, cure rates for childhood leukemia now approach 90% [4-5). Moreover, hematopoietic stem cell transplantation (HSCT) indications are still expanding for both malignant and non-malignant diseases.

Acetaminophen is considered as a safe analgesic and antipyretic drug in paediatric age. The main problem in the use of acetaminophen is acute liver failure after an overdose or an acute intoxication. We report a case of fulminant liver failure and spontaneous recovery in a patient treated with a prolonged course of acetaminophen at recommended dosages.

Neonatal anesthesia for major thoracic surgery

The authors describe the cultural background and methods they adopted to construct protocols for analgesia in newborns and children hospitalized in a surgical ward. Drugs and dosages are reported in the Appendix, whereas scales for pain measurement and cut off ratings for rescue doses (or otherwise relevant) are described respectively in Tables 2 and 3. Genetics and cognitive structures play a crucial role in pain and analgesia. Protocols have a critical role, however their application must be tailored to the single child.

AIM: Videoassisted thoracic surgical technique in children is being used with increasing frequency for an extensive variety of diagnostic and therapeutic procedures. The aim of the study was to assess respiratory, cardiocirculatory and body temperature changes in children undergoing thoracoscopy and to identify if the trend of such changes was modifiable by factors such as lung exclusion, length of the thoracoscopy and preoperative respiratory compromise. METHODS: A total of 50 patients (38 boys and 12 girls) undergoing general anaesthesia for diagnostic and therapeutic thoracoscopic procedures were analysed. The values of the monitored parameters were compared at 6 specific times: T1 - at the end of anaesthesia induction (considered the basal level); T2 - after lateral position; T3 - before pleural CO2 insufflation; T4 - 10 min after pleural CO2 insufflation; T5 - before pleural deflation; T6 - 10 min after pleural deflation. RESULTS: All patients tolerated the thoracoscopy well, without intraoperative complications. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly lower, and end-tidal CO2 (PETCO(2) significantly higher during thoracoscopy. Body temperature (BT) had a statistically significant reduction during thoracoscopy and after pleural deflation. During one-lung ventilation the PETCO(2) increased compared to two-lung ventilation with intrapleural insufflation, while during two-lung ventilation with intrapleural insufflation SBP and DBP decreased compared to one-lung ventilation. The length of the thoracoscopy increased the PETCO(2) and reduced the BT. The preoperative respiratory compromise increased the PETCO(2). CONCLUSIONS: Although thoracoscopy in children brings about certain respiratory, cardiocirculatory and body temperature changes, it is nevertheless a safe and efficient surgical technique.

The undertreatment of pain in children may lead to severe consequences. Basic knowledge about pain in this category of patients may improve pain assessment and its management. In line with the Project established by the Italian Ministry of Health, authors planned an educational program devoted to the pediatric nurses. The concept of brain and of cognitive development, the methodological bases of the pain measurement and the cognition of long-term consequences on pain have been the key points of the program. The course was efficacious and highly appreciated by nurses. The improvement of practice standards will be the true indicator of its efficacy.

The aim of this study was to describe a system of salvaging and reinfusing chyle which accumulated in the right pleural cavity of a patient after a thoracic duct lesion caused by a closed chest injury associated with amyelic fracture of the dorsal spine D10-D11. The chyle was collected in a reservoir (BT 844 Dideco), transfered by an electronic pump (BT 797 recovery Dideco) to a storage bag, microfiltered and then reinfused to the patient. A solution was needed to prevent the patient with severe chylothorax, from having immunological and metabolic imbalance. The long period of conservative treatment with our system was imposed by the onset of acute post-traumatic myocardic infarction which delayed surgery. From experience gained, we can say that using total parenteral nutrition, chyle can not only be salvaged but also reinfused, respecting the strict rules of hygiene.

Anaesthesia, surgical procedures and operating room temperature can deeply alter the human thermoregulatory system. Unexpected and sometimes serious perioperative complications can occur. Many studies have been carried out in order to describe and evaluate the detrimental effects produced by different anaesthesia procedures (whether by general, regional or integrated anaesthesia) on thermic homeostasis. More recently it has also been reported that perioperative hypothermia significantly affects patients' outcome, increasing intraoperative blood losses, incidence of postoperative wound infection, and hospital stay. Italian anaesthetists have still a poor consideration about intraoperative body temperature monitoring and patients' warming as basic important skills for a better anaesthesiologic patients management. According with the literature, we do believe that this is not a right opinion. The purpose of the present paper would be to point out the most important knowledges concerning thermic homeostasis management, in order to increase anaesthesiologist's awareness in this essential field of patients perioperative care.

Este trabalho apresenta um estudo preliminar sobre a resposta de um modelo constitutivo a dano, do tipo isótropo, na análise do comportamento nao linear de elementos estruturais (vigas e placas) em concreto e argamassa armada. Os resultados obtidos coniprovam a boa performance do modelo empregado e asseguram urna continuidade para os estudos aqui iniciados.

INTRODUCTION: The aim of this paper was to report the management of a very rare malformative association of Left Pulmonary Artery (LPA) sling and Tracheal Lobe which is not still reported in scientific literature. MATERIALS AND METHODS: The Authors describe the clinical case of a 6 years old girl that was admitted for chronic respiratory symptoms associated with recurrent upper respiratory infections. The CT-scan with virtual bronchoscopy showed an ectopic bronchus arising from the right side of the upper third of the trachea and ending in an accessory pulmonary lobe, covered by normal pleura, located in the upper mediastinum. The tracheo-broncoscopy showed a stenotic tracheal lumen with complete cartilaginous ring with an evident vascular pulsation in the middle of stenotic tract. An angio-CT confirmed the vascular anomalies with the LPA which passes between the lower trachea and the accessory tracheal bronchus and the coexistence of a persistent left superior vena cava. The surgical approach, after the thoracoscopic exploration, was a double procedure through a median sternotomy with cardiopulmonary bypass has permitted to excise completely the tracheal lobe and to reimplant the left pulmonary artery into the main pulmonary artery. RESULTS: No more upper respiratory symptoms or pulmonary infections have been observed during the clinical and instrumental follow up. CONCLUSIONS: Current controversy in the management of Pulmonary Artery sling include surgical approach (median sternotomy versus left thoracotomy), use or non-use of cardiopulmonary bypass, and reimplantation versus translocation with distal tracheal resection. In our experience LPA reimplantation and tracheal lobe resection have been made easily and safely by the same sternotomy utilized for the cardio-pulmonary by-pass.