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The primary aim of this retrospective study was to evaluate whether adherence to a goal-directed fluid-therapy (GDFT) protocol affects the occurrence of postoperative complications in patients undergoing pancreaticoduodenectomy. The secondary aim was to investigate the relationship between blood loss and adherence to GDFT protocol. As adherence to GDFT varies widely during high-risk surgery, we hypothesized that patients in the best quartile of adherence (>75%) had a better outcome when compared with those of the worst quartile (with adherence <=25%). One hundred and three patients scheduled for pancreaticoduodenectomy underwent a stroke volume (SV)-guided fluid therapy using an uncalibrated pulse contour device (Vigileo/FloTrac system version 4.0, Edwards Lifesciences, Irvine, California, USA) according to the NICE (National Institute for Health and Care excellence) protocol. The main finding of this study, with limitations because of the retrospective design, was that adherence to GDFT protocol may affect postoperative complication rate. In particular, we found a relevant lower postoperative complication rate when adherence was above 75%. Furthermore, blood loss was the main factor influencing the patient’s deviation from SV trigger.

A new score which includes ultrasound-assessed tongue thickness to predict difficult intubation in morbidly obese patients: A prospective observational cohort study

INTRODUCTION: It has been hypothesized that routine use of deep neuromuscular block (dNMB) is advisable in laparoscopic bariatric surgery in order to optimize workspace conditions. dNMB seems to have advantages in laparoscopic procedures on non-obese patients as it improves surgical space conditions and reduces postoperative pain scores. This systematic review and meta-analysis aimed at comparing the impact of deep vs moderate NMB (mNMB) on surgical conditions and outcomes, including duration of surgery and postoperative pain in patients undergoing laparoscopic bariatric surgery. EVIDENCE ACQUISITION: Studies were identified from Medline, Embase and Cochrane library (update: Sep 1 2019). Randomized controlled trials (RCTs) comparing dNMB with mNMB were identified if they reported surgeon satisfaction for workspace conditions (primary outcome). The effects of dNMB on surgery duration and postoperative pain (secondary outcomes) were also investigated. EVIDENCE SYNTHESIS: Of the 45 retrieved records, 4 were finally included. dNMB improved the surgeon's satisfaction score about workspace (on a scale ranging from 1 to 5), with a mean difference (MD) of 0.52 (95% CI: 0.36-0.68). Surgical duration was not affected by block level (MD: -3.29 minutes; 95% CI: from -14.35 to 7.76). Only one study showed that dNMB also decreased postoperative pain. CONCLUSIONS: It was found that dNMB helps improve surgical space conditions in patients undergoing laparoscopic bariatric surgery whereas it fails to shorten procedure duration. More high-quality large-sampled RCTs are needed to confirm these results. The relationship between dNMB use and other clinical outcomes, such as complications occurrence, needs to be further investigated.

Effect of different manoeuvres on internal jugular vein cross-sectional area in obese and normal-weight patients

Objectives: Delayed graft function is a frequent complication in deceased-donor kidney transplant, with an incidence ranging from 10% to 50% among different centers; it is also associated with lower graft survival. In this study, we aimed to identify risk factors for delayed graft function, particularly those associated with perioperative management (including cold ischemia time) and nonmodifiable recipient- and donor-related factors. The effects of delayed graft function on graft and patient outcomes were also evaluated. Materials and Methods: Our retrospective analyses included 125 adult patients who underwent deceased-donor kidney transplant. Delayed graft function was diagnosed if at least 1 dialysis treatment was required during the first week posttransplant according to Perico’s definition. Results: Prevalence of delayed graft function was 30.4% (n = 38). Cold ischemia time was significantly prolonged in patients with delayed graft function compared with those without it. Multivariate regression showed that cold ischemia time was the only predictor of delayed graft function. A cutoff of 9 hours and 12 minutes was found as a limit beyond which delayed graft function occurred (sensitivity = 90%; specificity = 29%; area under the curve = 0.68). Greater donor and recipient age and longer pretransplant dialysis time in recipients were associated with occurrence of delayed graft function. In patients with delayed graft function, hospital stay duration was significantly greater and 1-year graft survival was significantly lower. Conclusions: Efforts should be focused on limiting cold ischemia time and associated injury to reduce occurrence of delayed graft function and consequently improve long-term graft survival in kidney transplant recipients. Optimization of posttransplant renal function with the help of new technologies, such as pulsatile perfusion, could be crucial for minimization of cold ischemia time.

It is well known that the coagulation processes may be seriously altered in end-stage liver disease (ESLD). Historically, hepatatopathic patient has always been considered auto- anticoagulated; however, recent acquisitions have led to considering this patient “rebalanced” towards a condition of labile and delicate hemostatic balance, due to a concomitant decrease of procoagulative and anticoagulative factors.These problems become more relevant in the case of surgical procedures and, even more, during liver transplantation (LT), a procedure that may be associated with large fluid shifts, huge blood losses and major hemodynamic changes.

Aim of this study was to evaluate if the use of a fluid-therapy protocol performed by a minimally-invasive hemodynamic device could improve outcome and reduce healthcare costs in patients undergoing pancreatic surgery.One-hundred-seventy-three patients undergoing pancreatic surgery were included in this before-and-after study. Patients underwent a goal-directed fluid-therapy (GDFT group) regimen by the Vigileo/FloTrac system following NICE (National Institute for Health and Care Excellence) protocol (GDFT, n=69 pts). The control group (CON group) consisted of 104 patients who underwent the same type of surgery in the previous 2 years. In CON group patients fluid-therapy was managed on the basis of conventional hemodynamic parameters. Exclusion criteria were age [removed]

BACKGROUND: the role of postreperfusion lactate clearance in assessing graft function has not yet been investigated. the aim of this study was to examine whether lactate clearance, assessed in the postreperfusion phase, can predict poor graft function in liver transplant patients. MetHoDs: seventy patients undergoing liver transplantation (lt) were enrolled. standardized anesthesia and intraoperative monitoring were applied. the lactate levels measured immediately after venous reperfusion and six hours later were used to calculate lactate clearance by the following formula: [(reperfusion lactate - 6 h post-reperfusion lactate)/ reperfusion lactate] ×100. student’s t-test was performed to evaluate differences in lactate clearance between patients with good and poor graft function. logistic regression was used to assess predictors of poor graft function. resUlts: Postreperfusion lactate clearance was lower in patients with poor graft function compared to those with good graft function (P=0.0007). logistic regression showed that postreperfusion lactate clearance may represent an early predictor of poor graft function (area under receiver operating characteristic curve =0.83). a lactate clearance cut-off of 59.7% was found (90% sensitivity, 38.3% specificity). CONCLUSIONS: Postreperfusion lactate clearance may be useful for the early identification of poor graft function after lt. in patients with lactate clearance <59.7%, it could be useful to search for the underlying cause of poor graft function.

objective: The aim of this retrospective study was to evaluate the role of surgical setting (urgent vs. elective) and approach (open vs. laparoscopic) in affecting postoperative pulmonary complications (PPCs) prevalence in patients undergoing abdominal surgery. patients and methods: After local Ethical Committee approval, 409 patients who had undergone abdominal surgery between January and December 2014 were included in the final analysis. PPCs were defined as the development of one of the following new findings: respiratory failure, pulmonary infection, aspiration pneumonia, pleural effusion, pneumothorax, atelectasis on chest X-ray, bronchospasm or un-planned urgent re-intubation. results: PPCs prevalence was greater in urgent (33%) vs. elective setting (7%) (X2with Yates correction: 44; p=0.0001) and in open (6%) vs. laparoscopic approach (1.9%) (X2with Yates correction: 12; p=0.0006). PPCs occurrence was positively correlated with in-hospital mortality (Biserial Correlation r=0.37; p=0.0001). Logistic regression showed that urgent setting (p=0.000), Ariscat (Assess Respiratory Risk in Surgical Patients in Catalonia) score (p=0.004), and age (p=0.01) were predictors of PPCs. A cutoff of 23 for Ariscat score was also identified as determining factor for PPCs occurrence with 94% sensitivity and 29% specificity. conclusions: Patients undergoing abdominal surgery in an urgent setting were exposed to a higher risk of PPCs compared to patients scheduled for elective procedures. Ariscat score fitted with PPCs prevalence and older patients were exposed to a higher risk of PPCs. Prospective studies are needed to confirm these results.

OBJECTIVE: The effect of remifentanil on stress response to surgery is unclear. However, there are not clinical studies investigating the relationship between blood remifentanil concentrations and stress hormones. Therefore, the aim of the present study was to assess the association between blood remifentanil concentrations measured after pneumoperitoneum and cortisol (CORT) or prolactin (PRL) ratio (intraoperative/preoperative value), in patients undergoing laparoscopic cholecystectomy. PATIENTS AND METHODS: Patients did not receive any pre-anesthetic medication. Anesthesia induction was standardized. Anesthesia maintenance was performed with inhaled sevoflurane at age-adjusted 1.0 minimum alveolar concentration and intravenous remifentanil at infusion rate ranging from 0.1 to 0.4 mcg/kg/min. Blood samples were withdrawn before anesthesia induction and 5 min after achieving a pneumoperitoneum pressure of 12 mmHg. Correlation analyses were performed to evaluate the relationship between measured blood remifentanil concentrations, CORT or PRL ratio (intraoperative/preoperative value) and remifentanil dose delivered by the pump. RESULTS: A significant inverse correlation was found between CORT ratio and measured blood remifentanil concentration (p=0.03) or planned remifentanil dose (p=0.04). No correlations were found between blood remifentanil concentration and PRL ratio (p=0.83). CONCLUSIONS: Our data suggest that the CORT response to surgical stress is more efficiently counteracted by increased blood remifentanil concentration.

Background. Many factors affect postoperative dream recall, including patient characteristics, type of anesthesia, timing of postoperative interview and stress hormone secretion. Aims of the study were to determine whether Bispectral Index (BIS)-guided anesthesia might decrease sevoflurane minimum alveolar concentration (MAC) when compared with hemodynamically-guided anesthesia, and to search for a MAC threshold useful for preventing arousal, dream recall and implicit memory. Methods. One hundred thirty patients undergoing elective thyroidectomy were enrolled. Anesthesia was induced with propofol 2 mg kg-1, fentanyl 3 mcg kg-1and cis-atracurium 0.15 mg kg-1. For anesthesia maintenance, patients were randomly assigned to one of two groups: a BIS-guided group in which sevoflurane MAC was adjusted on the basis of BIS values, and a hemodynamic parameters (HP)-guided group in which MAC was adjusted based on HP. An auditory recording was presented to patients during anesthesia maintenance. Dream recall and explicit/implicit memory were investigated upon awakening and approximately after 24 h. Results. Mean sevoflurane MAC during auditory presentation was similar in the two groups (0.85±0.16 and 0.87±0.17 [P=0.53] in BIS-guided and HP-guided groups, respectively). Frequency of dream recall was similar in the two groups: 27% (N.=17) in BIS-guided group, 18% (N.=12) in HP-guided group, P=0.37. In both groups, dream recall was less probable in patients anesthetized with MAC values ≥0.9 (area under ROC curve=0.83, sensitivity=90%, and specificity=49%). Conclusion. BIS-guided anesthesia was not able to generate different MAC values compared to HP-guided anesthesia. Independent of the guide used for anesthesia, a sevoflurane MAC over 0.9 was required to prevent postoperative dream recall.

Donorrecipient match is a matter of debate in liver transplantation. D-MELD (donor age x recipient biochemical model for end-stage liver disease [MELD]) and other factors were analyzed on a national Italian database recording 5946 liver transplants. Primary endpoint was to determine factors predictive of 3-year patient survival. D-MELD cutoff predictive of 5-year patient survival <50% (5yrsPS<50%) was investigated. A prognosis calculator was implemented (). Differences among D-MELD deciles allowed their regrouping into three D-MELD classes (A < 338, B 338-1628, C >1628). At 3 years, the odds ratio (OR) for death was 2.03 (95% confidence interval [CI], 1.442.85) in D-MELD class C versus B. The OR was 0.40 (95% CI, 0.24-0.66) in class A versus class B. Other predictors were hepatitis C virus (HCV; OR = 1.42; 95% CI, 1.11-1.81), hepatitis B virus (HBV; OR = 0.69; 95% CI, 0.51-0.93), retransplant (OR = 1.82; 95% CI, 1.16-2.87) and low-volume center (OR = 1.48; 95% CI, 1.1-11.99). Cox regressions up to 90 months confirmed results. The hazard ratio was 1.97 (95% CI, 1.592.43) for D-MELD class C versus class B and 0.42 (95% CI, 0.290.60) for D-MELD class A versus class B. Recipient age, HCV, HBV and retransplant were also significant. The 5yrsPS<50% cutoff was identified only in HCV patients (D-MELD = 1750). The innovative approach offered by D-MELD and covariates is helpful in predicting outcome after liver transplantation, especially in HCV recipients.

In this case report, we describe an accentuation of a pre-existing anisocoria shortly after tracheal intubation in a patient undergoing thyroidectomy. A 45-yr-old female patient with unequal pupillary diameter (right 2 mm > than left) and decreased light reflex in the right eye - due to a previous eye trauma - was scheduled for thyroidectomy because of multinodular goiter. Anesthesia was induced with propofol 2,5 mg/kg, fentanyl 3 mcg/kg and cisatracurium 0.15 mcg/kg. Immediately after tracheal intubation, examination of the right eye revealed a markedly dilated pupil (8 mm) which was nonreactive to direct and consensual light reflex. The left pupil was 2 mm, and normally reactive to light. An increase in heart rate was also registered (> 20% of baseline) with spontaneous return to baseline within 2 minutes. The right pupil returned to preoperative size within approximately one hour after awakening. From this case report, it emerges that a preexisting anisocoria may be exacerbated during anesthesia probably due to incomplete abolition of response to painful stimulus, such as tracheal intubation, provided by anesthetic drugs in the affected eye. The main contributing factor for accentuation of anisocoria could be sympathetic dominance in the pupil with pre-existing mechanical interruption in compensatory parasympathetic mechanisms.

Aim. An ideal anesthetic regimen for kidney transplantation should be able to assure haemodynamic stability to obtain an optimal graft reperfusion. The aim of this study was to compare 2 regimens of anesthesia for patients submitted to kidney transplantation. Methods. We studied 40 patients: 20 subjects (Group A) received balanced anesthesia with thiopental, fentanyl and isoflurane, to the others 20 (Group B), a total intravenous anesthesia (TIVA) with propofol and remifentanyl was given. In both groups muscle relaxation was obtained with a bolus of cisatracurium followed by a continuous infusion. We performed standard clinical, invasive blood pressure and central venous pressure monitoring. Hemodynamic data have been collected at standard times. During the postoperative period we evaluated the recovery (Aldrete Score) in the recovery room and the analgesia (VAS) at 1, 6, 24 h after the end of surgery. Results. The trend of hemodynamic parameters did not show statistically significant differences between the 2 groups. We observed statistically significant differences concerning the quality of the recovery and the postoperative analgesia. The recovery in group B was faster than in group A, but in group A the pain control was better than in group B at least during the first postoperative hour. Conclusion. For their pharmacokinetic properties, propofol, remifentanyl and cisatracurium allow to obtain a good control of the hemodynamic parameters and a fast and safe recovery of consciousness. Total intravenous anesthesia regimen seems to be an alternative to the balanced anesthesia for patients undergoing kidney transplantation.

Determinants of improvement in oxygenation consequent to reverse Trendelenburg position in anesthetized morbidly obese patients.

Background: Anesthetized morbidly obese patients often exhibit impaired pulmonary gas exchanges, mostly because of a reduction in functional residual capacity. At present, several approaches are suggested to ventilate these patients. Methods: The efficiency of positive end-expiratory pressure (PEEP) and reverse Trendelenburg position (RTP) were compared in order to improve oxygenation in 20 morbidly obese patients undergoing bariatric surgery. Results: Both PEEP and RTP determined a significant decrease in alveolar-arterial oxygen difference and an increase in total respiratory compliance (Ctot). RTP resulted in lower airway pressures than PEEP with similar improvements in Ctot and oxygenation. Concerning hemodynamic parameters, cardiac output (CO) significantly decreased with both PEEP and RTP. Conclusions: RTP and PEEP can be considered adequate ventilatory settings for morbidly obese patients, without any significant difference with regard to gas exchange improvement. However, the decrease in CO may partially counteract the beneficial effects on oxygenation of these ventilatory settings.

Background: Obesity causes anesthesiologists a broad variety of perioperative theoretical and practical problems. The aim of this study was to compare two protocols of anesthesia employing Isoflurane and Sevoflurane and evaluate the cardiorespiratory parameters, postoperative recovery and analgesia. Methods: 90 patients underwent biliopancreatic diversion. 60 patients (group A) received Isoflurane and 30 patients (group B) were anesthetized with Sevoflurane. Intraoperative monitoring consisted of EKG, invasive arterial pressure, SpO2, EtCO2, Etanest, Spirometry, urinary output and TOF. Cardiorespiratory parameters and end tidal expiratory concentrations of volatile agents were collected during specific phases of surgery: 1) before induction of anesthesia, 2) after intubation, 3) after skin incision, 4) after positioning of costal retractors, 5) in the reverse Trendelenburg position, 6) end of surgery. During the postoperative period the Aldrete test was carried out to evaluate the recovery from anesthesia. VAS was administered for 6 hours after the end of surgery to set the quality of analgesia. Results: No statistically significant differences in cardiorespiratory parameters were found between the two groups. Extubation time was significantly less in the Sevoflurane Group than in the Isoflurane (15 ± 7 min vs 24 ± 5 min, p< 0.05). The Sevoflurane Group showed an Aldrete score significantly higher than the Isoflurane (8.8 ± 0.3 vs 8.1 ± 0.4, p < 0.05). VAS values did not show statistical differences. Conclusion: The introduction of Sevoflurane, a volatile agent with rapid pharmacokinetic properties, seems to offer an interesting application in these patients.

BACKGROUND: Recent studies have suggested that electroencephalogram bispectral index (BIS) monitoring can improve recovery after anaesthesia and save money by shortening patients postoperative stay. The aim of the study is to evaluate the management of drugs and to measure immediate recovery after anaesthesia with or without BIS monitoring. METHODS: We studied 90 patients undergoing abdominal surgery randomly allocated to one of two groups of 45 each with or without BIS monitoring. Standard monitoring (EKG, arterial oxygen saturation and non-invasive blood pressure) was applied. All groups were monitored with BIS, using electrodes (Zipprep, Aspect Medical Systems) applied to the forehead. In the group 2 the BIS value was blinded to the anaesthesiologist. The BIS value was displayed using Spacelabs Medical BIS Ultraview Monitor. After obtaining baseline values for the BIS index (group 1) and haemodynamic data (all groups) anaesthesia was induced with a bolus dose of remifentanil and TPS, and vecuronium. The anaesthesia was maintained with Remifentanil and Sevoflurane. At standard times BIS, haemodynamic and respiratory parameters were recorded. Recovery times were measured by a study coordinator. Drug consumption was calculated. RESULTS: In group 1 the consumption of Sevoflurane decreased by 40 % while the consumption of remifentanil decreased by 10 % as compared to group 2. The use of vecuronium did not change in the 2 groups. In group 1 the time elapsed from cessation of anaesthetics to orientation decreased significantly. The difference was 5 min, from 11 to 6 min. CONCLUSIONS: BIS monitoring decrease both sevoflurane and remifentanil consumption, when compared to anaesthesia without BIS, with an immediate recovery after sevoflurane and remifentanil anaesthesia.