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Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure have demonstrated their efficacy in treating patients with diffused peritoneal carcinomatosis. As a counterpart patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. All these derangements demonstrated to be mild and short-lived in the majority of patients when timely addressed. Anesthesiologists, intensive care physicians and surgeons are involved in providing surveillance and organ support till the patient is effectively weaned after the operation. Moreover they are involved in pain control, metabolic and nutritional support. A malnourished state is common due to wasting syndrome from the tumor, difficult feeding and massive ascites. Lastly physicians need to be aware of the quality of life impact of this procedure.

The management of analgesia and sedation in critically ill patients is still a challenge due to the shortage of evidence-based treatments. The main objectives of the present study were to critically evaluate the quality of current clinical practice guidelines (CPGL) published on this matter and to identify the contrasting positions and unsolved questions.Four members of the Italian Society of Anesthesia and Intensive Care (SIAARTI) council, with an extensive background in the management of critically ill patients and practice guidelines, evaluated CPGL on sedation and analgesia in critically ill patients published from January 2006 to December 2013. Evaluation was performed in accordance with the appraisal of guidelines for research and evaluation tool (AGREE II).Five documents proposed by European and American scientific societies of critical care medicine were identified and evaluated. The CPGL published in 2013 by the American Society of Critical Care Medicine showed the highest scores in all domains of the AGREE II tool, whereas scores for CPGL published in 2006 by SIAARTI showed the lowest scores. In all documents, most recommendations on the use of drugs or non-pharmacological strategies for analgesia, sedation and delirium treatment had low evidence.This quality evaluation indicated that CPGLs published by the German Association of Scientific Medical Societies, the American College of Critical Care Medicine and the PanAmerican and Iberica Federation of the Critical Care Medicine Societies should be recommended for use. Even in guidelines with a high quality rating, numerous recommendations have moderate or low levels of evidence.

none 12 no Importance: Drug-induced sleep endoscopy is a diagnostic technique that allows dynamic evaluation of the upper airway during artificial sleep. The lack of a standardized procedure and the difficulties associated with direct visual detection of obstructive events result in poor intraobserver and interobserver reliability, especially when otolaryngology surgeons not experienced in the technique are involved. Objectives: To describe a drug-induced sleep endoscopy technique implemented with simultaneous polygraphic monitoring of cardiorespiratory parameters (DISE-PG) in patients with a diagnosis of obstructive sleep apnea syndrome and discuss the technique's possible advantages compared with the standard procedure. Design, Setting, and Participants: This prospective cohort study included 50 consecutive patients with obstructive sleep apnea syndrome who underwent DISE-PG from March 1, 2013, to June 30, 2014. A standard protocol was adopted, and all the procedures were carried out in an operation room by an experienced otolaryngology surgeon under the supervision of an anesthesiologist. Endoscopic and polygraphic obstructive respiratory events were analyzed offline in a double-blind setting and randomized order. Main Outcomes and Measures: The feasibility and safety of the DISE-PG technique, as well as its sensitivity in detecting respiratory events compared with that of the standard drug-induced sleep endoscopy procedure. Results: All 50 patients (43 men and 7 women; mean [SD] age, 51.1 [12.1] years) underwent DISE-PG without technical problems or patient difficulties regarding the procedure. As expected, polygraphic scoring was more sensitive than endoscopic scoring in identifying obstructive events (mean [SD] total events, 13.3 [6.8] vs 5.3 [3.6]; mean [SD] difference, 8.8 [5.6]; 95% CI, 7.3 to 10.4; Cohen d, -1.5). This difference was most pronounced in patients with a higher apnea-hypopnea index (AHI) at baseline (mean [SD] difference for AHI >30, 27.1% [31.0%]; 95% CI, -36.2% to 90.4%; Cohen d, 0.2; for AH I >40, 76.0% [35.5%]; 95% CI, 4.6% to 147.4%; Cohen d, 0.5; for AHI >50, 92.2% [37.2%]; 95% CI, 17.3% to 167.1%; Cohen d, 0.6) and a high percentage of hypopneas (≥75% of all obstructive events) at baseline (mean [SD] difference, 20.2% [5.4%]; 95% CI, 9.2% to 31.3%; Cohen d, 1.1). No other anthropomorphic or polygraphic features at baseline were associated with the differences between the DISE-PG and baseline home sleep apnea test. Conclusions and Relevance: The DISE-PG technique is feasible, safe, and more sensitive at detecting an obstructed breathing pattern than is drug-induced sleep endoscopy alone. The DISE-PG technique could be helpful for accurate comprehension of upper airway obstructive dynamics (ie, degree of obstruction and multilevel pattern) and a nonobstructive breathing pattern (ie, central apneas). mixed Gobbi, R; Baiardi, S; Mondini, S; Cerritelli, L; Piccin, O; Scaramuzzino, G; Milano, F; Melotti, R M; Mordini, F; Pirodda, A; Cirignotta, F; Sorrenti, G Gobbi, R; Baiardi, S; Mondini, S; Cerritelli, L; Piccin, O; Scaramuzzino, G; Milano, F; Melotti, R M; Mordini, F; Pirodda, A; Cirignotta, F; Sorrenti, G

Introduction The aim of the study was to assess whether adults admitted to hospitals with both Intensive Care Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs without an IMCU. Methods An observational multinational cohort study performed on patients admitted to participating ICUs during a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital mortality until hospital discharge (censored at 90 days). Results One hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113 (19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for patients in ICUs without an IMCU (median SAPS II: 29, P

BACKGROUND: Post-operative delirium (POD) is a common complication in elderly patients undergoing surgery, but the underpinning causes are not clear. We hypothesized that inflammaging, the subclinical low and chronic grade inflammation characteristic of old people, can contribute to POD onset. Accordingly, we investigated the association of pre-operative and circulating cytokines in elderly patients (>65 years), admitted for elective and emergency surgery. METHODS: This is a secondary analysis of a sub-cohort of patients belonging to a previous large case-control study, where 351 patients were clinically and cognitively thoroughly characterized, together with the assessment of POD (47 patients) by confusion assessment method and delirium rating scale. Seventy-four pre-operative plasma samples were selected from a larger bio-bank and they included 37 subjects with POD and 37 without POD. Inflammaging related cytokines, i.e., IL-1β, IL-2, IL-6, IL-8, IL-10, and TNF-α, were assayed by ELISA in pre-operative blood samples; univariate and multivariable analyses have been applied to identify cytokines independently associated to POD. Associations of cytokine levels with functional status, cognitive decline, intra-hospital mortality, and comorbidity were also analyzed independently of POD onset. RESULTS: High IL-6 and low-IL-2 levels were significantly associated with POD. After adjustment for potential confounders in multivariate analysis, high level of pre-operative IL-6 was confirmed to be significantly associated with risk of POD onset. High level of IL-6 was also associated with several baseline features (including poor functional status, cognitive impairment, emergency admission, and higher comorbidity burden) and intra-hospital mortality. CONCLUSION: Pre-operative, high-plasma level of IL-6 (≥9 pg/mL) was significantly associated with POD onset. We propose IL-6 as an additional risk factor of POD onset together with the previously identified factors. Discovery of all risk factors contributing to POD onset will permit to improve hospitalized patient management and the decrease of healthcare cost.