A. Zangrillo

Percutaneous tracheostomy, a systematic review.

Percutaneous dilatational tracheostomy (PDT) is a common procedure in intensive care units and the identification of the best technique is very important. We performed a systematic review and meta‐analysis of randomized studies comparing different PDT techniques in critically ill adult patients to investigate if one technique is superior to the others with regard to major and minor intraprocedural complications.

A Bayesian network meta-analysis on the effect of inodilatory agents on mortality

BACKGROUND Inodilators are commonly used in critically ill patients, but their effect on survival has not been properly studied to date. The objective of this work was to conduct a network meta-analysis on the effects of inodilators on survival in adult cardiac surgery patients, and to compare and rank drugs that have not been adequately compared in head-to-head trials. METHODS Relevant studies were independently searched in BioMedCentral, MEDLINE/PubMed, Embase, and the Cochrane Central Register of clinical trials (updated on May 1, 2014). The criteria for inclusion were: random allocation to treatment with at least one group receiving dobutamine, enoximone, levosimendan, or milrinone and at least another group receiving the above inodilators or placebo, performed in cardiac surgical patients. The endpoint was to identify differences in mortality at longest follow-up available. RESULTS The 46 included trials were published between 1995 and 2014 and randomised 2647 patients. The Bayesian network meta-analysis found that only the use of levosimendan was associated with a decrease in mortality when compared with placebo (posterior mean of OR=0.48, 95% CrI 0.28 to 0.80). The posterior distribution of the probability for each inodilator to be the best and the worst drug showed that levosimendan is the best agent to improve survival after cardiac surgery. The sensitivity analyses performed did not produce different interpretative result. CONCLUSION Levosimendan seems to be the most efficacious inodilator to improve survival in cardiac surgery.

Volatile compared with total intravenous anaesthesia in patients undergoing high-risk cardiac surgery: a randomized multicentre study

BACKGROUND The effect of anaesthesia on postoperative outcome is unclear. Cardioprotective properties of volatile anaesthetics have been demonstrated experimentally and in haemodynamically stable patients undergoing coronary artery bypass grafting. Their effects in patients undergoing high-risk cardiac surgery have not been reported. METHODS We performed a multicentre, randomized, parallel group, controlled study among patients undergoing high-risk cardiac surgery (combined valvular and coronary surgery) in 2008-2011. One hundred subjects assigned to the treatment group received sevoflurane for anaesthesia maintenance, while 100 subjects assigned to the control group received propofol-based total i.v. anaesthesia. The primary outcome was a composite of death, prolonged intensive care unit (ICU) stay, or both. Thirty day and 1 yr follow-up, focused on mortality, was performed. RESULTS All 200 subjects completed the follow-up and were included in efficacy analyses, conducted according to the intention-to-treat principle. Death, prolonged ICU stay, or both occurred in 36 out of 100 subjects (36%) in the propofol group and in 41 out of 100 subjects (41%) in the sevoflurane group; relative risk 1.14, 95% confidence interval 0.8-1.62; P=0.5. No difference was identified in postoperative cardiac troponin release [1.1 (0.7-2) compared with 1.2 (0.6-2.4) ng ml(-1), P=0.6], 1 yr all-cause mortality [11/100 (11%) compared with 11/100 (11%), P=0.9], re-hospitalizations [20/89 (22.5%) compared with 11/89 (12.4%), P=0.075], and adverse cardiac events [10/89 (11.2%) compared with 9/89 (10.1%), P=0.8]. CONCLUSIONS There was no observed beneficial effect of sevoflurane on the composite endpoint of prolonged ICU stay, mortality, or both in patients undergoing high-risk cardiac surgery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: identifier NCT00821262. Eudra CT (2008-001752-43).

Mitral valve surgery and acute renal failure

Acute renal failure (ARF) is a serious complication following cardiac operations performed with cardiopulmonary bypass (CPB) and carries a high mortality rate [1]. Prior studies have attempted to identify predictors of ARF or to develop risk stratification algorithms. Valve operations are an independent predictor of ARF [2,3]. To our knowledge, no study has attempted yet to find an independent association between ARF and a specific type of valve operation (i.e. repair or replacement). The aim of this study is to define the incidence, predictors and mortality related to ARF after different types of mitral valve (MV) surgery. From January 1998 to January 2003, we studied 1276 consecutive adult patients who underwent isolated MV surgery with CPB. We excluded from our population patients with dialysis dependence and combined procedures. MV repair was mostly performed with the edge-to-edge technique with the positioning of a rigid ring while patients who had mitral replacement mostly had a mechanical valve implanted. All patients received a standard premedication and monitoring. Anaesthesia was induced in all patients with fentanyl–propofol–pancuronium, maintained with propofol, isoflurane, and additional doses of fentanyl. CPB was conducted with an institutional custom pack including a coated membrane oxygenator, with mild hypothermia (32–33°C). Non-pulsatile perfusion was used throughout the study, with perfusion maintained between 2 and 2.8 L min 1m 2. The pumps were primed with crystalloid solution, mannitol 18% 0.5 g kg 1 formulated to achieve a haematocrit of 18% or more during CPB. Packed red blood cells were added to achieve the desired haematocrit and as required by the clinical circumstance. Intermittent cold (4°C) blood cardioplegia was infused by means of heat exchanger and two roller pumps. Perioperative ventricular dysfunction occurring after cardiac surgery and CPB was managed with heart rate and rhythm control, preload and afterload optimization and, when these manoeuvres were ineffective, with inotropic drugs. Dopamine was the first sympathomimetic drug used and when it was unable to resolve the low-output syndrome it was coupled with epinephrine and/or enoximone and/or an intra-aortic balloon pump. Prophylactic use of a balloon pump was performed in patients with functional MV disease and with ejection fraction 30%. Prophylactic strategies such as hydration, dopamine, fenoldopam and mannitol were used according to anaesthesiologist’s preference. Loop diuretics have been administered early in the course of ARF to convert an oliguric to a nonoliguric state. ARF was defined as a postoperative 100% increase in serum creatinine (doubling from baseline values). Renal replacement therapy was initiated by the attending nephrologist and intensivist based on the clinical situation. Renal support was provided in all cases by continuous veno-venous haemofiltration (CVVH, Prisma CFM, Hospal Lyon, France) using high flux AN69 membranes with a membrane surface of 0.60 m2. Statistical analysis. Data were analysed using the SAS statistics package. Dichotomous variables were compared using 2-test with Yates correction. Continuous measures are expressed as mean SD unless otherwise indicated and were compared with a t-test for paired or unpaired data, as appropriate. A multivariate stepwise logistic regression was used to assess the independent correlates of ARF. Of 1276 patients included in the study, 32 (2.5%) developed postoperative ARF. The incidence of ARF for MV replacement and MV repair was 8% (25/312) and 0.7% (7/964) respectively (P 0.001). The overall population was 57 12.8-yr-old, 41% (528) female, 6.3% (81) with ejection fraction 40%. All perioperative clinical and patient characteristics are depicted in Table 1 together with a univariate analysis to study their association to ARF: patients who developed ARF had a higher incidence of preoperative comorbidities and perioperative complications. At a multivariate analysis that included all factors in Table 1 with entry and exit values P 0.05, MV replacement was an independent risk factor for the development of postoperative ARF (odd ratio (OR): 4.0, 95% confidence interval (CI): 1.49–10.59, P 0.01) together with low-output syndrome (OR: 13.7, 5.4–34.9, P 0.01), emergency surgery (OR: 8.5, 1.4–52.2, P 0.02, creatinine 124 μmol L 1 (OR: 7.9, 2.8–22, P 0.01), reopening for bleeding (OR: 4.5, 1.4–14.3, P 0.01), diabetes (OR: 4.4, 1.08–18.2, P 0.04) and age 100 Correspondence

Self-citation in anaesthesia and critical care journals: introducing a flat tax

tive ARDS after Onyx embolization of an AVM which the authors proposed was caused by the excretion of DMSO via the lungs. Oxygen desaturation after embolization of aneurysms using Onyx in the early postoperative period has been reported. It has been suggested that DMSO is unlikely to be responsible for desaturation after its administration because the amount of DMSO metabolized to dimethyl sulphide is too small (1–3% of 10 ml DMSO is metabolized to dimethyl sulphide 100–300 mg which is exhaled over several days, with a peak at 12 h). However, this long-lasting pharmacokinetic characteristic of DMSO may support our hypothesis that DMSO does not cause toxic side-effects, if used appropriately.

Structure of an ECMO Network for Respiratory Support

In adult patients with respiratory failure refractory to conventional treatment, ECMO represents a potentially lifesaving option, and the CESAR trial indeed indicated that significantly more patients with severe ARDS survived without severe disability if they were transferred to a single ECMO center compared with patients who were managed conventionally at remote hospitals. During the 2009 influenza A (H1N1) pandemic, the Italian Ministry of Health instituted a national network of selected ICU centers, the Extracorporeal Membrane Oxygenation Network (ECMOnet). The Italian network was set up to centralize all potentially severe patients in a limited number of tertiary hospitals to provide advanced treatment options including ECMO and identify predictors of mortality in order to define the best timing of ECMO institution. The institution of the Italian ECMO network allowed a high survival rate of patients with severe ARDS due to H1N1 infection treated by ECMO, providing effective and safe centralization and creating an important organization platform to face future possible epidemics with high demand for critical care services and specialized respiratory support.

Thiopental is better than propofol for electroconvulsive therapy

Background and aim of the work: electroconvulsive therapy is a psychiatric procedure requiring general anesthesia. The choice of the hypnotic agent is important because the success of the intervention is associated to the occurrence and duration of motor convulsion. However, all available anesthetic agents have anti-convulsant activity. We compared the effect of thiopental and propofol on seizures. Methods: We designed a retrospective study at Mood Disorders Unit of a teaching Hospital. Fifty-six consecutive patients undergoing electroconvulsive therapy were enrolled. Patients received fentanyl followed by either thiopental or propofol. We evaluated the incidence and the duration of seizure after electric stimulus at the first session of electroconvulsive therapy for each patient. Adverse perioperative effects were recorded. Results: Patients were 60±12.1 years old and 64% was female. There was a statistically significant higher number of patients who had motor convulsion activity in the thiopental group when compared to the propofol group (25 vs 13, p=0.023). Seizure duration was statistically significant longer in the thiopental group than in the propofol group (35 sec vs 11 sec, p=0.046). No hemodynamic instability, oxygen desaturation episodes, prolonged recovery time from anesthesia and adverse effects related to anesthesia were recorded. Conclusions: Thiopental induction has a favourable effect on seizure when compared to propofol in patients undergoing electroconvulsive therapy. (www.actabiomedica.it)

Management of Postoperative Complications

Operative strategies for the treatment of descending thoracic and thoraco-abdominal aortic diseases have improved dramatically over the years, resulting in better surgical outcomes. Nevertheless, both open and endovascular procedures are at risk for morbidity and mortality. Major postoperative complications are pulmonary dysfunction, renal failure, cardiac events, re-exploration for bleeding, neurologic deficits, and gastrointestinal complications. A great deal of effort is usually applied in the preoperative and intraoperative periods by the entire management team, but successful outcomes depend on adequate monitoring, effective critical care, and appropriate multidisciplinary treatment of postoperative complications. In this chapter we focus on the management of neurologic, hemorrhagic/thrombotic, and gastrointestinal complications. Pulmonary, renal, and cardiac complications are addressed by other authors in this section.

Cardiac protection by volatile anaesthetics in high risk cardiac surgery patients: a randomized controlled study: O-15

with ischaemic heart disease (IHD). Alpha-2 agonists have beneficial effects on heart rate and provide adequate sedation in the perioperative period [1]. We investigated the effects of dexmedetomidine added to epidural anaesthesia on myocardial ischaemia and postoperative analgesic requirements in peripheral vascular surgery. Method: Twenty-eight patients with IHD undergoing peripheral vascular surgery were included in the study. Lumber epidural anaesthesia was initiated in all patients. In the first group (GD n 14) sedation was achieved with dexmedetomidine infusion, while the second (GM n 14) was sedated with midazolam. In the peroperative period we collected haemodynamic data and sedation scale. Holter ECG was performed during the first postoperative 24 hours. Dexmedetomidine infusion continued during 24 hours postoperatively. Troponin-T levels were determined preoperatively, and at postoperative 4th, 8th, 24th, 36th, 48th hours. Postoperative analgesic requirements according to patient-controlled analgesic pumps and visual analogue scale (VAS) were registered. Results: Demographic and operative data were similar between the two groups. There was no cardiac event in any group. Although heart rate was similar at the beginning of the study, it was slower at all times after dexmedetomidine infusion in GD. VAS were higher during postoperative 48 hours followup in GD. Analgesic requirements were higher in GM. Troponin-T levels decreased in GD during the study and were significatly lower at 8th, 24th, 36th hours in GD (0.036 vs. 0.15; 0.02 vs. 0.1 and 0.01 vs. 0.09 ng/mL respectively). Conclusion: Peripheral vascular surgery constitues a major risk for patients with IHD. Dexmedetomidine provides adequate sedation, decreases heart rate and also maintains haemodynamic stability. Dexmedetomidine is a safe alternative for peroperative sedation in ischaemic heart disease. Reference: 1 Talke P, Chen R, Thomas B, et al. The hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery. Anesth Analg 2000; 90: 834–839.