Andrea Gentili

Cardiocirculatory changes during videolaparoscopy in children: an echocardiographic study.

We examined cardiovascular changes associated with intra‐abdominal insufflation in 20 children (mean age 6.1 ± 4.7 years, ASA physical status I or II) undergoing laparoscopic surgery with general anaesthesia using echocardiography with a transthoracic approach. Intra‐abdominal pressure never exceeded 10 mmHg. Systolic blood pressure, diastolic blood pressure, endtidal CO2, peak, and mean airway pressure increased during intra‐abdominal insufflation (P < 0.001). Pneumoperitoneum was associated with increases (P < 0.001) in left ventricular enddiastolic volume, left ventricular end‐systolic volume and left ventricular endsystolic meridional wall stress. In addition, before, during and after intra‐abdominal insufflation, left ventricular fractional shortening and left ventricular ejection fraction, underwent slight, insignificant changes. Pneumoperitoneum in children has a major impact on cardiac volumes and function, mainly through the effect on ventricular load conditions. The sharp increase in intra‐abdominal pressure affects both preload and afterload, while systolic cardiac performance remains unchanged.

Contrast-enhanced ultrasound in non-operative management of pancreatic injury in childhood

We report a 5-year-old child with pancreatic trauma from a blunt abdominal injury that was monitored with contrast-enhanced sonography. Unenhanced US failed to demonstrate the abnormality that was recognized by CT and MRI. The injury was well demonstrated by contrast-enhanced US which was therefore used for follow-up until its healing.

Evaluation of the efficiency of heat and moisture exchangers during paediatric anaesthesia

This study evaluates the efficiency of heat and moisture exchangers (HMEs) in allowing adequate humidification and warming during anaesthesia in children. Eighteen paediatric patients undergoing anaesthesia were divided into two groups: group A ten patients: infants up to 10 kg→Hygrobaby HME; group B 8 patients: children above 10 kg→Hygroboy HME. The following parameters were evaluated: body temperature (bT), room temperature (rT), fresh gas temperature, HME warm‐up time, inspired and expired gases temperature and humidity, conserving efficiency, and duration of anaesthesia. Gas temperatures were recorded by means of a recorder fitted with four thermal probes. Humidity values were mathematically derived. The correlation between efficiency and rT, bT, and fresh gas temperature was computed. In both groups the inspired gases temperatures were below 30??C. Inspired absolute humidity was never more than 28 mgH2O??l−1. The conserving efficiency was good (0.93 in both groups). A positive correlation was found between efficiency and fresh gas temperature. HMEs did not meet the minimum standards for humidity and heating during anaesthesia in children, although their conserving efficiency was found to be satisfactory.

Exposure of personnel to sevoflurane during paediatric anaesthesia: influence of professional role and anaesthetic procedure

Background and objective: This study was performed to determine the individual exposure of paediatric operating theatre personnel to sevoflurane and to evaluate the impact of inhalation induction and various airway approaches on exposure to airborne sevoflurane. Methods: Mean individual environmental (workplace air) exposure to sevoflurane and a biomarker of exposure (urinary sevoflurane) were monitored in 36 subjects (10 anaesthetists, 10 surgeons, 12 nurses and 4 auxiliary personnel) working in two paediatric operating rooms. Results: Environmental and urinary values were significantly greater in anaesthetists compared with other groups, with median values of 0.65 ppm (interquartile range 1.36; 95th percentile 4.36) for breathing zone sevoflurane and 2.1 μgL−1 urine (interquartile range 2.6; 95th percentile 7.6) for urinary sevoflurane. Anaesthetists exceeded the 2 ppm maximum allowed environmental concentration recommended by the National Institute for Occupational Safety and Health in 4 of 22 cases (18.1%). A positive correlation was found between the number of patients undergoing inhalational induction each day and mean values of breathing zone and urinary sevoflurane. An increase in the number of daily laryngeal mask insertions, or the use of rigid bronchoscopy, are statistically related to higher environmental and urinary values (P < 0.01 and <0.00001 for breathing zone sevoflurane, P < 0.05 and <0.01 for urinary sevoflurane, respectively). Conclusions: Anaesthesia with sevoflurane can pose a hazard of chronic exposure with anaesthetists having the highest risk. Endotracheal intubation offers considerable protection against exposure. Routine anaesthesia using a standard facemask, a laryngeal mask or rigid bronchoscopy are risk factors for increased anaesthetic exposure.

Latex allergy in children with oesophageal atresia

Background: Latex allergy is frequently found in children and patients with spina bifida and urogenital abnormalities and have been considered at risk for latex sensitization. The aim of the study was to evaluate the incidence of latex sensitization in patients with oesophageal atresia and undergoing three or more surgical procedures and to identify possible risk factors in the process of latex sensitization.

Neurally adjusted ventilatory assist in weaning of neonates affected by congenital diaphragmatic hernia

Objective: The aim of the study is to evaluate the application of neurally adjusted ventilatory assist (NAVA) in the respiratory weaning of patients affected by congenital diaphragmatic hernia (CDH). Methods: We analyzed the NAVA weaning in 12 neonates affected by CDH, relating the effectiveness of the electrical activation of the diaphragm (EAdi) signal to the type of CDH repair (with or without patch), the size of the patch, the stomach and His angle position, and the trend evaluation of some cardiorespiratory parameters with NAVA compared to pressure-support-ventilation (PSV). Results: 5 neonates submitted to primary repair showed a regular EAdi signal and were successfully weaned with NAVA. Of the seven patients submitted to patch repair, five operated with patch limited to the diaphragmatic postero-lateral area had an active EAdi signal that permitted weaning with NAVA. Only in two neonates with hemidiaphragm agenesis was NAVA not feasible due to the impossibility to capture the EAdi signal. Compared to PSV, NAVA allows a significant improvement of oxygenation-linked indexes and paCO2, while PIP is reduced. Conclusion: Neonatal CDH with a postero-lateral diaphragmatic defect allows the NAVA catheter to obtain a correct EAdi signal and develop a viable NAVA ventilation. The lower risk of lung injury in NAVA appears compatible with current ventilatory strategies considered useful in CDH.

Tracheal agenesis: management of the first 10 months of life

Tracheal agenesis is a potentially lethal congenital anomaly, appearing only at birth. We describe a newborn preterm infant who presented with immediate respiratory distress and no audible cry. There was almost complete tracheal agenesis with a very short segment of distal trachea (only two tracheal rings) arising from the anterior wall of the esophagus, before dividing into the mainstem bronchi. The anomaly was unsuspected prenatally, as the scan showed pyloric atresia and complex congenital cardiac disease. Despite the patients difficult course, with correction of the rare‐associated malformations (cardiac and gastrointestinal tract anomalies), the fact that the child is lively and neurologically normal for her age, requires that we now consider the patency of the airway and the possibility of surgical correction, in accordance with a good quality of life.

Diagnosis of congenital myasthenic syndrome with mutation of the RAPSN gene after general anaesthesia.

Editor, In congenital myasthenia syndrome (CMS), a genetic defect causes a disruption of the neuromuscular transmission. Symptoms start perinatally or in the first years of life and consist mainly of bilateral ptosis, dysarthria, weak cry, feeding difficulties and muscle weakness accentuated by exertion. Diaphragmatic involvement may eventually lead to respiratory failure. Reflexes and sensibility are generally unchanged.

Anesthesiological management in ELBW infants: like ductal ligation, does necrotizing enterocolitis similarly lie between 'simple anesthesia' and 'extreme art'?

SIR—We read with interest the article of Wolf titled ‘Ductal ligation in the very low-birth-weight infant: simple anesthesia or extreme art’? (1). There is another condition that often requires highrisk anesthesia in very low-birth-weight infants, and above all, in extremely low-birth-weight infants (ELBW), necrotizing enterocolitis (NEC) when its clinical course requires a surgical solution (Bell’s stage III). Unlike ductal ligation, NEC involves a surgical approach difficult to plan and invariably urgent. NEC has now become the most common gastrointestinal emergency among ELBW infants. Its incidence is around 12%, with mortality of approximately 50% in cases submitted to surgery. In surgical NEC, the anesthesia is carried out in a clinical condition characterized by a drastic and rapid deterioration, frequently involving complications such as acidosis, electrolyte imbalances, lethargy, abdominal compartment syndrome, acute renal failure, coagulopathy, RDS, and cardiocirculatory failure. Often, the clinical picture is further complicated by the occurrence of toxic–septic shock with multiple organ dysfunction syndrome (MODS), which is triggered in an infant weighing <1000 g. As Wolf pointed out, the surgical treatment of ELBW infants requires the combined efforts of various specialists working together as a team. The anesthetist’s role is of fundamental importance. As the literature contains numerous reports concerning the treatment of NEC (2), but few references to the anesthesiological approach in ELBW (3), we believe that five points, often interdependent, need to be raised.

Revisiting Italian Emigration Before the Great War: A Test of the Standard Economic Model

Among the many studies on migration before the Great War, Italy has received little attention, with a few notable exceptions and without providing a convincing explanation of its economic and demographic determinants. Standard neoclassical approaches explain emigration as driven by relative wages, relative employment rates and the stock of previous emigrants. We aim at improving on earlier contributions by covering all migration outflows from Italy to the most significant destination countries and by adopting the most consistent and up-to-date econometric approaches. As it turns out, the standard model is not fully confirmed and a more nuanced analysis is needed.