Carmine D. Votta

Volatile Agents in Medical and Surgical Intensive Care Units: A Meta-Analysis of Randomized Clinical Trials

OBJECTIVE To comprehensively assess published randomized peer-reviewed studies related to volatile agents used for sedation in intensive care unit (ICU) settings, with the hypothesis that volatile agents could reduce time to extubation in adult patients. DESIGN Systematic review and meta-analysis of randomized trials. SETTING Intensive care units. PARTICIPANTS Critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The BioMedCentral, PubMed, Embase, and Cochrane Central Register databases of clinical trials were searched systematically for studies on volatile agents used in the ICU setting. Articles were assessed by trained investigators, and divergences were resolved by consensus. Inclusion criteria included random allocation to treatment (volatile agents versus any intravenous comparator, with no restriction on dose or time of administration) in patients requiring mechanical ventilation in the ICU. Twelve studies with 934 patients were included in the meta-analysis. The use of halogenated agents reduced the time to extubation (standardized mean difference = -0.78 [-1.01 to -0.55] hours; p for effect<0.00001; p for heterogeneity = 0.18; I(2) = 32% in 7 studies with 503 patients). Results for time to extubation were confirmed in all subanalyses (eg, medical and surgical patients) and sensitivity analyses. No differences in length of hospital stay, ICU stay, and mortality were recorded. CONCLUSIONS In this meta-analysis of randomized trials, volatile anesthetics reduced time to extubation in medical and surgical ICU patients. The results of this study should be confirmed by large and high-quality randomized controlled studies.

Prolonged transesophageal echocardiography during percutaneous closure of the left atrial appendage without general anesthesia: the utility of the Janus mask.

PurposeLeft atrial appendage (LAA) closure is an interventional procedure increasingly used to prevent stroke in patients with permanent atrial fibrillation and contraindications to anticoagulation therapy. As this procedure requires a relatively immobile patient and performance of continuous and prolonged transesophageal echocardiography (TEE), it is usually performed under general anesthesia. In this case series, we describe the feasibility of prolonged TEE for percutaneous LAA closure using a new noninvasive ventilation device that can avoid the need for endotracheal intubation and general anesthesia.Clinical featuresPercutaneous LAA closure was performed under deep sedation in three elderly patients with permanent atrial fibrillation. Sedation was obtained with a combination of midazolam, propofol, and remifentanil. Continuous intraoperative TEE was performed through the port of the newly available Janus mask (Biomedical Srl; Florence, Italy), allowing for noninvasive ventilation (pressure support = 12-16 cm H2O; positive end-expiratory pressure = 7 cm H2O; FiO2 = 0.3) in these spontaneously breathing patients. The total procedure times ranged from 75-90 min. The patients reported excellent satisfaction with the sedation received in terms of discomfort experienced during the procedure, capacity to recall the procedure, and comfort with the mask. The operators also rated the procedural conditions as excellent.ConclusionDeep sedation with noninvasive ventilation may be a reasonable and safe alternative to general endotracheal anesthesia in patients requiring prolonged TEE for noninvasive cardiac procedures, including LAA closure.RésuméObjectifLa fermeture de l’appendice auriculaire gauche (AAG) est une procédure interventionnelle de plus en plus utilisée pour prévenir les accidents vasculaires cérébraux chez les patients souffrant de fibrillation auriculaire chronique ou présentant des contre-indications à l’anticoagulothérapie. Comme cette intervention requiert que le patient soit relativement immobile et une échocardiographie transœsophagienne (ETO) continue et prolongée, elle est habituellement réalisée sous anesthésie générale. Dans cette série de cas, nous décrivons la faisabilité d’une ETO prolongée pour la fermeture percutanée de l’AAG à l’aide d’un nouveau dispositif de ventilation non invasif qui permet d’éviter l’intubation endotrachéale et l’anesthésie générale.Éléments cliniquesLa fermeture percutanée de l’AAG a été réalisée sous sédation profonde chez trois patients âgés atteints de fibrillation auriculaire chronique. La sédation a été obtenue avec un mélange de midazolam, de propofol et de rémifentanil. Une ETO peropératoire continue a été réalisée via le port du masque de Janus (Biomedical Srl; Florence, Italie) nouvellement commercialisé, qui a permis une ventilation non invasive (aide inspiratoire = 12-16 cm H2O; pression positive télé-expiratoire = 7 cm H2O; FiO2 = 0,3) de ces patients respirant spontanément. Les temps totaux pour l’intervention s’étalaient entre 75-90 min. Les patients ont rapporté être très satisfaits de la sédation reçue en termes d’inconfort ressenti pendant l’intervention, de leur capacité à se souvenir de l’intervention, et du confort du masque. Les opérateurs ont également évalué les conditions procédurales comme étant excellentes.ConclusionUne sédation profonde accompagnée d’une ventilation non invasive pourrait constituer une alternative raisonnable et sécuritaire à l’anesthésie générale avec intubation endotrachéale chez les patients nécessitant une ETO prolongée pour des interventions cardiaques non invasives, notamment la fermeture de l’AAG.

Bronchoscopy during non-invasive ventilation in a patient with acute respiratory distress syndrome

A 72-year-old man was transferred to our hospital for refractory severe acute respiratory syndrome. On arrival, he was intubated and mechanically ventilated. Furthermore, he required veno-venous extracorporeal membrane oxygenation. Two days later, he was extubated and sup-ported with periods of non-invasive ven-tilation (NIV), with a new mask. Because of large amounts of bronchial secretions that he was not able to expectorate, flex-ible fiberoptic bronchoscopy (FFB) was performed to remove the secretions, with-out interrupting NIV support. During the procedure, the patient remained hemody-namically stable, breathing spontaneously and with just a mild reduction in oxygen saturation (SpO2) (97.9% vs. 96.8%). This case report highlights the possibility of performing upper endoscopic procedures, such as FFB, during non-invasive ventila-tion in patients in whom this respiratory support is required and its interruption may be harmful.

Liberal Transfusion Strategy in the Perioperative Period

A proper oxygen and nutrients’ supply is physiologically essential. Similarly, a prompt removal of carbon dioxide and catabolites is as much important. For these reasons, it is fundamental to assure an efficient blood perfusion to all tissues at any time. This is possible thanks to three strictly associated components: (1) the heart, (2) the vascular system (arterial and venous), and (3) the blood. The impairment of even only one of them may seriously compromise tissues’ perfusion and thus cause one or more organ failure.

Left ventricular rotational dyssynchrony before cardiac resynchronization therapy: a step forward into ventricular mechanics.

Aims Heart failure patients show impaired left ventricular rotation and twist. In patients undergoing cardiac resynchronization therapy (CRT) significance of preimplant left ventricular rotational timing between different ventricular regions is unknown. We thoroughly evaluated, in patients eligible for CRT, baseline left ventricular rotational mechanics, also assessing segmental rotational timing, and investigated whether the presence of rotational dyssynchrony may be associated with echocardiographic response. Methods By two-dimensional speckle-tracking echocardiography, baseline peak apical and basal rotation, peak twist, and time-related parameters, such as delays between opposite segments at base and apex, were assessed in 55 CRT patients and 11 healthy participants. Results At 6 months, 30 (54%) patients were echocardiographic responders. Left ventricular rotation and twist had no association with response. All time-related parameters were significantly altered in CRT patients. Maximum basal and apical segments delay, and anteroseptal-posterior delays at base and apex, were longer in responders than in nonresponders (P < 0.05 for all), regardless of the presence of left bundle branch block (LBBB) and QRS duration. At multivariable analysis, apical anteroseptal-posterior delay resulted as independently associated with response [odds ratio (OR): 1.022 (1.007–1.038); P = 0.004]. A cut-off value of 97.5 ms for apical anteroseptal-posterior delay predicted response with 96% specificity and 57% sensitivity (AUC = 0.83). Magnitude of left ventricular reverse remodeling was significantly related to apical anteroseptal-posterior delay (P = 0.001). Conclusion In heart failure patients eligible for CRT, left ventricular rotational timing is altered. Dyssynchrony in rotational mechanics shows a specific pattern in responders regardless of the presence of LBBB. Apical anteroseptal-posterior rotational delay is independently associated with left ventricular reverse remodeling.

Échocardiographie transœsophagienne prolongée pendant la fermeture percutanée de l’appendice auriculaire gauche sans anesthésie générale: l’utilité du masque de Janus

PurposeLeft atrial appendage (LAA) closure is an interventional procedure increasingly used to prevent stroke in patients with permanent atrial fibrillation and contraindications to anticoagulation therapy. As this procedure requires a relatively immobile patient and performance of continuous and prolonged transesophageal echocardiography (TEE), it is usually performed under general anesthesia. In this case series, we describe the feasibility of prolonged TEE for percutaneous LAA closure using a new noninvasive ventilation device that can avoid the need for endotracheal intubation and general anesthesia.Clinical featuresPercutaneous LAA closure was performed under deep sedation in three elderly patients with permanent atrial fibrillation. Sedation was obtained with a combination of midazolam, propofol, and remifentanil. Continuous intraoperative TEE was performed through the port of the newly available Janus mask (Biomedical Srl; Florence, Italy), allowing for noninvasive ventilation (pressure support = 12-16 cm H2O; positive end-expiratory pressure = 7 cm H2O; FiO2 = 0.3) in these spontaneously breathing patients. The total procedure times ranged from 75-90 min. The patients reported excellent satisfaction with the sedation received in terms of discomfort experienced during the procedure, capacity to recall the procedure, and comfort with the mask. The operators also rated the procedural conditions as excellent.ConclusionDeep sedation with noninvasive ventilation may be a reasonable and safe alternative to general endotracheal anesthesia in patients requiring prolonged TEE for noninvasive cardiac procedures, including LAA closure.RésuméObjectifLa fermeture de l’appendice auriculaire gauche (AAG) est une procédure interventionnelle de plus en plus utilisée pour prévenir les accidents vasculaires cérébraux chez les patients souffrant de fibrillation auriculaire chronique ou présentant des contre-indications à l’anticoagulothérapie. Comme cette intervention requiert que le patient soit relativement immobile et une échocardiographie transœsophagienne (ETO) continue et prolongée, elle est habituellement réalisée sous anesthésie générale. Dans cette série de cas, nous décrivons la faisabilité d’une ETO prolongée pour la fermeture percutanée de l’AAG à l’aide d’un nouveau dispositif de ventilation non invasif qui permet d’éviter l’intubation endotrachéale et l’anesthésie générale.Éléments cliniquesLa fermeture percutanée de l’AAG a été réalisée sous sédation profonde chez trois patients âgés atteints de fibrillation auriculaire chronique. La sédation a été obtenue avec un mélange de midazolam, de propofol et de rémifentanil. Une ETO peropératoire continue a été réalisée via le port du masque de Janus (Biomedical Srl; Florence, Italie) nouvellement commercialisé, qui a permis une ventilation non invasive (aide inspiratoire = 12-16 cm H2O; pression positive télé-expiratoire = 7 cm H2O; FiO2 = 0,3) de ces patients respirant spontanément. Les temps totaux pour l’intervention s’étalaient entre 75-90 min. Les patients ont rapporté être très satisfaits de la sédation reçue en termes d’inconfort ressenti pendant l’intervention, de leur capacité à se souvenir de l’intervention, et du confort du masque. Les opérateurs ont également évalué les conditions procédurales comme étant excellentes.ConclusionUne sédation profonde accompagnée d’une ventilation non invasive pourrait constituer une alternative raisonnable et sécuritaire à l’anesthésie générale avec intubation endotrachéale chez les patients nécessitant une ETO prolongée pour des interventions cardiaques non invasives, notamment la fermeture de l’AAG.

Prolonged transesophageal echocardiography during percutaneous closure of the left atrial appendage without general anesthesia: the utility of the Janus mask@@@Échocardiographie transœsophagienne prolongée pendant la fermeture percutanée de l’appendice auriculaire gauche sans anesthésie générale: l’utilité du masque de Janus

PurposeLeft atrial appendage (LAA) closure is an interventional procedure increasingly used to prevent stroke in patients with permanent atrial fibrillation and contraindications to anticoagulation therapy. As this procedure requires a relatively immobile patient and performance of continuous and prolonged transesophageal echocardiography (TEE), it is usually performed under general anesthesia. In this case series, we describe the feasibility of prolonged TEE for percutaneous LAA closure using a new noninvasive ventilation device that can avoid the need for endotracheal intubation and general anesthesia.Clinical featuresPercutaneous LAA closure was performed under deep sedation in three elderly patients with permanent atrial fibrillation. Sedation was obtained with a combination of midazolam, propofol, and remifentanil. Continuous intraoperative TEE was performed through the port of the newly available Janus mask (Biomedical Srl; Florence, Italy), allowing for noninvasive ventilation (pressure support = 12-16 cm H2O; positive end-expiratory pressure = 7 cm H2O; FiO2 = 0.3) in these spontaneously breathing patients. The total procedure times ranged from 75-90 min. The patients reported excellent satisfaction with the sedation received in terms of discomfort experienced during the procedure, capacity to recall the procedure, and comfort with the mask. The operators also rated the procedural conditions as excellent.ConclusionDeep sedation with noninvasive ventilation may be a reasonable and safe alternative to general endotracheal anesthesia in patients requiring prolonged TEE for noninvasive cardiac procedures, including LAA closure.RésuméObjectifLa fermeture de l’appendice auriculaire gauche (AAG) est une procédure interventionnelle de plus en plus utilisée pour prévenir les accidents vasculaires cérébraux chez les patients souffrant de fibrillation auriculaire chronique ou présentant des contre-indications à l’anticoagulothérapie. Comme cette intervention requiert que le patient soit relativement immobile et une échocardiographie transœsophagienne (ETO) continue et prolongée, elle est habituellement réalisée sous anesthésie générale. Dans cette série de cas, nous décrivons la faisabilité d’une ETO prolongée pour la fermeture percutanée de l’AAG à l’aide d’un nouveau dispositif de ventilation non invasif qui permet d’éviter l’intubation endotrachéale et l’anesthésie générale.Éléments cliniquesLa fermeture percutanée de l’AAG a été réalisée sous sédation profonde chez trois patients âgés atteints de fibrillation auriculaire chronique. La sédation a été obtenue avec un mélange de midazolam, de propofol et de rémifentanil. Une ETO peropératoire continue a été réalisée via le port du masque de Janus (Biomedical Srl; Florence, Italie) nouvellement commercialisé, qui a permis une ventilation non invasive (aide inspiratoire = 12-16 cm H2O; pression positive télé-expiratoire = 7 cm H2O; FiO2 = 0,3) de ces patients respirant spontanément. Les temps totaux pour l’intervention s’étalaient entre 75-90 min. Les patients ont rapporté être très satisfaits de la sédation reçue en termes d’inconfort ressenti pendant l’intervention, de leur capacité à se souvenir de l’intervention, et du confort du masque. Les opérateurs ont également évalué les conditions procédurales comme étant excellentes.ConclusionUne sédation profonde accompagnée d’une ventilation non invasive pourrait constituer une alternative raisonnable et sécuritaire à l’anesthésie générale avec intubation endotrachéale chez les patients nécessitant une ETO prolongée pour des interventions cardiaques non invasives, notamment la fermeture de l’AAG.

QRS duration in left bundle branch block does not affect left ventricular twisting in chronic systolic heart failure

Left ventricular (LV) torsion is an important parameter of LV performance and can be influenced by several factors. Aim of this investigation was to evaluate whether QRS prolongation in left bundle branch block (LBBB) may influence global LV twist and twisting/untwisting rate in chronic systolic heart failure (HF) patients.