Edoardo De Robertis

Management of severe perioperative bleeding Guidelines from the European Society of Anaesthesiology

The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia and stabilisation of the macro- and microcirculations in order to optimise the patients tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists throughout Europe to integrate this knowledge into daily patient care wherever possible. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of scientific subcommittees and individual expert members of the ESA. Electronic databases were searched without language restrictions from the year 2000 until 2012. These searches produced 20 664 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. At the suggestion of the ESA Guideline Committee, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was initially used to assess the level of evidence and to grade recommendations. During the process of guideline development, the official position of the ESA changed to favour the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This report includes general recommendations as well as specific recommendations in various fields of surgical interventions. The final draft guideline was posted on the ESA website for four weeks and the link was sent to all ESA members. Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients.

ObjectiveTo describe clinical, neuroradiological and evolutionary findings in obstetric patients with posterior reversible encephalopathy syndrome (PRES).DesignRetrospective case series.SettingUniversity intensive care unit (ICU).PatientsFour critically ill patients. Two patients experienced PRES in late postpartum without the classical pre-eclamptic signs. All patients showed impairment of consciousness and epileptic seizures; two of them presented cortical blindness and headache, too. True status epilepticus (SE) occurred in two cases. In all patients MRI showed the typical feature of gray-white matter edema, mainly localized to the temporo-parieto-occipital areas.InterventionsNormalization of high blood pressure (BP) and treatment of seizures. Two patients with SE and severe impairment of consciousness were treated with an intravenous valproate (ivVPA) bolus followed by continuous infusion.Measurements and resultsIn three cases, neurological and MRI abnormalities completely resolved in about a week. Another patient died due to subarachnoid hemorrhage.ConclusionPosterior reversible encephalopathy syndrome is a well described clinical and neuroradiological syndrome characterized by headache, altered mental status, cortical blindness and seizures, and a diagnostic MRI picture; usually reversible, PRES can sometimes result in death or in irreversible neurological deficits, thus requiring early diagnosis and prompt treatment. PRES can have various etiologies, but pregnancy and postpartum more frequently lead to this condition. Treatment of seizures deserves special attention since the anti-epileptic drugs currently used in SE management may worsen vigilance as well as autonomic functions. Extensive research is needed to assess the role of ivVPA in this condition.

Seeking Worldwide Professional Consensus on the Principles of End-of-Life Care for the Critically Ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) Study

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.

Sepsis associated encephalopathy studied by MRI and cerebral spinal fluid S100B measurement.

The pathogenesis of sepsis associated encephalopathy (SAE) is not yet clear: the blood–brain barrier (BBB) disruption has been indicated among the possible causative mechanisms. S100B, a calcium binding protein, originates in the central nervous system but it can be also produced by extra-cerebral sources; it is passively released from damaged glial cells and neurons; it has limited passage through the BBB. We aimed to demonstrate BBB damage as part of the pathogenesis of SAE by cerebral spinal fluid (CSF) and serum S100B measurements and by magnetic resonance imaging (MRI). This paper describes four septic patients in whom SAE was clinically evident, who underwent MRI and S100B measurement. We have not found any evidence of CSF-S100B increase. Serum S100B increase was found in three out of four patients. MRI did not identify images attributable to BBB disruption but vasogenic edema, probably caused by an alteration of autoregulation, was diagnosed. S100B does not increase in CSF of septic patients; S100B increase in serum may be due to extracerebral sources and does not prove any injury of BBB. MRI can exclude other cerebral pathologies causing brain dysfunction but is not specific of SAE. BBB damage may be numbered among the contributors of SAE, which aetiology is certainly multifactorial: an interplay between the toxic mediators involved in sepsis and the indirect effects of hyperthermia, hypossia and hypoperfusion.

Anaesthesiologists in emergency medicine: the desirable manpower.

Doctors, healthcar e profe ssional s, and regi onal and national admi nistrators have realized the im portance of early diagno sis, treatm ent an d manage ment of patients with acute and urgent , l i fe-threateni ng, signs and symptoms fol lowing a vari ety of inju ries, disor ders and disease in recent years in Europe. An interesting deb ate ha s been going on between various European stakeh olders and in various contex ts for some time about how to offe r highquality emergency medi cine services to as many patients as possib le in any plac e and at any time in Eur ope. Moreover, the question has arisen of whet her the installation of a primar y special ty in emer gency medici ne would be benefi cial for many pati ents, in many places all over Eur ope. Thes e disc ussions are confus ing owing to many misconc eption s, false assum ptions and incons istent definitions . Therefor e, it is im portant to crea te some order and analyse differe nt aspect s o f this matter , star ting with the definition of emer gency medi cine. Fo r e m erg enc y med ic ine , a nu mbe r o f defi nit ion s hav e bee n for mul ate d. The Int er nat io nal Fe der at ion for Eme rge ncy Med ic ine defi ned eme rg enc y med ic ine as a ‘ fi eld of pra ct ic e’ dea lin g w i t h ‘ a cut e and urg ent asp ect s o f il lne ss’ (ht tp: //w ww. if em .cc /a bou t/a bout .ht m) , whe re as, mo re rec ent ly, the Eur opea n Soc ie ty for Eme rge ncy Med ici ne (EuS EM) has defi ned eme rg enc y m e dic in e a s a ‘s pec ia lt y’ dea lin g wit h ‘ur gen t and eme rg enc y asp ect s of il lne ss’ ( htt p:/ /ww w. eus em. or g/P age s/ Ab out _Eu SE M/ Pol ic y_S tate me nts /P oli cy_ Sta te men ts. ht ml) . Con fus ion re mai ns bec aus e o f a n ove rl ap in the mea nin gs of ‘e mer ge ncy ’, ‘u rge ncy ’ and ‘a cut e’ . I t i s o f not e tha t the me ani ng of urg ent (‘ enda nge ri ng vi tal fun ct ion s and /o r lif e thr ea te nin g’ ) i s rec og niz ed by al l par ti es to be an in teg ra l co nce pt in eme rg enc y med ic ine . The risk of a too wide or vague emer gency medicine definit ion is that emergen cy situation s, which can abruptly deteriorate and requ ire im mediate (minu tes) intervent ion to avoid death or disa bility and disease areas of medici ne wher e only initial care is needed for the acute ly ill pa tient are then con tained under the sam e umbre lla and , more specifically , i n the sam e medical organi zation. This leads to inef ficiency and an unne cessary sharp rise in costs. In the worst scenar io, patien ts with no emergen cy or acute illness at all may be forced to refer to the emer gency syst em only because of a deficie ncy in the healt hcare syst em. The conseque nces are an unaccepta ble overc rowded system at risk of failure or a bad ou tcome. We cannot forg et what Peter Safar wrote, ‘the most sophisti cated inte nsive care ofte n becom es unne cessari ly ex pensive terminal care when the preICU system fails’. In Europ ean countr ies, emergency medici ne edu cation and traini ng is well establish ed but varies widely betw een indi vidual EU Mem ber States. At unde rgradu ate level, emer gency medicin e i s a mandator y medical school subject, generall y held by inte rnists and anaest hesiologist s, in 16 countr ies. At postgrad uate level, emer gency care provi ders recei ve specialist ed ucation and traini ng in progr ammes offe red by universi ties, governm ent agenci es, private training inst itution s o r a s part of continuin g professi onal educat ion. In many cases , physicia ns come from differe nt speci alities, most ly anaesthesi a, inte rnal medici ne and surger y. It is a point of concern that the primary special ity in emer gency medici ne is on e o f the youn gest medi cal speci alties. It began in the United States in the early 1960s, wher e i t b e came a d e fined speci alty in the 1980s. It has to be pointed out that, in the United Stat es, emergen cy medi cine essent ially is acute medici ne for the 60 million America ns without medical insur ance. The Uni ted Kingdom was the first European country to inst itute a speci ality examinat ion in 1983. Toda y, in Eur ope, the prim ary spe cialty in emer gency medi cine is listed in the ‘Doctors’ Directiv e’ 2006/100 /EC in nine EU Mem ber Stat es out of 27. Althoug h not en listed in the dire ctive, in Belgi um, a primar y speci alty in emer gency medi cine is now active and coexists with the previ ous ed ucation in emer gency medici ne consi sting of a primar y speci alty in anaest hesia, inte rnal medici ne or other followed by a supe rspeciali ty traini ng. In Italy, a primar y speci alty in emer gency medi cine, abrupt ly created by law, has be en very recently inst ituted.

To streamline the guideline challenge: The European Society of Anaesthesiology policy on guidelines development.

Since its creation, the ESA has strongly supported the development of high-quality, evidence-based CPGs as a tool to harmonise and improve clinical practice in anaesthesiology (in the definition of ESA, this includes intensive care, emergency and perioperative medicine as well as pain therapy) throughout Europe. Accordingly, appropriate methodologies and rigorous strategies, which all medical Scientific Societies provide are of paramount importance in the CPG development process, because the potential benefits of CPGs are only as good as the quality of the CPGs themselves.

Re-inspiration of CO2 from ventilator circuit: effects of circuit flushing and aspiration of dead space up to high respiratory rate

IntroductionDead space negatively influences carbon dioxide (CO2) elimination, particularly at high respiratory rates (RR) used at low tidal volume ventilation in acute respiratory distress syndrome (ARDS). Aspiration of dead space (ASPIDS), a known method for dead space reduction, comprises two mechanisms activated during late expiration: aspiration of gas from the tip of the tracheal tube and gas injection through the inspiratory line - circuit flushing. The objective was to study the efficiency of circuit flushing alone and of ASPIDS at wide combinations of RR and tidal volume (VT) in anaesthetized pigs. The hypothesis was tested that circuit flushing and ASPIDS are particularly efficient at high RR.MethodsIn Part 1 of the study, RR and VT were, with a computer-controlled ventilator, modified for one breath at a time without changing minute ventilation. Proximal dead space in a y-piece and ventilator tubing (VDaw, prox) was measured. In part two, changes in CO2 partial pressure (PaCO2) during prolonged periods of circuit flushing and ASPIDS were studied at RR 20, 40 and 60 minutes-1.ResultsIn Part 1, VDaw, prox was 7.6 ± 0.5% of VT at RR 10 minutes-1 and 16 ± 2.5% at RR 60 minutes-1. In Part 2, circuit flushing reduced PaCO2 by 20% at RR 40 minutes-1 and by 26% at RR 60 minutes-1. ASPIDS reduced PaCO2 by 33% at RR 40 minutes-1 and by 41% at RR 60 minutes-1.ConclusionsAt high RR, re-breathing of CO2 from the y-piece and tubing becomes important. Circuit flushing and ASPIDS, which significantly reduce tubing dead space and PaCO2, merit further clinical studies.

European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults

&NA; Procedural sedation and analgesia (PSA) has become a widespread practice given the increasing demand to relieve anxiety, discomfort and pain during invasive diagnostic and therapeutic procedures. The role of, and credentialing required by, anaesthesiologists and practitioners performing PSA has been debated for years in different guidelines. For this reason, the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology have created a taskforce of experts that has been assigned to create an evidence-based guideline and, whenever the evidence was weak, a consensus amongst experts on: the evaluation of adult patients undergoing PSA, the role and competences required for the clinicians to safely perform PSA, the commonly used drugs for PSA, the adverse events that PSA can lead to, the minimum monitoring requirements and post-procedure discharge criteria. A search of the literature from 2003 to 2016 was performed by a professional librarian and the retrieved articles were analysed to allow a critical appraisal according to the Grading of Recommendations Assessment, Development and Evaluation method. The Taskforce selected 2248 articles. Where there was insufficiently clear and concordant evidence on a topic, the Rand Appropriateness Method with three rounds of Delphi voting was used to obtain the highest level of consensus among the taskforce experts. These guidelines contain recommendations on PSA in the adult population. It does not address sedation performed in the ICU or in children and it does not aim to provide a legal statement on how PSA should be performed and by whom. The National Societies of Anaesthesiology and Ministries of Health should use this evidence-based document to help decision-making on how PSA should be performed in their countries. The final draft of the document was available to ESA members via the website for 4 weeks with the facility for them to upload their comments. Comments and suggestions of individual members and national Societies were considered and the guidelines were amended accordingly. The ESA guidelines Committee and ESA board finally approved and ratified it before publication.

The use of sugammadex for bariatric surgery: analysis of recovery time from neuromuscular blockade and possible economic impact

Background Neuromuscular block (NMB) monitoring and use of reversal agents accelerate the recovery time and improve the workflow in the operating room. We aimed to compare recovery times after sugammadex or neostigmine administration, and estimate the time spent in operating theater and the possible economic impact of a faster recovery, in morbidly obese patients undergoing bariatric surgery. Methods We conducted a retrospective study that analyzed data from records of morbidly obese patients (body mass index >40 kg/m2) undergoing elective laparoscopic bariatric surgery in which sugammadex or neostigmine were used to reverse NMB. Patients were divided in two groups: group 1 (sugammadex group [SUG]) received rocuronium and sugammadex for reversal and group 2 (neostigmine group [NEO]) received either rocuronium or cisatracurium and neostigmine. Data are presented as mean (standard deviation). Results Compared with NEO, SUG group showed shorter times to achieve train-of-four ratio of 0.9 (P<0.05) and an Aldrete score of 10 (P<0.05), a higher cost (€146.7 vs €3.6 [P<0.05]), plus a remarkable less duration of operating theater occupancy (P<0.05). Sugammadex cost accounted for 2.58% of the total cost per surgery, while neostigmine cost accounted for 0.06%. Total time saved in SUG group was 19.4 hours, which could be used to perform 12 extra laparoscopic sleeve gastrectomies. Conclusion Reversal from NMB was significantly faster with sugammadex than with neostigmine. Although sugammadex was substantially more expensive, duration of operating theater occupancy was reduced with potentially workflow increase or personnel reduced cost.

Decreased Tissue COX5B Expression and Mitochondrial Dysfunction during Sepsis-Induced Kidney Injury in Rats

Background. Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated host response to infection. Sepsis is the dominant cause of acute kidney injury (AKI), accounting for nearly 50% of episodes of acute renal failure. Signaling cascades and pathways within the kidney are largely unknown and analysis of these molecular mechanisms may enhance knowledge on pathophysiology and possible therapeutic options. Material and Methods. 26 male Wistar rats were assigned to either a sham group (control, N = 6) or sepsis group (N = 20; cecal ligature and puncture model, 24 and 48 hours after CLP). Surviving rats (n = 12) were decapitated at 24 hours (early phase; n = 6) or 48 hours (late phase; n = 6) after CLP and kidneys removed for proteomic analysis. 2D-DIGE and DeCyder 2D software (t-test, P < 0.01) were used for analysis of significantly regulated protein spots. MALDI-TOF in combination with peptide mass fingerprinting (PMF) as well as Western Blot analysis was used for protein identification. Bioinformatic network analyses (STRING, GeneMania, and PCViz) were used to describe protein-protein interactions. Results. 12 spots were identified with significantly altered proteins (P < 0.01) in the three analyzed groups. Two spots could not be identified. Four different proteins were found significantly changed among the groups: major urinary protein (MUP5), cytochrome c oxidase subunit B (COX5b), myosin-6 (MYH6), and myosin-7 (MYH7). A significant correlation with the proteins was found for mitochondrial energy production and electron transport. Conclusions. COX5B could be a promising biomarker candidate since a significant association was found during experimental sepsis in the present study. For future research, COX5B should be evaluated as a biomarker in both human urine and serum to identify sepsis.