G. Della Rocca

Preload and haemodynamic assessment during liver transplantation: a comparison between the pulmonary artery catheter and transpulmonary indicator dilution techniques

Background and objective: Liver transplantation is characterized by several changes in intravascular blood volume due to vasodilatation based on neurohumoral mediators, intraoperative bleeding and anaesthesia technique effects. Today, with the transpulmonary indicator dilution technique, cardiac index-(CIart) can be evaluated and preload assessed in terms of the intrathoracic blood volume index (ITBVI). The aim was to analyse in patients undergoing liver transplantation two preload variables, pulmonary artery occlusion pressure (PAOP) and ITBVI with respect to cardiac index (CIpa) and stroke volume index (SVIpa), the correlation between ITBVI and PAOP, and secondary the relationship between the changes (Δ) of ITBVI and PAOP and the changes of CIpa and SVIpa, and the relationships between ΔITBVI and ΔPAOP. The reproducibility and precision of all CIart and CIpa measurements were also evaluated. Methods: A prospective study was performed in 60 patients monitored with a pulmonary artery catheter and with the PiCCO® system. The variables were evaluated with a linear regression model. Results: Linear regression analysis between ITBVI-CIpa and ITBVI-SVIpa were r2 = 0.47 (P < 0.0001) and r2 = 0.55 (P < 0.0001) respectively, while PAOP poorly correlated to CIpa (r2 = 0.02), SVIpa (r2 = 0.015) and ITBVI (r2 = 0.002). Only changes in ITBVI were correlated with changes in CIpa (Δ1, r2 = 0.37; Δ2, r2 = 0.32), and SVIpa (Δ1, r2 = 0.60; Δ2, r2 = 0.47). The mean bias between CIart and CIpa was 0.13 L min−1 m−2 (2 SD = 1.04 L min−1 m−2) (r2 = 0.86, P < 0.0001). Conclusions: In comparison with PAOP, ITBVI seems a more reliable indicator of cardiac preload in patients undergoing liver transplantation.

Italian intersociety consensus statement on antithrombotic prophylaxis in hip and knee replacement and in femoral neck fracture surgery.

Anticoagulant prophylaxis for preventing venous thromboembolism (VTE) is a worldwide established procedure in hip and knee replacement surgery, as well as in the treatment of femoral neck fractures (FNF). Different guidelines are available in the literature, with quite different recommendations. None of them is a multidisciplinary effort as the one presented. The Italian Society for Studies on Haemostasis and Thrombosis (SISET), the Italian Society of Orthopaedics and Traumatology (SIOT), the association of Orthopaedists and Traumatologists of Italian Hospitals (OTODI), together with the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) have set down easy and quick suggestions for VTE prophylaxis in hip and knee surgery as well as in FNF treatment. This inter-society consensus statement aims at simplifying the grading system reported in the literature, and its goal is to benefit its clinical application. Special focus is given to fragile patients, those with high bleeding risk, and those receiving chronic antiplatelet (APT) and vitamin K antagonists treatment. A special chapter is dedicated to regional anaesthesia and VTE prophylaxis.

Fenoldopam Mesylate and Renal Function in Patients Undergoing Liver Transplantation: A Randomized, Controlled Pilot Trial

To test the relative effects on serum creatinine (CRE), blood urea nitrogen (BUN), and urine output of small-dose dopamine and fenoldopam in patients undergoing liver transplantation, we randomized 43 patients to 1 of 2 continuous infusions over 48 h, starting with anesthesia induction: fenoldopam, 0.1 &mgr;g · kg−1 · min−1 or dopamine, 2 &mgr;g · kg−1 · min−1. We used predetermined hemodynamic and intravascular volume goals (intrathoracic blood volume index 800–1000 mL/m2, extravascular lung water index <7 mL/kg) to manage patients with an algorithm for use of mannitol and furosemide to maintain urine output >1 mL · kg−1 · h−1. At postoperative day 3, the median CRE increase was 0.2 mg/dL (interquartile range [IQR] −0.2–0.5) with fenoldopam and 0.5 mg/dL (IQR 0.3–0.9, P = 0.004) in the dopamine group. The BUN increase was median 2 mg/dL (IQR −2–8) versus 8.5 mg/dL (IQR 5–12, P = 0.01), respectively, with fenoldopam versus dopamine. Urine output was similar; however, significantly fewer fenoldopam patients required furosemide compared with dopamine patients (median 1 [IQR 0–3] versus 3 [IQR 2–4], respectively, P = 0.003). The hemodynamic effects of dopamine and fenoldopam were similar. Compared with dopamine, in the setting of liver transplantation, fenoldopam is associated with better CRE and BUN values.

Inhaled areosolized prostacyclin and pulmonary hypertension during anesthesia for lung transplantation

TREATMENT of pulmonary hypertension is a most important aspect of the anaesthetic management for lung transplantation and requires administration of pulmonary vasodilators and inotropic support. Intravenous administration of vasodilators such as nitrates or prostaglandins does not have a selective action on pulmonary vasculature leading to systemic hypotension and increasing intrapulmonary shunt. Inhaled areosolized prostacyclin (IAP) is attracting attention as a selective pulmonary vasodilator in various clinical conditions associated with pulmonary hypertension. The present study was designed to evaluate the effect of IAP during anesthesia for lung transplantation.

Knowledge of residual curarization: an Italian survey

Background: The use of neuromuscular blocking agents (NMBAs) is widespread in anesthetic practice; little is known about the current use of these drugs in Italy. This survey was conducted to obtain information about the most commonly used clinical tests and the train‐of‐four (TOF) ratios that are considered as being reliable for assessing recovery from neuromuscular blockade at the end of anesthesia and the estimated occurrence rates of post‐operative paralysis in Italian hospitals.

Reversal of rocuronium induced neuromuscular block with sugammadex or neostigmine: a large observational study.

This ‘real‐life’ study aimed to analyze the time from the start of neostigmine or sugammadex administration to recovery to a train of four ratio (TOFr) of 0.9 in a real‐life in patients receiving rocuronium. The secondary aims were to assess the proportion of patients: presenting TOFr < 0.9 after 5, 10, and 20 min from reversal agent administration, receiving opioids for intraoperative analgesia and extubated in the post‐anesthesia care unit (PACU).

The Liver Transplant Recipient With Cardiac Disease

Liver transplantation is a stressful condition for the cardiovascular system of patients with advanced hepatic disease. The underlying hemodynamic and cardiac status of patients with cirrhosis is crucial to determine which patients should became recipients. Generally preoperative cardiovascular testing is performed on potential candidates who are more than 45 years old, or have diabetes mellitus, or peripheral vascular disease, or more than two standard cardiac risk factors. Recent data suggest that the prevalence of coronary artery disease among patients with cirrhosis is much greater than previously believed; it likely mirrors or exceeds the prevalence rate in the healthy population. The morbidity and mortality of patients with coronary artery disease who undergo orthotopic liver transplantation (OLT) without treatment are unacceptably high. In conclusion, accurate preoperative cardiac evaluation according to the new American Heart Association & American College of Cardiology should lead to detect and treat coronary artery disease before liver transplantation. In case of alcohol-related cardiomyopathy, portopulmonary hypertension, and hypertrophic cardiomyopathy, there should be a case-by-case discussion by the hepatologist and cardiologist to consider the patient for liver transplantation. No robust data are available on the impact of decompensated dilated heart failure in this setting. If a recipient with cardiac disease is scheduled for OLT, we strongly suggest advanced intra- and postoperative hemodynamic monitoring plus transesophageal echocardiography.

Evaluation of new laryngoscope blade for tracheal intubation, Truview EVO2: a manikin study.

Background and objective Difficult airways present a clinical challenge for anaesthetists. The Truphatek Truview EVO2©; (Truphatek International Ltd, Netanya, Israel) is a new laryngoscope blade used for endotracheal intubation that could be used where there is difficulty in visualizing the laryngeal inlet. Methods Twenty anaesthetists (12 trainees and eight consultants) compared the Truphatek Truview EVO2©; with a conventional Macintosh size 3 blade. The Trucorp Airsim Bronchi©; (Trucorp Ltd, Belfast, Northern Ireland, UK) manikin was intubated under normal conditions and under simulated difficult conditions such as tongue inflation and neck rigidity. In each scenario, the Cormack–Lehane grade, time needed for successful intubation, perceived difficulty of tracheal intubation and personal preference of blade were compared. The results were analysed with t‐test (time of intubation), Wilcoxon signed‐rank sum (Cormack–Lehane grade, ease of manoeuvre, preferred blade) and analysis of variance with Bonferroni correction (augmentation of difficulties in different scenarios). Results The Truview EVO2 blade allowed the best laryngeal view as judged by the Cormack–Lehane grade (P < 0.05) in two separate situations: under simulated tongue inflation and under simulated neck rigidity. However, this blade did not reduce the intubation time or the ease of tracheal tube placement with respect to conventional Macintosh blade. Conclusion Compared with the classical Macintosh blade, the Truview EVO2 blade allowed a better view of the larynx, but did not facilitate endotracheal intubation in any of the difficult scenarios created with the adjustable manikin and in most scenarios in fact prolonged the intubation time.

II Italian intersociety consensus statement on antithrombotic prophylaxis in orthopaedics and traumatology

Pharmacological prophylaxis for preventing venous thromboembolism (VTE) is a worldwide established procedure in hip and knee replacement surgery, as well as in the treatment of femoral neck fractures, but few data exist in other fields of orthopaedics and traumatology. Thus, no guidelines or recommendations are available in the literature except for a limited number of weak statements about knee arthroscopy and lower limb fractures. In any case, none of them are a multidisciplinary effort as the one here presented. The Italian Society for Studies on Haemostasis and Thrombosis (SISET), the Italian Society of Orthopaedics and Traumatology (SIOT), the Association of Orthopaedic Traumatology of Italian Hospitals (OTODI), together with the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) and the Italian Society of General Medicine (SIMG) have set down easy and quick suggestions for VTE prophylaxis in a number of surgical conditions for which only scarce evidence is available. This inter-society consensus statement aims at simplifying the approach to VTE prophylaxis in the single patient with the goal to improve its clinical application.

Improved Results With Lung Transplantation for Cystic Fibrosis

YSTIC fibrosis (CF) is the most frequently inheritedlethal disorder among caucasians. Improvements intherapy have resulted in an average life span extending intothe third decade of life; however, no cure is available at thepresent time and 95% of deaths are related to chronicobstructive lung disease, bronchiectasis, and consequentrespiratory failure.