The anesthesiologist's perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance

The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.

Early Hospital Discharge on Day Two Post Robotic Lobectomy with Telehealth Home Monitoring: A Pilot Study

Despite the adoption of enhanced recovery programs, the reported postoperative length of stay after robotic surgery is 4 days even in highly specialized centers. We report preliminary results of a pilot study for a new protocol of early discharge (on day 2) with telehealth home monitoring after robotic lobectomy for lung cancer. All patients with a caregiver were discharged on postoperative day 2 with a telemonitoring device if they satisfied specific discharge criteria. Teleconsultations were scheduled once in the afternoon of post-operative day 2, twice on postoperative day 3, and then once a day until the chest tube removal. Post-discharge vital signs were recorded by patients at least four times daily through the device and were available for consultation by two surgeons through phone application. In case of sudden variation of vital signs or occurrence of adverse events, a direct telephone line was available for patients as well as a protected re-hospitalization path. Primary outcome was the safety evaluated by the occurrence of post-discharge complications and readmissions. Secondary outcome was the evaluation of resources optimization (hospitalization days) maintaining the standard of care. During the study period, twelve patients satisfied all preoperative clinical criteria to be enrolled in our protocol. Two of twelve enrolled patients were successively excluded because they did not satisfy discharge criteria on postoperative day 2. During telehealth home monitoring a total of 27/427 vital-sign measurements violated the threshold in seven patients. Among the threshold violations, only 1 out of 27 was a critical violation and was managed at home. No postoperative complication occurred neither readmission was needed. A mean number of three hospitalization days was avoided and an estimated economic benefit of about EUR 500 for a single patient was obtained if compared with patients submitted to VATS lobectomy in the same period. These preliminary results confirm that adoption of telemonitoring allows, in selected patients, a safe discharge on postoperative day 2 after robotic surgery for early-stage NSCLC. A potential economic benefit could derive from this protocol if this data will be confirmed in larger sample.

Near-infrared spectroscopy to monitor spinal cord oxygenation in οpen thoraco-abdominal aortic surgery. A case series

Objectives. We adopted the near-infrared spectroscopy (NIRS) technology to monitor the spinal oxygen supply through the paraspinous muscles oxygenation in agreement with the concept of “collateral network” circulation. We retrospectively investigated our database of subjects who underwent thoraco-abdominal aorta open repair assessing for the reliability of this monitoring to predict spinal cord injury. Methods. Consecutive patients who underwent elective thoraco-abdominal aorta open repair between March 2019 and September 2021. In addition to standard monitoring, patients received the monitoring of the paraspinous muscles oxygenation by NIRS. Results. In one patient a significant drop of the mean arterial pressure (49 mmHg) and the spinal-cord perfusion pressure (31 mmHg) occurred after the aortic clamping, with a contemporary lowering of the left-side oxygenation of paraspinous muscles (<40%). Both the blood pressure and the spinal cord perfusion pressure were restored within 10 minutes, but the oxygenation remained at an unsafe level (<55%) until the end of the surgery. This same patient experienced a lower-limb paralysis post-operatively. It did not happen in the other 11 cases of the sample. Conclusions. The main finding of our retrospective analysis indicates reliability of this technology to monitor the spinal cord oxygenation during open thoraco-abdominal aortic surgery and possibly predict spinal cord injury. Still, several questions need to be addressed about the suitability of this technology to the anatomic and pathophysiology of the spinal cord circulation

Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist

Simple Summary

Major high-risk surgery (HRS) exposes patients to potential perioperative adverse events. Hepatic resection of colorectal metastases can surely be included into the HRS class of operations. Limiting such risks is the main target of the perioperative medicine. In this context the collaboration between the anesthetist and the surgeon and the sharing of management protocols is of utmost importance and represents the key issue for a successful outcome. In our institution, we have been adopting consolidated protocols for patients undergoing this type of surgery for decades; this made our mixed team (surgeons and anesthetists) capable of achieving a safe outcome for the majority of our surgical population. In this narrative review, we report the most recent state of the art of perioperative management of hepatic resection of colorectal metastases along with our experience in this field, trying to point out the main issues.

Abstract

Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients’ management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist’s point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.

Value of renal resistive index in covid-19 ARDS patients: an early inflammation alert for the lung-kidney cross-talk?

We analysed RRI and other hemodynamic, re-spiratory and inflammation parameters in critically ill pa-tients affected by severe covid-19 with acute distress respi-ratory syndrome (ARDS) aiming at verifying their modifica-tions during supine and prone positioning and any mutual correlation or interplay with RRI.

Renal resistive index as a predictor of postoperative complications in liver resection surgery. Observational study

Mortality after liver surgery reduced during the last three decades to less than 2%, but post-operative morbidity occurs in 20-50% of cases. Patients are often considered eligible for post-operative intensive-care unit (ICU) admission. Predicting which patients that are at higher risk could lead to a more precise perioperative management. We investigated whether renal resistive index (RRI), alone or along with other items, can predict post-operative complication after hepatic resection. All consecutive patients undergoing hepatectomy for primary or metastatic neoplasm at our Institution between February 2015 and March 2017 were enrolled. They received RRI measurement before entering in operative room and after awakening from general anesthesia. 183 Patients were enrolled. High surgical invasiveness, surgery time > 360 min, pre-operative RRI and postoperative serum lactate clearance <  - 6%, showed to be associated with postoperative complications. Pre-operative RRI, complex liver resection, long-lasting surgery and poor lactate clearance (cLac) close to awakening from general anesthesia, all together may permit to classify the risk of post-operative adverse outcome after hepatic resection surgery.

Impact of the FloTrac/VigileoTM Monitoring on Intraoperative Fluid Management and Outcome after Liver Resection

BACKGROUNDS

Perioperative fluid-therapy is a still a debated issue. In hepatic surgery, volume load must be strictly monitored to assure both a safe hemodynamics and low central venous pressure (CVP) to limit the backflow bleeding. Retrospectively, we compared intraoperative fluid management before and after the adoption of a semi-invasive hemodynamic monitoring.

METHODS

We compared patients submitted to liver resection monitored by FloTrac/VigileoTM (group A) vs. patients who did not (group B). We searched for differences about hemodynamics, fluid therapy and outcome.

RESULTS

Three hundred fifty-five patients underwent hepatic resection due to neoplasm: group A - n = 179 and group B - n = 176. At the end of the resection, patients of group A showed a higher mean arterial pressure (MAP) than group B (74 ± 12 vs. 49.4 ± 8 mm Hg, respectively; p < 0.001). Cardiac index and stroke volume variation in group A were within a normal range. Fluid input was higher in group B than in group A (12.0 ± 3.4 vs. 7.6 ± 3.1 mL/kg/h, respectively; p < 0.001) and fluid balance was significantly different: group A -400 ± 1,527 vs. group B 326 ± 1,527 mL (p < 0.001). Group B showed a greater number of cases complicated outcomes (36 vs. 20; p = 0.014). Considering only those subjects who were able to reach their hemodynamic targets (MAP ≥65 mm Hg and CVP ≤7 mm Hg), we found similar data.

CONCLUSIONS

Patients who received a monitored fluid therapy experienced a safer outcome.

La nucleoaspirazione secondo Onik nel trattamento dell'ernia discale lombare analisi multicentrica dei primi risultati su oltre 650 trattamenti

Gli autori espongono i risultati ottenuti applicando la nucleotomia percutanea secondo Onik al trattamento dell'ernia discale lombare. Le casistiche sommate complessivamente ammontano a oltre 600 pazienti. Nel complesso i risultati sono buoni o ottimi nel 72% circa dei casi. I risultati insoddisfacenti, considerando globalmente i modest e gli invariati, corrispondonoal 26% circa. Eccezionali le complicanze (meno dell' 1 %): 1 discite (risolta con intervento chirurgico). La metodica di Onik può già essere serenamente considerata una possibilitanon trascurabile nel campo vasto e variegato dei trattamentidisponibili per l'ernia discale lombare

Cardiac output by Flotrac/VigileoTM validation trials: are there reliable conclusions?

We reviewed the comparative trials of the Flotrac/VigileoTM versus the thermodilution method, published in the last five years. The results about the agreement between the two methods measuring cardiac output are contrasting. We also noticed that almost the whole pertinent literature include studies conducted without a correct statistical design, particularly about the sample size. For this reason we consider that results of the published studies about the agreement between pulse contour analysis for cardiac output measurement and thermodilution method may be not reliable.

Seasonal and spatial variability of water quality parameters in the Port of Genoa, Italy, from 2000 to 2007

This paper presents the results of the statistical analysis of a set of physico-chemical and biological water quality parameters, monthly collected from 2000 to 2007 in the Genoa Harbour area (Ligurian Sea). We applied multivariate methods, such as principal component analysis (PCA) and dynamic factor analysis (DFA) for investigating the spatial and temporal variability and for providing important background information on pollution problems in the region. PCA evidenced the role of the sewage and river discharges and of the exchanges with the open sea in determining the harbour water quality. DFA was used to estimate underlying common trends in the time series. The DFA results partly show a general improvement of water quality over the 8-years period. However, in other areas, we found inter-annual variations but no significant multi-annual trend. Furthermore, we included meteorological variables in our statistical analyses because of their potential influence on the water quality parameters. These natural forcings explain part of the variability in water quality parameters that are superimposed on the dominating anthropogenic pollution factors.

Training resident anesthesiologists in adult challenging intubation comparing Truview EVO2 and Macintosh laryngoscope: a preliminary study

AIM

Teaching airway management continues to be of high importance to the anesthesiologist, since the care of each individual patient depends on the expertise, training and knowledge of the anesthetist with different airway devices, techniques and algorithms. The aim of our study was to compare intubation performed by resident anesthesiologists in training, under senior supervision, using Truview EVO2 (Group 1) or Macintosh blade (Group 2) in a group of adult patients undergoing elective surgery.

METHODS

This was a pilot prospective study. Thirty patients who were scheduled for surgery under general anesthesia were randomized into two groups. In Group 1, intubation was performed by using the Truview EVO2, and in Group 2 intubation was performed by using the Macintosh blade. Mallampati score, thyromental distance and neck mobility were recorded for each patient. The exclusion criteria included a Mallampati score =or<2 and a Patil distance >6 cm. The time of intubation and any occurrence of complications were recorded.

RESULTS

Intubation was always successful on the first attempt in Group 1, while it failed for 46.7% of patients in Group 2 (P=0.006). The time of intubation was not different between the two groups. No complications were recorded for Group 1 (Truview), while seven were reported in Group 2 (Macintosh) (P=0.003).

CONCLUSIONS

The resident managed to intubate all patients on the first attempt with the Truview, which led to a lower incidence of complications. Despite the exiguity of the population in the study, Truview EVO2 and other videolaryngoscopes can be considered to be useful tools in training resident anesthesiologists in elective intubation.

Association of a Wide Invasive Malignant Thymoma with Myastenia Gravis and Primary Hyperparathyroidism Due to Parathyroid Adenoma: Case Report and Review of the Literature

There are few cases described in the world literature reporting an association of thymoma (with myasthenia gravis or not) with hyperparathyroidism. In these cases the hyperparathyroidism was due to the presence of an adenoma or hyperplasic parathyroid tissue either in the cervical region or in an ectopic intrathymic location.(12345) In other cases the syndrome of hypercalcemia was due to the secretion of parathyroid-related protein (PTHRP) (6) or parathyroid hormone (PTH) (7) by the thymoma itself. We report the first case, at the best of our knowledge, of a wide invasive malignant thymoma (type B3), associated with myasthenia gravis and hyperparathyroidism caused by parathyroid adenoma.

The toxic benthic dinoflagellate Ostreopsis ovata: quantification of proliferation along the coastline of Genoa, Italy

Toxic harmful algal bloom (HAB) occurrence is becoming more frequent and problematic in highly urbanized coastal zones. In summer 2005 along the urbanized Genoa coastline (Ligurian Sea, North western Mediterranean Sea), local first aid stations treated about 200 people, who all showed similar symptoms following exposure to marine aerosols. The link with proliferation of Ostreopsis ovata was made, and it highlighted for the first time, the risks that benthic HABs may represent in highly urbanised temperate areas. Subsequently, a specific monitoring plan was designed and implemented in the same area in July 2006, before the first signs of Ostreopsis proliferation were detected. Here we report on this quantification of an Ostreopsis ovata bloom in the Ligurian Sea. Cells were quantified both in the water column and in the epiphytic community on macrophytes. Our results suggest a role of sea water temperature and weather conditions in favouring bloom development.

Evaluation and comparison of two selective extraction procedures for heavy metal speciation in sediments

Two sequential extraction procedures (the former proposed by the Standard, Measurements and Testing-SM&T-program of European Union and the latter derived from those of Tessier and Forstner with various modifications) have been compared, by analyzing a reference material (CRM 601) certified for the content of heavy metals in the three solutions resulting from the SM&T procedure. Scanning electron microscopy-energy dispersive X-ray analysis (SEM-EDX) was used to evaluate the composition of the residues after various extractions. Reliable results, both in terms of precision and accuracy, were obtained for the first two steps of the SM&T scheme. As regards the third step, because it was modified during this work, a direct comparison of our results with those certified is not possible. SEM analysis confirmed that the scheme previously used in the laboratory was more aggressive compared to the SM&T procedure, which has also the advantage that the only CRM available for metal partitioning in sediments is certified using this method.

The surgical treatment of cervical metastases

Vertebral instability and the neuroaggressiveness produced by the occurrence of cervical metastasis in a neoplastic patient during remission or quiescence of the disease is rare, but it may negatively influence the prognosis of the patient and drastically reduce his or her life expectancy. The authors describe their experience with conservative or surgical treatment in 151 patients affected with cervical metastases.

Lumbar stenosis surgery: "recalibrage" according to Senegas

In the treatment of lumbar stenosis the method known as "recalibrage" proposed by Senegas is the most recent alternative to extended traditional laminectomy. Posterior decompression, which is obtained by removal of the cephalic half of the laminae, the yellow ligaments and the intraforaminal part of the facet joint, reduces the risk of postsurgical instability and makes it possible to proceed with fusion which is not just posterolateral. In cases where there is intersegmental instability we applied the Hartshill rectangle, proposed by Doce, stabilized to the residual laminar and associated with genous grafting. Our experience is based on 48 cases treated with this method over the last three years. In 19 cases Hartshill fixation was used to complete "recalibrage". Results are generally satisfactory, although follow-up is short. The "relative gain" method proposed by Lassale and Garcon was used for evaluation.

Complex fractures of the tibial plateau

Out of 142 consecutive cases of fracture of the tibial plateau 48 cases (34%) of complex fractures are taken into consideration. Surgical treatment is based on two types of osteosynthesis: 1) osteosynthesis "of election" with interfragmentary plates and screws, which was used in most of the cases; 2) minimal osteosynthesis with Barr or lag screws, when there are lesions of the soft tissue and capsuloligamentous lesions. A total of 69% of the results were satisfactory (good and excellent). The most unfavorable prognostic factors are comminution of the fracture and residual widening of the tibial plateau.

Automated percutaneous lumbar diskectomy according to the Onik method: conclusive considerations

The Onik method of automated percutaneous diskectomy in the treatment of the herniated lumbar disk offers undeniable advantages which we have already elaborated in our preliminary studies. Nevertheless, further experience with this technique has allowed us to pinpoint several aspects worthy of more attention: patient selection and long-term results. The patient selection procedure must follow Maroon and Onik's original protocol to the letter in order to single out those patients in whom contained disk herniation has caused actual sciatic pain and not merely low back pain. Imaging tests such as CT scan, MRI, and myelography have proved useful mainly in identifying contraindications for the technique, while only intraoperative diskography has been capable of diagnosing the contained status of the disk herniation, the basic criterion for selection. We reviewed 98 automated percutaneous lumbar diskectomies after a follow-up period ranging from 6 months to 2 1/2 years and found the results to be satisfactory, in spite of a slight deterioration of the good results at 6-9 months, following which there was no further change.

Vertebral artery release in vertebro-basilar insufficiency due to cervical uncoarthrosis

The authors report 31 cases submitted to transversectomy and uncosectomy according to the Jung and Kehr method for the treatment of vertebrobasilar insufficiency secondary to compression of the vertebral artery due to cervical uncoarthrosis. The results obtained were all classified as excellent or good. Emphasis is placed on several diagnostic aspects such as arteriographic investigation, and some details of the surgical technique used for the prevention of complications are discussed.

The role of osteotomy in the treatment of pseudarthrosis of the neck of the femur in younger patients

The authors discuss 34 cases of pseudarthrosis of the neck of the femur that were subjected to two different types of osteotomy, namely the support osteotomy of Putti and the valgising osteotomy of Pauwels. The following conclusions were reached: both methods produced good healing of the pseudarthrosis; with regard to the functional result, valgising osteotomy associated with a degree of lateralisation must be the operation of choice because it compensates for the shortening and prevents the Trendelenburg gait.

Arthroprosthesis in old unreduced congenital dislocation of the hip, using the "false" acetabulum. A study of 34 cases

In adult patients with considerable loss of function due to an unreduced congenital dislocation of the hip with a false acetabulum, the authors posed the question "Is it feasible, with a reasonable chance of success, to perform an arthroprosthesis in the "pathological" position, using the false acetabulum as a seating for the cup?" The aim of this study was to assess, in particular, the holding properties of the cup which has to be fitted after appropriate reaming, into this rather precarious false acetabulum. They define the indications for this procedure and describe their technique. The results of 34 operations, followed up for an average of 5 years, confirm the validity of this procedure.