RESUMEN
Approximately 15-50% of patients with Crohn's disease (CD) will require surgery within ten years following the diagnosis. The management of modifiable risk factors before surgery is essential to reduce postoperative complications and to promote a better postoperative recovery. Preoperative malnutrition reduced functional capacity, sarcopenia, immunosuppressive medications, anemia, and psychological distress are frequently present in CD patients. Multimodal prehabilitation consists of nutritional, functional, medical, and psychological interventions implemented before surgery, aiming at optimizing preoperative status and improve postoperative recovery. Currently, studies evaluating the effect of multimodal prehabilitation on postoperative outcomes specifically in CD are lacking. Some studies have investigated the effect of a single prehabilitation intervention, of which nutritional optimization is the most investigated. The aim of this narrative review is to present the physiologic rationale supporting multimodal surgical prehabilitation in CD patients waiting for surgery, and to describe its main components to facilitate their adoption in the preoperative standard of care.
Asunto(s)
Enfermedad de Crohn , Complicaciones Posoperatorias , Cuidados Preoperatorios , Humanos , Enfermedad de Crohn/cirugía , Enfermedad de Crohn/terapia , Cuidados Preoperatorios/métodos , Complicaciones Posoperatorias/prevención & control , Estado Nutricional , Ejercicio Preoperatorio , Desnutrición/prevención & control , Desnutrición/etiologíaRESUMEN
BACKGROUND: Since the appearance of the first report on postoperative cognitive impairment in 1955, the number of papers focusing on perioperative neurocognitive disorders (PND) has constantly increased, both in the field of basic science and clinical research. A critical comprehensive review may explore the perception of how noteworthy PND is for physicians and clinical researchers. The aim of this systematic review is to describe how the clinical papers published to date with PND as primary or secondary outcome have changed over time in terms of editorial characteristics. RESULTS: A literature search was performed on PubMed, Embase, CINAHL, Cochrane, Scopus, and Web of Science databases, up to March 2021. Human prospective or retrospective clinical studies in which incidence, risk factors, treatments, or outcomes associated with PND are described among primary or secondary outcomes were included. A total of 2109 articles were considered. CONCLUSIONS: The bibliometric analysis suggests a stable increase in attention towards PND, particularly in general surgery adult-elderly patients, and underlines the importance for the clinicians not to underestimate this specific field.
RESUMEN
Extracorporeal membrane oxygenation (ECMO) is a temporary life support system used to assist patients with life-threatening severe cardiac and/or respiratory insufficiency. Patients requiring ECMO can be considered the sickest patients admitted to the intensive care unit (ICU). Acute kidney injury (AKI) represents a frequent complication during ECMO, affecting up to 70% of patients, with multifactorial pathophysiology and an independent risk factor for mortality. Severe AKI requiring Continuous Renal Replacement Therapy (CRRT) occurs in 20% of ECMO patients, but multiple indications and different timing may imply a significantly higher application rate in different centers. CRRT can be run in parallel to ECMO through different vascular access, or it can be conducted in series by connecting the circuits. Anticoagulation of ECMO is typically managed with systemic heparin, but several approaches can be applied for the CRRT circuit, from no anticoagulation to the addition of intra-filter heparin or regional citrate anticoagulation. The combination of CRRT and ECMO can be considered a form of multiple organ support therapy, but this approach still requires optimization in timing, set-up, anticoagulation, prescription and delivery. The aim of this report is to review the pathophysiology of AKI, the CRRT delivery, anticoagulation strategies and outcomes of patients with AKI treated with ECMO.
RESUMEN
BACKGROUND: The fluid challenge response in surgical patients can be predicted by functional haemodynamic tests. Two tests, the mini-fluid challenge (mini-FC) and end-expiratory occlusion test (EEOT), have been assessed in a few small single-centre studies with conflicting results. In general, functional haemodynamic tests have not performed reliably in predicting fluid responsiveness in patients undergoing laparotomy. OBJECTIVE: This trial is designed to address and compare the reliability of the EEOT and the mini-FC in predicting fluid responsiveness during laparotomy. DESIGN: Prospective, multicentre study. SETTING: Three university hospitals in Italy. PATIENTS: A total of 103 adults patients scheduled for elective laparotomy with invasive arterial monitoring. INTERVENTIONS: The study protocol evaluated the changes in the stroke volume index (SVI) 20âs (EEOT20) and 30âs (EEOT30) after an expiratory hold and after a mini-FC of 100âml over 1âmin. Fluid responsiveness required an increase in SVI at least 10% following 4âmlâkg-1 of Ringer's solution fluid challenge infused over 10âmin. MAIN OUTCOME MEASUREMENTS: Haemodynamic data, including SVI, were obtained from pulse contour analysis. The area under the receiver operating characteristic curves of the tests were compared with assess fluid responsiveness. RESULTS: Fluid challenge administration induced an increase in SVI at least 10% in 51.5% of patients. The rate of fluid responsiveness was comparable among the three participant centres (Pâ=â0.10). The area under the receiver operating characteristic curves (95% CI) of the changes in SVI after mini-FC was 0.95 (0.88 to 0.98), sensitivity 98.0% (89.5 to 99.6) and specificity 86.8% (75.1 to 93.4) for a cut-off value of 4% of increase in SVI. This was higher than the SVI changes after EEOT20, 0.67 (0.57 to 0.76) and after EEOT30, 0.73 (0.63 to 0.81). CONCLUSION: In patients undergoing laparotomy the mini-FC reliably predicted fluid responsiveness with high-sensitivity and specificity. The EEOT showed poor discriminative value and cannot be recommended for assessment of fluid responsiveness in this surgical setting. TRIAL REGISTRATION: NCT03808753.
Asunto(s)
Fluidoterapia , Quirófanos , Adulto , Presión Sanguínea , Hemodinámica , Humanos , Italia , Estudios Prospectivos , Curva ROC , Reproducibilidad de los Resultados , Respiración Artificial , Volumen SistólicoRESUMEN
BACKGROUND: Since late 2019, a severe acute respiratory syndrome, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread with overwhelming speed causing over 214 million confirmed infections and more than 4.5 million deaths worldwide. In this framework, Italy had the second highest number of SARS-CoV-2 infections worldwide, and the largest number of deaths. A global effort of both the scientific community and governments has been undertaken to stem the pandemic. The aim of this paper is to perform a narrative review of the Italian contribution to the scientific literature regarding intensive care management of patients suffering from COVID-19, being one of the first western countries to face an outbreak of SARS-CoV-2 infection. MAIN BODY: We performed a narrative review of the literature, dedicating particular attention and a dedicated paragraph to ventilatory support management, chest imaging findings, biomarkers, possible pharmacological interventions, bacterial superinfections, prognosis and non-clinical key aspects such as communication and interaction with relatives. CONCLUSIONS: Many colleagues, nurses and patients died leaving their families alone. To all of them, we send our thoughts and dedicate these pages.