Anaesthesia Management for Giant Intraabdominal Tumours: A Case Series Study.

BACKGROUND: Due to a lack of randomised controlled trials and guidelines, and only case reports being available in the literature, there is no consensus on how to approach anaesthetic management in patients with giant intraabdominal tumours. METHODS: This study aimed to evaluate the literature and explore the current status of evidence, by undertaking an observational research design with a descriptive account of characteristics observed in a case series referring to patients with giant intraabdominal tumours who underwent anaesthesia. RESULTS: Twenty patients diagnosed with giant intraabdominal tumours were included in the study, most of them women, with the overall pathology being ovarian-related and sarcomas. Most of the patients were unable to lie supine and assumed a lateral decubitus position. Pulmonary function tests, chest X-rays, and thoracoabdominal CT were the most often performed preoperative evaluation methods, with the overall findings that there was no atelectasis or pleural effusion present, but there was bilateral diaphragm elevation. The removal of the intraabdominal tumour was performed under general anaesthesia in all cases. Awake fiberoptic intubation or awake videolaryngoscopy was performed in five cases, while the rest were performed with general anaesthesia with rapid sequence induction. Only one patient was ventilated with pressure support ventilation while maintaining spontaneous ventilation, while the rest were ventilated with controlled ventilation. Hypoxemia was the most reported respiratory complication during surgery. In more than 50% of cases, there was hypotension present during surgery, especially after the induction of anaesthesia and after tumour removal, which required vasopressor support. Most cases involved blood loss with subsequent transfusion requirements. The removal of the tumor requires prolonged surgical and anaesthesia times. Fluid drainage from cystic tumour ranged from 15.7 L to 107 L, with a fluid extraction rate of 0.5-2.5 L/min, and there was no re-expansion pulmonary oedema reported. Following surgery, all the patients required intensive care unit admission. One patient died during hospitalization. CONCLUSIONS: This study contributes to the creation of a certain standard of care when dealing with patients presenting with giant intraabdominal tumour. More research is needed to define the proper way to administer anaesthesia and create practice guidelines.

Effects of Tocilizumab on Inflammation and Iron Metabolism in Critically Ill Patients with COVID-19.

COVID-19 produces cytokine-mediated persistent inflammation and is associated with elevated iron stores and low circulating iron. It is believed that central to the pathophysiological mechanism is interleukin 6 and hepcidin. A state of iron overload, termed hyperferritinemia, and inflammatory anemia take place. Both conditions are linked to a worse result in critically ill patients. Blocking the interleukin 6-hepcidin pathway with Tocilizumab could present favorable outcomes. The aim of this study was to evaluate if Tocilizumab influences survival, the occurrence of sepsis, anemia and transfusions in critically ill patients suffering from COVID-19. This prospective observational study focused on levels of interleukin 6, hepcidin and blood iron parameters in patients treated with Tocilizumab. Data were compared before and after therapy as well as between treated and control groups. Results indicate that there is no difference in terms of survival nor in the rate of anemia or sepsis occurrence. Hepcidin was elevated and anemia ensued after treatment, which could indicate alternative pathways. In conclusion, when the classic interleukin 6-hepcidin pathway is blocked, inflammation seems to use alternative routes. Further understanding of these pathways is required and new pharmacological therapies need to be developed to treat persistent inflammation.

Association of Moral Distress with Anxiety, Depression, and an Intention to Leave among Nurses Working in Intensive Care Units during the COVID-19 Pandemic.

BACKGROUND: Wide geographical variations in depression and anxiety rates related to the ethical climate have been reported during the COVID-19 pandemic in intensive care units (ICUs). The objective was to investigate whether moral distress is associated and has predictive values for depression, anxiety, and intention to resign. METHODS: 79 consenting ICU nurses completed MMD-HP and PHQ-4 scales in this cross-sectional study between October 2020-February 2021, after ethical approval. The association between MMD-HP and PHQ-4, and the predictive value of MMD-HP for anxiety, depression, and an intention to leave were analyzed (linear regression and receiver operating characteristics curve analysis). RESULTS: From MMD-HP items, system related factors had highest scores (Kruskal-Wallis test, p < 0.0001). MMD-HP and PHQ-4 were weakly correlated (r = 0.41 [0.21-0.58]). MMD-HP and its system-related factors discriminate between nurses with and without depression or anxiety, while system-related factors differentiate those intending to resign (p < 0.05). The MMD-HP score had 50 [37.54-62.46] sensitivity with 80.95 [60-92.33] specificity to predict the intention to leave, and 76.12 [64.67-84.73] sensitivity with 58.33 [31.95-80.67] specificity to detect anxiety or depression symptoms. CONCLUSIONS: During the COVID-19 pandemic, system-associated factors seem to be the most important root factors inducing moral distress. Moral distress is associated with negative psychological outcomes.

A.B.C. approach proposal for POCUS in COVID-19 critically ill patients.

The rapid spread of SARS-CoV-2 (COVID-19) since December 2019 forced Intensive Care Units to face high numbers of patients admitted simultaneously with limited resources. COVID-19 critically ill patients, especially those on mechanical ventilators, demand special attention as they can develop potential complications with critical hemodynamic and respiratory consequences. Point of Care Ultrasound (POCUS) might have important roles in assessing the critically ill SARS-CoV-2 patient. Mostly, lung ultrasound has been presented as having a role in diagnosis and monitoring, but airway examination and hemodynamic evaluation are of interest also. We propose an A.B.C. POCUS approach focusing on A-airway (orotracheal intubation), B-breathing (interstitial syn-dromes, pneumothorax, atelectasis, pneumonia), and C-circulation (cardiac function, pulmonary embolism, volume status, deep veins thrombosis). This A.B.C. approach has emerged during ICU care for 22 adult COVID-19 critically ill patients, along with the analysis of recent papers describing ultrasound in COVID-19 patients including the use of ultrasound that is currently applied in the management of the general critically ill population. This A.B.C- POCUS algorithm parallels the well-established clinical A.B.C. algorithms. There are few extensive ultrasonographic studies in COVID-19 critically ill patients up to now, but techniques extrapolated from non-COVID studies seem reasonable even though comparative studies are not available yet.

Clinical versus Ultrasound Measurements of Hyomental Distance Ratio for the Prediction of Difficult Airway in Patients with and without Morbid Obesity.

PURPOSE: To describe the correlation between clinically measured hyomental distance ratio (HMDRclin) and the ultrasound measurement (HMDRecho) in patients with and without morbid obesity and to compare their diagnostic accuracy for difficult airway prediction. METHODS: HMDRclin and HMDRecho were recorded the day before surgery in 160 consecutive consenting patients. Laryngoscopy was performed by a skilled anesthesiologist, with grades III and IV Cormack-Lehane being considered difficult views of the glottis. Linear regression was used to assess the correlation between HMDRclin and HDMRecho and receiver operating curve analysis was used to compare the performance of the two for predicting difficult airway. RESULTS: The linear correlation between HMDRclin and HDMRecho in patients without morbid obesity had a Pearson coefficient of 0.494, while for patients with morbid obesity this was 0.14. A slightly higher area under the curve for HMDRecho was oberved: 0.64 (5%CI 0.56-0.71) versus 0.52 (95%CI, 0.44-0.60) (p = 0.34). CONCLUSION: The association between HMDRclin and HDMRecho is moderate in patients without morbid obesity, but negligible in morbidly obese patients. These might be explained by difficulties in palpating anatomical structures of the airway.

Increased Susceptibility to Postoperative PCA Morphine-Induced Respiratory Depression in a Patient with an Undiagnosed Traumatic Porencephalic Cyst - A Case Report.

INTRODUCTION: Patient-controlled analgesia with morphine is routinely used for postoperative pain management. Due to the safety profiles of the technique, which are patient/disease related or technique/equipment related, severe respiratory depression requiring opioid antagonists or airway management are uncommon. CASE PRESENTATION: The case of a patient with right colon carcinoma who was operated on for hemicolectomy under general anaesthesia and who presented with apnoea, after postoperatively receiving an initial bolus of 1mg of morphine. A large post-traumatic porencephalic cyst of the left brain hemisphere, previously undiagnosed, was found on the computed tomography scan. We excluded human errors, technique and equipment factors, and the patient did not have any other predisposing conditions like sleep apnoea, obesity, recent head injury or concurrent use of other sedatives. Previously the patient had been entirely asymptomatic, and her increased susceptibility to respiratory depression was the only clinical manifestation of porencephaly. CONCLUSION: Adult acquired porencephaly is seldom reported in the literature, clinical manifestations depending on the location and size of the cyst. In the present reported case, increased susceptibility to low-dose opioids might be associated with the structural and functional reorganisation of the brain after head trauma with the occurrence of the porencephalic cyst of the brain.

Can APACHE II, SOFA, ISS, and RTS Severity Scores be used to Predict Septic Complications in Multiple Trauma Patients?

BACKGROUND: Physiological composite scores are used to predict mortality in multiple trauma patients. Sepsis is the leading cause of late mortality in trauma victims brought about by immune suppression due to homeostasis dysregulation. OBJECTIVE: To determine whether APACHE II, SOFA, ISS and RTS scores can predict the occurrence of sepsis in multiple trauma patients. METHODS: APACHE II, SOFA, ISS, and RTS scores were calculated during the first twenty-four hours after the injury for sixty-four adult poly-traumatic patients. The occurrence of infectious complications was investigated over a fourteen-day period. The infection-free rates for the multiple trauma patients were considered as end-points in the Kaplan-Meier plot analysis. RESULTS: For SOFA, a cutoff score of 4 points was identified as a predictor of the occurrence of sepsis, with 89% of the patients with SOFA<4 being infection-free, while 37% of those with SOFA>4 were infection-free (p<0.01). None of the patients with APACHE II≤5 points developed infections. Eighty-four percent of patients with APACHE II scores of 5-10 did not develop sepsis, while 49% with APACHE II≥11 were infection-free (p<0.01). A cutoff of 7 points was found to be most discriminative for RTS. Eighty-eight percent of the patients with RTS≤7 and 43% of those with RTS<7 were infection-free (p<0.01). Eighty-eight percent of patients with ISS≥22 did not develop sepsis and 56% with ISS>22 did not develop sepsis (p<0.01). CONCLUSION: APACHE II, SOFA, ISS, and RTS functional severity scores can predict mortality as well as the occurrence of sepsis in multiple trauma patients.