SUGAMMADEX versus neostigmine after ROCURONIUM continuous infusion in patients undergoing liver transplantation.

BACKGROUND: Rapid neuromuscular block reversal at the end of major abdominal surgery is recommended to avoid any postoperative residual block. To date, no study has evaluated sugammadex performance after rocuronium administration in patients undergoing liver transplantation. This is a randomized controlled trial with the primary objective of assessing the neuromuscular transmission recovery time obtained with sugammadex versus neostigmine after rocuronium induced neuromuscular blockade in patients undergoing orthotopic liver transplantation. METHODS: The TOF-Watch SX®, calibrated and linked to a portable computer equipped with TOF-Watch SX Monitor Software®, was used to monitor and record intraoperative neuromuscular block maintained with a continuous infusion of rocuronium. Anaesthetic management was standardized as per our institution's internal protocol. At the end of surgery, neuromuscular moderate block reversal was obtained by administration of 2 mg/kg of sugammadex or 50 mcg/kg of neostigmine (plus 10 mcg/kg of atropine). RESULTS: Data from 41 patients undergoing liver transplantation were analysed. In this population, recovery from neuromuscular block was faster following sugammadex administration than neostigmine administration, with mean times±SD of 9.4 ± 4.6 min and 34.6 ± 24.9 min, respectively (p < 0.0001). CONCLUSION: Sugammadex is able to reverse neuromuscular block maintained by rocuronium continuous infusion in patients undergoing liver transplantation. The mean reversal time obtained with sugammadex was significantly faster than that for neostigmine. It is important to note that the sugammadex recovery time in this population was found to be considerably longer than in other surgical settings, and should be considered in clinical practice. TRIAL REGISTRATION: ClinicalTrials.govNCT02697929 (registered 3rd March 2016).

Association between preoperative evaluation with lung ultrasound and outcome in frail elderly patients undergoing orthopedic surgery for hip fractures: study protocol for an Italian multicenter observational prospective study (LUSHIP).

BACKGROUND: Hip fracture is one of the most common orthopedic causes of hospital admission in frail elderly patients. Hip fracture fixation in this class of patients is considered a high-risk procedure. Preoperative physical examination, plasma natriuretic peptide levels (BNP, Pro-BNP), and cardiovascular scoring systems (ASA-PS, RCRI, NSQIP-MICA) have all been demonstrated to underestimate the risk of postoperative complications. We designed a prospective multicenter observational study to assess whether preoperative lung ultrasound examination can predict better postoperative events thanks to the additional information they provide in the form of "indirect" and "direct" cardiac and pulmonary lung ultrasound signs. METHODS: LUSHIP is an Italian multicenter prospective observational study. Patients will be recruited on a nation-wide scale in the 12 participating centers. Patients aged > 65 years undergoing spinal anesthesia for hip fracture fixation will be enrolled. A lung ultrasound score (LUS) will be generated based on the examination of six areas of each lung and ascribing to each area one of the four recognized aeration patterns-each of which is assigned a subscore of 0, 1, 2, or 3. Thus, the total score will have the potential to range from a minimum of 0 to a maximum of 36. The association between 30-day postoperative complications of cardiac and/or pulmonary origin and the overall mortality will be studied. Considering the fact that cardiac complications in patients undergoing hip surgery occur in approx. 30% of cases, to achieve 80% statistical power, we will need a sample size of 877 patients considering a relative risk of 1.5. CONCLUSIONS: Lung ultrasound (LU), as a tool within the anesthesiologist's armamentarium, is becoming increasingly widespread, and its use in the preoperative setting is also starting to become more common. Should the study demonstrate the ability of LU to predict postoperative cardiac and pulmonary complications in hip fracture patients, a randomized clinical trial will be designed with the scope of improving patient outcome. Trial registration ClinicalTrials.gov, NCT04074876. Registered on August 30, 2019.

Assessment of Pleural Effusion and Small Pleural Drain Insertion by Resident Doctors in an Intensive Care Unit: An Observational Study.

Small-bore pleural drainage device insertion has become a first-line therapy for the treatment of pleural effusions (PLEFF) in the intensive care unit; however, no data are available regarding the performance of resident doctors in the execution of this procedure. Our aim was to assess the prevalence of complications related to ultrasound-guided percutaneous small-bore pleural drain insertion by resident doctors. In this single-center observational study, the primary outcome was the occurrence of complications. Secondary outcomes studied were as follows: estimation of PLEFF size by ultrasound and postprocedure changes in PaO2/FiO2 ratio. In all, 87 pleural drains were inserted in 88 attempts. Of these, 16 were positioned by the senior intensivist following a failed attempt by the resident, giving a total of 71 successful placements performed by residents. In 13 cases (14.8%), difficulties were encountered in advancing the catheter over the guidewire. In 16 cases (18.4%), the drain was positioned by a senior intensivist after a failed attempt by a resident. In 8 cases (9.2%), the final chest X-ray revealed a kink in the catheter. A pneumothorax was identified in 21.8% of cases with a mean size (±SD) of just 10 mm (±6; maximum size: 20 mm). The mean size of PLEFF was 57.4 mm (±19.9), corresponding to 1148 mL (±430) according to Balik's formula. Ultrasound-guided placement of a small-bore pleural drain by resident doctors is a safe procedure, although it is associated with a rather high incidence of irrelevant pneumothoraces.