Dynamic inflation prevents and standardized lung recruitment reverts volume loss associated with percutaneous tracheostomy during volume control ventilation: results from a Neuro-ICU population.

To determine how percutaneous tracheostomy (PT) impacts on respiratory system compliance (Crs) and end-expiratory lung volume (EELV) during volume control ventilation and to test whether a recruitment maneuver (RM) at the end of PT may reverse lung derecruitment. This is a single center, prospective, applied physiology study. 25 patients with acute brain injury who underwent PT were studied. Patients were ventilated in volume control ventilation. Electrical impedance tomography (EIT) monitoring and respiratory mechanics measurements were performed in three steps: (a) baseline, (b) after PT, and (c) after a standardized RM (10 sighs of 30 cmH2O lasting 3 s each within 1 min). End-expiratory lung impedance (EELI) was used as a surrogate of EELV. PT determined a significant EELI loss (mean reduction of 432 arbitrary units p = 0.049) leading to a reduction in Crs (55 ± 13 vs. 62 ± 13 mL/cmH2O; p < 0.001) as compared to baseline. RM was able to revert EELI loss and restore Crs (68 ± 15 vs. 55 ± 13 mL/cmH2O; p < 0.001). In a subgroup of patients (N = 8, 31%), we observed a gradual but progressive increase in EELI. In this subgroup, patients did not experience a decrease of Crs after PT as compared to patients without dynamic inflation. Dynamic inflation did not cause hemodynamic impairment nor raising of intracranial pressure. We propose a novel and explorative hyperinflation risk index (HRI) formula. Volume control ventilation did not prevent the PT-induced lung derecruitment. RM could restore the baseline lung volume and mechanics. Dynamic inflation is common during PT, it can be monitored real-time by EIT and anticipated by HRI. The presence of dynamic inflation during PT may prevent lung derecruitment.

Enhanced recovery (fast-track surgery) after total ankle replacement: The state of the art.

The post-operative results of a total ankle replacement are not determined solely by an optimal surgical technique, but by an appropriate anesthesiological and rehabilitative post-operative approach. Enhanced functional recovery often depends on a multidisciplinary approach based on a correct framework of the patient and his needs, requests, and characteristics. Extensive bibliographical research has been performed on Pubmed, Google Scholar, Scopus. This comprehensive and inclusive review of the literature aims to examine the state of the art of "fast-track" protocols employed in total ankle replacement (TAR), considering pre-operative preparation, anesthetic management, intraoperative and surgical factors, post-operative rehabilitative care and reduction of hospitalization time.

Toward a Spatiotemporal Understanding of Dolomite Dissolution in Sandstone by CO2-Enriched Brine Circulation.

In this study, we introduce a stochastic method to delineate the mineral effective surface area (ESA) evolution during a recycling reactive flow-through transport experiment on a sandstone under geologic reservoir conditions, with a focus on the dissolution of its dolomite cement, Ca1.05Mg0.75Fe0.2(CO3)2. CO2-enriched brine was circulated through this sandstone specimen for 137 cycles (∼270 h) to examine the evolution of in situ hydraulic properties and CO2-enriched brine-dolomite geochemical reactions. The bulk permeability of the sandstone specimen decreased from 356 mD before the reaction to 139 mD after the reaction, while porosity increased from 21.9 to 23.2% due to a solid volume loss of 0.25 mL. Chemical analyses on experimental effluents during the first cycle yielded a dolomite reactivity of ∼2.45 mmol m-3 s-1, a corresponding sample-averaged ESA of ∼8.86 × 10-4 m2/g, and an ESA coefficient of 1.36 × 10-2, indicating limited participation of the physically exposed mineral surface area. As the dissolution reaction progressed, the ESA is observed to first increase and then decrease. This change in ESA can be qualitatively reproduced employing scanning electron microscopy-image-based stochastic analyses on dolomite dissolution. These results provide a new approach to analyze and upscale the ESA during geochemical reactions, which are involved in a wide range of geoengineering operations.

Intracranial Hemorrhage Diagnosed with Transcranial Ultrasound in a Comatose, Postliver Transplant Patient.

Transcranial ultrasound is a well validated diagnostic technique used to assess cerebral perfusion or to detect structural damage in intensive care unit patients. We report a case of an intracranial hemorrhage first suspected during a trans-cranial Doppler assessment of a postorthotopic liver transplant patient. The patient was at considerable risk of bleeding, due to a primary graft nonfunction, but he had also elevated ammonium levels, justifying the comatose state, and no focal neurological deficits. The clinical conditions were unstable, making the transportation to the radiology suite at elevated risk. The hemorrhage was identified by B-mode ultrasound before the development of focal neurological signs or alterations in the middle cerebral artery Doppler flow and optical nerve sheath diameter. We suggest that transcranial B-mode ultrasound may prove useful as a monitoring tool in selected patients, also providing early clinical suspicion for the onset of intracranial hemorrhage even before the development of intracranial hypertension or focal neurological deficits.

Perioperative Management of Pheochromocytoma: From a Dogmatic to a Tailored Approach.

BACKGROUND: Perioperative management of pheochromocytoma (PCC) remains under debate. METHODS: A bicentric retrospective study was conducted, including all patients who underwent laparoscopic adrenalectomy for PCC from 2000 to 2017. Patients were divided into two groups: Group 1 treated with alpha-blockade, and Group 2, without alfa-blockers. The primary end point was the major complication rate. The secondary end points were: the need for advanced intra-operative hemostasis, the admission to the intensive care unit (ICU), the length of stay (LOS), systolic (SBP), and diastolic blood pressure (DBP). Univariate and multivariate analysis was conducted. A p-value < 0.05 was considered statistically significant. RESULTS: Major postoperative complications were similar (p = 0.49). Advanced hemostatic agents were 44.9% in Group 1 and 100% in Group 2 (p < 0.001). In Group 2, no patients were admitted to the ICU, while only 73.5% of Group 1 (p < 0.001) were admitted. The median length of stay was larger in Group 1 than in Group 2 (p = 0.026). At the induction, SBP was 130 mmHg in Group 1, and 115 mmHg (p < 0.001). The pre-surgery treatment was the only almost statistically significant variable at the multivariate analysis of DBP at the end of surgery. CONCLUSION: The preoperative use of alfa-blockers should be considered not a dogma in PCC.

1,3,4-Azadiphospholides as building blocks for scorpionate and bidentate ligands in multinuclear complexes.

Annulated oxy-substituted 1,3,4-azadiphospholides such as the anion in Na[1] are readily accessible phosphorus heterocycles made from the phosphaethynolate anion (OCP)- and 2-chloropyridines. The sodium salt Na[1] reacts with oxophilic element halides such as OPCl3, PhSiCl3, PhBCl2 and CpTiCl3 at room temperature to form exclusively the oxygen bound tris-substituted compounds E(1)3 (with E = OP, PhSi, PhB- or CpTi). Six equivalents of Na[1] with group four metal chlorides MCl4 (M = Ti, Zr, Hf) form cleanly the hexa-substituted dianions (Na2[M(1)6]) which are isolated in excellent yields. The titanium complexes are deeply coloured species due to ligand to metal charge transfer (LMCT) excitations. In all complexes, the phosphorus atoms of the azadiphosphole moieties are able to coordinate to a soft metal center as shown in their reactions with [Mo(CO)3Mes], yielding complexes in which the Mo(CO)3 binds in a fac manner. Functionalization of the oxy group with amino phosphanes allows isolation of tridentate ligands, which have been used as synthons for macrocyclic molybdenum carbonyl complexes.

[Ultrasound-guided thoracic paravertebral block for closed loop ileostomy repair in severe COPD: a case report]. / Bloqueio paravertebral torácico guiado por ultrassom para correção de ileostomia em alça em DPOC grave: um relato de caso.

BACKGROUND AND OBJECTIVES: Ultrasound-guided thoracic paravertebral block is usually considered a good alternative to epidural thoracic for anesthesia and pain control in thoracic and breast surgery. Furthermore it has also been used during abdominal surgery lately, especially hepatic and renal surgery. However, its role is poorly defined in this context. The purpose of this report was to highlight the role of thoracic paravertebral block in providing effective anesthesia and analgesia during both the abdominal surgical intervention and pain control in post-operative period, avoiding possible complications which general anesthesia may arise, which are fairly common in patients with chronic obstructive pulmonary disease and similar comorbidities. CASE REPORT: The authors present a case of abdominal surgery successfully performed on a woman affected by severe chronic obstructive pulmonary disease requiring closed loop ileostomy repair performed with ultrasound guided thoracic paravertebral block without any complications. CONCLUSIONS: Thoracic paravertebral block may be a safe anesthetic method for abdominal surgery in those patients who would undergo potential severe complications by using general anesthesia.

Detecting and Number Counting of Single Engineered Nanoparticles by Digital Particle Polymerase Chain Reaction.

The concentrations of nanoparticles present in colloidal dispersions are usually measured and given in mass concentration (e.g. mg/mL), and number concentrations can only be obtained by making assumptions about nanoparticle size and morphology. Additionally traditional nanoparticle concentration measures are not very sensitive, and only the presence/absence of millions/billions of particles occurring together can be obtained. Here, we describe a method, which not only intrinsically results in number concentrations, but is also sensitive enough to count individual nanoparticles, one by one. To make this possible, the sensitivity of the polymerase chain reaction (PCR) was combined with a binary (=0/1, yes/no) measurement arrangement, binomial statistics and DNA comprising monodisperse silica nanoparticles. With this method, individual tagged particles in the range of 60-250 nm could be detected and counted in drinking water in absolute number, utilizing a standard qPCR device within 1.5 h of measurement time. For comparison, the method was validated with single particle inductively coupled plasma mass spectrometry (sp-ICPMS).

Ultrasound-guided thoracic paravertebral block for closed loop ileostomy repair in severe COPD: a case report / Bloqueio paravertebral torácico guiado por ultrassom para correção de ileostomia em alça em DPOC grave: um relato de caso

Abstract Background and objectives: Ultrasound-guided thoracic paravertebral block is usually considered a good alternative to epidural thoracic for anesthesia and pain control in thoracic and breast surgery. Furthermore it has also been used during abdominal surgery lately, especially hepatic and renal surgery. However, its role is poorly defined in this context. The purpose of this report was to highlight the role of thoracic paravertebral block in providing effective anesthesia and analgesia during both the abdominal surgical intervention and pain control in post-operative period, avoiding possible complications which general anesthesia may arise, which are fairly common in patients with chronic obstructive pulmonary disease and similar comorbidities. Case report: The authors present a case of abdominal surgery successfully performed on a woman affected by severe chronic obstructive pulmonary disease requiring closed loop ileostomy repair performed with ultrasound guided thoracic paravertebral block without any complications. Conclusions: Thoracic paravertebral block may be a safe anesthetic method for abdominal surgery in those patients who would undergo potential severe complications by using general anesthesia.

Resumo Justificativa e objetivos: O bloqueio paravertebral torácico guiado por ultrassom é geralmente considerado uma boa alternativa à anestesia peridural torácica para o controle da dor em cirurgia torácica e mamária. Além disso, ultimamente o bloqueio paravertebral torácico tem sido usado durante cirurgias abdominais, especialmente hepática e renal. No entanto, seu papel está mal definido nesse contexto. O objetivo deste relato foi destacar o papel do bloqueio paravertebral torácico em fornecer anestesia e analgesia efetiva tanto na intervenção cirúrgica abdominal quanto no controle da dor pós-operatória, evitando as possíveis complicações que podem surgir da anestesia geral, bastante comuns em pacientes com doença pulmonar obstrutiva crônica e comorbidades similares. Relato de caso: Apresentamos um caso de cirurgia abdominal realizada com sucesso em uma mulher com doença pulmonar obstrutiva crônica grave que precisou de correção de ileostomia em alça, realizada com bloqueio paravertebral torácico guiado por ultrassom sem complicações. Conclusões: O bloqueio paravertebral torácico pode ser um método anestésico seguro para cirurgia abdominal em pacientes que poderiam apresentar complicações possivelmente graves com o uso de anestesia geral.