Anesthesia and cancer recurrence: an overview.

Several perioperative factors are responsible for the dysregulation or suppression of the immune system with a possible impact on cancer cell growth and the development of new metastasis. These factors have the potential to directly suppress the immune system and activate hypothalamic-pituitary-adrenal axis and the sympathetic nervous system with a consequent further immunosuppressive effect.Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system, inflammatory system, and angiogenesis, with a possible impact on cancer recurrence and long-term outcome. Even if the current data are controversial and contrasting, it is crucial to increase awareness about this topic among healthcare professionals for a future better and conscious choice of anesthetic techniques.In this article, we aimed to provide an overview regarding the relationship between anesthesia and cancer recurrence. We reviewed the effects of surgery, perioperative factors, and anesthetic agents on tumor cell survival and tumor recurrence.

Percutaneous Tracheostomy in COVID-19 Critically Ill Patients: Experience from 30 Consecutive Procedures

Abstract Introduction Percutaneous tracheostomy (PT) in the intensive care unit (ICU) is a well-established practice that shows a reduced risk of wound infection compared with surgical tracheostomy, thus facilitating mechanical ventilation, nursing procedures, reduction in sedation and early mobilization. Objective This is an observational case-control study that compares the results of PT in ICU patients with coronavirus disease 2019 (COVID-19) prospectively enrolled to a similar group of subjects, retrospectively recruited, without COVID-19. Methods Ninety-eight consecutive COVID-19 patients admitted to the ICU at Pisa Azienda Ospedaliero Universitaria Pisana between March 11th and May 20th, 2020 were prospectively studied. Thirty of them underwent PT using different techniques. Another 30 non-COVID-19 ICU patients were used as a control-group. The main outcome was to evaluate the safety and feasibility of PT in COVID-19 patients. We measured the rate of complications. Results Percutaneous tracheostomy was performed with different techniques in 30 of the 98 COVID-19 ICU patients admitted to the ICU. Tracheostomy was performed on day 10 (mean 10 ± 3.3) from the time of intubation. Major tracheal complications occurred in 5 patients during the procedure. In the control group of 30 ICU patients, no differences were found with regards to the timing of the tracheostomy, whereas a statistically significant difference was observed regarding complications with only one tracheal ring rupture reported. Conclusion Percutaneous tracheostomy in COVID-19 patients showed a higher rate of complications compared with controls even though the same precautions and the same expertise were applied. Larger studies are needed to understand whether the coronavirus disease itself carries an increased risk of tracheal damage.

Airway Fire during Laser Surgery of the Vocal Cords in Children: A Case Report.

OBJECTIVES: Fire in the operating theater is a potential source of important morbidity for the patient. Laser surgery of the head and neck district presents a particularly high risk of fire due to the presence of all three elements of the 'fire triad,' necessary to cause combustive or explosive events: an oxidiser, a fuel, and a heat source. The aim of the present study is to emphasise the need of new prevention tools and greater adherence to the recommendations available in the literature. METHODS: The sudden occurrence of combustion within the airway of an infant undergoing laryngeal laser surgery was presented along with his management. RESULTS: An infant underwent CO2 laser surgery for the treatment of the laryngeal stenosis. Unfortunately, the endoscopic procedure was complicated by a fire of the tracheal tube. The tube was immediately removed, the saline was flushed down the trachea and the ventilation was maintained through a face mask. Subsequently, a fiberoscopy was performed and showed a vocal cord burn. CONCLUSIONS: Since operating room fires are still an underreported occurrence, we believe that this present work might raise awareness about this potential complication and give useful suggestions for the management of airway fires in paediatric anaesthesia.

Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients With COVID-19.

Importance: Full-thickness tracheal lesions and tracheoesophageal fistulas are severe complications of invasive mechanical ventilation. The incidence of tracheal complications in ventilated patients with coronavirus disease 2019 (COVID-19) is unknown. Objective: To evaluate whether patients with COVID-19 have a higher incidence of full-thickness tracheal lesions and tracheoesophageal fistulas than matched controls and to investigate potential mechanisms. Design, Setting, and Participants: This is a retrospective cohort study in patients admitted to the intensive care unit in a tertiary referral hospital. Among 98 consecutive patients with COVID-19 with severe respiratory failure, 30 underwent prolonged (≥14 days) invasive mechanical ventilation and were included in the COVID-19 group. The control group included 45 patients without COVID-19. Patients with COVID-19 were selected from March 1 to May 31, 2020, while the control group was selected from March 1 to May 31, 2019. Exposures: Patients with COVID-19 had severe acute respiratory syndrome coronavirus 2 infection diagnosed by nasopharyngeal/oropharyngeal swabs and were treated according to local therapeutic procedures. Main Outcomes and Measures: The primary study outcome was the incidence of full-thickness tracheal lesions or tracheoesophageal fistulas in patients with prolonged invasive mechanical ventilation. Results: The mean (SD) age was 68.8 (9.0) years in the COVID-19 group and 68.5 (14.1) years in the control group (effect size, 0.3; 95% CI, -5.0 to 5.6). Eight (27%) and 15 (33%) women were enrolled in the COVID-19 group and the control group, respectively. Fourteen patients (47%) in the COVID-19 group had full-thickness tracheal lesions (n = 10, 33%) or tracheoesophageal fistulas (n = 4, 13%), while 1 patient (2.2%) in the control group had a full-thickness tracheal lesion (odds ratio, 38.4; 95% CI, 4.7 to 316.9). Clinical and radiological presentations of tracheal lesions were pneumomediastinum (n = 10, 71%), pneumothorax (n = 6, 43%), and/or subcutaneous emphysema (n = 13, 93%). Conclusions and Relevance: In this cohort study, almost half of patients with COVID-19 developed full-thickness tracheal lesions and/or tracheoesophageal fistulas after prolonged invasive mechanical ventilation. Attempts to prevent these lesions should be made and quickly recognized when they occur to avoid potentially life-threatening complications in ventilated patients with COVID-19.

Iron metabolism and lymphocyte characterisation during Covid-19 infection in ICU patients: an observational cohort study.

BACKGROUND: Iron metabolism and immune response to SARS-CoV-2 have not been described yet in intensive care patients, although they are likely involved in Covid-19 pathogenesis. METHODS: We performed an observational study during the peak of pandemic in our intensive care unit, dosing D-dimer, C-reactive protein, troponin T, lactate dehydrogenase, ferritin, serum iron, transferrin, transferrin saturation, transferrin soluble receptor, lymphocyte count and NK, CD3, CD4, CD8 and B subgroups of 31 patients during the first 2 weeks of their ICU stay. Correlation with mortality and severity at the time of admission was tested with the Spearman coefficient and Mann-Whitney test. Trends over time were tested with the Kruskal-Wallis analysis. RESULTS: Lymphopenia is severe and constant, with a nadir on day 2 of ICU stay (median 0.555 109/L; interquartile range (IQR) 0.450 109/L); all lymphocytic subgroups are dramatically reduced in critically ill patients, while CD4/CD8 ratio remains normal. Neither ferritin nor lymphocyte count follows significant trends in ICU patients. Transferrin saturation is extremely reduced at ICU admission (median 9%; IQR 7%), then significantly increases at days 3 to 6 (median 33%, IQR 26.5%, p value 0.026). The same trend is observed with serum iron levels (median 25.5 µg/L, IQR 69 µg/L at admission; median 73 µg/L, IQR 56 µg/L on days 3 to 6) without reaching statistical significance. Hyperferritinemia is constant during intensive care stay: however, its dosage might be helpful in individuating patients developing haemophagocytic lymphohistiocytosis. D-dimer is elevated and progressively increases from admission (median 1319 µg/L; IQR 1285 µg/L) to days 3 to 6 (median 6820 µg/L; IQR 6619 µg/L), despite not reaching significant results. We describe trends of all the abovementioned parameters during ICU stay. CONCLUSIONS: The description of iron metabolism and lymphocyte count in Covid-19 patients admitted to the intensive care unit provided with this paper might allow a wider understanding of SARS-CoV-2 pathophysiology.

Ultrasound- versus landmark-guided subclavian vein catheterization: a prospective observational study from a tertiary referral hospital.

This was a single-center, observational, prospective study designed to compare the effectiveness of a real-time, ultrasound- with landmark-guided technique for subclavian vein cannulation. Two groups of 74 consecutive patients each underwent subclavian vein catheterization. One group included patients from intensive care unit, studied by using an ultrasound-guided technique. The other group included patients from surgery or emergency units, studied by using a landmark technique. The primary outcome for comparison between techniques was the success rate of catheterization. Secondary outcomes were the number of attempts, cannulation failure, and mechanical complications. Although there was no difference in total success rate between ultrasound-guided and landmark groups (71 vs. 68, p = 0.464), the ultrasound-guided technique was more frequently successful at first attempt (64 vs. 30, p < 0.001) and required less attempts (1 to 2 vs. 1 to 6, p < 0.001) than landmark technique. Moreover, the ultrasound-guided technique was associated with less complications (2 vs. 13, p < 0.001), interruptions of mechanical ventilation (1 vs. 57, p < 0.001), and post-procedure chest X-ray (43 vs. 62, p = 0.001). In comparison with landmark-guided technique, the use of an ultrasound-guided technique for subclavian catheterization offers advantages in terms of reduced number of attempts and complications.

Anaphylactic Shock During Pediatric Anesthesia: An Unexpected Reaction to Sevoflurane.

During general anesthesia, while muscle relaxants, latex and antibiotics are normally considered as very common causes of anaphylactic reactions, there are no documented cases of anaphylaxis due to inhalational agents. We report the case of a 6-year-old child scheduled for adenotonsillectomy who had an anaphylactic shock reaction due to Sevoflurane. Several allergic tests were performed to detect the trigger. Drugs used during operation were tested on both patient and three matched controls. While controls were negative, the patient displayed a positive reaction to Sevoflurane. To our knowledge, this is the first published report describing an allergic reaction caused by a volatile anesthetic.

Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials.

PURPOSE: The transversus abdominal plane (TAP) block has been described as an effective pain control technique after abdominal surgery. We performed a systematic review and meta-analysis of randomized-controlled trials (RCTs) to account for the increasing number of TAP block studies appearing in the literature. The primary outcome we examined was the effect of TAP block on the postoperative pain score at six, 12, and 24 hr. The secondary outcome was 24-hr morphine consumption. SOURCE: We searched the United States National Library of Medicine database, the Excerpta Medica database, and the Cochrane Central Register of Controlled Clinical Studies and identified RCTs focusing on the analgesic efficacy of TAP block compared with a control group [i.e., placebo, epidural analgesia, intrathecal morphine (ITM), and ilioinguinal nerve block after abdominal surgery]. Meta-analyses were performed on postoperative pain scores at rest at six, 12, and 24 hr (visual analogue scale, 0-10) and on 24-hr opioid consumption. PRINCIPAL FINDINGS: In the 51 trials identified, compared with placebo, TAP block reduced the VAS for pain at six hours by 1.4 (95% confidence interval [CI], -1.9 to -0.8; P < 0.001), at 12 hr by 2.0 (95% CI, -2.7 to -1.4; P < 0.001), and at 24 hr by 1.2 (95% CI, -1.6 to -0.8; P < 0.001). Similarly, compared with placebo, TAP block reduced morphine consumption at 24 hr after surgery (mean difference, -14.7 mg; 95% CI, -18.4 to -11.0; P < 0.001). We observed this reduction in pain scores and morphine consumption in the TAP block group after gynecological surgery, appendectomy, inguinal surgery, bariatric surgery, and urological surgery. Nevertheless, separate analysis of the studies comparing ITM with TAP block revealed that ITM seemed to have a greater analgesic efficacy. CONCLUSIONS: The TAP block can play an important role in the management of pain after abdominal surgery by reducing both pain scores and 24-hr morphine consumption. It may have particular utility when neuraxial techniques or opioids are contraindicated.

RéSUMé: OBJECTIF: Le bloc dans le plan du muscle transverse de l'abdomen (ou TAP bloc) a été décrit comme une technique efficace de contrôle de la douleur après une chirurgie abdominale. Nous avons réalisé une revue systématique et une méta-analyse des études randomisées contrôlées (ERC) pour faire un état des lieux du nombre croissant d'études sur le TAP bloc qui s'ajoutent à la littérature. Le critère d'évaluation principal était l'effet d'un TAP bloc sur les scores de douleur postopératoire à six, 12 et 24 h. Le critère d'évaluation secondaire était la consommation de morphine à 24 h. SOURCE: Nous avons effectué des recherches dans la base de données de la Bibliothèque nationale américaine de médecine (United States National Library of Medicine) ainsi que dans le Registre central Cochrane des études cliniques contrôlées (Cochrane Central Register of Controlled Clinical Studies). Nous avons ensuite identifié les ERC se concentrant sur l'efficacité analgésique des TAP blocs par rapport à un groupe témoin [c.-à-d. placebo, analgésie péridurale, morphine intrathécale (MIT) et bloc nerveux ilio-inguinal] après une chirurgie abdominale. Des méta-analyses ont été réalisées en examinant les scores de douleur postopératoire au repos à six, 12 et 24 h (échelle visuelle analogique [EVA], 0-10) et la consommation d'opioïdes sur une période de 24 h. CONSTATATIONS PRINCIPALES: Parmi les 51 études identifiées, par rapport à un placebo, le TAP bloc a réduit le score de douleur de 1,4 sur l'EVA après six heures (intervalle de confiance [IC] 95 %, −1,9 à −0,8; P < 0,001), de 2,0 après 12 h (IC 95 %, −2,7 à −1,4; P < 0,001) et de 1,2 après 24 h (IC 95 %, −1,6 à −0,8; P < 0,001). De la même façon, par rapport au placebo, le TAP bloc a réduit la consommation de morphine à 24 h après la chirurgie (différence moyenne, −14,7 mg; IC 95 %, −18,4 à −11,0; P < 0,001). Nous avons observé cette réduction en matière de scores de douleur et de consommation de morphine dans le groupe TAP bloc après des chirurgies gynécologiques, des appendicectomies, des chirurgies inguinales, des chirurgies bariatriques et des chirurgies urologiques. Toutefois, une analyse séparée des études comparant la MIT au TAP bloc a révélé que la MIT semblait avoir une efficacité analgésique plus prononcée. CONCLUSION: Le TAP bloc peut jouer un rôle important dans la prise en charge de la douleur après une chirurgie abdominale en réduisant les scores de douleur et la consommation de morphine à 24 h. Il pourrait être particulièrement utile lorsque l'utilisation de techniques neuraxiales ou les opioïdes sont contre-indiqués.