The Association of Ischemia Type and Duration with Acute Kidney Injury after Robot-Assisted Partial Nephrectomy.

BACKGROUND: Acute kidney injury (AKI) after robot-assisted partial nephrectomy (RAPN) is a robust surrogate for chronic kidney disease. The objective of this study was to evaluate the association of ischemia type and duration during RAPN with postoperative AKI. MATERIALS AND METHODS: We reviewed all patients who underwent RAPN at our institution since 2011. The ischemia types were warm ischemia (WI), selective artery clamping (SAC), and zero ischemia (ZI). AKI was defined according to the Risk Injury Failure Loss End-Stage (RIFLE) criteria. We calculated ischemia time thresholds for WI and SAC using the Youden and Liu indices. Logistic regression and decision curve analyses were assessed to examine the association with AKI. RESULTS: Overall, 154 patients met the inclusion criteria. Among all RAPNs, 90 (58.4%), 43 (28.0%), and 21 (13.6%) were performed with WI, SAC, and ZI, respectively. Thirty-three (21.4%) patients experienced postoperative AKI. We extrapolated ischemia time thresholds of 17 min for WI and 29 min for SAC associated with the occurrence of postoperative AKI. Multivariable logistic regression analyses revealed that WIT ≤ 17 min (odds ratio [OR] 0.1, p < 0.001), SAC ≤ 29 min (OR 0.12, p = 0.002), and ZI (OR 0.1, p = 0.035) significantly reduced the risk of postoperative AKI. CONCLUSIONS: Our results confirm the commonly accepted 20 min threshold for WI time, suggest less than 30 min ischemia time when using SAC, and support a ZI approach if safely performable to reduce the risk of postoperative AKI. Selecting an appropriate ischemia type for patients undergoing RAPN can improve short- and long-term functional kidney outcomes.

Perioperative Hypothermia-A Narrative Review.

Unintentional hypothermia (core temperature < 36 °C) is a common side effect in patients undergoing surgery. Several patient-centred and external factors, e.g., drugs, comorbidities, trauma, environmental temperature, type of anaesthesia, as well as extent and duration of surgery, influence core temperature. Perioperative hypothermia has negative effects on coagulation, blood loss and transfusion requirements, metabolization of drugs, surgical site infections, and discharge from the post-anaesthesia care unit. Therefore, active temperature management is required in the pre-, intra-, and postoperative period to diminish the risks of perioperative hypothermia. Temperature measurement should be done with accurate and continuous probes. Perioperative temperature management includes a bundle of warming tools adapted to individual needs and local circumstances. Warming blankets and mattresses as well as the administration of properly warmed infusions via dedicated devices are important for this purpose. Temperature management should follow checklists and be individualized to the patient's requirements and the local possibilities.

Infection rate and clinical management of cancer patients during the COVID-19 pandemic: experience from a tertiary care hospital in northern Italy.

BACKGROUND: Optimal management of patients with cancer during COVID-19 pandemic is still pending. METHODS: Our patients were advised to maintain their scheduled appointments, and planned cancer treatment was continued without unnecessary delays in an outpatient setting. Additional strict preventive infection measures were rapidly implemented at our outpatient department. When COVID-19 test became widely available, universal testing of healthcare workers and vigorous screening of all patients coming to our facility for COVID-19 infection were performed by SARS-CoV-2 real-time reverse transcription PCR on rhinopharyngeal swab. RESULTS: As of the data cut-off on 9 April 2020, a total of 156 oncology patients with a median age of 67 (range 26-86) years and 63 haematology patients (median age 69 years, range 23-89) were screened for COVID-19 during active cancer treatment. Prevalence (1.8%; 4/219) of COVID-19 in patients with cancer was significantly higher compared with a respective control group of asymptomatic counterparts (p=0.018). Outcomes of COVID-19 positive patients were good, with only one observed death due to progression of advanced metastatic disease. CONCLUSION: Our data indicate that continuation of anticancer treatment in epidemic areas during the COVID-19 pandemic seems to be safe and feasible, if adequate and strict preventive measures are vigorously and successfully carried out.

Venous Pooling in Suspension Syndrome Assessed with Ultrasound.

INTRODUCTION: Suspension syndrome describes a potentially life-threatening event during passive suspension on a rope. The pathophysiological mechanism is not fully understood; however, the most widespread hypothesis assumes blood pools in the lower extremities, prompting a reduction in cardiac preload and cardiac output and leading to tissue hypoperfusion, loss of consciousness, and death. The aim of this study was to assess venous pooling by ultrasound in simulated suspension syndrome using human subjects. METHODS: In this trial, 20 healthy volunteers were suspended in a sit harness for a maximum of 60 min with and without preceding exercise. Venous pooling was assessed by measuring the diameter of the superficial femoral vein (SFV) with ultrasound at baseline in supine and standing positions as well as during and after suspension. RESULTS: SFV diameter increased and blood flow became progressively sluggish. In 30% of the tests, near syncope occurred. However, SFV diameter did not differ between subjects with and without near syncope. CONCLUSIONS: Free hanging in a harness leads to rapid venous pooling in the lower limbs. The most important measure to prevent suspension syndrome might be constant movement of the legs.

Suspension syndrome: a potentially fatal vagally mediated circulatory collapse-an experimental randomized crossover trial.

PURPOSE: Suspension syndrome describes a potentially life-threatening event during passive suspension on a rope. The pathophysiological mechanism is not fully understood and optimal treatment unknown. We aimed to elucidate the pathophysiology and to give treatment recommendations. METHODS: In this experimental, randomized crossover trial, 20 healthy volunteers were suspended in a sit harness for a maximum of 60 min, with and without prior climbing. Venous pooling was assessed by measuring the diameter of the superficial femoral vein (SFV), lower leg tissue oxygenation (StO2) and by determining localized bioelectrical impedance. Hemodynamic response was assessed by measuring heart rate, blood pressure, stroke volume, and left ventricular diameters. Signs and symptoms of pre-syncope were recorded. RESULTS: Twelve (30%) out of 40 tests were prematurely terminated due to pre-syncopal symptoms (mean 44.7 min, minimum 13.4, maximum 59.7). SFV diameter increased, StO2 and the capacitive resistance of the cells decreased indicating venous pooling. Heart rate and blood pressure did not change in participants without pre-syncope. In contrast, in participants experiencing pre-syncope, heart rate and blood pressure dropped immediately before the event. All symptoms dissolved and values returned to normal within 5 min with participants in a supine position. CONCLUSIONS: Sudden pre-syncope during passive suspension in a harness was observed in 30% of the tests. Blood pools in the veins of the lower legs; however, a vagal mechanism finally leads to loss of consciousness. Time to pre-syncope is unpredictable and persons suspended on a rope should be rescued and put into a supine position as soon as possible.

Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology.

: The purpose of this update of the European Society of Anaesthesiology (ESA) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence. Well performed randomised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries. This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care. The Guidelines Committee of the ESA formed a task force comprising members of the previous task force, members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies. Electronic databases were searched from July 2010 (end of the literature search of the previous ESA guidelines on pre-operative evaluation) to May 2016 without language restrictions. A total of 34 066 abtracts were screened from which 2536 were included for further analysis. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

Feasibility of abiraterone acetate treatment in patients with metastatic castration-resistant prostate cancer and atrial fibrillation.

BACKGROUND: Abiraterone acetate (AA), a selective inhibitor of the CYP17 enzyme, demonstrated a significant improvement in the treatment of patients with metastatic castration-resistant prostate cancer. The risk of endocrine side effects, mainly an increased adrenal mineralocorticoid production, could limit its use in patients with atrial fibrillation. METHODS: We retrospectively reviewed the clinical records of 85 metastatic castration-resistant prostate cancer patients treated with AA at our institutions and identified six patients suffering from concomitant atrial fibrillation. RESULTS: In these six patients, the median duration of AA treatment was 11.5 months (range 4-22 months) with a biochemical response in three patients. No significant cardiac events were observed during the treatment. CONCLUSION: Our data suggest that AA may be safely administered in patients with atrial fibrillation.

[Emergency medicine at the limit: shock-, analgesic therapy and airway management in difficult terrain]. / Notfallmedizin im alpinen Gelände - Schock-, Schmerztherapie und Atemwegssicherung.

Rescue operations in mountain and remote areas pose special challenges for the rescue team and often differ substantially from rescue missions in the urban environment. Given the growing sports and leisure activities in mountains, incidence of alpine emergencies is expected to rise further. The following article describes the treatment of haemorrhagic shock, analgesic therapy and airway management in mountain rescue.