ABSTRACT
The aim of this study is to establish the feasibility of awake laparotomy under neuraxial anesthesia (NA) in a suburban hospital. A retrospective analysis of the results of a consecutive series of 70 patients undergoing awake abdominal surgery under NA at the Department of Surgery of our Hospital from February 11th, 2020 to October 20th, 2021 was conducted. The series includes 43 cases of urgent surgical care (2020) and 27 cases of elective abdominal surgery on frail patients (2021). Seventeen procedures (24.3%) required sedation to better control patient discomfort. Only in 4/70 (5.7%) cases, conversion to general anesthesia (GA) was necessary. Conversion to GA was not related to American Society of Anesthesiology (ASA) score or operative time. Only one of the four cases requiring conversion to GA was admitted to the Intensive Care Unit (ICU) postoperatively. Fifteen patients (21.4%) required postoperative ICU support. A statistically non-significant association was observed between conversion to GA and postoperative ICU admission. The mortality rate was 8.5% (6 patients). Five out of six deaths occurred while in the ICU. All six were frail patients. None of these deaths was related to a complication of NA. Awake laparotomy under NA has confirmed its feasibility and safety in times of scarcity of resources and therapeutic restrictions, even in the most frail patients. We believe that this approach should be considered as an useful asset, especially for suburban hospitals.
ABSTRACT
INTRODUCTION: This paper describes how mortality among hospitalised COVID-19 patients changed during the first three waves of the epidemic in Italy. METHODS: This prospective cohort study used the Kaplan-Meier method to analyse the time-dependent probability of death of all of the patients admitted to a COVID-19 referral centre in Milan, Italy, during the three consecutive periods of: 21 February-31 July 2020 (first wave, W1), 1 August 2020-31 January 2021 (second wave, W2), and 1 February-30 April 2021 (third wave, W3). Cox models were used to examine the association between death and the period of admission after adjusting for age, biological sex, the time from symptom onset to admission, disease severity upon admission, obesity, and the comorbidity burden. RESULTS: Of the 2,023 COVID-19 patients admitted to our hospital during the study period, 553 (27.3%) were admitted during W1, 838 (41.5%) during W2, and 632 (31.2%) during W3. The crude mortality rate during W1, W2 and W3 was respectively 21.3%, 23.7% and 15.8%. After adjusting for potential confounders, hospitalisation during W2 or W3 was independently associated with a significantly lower risk of death than hospitalisation during W1 (adjusted hazard ratios [AHRs]: 0.75, 95% confidence interval [CI] 0.59-0.95, and 0.58, 95% CI 0.44-0.77). Among the patients aged >75 years, there was no significant difference in the probability of death during the three waves (AHRs during W2 and W3 vs W1: 0.93, 95% CI 0.65-1.33, and 0.88, 95% CI 0.59-1.32), whereas those presenting with critical disease during W2 and W3 were at significantly lower risk of dying than those admitted during W1 (AHRs 0.61, 95% CI 0.43-0.88, and 0.44, 95% CI 0.28-0.70). CONCLUSIONS: Hospitalisation during W2 and W3 was associated with a reduced risk of COVID-19 death in comparison with W1, but there was no difference in survival probability in patients aged >75 years.