Time course of cytokines, hemodynamic and metabolic parameters during hyperthermic intraperitoneal chemotherapy.

INTRODUCTION: Systemic response to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) causes the activation of endocrine, metabolic, hemodynamic and inflammatory processes. The aim of this work is to describe and analyze the time course of the inflammatory markers concentration during CRS+HIPEC in plasma and peritoneal fluids and the association with hemodynamic and metabolic parameters. MATERIAL AND METHODS: Pre-, Intra- and Post-operative data were collected. Tumor necrosis factor (TNF), interleukine 6, procalcitonine (PCT), cancer antigen 125 (CA-125) in blood and in peritoneal fluids were evaluated. RESULTS: Thirty-eight patients included, 29 (76.3%) female. Mean/median PCI: 9.2/5. Primary malignancy: 5 colo-rectal (13.2%), 5 gastric (13.2%), 23 ovarian (60.5%) and 5 others (13.2%). CCR 0-1 reached in all patients. Cardiac Index, Heart rate and Central Venous Pressure, increased during the procedure while Stroke Volume Variation showed a decrease. Mean Arterial Pressure and Superior Vena Cava Oxygenation were stable through the whole procedure. TNF and CA-125 were steady during the whole procedure; IL-6 had a relevant increase from baseline to start of perfusion (p<0.01); PCT had a steady increase at every time point. Peritoneal sampling showed a statistically significant increase (p<0.01) between start and end of the perfusion phase for all markers but TNF. Serum and peritoneal marker concentration were similar for TNF, PCT and CA-125. IL-6 showed a sharp difference. CONCLUSION: The most significant variations are those of IL-6 and PCT. The cytokines level parallel the hemodynamic derangements. Treatment during HIPEC should mimic the established treatment during sepsis and septic shock.

Preoperative evaluation in infants and children: recommendations of the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI).

BACKGROUND: The preoperative assessment involves the process of evaluating the patient's clinical condition, which is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommendation was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing elective surgery or diagnostic/therapeutic procedures. METHODS: We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the electronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed by the Italian Center for Evaluation of the Effectiveness of Health Care's scoring system for assessing the level of evidence and strength of recommendations. RESULTS: We produce a set of consensus guidelines on the preoperative assessment and on the request for preoperative tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus, emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio. CONCLUSION: Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned, and replaced by a selective and rational prescription, based on the patient history and clinical examination performed during the preoperative evaluation.

Duration of mechanical ventilation after craniosynostosis repair reduces over time.

BACKGROUND: Pediatric craniosynostosis repair (CR) involves wide scalp dissections with multiple osteotomies and has been associated with significant morbidity. The aim of this study was to document the impact of perioperative complications on prolonged mechanical ventilation after CR. METHODS: Data were collected from the anesthesia records, Pediatric Intensive Care Unit (PICU) progress notes and discharge summaries. All the patients were transferred from the operating room sedated and on mechanical ventilation to the PICU. To highlight the determinants of prolonged mechanical ventilation we performed a logistic regression analysis.. RESULTS: Fifty-five patients underwent CR, but 6 were excluded due to incomplete records. The main intraoperative complications were: metabolic acidosis (32%), hypotension (20%), dural tears laceration (22%) and altered coagulation (18%). Metabolic acidosis (46%) and relative polycythemia (24%) were detected on arrival to the PICU. All children received intraoperative blood products and 23 (46%) were transfused in the postoperative period too. No infective complications were detected. The only determinant associated significantly with a prolonged mechanical ventilation was to have surgery in the first 5 years of the program (P=0.05) (95% CI 0.358-0.996). CONCLUSION: All life-threatening complications were intraoperative whereas only milder ones, such as hypercloremic and lactic acidosis were noticed in PICU. All children are alive without any neurological deficit. Even though we deal on a daily basis with complex surgical cases, only time, hence experience, showed an impact on prolonged mechanical ventilation.

The impact of perioperative transfusion of blood products on survival after pediatric liver transplantation.

Intraoperative transfusion of red blood cells (RBC) is associated with adverse outcome after LT in adult patients. This relationship in pediatric patients has not been studied in depth, and its analysis is the scope of this study. Forty-one variables associated with outcome, including blood product transfusions, were studied in a cohort of 243 pediatric patients undergoing a cadaveric LT between 2002 and 2009 at the General Hospital of Bergamo. Multivariate stepwise Cox proportional hazards models were adopted with adjustment by propensity scores to minimize factors associated with the use of blood products. Median age at transplant was 1.37 yr. In uni- and multivariate analyses, perioperative transfusion of FFP and RBC was an independent risk factor for predicting one-yr patient and graft survival. The effect on one-yr survival was dose-related with a hazard ratio of 3.15 for three or more units of RBC (p = 0.033) and 3.35 for three or more units of FFP (p = 0.021) when compared with 1 or no units transfused. The negative impact of RBC and FFP transfusion was confirmed by propensity score-adjusted analysis. These findings may have important implications for transfusion practice in the LT pediatric recipients.

A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients.

BACKGROUND: Video-assisted thoracoscopic extended thymectomy (VATET) is well established in the treatment of myasthenia gravis; however, patient selection remains controversial. Perioperative management protocol is lacking, and concerns regarding post-operative myasthenic crisis still remain. We performed a retrospective observational study evaluating the impact of the introduction of a protocol in the perioperative management of patients with myasthenia gravis who underwent VATET. METHODS: The perioperative management protocol was developed by a team of neurologists and anesthesiologists who reviewed the literature and their previous experience on myasthenia gravis patients. Respiratory, clinical, and neurological patient features were included in the protocol evaluation. A retrospective review of patients who underwent VATET before and after introduction to the protocol was finally performed. RESULTS: The medical records of 66 patients (pre-protocol group) and 44 patients (protocol group) were available for the study. In the pre-protocol group, 17 patients (26%) were admitted to intensive care unit (ICU) during the post-operative period, while three patients (6.8%) of the protocol group met the criteria for ICU post-operative admission. This resulted in a reduction of 73.5% of patients admitted to ICU (P = 0.023) and in an 80% (P = 0.002) reduction of the use neuromuscular blocking agents. Two post-operative myasthenic crises preceded by bulbar symptoms (1.8%) were identified in the pre-protocol group patients. CONCLUSIONS: Although the application of our protocol results in a substantial reduction in the recovery of patients in the ICU and in hospital costs, there was no substantial difference in mortality and morbidity between patients admitted to the surgical ward or to ICU.

Intestinal transplantation in children: the first successful Italian series.

The preliminary experience of the first Italian program of pediatric intestinal transplantation is presented herein. A multidisciplinary group with broad experience in pediatric solid organ transplantation started the program. Nine children with complications of chronic intestinal failure were listed for transplantation. One child died on the waiting list; one received an isolated liver transplantation; three isolated intestinal; three multivisceral; and one, a combined liver/intestine transplantation. There was no in-hospital mortality, and all children were weaned from parenteral nutrition. The recipient of the multivisceral graft died after 14 months for unknown causes. All other recipients are alive after a median follow-up of 13 months. Patient and graft actuarial survivals for recipients of intestinal grafts were 100% at 1 year and 75% at 2 years.

The use of desflurane or propofol in combination with remifentanil in myasthenic patients undergoing a video-assisted thoracoscopic-extended thymectomy.

BACKGROUND: Although several studies of the use of desflurane in anesthesia have revealed many desirable qualities, there are no data on the use and effects especially on the neuromuscular function of desflurane on myasthenia gravis (MG) patients. The purpose of this study was to evaluate the use of either desflurane or propofol, both combined with remifentanil, in patients with MG undergoing a video-assisted thoracoscopic-extended thymectomy (VATET). METHODS: Thirty-six MG patients who underwent VATET were enrolled. Nineteen patients were anesthetized with remifentanil and propofol infused with a target-controlled infusion plasma model, and 17 patients with desflurane and remifentanil. No muscle relaxant was used. The intubating conditions, hemodynamic and respiratory changes, neuromuscular transmission and post-operative complications were evaluated. RESULTS: Neuromuscular transmission was significantly decreased in the desflurane group (6.7%, from 3% to 9% during anesthesia P=or<0.05). The intubating conditions were good in all 36 patients and 35 patients were successfully extubated in the operating room. The time-to-awakening, post-operatory pH and base excess were significantly different in the two groups, with a decreasing mean arterial pressure in the group administered with desflurane. No patients required reintubation due to myasthenic or cholinergic crisis, or respiratory failure. No other significant differences between the two groups studied were observed. CONCLUSION: Our experience indicates that anesthesia with desflurane plus remifentanil in patients with MG could determine a reversible muscle relaxation effect, but with no clinical implication, allowing a faster recovery with no difference in extubation time and post-operative complications in the two groups.

Analgesic effectiveness of caudal levobupivacaine and ketamine.

BACKGROUND: Ketamine is used increasingly in paediatric anaesthetic practice to prolong the action of a caudal block. This study was designed to determine if adding S(+)-ketamine 0.5 mg kg(-1) allows a lower concentration of levobupivacaine to be used for caudal anaesthesia without loss of clinical effectiveness. METHODS: One hundred and sixty-four children (ASA I or II) aged 3 months-6 yr were randomly allocated to receive 1 ml kg(-1) of levobupivacaine 0.15% with 0.5 mg kg(-1) S(+)-ketamine (Group 1), levobupivacaine 0.175% with 0.5 mg kg(-1) S(+)-ketamine (Group 2), or levobupivacaine 0.2% (Group 3) by the caudal route. Pain, motor block, sedation, and requirement for postoperative analgesia were assessed up to 6 h after operation. RESULTS: There was no significant difference between the groups in effectiveness at first surgical incision. Significantly lower analgesic requirements were reported in Group 2 compared with Group 3 at wakeup, 180 and 360 min after operation. Time to first rescue analgesia was longer in Group 2 compared with Group 1 or 3. Kaplan-Meier survival analysis of analgesia free time demonstrated a significant advantage of Group 2 over Groups 1 and 3 (log rank P=0.05). The incidence of postoperative motor block was not significantly different between the groups. No excess sedation or dysphoric reactions were observed in the ketamine groups. CONCLUSIONS: The addition of 0.5 mg kg(-1) S(+)-ketamine to levobupivacaine 0.175% for caudal analgesia for lower abdominal and urological surgery is significantly more effective in providing postoperative analgesia than levobupivacaine 0.15% with 0.5 mg kg(-1) S(+)-ketamine or levobupivacaine 0.2%.

Combined double lung-liver transplantation for cystic fibrosis without cardio-pulmonary by-pass.

Sequential bilateral single lung-liver transplantation (SBSL-LTx) is a therapeutic option for patients with end stage lung and liver disease (ESLLD) due to cystic fibrosis (CF). A few cases have been reported, all of them were performed with the use of cardio-pulmonary by-pass (CPB). We performed SBSL-LTx in three young men affected by CF. All the recipients had respiratory failure and portal hypertension with hypersplenism. Along with lung transplants, two patients received a whole liver graft and one an extended right graft from an in situ split liver. During transplantation neither CPB nor veno-venous by-pass (VVB) were employed. Immunosuppression was based on basiliximab, tacrolimus, steroids and azathioprine. The three recipients are alive with a median follow-up of 670 days (range 244-1,533). Combined SBSL-LTx is a complex but effective procedure for the treatment of ESLLD due to CF, not necessarily requiring the use of CPB or VVB.

Transplantation for acute liver failure in children.

We reviewed the clinical data of 30 children-hospitalized for acute liver failure in the last 6 years. Ten patients were not listed for liver transplantation OLTX. Their clinical conditions gradually improved and they are all alive without deficit. Among 20 patients listed, 15 underwent urgent OLTX. Two children died on the waiting list and three were suspended from waiting list after few days because of improvement. Survival according to age class was analyzed dividing the patients into two groups: A, age 1 year or less versus B, age between 1 and 16 years. The patient survival was 86% at 6 months and 61% both at 1 and 2 years. Survival at 6 months and 1 and 2 years was 88%, 67%, and 45% for the patients in group A and 83%, 83%, and 83% for the patients in group B (P = NS). Observing graft-to-recipient weight ratio and donor-to-recipient weight ratio most patients received an optimal sized graft. The split-liver technique is considered the preferred method of liver transplantation even in the pediatric patients with acute liver failure; especially in the setting of a cooperative system in which all livers that are suitable for split-liver transplantation are shared between centers. In order to have the best chance for survival, children with acute liver failure should be referred as soon as possible to an highly specialized pediatric liver transplantation center that can offer all the treatment modalities that are currently available.

Randomized, double-blind, phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25% by the caudal route in children.

BACKGROUND: The rationale for replacing racemic bupivacaine with the s-enantiomers levobupivacaine and ropivacaine is to provide a wider margin of safety with the same analgesic efficacy and less postoperative motor block. In a randomized, double-blind, phase III, controlled trial we compared the caudal administration of levobupivacaine 0.25% and ropivacaine 0.25% with bupivacaine 0.25% in children. METHODS: Ninety-nine ASA I-II children less than 10 yr old scheduled for elective sub-umbilical surgery were randomized to receive caudal block with bupivacaine 0.25%, ropivacaine 0.25% or levobupivacaine 0.25%. The primary outcome of the study was the clinical efficacy of the caudal block during the operation. Secondary outcome measures were analgesic onset time, pain relief after the operation and residual motor blockade. RESULTS: The proportion of children with effective analgesia during the operation was similar among groups. There were no significant differences in the analgesic onset time of the caudal block. Bupivacaine produced a significant incidence of residual motor block compared with levobupivacaine or ropivacaine at wake-up (P<0.01). There were no significant differences in the number of patients receiving rescue analgesia after surgery. However, analgesic block lasted significantly longer in patients receiving bupivacaine (P=0.03). CONCLUSION: During sub-umbilical surgery, caudal levobupivacaine, ropivacaine and bupivacaine provided comparable analgesic efficacy. Bupivacaine produced a higher incidence of residual motor blockade and a longer analgesic block than ropivacaine and levobupivacaine.

Erythropoietin therapy and preoperative autologous blood donation in children undergoing open heart surgery.

We assessed the feasibility and efficacy of subcutaneous erythropoietin alpha (EPO) therapy and preoperative autologous blood donation (ABD) in children undergoing open heart surgery. Thirty-nine children were treated consecutively with EPO (100 U x kg(-1) s.c. three times a week in the 3 weeks preceding the operation and i.v. on the day of surgery) and two ABDs were made (Group 1). As controls to compare transfusion requirements, 39 consecutive age-matched patients who had undergone open heart surgery during the two preceding years were selected (Group 2). In a mean time of 20 (SD 5) days, 96% of scheduled ABDs were performed and only three mild vasovagal reactions were observed. The mean volume of autologous red blood cells (RBC) collected was 6 (1) ml x kg(-1) and the mean volume of autologous RBC produced as a result of EPO therapy before surgery was 7 (3) ml x kg(-1), corresponding to a 28 (11)% increase in circulating RBC volume. The mean volume of autologous RBC collected was not different from that produced [6 (1) vs 7 (3) ml x kg(-1), P=0.4]. Allogenic blood was administered to three out of 39 children in Group 1 (7.7%) and to 24 out of 39 (61.5%) in Group 2. Treatment with subcutaneous EPO increases the amount of autologous blood that can be collected and minimizes allogenic blood exposure in children undergoing open heart surgery.

[Traumatic rupture of the aortic isthmus. Our experience with 23 cases]. / Rottura traumatica dell'istmo aortico. Nostra esperienza in 23 casi.

BACKGROUND: Traumatic rupture of the aortic isthmus is a highly lethal lesion. Controversy currently exists regarding the best management of the lower body circulation system during repair of an acute aortic transsection. The aim of this study was to evaluate our results using different methods of distal aorta perfusion in order to prevent ischemia of the spinal cord. METHODS: Between October 1987 and October 1999, 23 patients (20 males, 3 females, mean age 28 years) with rupture of the thoracic aorta underwent surgical repair; 18 of these were acute ruptures and 5 post-traumatic pseudoaneurysms. RESULTS: All cases of rupture were associated with violent, sudden deceleration and in all but one subject it was due to a traffic accident. Twenty patients had severe associated lesions involving the cranium, abdomen, thorax or leg fractures. The operation was performed with a left postero-lateral thoracotomy in all but one case which underwent sternotomy (the patient with an associated lesion of the distal part of the arch). In 1 patient repair was accomplished using simple aortic cross-clamping, in another with total cardiopulmonary bypass, deep hypothermia and cardiac arrest and in 4 cases with partial cardiopulmonary bypass (1 left atrium-femoral artery and 3 femoro-femoral bypass). Seventeen patients were treated using the centrifugal pump (Bio-Medicus) for left atrium-femoral artery bypass. The perioperative mortality was 8.6%, including 2 patients operated in cardiogenic shock. In the 21 surviving patients the postoperative period was free from any cardiovascular complications, with no cases of paraplegia. There were no late deaths (mean follow-up 4 years) and all patients are in good clinical conditions. CONCLUSIONS: These results indicate that the outcome mainly depends on preoperative clinical conditions, associated lesions and the timing of the operation. We conclude that the Bio-Medicus centrifugal pump is a simple and safe means of perfusing the lower body, kidney, and spinal cord without heparinization in a patient with multiple injuries.

[The effect of antithrombin iii concentrations during cardiopulmonary surgery]. / Impiego dei concentrati di antitrombina III nella chirurgia coronarica.

BACKGROUND: Evaluation of influence of pre-op continuous e.v. heparin infusion in patients undergoing urgent myocardial surgical revascularization, on the anticoagulation threshold needed for cardiopulmonary bypass. Analysis of the efficacy of ATIII substitutional therapy to allow best ACT values during extracorporeal circulation, and to reduce intra and post-op bleeding and need for homologus transfusion. SETTING: Operative room and ICU of a cardiac surgery unit in a regional hospital. METHODS: Two groups of coronary patients in preoperative treatment with heparin were randomized in a prospective double blind study for an intraoperative treatment with heparin and ATIII (Group A) and heparin plus placebo (Group B). An investigation was made on the influence of preoperative heparin treatment regarding extracorporeal circulation, the variation of the coagulation parameters in CEC with substitutive therapy of ATIII and the reduction of the therapeutic strength of heparin during perfusion, the problem of bleeding and the incidence of blood transfusions and lastly the economic questions of the two procedures. RESULTS: The study showed the necessity of repeated bolus of heparin during CEC and the rapid loss of its effect in the group not subjected ATIII therapy. A less incidence of bleeding in Group A was observed; for this reason the patients received significantly less packed red cells and FFP and a discrete number of patients of this group were not transfused. Surely the method of using the ATIII is much more expensive from the economic point of view, but the benefits of avoiding the problems of a blood transfusion (infections, immunodepression etc.), of the reduced stay in the Intensive Care Unit, of the riduced risk involved with problems of bleeding and the need of repeated operative procedures make this method fundamental in patients with reduced plasma levels of ATIII such as coronary patients who are under heparin treatment for several days. CONCLUSIONS: Intraoperative administration of ATIII can reduce most problems due to heparinization of the extracorporeal circuit, such as onset of fibrinolysis, CID and platelets depletion or inactivation causing intra and post-op massive bleeding.

[Plasmapheresis and intraoperative hemodilution. Comparison of 2 methods]. / Plasmaferesi ed emodiluizione intraoperatoria. Due metodiche a confronto.

Fifty patients undergoing cardiac surgery suffering from coronary artery disease and valvular incompetence or stenosis, were randomly divided into two groups of 25 patients to compare the plasmapheresis effects on bleeding, transfusion requirements, economicity and paramedical staff compliance versus intraoperative autotransfusion. Standardized anesthetics, perfusion, and surgical techniques were used. We used plasmapheresis with cell saver and haemodilution with bypass ultrafiltration. Platelet counts, haemoglobin concentration, haematocrit, fibrinogen, bleeding times were evaluated at fixed times for the patients on plasmapheresis and after surgical homologous transfusion. It was that these parameters did not change significantly in the two groups. Intraoperative plasmapheresis is more expensive and less accepted into an operating room than autotransfusion. Intraoperative plasmapheresis will be a good alternative to haemodilution for selected patients.

[Rationale for anesthesia in non-cardiac surgery on patients with heart transplant]. / Il rationale dell'anestesia per interventi non cardiochirurgici nei pazienti cardiotrapiantati.

The introduction of cyclosporine in the prevention of rejection, together with the improvement of surgical and anaesthetic techniques, produced a tangible increase in long term survival time and the life quality of heart-transplanted patients, so that, they have to undergo non-cardiac surgical operation, more and more frequently. The aim of this report is to analyse the essential physio-pathological, clinical, haemodynamic and pharmacological knowledge in order to perform a safe anaesthesia on the above mentioned patients. The Authors are basing this report on experience obtained in deep study of their own cases. In fact they have anaesthetized 190 patients during heart transplantation; later on, 27 of these patients have undergone subsequent major or minor non-cardiac surgical operations.

[Transfusional needs and blood saving strategies during orthotopic heart transplantation]. / Necessità trasfusionali e strategie di risparmio di sangue durante trapianto cardiaco ortotopico.

It is difficult to evaluate transfusional needs during cardiac surgery. One hundred fifty patients undergoing orthotopic cardiac transplantation were divided into two groups (A and B) according to the blood saving strategies. (Group A: no important saving strategies; group B: all blood saving techniques utilized). A low blood, plasma and platelet consumption was observed, with good clinical results, in group B. During orthotopic cardiac transplantation, it would be suitable to use all the saving transfusional blood strategies and a correct use of hemocomponents as during all cardiac surgery.