Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper.

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann's procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

Knowledge, attitude, barriers, professional behaviour and possible interventions: a survey on healthcare-associated infections among the healthcare workers of an intensive care unit in a large teaching hospital in Rome.

Methods: A questionnaire of 36 questions was developed and administered to assess socio-occupational characteristics, knowledge of Healthcare-associated infections, attitudes and barriers encountered in compliance with hygiene standards, self-analysis of professional behaviour, and proposals for new interventions. Variables were evaluated by univariate analysis, and multivariable logistic regression models were constructed to identify predictors of adequate knowledge, positive attitude and appropriate professional behaviour. Background: Healthcare-associated infections are the main complications of hospitalization. A bottom-up approach, where the Healthcare workers involved play a key role, can be adopted to limit the Healthcare-associated infections burden. To this end, a survey was conducted in the main intensive care unit of Umberto I Teaching Hospital of Rome, where an active surveillance system has been in place since April 2016. Results: Overall, 79/89 Healthcare workers completed the questionnaire. Multivariate analysis showed that Healthcare workers, who participated in ward meetings to share active surveillance reports, were more likely to have adequate knowledge (aOR=4.21, 95% CI: 1.36-13.07). Only job type seemed to be a predictor of adequate behaviour, since nurses and physicians were more likely to show adequate behaviour than residents in training (aOR=0.21, 95% CI: 0.06-0.74). Direct observation of compliance with standard hygiene precautions and the identification of 'local champions' to manage Healthcare-associated infections' issues were the most requested interventions. Conclusions: Our study suggests that the training of healthcare professionals is a key factor in preventing and containing the spreading of Healthcare-associated infections. Moreover, by encouraging greater Healthcare workers' involvement, we conclude that a bottom-up approach is likely to improve Healthcare-associated infections' prevention and management.

Multimodal surveillance of healthcare associated infections in an intensive care unit of a large teaching hospital

BACKGROUND: Healthcare-associated infections (HAIs), or nosocomial infections, represent a significant burden in terms of mortality, morbidity, length of stay and costs for patients hospitalized in intensive care units (ICUs). Surveillance systems are recommended by national and international institutions to gather data on HAIs in order to develop and evaluate interventions that reduce the risk of HAIs. STUDY DESIGN: Here we describe the methodology and the results of the surveillance system implemented in the ICU of the Policlinico Umberto I, a large teaching hospital in Rome, from April 2016 to October 2018. METHODS: The multimodal infection surveillance system integrates four different approaches: i) active surveillance of inpatients; ii) environmental microbiological surveillance; iii) surveillance of isolated microorganisms; and iv) behavioral surveillance of healthcare personnel. Data were collected on catheter-related bloodstream infections, ventilation-associated pneumonia, catheter-associated urinary tract infections and primary bloodstream infections that developed in patients after 48 h in the ICU. For environmental surveillance 14 points were selected for sampling (i.e. bed edges, medication carts, PC keyboards, sink faucets). The system of active surveillance of HAIs also included surveillance of microorganisms, consisting of the molecular genotyping of bacterial isolates by pulsed-field gel electrophoresis (PFGE). From 1 November 2016, monitoring of compliance with guidelines for hand hygiene (HH) and proper glove or gown use by healthcare personnel was included in the surveillance system. After the first six months (baseline phase), a multimodal intervention to improve adherence to guidelines by healthcare personnel was conducted with the ICU staff. RESULTS: Overall, 773 patients were included in the active surveillance. The overall incidence rate of device-related HAIs was 14.1 (95% CI: 12.2-16.3) per 1000 patient-days. The monthly device-related HAI incident rate showed a decreasing trend over time, with peaks of incidence becoming progressively lower. The most common bacterial isolates were Klebsiella pneumoniae (20.7%), Acinetobacter baumannii (17.2%), Pseudomonas aeruginosa (13.4%) and Staphylococcus aureus (5.4%). Acinetobacter baumannii and Klebsiella pneumoniae showed the highest proportion of isolates with a multidrug-resistant profile. A total of 819 environmental samples were collected, from which 305 bacterial isolates were retrieved. The most frequent bacterial isolates were Acinetobacter baumannii (27.2%), Staphylococcus aureus (12.1%), Enterococcus faecalis (11.1%), Klebsiella pneumoniae (5.2%) and Pseudomonas aeruginosa (4.7%). All Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae environmental isolates were at least multidrug-resistant. Genotyping showed a limited number of major PFGE patterns for both clinical and environmental isolates of Klebsiella pneumoniae and Acinetobacter baumannii. Behavioral compliance rates significantly improved from baseline to post-intervention phase. CONCLUSIONS: By integrating information gathered from active surveillance, environmental microbiological surveillance, surveillance of bacterial isolates and behavioral surveillance of healthcare personnel, the multimodal infection surveillance system returned a precise and detailed view of the infectious risk and microbial ecology of the ICU.

Inguinal hernia repair in day surgery: the role of MAC (Monitored Anesthesia Care) with remifentanil.

BACKGROUND: The extension of indications for procedures in a Day Surgery (DS) setting has led to changes in the anesthetic and surgical treatment of Inguinal Hernias (IH). According to the recommendations of the European Hernia Society, the treatment of IH in DS units should be performed under Monitored Anesthesia Care (MAC). PATIENTS AND METHODS: 960 patients underwent IH repairs over a period of 24 months. The patients were randomly divided into two groups: R (remifentanil) and F (fentanyl); the group F was considered as a control group. The exclusion criteria in both group were: morbid obesity (BMI>40 or BMI>35 in association with high blood pressure or diabetes); coagulopathy; OSAS (obstructive sleep apnea syndrome) with AHI >10; cardiovascular, respiratory, renal, hepatic or metabolic disease; history of substances abuse; GERD-related esophagitis (gastro-esophageal reflux disease); chronic analgesic use; allergy to local anesthetic and ASA>III. Patients reported their level of pain on a verbal numeric scale (VNS), with scores ranging from 0 to 10. For each patient systolic and diastolic blood pressure (SBP and DBP), mean arterial pressure (MAP), heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded. The results are presented as the mean value ± standard deviations; statistical analysis was performed using Student's t-test. RESULTS: Amongst the 960 procedures, complications or side effects related to the anesthetic techniques didn't occur; no procedure-related complications requiring mechanical ventilation support were reported. Our research focused on evaluating remifentanil effectiveness in pain control and its impact on hemodynamic stability and respiratory function. There was a significant difference between the two groups with regard to the VNS. CONCLUSIONS: Remifentanil, is an excellent drug for pain control during intra-operative procedures, that allows an optimal hemodynamic stability for IH repairs in a DS setting, due to its pharmacokinetic and pharmacodynamic properties and few adverse effects.

Clinical problems in patient with Ehlers-Danlos syndrome and Multiple Chemical Sensitivity undergoing total thyroidectomy.

Clinical practice sometimes brings to face with situations quite peculiar, potentially dangerous for the patient's life. In the great majority of cases, pathologies associated with each other (cardiovascular, respiratory, neurological), while in other cases we can treat rare diseases or syndromes. It's considered exceptional the simultaneous presence of "rare" pathologies in a single patient. This exceptionality has been a push to treat a patient as a "unique" asking for help to deeper studies of pharmacogenetics. Our case reports the management of a patient with Ehlers-Danlos syndrome (EDS) and Multiple Chemical Sensitivity (MCS), undergoing a total thyroidectomy. We found several problems, and we tried to find effective solutions for the management of the patient during the whole peri-operative process, from a clinical, pharmacological and also from a surgical point of view.

Exploring the Role of Caregivers in Day Surgery for Patients Undergoing Plastic and Reconstructive Surgery: A Comprehensive Patient and Caregiver Survey Approach.

This study investigates the interplay between plastic and reconstructive surgery patients and their respective caregivers in the Day Surgery Unit of Policlinico Umberto I, Rome, Italy. Utilizing a dual survey approach, we explored the role in patient safety and the challenges faced by caregivers during the perioperative period. This study, conducted at Policlinico Umberto I, covers all surgical procedures from October to December 2023, encompassing skin cancer removal, fat grafting, scar revisions, hand surgeries, and eyelid surgeries. Patient demographics reflect varying age distributions: 18-39 (4.9%), 40-59 (31.7%), 60-75 (34.1%), and over 76 years (29.3%).

Effect of L-carnitine on oxidative stress and platelet activation after major surgery.

BACKGROUND: The surgical/anesthesia trauma is associated with an increased production of reactive oxygen species (ROS). This enhanced oxidative stress leads to cell damage resulting in various complications such as sepsis, myocardial injury and increased mortality. The aim of this study was to investigate the role of antioxidant treatment with l-carnitine in oxidative stress and platelet activation in patients undergoing major abdominal surgery. METHODS: Forty patients scheduled for abdominal surgery were randomly allocated to l-carnitine, administered with a rapid infusion (0.05 g/kg) diluted in 250 ml of saline solution, vs. placebo treatment just before the surgical intervention. At baseline and after treatment, oxidative stress was evaluated by detection of circulating levels of soluble NOX2-derived peptide (sNOX2-dp), a marker of NADPH oxidase activation, and by analyzing platelet ROS formation. Platelet activation was studied by dosing sCD40L. RESULTS: We observed an increase of soluble sNOX2-dp, sCD40L and ROS production in the placebo group compared with the baseline after the surgical intervention. Conversely, in the l-carnitine-treated group, sNOX2-dp, sCD40L and ROS production did not significantly differ from the baseline. A linear correlation analysis showed that Δ of ROS correlated with Δ of sNOX2 (R(s) =0.817; P<0.001) and Δ of sCD40L (R(s) =0.780; P<0.001). Multiple linear regression analysis showed that the only independent predictive variable associated with Δ of ROS was Δ of serum NOX2 levels (SE=0.05; standardized coefficient ß=1.075; P<0.001). CONCLUSION: Our findings suggest that l-carnitine could be helpful in modulating oxidative stress and platelet activation during major abdominal surgery-dependent oxidative damage.

Chemoradiation for anal squamous cell carcinoma: case report.

INTRODUCTION: Anal squamous cell carcinoma is rare and seems to be associated with chronic inflammatory conditions, infections and immunosuppression. Their incidence has been arising since the last 25 years. Compared to adenocarcinoma of the rectum and squamous cell cancer of the anal canal, squamous cell carcinoma is a distinct entity with a different etiology, pathogenesis, prognosis and requires a different therapeutic approach. Even if surgery remains the main therapeutic option, recent advances have made chemoradiation a valuable therapeutic addition. This case discuss the efficacy of chemoradiation wich can prevent complications and can improve the quality of life. CASE REPORT: A 63-year-old woman presented with history of bloody stool for the last past month. The colonoscopy showed a 2 cm circular lesion on the posterior wall of the anal canal. Biopsy was positive for squamous cell carcinoma and afterwards the patient underwent chemoradiation. At 1 year of follow-up the patient is disease free, with a good sphincter control and had no late complications. CONCLUSION: Since the first studies in 1974, chemoradiation seems to be a good option for most patients with squamous cell carcinoma avoiding surgery.

Awake fiberoptic intubation in patients with stenosis of the upper airways: Utility of the laryngeal nerve block.

Awake fiberoptic intubation (AFOI) is mandatory to manage difficult airways. Superior laryngeal nerve block (SLNB) could reduce risks and improve patient comfort. The aim of this study is to assess the procedural comfort of SLNB during AFOI in a population of patients undergoing upper airway oncological surgery. Forty patients were randomized into two groups and were treated with continuous infusion of remifentanil, topic anesthesia and intercricoid block. In the study group (=20), SLNB was performed with lidocaine (L-SLNB); in the control group (n=20) SLNB was performed using saline (S-SLNB). AFOI was more comfortable in the L-SLNB group compared to S-SLNB patients [FOICS ≤ 1 in 18 patients (90%) L-SLNB; 2 (10%) S-SLNB (P <0.001)]. Intubation was faster in L-SLNB (47.45 ±15.38 sec) than S-SLNB (80.15 ±37.91 sec) (p <0.001). The SLNB procedure during AFOI is a safe and comfortable procedure in a population of patients undergoing upper airways surgery. Time to intubation was shorter in L-SLNB than in S-SLNB.

Perioperative management in patients undergoing pancreatic surgery: the anesthesiologist's point of view.

BACKGROUND: A high rate of mortality and morbidity has been associated with pancreaticoduodenectomy; the 5-year survival rate is 15% to 25% compared with 1% to 5% among those who did not have any cancer-directed treatment. Systemic rather than surgical complications cause the majority of perioperative deaths, so the anesthesiologist has a crucial role in the management of these patients. This work sought to evaluate an improved approach to perioperative pain management, postsurgical complications as well as outcomes. PATIENTS: From 2002 to 2007, 40 patients underwent pancreaticoduodenectomy for pancreatic or periampullary cancer. The anesthesia protocol was standardized for postoperative pain control. Patients were randomly divided into two groups: 16 patients received an epidural analgesia with local anesthetics combined with opioids (T(9)-T(10); group A) and 24 had IV analgesia with morphine (group B). RESULTS: Postoperative mortality was 2.5%. With regard to complications we observed 4 biliary fistulas, 2 pancreatic fistulas with spontaneous healing in one patient and death in the other as well as wound infections. Patients treated with epidural analgesia experienced better pain relief, compared with subjects receiving IV analgesia, which demonstrated a higher incidence of opioid-related adverse effects such as sedation and respiratory depression. CONCLUSION: Adequate perioperative treatment included suitable nutritional support and pain management using loco-regional techniques, which seem to improve the surgical outcomes among pancreatic cancer patients.

Serum neopterin and soluble interleukin-2 receptor for prediction of a shock state in gram-negative sepsis.

PURPOSE: This study aimed to investigate the predictive value of neopterin and soluble interleukin-2 (IL-2) receptor for shock occurrence in gram-negative sepsis. METHODS: We examined 57 patients admitted to an intensive care unit with gram-negative sepsis diagnosed according to preestablished criteria. Blood samples were collected every 24 hours and neopterin and soluble IL-2 receptor were measured by using commercially available test kits. To judge the predictive significance of these analyses the Cox proportional hazards regression model was used. RESULTS: Both neopterin (P < .05) and soluble IL-2 receptor (P < .01) were identified as significant predictors of a shock state, but the prognostic strength of neopterin exceeded that of soluble IL-2 receptor. To further assess if other factors could interfere with the predictive significance of both compounds, we also investigated other clinical and laboratory variables but these candidate predictors did not contribute any additional significant predictive information. CONCLUSION: The measurement of serum neopterin and soluble IL-2 receptor concentrations has predictability for identifying patients with gram-negative sepsis at risk for progression toward the syndrome of septic shock.

Variation of acid-base balance, glycemia, electrolytes and ETCO2 after fast i.v. infusion of 5% fructose and/or glucose.

Intraoperative fluid infusion has precise goals and the rapid infusion of some solutions can induce important modifications of homeostatic parameters, which must be known. Rapid infusion of fructose and glucose 5% solutions has been carried out and modifications of acid-base balance, glycemia, serum electrolytes, ETCO2 have been registered. The administration of fructose 5% determines a mixed acidosis while the administration of glucose does not cause this phenomenon; the administration of both carbohydrates reduces serum chloride and sodium, while serum potassium rises only after fructose infusion and glycemia only after glucose infusion. All the variations described reach significant levels.

The use of di-hydroxypropylphenol (propophol) in endoscopic procedures.

The authors illustrate different endoscopic procedures that may require anaesthesiological assistance through analgo-sedation procedures. Analgo-sedation is useful to the patient and to the endoscopist that can carry out the exam more rapidly and in optimal conditions. The technique employed consists in the administration of propophol, starting with an initial bolus of the drug followed by a continuous perfusion to maintain the hypnotic state. Monitoring of cardiovascular and respiratory parameters shows a great reliability of the drug and effectiveness of the method.

Laparoscopic surgery complications: pneumothorax and pneumomediastinum. Description of two cases.

After having illustrated the surgical "advantages" of laparoscopic procedures, the authors discuss the negative aspects of this technique on the anaesthesiological management of the patient. Two cases of pneumothorax during Nissen fundoplicatio are illustrated and the deranged parameters, that allow a precocious diagnosis, are extensively analyzed.

Analgesia and sedation with propofol-NSAIDs for day-hospital extracorporeal shock wave lithotripsy (ESWL).

After a brief history of extracoporeal therapies for calculosis, with particular attention devoluted to renal calculosis and to the instruments that consent these therapeutic alternatives, the authors report the results obtained with a technique of analgesia and sedation. The drugs employed are two NSAIDs, keto-prophene and ketorolac tromethamine associated with propofol. The main advantages consist in the limited cardiovascular and respiratory depression, typical of the first minutes of administration of propofol and the rapid return of a complete functional autonomy in relative brief time intervals, with possibility of dismissing the patient after 4 hours from che end of treatment.

Transcutaneous ethanol injection in hepatocarcinoma: problems in analgesia and sedation.

Therapeutic ethanol injection into primitive or secondary hepatic tumours if performed in "one shot" causes a great deal of pain. For this reason an analgesic/sedation protocol was devised. This relies on the administration of ketorolac-propofol-nitrogen oxide mixture that has been used to treat patients with neoplastic hepatic diseases. A 20 patient series is described. Analgesic protocol was very effective and the only drawbacks were a residual sleepiness than in part is probably dependent on ethanol emigration into the bloodstream and consequently to the central nervous system depression.

[Laparoscopic cholecystectomy: evaluation of intraoperative complications with respect to 2 different kinds of anesthesia]. / Colecistectomia laparoscopica: stima di alcune complicanze perioperatorie in rapporto a due differenti metodiche di anestesia.

Two anaesthetic managements for elective laparoscopic cholecystectomy were compared in 64 patients in order to investigate some perioperative complications: 1) bowel distension during surgery. 2) recovery from anaesthesia. 3) post-surgery incidence of emesis and pain. In addition, the quality of postoperative peristalsis as well as the time of dimissal were recorded. Group I (n = 30) was treated with NLA in N2O-O2 and Group II (n = 34) received propofol plus fentanyl in air-O2. Bowel distension, evaluated by surgeon at 15 min intervals throughout the operation was similar in both the groups as well as postoperative peristalsis recuperation. During the first 12 hours after laparoscopy no differences were found at any times of observation in the incidence or severity of emesis and pain between the two different anaesthesia patients. In subjects which were given propofol the psychomotor recovery was more rapid than after NLA, particularly during the first 6 hours after surgery. The patients were discharged between 36-48 hours following the operation independently from anaesthetic management. It is concluded that both the anaesthetic techniques provide similar intra/postoperative conditions, except the early recovery that is more rapid for the propofol patients. The overall frequency of emesis and pain was rather high in both the groups, suggesting a routine medication with analgesics and antiemetics.

Lymphocyte apoptosis, caspase activation and inflammatory response in septic shock.

BACKGROUND: We examined lymphocyte apoptosis, activity of caspases-1, -3, -8 and -9 and the relationship between those two events and inflammation response in septic shock. MATERIALS AND METHODS: Blood samples were obtained within 24 h after diagnosis of septic shock from 16 patients to measure apoptosis, caspases-3, -8, -9 expression, changes in mitochondrial transmembrane potential and expression of Fas/FasL system of peripheral blood mononuclear cells (PBMCs). Moreover, serum levels of caspase-1 and blood concentrations of IL-6, IL-12, IL-15 and IL-18 were assessed. RESULTS: PBMCs from patients with septic shock compared to control individuals exhibited a greatly increased frequency of apoptosis (39.10 +/- 7.33% vs 4.19 +/- 1.13%; p < 0.001), an over expression of caspases-3, -8, and -9 (p < 0.01, p < 0.05, p < 0.001 for caspases-3, -8 and -9, respectively) as well as of Fas/FasL system (p < 0.05) and significant changes in mitochondrial transmembrane potential. Blood levels of caspase-1 (101.5 +/- 18.2 pg/ml vs 9.09 +/- 2.7 pg/ml, p < 0.001) and of IL-6, IL-12, IL-15 and IL-18 were significantly higher in septic patients vs control (p < 0.0001, p < 0.05, p < 0.05 and p < 0.0001, respectively). Furthermore, a correlation linking IL-6 blood level with both the apoptotic rate (r(2) = 0.75; p = 0.001) and caspase-9 expression (r(2) = 0.92; p = 0.0001) of PBMCs was observed.

Subarachnoid sufentanil as sole agent vs standard spinal bupivacaine in transurethral resection of the bladder.

AIM: The aim of the study was to determine whether intrathecal sufentanil alone provides an adequate analgesia for patients undergoing transurethral resection of the bladder (TURB) and to compare it to standard spinal bupivacaine anesthesia in terms of motor and sensory blockade, discharge time and side effects. METHODS: Sixty-two patients were blindly and randomly assigned to receive either intrathecal bupivacaine (10 mg of 0.5% hyperbaric bupivacaine) or intrathecal sufentanil (15 microg). Motor and sensory blockade was evaluated using a modified Bromage scale as well as cold and pinprick tests. Severity of pain was assessed by means of a 10-point verbal analog scale. RESULTS: We found that the mean duration of sensory blockade was similar for both sufentanil and bupivacaine patients but the quality of analgesia induced by sufentanil alone was poor as compared with spinal bupivacaine anesthesia. CONCLUSION: The subarachnoid administration of sufentanil 15 mg seems to be inadequate for TURB surgery. In addition, the advantage of a faster recovery we observed in sufentanil patients is minimized by the occurrence of a troublesome symptom such as pruritus. On the other hand, spinal bupivacaine produces an undesirable motor blockade exceeding, in our opinion, the requirement for TURB procedure.