Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review.

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Noninvasive high-frequency percussive ventilation in the prone position after lung transplantation.

Noninvasive positive-pressure ventilation (NIV), which represents a consolidated treatment of both acute and chronic respiratory failure, is increasingly being used to maintain spontaneous ventilation in lung transplant patients with impending pulmonary complications. Adding a noninvasive inspiratory support plus positive end-expiratory pressure (PEEP) has proven to be useful in preventing endotracheal mechanical ventilation, airway injury, and infections. Lung recipients with closure of the small airways in the dependent regions may also benefit from the prone position, which is helpful to promote recruitment of nonaerated alveoli and faster healing of consolidated atelectatic areas. In patients with localized or diffuse lung infiltrates, high-frequency percussive ventilation (HFPV), by either an invasive airway or a facial mask, has been adopted as an alternative ventilatory mode to enhance airway opening, limit potential respirator-associated lung injury, and improve mucus clearance. In nonintubated lung recipients at risk for volubarotrauma with conventional mechanical ventilation, it allows oxygen diffusion into the distal airways at lower mean airway pressures while avoiding repetitive cyclical opening and closing of the terminal airways. We summarize the clinical course of 3 patients with post-lung transplantation respiratory complications who were noninvasively ventilated with HFPV in the prone position. Major advantages of this treatment included gradual improvement of spontaneous clearance of bronchial secretions, significant attenuation of graft infiltrates and consolidations, a reduction in the number of bronchoscopies required, a decrease in spontaneous respiratory rate and work of breathing, and a significant improvement in gas exchange. The patients found HFPV with either standard facial mask or total mask interface to be comfortable or only mildly uncomfortable, and after the sessions they felt more restored. HFPV by facial mask in the prone position may be an interesting and attractive alternative to standard NIV, one that is more useful when implemented before full-blown respiratory failure is established.

Early tracheostomy following lung transplantation.

BACKGROUND: Despite the common use of tracheostomy in lung transplant (LT) patients, little data exist regarding the indications, timing, periprocedural complications, and impact on outcomes of the procedure. METHODS: We retrospectively analyzed some characteristics and timing of all tracheostomies performed in our lung transplant recipients during a 5-year period. RESULTS: Between January 2004 and November 2009, 31 of 126 lung transplant patients (24.6%) underwent a tracheostomy. They included 14 men with a mean age of 42 years (range, 10 to 61 years) and 17 women with a mean age of 45 years (range, 10 to 64 years). Twenty eight patients undergoing a tracheostomy had a prior bilateral sequential LT and 4 had accepted a single lung. Tracheostomy was surgically performed (ST) in 6 of 31 patients (19.3%); percutaneous tracheostomy (PT) techniques were applied for the other 25 (80.6%) cases. The decision to perform a tracheostomy was made within 4 days from LT in 21 of 31 patients (67.7%), within 8 days in 6 (19.3%) and after 10 days for the other 4 (12.9%) cases. There were no major complications during the PT procedures; no conversion to ST, no loss of airway, no paratracheal insertion, and no accidental tracheal extubation. No pneumothorax, pneumomediastinum, hypotension, hypoxemia, or arrythmyas were recorded in the early post-procedural period. The mean post-LT duration of cannulation was 17 days (range, 5 to 72 days). DISCUSSION: An early tracheostomy may be of considerable benefit for the debilitated patient who will likely require prolonged mechanical ventilation because of a complicated intraoperative course and poor recovery of graft function. PT was performed more quickly and was associated with fewer postoperative complications than ST. We recommend an aggressive strategy in the immediate posttransplant period when extubation fails or is delayed for various reasons.

Thoracic epidural analgesia in lung transplantation.

Achieving optimal pain relief after lung transplantation (LT) is often difficult, because both systemic analgesics and regional techniques have specific advantages and disadvantages. Uncontrolled pain impedes repeated powerful coughs and hinders valid respiratory excursions and graft expansion; these consequences markedly increase the risk of pulmonary complications. Thoracic epidural analgesia (TEA) is a universally accepted method of pain management after unilateral or bilateral thoracotomy, and in clinical experience it has proven to be the best option after LT. The combination of epidural local anesthetic plus opioid is associated with significant reduction in pain scores and/or supplementary analgesic requirement compared with parenteral opioid analgesia. Even though the benefits of epidural techniques in reduction of respiratory morbidity and protection from stress response to surgery have to be weighted against the risk of spinal bleeding, a well functioning thoracic sensory blockade provides satisfactory pain control and avoids the excessive sedation associated with systemic opiates. Multiple factors determine the quality of postoperative assistance, and a clear relationship between "adequate" or "high-quality" postoperative analgesia and improved outcome is difficult to establish. However, an individualized perimedullary analgesic regimen may certainly contribute to greater cooperation with physical maneuvers, avoid noxious limitations to graft expansion, and possibly decrease overall morbidity.

Helicopter rescue and prehospital care for drowning children: two summer season case studies.

BACKGROUND: Drowning is the second leading cause of unintentional injury-related death in children <14 years of age and is one of the most important causes of accidental injury between the ages of 1 and 4 years. In this study, the characteristics of non-fatal unintentional drownings in a small series of pediatric victims were examined. METHODS: We retrospectively analyzed data collected by the rescue team from May to October in two consecutive years (2006, 2007). RESULTS: Nine accidents occurred in public waters, while 5 occurred in lakes and rivers. The submersion time reported ranged from approximately 5 to 15 min. The ground emergency service with basic life support rescue experts intervened within a mean of 12 min. Advanced cardiac life support maneuvers were implemented by the helicopter medical crew for all victims. Ten of the 14 children remained in cardiocirculatory arrest despite cardiopulmonary resuscitation (CPR). The Glasgow Coma Scale (GCS) was <8 in all cases. Field resuscitation ultimately proved successful for every child. Thus, none was transported by the helicopter with ongoing CPR. All submersion-injured children survived. No postanoxic cerebral injury or major neurological complications were detected. CONCLUSION: Assuring safe tracheal ventilation, achieving intravenous access, and stabilizing both respiratory and hemodynamic disturbances on the ground before transferring the patient are the keys to out-of-hospital management. Our 100% survival rate likely results from adequate primary out of-hospital care. Promptly dispatching a helicopter with a specialized medical crew is very expensive, but is worth the cost because it offers a better chance of survival.

Microbiologic contamination of intraoperative blood salvaged during liver transplantation.

Bacterial contamination is one of the potential risks of blood salvage and reinfusion during orthotopic liver transplantation (OLT) because cell-saver machines lack antibacterial protection devices. This study was designed to analyze the potential bacterial contamination of blood salvaged during OLT; a secondary end point was to evaluate whether reinfusion of potentially contaminated blood may have been responsible for clinically manifested infective complications in the same patient. After induction of anesthesia, a blood sample was drawn from the central venous catheter (CVC) immediately after its positioning, to exclude potential coexisting hematic contamination of the recipient. During the procedure, 2 other samples of salvaged blood were collected for bacteriological analysis. Twenty-six of 38 samples of salvaged blood were positive for microorganisms, whereas 12 did not reveal the presence of infectious agents. In 19 of 26 positive samples, Staphylococcus species (73%) were isolated with only 2 of 38 samples drawn from CVC being contaminated. Candida Albicans was cultured in 2 samples. The high percentage (73%) of coagulase-negative Staphylococci indicates that blood contamination could have been caused by microorganisms from the air or suctioned from contact surfaces and the surgical field. Although almost 70% of processed and reinfused units tested positive for microbes, none of the postoperative blood cultures (at day 1 and day 3) revealed growth of the same species, not even in the 2 patients who had positive CVC cultures after induction of anesthesia.

Demand and availability of Intensive Care beds. A study based on the data collected at the SUEM 118 Central of Padua from October 1996 to December 2001.

AIM: This study aims to evaluate the management of intensive care beds according to the demands received by the SUEM 118 of Padua. It has been carried out by examining the reports drawn up by SUEM physicians from October 1996 to December 2001. The study rated the number of patients for whom an admission to the Intensive Care Unit (ICU) was required, according to the specific clinical situation at the moment of the request. A secondary objective was to evaluate if the critically ill patients had been admitted and treated in the most appropriate medical facility. METHODS: The research is based on 7 087 reports concerning a population of adult and pediatric patients for whom an ICU bed was required in the period previously mentioned. For each report, it analyses the following data (keeping them anonymous): date of demand, main pathology and severity of clinical condition, sex and age, provenence and destination. RESULTS: Even though the number of annual demands for an ICU bed made to SUEM Central 118 has remained unchanged (approximately 1 350 per year), the number of beds made available in the operating rooms of the Hospital of Padua markedly increased. What has been experienced so far, and the data collected in this study has revealed, was that the requests for an intensive treatment for the overall population (hospitalized and non hospitalized) increased disproportionally in relation to the availability of ICU beds. In fact, the total number of hospitalizations in the different ICUs rose steadily year by year (from 3 495 in 1996 to 4 640 in 2001). CONCLUSION: The Hospital of Padua is a landmark center for patients who need specialized treatment. It is therefore important to increase the assistance and safety standards of its ICUs. In recent years there has been a great need for specialized ICUs either for more aggressive procedures (neurosurgical, cardiosurgical, respiratory, cardiologic, etc.) or for the increased use of adequate and invasive treatment for advanced diseases. The available resources of ICU beds should be more rationally distributed between the peripheral and the Regional Hospitals, since the activation of an ICU bed in the operating theatre is a valid, transient option.

[Prognostic systems in intensive care: TRISS, SAPS II, APACHE III]. / Scale prognostiche in terapia intensiva: TRISS, SAPS II, APACHE III.

BACKGROUND: To validate the accuracy of SAPS II, APACHE III and TRISS for the prediction of mortality in Intensive Care Unit (ICU) at polytrauma patients admission. The outcome of multiple trauma patients is often linked to the degree of physiologic dysfunction and to the extension of anatomic lesions, the age of the patient and the lesion mechanism. METHODS: The study population consisted of 93 cases of multiple injured patients hospitalised at the ICU of the Padua hospital from October 1998 to October 1999; the term polytraumatized patient is referred to patients who have multiple lesions of which at least one potentially endangers, immediately or in a short term, their life. These cases were evaluated with the APACHE III, SAPS II, Revised Trauma Score and Injury Severity Score. The predictive power of each system was evaluated by using decision matrix analysis to compare observed and predicted outcome with a decision criterion of 0.50 and 0.40 for risk of hospital death. RESULTS: All trauma score systems under study showed high accuracy rates, above all if they are used with a 40% positive test. CONCLUSIONS: The prognostic scales used in this study showed a good correlation between expected and observed cases, particularly with TRISS and APACHE III systems. The APACHE III system seems to be the most reliable of the different methods analysed. These prognostic systems are seldom or occasionally used in the ICU, in Padua and in the whole of Italy, so Italian data are not suitable to be compared to international ones. Due to urgency, the importance of the evaluation scales is often underestimated, but even if they require time and attention, they surely can be useful in the evaluation of the treatment, and not only of a polytraumatized patient.