Deep Neck Infections: Decisional Algorithm for Patients with Multiple Spaces Involvement.

BACKGROUND: Deep Neck Infections (DNIs) spread along fascial planes and involve neck spaces. Recently, their incidence has decreased due to the introduction of antibiotics; nevertheless, complications related to DNIs are often life-threatening. OBJECTIVE: The purpose of this article is focused on the identification of predisposing factors of these complications, as well as on the development of a reliable therapeutic algorithm. METHODS: Sixty patients with DNIs were enrolled from 2006 to 2019 for a retrospective study. The exclusion criteria for the present study were cellulitis, small abscesses responding to empiric or specific antibiotic therapy, or involvement of only one deep neck space. During the analysis, the following parameters of interest have been evaluated: gender, age, site of origin, pathways of spread, comorbidities, clinical features, bacteriology data, type of surgical approach required, complications, duration of hospitalization and mortality rate. On admission, microbial swab analysis was performed. RESULTS: Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), iron deficiency anemia and the involvement of multiple spaces have been associated with a significantly higher risk of developing complications. Most of our patients had polymicrobial infections. All patients underwent surgical drainage. The complication rate had occurred in 56.6% of patients, while death in 18.3%. CONCLUSION: DNIs represent a medical and surgical emergency with potentially serious complications; thus, avoidance of diagnostic delay is mandatory. Our preliminary data suggest the importance of evaluating the extent of infections because the involvement of multiple spaces requires timely surgery due to the higher risk of complications and mortality.

Successful weaning from mechanical ventilation after Serratus Anterior Plane block in a chest trauma patient.

OBJECTIVES: Chest trauma is associated with severe pain, which can hamper normal breathing. Serratus Anterior Plane block (SAPB) is a novel technique, which provides analgesia for chest wall surgery. We describe an interesting clinical case about the use of SAPB to improve pain and pulmonary function in a patient with severe chest trauma. CASE PRESENTATION: We report the pain management and the clinical evolution of a patient in ICU, with a severe chest trauma, after performing the SAPB. Following the SAPB, the patient had a reduction in pain intensity and an improvement in both respiratory mechanics and blood gas analysis allowing a weaning from mechanical ventilator. CONCLUSIONS: Pain control greatly affects mortality and morbidity in patients with chest trauma. SAPB seems to be safer and equally effective in pain control compared to epidural analgesia in patients with chest trauma.

Cardiopulmonary resuscitation (CPR) during spaceflight - a guideline for CPR in microgravity from the German Society of Aerospace Medicine (DGLRM) and the European Society of Aerospace Medicine Space Medicine Group (ESAM-SMG).

BACKGROUND: With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency - cardiac arrest. METHODS: After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology. RESULTS: We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved. DISCUSSION: CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.

Accuracy and trending ability of hemoglobin measurement by the Pulse CO-Oximeter during vascular surgery.

Real time information of Hb concentration can guide a tailored patient blood management. The study investigates the accuracy, precision and trending ability of the Pulse CO-Oximeter (SpHb) and blood gas analyzer in measuring the Hb concentration, compared to hematological analysis, in surgery at high risk of hemorrhage. We performed an observational study, involving 48 patients undergoing abdominal aortic open surgery. The primary endpoints of the study were to compare the accuracy in measuring the Hb concentration using non-invasive method (Masimo rainbow SET® Radical 7 Pulse CO-Oximetry™) compared to the values provided by invasive conventional blood gas analyzer and hematological analysis. The secondary endpoint was to compare the differences between the baseline and the final value of the Hb after surgery (Δ-values), as well as the trending ability. Bias (precision) for the SpHb was 1.63 g/dL (± 0.05) with 95% limits of agreement between 0.85 and + 2.4 g/dL, while for the blood gas analyzer was 0.69 g/dL (± 0.04) with 95% limits of agreement between 0.07 and 1.3 g/dL. Δ-values values were not statistically different from the reference values of ΔHb obtained with the hematological analysis. Trending ability was good for both Pulse CO-Oximeter and blood gas analysis. Our results have shown that the SpHb is not precise enough to replace an invasive approach, but the trending ability of SpHb is accurate and may provide important information on the changes in hemoglobin concentration to guide blood management.

The use of sugammadex for bariatric surgery: analysis of recovery time from neuromuscular blockade and possible economic impact.

BACKGROUND: Neuromuscular block (NMB) monitoring and use of reversal agents accelerate the recovery time and improve the workflow in the operating room. We aimed to compare recovery times after sugammadex or neostigmine administration, and estimate the time spent in operating theater and the possible economic impact of a faster recovery, in morbidly obese patients undergoing bariatric surgery. METHODS: We conducted a retrospective study that analyzed data from records of morbidly obese patients (body mass index >40 kg/m(2)) undergoing elective laparoscopic bariatric surgery in which sugammadex or neostigmine were used to reverse NMB. Patients were divided in two groups: group 1 (sugammadex group [SUG]) received rocuronium and sugammadex for reversal and group 2 (neostigmine group [NEO]) received either rocuronium or cisatracurium and neostigmine. Data are presented as mean (standard deviation). RESULTS: Compared with NEO, SUG group showed shorter times to achieve train-of-four ratio of 0.9 (P<0.05) and an Aldrete score of 10 (P<0.05), a higher cost (€146.7 vs €3.6 [P<0.05]), plus a remarkable less duration of operating theater occupancy (P<0.05). Sugammadex cost accounted for 2.58% of the total cost per surgery, while neostigmine cost accounted for 0.06%. Total time saved in SUG group was 19.4 hours, which could be used to perform 12 extra laparoscopic sleeve gastrectomies. CONCLUSION: Reversal from NMB was significantly faster with sugammadex than with neostigmine. Although sugammadex was substantially more expensive, duration of operating theater occupancy was reduced with potentially workflow increase or personnel reduced cost.