Preoperative clear fluids fasting times in children: retrospective analysis of actual times and complications after the implementation of 1-h clear fasting.

BACKGROUND: Preoperative fasting before elective pediatric surgery is a matter of ongoing debate. The objectives of this study were to evaluate the compliance to a recently implemented preoperative fasting protocol (clear fluids until 1 hour from the induction of anesthesia), to identify predictors of prolonged preoperative fasting time, and to determine whether duration of preoperative fasting was associated with adverse outcomes. METHODS: Retrospective single-center study in an operating theater of a tertiary pediatric hospital. RESULTS: In a 6-month period, 1820 consecutive patients were analyzed. The data collected in the questionnaire reporting the time of last food, milk and/or liquid intake, and eventual reasons for nonadherence was analyzed. Median (interquartile range) preoperative fasting time was 186 (110-345) min. In 502 patients (27.6%), duration of preoperative fasting to clear fluid ranged from 60 to 119 min, whereas in 616 (34%) it was 120-240 min. The reasons for not respecting fasting time rules are mostly related to communication issues or unwillingness by the patients. A significant difference in fasting times was evident between infants and children older than 10 years (188, 105-290 vs. 198, 115-362; p = 0.02). Fasting times were significantly shorter in the inpatient group and in the first scheduled patients of the morning. Clear fluids fasting times were significantly longer in patients with hypovolemia complications than in those without, 373 (185-685) vs. 180 (110-330) min (p < 0.0001). Longer fasting times to clear fluids, younger age, and scheduled surgery time were independently associated with the odds of experiencing complications. CONCLUSIONS: In this single pediatric center study, median clear fluids fasting time was three times higher (180 min) than those recommended by the preoperative fasting protocol. Compliance to the protocol was observed in approximately 1 out of 4 patients (27.6%). Longer fasting times were associated with an increased risk of complications, which might be due to dehydration and/or hypovolemia.

Temporal trends and differences of SARS-CoV-2-specific antibody responses in symptomatic and asymptomatic subjects: a longitudinal study from Umbria in Italy.

OBJECTIVES: Dynamics of antibody responses following SARS-CoV-2 infection are controversial in terms of immunity and persistence. We aimed to assess longitudinally the trend of antibody serological titres, their correlation with clinical severity as well as clinical reinfection during a follow-up. DESIGN: Longitudinal cohort, 12 months follow-up study. SETTING: USL Umbria 2. PARTICIPANTS: Consecutive subjects aged 15-75 who were discharged with the diagnosis of Sars-Cov-2 from the hospitals of the AUSL Umbria 2, or resulted positive to a PCR test for SARS-CoV-2 infection with or without symptoms were recruited. SARS-CoV-2 serological testing for antibodies targeting the Nucleocapside and Spike proteins were determined. RESULTS: Of 184 eligible subjects, 149 were available for evaluation: 17 were classified as oligo/asymptomatic, 107 as symptomatic, 25 as hospital admitted. Participants differed in terms of signs and symptoms as well as treatment. Overall there was a significant difference in terms of antibody titres between groups (anti-S: p<0.00; anti-N: p=0.019). Median anti-S titres in the symptomatic and hospital admitted participants were significantly higher compared with the oligo/asymptomatic participants. During follow-up, the median titre of anti-S antibodies did not show significant variations (p=0.500) and the difference within groups remained constant overtime. Subjects that showed an anti-S titre above the threshold of 12 U/mL were 88.7% at first visit and 88.2% at last follow-up. Anti-N values were higher in the hospital admitted participants compared with the other two groups. Anti-N titre reduced constantly overtime (p<0.001) and across the three groups of participants. The percentage of the subjects with serological titre above threshold (<1.4 U/mL) decreased from 74.5%% to 29.2% (p<0.001). None of the participants developed clinically evident reinfection. CONCLUSION: Anti-N and anti-S correlate well with clinical severity. While anti-N declines overtime, anti-S antibodies persist for at least 1 year.

Reduction of non-enzymatic antioxidants in plasma during ECMO-treatment in ARDS by influence A H1N1.

PURPOSE: In critically ill patient it is observed a severe oxidative stress, not only due to the acute pathology but also for some therapeutic treatments. The aim of the present study was to analyze the variations of non-enzymatic antioxidants in plasma during veno-venous ECMO-treatment in a homogeneous population of critical patients with ARDS. MATERIALS AND METHODS: We carried out a retrospective study enrolling all patients with ARDS by influence A H1N1 treated with veno-venous ECMO. In all patients included, we have recorded clinical and laboratory parameters considered indicators of oxidative stress during the first week of treatment. RESULTS: With regard to non-enzymatic antioxidants evaluated, we observed that both albumin and uric acid decreased significantly, at all observation times, after ECMO-treatment [(25.88±4.51, 18.05±4.27, 16.32±4.57, 19.07±5.10, p<0.05)(g/l), (5.46±1.43, 2.30±1.15, 2.90±2.09, 2.07±1.03, p<0.05)(mg/dl), respectively]. At the same time the amount of insulin administered daily was increased with statistical significance (p=0.03). CONCLUSIONS: The veno-venous ECMO-treatment causes a significant reduction of some of the major non-enzymatic antioxidants and a possible increase in insulin resistance in patients with ARDS by influence A H1N1.

Perioperative Levels of Adiponectin and Oxidative Stress in Patients Undergoing Laparoscopic Abdominal Surgery for Cancer.

BACKGROUND: Low circulating levels of adiponectin are associated with the occurrence of infection after surgery in patients with cancer. Data are lacking on whether surgical stress is associated with a reduction in circulating levels of adiponectin. Furthermore, the relationship between oxidative stress and postoperative complications has not been investigated. OBJECTIVE: The aim of this study was to evaluate the pre-, intra-, and postoperative levels of adiponectin in patients who underwent major abdominal surgery for malignancy and their association with postoperative complications. METHODS: An observational, prospective, single-center study was conducted in patients undergoing abdominal surgery for cancer. Circulating levels of adiponectin and of two biomarkers of oxidative stress were measured preoperatively, at the end of surgery, 24 and 48 hours after surgery. Patients were divided into two groups: complicated (CL+) and uncomplicated (CL-), according to the Clavien-Dindo classification. Temporal patterns of adiponectin and markers of oxidative stress were followed at different time points. RESULTS: Twelve patients were enrolled, seven with postoperative complications (CL+) and five without (CL-). The preoperative median levels of adiponectin were statistically different between CL+ and CL- groups (3.2 µg/ml vs 10.9 µg/ml; p=0.03). Levels of preoperative adiponectin were inversely related to the severity of postoperative complications (Rho= -0.68; p= 0.02). Pre-, intra- and postoperative levels of oxidative stress products were not statistically different between the two groups. Adiponectin levels decreased during surgery in both groups, while those of oxidative stress tended to increase. CONCLUSIONS: Preoperative adiponectin levels correlate with postoperative complications after cancer surgery.

The New MIRUS System for Short-Term Sedation in Postsurgical ICU Patients.

OBJECTIVES: To evaluate the feasibility and safety of the MIRUS system (Pall International, Sarl, Fribourg, Switzerland) for sedation with sevoflurane for postsurgical ICU patients and to evaluate atmospheric pollution during sedation. DESIGN: Prospective interventional study. SETTING: Surgical ICU. February 2016 to December 2016. PATIENTS: Postsurgical patients requiring ICU admission, mechanical ventilation, and sedation. INTERVENTIONS: Sevoflurane was administered with the MIRUS system targeted to a Richmond Agitation Sedation Scale from -3 to -5 by adaptation of minimum alveolar concentration. MEASUREMENTS AND MAIN RESULTS: Data collected included Richmond Agitation Sedation Scale, minimum alveolar concentration, inspired and expired sevoflurane fraction, wake-up times, duration of sedation, sevoflurane consumption, respiratory and hemodynamic data, Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment, and laboratory data and biomarkers of organ injury. Atmospheric pollution was monitored at different sites: before sevoflurane delivery (baseline) and during sedation with the probe 15 cm up to the MIRUS system (S1) and 15 cm from the filter-Reflector group (S2). Sixty-two patients were enrolled in the study. No technical failure occurred. Median Richmond Agitation Sedation Scale was -4.5 (interquartile range, -5 to -3.6) with sevoflurane delivered at a median minimum alveolar concentration of 0.45% (interquartile range, 0.4-0.53) yielding a mean inspiratory and expiratory concentrations of 0.79% (SD, 0.24) and 0.76% (SD, 0.18), respectively. Median awakening time was 4 minutes (2.2-5 min). Median duration of sevoflurane administration was 3.33 hours (2.33-5.75 hr), range 1-19 hours with a mean consumption of 7.89 mL/hr (SD, 2.99). Hemodynamics remained stable over the study period, and no laboratory data indicated liver or kidney injury or dysfunction. Median sevoflurane room air concentration was 0.10 parts per million (interquartile range, 0.07-0.15), 0.17 parts per million (interquartile range, 0.14-0.27), and 0.15 parts per million (interquartile range, 0.07-0.19) at baseline, S1, and S2, respectively. CONCLUSIONS: The MIRUS system is a promising and safe alternative for short-term sedation with sevoflurane of ICU patients. Atmospheric pollution is largely below the recommended thresholds (< 5 parts per million). Studies extended to more heterogeneous population of patients undergoing longer duration of sedation are needed to confirm these observations.

Hemodialysis with High Cut-Off Hemodialyzers in Patients with Multi-Drug Resistant Gram-Negative Sepsis and Acute Kidney Injury: A Retrospective, Case-Control Study.

BACKGROUND: Hemodialysis with high cut-off continuous veno-venous hemodialyzer (HCO-CVVHD) removes mediators of organ dysfunction during sepsis. This study assessed the clinical effects of HCO-CVVHD as compared to high-flux (HF) membranes during gram-negative sepsis. METHODS: Intensive care unit (ICU), septic patients treated with HCO-CVVHD or HF-CVVHDF for AKI were retrospectively observed (January 2013-December 2014). Mechanical ventilation, vasopressors' requirements, ICU length of stay (LOS) and ICU in-hospital mortality were compared between groups. RESULTS: Sixteen HCO and 8 HF patients were observed. Isolated pathogens included Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli and Pseudomonas aeruginosa. Median ratios of days-on-vasopressors and days-on-mechanical ventilation/ICU-LOS were 0.5, 1 and 0.8, 1 for HCO and HF groups (p < 0.03), respectively. ICU-LOS was 16 and 9 days (HCO- and HF-group, p = 0.03). ICU mortality rates were 37.5 and 87.5% for HCO and HF groups, respectively (p = 0.03). No statistical difference was found in in-hospital morality. CONCLUSION: Patients in HCO-CVVHD group spent lesser number of days on vasopressors and mechanical ventilation as a ratio to total ICU-LOS. In the same group, a reduction in ICU mortality was observed.

Ultrasound evaluation of the stomach and gastric emptying in pregnant women at term: a case-control study.

BACKGROUND: This study aims to assess the rate of gastric emptying in pregnant women in the third trimester scheduled for elective caesarean section (CS), in view to highlight the aspiration risk. METHODS: A prospective case-control study, with the approval of the Ethics Committee, was performed. At term pregnant women (group A) scheduled for CS and volunteer controls were recruited (group B). The ultrasonographic measurement of the antral area was performed, after a standardized meal, with a Convex probe. The antrum was displayed in the sagittal or parasagittal projections in the right upper quadrant, medial to the mid-clavicular line. The diameters of the antrum were measured and then the antral area was calculated. The measurements were conducted at 10 (T1), 90 (T2) and 240 (T3) minutes from the meal. Anthropometric data were collected for each patient. RESULTS: In group B, antrum distention was observed already after 10 minutes from the meal, and then a gradual decrease in the antral area until 4 hours after the meal was registered. On the contrary, in group A (at term pregnant) there was an initial smaller increase of antral area, followed by a greater increase that lasts up to 90 minutes, and finally a delayed and smaller reduction. CONCLUSIONS: In pregnant women at term, the stomach does not seem to be able to expand immediately after the meal. The transit of food is completed later than in not pregnant women. The ultrasound of the stomach allows identifying delays gastric emptying and highlighting patients at risk of aspiration.

Glycocalyx and sepsis-induced alterations in vascular permeability.

Endothelial cells line the inner portion of the heart, blood vessels, and lymphatic vessels; a basal membrane of extracellular matrix lines the extraluminal side of endothelial cells. The apical side of endothelial cells is the site for the glycocalyx, which is a complex network of macromolecules, including cell-bound proteoglycans and sialoproteins. Sepsis-associated alterations of this structure may compromise endothelial permeability with associated interstitial fluid shift and generalized edema. Indeed, in sepsis, the glycocalyx acts as a target for inflammatory mediators and leukocytes, and its ubiquitous nature explains the damage of tissues that occurs distant from the original site of infection. Inflammatory-mediated injury to glycocalyx can be responsible for a number of specific clinical effects of sepsis, including acute kidney injury, respiratory failure, and hepatic dysfunction. Moreover, some markers of glycocalyx degradation, such as circulating levels of syndecan or selectins, may be used as markers of endothelial dysfunction and sepsis severity. Although a great deal of experimental evidence shows that alteration of glycocalyx is widely involved in endothelial damage caused by sepsis, therapeutic strategies aiming at preserving its integrity did not significantly improve the outcome of these patients.

Selenium supplementation in critically ill patients: a systematic review and meta-analysis.

PURPOSE: The oxidative stress is recognized as a constant feature in critical illness. Nevertheless, the use of antioxidant therapy remains controversial. We tried to demonstrate that intravenous selenium supplementation could promote antioxidant status and help protect against infection and organ failure, improving outcome in critically ill patients. MATERIALS AND METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the exogenous supplementation of selenium versus standard therapy without any adjuvant in critically ill adults. RESULTS: Nine RCTs met inclusion criteria. Selenium supplementation was associated with a reduction in 28-day mortality of borderline statistical significance (risk ratio = 0.84, 95% confidence interval 0.71-0.99, P = .04). The analysis of pre-defined subgroups detected no significant effects regarding the supplementation with doses of selenium ≤ 500 µg/d, administration of a load dose with a bolus and duration of treatment. Only 2 studies analyzed 6-month mortality and could not show a difference. No effects could be demonstrated on hospital length of stay, pulmonary infections, or renal failure. CONCLUSIONS: The use of high-dose selenium might be associated with a beneficial effect on 28-day mortality in critically ill patients. Nevertheless, the use of selenium as adjuvant therapy needs further evaluations.