Neuromuscular block in Italy: a survey of current management.

BACKGROUND: Little is known about current use of neuromuscular blocking agents by Italian anesthetists. This paper reports the results of a survey conducted to obtain information about current management of neuromuscular block in Italy. METHODS: A questionnaire was given to Italian Anesthetists attending the 64nd National Congress of the Italian Society of Anesthesia, Intensive Care, Analgesia and Intensive Therapy S.I.A.A.R.T.I. (Parma, 13th-16th October 2010). Collected data were stratified by age, geographical location, and the total number of surgical procedures performed in the hospitals concerned. RESULTS: One thousand four hundred forty patients correctly compiled questionnaires were collected. 50% of respondents used clinical tests to monitor the level of neuromuscular blockade. The main clinical tests cited for the evaluation were: keeping the head lifted up for 5 seconds, protruding the tongue and opening the eyes. Train-of-four was used by 50% of respondents on a routine basis. Only 33% of anesthetists reply that a train-of-four ratio of 90% or more is the safe level prior to extubation. CONCLUSION: Clinical signs are used by most of the Italian anesthetists to assess the recovery from neuromuscular blockade. There is poor awareness about their inability to indicate even a significant degree of residual neuromuscular block. A more extensive use of quantitative instrumental monitoring is required for the more rational use of neuromuscular blocking agents.

ITalian Observational Study of the management of mild-to-moderate Post-Operative Pain (ITOSPOP).

BACKGROUND: The multicenter observational ITalian Observational Study on the management of mild-to-moderate PostOperative Pain (ITOSPOP) was carried out in 24 hospitals to describe current postoperative pain management in Italy and the intensity of pain experienced by patients during the first 48 hours after surgery. METHODS: Adult patients, after surgery expected to result in mild-moderate postoperative pain, underwent six evaluations. The primary endpoint was the level of organization and standardization of postoperative pain management. Secondary objectives included the intensity of postoperative pain, and an assessment of incident pain, postoperative analgesic and concomitant treatment administration. RESULTS: Only 16.7% hospitals had an acute pain service and 41.7% hospitals applied a standardized protocol for postoperative pain management. The majority (>60%) of the 1952 patients monitored underwent all six assessments, >70% of which were performed by a physician. The proportion of patients with moderate pain decreased during the study period, but almost 10% of patients still experienced moderate pain at study end. Mild pain was reported by 50% of the patients for the entire study duration. At the final assessment, 5% of patients still presented with incident pain frequently interfering with daily activities. Most patients were treated with analgesics, but 20% of patients did not receive any pain medications despite experiencing pain. CONCLUSION: The level of organization and standardization of postoperative pain management in Italian hospitals remains low. Postoperative analgesic treatment remained suboptimal and almost two-thirds of patients continued to experience pain.

Knowledge of residual curarization: an Italian survey.

BACKGROUND: The use of neuromuscular blocking agents (NMBAs) is widespread in anesthetic practice; little is known about the current use of these drugs in Italy. This survey was conducted to obtain information about the most commonly used clinical tests and the train-of-four (TOF) ratios that are considered as being reliable for assessing recovery from neuromuscular blockade at the end of anesthesia and the estimated occurrence rates of post-operative paralysis in Italian hospitals. METHODS: The questionnaire was given to Italian anesthesiologists attending the 62nd National Congress of the Italian Society of Anesthesia, Analgesia and Intensive Therapy. Collected data were stratified by age and the total number of surgical procedures performed in the hospitals concerned. RESULTS: Seven hundred and fifty-four correctly compiled questionnaires were collected (response rate 88.7%). Seventy three percent of the respondents only used clinical tests for monitoring the level of neuromuscular blockade. The main clinical tests cited for the evaluation of residual paralysis were keeping the head lifted up for 5 s, protruding the tongue and opening the eyes. TOF was used by 35% of the respondents on a routine basis. Only 24% of the interviewed anesthesiologists reported that before extubation, a TOF ratio of at least 0.9 should be reached. CONCLUSIONS: Most Italian anesthetists assess the recovery from neuromuscular blockade only by clinical signs. There is poor awareness about the inability of such techniques to indicate even a significant amount of residual neuromuscular block. A more extensive use of quantitative instrumental monitoring is required for the more rational use of NMBAs.

Reducing the risk of major elective non-cardiac surgery: is there a role for levosimendan in the preoperative optimization of cardiac function?

Patients with heart failure undergoing non-cardiac surgery still have an unacceptably high morbidity and mortality. Compromised myocardial physiologic reserves in combination with extensive surgery and anesthesia appear to play a crucial role in determining high perioperative morbidity and mortality. Nevertheless, several other mechanisms and pathways such as metabolic factors, ischemia-reperfusion conditions, neurohormonal activation, inflammation and oxidative stress contribute to the adverse outcome. Several cardiovascular drugs have been investigated with the attempt to reduce the incidence of cardiovascular adverse events after major non-cardiac surgery. In the last years, increasing attention has been paid to the use of levosimendan in the perioperative period of patients undergoing cardiac surgery. As an inodilator, levosimendan - at low energy expenditure - may improve perioperative cardiac performance of heart failure patients by optimizing ventriculo-arterial coupling, rather than by increasing myocardial contractility itself. By its vasodilating properties, levosimendan may also improve systemic and regional blood flow. In addition to these hemodynamic properties, non hemodynamic effects of levosimendan may further improve microcirculation and organ function. At the cellular level in the heart, kidney, lung, liver as well as the gut, levosimendan exerts protective preconditioning effects secondary to activation of adenosine triphosphate (ATP)-sensitive potassium channels. Taking into account these multiple but complementary mechanisms, levosimendan appears to be a suitable agent for preoperative optimization of cardiac functions in heart failure patients undergoing major elective surgery. Nevertheless, large-scale trials are needed before final conclusions can be drawn on the use of levosimendan in this indication.

Extracorporeal removal CO2 using a venovenous, low-flow system (Decapsmart) in a lung transplanted patient: a case report.

BACKGROUND: Primary graft dysfunction (PGD) is a syndrome that may occur after lung transplantation. In some cases of severe PGD, conventional therapies like ventilatory support, administration of inhaled nitric oxide (iNO), and surfactant and intravenous prostacyclins are inadequate to achieve adequate gas exchange. The only lifesaving option is to use an extracorporeal membrane oxygenator. The Decapsmart is a new venovenous, low-flow extracorporeal device to removal carbon dioxide (CO(2)). It does not need a specialized staff. Herein we have presented a case report of a patient who underwent single lung transplantation and experienced respiratory failure. METHODS: On November 2007, a 52-year-old woman underwent a single right lung transplantation, and developed severe PGD in the postoperative period. After institution of conventional treatments, including ventilatory and hemodynamic support, iNO, and prostaglandine E1, we started treatment with Decapsmart to remove CO(2). Hemodynamic and respiratory parameters were assessed at baseline and after 3, 12, 24, and 48 hours. RESULTS: No adverse events occurred. From baseline to 48 hours, pH values increased and partial pressure of CO(2) reduced. At the same time ventilatory support was reduced, thereby mitigating barotrauma and risk of overdistension. CONCLUSION: The use of Decapsmart may be an important aid for patients with severe respiratory acidosis in association with conventional therapy during the perioperative period after lung transplantation.

Levosimendan pre-treatment improves outcomes in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: The calcium sensitizer levosimendan has anti-ischaemic effects mediated via the opening of sarcolemmal and mitochondrial ATP-sensitive potassium channels. These properties suggest potential application in clinical situations where cardioprotection would be beneficial, such as cardiac surgery. We thus decided to investigate whether pharmacological pre-treatment with levosimendan reduces intensive care unit (ICU) length of stay in patients undergoing elective myocardial revascularization under cardiopulmonary bypass. METHODS: One hundred and six patients undergoing elective coronary artery bypass grafting were randomly assigned in a double-blind manner to receive levosimendan or placebo. Levosimendan (24 microg kg(-1)) or placebo was administered as a slow i.v. bolus over a 10 min period before the initiation of bypass. RESULTS: Tracheal intubation time and the length of ICU stay were significantly reduced in the levosimendan group (P<0.01). The number of patients needing inotropic support for >12 h was significantly higher in the control group (18.0% vs 3.8%; P=0.021). Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.0001) and a higher cardiac power index (P<0.0001). CONCLUSIONS: Pre-treatment with levosimendan in patients undergoing surgical myocardial revascularization resulted in less myocardial injury, a reduction in tracheal intubation time, less requirement for inotropic support, and a shorter length of ICU stay.

Inhaled aerosolized prostaglandin E1, pulmonary hemodynamics, and oxygenation during lung transplantation.

BACKGROUND: The use of inhaled aerosolized prostaglandin E(1) (aerPGE(1)), a pulmonary vasodilator, has not been widely analyzed. In contrast to prostacyclin, PGE(1) has a shorter lifetime and is metabolized in a greater amount from the lungs, lowering the risk of systemic effects. The aim of this study was to analyse the effects of aerPGE(1) administration on pulmonary hemodynamics and oxygenation during lung transplantation. METHODS: Eighteen patients undergoing lung transplantation were enrolled in this study. During the first lung implantation, systemic and pulmonary hemodynamic and oxygenation data were evaluated in three phases: -- baseline in 100% O(2); during aerPGE(1) -- after 15 min of aerosolized prostaglandin E(1) administration in 100% O(2); after aerPGE(1) -- 15 min after the end of the prostaglandin E(1) administration in 100% O(2). RESULTS: During aerPGE(1) a reduction in mPAP, PVRI, and Qs/Qt and an increase in PaO(2)/FiO(2) were observed. Soon after prostaglandin inhalation was ceased, the mPAP, the PVRI, and the Qs/Qt increased while PaO(2)/FiO(2) decreased. During the study, no significant difference in systemic pressure among the phases was noted. A high correlation between changes in mPAP, Qs/Qt and PaO(2)/FiO(2) after aerPGE(1) administration and baseline values was observed. ROC curve analysis showed that values of 40 mmHg of mPAP, 21.7% of the pulmonary shunt, and 364 mmHg for PaO(2)/FiO(2) predict a decrease in mean pulmonary arterial pressure and pulmonary shunt or an improvement in oxygenation of 10% with respect to baseline values. CONCLUSION: A low dose of aerosolized prostaglandin E(1) decreases pulmonary arterial pressure and improves oxygenation without impairment on systemic hemodynamics, also during anesthesia for lung transplantation. The effect seems to depend on baseline values, which can be considered to be a predictor of the prostaglandin response.

Diagnostic accuracy of bedside ultrasonography in the ICU: feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracic trauma.

BACKGROUND: Blunt thoracic trauma is a major concern in critically ill patients. Repeated lung diagnostic evaluations are needed in order to follow up the clinical situation and the results of the therapeutic strategies. The aim of this prospective clinical study was to evaluate the possible role of lung ultrasound (LU) compared with bedside radiography (CXR) and computed tomography (CT) used as the gold standard in the evaluation of trauma patients admitted to the intensive care unit with acute respiratory failure. METHOD: A total of 15 thoracic trauma patients were studied at intensive care unit (ICU) arrival (T1) and 48 h later (T2) with CT, CXR and LU. We evaluated the presence of pleural effusion (PE) and lung contusion (LC). For this purpose the lung parenchyma was divided into 12 regions so that we could compare 180 lung regions at T1 and T2, respectively. RESULTS: Sensitivity of ultrasound was 0.94 for PE and 0.86 for LC while specificity 0.99 and 0.97, respectively. The likelihood ratio was 94 (rho(+)) and 0.06 (rho(-)) for PE and 28.6 (rho(+)) and 0.14 (rho(-)) for LC. CONCLUSIONS: Ultrasound provides a reliable noninvasive, bedside method for the assessment of chest trauma patients with acute respiratory failure in the ICU.

Effects of short-term simultaneous infusion of dobutamine and terlipressin in patients with septic shock: the DOBUPRESS study.

BACKGROUND: Terlipressin bolus infusion may reduce cardiac output and global oxygen supply. The present study was designed to determine whether dobutamine may counterbalance the terlipressin-induced depression in mixed-venous oxygen saturation (Svo) in patients with catecholamine-dependent septic shock. METHODS: Prospective, randomized, controlled study performed in a university hospital intensive care unit. Septic shock patients requiring a continuous infusion of norepinephrine (0.9 microg kg(-1) min(-1)) to maintain mean arterial pressure (MAP) at 70 (sd 5) mm Hg were randomly allocated to be treated either with (i) sole norepinephrine infusion (control, n=20), (ii) a single dose of terlipressin 1 mg (n=19), or (iii) a single dose of terlipressin 1 mg followed by dobutamine infusion titrated to reverse the anticipated reduction in Svo2 (n=20). Systemic, pulmonary, and regional haemodynamic variables were obtained at baseline and after 2 and 4 h. Laboratory surrogate markers of organ (dys)function were tested at baseline and after 12 and 24 h. RESULTS: Terlipressin (with and without dobutamine) infusion preserved MAP at 70 (5) mm Hg, while allowing to reduce norepinephrine requirements to 0.17 (0.2) and 0.2 (0.2) microg kg(-1) min(-1), respectively [vs1.4 (0.3) microg kg(-1) min(-1) in controls at 4 h; each P<0.001]. The terlipressin-linked decrease in Svo2 was reversed by dobutamine at a mean dose of 20 (8) microg kg(-1) min(-1) [Svo2 at 4 h: 59 (11)% vs 69 (12)%, P=0.028]. CONCLUSIONS: In human catecholamine-dependent septic shock, terlipressin (with and without concomitant dobutamine infusion) increases MAP and markedly reduces norepinephrine requirements. Although no adverse events were noticed in the present study, potential benefits of increasing Svo2 after terlipressin bolus infusion need to be weighted against the risk of cardiovascular complications resulting from high-dose dobutamine.

Clinical effects of direct hemoperfusion using a polymyxin-B immobilized column in solid organ transplanted patients with signs of severe sepsis and septic shock. A pilot study.

BACKGROUND: Polymyxin B (PMX-B) is a polycationic antibiotic, known to bind the lipid A portion of endotoxin, a cell wall component found exclusively in gram negative bacteria (GNB). An extracorporeal hemoperfusion device (TORAYMYXIN) has been developed: PMX is covalently bound on the surface of an insoluble carrier material so that the endotoxin can be inactivated in the blood without exerting its toxicity on the brain and kidney. The aim of this study was to clarify the efficacy, safety and clinical effects of direct hemoperfusion with an immobilized polymyxin-B fiber column (DHP-PMX) in solid organ transplanted patients with severe sepsis or septic shock. METHODS: From June 2004 to May 2005, 15 patients (10 men and 5 women), mean age 55 years old (46-65 range), underwent kidney or liver transplantation and developed severe sepsis or septic shock, as defined by the Consensus Conference of American College Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. GNB were detected in all the patients receiving conventional treatments including antibiotic therapy, vasopressive or inotropic agents, and ventilation support. The DHP-PMX treatment was performed three times in each patient. Hemodynamic and respiratory parameters, dosage of vasopressor/inotropic drugs were assessed at baseline and after each treatment. RESULTS: No adverse events occurred. From baseline to 3rd treatment, mean arterial pressure (MAP) was increased (from 63+/-5 to 83+/-4 mmHg), while the dosage of dobutamine (from 7.5+/-3 to 3+/-2 mcg/kg/min) and noradrenaline (from 1.3+/-0.45 to 0.05+/-0.02 mcg/kg/min) were reduced. The PaO2/FiO2 ratio increased (from 234+/-38.47 to 290+/-107.48 mmHg). CONCLUSION: The use of DHP-PMX in association with conventional therapy may be an important aid in patients with sepsis.

Activated recombinant factor VII in orthotopic liver transplantation.

UNLABELLED: Orthotopic liver transplantation (OLT) is affected by important alterations of hemostasis. The aim of this study was to evaluate the efficacy of recombinant factor VII activated (rFVIIa) to reduce intraoperative bleeding during OLT. METHODS: Twenty OLT patients were assigned in double-blind way to a rFVIIa group or a control group. Inclusion criteria were hemoglobin > 8 g/dL: INR > 1,5 and fibrinogen > 100 mg/dL. We administered a single bouls of rFVIIa (40 microg/kg) or placebo. We determined INR, partial thromboplastin time, fibrinogen, ATIII, and blood cell counts. Blood products were administered as follows: 4 units of fresh frozen plasma when INR > 1.5, and 1 unit of RBC for Hb < 10 g/dL. The study ended 6 hours after the bolus. RESULTS: No thromboembolic events occurred. The INR was different between rFVIIa group and the controls at T0 (1.9 vs 1.6 P < .021) and during T1 (1.2 vs 1.6 P < .004). The total transfused red blood cells was 300 mL +/- 133 in rFVIIa group and 570 mL +/- 111 in control group (P < .017). The total fresh frozen plasma was 600 mL +/- 154 in rFVIIa group and 1400 mL +/- 187 in control group (P < .001). Total blood loss was greater in the control group than the rFVIIa group: 1140 mL +/- 112 vs 740 mL +/- 131 (P < .049). DISCUSSION: The use of rFVIIa during OLT can reduce the risk of bleeding during surgery. The literature has described cases who did not benefit from the treatment. An adequate cut-off of INR, allowed us to treat only patients at greater bleeding risk.

Fenoldopam and gastric tonometry during orthotopic liver transplantation.

UNLABELLED: The aim of this study was to evaluate the effects of continuous infusion of fenoldopam on splanchnic perfusion in orthotopic liver transplant (OLT) recipients. PATIENTS AND METHODS: We enrolled 40 patients of mean age 57+/-16 years who underwent (OLT). They were randomly divided into two double blinded groups; continuous fenoldopam (0.06 mcg/kg per minute) or placebo infusion. Hemodynamics, gastric tonometry, urine output, renal function parameters, and diuretics use were collected during selected phases of the surgery and postoperatively every 12 hours for 72 hours in the intensive care unit. RESULTS: No significant differences were observed between the two groups concerning hemodynamics, though in the fenoldopam group we observed increased splanchnic perfusion during the whole study period but particularly after arterial unclamping (pHi 7,31+/-0.04 vs 7.28+/-0.05; P < .05) and at 48 hours after surgery (pHi 7.49+/-0.15 vs 7.39+/-0.15; P < .05). Creatinine and blood urea nitrogen values were slightly higher in the placebo group, but this data did not reach statistical significance, while higher doses of furosemide were administered to the placebo group to maintain a urinary output over 200 mL/hour during the whole study. DISCUSSION: In this study we observed that continuous fenoldopam infusion (0.06 mg/kg per minute) improved splanchnic perfusion without affecting systemic pressure. CONCLUSION: Patients undergoing OLT have altered splanchnic perfusion related to cirrhosis, surgical manipulation, and fluid shifts during and after surgery. The use of a splanchnic vasodilator drug improved outcomes in these patients.

Clinical effects of use polymyxin B fixed on fibers in liver transplant patients with severe sepsis or septic shock.

UNLABELLED: Polymyxin B (PMX-B) is a polycationic antibiotic, known to bind the lipid A portion of endotoxin, a cell wall component exclusively found in gram-negative bacteria (GNB). An extracorporeal hemoperfusion device (TORAYMYXIN) has been developed: PMX is covalently bound to the surface of an insoluble carrier material to inactivate endotoxin in blood without exerting toxicity on the brain or the kidney. The aim of this study was to evaluate the efficacy, safety, and clinical effects of direct hemoperfusion with an immobilized polymyxin B fiber column (DHP-PMX) among liver transplant patients with severe sepsis or septic shock. METHODS: From June 2004 to May 2005, 10 patients (6 men and 4 women) of overall mean age of 55 years (46-65 range) underwent orthotopic liver transplantation (OLT) and developed severe sepsis or septic shock according to The Consensus Conference of American College Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. GNB were detected in all treated patients who received conventional antibiotic therapy, vasopressor or inotropic agents, and ventilatory support. The DHP-PMX treatment was performed three times in each patient. Hemodynamic and respiratory parameters and dosages of vasopressor or inotropic drugs were assessed at baseline and after each treatment. RESULTS: No adverse events occurred. From baseline to the third treatment the mean arterial pressure increased from 64 +/- 5 mm Hg to 89 +/- 4 mm Hg); while the dosages of dobutamine and norepinephrine were reduced: 6.4 to 1 mcg/kg/min and 1.3 to 0.001 mcg/kg per min, respectively. The PaO(2)/FiO(2) ratio increased: 214 to 291 mm Hg. CONCLUSION: The use of DHP-PMX may be an important aid in patients with sepsis in association with conventional therapy.

Incidence of fungal infections in a solid organ recipients dedicated intensive care unit.

UNLABELLED: Invasive fungal infections are a significant cause of morbidity and mortality for patients undergoing solid organ transplantation. Our aim was to evaluate the incidence of invasive fungal infections in solid organ recipients within a dedicated intensive care unit (ICU). MATERIALS AND METHODS: From May 2002 to May 2005, 278 patients undergoing solid organ transplantation (105 liver, 142 kidney, 20 lung, 2 combined liver-kidney, 9 combined pancreas-kidney) were admitted to our posttransplant intensive care unit. We retrospectively analyzed data obtained from the ICU stay. Fungal infection was defined by positivity of normally sterile biological samples and by elevated positivity of normally non sterile biological samples. We did not consider superficial fungal infections and asymptomatic colonizations. RESULTS: Forty-six patients (16.5%) developed a fungal infection; at least one mycotic agent was isolated from each patient. Candida albicans was the most common pathogen, isolated from 71 % of infected patients (33 of 46). Infected patients showed a mortality rate of 35%, while that for non infected recipients was 3.5%. Total length of ICU stay was the most significant risk factor among infected patients (30.26 days vs 5.04 days P < .0001). Mean time between transplantation and first positive samples was 6.17 days (SD 8.88). CONCLUSION: Fungal infections in solid organ transplant patients are a major issue because of their associated morbidity and mortality. Candida albicans was the most common pathogen and total length of ICU stay was the most important risk factor.

Modifications of intracranial pressure after molecular adsorbent recirculating system treatment in patients with acute liver failure: case reports.

UNLABELLED: Cerebral dysfunction may be fatal in patients with acute liver failure (ALF); intracranial pressure (ICP) monitoring may be mandatory to direct measures to prevent further cerebral edema. Recently the introduction of dialysis with the molecular adsorbent recirculating system (MARS) has improved the outcomes among patients with ALF. The aim of this study was to evaluate ICP changes after MARS treatment among patients with ALF. METHODS: Three patients -- 14, 18 and 16 years old -- were admitted to the ICU for acute liver failure induced by HBV in two cases and by acetaminophen in the other one. Because of Glasgow Coma Score (GCS) <8, they were intubated and ventilated to protect the airway and maintain moderate hypocapnia. Invasive monitoring of intracranial pressure MARS treatments were performed in all patients. RESULTS: The patients received MARS treatments every day after their admission to liver transplantation. After MARS therapy the ICP decreased on average from 21 to 7 mm Hg. Significant hemodynamic modifications were not observed and their neurological conditions improved. CONCLUSION: MARS treatment improved the clinical pictures of these patients increasing the available time to obtain an urgent liver graft.

Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study.

BACKGROUND AND OBJECTIVES: The aim of this prospective, observational study was to evaluate changes in regional cerebral oxygen saturation (rSO2) and incidence of intraoperative cerebral desaturation in a cohort of elderly patients undergoing major abdominal surgery. METHODS: rSO2 was continuously monitored on the left and right sides of the forehead in 60 patients older than 65 yr (35 males and 25 females; ASA II-III; age: 72 +/- 5 yr; without pre-existing cerebral pathology, and baseline Mini Mental State Examination (MMSE) score >23) undergoing sevoflurane anaesthesia for major abdominal, non-vascular surgery >2 h. RESULTS: Baseline rSO2 was 63 +/- 8%; cerebral desaturation (rSO2 decrease <75% of baseline or <80% in case of baseline rSO2 <50%) occurred in 16 patients (26%). The MMSE decreased from 28 +/- 1 before surgery to 27 +/- 2 on 7th postoperative day (P = 0.05). A decline in cognitive function (decrease in MMSE score > or = 2 points one week after surgery as compared to baseline value) was observed in six patients without intraoperative cerebral desaturation (13.6%) and six patients who had intraoperative cerebral desaturation (40%) (P = 0.057) (odds ratio: 4.22; CI95%: 1.1-16). Median (range) hospital stay was 14 (5-41) days in patients with an area under the curve of rSO2 <50% (AUCrSO2<50%) >10 min%, and 10 (4-30) days in those with an AUCrSO2<50% <10 min% (P = 0.0005). CONCLUSIONS: In a population of healthy elderly patients, undergoing non-vascular abdominal surgery cerebral desaturation can occur in up to one in every four patients, and the occurrence of cerebral desaturation is associated with a higher incidence of early postoperative cognitive decline and longer hospital stay.

Extracorporeal circulation with low systemic heparinization during lung transplantation.

BACKGROUND: Some lung transplantation (LT) recipients suffer from pulmonary hypertension and right ventricular dysfunction or failure requiring extracorporeal circulation (ECC) to avoid catastrophic complications during surgery. The extracorporeal support usually requires systemic heparinization which is potentially associated with important side effects. We performed eight LT using preheparinized ECC circuits and an oxygenator associated with a lower level of systemic heparinization without evidence of perioperative complications. PATIENTS AND METHODS: From May 2002 to May 2005, 8 patients (5 men and 3 women) of mean age 22.5 +/- 9.5 years underwent bilateral sequential lung transplantation (BSLT) for cystic fibrosis (n = 6) or idiopathic pulmonary fibrosis (n = 2). All procedures were performed with ECC through a femoro-femoral veno-arterial bypass with preheparinized circuits and an oxygenator. RESULTS: No intraoperative mortality occurred. The mean ECC time was 147.8 +/- 31.3 minutes and the mean heparin administered was 3525 +/- 969.16 UI. No coagulopathy or thrombotic events were observed perioperatively. CONCLUSIONS: Our study confirmed the efficacy and safety of prehepanized circuits and oxygenator for femoro-femoral veno-arterial bypass during LT for patients with severe pulmonary hypertension requiring ECC.

Preconditioning effects of levosimendan in coronary artery bypass grafting--a pilot study.

BACKGROUND: The calcium sensitizer levosimendan protects against myocardial ischaemia and reperfusion injury in animal models. METHODS: The present pilot study investigated whether a short infusion before coronary artery bypass grafting (CABG) would protect the myocardium and improve postoperative haemodynamics. Twenty-four patients with stable angina undergoing elective CABG surgery were randomized to receive either placebo or levosimendan (24 microg kg(-1)) infused i.v. over a 10 min period just before placing the patient on cardiopulmonary bypass. RESULTS: Perioperative haemodynamic variables, concentrations of cardiac troponin I over the 48 h postoperative period, and clinical outcomes were assessed. There were no adverse effects related to levosimendan. Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.05) and a higher cardiac index (P<0.05). CONCLUSION: Patients receiving a short infusion of levosimendan before CABG showed evidence of less myocardial damage, suggestive of a preconditioning effect. Larger outcome studies are thus indicated to confirm benefit.