Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery.

BACKGROUND: Obstructive sleep apnea (OSA) is a common disease which increases the risk of perioperative complications. The aim of this study is to assess the clinical utility of preoperative screening for OSA in determining the prevalence of patients at high risk of OSA in a surgical population, the incidence of difficult airway management and the incidence of perioperative complications. METHODS: We conducted a multisite, prospective observational study on adult patients scheduled for elective surgery. All patients completed a STOP-Bang questionnaire as a part of their preoperative evaluation. Collected data included: demographic data, type of surgery, ASA class, postoperative course, complications within 48 hours, difficult intubation (DI) and difficult mask ventilation (DMV) rates. RESULTS: A total of 3452 consecutive patients were recruited; 2997 (87%) were identified as low OSA risk patients and 455 (13%) were identified as high OSA risk patients; 113 (3%) postoperative complications, 315 (9%) cases of DMV and 375 (11%) of DI were observed. The percentage of postoperative complications in patients with HR-OSA was 9%, while the percentage of DI was 20% and the percentage of DMV was 23%. High risk for OSA and higher BMI (≥30 Kg m-2) were independently associated with risk for perioperative complications. CONCLUSION: In conclusion, this study demonstrates that the prevalence of high OSA risk patients in the surgical population is high. The increase in the rates of perioperative complications justifies the implementation of perioperative strategies that use the STOP-Bang as a tool for triage.

Effectiveness and predictors of success of noninvasive ventilation during H1N1 pandemics: a multicenter study.

BACKGROUND: The use of non-invasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF) due to H1N1 virus infection is controversial. In this multicenter study we aimed to assess the efficacy of NIV in avoiding endotracheal intubation (ETI) and to identify predictors of success or failure. METHODS: In this prospective multicenter study, 98 patients with new pulmonary infiltrate(s) sustained by H1N1 virus and a PaO(2)/FiO2<300 were eligible for study; 38/98 required immediate ETI, while the others received NIV as a first line therapy; 13/60 patients failed NIV and were intubated after 5.8+5.5 hours from enrolment. The remaining 47/60 patients were successfully ventilated with NIV. RESULTS: Hospital mortality was significantly higher in those patients who failed NIV vs. those who succeeded (53.8% vs. 2.1%; OR=0.52, P<0.001). ETI was associated with higher number of infectious complications, mainly sepsis and septic shock. The OR of having one of these events in the NIV failure group vs. NIV success was 16.7, P<0.001. According to logistic regression model, a SAPS II>29 and a PaO(2)/FIO(2)≤127 at admission and PaO2/FIO(2)≤149 after 1 hr of NIV were independently associated with the need for ETI. CONCLUSION: The early application of NIV, with the aim to avoid invasive ventilation, during the H1N1 pandemics was associated with an overall success rate of 47/98 (48%). Patients presenting at admission with an high SAPS II score and a low PaO(2)/FiO(2) ratio and/or unable to promptly correct gas exchange are at high risk of intubation and mortality.

Time course of proadrenomedullin in the early phase of septic shock. A comparative study with other proinflammatory proteins.

AIM: It has been shown that pro-adrenomedullin is a good marker of the severity of septic shock but there are no data on the early changes in serum pro-adrenomedullin concentrations in patients with shock. METHODS: Twenty-one patients with septic shock and 21 healthy subjects studied as controls. Serum concentrations of pro-adrenomedullin, procalcitonin, ferritin, CRP and IL-6 were determined in all subjects at the initial observation. Patients with septic shock were also studied after 24 and 48 hours. RESULTS: The concentrations of the acute phase proteins were significantly higher in patients with septic shock than in the control subjects during the entire study period (P<0.001). Only procalcitonin significantly decreased on the third day of observation with respect to both the first day (P=0.002) and the second day (P=0.006). Proadrenomedullin (P=0.017) and IL-6 (P=0.001) showed an AUC significantly different from the null hypothesis in differentiating the patients who survived and those who did not. The sensitivity and specificity of pro-adrenomedullin in the assessment of death were 71.4% and 72.7%, respectively, while IL-6 had a sensitivity of 92.9% and a specificity of 60.6%. CONCLUSION: Proadrenomedullin is a reliable prognostic marker in patients with shock; further studies on a more consistent number of septic patients will definitively assess whether proadrenomedullin may replace the current prognostic markers in critically ill patients with shock due to sepsis.

Wernicke's encephalopathy and pancreatic encephalopathy after necrotic-hemorrhagic pancreatitis. A case report.

This case report describes a case of acute necrotic-hemorrhagic pancreatitis complicated by Wernicke's encephalopathy (WE) and stresses the importance of a correct dietetic regimen. A 39-year-old Chinese male patient with negative remote pathological anamnesis was hospitalized in the Medical Department with a diagnosis of gallstones. The clinical course was complicated with the onset of acute pancreatitis. Enteral fasting was imposed with intravenous feeding without vitamin supplementation. The progressive worsening of the clinical, radiodiagnostic and laboratory profile combined with deterioration in the state of consciousness promoted, on the 36th day exploratory laparotomy revealed necrotic-hemorrhagic pancreatitis. The patient was, therefore, admitted to the Intensive Care Unit in a deep coma. The recent medical history, neurological examination, and encephalic computed tomography suggested a revealing diagnosis of WE combined with pancreatic encephalopathy.

Protocols to manage postoperative pain in neonates and children hospitalized in a surgical ward. Methodological issues and cultural background.

The authors describe the cultural background and methods they adopted to construct protocols for analgesia in newborns and children hospitalized in a surgical ward. Drugs and dosages are reported in the Appendix, whereas scales for pain measurement and cut off ratings for rescue doses (or otherwise relevant) are described respectively in Tables 2 and 3. Genetics and cognitive structures play a crucial role in pain and analgesia. Protocols have a critical role, however their application must be tailored to the single child.

Thoracoscopy in children: anaesthesiological implications and case reports.

AIM: Videoassisted thoracic surgical technique in children is being used with increasing frequency for an extensive variety of diagnostic and therapeutic procedures. The aim of the study was to assess respiratory, cardiocirculatory and body temperature changes in children undergoing thoracoscopy and to identify if the trend of such changes was modifiable by factors such as lung exclusion, length of the thoracoscopy and preoperative respiratory compromise. METHODS: A total of 50 patients (38 boys and 12 girls) undergoing general anaesthesia for diagnostic and therapeutic thoracoscopic procedures were analysed. The values of the monitored parameters were compared at 6 specific times: T1 - at the end of anaesthesia induction (considered the basal level); T2 - after lateral position; T3 - before pleural CO2 insufflation; T4 - 10 min after pleural CO2 insufflation; T5 - before pleural deflation; T6 - 10 min after pleural deflation. RESULTS: All patients tolerated the thoracoscopy well, without intraoperative complications. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly lower, and end-tidal CO2 (PETCO(2) significantly higher during thoracoscopy. Body temperature (BT) had a statistically significant reduction during thoracoscopy and after pleural deflation. During one-lung ventilation the PETCO(2) increased compared to two-lung ventilation with intrapleural insufflation, while during two-lung ventilation with intrapleural insufflation SBP and DBP decreased compared to one-lung ventilation. The length of the thoracoscopy increased the PETCO(2) and reduced the BT. The preoperative respiratory compromise increased the PETCO(2). CONCLUSIONS: Although thoracoscopy in children brings about certain respiratory, cardiocirculatory and body temperature changes, it is nevertheless a safe and efficient surgical technique.

Secondary prevention of latex allergy in children: analysis of results.

OBJECTIVE: Latex allergy has become an increasing and clinically important problem. Several recommendation for secondary preventive measures have been advised. The aims of the study were to illustrate the results of the latex-safe protocol and to evaluate in allergic patients the role of risk factors for the development of latex allergy. METHODS: Latex-safe treatment was divided into the following phases: anamnestic identification, allergologic assessment, patient selection, intervention programme, preventive medication, operating room equipment, postoperative management, patient and family training, follow-up. RESULTS: Between 1998 and 2004, 6.832 patients underwent 7.333 operations. Anamnestic and diagnostic tests showed that 26 patients had latex allergy. 44 secondary perioperative latex-safe management have been accomplished in 26 children. No allergic event or complications linked to the procedure occurred. Atopy, congenital malformations frequently associated with latex allergy and the presence of 5 or more surgical procedures were the major risk factors recognized. Six out of the 26 patients (23%) had only one risk factor (atopy). Twenty out of 26 children (77%) had several associated risk factors: 8 of them had simultaneously 9 of the 10 analysed risk factors. Our data shows that, the higher their number, the higher the gravity of the allergy. CONCLUSIONS: Although latex allergy is a limited phenomenon, it is nevertheless quite frequent within risk groups. Most patients have simultaneously many risk factors for the development of such an allergy, and the occurrence of several risk factors increases severity of the allergy. Latex-safe perioperative management offers guarantees of safety against latex allergy phenomena.

The role of emergency thoracoscopy in the management of congenital cystic adenomatoid malformation of the lung associated with oesophageal atresia.

Congenital cystic adenomatoid malformation of the lung associated with oesophageal atresia is exceptional. The authors describe a case of a mixed type I - II congenital cystic adenomatoid malformation of the left lung associated with oesophageal atresia and tracheooesophageal fistula in a male infant. The interesting aspect of this case is not only the extremely rare association - only two reports in the literature - but the surgical choices. In fact, two weeks after surgical repair of the oesophageal atresia, the growth of the cystic volume of the congenital adenomatoid malformation made respiratory weaning very difficult, and it was therefore decided to solve the respiratory distress by opening the tensional cysts using a thoracoscopic access. The advantage of this treatment was that it decompressed the underlying healthy lung tissue and permitted the expansion of the normal lobar parenchyma. This is a palliative approach that allows the mandatory definitive resection of the affected lung lobe to be postponed until a later time.

Exposure of personnel to sevoflurane during paediatric anaesthesia: influence of professional role and anaesthetic procedure.

BACKGROUND AND OBJECTIVE: This study was performed to determine the individual exposure of paediatric operating theatre personnel to sevoflurane and to evaluate the impact of inhalation induction and various airway approaches on exposure to airborne sevoflurane. METHODS: Mean individual environmental (workplace air) exposure to sevoflurane and a biomarker of exposure (urinary sevoflurane) were monitored in 36 subjects (10 anaesthetists, 10 surgeons, 12 nurses and 4 auxiliary personnel) working in two paediatric operating rooms. RESULTS: Environmental and urinary values were significantly greater in anaesthetists compared with other groups, with median values of 0.65ppm (interquartile range 1.36; 95th percentile 4.36) for breathing zone sevoflurane and 2.1 microgL(-1) urine (interquartile range 2.6; 95th percentile 7.6) for urinary sevoflurane. Anaesthetists exceeded the 2ppm maximum allowed environmental concentration recommended by the National Institute for Occupational Safety and Health in 4 of 22 cases (18.1%). A positive correlation was found between the number of patients undergoing inhalational induction each day and mean values of breathing zone and urinary sevoflurane. An increase in the number of daily laryngeal mask insertions, or the use of rigid bronchoscopy, are statistically related to higher environmental and urinary values (P < 0.01 and <0.00001 for breathing zone sevoflurane, P < 0.05 and <0.01 for urinary sevoflurane, respectively). CONCLUSIONS: Anaesthesia with sevoflurane can pose a hazard of chronic exposure with anaesthetists having the highest risk. Endotracheal intubation offers considerable protection against exposure. Routine anaesthesia using a standard facemask, a laryngeal mask or rigid bronchoscopy are risk factors for increased anaesthetic exposure.

Tracheal agenesis: management of the first 10 months of life.

Tracheal agenesis is a potentially lethal congenital anomaly, appearing only at birth. We describe a newborn preterm infant who presented with immediate respiratory distress and no audible cry. There was almost complete tracheal agenesis with a very short segment of distal trachea (only two tracheal rings) arising from the anterior wall of the esophagus, before dividing into the mainstem bronchi. The anomaly was unsuspected prenatally, as the scan showed pyloric atresia and complex congenital cardiac disease. Despite the patient's difficult course, with correction of the rare-associated malformations (cardiac and gastrointestinal tract anomalies), the fact that the child is lively and neurologically normal for her age, requires that we now consider the patency of the airway and the possibility of surgical correction, in accordance with a good quality of life.

Peripherally inserted central venous catheters in preterm newborns: two unusual complications.

This report describes the case of two newborns who suffered unusual complications after peripheral insertion of a central venous catheter. In one baby a fragment of the catheter tip became embolized in a peripheral branch of the left pulmonary artery. In the other baby, the catheter perforated a peripheral branch of the pulmonary artery, giving rise to chemical pneumonitis with extensive pleural effusion. The outcome was positive for both babies. A large clinical series is necessary to establish the complications of this procedure, their prevention and management.

Latex allergy in children with oesophageal atresia.

BACKGROUND: Latex allergy is frequently found in children and patients with spina bifida and urogenital abnormalities and have been considered at risk for latex sensitization. The aim of the study was to evaluate the incidence of latex sensitization in patients with oesophageal atresia and undergoing three or more surgical procedures and to identify possible risk factors in the process of latex sensitization. METHODS: A total of 20 patients were analysed: 19 boys and one girl. The oesophageal atresias were as follows: type I in three children, type II in two and type III in 15 children. Surgical and anaesthetic procedures, intensive care management, age, type of oesophageal atresia, associated congenital malformations, Waterston and Montreal prognostic classifications were considered as risk factors that may be implicated in the process of sensitization. RESULTS: Five patients (25%) were considered sensitized to latex (group 1) and 15 (75%) nonsensitized (group 2). Among the five sensitized patients, three reported clinical reactions to latex, while the other two presented only specific IgE sensitization. The number of operations, the total hours of surgery, the number of drainages, the total days of drainage, the total days of central venous catheter were significantly greater in group 1 than in group 2. Both of the highest risk oesophageal atresia classes (Waterston C and Montreal II) were related to latex allergy. CONCLUSIONS: Oesophageal atresia, especially in cases of prolonged management, must be considered as a risk for the development of latex allergy.

Gastric perforation in a newborn.

Gastric perforation in neonates is an uncommon condition. In most cases, it is attributed to peptic ulceration and/or hemorrhagic gastritis. The high mortality rate in such patients can be improved by early diagnosis and prompt resuscitation, followed by surgery. We report a full-term female newborn, who developed a gastric perforation in the first day of life. The possible aetiology and the perioperative management are discussed.

[In-hospital pediatric cardiopulmonary resuscitation]. / Emergenze intraospedaliere pediatriche.

Between 0,7-3% of pediatric patients may require resuscitation during hospital stay. The physicians of the Pediatric Intensive Care Unit of the C.O.U. Anesthesia and Intensive Care-Baroncini developed a plan for the management of pediatric emergencies inside the Department of Pediatric Medical and Surgical Sciences. The plan consisted of: the drawing up of a PI 34-Procedure; the preparation and implementation of a training course for doctors and nurses; the purchase of 12 emergency-trolleys according to the Broselow Pediatric Resuscitation Measuring Tape and the implementation of a specific system for the emergency-call. Precise duty for anesthesiologists and intensivists is the emergency- planning and management, in order to diffuse the medical knowledge needed to assist patients requiring vital functions support. The management of the intra-hospital pediatric emergencies is strictly dependent on the training of the staff, based on a specific support algorithm, and specific equipment for the different ages.

Agenesis of the appendix vermiformis.

Agenesis of the appendix vermiformis represents a rare condition that accounts in approximately 1 in 100.000 laparotomies performed for suspected acute appendicitis. L.B., female, born at term after a normal pregnancy. Shortly after birth she presented respiratory distress; chest x-ray showed a left diaphragmatic hernia (CDH). At operation was noted the absence of the appendix and of the mesenteriolum as well together with the presence of a mesenterium commune. Other associated anomalies were detected: dextroposition of the heart, hypoplasia cnemis, hexadactylism of right foot, congenital hip displacement and bilateral congenital cataract. Etiopathogenesis of the agenesis of the appendix can be easily understood from an embryological point of view, following the cecal pole development. Diagnosis of this malformation is possible only after an accurate laparotomic or laparoscopic exploration around the ileocecal and retrocecal zone.

Bronchoscopy in newborns with esophageal atresia.

The aim was to evaluate the influence of rigid laryngotracheo-bronchoscopy in newborns with oesophageal atresia (OA) and tracheoesophageal fistula (TOF) in preventing complications, improving diagnosis and surgical treatment. Among 76 consecutive newborns, received in the Paediatric Intensive Care Unit (PICU) from January 1990 to September 2001 with prenatal o perinatal suspected OA, forty-five had one or more other congenital anomalies. They were divided in I Montreal's risk group for 73.7% (56) and in the II one for 26.3% (20). Endoscopic procedure was performed in the operating room with Storz's rigid ventilating bronchoscope just before surgery, in all babies. With bronchoscopic examination we were able to identify the level, number and size of TOF and to visualise anatomical variants in 76 children. 15 children with OA had a gasless abdomen, but an upper pouch fistula was found only in three cases. In another four cases bronchoscopy confirmed the diagnosis of an "H" fistula and cervical surgical approach was established. One case had only oesophageal stenosis. 56 patients had fistula in lower pouch and in the last 38 cases we proceeded with selective transtracheal fistula incannulation and then we provided gastric drainage. One quadriforcation, 2 triforcations, 3 aberrant right upper lobe bronchi, 1 congential subglottic stenosis and 1 associated with a congenital subglottic stenosis and 1 left main bronchus agenesia were detected. No complications were correlated to the procedure and no babies had early pneumonia. Continuous feeding was achieved in 70 out of 76 patients: 46 primary anastomosis with 12 staged repairs (OA I and II type long gap), 4 resections of TEF, 8 oesophagocoloplasty. Nine babies (11.8%) did not survive. Clinical follow-up was possible in all the survivors. Mortality rate in the high-risk patients with OA remains high because of the many complications that may occur. Tracheal endoscopy is useful in improving the diagnostic approach and to prevent pulmonary complications. Fistula incannulation minimizes the risk of gastric distension and its detrimental effect on ventilation, helping the surgeon to identify TEF easily and quickly. Moreover, the endoscopic approach offers obvious advantages for the anaesthesiologist and the surgeon and has proven, in our experience, to be effective.