Endosonographic evaluation of the mediastinum through the i-gel O2 supraglottic airway device.

INTRODUCTION: Endobronchial ultrasound (EBUS) is an endoscopic diagnostic procedure combining flexible fibrobronchoscopy with ultrasound techniques; it allows transbronchial needle aspiration biopsy for the diagnosis and staging of mediastinal masses. We present our preliminary experience with the use of the i-gel O2 supraglottic airway device for management of EBUS procedures. METHODS: An observational study on 39 patients who underwent EBUS under general anesthesia was performed. Airways were managed with i-gel O2 by anesthesiologists unfamiliar with it. Data collected included patient characteristics, i-gel O2 positioning, mechanical ventilation, procedure, and complications occurring during and after the EBUS. RESULTS: The i-gel airway was successfully positioned during the first attempt in 34/39 cases (87.2%). No failed positioning was recorded. The EBUS scope easily passed through the i-gel in all patients and in 14 (35.6%) cases it was also inserted through the esophagus allowing the examination or fine needle aspiration of paraesophageal lymph nodes. In one case, during the EBUS procedure, the i-gel was dislocated but easily put in place again. During EBUS, air leakages were significant in 2 cases (5.1%) and minimal in 14 cases (35.9%). A brief self-solved laryngospasm and a bronchospasm during bronchoscopy were recorded. After recovery, no patients had dysphagia; mild odynophagia and pharyngodinia were referred by 2 (5.1%) and 12 (30.1%) patients, respectively. CONCLUSIONS: The i-gel O2 airway is easy to position and manage even for anesthesiologists unfamiliar with it. This supraglottic airway device is suitable for a complete endosonographic evaluation of the mediastinum.

Malnutrition and Perioperative Nutritional Support in Retroperitoneal Sarcoma Patients: Results from a Prospective Study.

INTRODUCTION: Retroperitoneal soft tissue sarcomas (RPSs) are mesenchymal neoplasms. The prevalence of protein energetic malnutrition (PEM) and its impact in RPS patients who were candidates for surgery is unknown. MATERIALS AND METHODS: A prospective feasibility study enrolled 35 patients with primary RPS who were candidates for extended multivisceral resection. PEM was screened at enrollment. Preoperative high protein ß-hydroxy-ß-methyl butyrate oral nutritional support (ONS) was provided according to the degree of PEM. After surgery, nutritional support followed standard practice, targeting at least 1 g/kg/day protein and 20 kcal/kg/day caloric intake within the third postoperative day (POD). PEM was re-evaluated before surgery on POD 10, and at 4 and 12 months after surgery. Primary outcomes were the patient's compliance to preoperative ONS and the physician's compliance to postoperative nutritional targets. RESULTS: PEM was documented in 46% of patients at baseline; ONS met a 91% adherence (overall well tolerated). After ONS, PEM reduced to 38% (p = 0.45). The postoperative caloric target was reached on day 4.1 (standard error ± 2.7), with a protocol adherence rate of 52%. On POD 10, 91% of patients experienced PEM, the worsening of which was greater after resection of four or more organs (p = 0.06). At 4 and 12 months after surgery, almost all patients had fully recovered. A significant correlation between PEM at surgery and postoperative complications was found (p = 0.04). CONCLUSIONS: Relevant PEM prevalence in RPS is documented for the first time. PEM correlates with greater morbidity. In this setting, preoperative ONS was feasible and well-tolerated. Disease-related factors for PEM and the ideal perioperative caloric target in the context of extended multivisceral resection need to be further investigated. Nutritional support should be included in enhanced recovery after surgery programs for RPS. TRIAL REGISTRY: ClinicalTrials.gov identifier: NCT03877588.

Comparison Between Swan-Ganz Catheter and Minimally Invasive Hemodynamic Monitoring During Liver Transplantation: Report of a Monocentric Case Series.

INTRODUCTION: The aim of the present investigation was to retrospectively evaluate the utilization of Swan-Ganz catheter during orthotopic liver transplantation as opposed to FloTrac/Vigileo in selected cases, comparing a number of clinical outcomes across postoperative hospitalization. MATERIALS AND METHODS: Before 2015 all recipients received pulmonary artery catheter (Swan-Ganz group, n = 109). After 2015 Swan-Ganz was used only if coronary artery disease or high-grade portal hypertension or Child-Pugh C were present; the remaining recipients were assigned to FloTrac/Vigileo monitoring (Mini group, n =100). A number of clinical outcomes were considered. RESULTS: Donor's Risk Index was similar between groups (median value 1.7, P = .27). Anthropometric characteristics of the recipients were similar in the 2 groups. There were no significant differences in the proportion of patients with Child-Pugh C (P = .873), coronary artery disease (P = .18), and grade of portal hypertension (P = .733). The Model for End-Stage Liver Disease score was slightly higher in the Mini group: (9 [7-11] vs 9 [8-12], Swan-Ganz vs Mini, respectively, P < .035). Swan-Ganz utilization decreased over time (92% vs 26%, Swan-Ganz vs Mini, P < .001). Upon admission to the intensive care unit, patients of the Mini group presented a higher SAPS II score with similar values of Sequential Organ Failure Assessment score. Days on mechanical ventilation were similar between groups. The incidence of graft failure was similar between groups (2% vs 5%, Swan-Ganz and Mini group respectively, P = .376). Recipients' hospital length of stay was similar (13 days [11-19] vs 14 [11-20], P < .083). CONCLUSIONS: Our data suggest that the intraoperative utilization of FloTrac/Vigileo for oncologic patients with low grade end stage liver disease is reasonably safe.

Unexpected postpneumonectomy exertion-induced acute right heart failure.

INTRODUCTION: Thoracic surgery can have serious side effects. Accurate preoperative evaluation to assess which patients with anatomically resectable disease are suitable candidates for surgery is mandatory. CASE DESCRIPTION: A 58-year-old man, scheduled for left pneumonectomy for lung cancer, passed all the preoperative examinations suggested by guidelines and underwent the surgery. Three days after pneumonectomy, he experienced hemorrhagic shock and subsequent acute respiratory distress syndrome. Fifteen days after left pneumonectomy, he experienced exertional acute right heart failure (ARHF). We administered sildenafil and he improved, clinically and echocardiographically. During the following 2 years of follow-up, he was asymptomatic at rest but under exercise test, he developed pulmonary hypertension with echocardiographic signs of right ventricular impairment. CONCLUSIONS: In patients scheduled for major lung resections, preoperative stress echocardiography may give an adjunctive value to cardiopulmonary exercise test, quantifying the exercise-induced reduction in right ventricle ejection fraction and identifying asymptomatic patients at risk for postoperative ARHF.

Perioperative steroids administration in pediatric cardiac surgery: a meta-analysis of randomized controlled trials*.

OBJECTIVE: To evaluate the effects of prophylactic perioperative corticosteroid administration, compared with placebo, on postoperative mortality and clinical outcomes (renal dysfunction, duration of mechanical ventilation, and ICU length of stay) in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. DATA SOURCES: MEDLINE and Cochrane Library were screened through August 2013 for randomized controlled trials in which perioperative steroid treatment was adopted. STUDY SELECTION: Included were randomized controlled trials conducted on pediatric population that reported clinical outcomes about mortality and morbidity. DATA EXTRACTION: Eighty citations (PubMed, 48 citations; Cochrane, 32 citations) were identified, of which 14 articles were analyzed in depth and six articles fulfilled eligibility criteria and reported mortality data (232 patients), two studies reported ICU length of stay and mechanical ventilation duration (60 patients), and two studies reported renal dysfunction (49 patients). DATA SYNTHESIS: A nonsignificant trend of reduced mortality was observed in steroid-treated patients (11 [4.7%] vs 4 [1.7%] patients; odds ratio, 0.41; 95% CI, 0.14-1.15; p = 0.089). Steroids had no effects on mechanical ventilation time (117.4 ± 95.9 hr vs 137.3 ± 102.4 hr; p = 0.43) and ICU length of stay (9.6 ± 4.6 d vs 9.9 ± 5.9 d; p = 0.8). Perioperative steroid administration reduced the prevalence of renal dysfunction (13 [54.2%] vs 2 [8%] patients; odds ratio, 0.07; 95% CI, 0.01-0.38; p = 0.002). CONCLUSION: Despite a demonstrated attenuation of cardiopulmonary bypass-induced inflammatory response by steroid administration, a systematic review of randomized controlled trials performed so far reveals that steroid administration has potential clinical advantages (lower mortality and significant reduction of renal function deterioration). A larger prospective randomized study is needed to verify clearly the effects of steroid prophylaxis in pediatric patients.

Outcome of children admitted to adult intensive care units in Italy between 2003 and 2007.

BACKGROUND: Centralisation of critically ill children to paediatric intensive care units is supported by a strong rationale, but evidence is not overwhelming. OBJECTIVE: To compare the outcome of children admitted to adult intensive care units (ICUs) in Italy between 2003 and 2007 with that of children admitted to paediatric intensive care units (PICUs) in Italy between 1994 and 1995. METHODS: Prospective, multicenter cohort study and historical controls. Risk of ICU mortality was assessed with the PRISM score in both study and historical control groups. Descriptive statistics, standardized mortality ratios (SMRs) with their 95% confidence intervals, and the calibration plots were reported. RESULTS: A total of 1,265 children admitted to 124 adult ICUs between 2003 and 2007 were compared with an historical control group formed by 1,533 children admitted to 26 PICUs between 1994 and 1995. The PRISM score slightly underestimated hospital deaths for low-risk patients in both groups. The overall SMR was 1.11 (95% CI 0.91-1.31) for adult ICUs and 1.04 (95% CI: 0.88-1.19) for PICUs. CONCLUSIONS: The level of care provided nowadays to children admitted to adult ICUs in Italy is similar to that provided by Italian PICUs 10 years earlier. On the other hand, there is evidence that Italian PICUs have improved the level of care in the same period. These findings, if confirmed, suggest a better quality of care for children admitted to PICUs as compared to adult ICUs and support the indication, when possible, of early referral to more specialized units in countries where paediatric intensive care is not centralised.

Successful bleeding control by a combined conventional surgical approach and video-assisted surgery: a case report.

The use of central venous catheters (CVCs) nowadays is a routine practice in the treatment of severely acute-diseased children. However, the procedure still carries a risk of morbidity, and severe complications are reported. When respiratory and/or hemodynamic instability develop after the procedure, prompt patient evaluation to exclude iatrogenic damage is mandatory, regardless of the primary patient condition. If a vascular injury related to CVC placement procedure is detected, the availability of an interventional radiologist and/or any surgical facilities plays an important role in the management of this life-threatening complication. We report the case of a 12-year-old boy hospitalized in the Pediatric Intensive Care Unit of our hospital for a severe motorveicle accident, who, about 30 minutes from the percutaneous CVC placement, developed tachycardia, hypoxemia, and hypotension. A chest X-ray confirmed the right positioning of the catheter, the presence also of a large left hemothorax. Interventional radiology took place, but it failed to stop the bleeding. Urgent anterolateral thoracotomy was performed while the patient was kept in a supine position because of a cervical spine luxation. During surgery, bleeding was found coming from the thoracic dome and because of a tear next to the left subclavian artery. Access to that area was technically difficult; after blood and clots were removed, multiple attempts to obtain the hemostasis failed, and definitive control of the hemorrhage was achieved only by video-assisted thoracic surgery (VATS). The postoperative period was uneventful. In this study, the authors discuss the management of this kind of complication and the value of a combined surgical approach (conventional, with a minimal access surgery procedure such as VATS) in the treatment of thoracic vascular injuries related to the insertion of a percutaneous CVC. To the best of our experience, this is the first time in which this combination of procedures has been reported in the literature.

Continuous positive airway pressure with modified helmet for treatment of hypoxemic acute respiratory failure in infants and a preschool population: a feasibility study.

OBJECTIVE: To analyze the feasibility of using continuous positive airway pressure (CPAP) delivered via a modified helmet to treat children with hypoxemic acute respiratory failure. DESIGN: A single-center, prospective, clinical study. SETTING: Pediatric intensive care unit in a university hospital. PATIENTS: Fifteen consecutive children (from 1 month to 5 yrs of age) with hypoxemic acute respiratory failure (defined as Pao2/Fio2 <300). INTERVENTIONS: CPAP was delivered via a modified helmet (CaStar, Starmed, Italy) of reduced size, fastened by a device we call a "baby-body." The feasibility of CPAP with the helmet was the primary end point. The improvement of gas exchange was the secondary one. MEASUREMENTS AND MAIN RESULTS: Ten of 15 children had multiple organ failure. Nine of 15 children were

Coma and respiratory failure in a child with severe vitamin B(12) deficiency.

OBJECTIVE: Psychofunctional follow-up of severe vitamin B(12) deficit. DESIGN: Case report. SETTING: Pediatric intensive care unit. PATIENT: Ten-month-old boy. INTERVENTION: Follow-up at 3 yrs. MEASUREMENTS AND MAIN RESULTS: A 10-month-old boy was admitted to the pediatric intensive care unit with respiratory failure, muscular hypotonia, and involuntary movements. Although a central nervous system infection was excluded, computed tomography scan showed a diffuse cortical-subcortical atrophy. Vitamin B(12) deficiency was suspected because of a red-cell count of 1,350,000/mm(3) and a hemoglobin value 5.9 g/dL (MCV 116). The baby had been exclusively breast-fed, but his mother had been a strict vegan for 10 yrs. Chronic dietary vitamin B(12) deprivation was confirmed by blood and urinary samples. Treatment with vitamin B(12) led in 2 wks to rapid and complete hematological improvement and to partial regression of neurologic symptoms. During the following 3 yrs the boy had normal vitamin intake and underwent intensive rehabilitative treatment. The brain atrophy regressed, but linguistic and psychomotor delay persisted. CONCLUSIONS: Rapid clinical improvement after vitamin supply does not correlate with a complete recovery.

Combined kidney and liver transplantation for familial haemolytic uraemic syndrome.

Recurrent haemolytic uraemic syndrome (HUS) is a genetic form of thrombotic microangiopathy that is mostly associated with low activity of complement factor H. The disorder usually develops in families, leads to end stage renal disease, and invariably recurs after kidney transplantation. We did a simultaneous kidney and liver transplantation in a 2-year-old child with HUS and a mutation in complement factor H to restore the defective factor H, with no recurrence of the disease. The operation was successful, and at discharge, the child had healthy kidney and liver function, with no sign of haemolysis.