Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know.

Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium-left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair.

Anesthesiological approach to the floppy child.

Children with symptoms of hypotonia (reduction of postural tone of lower limbs and trunk with or without changes in phasic tone) are frequently anesthetized for diagnostic and therapeutic interventions. This review outlines the underlying causes and classifications, and the anesthesiologic pre- and peri-operative management of hypotonic children. Hypotonia may have a large range of etiologies that are categorized into central and peripheral hypotonia. A multidisciplinary approach towards the (differential) diagnosis of the underlying cause of the symptoms in cooperation with a pediatrician and/or pediatric neurologist is emphasized. Anesthetic management involves the anticipation of an increased risk in difficult airway management because of macroglossia, reduced mouth opening, obesity and limited neck mobility, which increases with age. There are no specific restrictions towards the use of intravenous or inhalational anesthetics. Short acting opioids and hypnotics, avoiding neuromuscular blockade, and locoregional techniques are preferred. Most patients are sensitive to the cardiac and depressive effects of anesthetics and all dystrophic myopathies are considered at risk of malignant hyperthermia. Depolarizing neuromuscular blockers are contraindicated. The use of a peripheral nerve stimulator is recommended to detect the severity of muscle relaxation before extubating. Accurate control and management of IV fluids, electrolytes and temperature is mandatory. Adequate postoperative pain treatment is essential to limit stress and metabolic alteration. Preferably a locoregional technique is used to reduce the increased risk of respiratory depression. A multidisciplinary preoperative approach taking into account the differential diagnosis of the underlying disease of the floppy child is recommended.

VAC therapy with long term continuous saline infusion for secondary septic peritonitis: A new strategy for the reduction of perioperative risks?

BACKGROUND: The management of a septic peritonitis open abdomen is a serious problem for clinicians. Open surgery is associated with several complications such as bleeding and perforation of the bowel. CASE PRESENTATION: The authors report a case of a 59-years-old female who underwent a sigmoid resection with an latero-terminal (L-T) anastomosis for the perforation of a diverticulum. After a few days the patients developed a new widespread peritonitis. At the emergency re-laparotomy, surgeons found dehiscence of the posterior wall of the anastomosis with fecal contamination. At admission in ICU (Intensive Care Unit) the patient had open abdomen with dehiscence of cutaneous and subcutaneous layers. CONCLUSION: Conservative therapy with antibiotic therapy and use of the Vacuum-Assisted Closure® (VAC) Therapy with a long term continuous saline infusion led to the resolution of the septic shock and to the wound healing.

Delayed fatal diagnosis in atypical rickettsial infectious disease.

We report the case of an 84-year-old man admitted to ICU with symptoms/signs occurring after upper respiratory airways disease. The upper respiratory condition consisting in an uvula oedema required an empiric anti-inflammatory and antibiotic therapy which masked the clinical features usually seen in the case of rickettsial infections, especially cutaneous rash. Although the patient subsequently presented unexplained cardiac and neurological involvement, the starting treatment interfered with the diagnostic process, resulting in a delayed diagnosis. Rickettsia and other conditions related with a possible tick bite have to be considered in the list of differential diagnosis especially in the case of severe systemic or localised disease, particularly when the only suspicious sign is a clinical history indicative of a patient living in poor conditions of hygiene.