Association between preoperative evaluation with lung ultrasound and outcome in frail elderly patients undergoing orthopedic surgery for hip fractures: study protocol for an Italian multicenter observational prospective study (LUSHIP)

Hip fracture is one of the most common orthopedic causes of hospital admission in frail elderly patients. Hip fracture fixation in this class of patients is considered a high-risk procedure. Preoperative physical examination, plasma natriuretic peptide levels (BNP, Pro-BNP), and cardiovascular scoring systems (ASA-PS, RCRI, NSQIP-MICA) have all been demonstrated to underestimate the risk of postoperative complications. We designed a prospective multicenter observational study to assess whether preoperative lung ultrasound examination can predict better postoperative events thanks to the additional information they provide in the form of "indirect" and "direct" cardiac and pulmonary lung ultrasound signs

Neuromuscular block monitoring by smartphone application (i-TOF© system): an observational pilot study

Abstract Neuromuscular block monitoring is recommended by international guidelines to improve myorelaxation during surgery and reduce the risk of postoperative residual curarization. We conducted a pilot study to verify the efficacy of i-TOF, a wireless neuromuscular monitoring device connectable to a smartphone, comparing it with TOF WATCH SX. We enrolled 53 patients who underwent general anesthesia. For each patient, we recorded by both devices, in different time intervals, train-of-four (TOF) count/ratio after induction to general anesthesia (TI0–TI3) and during recovery (TR0–TR3). Moreover, post-tetanic count (PTC) was evaluated during deep neuromuscular block (TP0–TP2). We noticed no significant differences between the devices in recorded mean values of TOF ratio, TOF count, and PTC analyzed at time intervals for every phase of general anesthesia, although the i-TOF tends to an underestimation compared to TOF WATCH SX. For each patient, data sessions were successfully recorded by a smartphone. This aspect could be relevant for clinicians in order to have a stored proof of good clinical practice to be added on anesthesiologist records. By our results, i-TOF demonstrates a comparable efficacy to TOF WATCH SX, suggesting that it could be a proven alternative to standard devices for neuromuscular block monitoring. Further studies are needed to confirm our findings

Evolution of Anesthetic Techniques for Shoulder Surgery: A Narrative Review

Shoulder surgery has radically evolved within the last 70 years, from a marginal orthopedic sub-specialty to an area of great research and advancement; consequently, anesthetic techniques have undergone important development. In fact, a wide variety of anesthetic strategies have emerged, to provide anesthesia and post-operative analgesia: general anesthesia (GA), regional anesthesia (RA), or combined GA and RA. A literature review on online databases was carried out about the different anesthetic approaches for shoulder surgery and their evolution through the years, taking in consideration papers from 1929 to 2021. A comprehensive preoperative assessment of patients undergoing shoulder surgery allows to identify and modify potential risk factors and complications of general anesthesia. Moreover, the use of ultrasound-guided regional blocks could improve the effectiveness of these techniques and bring better postoperative outcomes. Anesthetic management for shoulder surgery has progressed drastically during the last century. More studies are needed to finally standardize anesthetic techniques for specific procedure

Volatile anesthetics in cardiac surgery: the impalpable benefit

Nowadays, there are numerous studies demonstrating that volatile anesthetics reduce mortality and morbidity with a cardio-protective effect. The mechanisms involved in protecting perioperative cardiac ischemic damage provided by desflurane and sevoflurane are not fully known. Volatile anesthetics are commonly used in cardiac surgery. This mini-review aims to summarize the mechanism of action for cardio-protection of volatile anesthetics and discuss the potential therapeutic implications. Human studies have shown that volatile anesthetics can reduce mortality, but also the use of mechanical ventilation in cardiac patients, especially coronary artery bypass grafting. In contrast, total intravenous anesthesia has not shown any significant benefit compared to halogenated agents. Volatile anesthetics are among the few drugs that affect survival in the perioperative period. In addition, they can be administered in areas other than cardiac surgery due to their cardioprotective effects, which may add future perspectives in their use

Transcatheter aortic valve replacement: is anesthesiologic management linked to surgical outcomes?

Aortic valve replacement (AVR) is the current standard treatment for severe aortic stenosis, nonetheless, many patients are not suitable to AVR because of high risk related to advanced age, impaired cardiac function, or comorbidities. Given these considerations, transcatheter aortic valve replacement or implantation (TAVR or TAVI) has emerged in the last decade as an alternative to surgery and has become the treatment of choice for severe aortic stenosis in patients with prohibitive surgical risk. In the context of this kind of hybrid procedure, the anesthesiologist plays a central role because the choice of anesthetic technique is strongly related to clinical features of the patients and technical considerations, which must be discussed collegially with the surgeons. The choice of anesthesiologic management is different among hospitals, but it is generally based on preoperative comorbidities, procedural approach used for TAVR and even hospital logistic. Some centers used to perform TAVR under general anesthesia (GA), some else under local anesthesia plus sedation (LAS), some of them start their TAVR program under GA, but convert in LAS when the team get enough experience. Also, anesthesiologists involved in TAVR procedures must be part of a “heart team”, and should be confident with anesthesia for cardiovascular surgery, mechanical circulatory support, and with transesophageal echocardiography. The aim of this article is to provide a general overview about anesthetic techniques in TAVR and to evaluate pathways for future researches

Triple Monitoring May Avoid Intraneural Injection during Interscalene Brachial Plexus Block for Arthroscopic Shoulder Surgery: A Prospective Preliminary Study

Nerve injury is a feared complication of peripheral nerve blockade. The aim of this study was to test the effectiveness of a triple monitoring (TM), i.e., a combination of ultrasound (US), nerve stimulation (NS) and opening injection pressure (OIP) during interscalene brachial plexus block (IBPB) for surgery of the shoulder. Sixty patients undergoing IBPB for shoulder arthroscopy received TM. BSmart®, an inline injection device connected to a 10 mL syringe, was used to detect OIP during IBPB. Nerve stimulation was set to 0.5 mA to rule out any motor response, and if OIP was below 15 PSI, 10 mL of local anaesthetic was injected under US guidance between the C5 and C6 roots. The main outcome was the ability of TM to detect a needle–nerve contact. Other outcomes including the duration of IBPB; pain during injection; postoperative neurologic dysfunction. Triple monitoring revealed needle–nerve contact in 33 patients (55%). In 18 patients, NS evoked motor responses despite first control with US; in a further 15 patients, BSmart® detected an OIP higher than 15 PSI, despite the absence of motor response to NS. Mean duration of IBPB was 67.2 ± 5.3 seconds; neither pain during injection nor postoperative neurologic dysfunctions were detected. Clinical follow up excluded the presence of postoperative neuropathies. Triple monitoring showed to be a useful and feasible tool while performing IBPB for arthroscopic shoulder surgery. Future studies will be needed to confirm our findings

Systolic-dicrotic notch pressure difference can identify tachycardic patients with septic shock at risk of cardiovascular decompensation following pharmacological heart rate reduction

International audienceBackground: During sepsis, heart rate (HR) reduction could be a therapeutic target, but identification of responders (non-compensatory tachycardia) and non-responders (compensatory for ‘fixed’ stroke volume [SV]) is challenging. We tested the ability of the difference between systolic and dicrotic pressure (SDPdifference), which reflects the coupling between myocardial contractility and a given afterload, in discriminating the origin of tachycardia. Methods: In this post hoc analysis of 45 patients with septic shock with persistent tachycardia, we characterised features of haemodynamic response focusing on SDPdifference, classifying patients according to variations in arterial dP/dtmax after 4 h of esmolol administration to maintain HR <95 beats min−1. A cut-off value of 0.9 mm Hg ms−1 was used for group allocation. Results: After reducing HR, arterial dP/dtmax remained above the cut-off in 23 patients, whereas it decreased below the cut-off in 22 patients (from 0.99 [0.37] to 0.63 [0.16] mm Hg ms−1; mean [SD], P<0.001). At baseline, patients with decreased dP/dtmax after esmolol had lower SDPdifference than those with higher dP/dtmax (40 [19] vs 53 [16] mm Hg, respectively; P=0.01). The SDPdifference remained unchanged after esmolol in the higher dP/dtmax group (49 [16] mm Hg), whereas it decreased significantly in patients with lower dP/dtmax (29 [11] mm Hg; P<0.001). In the latter, the HR reduction resulted in a significant cardiac output reduction with unchanged SV, whereas in patients with higher dP/dtmax SV increased (from 48 [12] to 67 [14] ml; P<0.001) with maintained cardiac output. Conclusions: A decrease in SDPdifference could discriminate between compensatory and non-compensatory tachycardia, revealing a covert loss of myocardial contractility not detected by conventional echocardiographic parameters and deteriorating after HR reduction with esmolol. Clinical trial registration: NCT02188888

Association between preoperative evaluation with lung ultrasound and outcome in frail elderly patients undergoing orthopedic surgery for hip fractures: study protocol for an Italian multicenter observational prospective study (LUSHIP)

Abstract Background Hip fracture is one of the most common orthopedic causes of hospital admission in frail elderly patients. Hip fracture fixation in this class of patients is considered a high-risk procedure. Preoperative physical examination, plasma natriuretic peptide levels (BNP, Pro-BNP), and cardiovascular scoring systems (ASA-PS, RCRI, NSQIP-MICA) have all been demonstrated to underestimate the risk of postoperative complications. We designed a prospective multicenter observational study to assess whether preoperative lung ultrasound examination can predict better postoperative events thanks to the additional information they provide in the form of “indirect” and “direct” cardiac and pulmonary lung ultrasound signs. Methods LUSHIP is an Italian multicenter prospective observational study. Patients will be recruited on a nation-wide scale in the 12 participating centers. Patients aged  >  65 years undergoing spinal anesthesia for hip fracture fixation will be enrolled. A lung ultrasound score (LUS) will be generated based on the examination of six areas of each lung and ascribing to each area one of the four recognized aeration patterns—each of which is assigned a subscore of 0, 1, 2, or 3. Thus, the total score will have the potential to range from a minimum of 0 to a maximum of 36. The association between 30-day postoperative complications of cardiac and/or pulmonary origin and the overall mortality will be studied. Considering the fact that cardiac complications in patients undergoing hip surgery occur in approx. 30% of cases, to achieve 80% statistical power, we will need a sample size of 877 patients considering a relative risk of 1.5. Conclusions Lung ultrasound (LU), as a tool within the anesthesiologist’s armamentarium, is becoming increasingly widespread, and its use in the preoperative setting is also starting to become more common. Should the study demonstrate the ability of LU to predict postoperative cardiac and pulmonary complications in hip fracture patients, a randomized clinical trial will be designed with the scope of improving patient outcome. Trial registration ClinicalTrials.gov, NCT04074876. Registered on August 30, 2019