Electrocardiographic changes in a rare case of flecainide poisoning: a case report

Flecainide is a class Ic anti - arrhythmic drug with sodium channel blocking activities. We report a case of a 57 year - old woman who attempted a suicide by ingesting approximately 1,8 gr of flecainide. On the surface electrocardiogram this results in a large QRS complex and in prolongation of the QTc interval. Overdose with a class Ic drug is very uncommon, its management is difficult and the mortality high

Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines

Background Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team. Material and methods An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript. Conclusion Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies

Postoperative pain management in non-traumatic emergency general surgery : WSES-GAIS-SIAARTI-AAST guidelines

Background Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team. Material and methods An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript. Conclusion Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.Peer reviewe

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P < 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

Background: Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. Methods/design The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs. Trial registration ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1929-0) contains supplementary material, which is available to authorized users

Thyrotoxic storm during sepsis: study of a rare complication, clinical and biological observations

We describe an uncommon severe clinical complication of sepsis – thyrotoxic storm (TS). Common biologic, pathogenic, clinical conditions that can determine sepsis can cause a TS. High circulating values of vascular cellular adhesive molecules-1 and various pro-inflammatory citochines are related with thyroid damage. During sepsis, moderate dysfunctions are not expression of actual disease, but severe damage in pituitary-thyroid hormonal axis. Thyroid stimulated hormon release, and consequent overproduction of thyroid hormones can cause TS. In critical patients, presence of hormonal dysfunctions determines more elevated clinical score of sepsis severity and higher risk of death than control groups (without thyroid disease) or survived patients

Evone® Flow controlled ventilation: a new device for laryngotracheal surgery

The success of laryngotracheal surgery is mainly related to adequate exposure of the airway lumen. To render airway surgery more efficient, many efforts have been made in recent decades to obtain a safe ventilation system which uses an orotracheal tube that is as small as possible. The first attempt was made by introducing the high frequency jet ventilation (HFJV) technology in clinical practice. Nonetheless, HFJV has some risks related to the high pressure needed for ventilation in the catheter. First, during HFJV, the expiration of air from the lungs is a passive backflow on the trachea wall, potentially causing hypercapnia and air trapping. Second, HFJV creates an open ventilation system that leads to aerosolisation of airborne particles with an increased infectious risk for the surgeon. To overcome these issues, an innovative flow-controlled ventilation (FCV) system with a narrow-cuffed catheter (Evone(®); Ventinova, Eindhoven, The Netherlands) was introduced in clinical practice. This paper describes our initial experience with the Evone(®) FCV system, reporting the first 5 cases ventilated with this technology. In this observational study, we evaluate the feasibility and safety of the Evone(®) system and deliver a critical appraisal of this novel method of ventilation

Continuous epidural versus wound infusion plus single morphine bolus as postoperative analgesia in open abdominal aortic aneurysm repair: a randomized non-inferiority trial

BACKGROUND: We compared a bundle of interventions including wound infiltration and continuous infusion with local anaesthetics plus a single morphine bolus (CWI-M) with continuous epidural infusion (CEI) as postoperative analgesia. METHODS: Fifty-one adults undergoing open abdominal aortic aneurysm repair were randomised in this non-inferiority open-label trial. In the CEI group, patients received thoracic epidural levobupivacaine 0.12% plus sufentanil 0.4 \uf06dg\ub7ml-1 infusion for 48h. In the CWI-M group, the wound was infiltrated with 10 ml levobupivacaine 0.5%, patients received a morphine bolus before the end of anaesthesia and levobupivacaine 0.25% infusion through two multi-holed pre-peritoneal catheters for 48h. Systemic morphine was administered as rescue in both groups. The primary endpoint was the mean NRS in the first 48h after surgery. RESULTS: Mean NRS was 1.7 (95% CI: from 1.2 to 2.2) in the CEI and 2.2 (95% CI: from 1.7 to 2.7) in the CWI-M group, the 90% CI of difference was from -0.1 to 1.1, not including the non- inferiority margin of 1.3. The cumulative rescue morphine dose per patient was higher in CWI-M than in CEI group (3.7 \ub1 4.4 mg vs. 0.8 \ub1 2.4, p = 0.006); moreover, NRS at arousal was higher in CWI-M (p = 0.003). No differences were observed in postoperative haemodynamic parameters, recovery-related outcomes, length of stay nor complications. CONCLUSIONS: CWI-M was comparable to CEI in in postoperative pain control, but it was associated with higher need of rescue systemic opiates and with a worse early pain control

Timing of surgery and elective perioperative management of patients with previous SARS-CoV-2 infection: a SIAARTI expert consensus statement

Background The appropriate timing of surgery and perioperative management of patients with previous SARS-CoV-2 infection are open issues. The purpose of this document is to support the clinical decision-making process regarding the patient with previous Sars-CoV-2 infection to undergo elective surgery. The recipients of this document are physicians, nurses, healthcare personnel, and other professionals involved in the patient’s surgical process. Methods The Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) selected 11 experts to reach a consensus on key aspects of this theme in adult and pediatric population. The methods of this process document were in accordance to the principles of rapid review of the scientific literature and modified Delphi method. The experts produced statements and supporting reasons in the form of an informative text. The overall list of statements was subjected to a vote in order to express the degree of consent. Results Patients should not undergo elective surgery within 7 weeks of infection unless there is the risk of a negative evolution of the disease. To mitigate the risk of postsurgical mortality, a multidisciplinary approach seemed useful in addition to the use of validated algorithms to estimate the risk of perioperative morbidity and mortality; the risk related to SARS-CoV-2 infection should be added. The risk of potential nosocomial contagion from a positive patients should also be considered when deciding to proceed with surgery. Most of the evidence came from previous SARS-CoV-2 variants, so the evidence should be considered indirect. Conclusion A balanced preoperative multidisciplinary risk–benefit evaluation is needed in patients with previous infection by SARS-CoV-2 for elective surgery