Sedation after cardiac arrest and during therapeutic hypothermia.

Mild therapeutic hypothermia (MTH) has improved neurological outcome of comatose patients after cardiac arrest (CA). Since the first clinical studies performed in this setting, sedation has always been associated with cooling procedures. The use of sedative drugs during MTH is required because it allows faster achievement and better maintenance of target temperature. Further studies are necessary to prove any potential neuroprotective effects of sedation after CA. No differences in clinical outcomes have been found among different drugs, except for those related to their intrinsic pharmacological properties: the association propofol/remifentanil provides a faster recovery of consciousness than midazolam/fentanyl but is associated with the need of more vasopressors to maintain stable hemodynamic. Moreover, pharmacokinetic properties of these drugs are often altered during MTH so that standard drug regimens could result in overdosing because of reduced clearance. Neuromonitoring could be helpful to titrate drugs' effects and detect earlier complications (i.e. seizure), while a wake-up test should be avoidedì during the first 24 hours after CA.JOURNAL ARTICLESCOPUS: re.jinfo:eu-repo/semantics/publishe

How to manage withdrawal of sedation and analgesia in mechanically ventilated covid-19 patients?

COVID-19 patients suffering from severe acute respiratory distress syndrome (ARDS) require mechanical ventilation (MV) for respiratory failure. To achieve these ventilatory goals, it has been observed that COVID-19 patients in particular require high regimens and prolonged use of sedatives, analgesics and neuromuscular blocking agents (NMBA). Withdrawal from analgosedation may induce a “drug withdrawal syndrome” (DWS), i.e. clinical symptoms of anxiety, tremor, agitation, hallucinations and vomiting, as a result of adrenergic activation and hyperalgesia. We describe the epidemiology, mechanisms leading to this syndrome and our strategies to prevent and treat it.SCOPUS: re.jinfo:eu-repo/semantics/publishe

Perioperative management of oral glucose-lowering drugs in the patient with type 2 diabetes

SCOPUS: re.jinfo:eu-repo/semantics/publishe

Deep Inferior Epigastric Perforator Flap (D.I.E.P) for Breast Reconstruction: Impact of Intraoperative Intrathecal Morphine on Outcome

info:eu-repo/semantics/publishe

Predictors of poor outcome after extra-corporeal membrane oxygenation for refractory cardiac arrest (ECPR): A post hoc analysis of a multicenter database

Background: The objective was to assess predictors for unfavorable neurological outcome (UO) in out-of-hospital (OHCA) and in-hospital (IHCA) cardiac arrest patients treated with Extracorporeal cardiopulmonary resuscitation (ECPR). Methods: A post hoc analysis of retrospective data from five European ECPR centers (January 2012-December 2016) was performed. The primary composite endpoint was 3-month UO defined as survival with a cerebral performance category (CPC) of 3-4 or death (CPC 5). Results: A total of 413 patients treated with ECPR were included (median age was 57 [48-65] years, male gender 78%): 61% of patients (n = 250) suffered OHCA. The median time from collapse to ECMO placement was 63 [45-82] minutes. Overall, 81% patients (n = 333) showed unfavorable UO, which was higher in OHCA patients (90% vs 66%), as compared to IHCA. In OHCA, prolonged time from collapse to ECMO initiation (OR 1.02, p < 0.01) and higher ECMO blood flow (OR 1.99, p = 0.01) were associated with UO while initial shockable rhythm (OR 0.04, p < 0.01), previous heart disease (OR 0.20, p < 0.01) and pre-hospital hypothermia (OR 0.08, p < 0.01) had a protective role. In IHCA, prolonged time from arrest to ECMO implantation (OR 1.02, p = 0.03), high lactate level on admission (OR 1.15, p < 0.01) and higher body weight (OR 1.03, p < 0.01) were independently associated with UO. Conclusions: IHCA and OHCA patients receiving ECPR have different predictors of UO at presentation, suggesting that selection criteria for ECPR should be decided according to the location of CA. After ECMO initiation, ECMO blood flow management and mean arterial pressure targets might also impact neurological recovery