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

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

Dal polmone alla linea pleurica: il ruolo dell'analisi di secondo ordine per la diagnosi differenziale ecografica dell'edema polmonare.

L’aumento dell’acqua libera polmonare determina l’insorgenza di edema polmonare che è una causa frequente di insufficienza respiratoria acuta nei reparti di terapia intensiva. Esso può essere individuato, monitorato e messo in diagnosi differenziale con la sindrome alveolare interstiziale anche grazie all’ecografia toracica. La semeiologia ecografica dell’edema polmonare è caratterizzata dalla presenza di artefatti che originano dalla linea pleurica e si dispongono perpendicolarmente ad essa detti linee B la cui comparsa è dovuta ad il cambiamento di densità delle interfacce al di sotto della pleura stessa. L’ecografia toracica bedside seppur semplice come esame è gravato da alcune limitazioni quali la variabilità inter- ed intraosservatore, la mancanza di un unico sistema standardizzato di acquisizione e di scoring per la sindrome alveolo-interstiziale e la mancata correlazione tra l’aumento delle linee B , la congestione polmonare e l’incremento dell’acqua libera extravascolare. Infine,basandosi solo sulla semeiologica ecografica, risulta particolarmente difficoltoso per il clinico andare a differenziare l’edema polmonare da causa cardiogena, dovuto a incremento delle pressioni di riempimento atriale che provoca un aumento dell’acqua extravascolare per aumento della pressione idrostatica , dalla sindrome interstiziale dovuta a sindrome da distress respiratorio acuto o ARDS causata invece da un alterazione della permeabilità della membrana alveolo-capillare. L’obiettivo del nostro studio è stato quello di indagare se lo studio della matrice di co-occorrenza dei livelli di grigio (GLCM) delle immagini ecografiche polmonari della linea pleurica possa differenziare la ARDS dall’edema polmonare cardiogeno. Abbiamo incluso nello studio in maniera prospettica un campione di 47 soggetti di cui 23 soggetti sani di controllo e 24 malati critici (16 con segni clinici di edema polmonare cardiogeno e 8 con ARDS), ammessi in terapia intensiva per insufficienza respiratoria acuta con indicazione al monitoraggio dell’EVLW (extravascular lung water) attraverso la termodiluizione transpolmonare. La ARDS, soddisfatti i criteri della definizione di Berlino, è stata diagnosticata con EVLWi 3.0. Ai pazienti con EVLWi >10 mL/kg e con un aumento della pressione nell’atrio sinistro rilevato dall’ecocardiografia è stata diagnosticata la CPE. L’ecografia polmonare è stata usata per il monitoraggio clinico in conformità alla pratica clinica standard. Comparando i sottogruppi di pazienti ARDS e CPE con il gruppo di controllo, i modelli ANOVA hanno rilevato significatività in 9 delle 11 caratteristiche GLCM. Successive comparazioni a coppia hanno rilevano significatività in ogni matrice per ARDS vs. CPE e per CPE vs. HCG (P≤0.001 per tutti). Per ARDS vs. HCG si è verificata una significatività solamente per due matrici (Correlazione: P=0.005; omogeneità, P=0.048). Possiamo quindi dire che il metodo quantitativo proposto ha mostrato un’alta accuratezza diagnostica per differenziare una situazione polmonare normale dalla ARDS o dall’edema polmonare cardiogeno, e una buona accuratezza diagnostica per distinguere l’edema polmonare cardiogeno dalla ARDS. Quindi la GLCM delle immagini ecografiche della pleura e dello spazio subpleurico è potenzialmente di aiuto nella diagnosi differenziale dell’edema polmonare e può esserlo anche nella differenziazione dell’ARDS dal quadro ecografico di polmonite da SARS Cov2 . Sulla base di quanto emerso possiamo asserire che una diagnosi automatizzata dell’immagine ecografica basata sull’analisi computerizzata della linea pleurica può fornire al clinico un utile ausilio nella diagnosi differenziale dell’edema polmonare fornendo informazioni utili riguardo le basi fisiopatologiche sottostanti all’origine della “linee B”. In futuro l’analisi automatizzata delle immagini ecografiche toraciche potrà essere uno strumento di facile utilizzo per ridurre la variabilità intra ed interosservatore e per standandardizzare i sistemi di acquisizione e scoring ecografici consentendo al contempo un’acquisizione dati più veloce senza incremento dei costi o dei rischi per il paziente

Ten conditions where lung ultrasonography may fail: limits, pitfalls and lessons learned from a computer-aided algorithmic approach

Lung ultrasonography provides relevant information on morphological and functional changes occurring in the lungs. However, it correlates weakly with pulmonary congestion and extra vascular lung water. Moreover, there is lack of consensus on scoring systems and acquisition protocols. The automation of this technique may provide promising easy-to use clinical tools to reduce inter-and intra-observer variability and to standardize scores, allowing faster data collection without increased costs and patients risks. (Cite this article as: Corradi F, Vetrugno L, Isirdi A, Bignami E, Boccacci P, Forfori F. Ten conditions where lung ultrasonography may fail: limits, pitfalls and lessons learned from a computer-aided algorithmic approach. Minerva Anestesiol 2022;88:308-13. DOI: 10.23736/S0375-9393.22.16195-X

Second-order grey-scale texture analysis of pleural ultrasound images to differentiate acute respiratory distress syndrome and cardiogenic pulmonary edema

Discriminating acute respiratory distress syndrome (ARDS) from acute cardiogenic pulmonary edema (CPE) may be challenging in critically ill patients. Aim of this study was to investigate if gray-level co-occurrence matrix (GLCM) analysis of lung ultrasound (LUS) images can differentiate ARDS from CPE. The study population consisted of critically ill patients admitted to intensive care unit (ICU) with acute respiratory failure and submitted to LUS and extravascular lung water monitoring, and of a healthy control group (HCG). A digital analysis of pleural line and subpleural space, based on the GLCM with second order statistical texture analysis, was tested. We prospectively evaluated 47 subjects: 16 with a clinical diagnosis of CPE, 8 of ARDS, and 23 healthy subjects. By comparing ARDS and CPE patients’ subgroups with HCG, the one-way ANOVA models found a statistical significance in 9 out of 11 GLCM textural features. Post-hoc pairwise comparisons found statistical significance within each matrix feature for ARDS vs. CPE and CPE vs. HCG (P ≤ 0.001 for all). For ARDS vs. HCG a statistical significance occurred only in two matrix features (correlation: P = 0.005; homogeneity: P = 0.048). The quantitative method proposed has shown high diagnostic accuracy in differentiating normal lung from ARDS or CPE, and good diagnostic accuracy in differentiating CPE and ARDS. Gray-level co-occurrence matrix analysis of LUS images has the potential to aid pulmonary edemas differential diagnosis

The use of continuous positive airway pressure during the second and third waves of the COVID-19 pandemic

Background In a preliminary study during the first COVID-19 pandemic wave, we reported a high rate of success with continuous positive airway pressure (CPAP) in preventing death and invasive mechanical ventilation (IMV). That study, however, was too small to identify risk factors for mortality, barotrauma and impact on subsequent IMV. Thus, we re-evaluated the efficacy of the same CPAP protocol in a larger series of patients during second and third pandemic waves. Methods 281 COVID-19 patients with moderate-to-severe acute hypoxaemic respiratory failure (158 full-code and 123 do-not-intubate (DNI)), were managed with high-flow CPAP early in their hospitalisation. IMV was considered after 4 days of unsuccessful CPAP. Results The overall recovery rate from respiratory failure was 50% in the DNI and 89% in the full-code group. Among the latter, 71% recovered with CPAP-only, 3% died under CPAP and 26% were intubated after a median CPAP time of 7 days (IQR: 5–12 days). Of the patients who were intubated, 68% recovered and were discharged from the hospital within 28 days. Barotrauma occurred during CPAP in <4% of patients. Age (OR 1.128; p <0.001) and tomographic severity score (OR 1.139; p=0.006) were the only independent predictors of mortality. Conclusions Early treatment with CPAP is a safe option for patients with acute hypoxaemic respiratory failure due to COVID-19

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

Background To assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard. Methods A prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients. Results As per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view. Conclusions The concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure

Second-order grey-scale texture analysis of pleural ultrasound images to differentiate acute respiratory distress syndrome and cardiogenic pulmonary edema

Discriminating acute respiratory distress syndrome (ARDS) from acute cardiogenic pulmonary edema (CPE) may be challenging in critically ill patients. Aim of this study was to investigate if gray-level co-occurrence matrix (GLCM) analysis of lung ultrasound (LUS) images can differentiate ARDS from CPE. The study population consisted of critically ill patients admitted to intensive care unit (ICU) with acute respiratory failure and submitted to LUS and extravascular lung water monitoring, and of a healthy control group (HCG). A digital analysis of pleural line and subpleural space, based on the GLCM with second order statistical texture analysis, was tested. We prospectively evaluated 47 subjects: 16 with a clinical diagnosis of CPE, 8 of ARDS, and 23 healthy subjects. By comparing ARDS and CPE patients' subgroups with HCG, the one-way ANOVA models found a statistical significance in 9 out of 11 GLCM textural features. Post-hoc pairwise comparisons found statistical significance within each matrix feature for ARDS vs. CPE and CPE vs. HCG (P <= 0.001 for all). For ARDS vs. HCG a statistical significance occurred only in two matrix features (correlation: P = 0.005; homogeneity: P = 0.048). The quantitative method proposed has shown high diagnostic accuracy in differentiating normal lung from ARDS or CPE, and good diagnostic accuracy in differentiating CPE and ARDS. Gray-level co-occurrence matrix analysis of LUS images has the potential to aid pulmonary edemas differential diagnosis

Extracorporeal membrane oxygenation (ECMO) in COVID-19 patients: a pocket guide for radiologists

During the coronavirus disease 19 (COVID-19) pandemic, extracorporeal membrane oxygenation (ECMO) has been proposed as a possible therapy for COVID-19 patients with acute respiratory distress syndrome. This pictorial review is intended to provide radiologists with up-to-date information regarding different types of ECMO devices, correct placement of ECMO cannulae, and imaging features of potential complications and disease evolution in COVID-19 patients treated with ECMO, which is essential for a correct interpretation of diagnostic imaging, so as to guide proper patient management