Locoregional versus general anesthesia in carotid surgery: Is there an impact on peri-operative myocardial ischemia? Results of a prospective monocentric randomized trial.

PURPOSE: The incidence of cardiac morbidity and mortality in patients who undergo carotid surgery ranges from 0.7% to 7.1%, but it still represents almost 50% of all perioperative complications. Because no data are available in literature about the impact of the anesthetic technique on such complications, a prospective randomized monocentric study was undertaken to evaluate the role of local anesthesia (LA) and general anesthesia (GA) on cardiac outcome. METHODS: From November 1995 to February 1998, 107 patients were classified by the cardiologist as cardiac patients (IHD; history of myocardial infarction, previous myocardial revascularization procedures, or myocardial ischemia documented by means of positive electrocardiogram [ECG] stress test results) or noncardiac patients (NIHD; no history of chest pain or negative results for an ECG stress test). The patients were operated on after the randomization for the type of anesthesia (general or local). Continuous computerized 12-lead ECG was performed during the operative procedure and 24 hours postoperatively. The end points of the study were ECG modifications (upsloping or downsloping more than 2 mm) of the sinus tachycardia (ST) segment. RESULTS: Fifty-five patients were classified as IHD, and 52 were classified as NIHD. Twenty-seven of the 55 IHD patients (49%) and 24 of 52 NIHD patients (46%) were operated on under GA. Thirty-six episodes of myocardial ischemia occurred in 22 patients (20.5%). Episodes were slightly more frequent (58%) and longer in the postoperative period (intraoperative, 10 +/- 5 min; postoperative, 60 +/- 45 min; P <. 001). As expected, the prevalence of myocardial ischemia was higher in the group of cardiac patients than in noncardiac group (15 of 55 patients [27%] vs 7 of 52 patients [13%]; P <.02). By comparing the two anesthetic techniques in the overall population, we found a similar prevalence of patients who had myocardial ischemia (GA, 12 of 52 [23%]; LA, 10 of 55 [18%]; P = not significant) and a similar number of ischemic episodes per patient (GA, 1.5 +/- 0.4; LA, 1.8 +/- 0.6; P = not significant). Episodes of myocardial ischemia were similarly distributed in intraoperative and postoperative periods in both groups. It is relevant that under GA, IHD patients represent most of the population who suffered myocardial ischemia (83%). On the contrary, in the group of patients operated on under LA, the prevalence was equally distributed in the two subpopulations. CONCLUSION: The results confirm the different hemodynamic impact of the two anesthetic techniques. Patients who received LA had a rate of myocardial ischemia that was half that of patients who had GA. The small number of cardiac complications do not permit us to make any definitive conclusion on the impact of the two anesthetic techniques on early cardiac morbidity, but the relationship between perioperative ischemic burden and major cardiac events suggests that LA can be used safely, even in high-risk patients undergoing carotid endarterectomy

Imported severe malaria and risk factors for intensive care: A single-centre retrospective analysis.

OBJECTIVES: This study aims to identify the risk factors for intensive care (IC) in severe malaria patients admitted to the "Lazzaro Spallanzani" National Institute for Infectious Diseases, Rome, Italy. METHODS: All patients with confirmed severe malaria and hospitalized between 2007 and 2015 were included in the analysis and stratified into two groups: those requiring IC and those who did not. Five prognostic malaria scores were estimated; clinical severity at IC unit admission was assessed using the Sequential Organ Failure Assessment and the quick-Sequential Organ Failure Assessment scores. Univariate and multivariate analysis were performed to assess factors independently associated to IC. RESULTS: A total of 98 severe malaria patients were included; 10 of them required IC. There were no deaths or sequelae. Patients requiring IC had higher severity scores. At the multivariate analysis, only the number of World Health Organization criteria and the aspartate aminotransferase value were independently associated with the need of IC. CONCLUSIONS: An early and accurate assessment of the severity score is essential for the management of severe malaria patients

Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate–Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital

Background: COVID-19 is a novel cause of acute respiratory distress syndrome (ARDS). Indeed, with the increase of ARDS cases due to the COVID-19 pandemic, there has also been an increase in the incidence of cases with pneumothorax (PNX) and pneumomediastinum (PNM). However, the incidence and the predictors of PNX/PMN in these patients are currently unclear and even conflicting. (2) Methods: The present observational study analyzed the incidence of barotrauma (PNX/PNM) in COVID-19 patients with moderate–severe ARDS hospitalized in a year of the pandemic, also focusing on the three waves occurring during the year, and treated with positive-pressure ventilation (PPV). We collected demographic and clinical data. (3) Results: During this period, 40 patients developed PNX/PNM. The overall incidence of barotrauma in all COVID-19 patients hospitalized in a year was 1.6%, and in those with moderate–severe ARDS in PPV was 7.2% and 3.8 events per 1000 positive-pressure ventilator days. The incidence of barotrauma in moderate–severe ARDS COVID-19 patients during the three waves was 7.8%, 7.4%, and 8.7%, respectively. Treatment with noninvasive respiratory support alone was associated with an incidence of barotrauma of 9.1% and 2.6 events per 1000 noninvasive ventilator days, of which 95% were admitted to the ICU after the event, due to a worsening of respiratory parameters. The incidence of barotrauma of ICU COVID-19 patients in invasive ventilation over a year was 5.8% and 2.7 events per 1000 invasive ventilator days. There was no significant difference in demographics and clinical features between the barotrauma and non-barotrauma group. The mortality was higher in the barotrauma group (17 patients died, 47.2%) than in the non-barotrauma group (170 patients died, 37%), although this difference was not statistically significant (p = 0.429). (4) Conclusions: The incidence of PNX/PNM in moderate–severe ARDS COVID-19 patients did not differ significantly between the three waves over a year, and does not appear to be very different from that in ARDS patients in the pre-COVID era. The barotrauma does not appear to significantly increase mortality in COVID-19 patients with moderate–severe ARDS if protective ventilation strategies are applied. Attention should be paid to the risk of barotrauma in COVID-19 patients in noninvasive ventilation because the event increases the probability of admission to the intensive care unit (ICU) and intubation