St. Jude Trifecta Versus Carpentier-Edwards Perimount Magna valves for the treatment of aortic stenosis: comparison of early Doppler-Echocardiography and hemodynamic performance

Objective. Aim of this study was to compare the hemodynamic profiles of 2 aortic valve bioprostheses: the Carpentier Edwards Perimount Magna (CEPM) valve and the Trifecta valve. Methods. 100 patients who underwent AVR for severe symptomatic AS between September 2011 and October 2012 were analyzed by means of standard trans-thoracic Doppler-echocardiography. Results. Mean and peak gradients were significantly lower for the 21 mm Trifecta vs CEPM (11 ± 4 vs 15 ± 4 mmHg, and 20 ± 6 vs 26 ± 7 mmHg, respectively; all p < 0.05) and the 23 mm Trifecta vs CEPM (8 ± 2 vs 14 ± 4 mmHg, and 17 ± 6 vs 25 ± 9 mmHg; all p < 0.05). Effective orifice area tended to be slightly higher for the Trifecta valve. Conclusion. The new bioprosthetic valve Trifecta has an excellent hemodynamic profile, and lower trans-prosthesic gradients when compared to CEPM valve

Experience of Remifentanil in Extremely Low-birth-weight Babies Undergoing Laparotomy

Premature babies experience pain and require adequate analgesia for any painful procedure. Fentanyl and morphine resulted in safe and effective anesthesia in the past; however, their pharmacokinetics may be impaired in preterm babies with multiorgan failure. Remifentanil, despite the absence of available pharmacokinetic data in preterm infants and few reports in newborns, demonstrated its advantages in children undergoing either major surgery or minor painful procedures and has been shown to be useful even in neonates, because its elimination is independent of organ function. We report two cases of babies born at 26 weeks’ and 27 weeks’ gestation, weighing 580g and 400g, respectively, undergoing laparotomy for necrotizing enterocolitis. Both received midazolam bolus and remifentanil infusion at high doses. This technique seems to be an advantageous alternative even in extremely low-birth-weight prematures. Furthermore, it becomes a technique of choice in these babies because the available ventilators are often not equipped with halogenated vaporizers. Particularly in intensive care, where there are no scavenger systems, it could allow to operate without moving out the preterm babies and avoiding stress and hypothermia

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Capnography and the Bispectral Index—Their Role in Pediatric Sedation: A Brief Review

Sedation in children is increasingly emerging as a minimally invasive technique that may be associated with local anaesthesia or diagnostic and therapeutic procedures which do not necessarily require general anaesthesia. Standard monitoring requirements are not sufficient to ensure an effective control of pulmonary ventilation and deep sedation. Capnography in pediatric sedation assesses the effect of different drugs on the occurrence of respiratory failure and records early indicators of respiratory impairment. The Bispectral index (BIS) allows the reduction of dose requirements of anaesthetic drugs, the reduction in the time to extubation and eye opening, and the reduction in the time to discharge. In the field of pediatric sedation, capnography should be recommended to prevent respiratory complications, particularly in spontaneous ventilation. The use of the BIS index, however, needs further investigation due to a lack of evidence, especially in infants. In this paper, we will investigate the role of capnography and the BIS index in improving monitoring standards in pediatric sedation

Experience of Remifentanil in Extremely Low-birth-weight Babies Undergoing Laparotomy

Premature babies experience pain and require adequate analgesia for any painful procedure. Fentanyl and morphine resulted in safe and effective anesthesia in the past; however, their pharmacokinetics may be impaired in preterm babies with multiorgan failure. Remifentanil, despite the absence of available pharmacokinetic data in preterm infants and few reports in newborns, demonstrated its advantages in children undergoing either major surgery or minor painful procedures and has been shown to be useful even in neonates, because its elimination is independent of organ function. We report two cases of babies born at 26 weeks’ and 27 weeks’ gestation, weighing 580 g and 400 g, respectively, undergoing laparotomy for necrotizing enterocolitis. Both received midazolam bolus and remifentanil infusion at high doses. This technique seems to be an advantageous alternative even in extremely low-birth-weight prematures. Furthermore, it becomes a technique of choice in these babies because the available ventilators are often not equipped with halogenated vaporizers. Particularly in intensive care, where there are no scavenger systems, it could allow to operate without moving out the preterm babies and avoiding stress and hypothermia

Unsuspected cervical osteophytes and complex endoscopy: There is cause for concern!

Cervical osteophytes are a common disorder in elderly people [1]. The most common warning sign that cervical osteophytes may be present is dysphagia [2] [3]; however, the condition is often asymptomatic. During complex endoscopic procedures they can cause major difficulties in both airway management and the insertion and positioning of large endoscopes. We report our experience with an 80-year-old man with no swallowing or respiratory impairment, who was scheduled to undergo endoscopic retrograde cholangiopancreatography (ERCP) for ultrasonographically suspected common bile duct stones. After induction of general anesthesia, intubation was complicated by an unexpected difficulty. The laryngeal aditus was clearly visualized with the aid of an Airtraq device (Prodol Meditec, Vizcaya, Spain) but nevertheless introduction of a standard endotracheal tube (diameter 6.5\u200amm) was not possible because of an obstruction at the subglottal level. We reduced the size of the endotracheal tube until a 5-mm tube was inserted smoothly in the trachea. Using a 13.7-mm duodenoscope, the endoscopist had the same difficulty crossing the upper esophageal sphincter. Use of a 5.9-mm nasal gastroscope also failed. In the absence of ongoing cholangitis the procedure was aborted, and a policy of waiting was adopted. Because of severe laryngeal edema, the sedated and intubated patient was transferred to the postoperative intensive care unit until weaning from mechanical ventilation and extubation were possible. A postoperative cervical computed tomography scan ([Fig.\u200a1]) showed a large anterior cervical osteophyte at C6\u200a\u2013\u200aC7. Our experience focuses attention on a concern that is not usually considered. In the time since an old report in 1998 [4], the possibility of undiagnosed osteophytes has not been adequately investigated. We need to consider whether the aging of the patient population and the increased demand for complex endoscopic procedures necessitates a specific assessment for this underestimated but insidious risk facto

Anesthesia for complex endoscopy: a made-to-measure suit

We were particularly interested by the editorial on new frontiers of anesthesia in endoscopy, recently published in Endoscopy [1]. This editorial, commenting on a report by Lara et al. [2] on adverse events of anesthesiological procedures in the endoscopy setting, takes the opportunity to state \u201ca new paradigm\u201d and to highlight some key messages. We really appreciated this new approach which finally surmounts the inheritance of a strict separation between general anesthesia in the operating room and sedation in the endoscopy suite. Advances in pharmacology and in monitoring allow performance everywhere of a continuum of anesthesiological techniques, ranging from simple monitored anesthesia care to very deep anesthesia with a wide number of options. The choice should be made on a case-by-case basis after a comprehensive evaluation of the individual patient. Sedation in advanced endoscopy is very often a challenge for providers. The high number of adverse events reported by Lara et al. and by other authors [3] often corresponds to reality. However, when the basic data are examined, the quality of sedation is not always as good as expected. In the study by Lara et al., many sedations had been performed without real control of the effect-site concentration of propofol [4] and by providers who were not always specifically dedicated to endoscopy The question is not, therefore, sedation vs. general anesthesia, but rather, how can the quality of anesthesia care be improved? Over the last year, at our tertiary referral center, over 2100 complex endoscopies with anesthesiological support were performed. However, focusing only on the 1365 ERCPs, 1124 (82\u200a%) were performed with general anesthesia, 140 (10\u200a%) with deep sedation (with propofol and/or remifentanil by means of target-controlled infusion, sevorane by nasal cannula, midazolam and opioids) administered by the anesthesiologist, 99 (7\u200a%) with conscious sedation (midazolam and fentanyl) administered by the endoscopist, and 2 procedures without any sedation. Despite the high number of ERCPs, no life-threatening adverse event occurred. It is also interesting to observe that although only three anesthesiologists performed over 95\u200a% of the activity, the anesthesiological techniques were wide-ranging, for both airways management (endotracheal intubation, nasopharyngeal cannula, or simply jaw thrust) and drugs employed for anesthesia/sedation, and showed similar profiles in safety and efficacy. On what were our choices based? The answer to this question is not simple, because anesthesiological evaluation requires a multimodal approach. We think that, before selecting from the range of options, the anesthesiologist should be able to assess at least three parameters: the skills of the entire team of providers, patient condition, and logistics (availability of equipment, the available range of medical and economic resources, facilities for coping with adverse events, etc). They are the cornerstones on which we must build our medical support. When the experience, as a team, of the clinicians and paramedical staff, and the endoscopic logistics are favorable, as well as the mental and physical status of the patient and the logistic resources, we can safely increase the number of sedations at the expense of general anesthesia [5]. In our case the high rate of general anesthesia is related to the poor clinical condition of most patients (ASA physical status III\u200a\u2013\u200aIV) and to the need for a quick turnover. Indeed the correct titration of intravenous drugs used for sedation usually entails delay in achieving an adequate plasma concentration that is useful for obtaining immobility of the patient. Especially in this field, the synergy between anesthesiologists and endoscopists should be improved, with reciprocal provision of information so that they are always on the same wavelength. We encourage all colleagues to improve the quality of care, looking at the wide range of possibilities regarding techniques and new devices, always keeping in mind that there is no a priori better anesthesia strategy, but only a better anesthesia strategy for each individual patient

Perioperative management of children with neuromuscular disorders based on a common protocol: A prospective, national study in Italy

BACKGROUND: Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared peri-operative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped).METHOD: We conducted a multicenter, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals.RESULTS: We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 [2-14] days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher ICU admission rate and longer hospital LOS.CONCLUSION: Diseases severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs