How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Fluid leakage across tracheal tube cuff, effect of different cuff material, shape, and positive expiratory pressure: A bench-top study

Purpose: Standard polyvinylchloride (PVC) endotracheal tube (ETT) cuffs do not protect from aspiration across the cuff, a leading cause of ventilator-associated pneumonia (VAP). In a long-lasting in vitro study we compared the effect of different cuff materials (PVC, polyurethane, and guayule latex), shapes (cylindrical, conical), and positive end expiratory pressures (PEEP) in reducing fluid leakage across the cuff. Methods: We compared fluid leakage across a cylindrical double-layer guayule latex prototype cuff, three cylindrical PVC cuffs (Mallinckrodt Hi-Lo, Mallinckrodt HighContour, Portex Ivory), one conical PVC cuff (Mallinckrodt TaperGuard), and two polyurethane cuffs (Mallinckrodt SealGuard, conical; Microcuff, cylindrical). Ten centimeters of dyed water was poured above the cuffs inflated (pressure 30 cmH2O) in a vertical cylinder (diameter 20 mm). A respiratory circuit connected the bottom of the cylinder to a breathing bag inflated at four pressures (PEEP = 0, 5, 10, 15 cmH2O). Pictures were taken every 60 s for 24 h to measure leakage as a reduction in the water column above the cuff. Five new ETTs of each type were tested. Results: The guayule latex cuffs showed no leakage at all the PEEP levels. Both the cylindrical and conical polyurethane cuffs showed limited leakage (2.1 \uc2\ub1 1.8 cm of water) only for PEEP zero. The PVC cuffs showed reduced leakage with increasing PEEP: 8.4 \uc2\ub1 1.5, 7.8 \uc2\ub1 2.2, 2.2 \uc2\ub1 1.0, and 0 cm of water at 0, 5, 10, and 15 cmH2O, respectively. Among all the PVC cuffs, the conical shape ensured higher sealing properties. Conclusions: The guayule latex cuffs always prevented fluid leakage; the polyurethane and PVC cuffs required incremental levels of PEEP to prevent fluid leakage ever-present at zero PEEP. \uc2\ua9 Copyright jointly held by Springer and ESICM 2010

Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study

Purpose: Prone positioning (PP) improves oxygenation and outcome of patients with acute respiratory distress syndrome undergoing invasive ventilation. We evaluated feasibility and efficacy of PP in awake, non-intubated, spontaneously breathing patients with hypoxemic acute respiratory failure (ARF). Material and Methods: We retrospectively studied non-intubated subjects with hypoxemic ARF treated with PP from January 2009 to December 2014. Data were extracted from medical records. Arterial blood gas analyses, respiratory rate, and hemodynamics were retrieved 1 to 2 hours before pronation (step PRE), during PP (step PRONE), and 6 to 8 hours after resupination (step POST). Results: Fifteen non-intubated ARF patients underwent 43 PP procedures. Nine subjects were immunocompromised. Twelve subjects were discharged from hospital, while 3 died. Only 2 maneuvers were interrupted, owing to patient intolerance. No complications were documented. PP did not alter respiratory rate or hemodynamics. In the subset of procedures during which the same positive end expiratory pressure and Fio2were utilized throughout the pronation cycle (n = 18), PP improved oxygenation (Pao2/Fio2124 ± 50 mmHg, 187 ± 72 mmHg, and 140 ± 61 mmHg, during PRE, PRONE, and POST steps, respectively, P < .001), while pH and Paco2were unchanged. Conclusions: PP was feasible and improved oxygenation in non-intubated, spontaneously breathing patients with ARF

ECMO for intractable status asthmaticus following atracurium

Intraoperative allergic reactions are rare but serious events associated with increased morbidity and mortality. We report the salvage of intraoperative anaphylaxis leading to extreme hypercapnic respiratory failure by veno-venous extracorporeal membrane oxygenation (ECMO). A 38-year-old woman undergoing thyroidectomy developed intractable bronchospasm after administration of atracurium, leading to extreme hypercapnic respiratory failure (PaCO2\uc2\ua0>\uc2\ua0250\uc2\ua0mmHg, pH 6.773). After the failure of conventional medical therapy and ventilatory optimization, the patient was connected to a veno-venous ECMO circuit. PaCO2of 45.6\uc2\ua0mmHg and pH of 7.25 were achieved in 1\uc2\ua0h, by slowly increasing sweep gas flows up to 3.5 L/min and using continuous end-tidal CO2monitoring to gauge the procedure. After extubation and disconnection from ECMO, the patient was discharged on the 6th day without sequelae. Rapid reversal of extreme hypercapnic acidosis by ECMO was feasible, without any neurologic sequelae. Veno-venous ECMO support may be a valuable option for the salvage of intraoperative anaphylaxis

Interstitial pneumonia with autoimmune features: an additional risk factor for ARDS?

Abstract Background Interstitial pneumonia with autoimmune features (IPAF) identifies a recently recognized autoimmune syndrome characterized by interstitial lung disease and autoantibodies positivity, but absence of a specific connective tissue disease diagnosis or alternative etiology. We retrospectively reviewed the clinical presentation, diagnostic workup and management of seven critically ill patients who met diagnostic criteria for IPAF. We compared baseline characteristics and clinical outcome of IPAF patients with those of the population of ARDS patients admitted in the same period. Results Seven consecutive patients with IPAF admitted to intensive care unit for acute respiratory distress syndrome (ARDS) were compared with 78 patients with ARDS secondary to a known risk factor and with eight ARDS patients without recognized risk factors. Five IPAF patients (71%) survived and were discharged alive from ICU: Their survival rate was equal to that of patients with a known risk factor (71%), while the subgroup of patients without risk factors had a markedly lower survival (38%). According to the Berlin definition criteria, ARDS was severe in four IPAF patients and moderate in the remaining three. All had multiple organ dysfunction at presentation. The most frequent autoantibody detected was anti-SSA/Ro52. All patients required prolonged mechanical ventilation (median duration 49 days, range 10–88); four received extracorporeal membrane oxygenation and one received low-flow extracorporeal CO2 removal. All patients received immunosuppressive therapy. Conclusions This is the first description of a cohort of critical patients meeting the diagnostic criteria for IPAF presenting with ARDS. This diagnosis should be considered in any critically ill patient with interstitial lung disease of unknown origin. While management is challenging and level of support high, survival appears to be good and comparable to that of patients with ARDS associated with a known clinical insul

Blood acidification enhances carbon dioxide removal of membrane lung: An experimental study

Purpose: Extracorporeal CO2removal is an effective procedure to allow a protective ventilatory strategy in ARDS patients, but it is technically challenging due to the high blood flow required. Increasing the CO2transfer through the membrane lung (ML) may lower the demand of extracorporeal blood flow and consequently allow for a wider clinical application of this technique. Since only the dissolved CO2(5% of the total CO2content) is easily removed by the ML, we tested whether acidifying the blood entering the ML to convert bicarbonate ions towards dissolved CO2could enhance the CO2transfer though the ML. Methods: Six pigs were connected to an extracorporeal circuit comprising a ML. The extracorporeal blood flow was 500 ml/min, while the gas flow was 10 l/min. A 15-min continuous infusion of 0.5 N lactic acid was added to the extracorporeal blood flow before the ML at a rate of 1, 2 and 5 mEq/min. Between steps we waited for a reequilibration time of at least 30 min. Results: Acid infusion at 0, 1, 2 and 5 mEq/min increased pCO2(56.19 \uc2\ub1 7.92, 68.24 \uc2\ub1 11.73, 84.28 \uc2\ub1 11.17 and 136.66 \uc2\ub1 18.46 mmHg, respectively) and decreased pH (7.39 \uc2\ub1 0.05, 7.30 \uc2\ub1 0.05, 7.20 \uc2\ub1 0.05 and 6.91 \uc2\ub1 0.05, respectively). ML CO2removal increased 11, 23 and 70% during acid infusion at 1, 2 and 5 mEq/min, respectively. Conclusions: Blood acidification at the inlet of a ML with infusion of 1, 2 and 5 mEq/min of lactic acid can increase the CO2removal capacity of the ML up to 70%. \uc2\ua9 2009 Springer-Verlag

Infusion of 2.5 meq/min of lactic acid minimally increases CO2 production compared to an isocaloric glucose infusion in healthy anesthetized, mechanically ventilated pigs

Introduction: Blood acidification by lactic acid infusion converts bicarbonate to CO2. This effect can be exploited to increase the transmembrane PCO2 gradient of an extracorporeal membrane lung, resulting in a significant increase of extracorporeal CO2 removal. Lactic acid, however, is an energetic substrate and its metabolism might increase total body CO2 production (VCO2), limiting the potential beneficial effects of this technique. The aim of our study was to compare VCO; during isocaloric infusion of lactic acid or glucose.Methods: Six pigs (45 \uc2\ub1 5 kg) were sedated and mechanically ventilated. Estimated caloric needs were 2,300-2,400 Kcal/die (95 to 100 Kcal/h). A sequence of two steps lasting four hours each was performed: 1) Glucose, 97 kcal/h were administered as 50% glucose solution, and 2) Lactic Acid, approximately 48.5 kcal/h were administered as lactic acid and approximately 48.5 kcal/h as 50% glucose solution. This sequence was repeated three times with two-hour intervals. Every hour VCO;, arterial blood gases and lactate were measured. Blood glucose level was kept constant by titrating an insulin infusion, ventilation was adjusted to maintain arterial PCO2 at 50 mmHg, a normal value for our animal model.Results: During Lactic Acid steps VCO2 increased less than 5% compared to the Glucose steps (282 vs. 269 ml/min, P <0.05); blood glucose did not differ between the two groups (respectively 101 \uc2\ub1 12 vs. 103 \uc2\ub1 8 mg/dl). Arterial lactate was always lower than 3 mmol/L. Arterial pH was lower during Lactic Acid steps (7.422 vs. 7.445, P <0.05).Conclusions: Replacing 50% of the caloric input with lactic acid increased total CO2 production by less than 5% compared to an equal caloric load provided entirely by a 50% glucose solution. \uc2\ua9 2013 Zanella et al.; licensee BioMed Central Ltd

Extracorporeal carbon dioxide removal through ventilation of acidified dialysate: An experimental study

Background: Extracorporeal (EC) carbon dioxide (CO2) removal (ECCO2R) may be a powerful alternative to ventilation, possibly avoiding the need for mechanical ventilation and endotracheal intubation. We previously reported how an infusion of lactic acid before a membrane lung (ML) effectively enhances ECCO2R. We evaluated an innovative ECCO2R technique based on ventilation of acidified dialysate. Methods: Four swine were sedated, mechanically ventilated, and connected to a venovenous dialysis circuit (blood flow, 250 ml/min). The dialysate was recirculated in a closed loop circuit including a ML (gas flow, 10 liters/min) and then returned to the dialyzer. In each animal, 4 different dialysis flows (DF) of 200, 400, 600, and 800 ml/min were evaluated with and without lactic acid infusion (2.5 mEq/min); the sequence was completed 3 times. At the end of each step, we measured the volume of CO2R by the ML (Vco2ML) and collected blood and dialysate samples for gas analyses. Results: Acid infusion substantially increased Vco2ML, from 33 \uc2\ub1 6 ml/min to 86 \uc2\ub1 7 ml/min. Different DFs had little effect on Vco2ML, which was only slightly reduced at DF 200 ml/min. The partial pressure of CO2of blood passing through the dialysis filter changed from 60.9 \uc2\ub1 3.6 to 37.1 \uc2\ub1 4.8 mm Hg without acidification and to 32.5 \uc2\ub1 5.3 mm Hg with acidification, corresponding to a pH increase of 0.18 \uc2\ub1 0.03 and 0.03 \uc2\ub1 0.04 units, respectively. Conclusions: Ventilation of acidified dialysate efficiently increased ECCO2R of an amount corresponding to 35% to 45% of the total CO2production of an adult man from a blood flow as low as 250 ml/min. \uc2\ua9 2014 International Society for Heart and Lung Transplantation. All rights reserved