Dhea as marker of good surgical homeostasis

The serum DHEA concentration can represent a valuable indicator of an "equilibrated" metabolic condition

Delirium in Older Adults: What a Surgeon Needs to Know

Delirium remains a challenging clinical problem in hospitalized older adults, especially for postoperative patients. This complication, with a high risk of postoperative mortality and an increased length of stay, frequently occurs in older adult patients. This brief narrative paper aims to review the recent literature regarding delirium and its most recent update. We also offer physicians a brief and essential clinical practice guide to managing this acute and common disease

Plasma Renin Concentration in Critically Ill COVID-19 Patients

Investigations of plasma renin concentration as a marker of organ perfusion in several intensive care settings have shown a significant correlation between its increase and a lack of perfusion in critical tissues, especially in septic patients. Castillo et al. proposed that activation of the non-canonical pathway of the renin–angiotensin–aldosterone system could improve cardiovascular homeostasis under COVID-19. During the first wave of COVID-19, we preliminarily enrolled a small cohort of subjects admitted to the Intensive Care Unit with a diagnosis of COVID-19 and acute respiratory distress syndrome. Their plasma renin value was measured in the first 24 h (T0), in the following 72 h (T1), and after one week (T2). In eight patients, we observed a higher plasma renin concentration—patients with difficulty weaning and in non-survivors. This is a preliminary observation. The variation of plasma renin levels in a septic condition is known, but settings such as COVID-19 infection have recently been investigated, showing a correlation with angiotensin-converting enzyme 2 receptor expression and functionality; in the near future, it will be interesting to have more data about its variation and value in COVID-19 patients

Disfunzioni postoperatorie nel grande anziano

Introduzione L'Italia è al secondo posto per longevità nel mondo, preceduta solo dal Giappone. La speranza di vita italiana registrata è di 85,2 anni (donne) e 80,6 anni (uomini). I pazienti anziani, oltre questa soglia, sono solitamente coinvolti anche in interventi di chirurgia maggiore e minore. Le disfunzioni cognitive postoperatorie sono prevalenti, specialmente nei pazienti anziani. L'esito primario di questa ricerca è quello di indagare la disfunzione cognitiva postoperatoria in questa particolare coorte di pazienti. Metodi Dopo l'approvazione etica, dall'8/9/2018 al 30/06/2019, abbiamo condotto uno studio prospettico osservazionale e abbiamo arruolato anziani con età superiore all'aspettativa di vita in un intervento chirurgico programmato. Abbiamo registrato i seguenti dati: dati demografici e anamnestici, dati clinici, esami di laboratorio, punteggi di rischio. Abbiamo misurato la condizione clinica prima e dopo l'intervento chirurgico attraverso test cognitivi di sei item (6ICIT), metodo di valutazione della confusione e Barthel. Indice. Quindi abbiamo misurato la mortalità a 24 ore, 30 giorni e un anno dopo. Risultati Nel periodo di studio, 90 erano eleggibili, abbiamo arruolato 76 pazienti: (50,91 femmine) età media 86,89 anni (IC 85,93-87,86). Il valore medio dell'indice di Charlson era 6,43 (CI 5,83-7,03). Il 39,47% dei pazienti è stato sottoposto a chirurgia maggiore, il restante a chirurgia minore. Il 40,79% dei pazienti è stato sottoposto ad anestesia generale, il 39,47% ad anestesia locoregionale e il 19,74% ad anestesia locale più sedazione. La mortalità a 30 giorni è stata del 2,63%, il punteggio CAM è aumentato nel 6,67%, il 6ICIT positivo nel 38,16% prima dell'intervento chirurgico, il 6ICIT è stato positivo nel 55,26% prima della dimissione valore p 0,0029*. Discussione, conclusione La disfunzione postoperatoria è un problema crescente e in arrivo correlato all'aumento dell'età dei pazienti sottoposti a un intervento chirurgico. Il deterioramento cognitivo è correlato all'età, ma probabilmente lo stress chirurgico può renderlo più veloce..Introduction Italy is in the second position for longevity in the world, preceded only by Japan. Italian life expectancy recorded is 85,2 years (women) and 80,6 years (men). Elderly patients, over this threshold, are usually involved even in major and minor surgery. Postoperative cognitive dysfunctions are prevalent, especially in elderly patients. The primary outcome of this research is to investigate postoperative cognitive dysfunction in this particular cohort of patients. Methods After Ethical Approval, from 8/9/2018 to 30/06/2019, we conducted a observational prospectic study and we enrolled elderly with age over life expectancy in planned surgery. We recorded the following data demographic and anamnestic data, clinical data, laboratory exams, risk scores. We measured the clinical condition before and after the surgical operation across six items cognitive test (6ICIT), confusion assessment method and Barthel. Index. Then we measured mortality at 24 hours, 30 days and one year later. Results In the study period, 90 were eligible, we enrolled 76 patients: (50.91 female) mean age 86.89 years (CI 85.93- 87.86). The mean value of the Charlson Index was 6.43 (CI 5.83-7.03). The 39.47% of patients underwent major surgery, the remaining minor surgery. 40.79% of patients underwent general anesthesia, 39.47% locoregional anesthesia, and 19.74% local anesthesia plus sedation. The 30 days mortality was 2.63%, CAM Score increased in the 6.67%, 6ICIT positive 38.16% before surgery, the 6ICIT was positive in the 55.26% before discharge p-value 0.0029*. Discussion, conclusion Postoperative dysfunction is an increasing and incoming problem related to the rising age of patients undergoing a surgical operation. Cognitive impairment correlates with age, but probably, surgical stress can make it faster

Delirium in Older Adults: What a Surgeon Needs to Know

Delirium remains a challenging clinical problem in hospitalized older adults, especially for postoperative patients. This complication, with a high risk of postoperative mortality and an increased length of stay, frequently occurs in older adult patients. This brief narrative paper aims to review the recent literature regarding delirium and its most recent update. We also offer physicians a brief and essential clinical practice guide to managing this acute and common disease

Epidural catheter cutting: mechanisms and management.

To the Editor, Epidural catheter insertion can be followed by different complications appearing at its insertion, maintenance and removal. They can be distinguished in haemorrhagic, infectious and mechanical, when directly involving the device with different mechanisms: obstruction, kinking, knotting, displacement, migration, and breakage, or more frequently cutting [1]. Our experience, even limited to a single case, illustrates well this uncommon and unexpected event. A young man with no prior medical history, and a normal body mass index was scheduled for a radical cysto-prostatectomy for a bladder leio-myosarcoma. As usually, a tactile modified point epidural Thouy needle, 18 G, 3.5 in. length, was inserted with a right paramedian approach at the L1–L2 vertebral interlaminar space with the patient in a sitting position; a closed end, 3 holes, 20 G, 36 in. long polyamide catheter was inserted; the aspiration test was negative. At this moment, the patient presented a sudden vaso-vagal crisis, with involuntary contraction of its lumbar muscles. The Thouy's needle, with the catheter inside, was removed without difficulties. Unexpectedly the catheter was discovered sharply cut and missing 2 cm in its distal part. Considering the absence of local or neurological signs, the quick resolution of the vaso-vagal crisis, and the most probably extradural position of the catheter, it was decided to proceed with surgery, which providentially was successful. The first postoperative was uneventful, in particular without motor or sensitive neurological signs. On day 1 a Computed Tomography (CT) showed inside the right epidural space a tubular foreign body, 2 cm long, and exactly corresponding to the missed distal part of the catheter, without signs of other complications as haematoma, oedema or serous collection (Fig. 1). The conservative treatment was confirmed and a second CT control after three months did not show differences. The 6 months follow-up persisted negative for neurological signs. Considering the entire dynamics of the events, we suppose that the polyamid catheter was completely cut, just after its insertion, by the sharp bevel of the Thouy's, needle inadvertently pushed forward by the involuntary contraction of the spine muscle during the vaso-vagal crisis. Most probably, the vertebral transverse process and the yellow ligament acted as a plane of contra-resistance. Critically evaluating our experience we acknowledge that every not-urgent surgical procedure must be postponed when an epidural catheter, removed, is found damaged or missing in a part. On the base of the recent literature, we propose an algorithm in case of epidural catheter cutting or breakage (Fig. 2).The missed fragment must be localized by cross-sectional imaging tools, Computer Tomography (CT) or Magnetic Resonance [2]. When it is found intrathecal, or complicated by infection, subdural or epidural haematoma, or by a large blood effusion inside the spinal muscles, its quick extraction is mandatory. Similarly, when the missed fragment is in the sub-cutaneous tissue or close to lumbar fascia, its easy removal can be performed. On the contrary, if the fragment remains fixed in the epidural space, in absence of further complications, its extraction is not directly indicated, considering also the good tissue tolerance of the actual polyamide devices [3]; [4] ; [5]. To avoid this complication, we underline that, after insertion of the epidural catheter, the external needle must be carefully removed with a slow and continuous traction, avoiding any movement of re-pushing forward

Contemporary Thoracic Aortic and Abdominal Injuries: An Emergency Strategy.

To the Editor: Topcu and colleagues [1] interestingly bring attention to the management of contemporary injury of the thoracic aorta and spleen. On the basis of our experience, we would like to consider some basic points. In each case of severe thoracoabdominal trauma, it is essential to perform a hemodynamic monitoring and contrast-enhanced computed tomography (CT) angiography to detect a condition of circulatory instability, and to obtain a complete imaging of the thorax, abdomen, and vessels. The most common injuries of the thoracic aorta involve isthmus. In addition, high-grade lesions (III and IV) are preferentially treated with an endovascular technique [2]. Usually, treatment priority is given to the aortic isthmus injuries, possibly considering an endovascular procedure [3]. Subsequently, the other concomitant injuries, especially abdominal ones, must be treated adequately. This strategy was applied successfully in our last consecutive 5 cases of injuries of the aortic isthmus of grade IV, with an associated spleen rupture (3 cases) and a liver laceration (2 cases), obtaining a complete recovery without important complications. On the contrary, a prompt emergency laparotomy becomes necessary when an endovascular treatment is not possible, and the subsequent cardiovascular surgery requires a cardiopulmonary bypass and a prolonged full heparinization, with the risk of increased or recurrent abdominal hemorrhage [1]. Interestingly, we applied an equivalent strategy in three cases of injuries of the left subclavian artery, with secondary hemothorax and associated blunt abdominal trauma [4]. CT allowed a precise diagnosis of the vascular injury. A prompt endovascular treatment was successful, and the subsequent laparotomy for spleen rupture followed without difficulties. When this strategy is not possible, direct surgery of the injured supraaortic branch is indicated. In cases of polytrauma involving contemporaneously the thoracic aorta or its supraaortic branches and the abdomen, and an associated massive hemoperitoneum and hemodynamic instability, a prompt laparotomy becomes necessary. It must be performed under careful hemodynamic control, avoiding increase or recurrence of the thoracic hemorrhage after resolution of the circulatory hypotension. We believe that these challenging clinical situations merit further study and contributions