Sugammadex for reversal of neuromuscular blockade: A retrospective analysis of clinical outcomes and cost-effectiveness in a single center

OBJECTIVE: The aim of the study is to evaluate the clinical and economic impact of introducing a rocuronium-neostigmine-sugammadex strategy into a cisatracurium-neostigmine regimen for neuromuscular block (NMB) management. METHODS: We conducted a retrospective analysis of clinical outcomes and cost-effectiveness in five operating rooms at University Hospital of Padova. A clinical outcome evaluation after sugammadex administration as first-choice reversal drug in selected patients (rocuronium-sugammadex) and as rescue therapy after neostigmine reversal (rocuronium-neostigmine-sugammadex) compared to control was performed. A cost-analysis of NMB management accompanying the introduction of a rocuronium-neostigmine-sugammadex strategy into a cisatracurium-neostigmine regimen was carried out. To such purpose, two periods were compared: 2011-2012, without sugammadex available; 2013-2014, with sugammadex available. A subsequent analysis was performed to evaluate if sugammadex replacing neostigmine as first choice reversal drug is cost-effective. RESULTS: The introduction of a rocuronium-neostigmine-sugammadex strategy into a cisatracurium-neostigmine regimen reduced the average cost of NMB management by 36%, from €20.8/case to €13.3/case. Patients receiving sugammadex as a first-choice reversal drug (3%) exhibited significantly better train-of-four ratios at extubation (P<0.001) and were discharged to the surgical ward (P<0.001) more rapidly than controls. The cost-saving of sugammadex as first-choice reversal drug has been estimated to be €2.9/case. Patients receiving sugammadex as rescue therapy after neostigmine reversal (3.2%) showed no difference in time to discharge to the surgical ward (P=0.44) compared to controls. No unplanned intensive care unit (ICU) admissions with rocuronium-neostigmine-sugammadex strategy were observed. The potential economic benefit in avoiding postoperative residual curarization (PORC)-related ICU admission in the 2013-2014 period was estimated at an average value of €13,548 (€9,316-€23,845). CONCLUSION: Sugammadex eliminated PORC and associated morbidities. In our center, sugammadex reduced the costs of NMB management and promoted rapid turnover of patients in operating rooms, with total cost-effectiveness that counteracts the disadvantages of its high cost

Static compliance and driving pressure are associated with ICU mortality in intubated COVID-19 ARDS

Background Pathophysiological features of coronavirus disease 2019-associated acute respiratory distress syndrome (COVID-19 ARDS) were indicated to be somewhat different from those described in nonCOVID-19 ARDS, because of relatively preserved compliance of the respiratory system despite marked hypoxemia. We aim ascertaining whether respiratory system static compliance (Crs), driving pressure (DP), and tidal volume normalized for ideal body weight (VT/kg IBW) at the 1st day of controlled mechanical ventilation are associated with intensive care unit (ICU) mortality in COVID-19 ARDS. Methods Observational multicenter cohort study. All consecutive COVID-19 adult patients admitted to 25 ICUs belonging to the COVID-19 VENETO ICU network (February 28th-April 28th, 2020), who received controlled mechanical ventilation, were screened. Only patients fulfilling ARDS criteria and with complete records of Crs, DP and VT/kg IBW within the 1st day of controlled mechanical ventilation were included. Crs, DP and VT/kg IBW were collected in sedated, paralyzed and supine patients. Results A total of 704 COVID-19 patients were screened and 241 enrolled. Seventy-one patients (29%) died in ICU. The logistic regression analysis showed that: (1) Crs was not linearly associated with ICU mortality (p value for nonlinearity = 0.01), with a greater risk of death for values &lt; 48 ml/cmH(2)O; (2) the association between DP and ICU mortality was linear (p value for nonlinearity = 0.68), and increasing DP from 10 to 14 cmH(2)O caused significant higher odds of in-ICU death (OR 1.45, 95% CI 1.06-1.99); (3) VT/kg IBW was not associated with a significant increase of the risk of death (OR 0.92, 95% CI 0.55-1.52). Multivariable analysis confirmed these findings. Conclusions Crs &lt; 48 ml/cmH(2)O was associated with ICU mortality, while DP was linearly associated with mortality. DP should be kept as low as possible, even in the case of relatively preserved Crs, irrespective of VT/kg IBW, to reduce the risk of death

The SARS-CoV-2 pandemic as a source of unprecedented bioethical and biolaw issues: lessons for intensivists

Abstract The following article presents the relevant and unprecedented bioethical and biolaw issues posed by the SARS-COV-2 pandemic and summarizes the initiatives adopted by the Italian Society of Anesthesia and Resuscitation (SIAARTI) as well as by the Veneto Region ICU Network. Since the initial phase of the pandemic, in March 2020, there has been a strong appeal from both SIAARTI and the Veneto Region ICU Network to consider “the appropriate intensive treatment.” During the pandemic, the principle of proportionality must be applied, in compliance with the main principle in bioethics. This encompasses the concept of clinical appropriateness, based on the efficacy of the treatment in specific case and context, as well as the concept of ethical appropriateness, which refers to ethical and juridical principles of acceptance of health care. The “appropriate treatment” must never interfere with the withdrawal of patients, who are not eligible for intensive treatments since they would not benefit from them and who are eligible for ordinary treatments that must be maintained, and, where necessary, palliative treatments were initiated. On the other hand, it must not encroach on unreasonable obstinacy. At the end of 2020, the SIAARTI-SIMLA (Italian Society of Insurance and Legal Medicine) document provides healthcare professionals with a tool for responding appropriately to the emergency of the pandemic, in the event of an imbalance between healthcare demand and available resources. The document states that the ICU triage should be based on global evaluation of each patient, taking into account well-defined parameters and stresses that each person potentially eligible for intensive care should have a shared care planning (SCP) stipulated, and, when necessary, a proxy should be nominated. This has illustrated how the biolaw issues encountered by intensivists during the pandemic, such as those relating to consent and refusal to medical treatment, even when it is lifesaving, as well as requests for treatment of unproven clinical efficacy, were subject to appropriate guidelines and solutions through the application of Law 219/2017 (provisions for informed consent and advance directives treatment). Communication with family members and the management of sensitive personal data; the evaluation of “legal capacity” of comprehension and informed decision-making regarding the proposed treatment plan; and the need for emergency medical intervention in the absence of consent are all addressed in light of the relevant regulations and the particular conditions of social isolation induced by the pandemic. The collaborative ICUs network sustained by the Veneto Region has given great prominence to clinical bioethics issues, and as a result, multidisciplinary integration with the help of legal and juridical experts was developed. This has led to an increase in skills in the bioethical field, as well as providing a valuable lesson for the improvement of therapeutic relationships with critically ill patients and their families

Conductometric Sensing with Individual InAs Nanowires

In this work, we isolate individual wurtzite InAs nanowires and fabricate electrical contacts at both ends, exploiting the single nanostructures as building blocks to realize two different architectures of conductometric sensors: (a) the nanowire is drop-casted onto&mdash;supported by&mdash;a SiO2/Si substrate, and (b) the nanowire is suspended at approximately 250 nm from the substrate. We test the source-drain current upon changes in the concentration of humidity, ethanol, and NO2, using synthetic air as a gas carrier, moving a step forward towards mimicking operational environmental conditions. The supported architecture shows higher response in the mid humidity range (50% relative humidity), with shorter response and recovery times and lower detection limit with respect to the suspended nanowire. These experimental pieces of evidence indicate a minor role of the InAs/SiO2 contact area; hence, there is no need for suspended nanostructures to improve the sensing performance. Moreover, the sensing capability of single InAs nanowires for detection of NO2 and ethanol in the ambient atmosphere is reported and discussed

Apical Sealing Quality of In Vitro Apicectomy Procedures After Using Both Er:YAG and Nd:YAG

The aim of this study was to evaluate the apical sealing of dentinal tubules after root-end surface cutting by using Er:YAG and Nd:YAG lasers. After root-canal instrumentation and filling, apices of 50 extracted maxillary canine human teeth were resected by Er: YAG with 400 mJ, 10 Hz, for 30 sec. The samples were randomly assigned to five groups (n = 10): (GI) treated without root-end cavity, but with Nd: YAG (1.0W, 10 Hz, 20 sec) for dentinal tubules sealing; (GII) treated with root-end cavity without the use of Nd: YAG; (GIII) treated with root-end cavity and Nd: YAG application; (GIV) treated with root-end cavity made by Er: YAG with no focus and without Nd: YAG application; and (GV) treated without root-end cavity and without Nd: YAG application. The root-end cavities were performed by using Er: YAG at 300 mJ, 10 Hz, for 20 sec. Subsequently, all teeth were waterproofed and immersed in 2% methylene blue for 48 h in a vacuum environment. The samples were longitudinally sectioned, and microleakage was measured. ANOVA and the Fisher LSD test showed that GIV was less susceptible to microleakage than were the other groups (p < 0.05). Interestingly, the use of the Er: YAG with no focus showed superior dentinal tubule sealing in comparison with the other groups, even with or without root-end cavity and Nd: YAG application