Acute mesenteric ischaemia in refractory shock on veno-arterial extracorporeal membrane oxygenation

Background: Acute mesenteric ischaemia is a severe complication in critically ill patients, but has never been evaluated in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). This study was designed to determine the prevalence of mesenteric ischaemia in patients supported by V-A ECMO and to evaluate its risk factors, as well as to appreciate therapeutic modalities and outcome. Methods: In a retrospective single centre study (January 2013 to January 2017), all consecutive adult patients who underwent V-A ECMO were included, with exclusion of those dying in the first 24 hours. Diagnosis of mesenteric ischaemia was performed using digestive endoscopy, computed tomography scan or first-line laparotomy. Results: One hundred and fifty V-A ECMOs were implanted (65 for post-cardiotomy shock, 85 for acute cardiogenic shock, including 39 patients after refractory cardiac arrest). Overall, median age was 58 (48-69) years and mortality 56%. Acute mesenteric ischaemia was suspected in 38 patients, with a delay of four (2-7) days after ECMO implantation, and confirmed in 14 patients, that is, a prevalence of 9%. Exploratory laparotomy was performed in six out of 14 patients, the others being too unstable to undergo surgery. All patients with mesenteric ischaemia died. Independent risk factors for developing mesenteric ischaemia were renal replacement therapy (odds ratio (OR) 4.5, 95% confidence interval (CI) 1.3-15.7, p=0.02) and onset of a second shock within the first five days (OR 7.8, 95% CI 1.5-41.3, p=0.02). Conversely, early initiation of enteral nutrition was negatively associated with mesenteric ischaemia (OR 0.15, 95% CI 0.03-0.69, p=0.02). Conclusions: Acute mesenteric ischaemia is a relatively frequent but dramatic complication among patients on V-A ECMO

Predictors of mortality following emergency open colectomy for ischemic colitis: A single-center experience

Background: Ischemic colitis (IC) is a severe emergency in gastrointestinal surgery. The aim of the present study was to identify the predictors of postoperative mortality after emergent open colectomy for IC treatment. Additionally, we compared postoperative outcomes of patients undergoing emergent colectomy due to aortic surgery-related IC (AS-IC group) vs. other IC etiologies (Other-IC group). Methods: We analyzed records of consecutive patients who underwent emergency open colectomy for IC between 2008 and 2019. Logistic regression analysis was performed to identify clinical and operative parameters associated with postoperative mortality. The AS-IC and Other-IC groups were compared for mortality, morbidity, ICU stay, hospital stay, and survival. Results: During the study period, 94 patients (mean age, 67.4 ± 13.7 years) underwent emergent open colectomy for IC. In the majority of cases, IC involved the entire colon (53.2%) and vasopressor agents were required preoperatively (63.8%) and/or intraoperatively (78.8%). Thirty-four patients underwent surgery due to AS-IC, whereas 60 due to Other-IC causes. In the AS-IC group, 9 patients had undergone endovascular aortic repair and 25 open aortic surgery; 61.8% of patients needed aortic surgery for ruptured abdominal aortic aneurism (AAA). Overall, 66 patients (70.2%) died within 90 days from surgery. The AS-IC and Other-IC groups showed similar operative outcomes and postoperative complication rates. However, the duration of the ICU stay (19 days vs. 11 days; p = 0.003) and of the total hospital stay (22 days vs. 16 days; p = 0.016) was significantly longer for the AS-IC group than for the Other-IC group. The rate of intestinal continuity restoration at 1 year after surgery was higher for the Other-IC group than for the AS-IC group (58.8% vs. 22.2%; p = 0.05). In the multivariate model, preoperative increased lactate levels, a delay between signs/symptoms' onset and surgery > 12 h, and the occurrence of postoperative acute kidney injury were statistically associated with postoperative mortality. Neither IC etiology (aortic surgery vs. other etiology) nor ruptured AAA was associated with postoperative mortality. Conclusion: Emergency open colectomy for IC is associated with high postoperative mortality, which appears to be unrelated to the IC etiology. Preoperative lactate levels, > 12-h delay to surgery, and postoperative acute kidney injury are independent predictors of postoperative mortality

Surgery and COVID-19: Balancing the nosocomial risk a french academic center experience during the epidemic peak

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Difficult intubation and extubation in adult anaesthesia.

To provide an update to French guidelines about "Difficult intubation and extubation in adult anaesthesia 2006". A consensus committee of 13 experts was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Few recommendations were ungraded. The panel focused on 6 questions: 1) Why must oxygen desaturation be avoided during intubation and what preoxygenation and oxygenation techniques should be used to prevent it? 2) Should videolaryngoscopes be used instead of standard laryngoscopy with or without a long stylet to achieve a better success rate of intubation after the first attempt during anticipated difficult intubation off fiberoptic intubation? 3) Should TCI or target controlled inhalation anaesthesia (TCIA) be used instead of bolus sedation for airway control in the event of suspected or proven difficulty in a patient spontaneously breathing? 4) What mode of anaesthesia should be performed in patients with difficult intubation criteria and potentially difficult mask ventilation? 5) In surgical patients, what criteria predict difficulties encountered during postoperative tracheal extubation? 6) Should decision trees and algorithms be employed to direct decision-making for the management of difficult intubation, whether foreseen or not? (based on the information from the preceding five issues). Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE <sup>®</sup> methodology. The SFAR Guideline panel provided 13 statements on difficult intubation and extubation in adult anaesthesia. After two rounds of discussion and various amendments, a strong agreement was reached for 99% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), 8 have a low level of evidence (Grade 2±). No recommendation was provided for one question. Substantial agreement exists among experts regarding many strong recommendations for the best care of patients with difficult intubation and extubation in adult anaesthesia

Somatosensory Evoked Potentials suppression due to remifentanil during spinal operations; a prospective clinical study

<p>Abstract</p> <p>Background</p> <p>Somatosensory evoked potentials (SSEP) are being used for the investigation and monitoring of the integrity of neural pathways during surgical procedures. Intraoperative neurophysiologic monitoring is affected by the type of anesthetic agents. Remifentanil is supposed to produce minimal or no changes in SSEP amplitude and latency. This study aims to investigate whether high doses of remifentanil influence the SSEP during spinal surgery under total intravenous anesthesia.</p> <p>Methods</p> <p>Ten patients underwent spinal surgery. Anesthesia was induced with propofol (2 mg/Kg), fentanyl (2 mcg/Kg) and a single dose of cis-atracurium (0.15 mg/Kg), followed by infusion of 0.8 mcg/kg/min of remifentanil and propofol (30-50 mcg/kg/min). The depth of anesthesia was monitored by Bispectral Index (BIS) and an adequate level (40-50) of anesthesia was maintained. Somatosensory evoked potentials (SSEPs) were recorded intraoperatively from the tibial nerve (P37) 15 min before initiation of remifentanil infusion. Data were analysed over that period.</p> <p>Results</p> <p>Remifentanil induced prolongation of the tibial SSEP latency which however was not significant (p > 0.05). The suppression of the amplitude was significant (p < 0.001), varying from 20-80% with this decrease being time related.</p> <p>Conclusion</p> <p>Remifentanil in high doses induces significant changes in SSEP components that should be taken under consideration during intraoperative neuromonitoring.</p