Abstract Background: Aim of this prospective study was to evaluate the sensory block quality and hemodynamic effects in patients undergoing urologic surgery under Combined Sequential Spinal Epidural Anesthesia (CSSE). Methods: Fifty patients were included in the study. Inclusion criteria were age ≥ 18 years and surgery scheduled to last ≤ 2 hours. Patients with a history of hypertension, congestive heart failure, any active medication for cardiovascular disease or any other absolute or relative contraindication to spinal anesthesia were excluded from the study. Patients undergoing urologic procedures received CSSE with 4 ml of Levobupivacaine 0.075% intratecally, followed by 10 ml of Levobupivacaine 1.5% epidurally. Sensory block spread was assessed by a pin prick test. Cardiac index (CI), blood pressure (BP), heart rate (HR) and arterial saturation of O2 (SpO2) were continuously monitored and recorded. Before discharge, patient’s functional status was assessed by the Aldrete Score. Results: CSSE allowed a pain free procedure. The pinprick test score was 1.2 ± 0.7 at the T7 dermatome level. CI, mean BP and HR were stable during the entire procedure. The Aldrete Score was 9.84 ± 0.4. Conclusion: CSSE performed with low doses of local anaesthetics allowed a good sensory block and was associated with good hemodynamic conditions and recovery score.

Continuous spinal anesthesia (CSA) has not been widely used for postoperative analgesia, mainly to avoid complications from the subarachnoid injection. Recently, the introduction of low caliber CSA catheters (Spinocath(®)), has allowed to decrease anesthetics doses and volumes with good analgesia and reduced complications. The aim of this present study was to compare two concentrations of levobupivacaine administered through CSA for postoperative pain management after major orthopedic surgery. Secondary outcomes were adverse events associated with CSA.

Background: We tested the hypothesis that during laparoscopic surgery, Trendelenburg position and pneumoperitoneum (PnP) may worsen chest wall elastance (ECW), concomitantly decreasing transpulmonary pressure (PL) and that a protective ventilator strategy applied after PnP induction, by increasing PL would result in alveolar recruitment and improvement in respiratory mechanics and gas exchange. Methods: In twenty-nine consecutive patients an open lung strategy (OLS) consisting in a recruiting manoeuvre (RM) followed by PEEP 5cmH20 maintained until the end of surgery was applied after PnP induction. Respiratory mechanics, gas exchange, blood pressure (BP) and cardiac index (CI) were measured before (TBSL) and after PnP with zero PEEP (TpreOLS), after RM with PEEP (TpostOLS), after peritoneum desufflation with PEEP (Tend). Results: Esophageal pressure was used for partitioning respiratory mechanics between lung and chest wall (data are mean +-standard deviation, SD): on TpreOLS, ECW and the elastance of the lung (EL) increased (respectively 8.2±0.9cmH2O/L vs 6.2±1.2cmH2O/L on TBSL, p=0.00016; and 11.69±1.68cmH2O/L vs 9.61±1.52cmH2O/L on TBSL; p=0.0007). After OLS both ECW and EL decreased (5.2±1.2cmH2O/L and 8.62±1.03cmH2O/L respectively; both p=0.00015 vs TpreOLS ), and PaO2/FiO2 improved (491+107 vs 425±97 on TpreOLS; p=0.008) remaining stable thereafter. Recruited volume (computed as the difference in lung volume for the same static airway pressure), was 194±80ml. PplatRS remained stable while inspiratory transpulmonary pressure (PplatL) increased (11.65+1.37 cmH2O vs 9.21+2.03 on TpreOLS; p=0.007). All respiratory mechanics parameters remained stable after abdominal desufflation. Hemodynamic parameters remained stable throughout the study. Conclusions: In patients submitted to laparoscopic surgery in Trendelenburg position, an OLS applied after PnP induction increased PL and led to alveolar recruitment and improvement of ECW, EL and gas exchange.

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Patients meeting the Berlin definition for the acute respiratory distress syndrome (ARDS) might lack exposure to one or more "common" risk factors and exhibit different clinical phenotype and outcomes. We aimed to compare the clinical presentation and outcome of ARDS patients with or without risk factors, the impact on hospital mortality, and to assess the diagnostic work-up performed. The current study is an ancillary analysis of an international, multicenter, prospective cohort study (the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure, LUNG SAFE). Patients meeting ARDS criteria within 2 days of acute hypoxemic respiratory failure onset were included in the study and categorized as having risk factors or not. Outcomes were compared using propensity score matching.

Summary Background The role of positive end-expiratory pressure in mechanical ventilation during general anaesthesia for surgery remains uncertain. Levels of pressure higher than 0 cm H2O might protect against postoperative pulmonary complications but could also cause intraoperative circulatory depression and lung injury from overdistension. We tested the hypothesis that a high level of positive end-expiratory pressure with recruitment manoeuvres protects against postoperative pulmonary complications in patients at risk of complications who are receiving mechanical ventilation with low tidal volumes during general anaesthesia for open abdominal surgery. Methods In this randomised controlled trial at 30 centres in Europe and North and South America, we recruited 900 patients at risk for postoperative pulmonary complications who were planned for open abdominal surgery under general anaesthesia and ventilation at tidal volumes of 8 mL/kg. We randomly allocated patients to either a high level of positive end-expiratory pressure (12 cm H2O) with recruitment manoeuvres (higher PEEP group) or a low level of pressure (2 cm H2O) without recruitment manoeuvres (lower PEEP group). We used a centralised computergenerated randomisation system. Patients and outcome assessors were masked to the intervention. Primary endpoint was a composite of postoperative pulmonary complications by postoperative day 5. Analysis was by intention-to-treat. The study is registered at Controlled-Trials.com, number ISRCTN70332574. Findings From February, 2011, to January, 2013, 447 patients were randomly allocated to the higher PEEP group and 453 to the lower PEEP group. Six patients were excluded from the analysis, four because they withdrew consent and two for violation of inclusion criteria. Median levels of positive end-expiratory pressure were 12 cm H2O (IQR 12–12) in the higher PEEP group and 2 cm H2O (0–2) in the lower PEEP group. Postoperative pulmonary complications were reported in 174 (40%) of 445 patients in the higher PEEP group versus 172 (39%) of 449 patients in the lower PEEP group (relative risk 1·01; 95% CI 0·86–1·20; p=0·86). Compared with patients in the lower PEEP group, those in the higher PEEP group developed intraoperative hypotension and needed more vasoactive drugs. Interpretation A strategy with a high level of positive end-expiratory pressure and recruitment manoeuvres during open abdominal surgery does not protect against postoperative pulmonary complications. An intraoperative protective ventilation strategy should include a low tidal volume and low positive end-expiratory pressure, without recruitment manoeuvres.

Abstract Purpose: Imaging has become increasingly important across medical specialties for diagnostic, monitoring, and investigative purposes in acute respiratory distress syndrome (ARDS). Methods: This review addresses the use of imaging techniques for the diagnosis and management of ARDS as well as gaining knowledge about its pathogenesis and pathophysiology. The techniques described in this article are computed tomography, positron emission tomography, and two easily accessible imaging techniques available at the bedside—ultrasound and electrical impedance tomography (EIT). Results: The use of computed tomography has provided new insights into ARDS pathophysiology, demonstrating that ARDS does not homogeneously affect the lung parenchyma and that lung injury severity is widely distributed in the ARDS population. Positron emission tomography is a functional imaging technique whose value resides in adding incremental insights to morphological imaging. It can quantify regional perfusion, ventilation, aeration, lung vascular permeability, edema, and inflammation. Lung ultrasound and EIT are radiation-free, noninvasive tools available at the bedside. Lung ultrasound can provide useful information on ARDS diagnosis when x-rays or CT scan are not available. EIT is a useful tool to monitor lung ventilation and to assess the regional distribution of perfusion. Conclusions: The future of imaging in critical care will probably develop in two main directions: easily accessible imaging techniques that can be used at the bedside and sophisticated imaging methods that will be used to aid in difficult diagnostic cases or to advance our understanding of the pathogenesis and pathophysiology of an array of critical illnesses.

Prolonged controlled mechanical ventilation depresses diaphragmatic efficiency. Assisted modes of ventilation should improve it. We assessed the impact of pressure support ventilation versus neurally adjusted ventilator assist on diaphragmatic efficiency.

To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS) patients with diffuse loss of aeration, the application of the open lung approach (OLA) would improve homogeneity in lung aeration and lung mechanics, without affecting hemodynamics.