Is Night Surgery a Nightmare for Lung Transplantation?

Night work is frequently associated with sleep deprivation and is associated with greater surgical and medical complications. Lung transplantation (LT) is carried out both at night and during the day and involves many medical healthcare workers. The goal of the study was to compare morbidity and mortality between LT recipients according to LT operative time. We performed a retrospective, observational, single-center study. When the procedure started between 6 AM and 6 PM, the patient was allocated to the Daytime group. If the procedure started between 6 PM and 6 AM, the patient was allocated to the Nighttime group. Between January 2015 and December 2020, 253 patients were included. A total of 168 (66%) patients were classified into the Day group, and 85 (34%) patients were classified into the Night group. Lung Donors' general characteristics were similar between the groups. The 90-day and one-year mortality rates were similar between the groups (90-days: n = 13 (15%) vs. n = 26 (15%), p = 0.970; 1 year: n = 18 (21%) vs. n = 42 (25%), p = 0.499). Daytime LT was associated with more one-year airway dehiscence (n = 36 (21%) vs. n = 6 (7.1%), p = 0.004). In conclusion, among patients who underwent LT, there was no significant association between operative time and survival.

Management of anaphylactic shock in the operating room.

Diagnosis of anaphylactic shock occurring during anesthesia is challenging because of altered clinical signs and confounding diagnoses (e.g. arterial hypotension). A major sign of clinical severity in the presence of arterial hypotension is a low end-tidal CO2 concentration (below 20mmHg). Acute hemoconcentration (increase of hemoglobin concentrations) is highly suggestive of vascular leak triggered by anaphylactic shock. Guidelines for management of anaphylactic shock occurring during anesthesia are based on withdrawal of the suspected allergen, airway control, increased cardiac preload by the Trendelenbourg position and volume expansion, epinephrine, glucocorticoids and monitoring for 24hours, although evidence for the efficacy of these therapeutic interventions is absent or very weak. Refractory anaphylactic shock although not defined could be characterized by persistent clinical signs after more than 10minutes of adequately managed resuscitation. It should trigger enhanced cardiac monitoring through echocardiography to detect primary myocardial dysfunction and alert for extracorporeal life support. Drugs that may be used for refractory anaphylactic shock in addition to epinephrine are glucagon, norepinephrine, vasopressin, methylene blue but there are only animal studies where these drugs were compared to epinephrine. Follow-up after resuscitation includes patient information on the drugs given before occurrence of clinical signs, scheduled allergology investigation, pharmacovigilance report and recovery of the conclusions of allergology investigation with clear decisions on the identification of the culprit agent and subsequent avoidance. All these conclusions have to be traced in the medical record and shared with the patient.

Current and Future Considerations for the Treatment of Hospital-Acquired Pneumonia.

UNLABELLED: Hospital-acquired pneumonia (HAP) and health-care-associated pneumonia (HCAP) are leading causes of death, morbidity, and resource utilization in hospitalized patients, and are associated with a broad range of Gram-positive and Gram-negative pathogens. Here, we discuss the different definitions of HAP and HCAP, review current guidelines regarding the treatment of these conditions, highlight the shortcomings of current therapeutic options, and discuss new antibiotic treatments. To optimize therapeutic outcomes in patients with HAP/HCAP, initial antimicrobial treatment must be appropriate and should be given as soon as possible; inappropriate or delayed therapy greatly increases morbidity and mortality. Selection of the most appropriate antimicrobial agent depends on the causative pathogen(s); initial broad-spectrum therapy is commonly recommended and should cover all pathogens that may be present. Treatment selection should also take into consideration the following factors: knowledge of underlying local risk factors for antimicrobial resistance, disease staging, and risk factors related to specific pathogens such as Pseudomonas aeruginosa, Acinetobacter spp., and methicillin-resistant Staphylococcus aureus (MRSA). Guidelines consistently emphasize the importance of treating HAP and HCAP with early and appropriate broad-spectrum antibiotics, and recent developments in this field have resulted in the availability of several additional treatment options. Telavancin shows potent activity against Gram-positive bacteria including MRSA and can be administered once daily; it was approved in the USA and European Union for the treatment of HAP after demonstrating non-inferiority to vancomycin. Ceftobiprole medocaril exhibits rapid antimicrobial activity against a broad range of both Gram-positive and Gram-negative pathogens, including MRSA. It was approved for the treatment of HAP (excluding ventilator-associated pneumonia) and community-acquired pneumonia in Europe in 2013. These new treatments may offer effective alternative therapeutic options for the management of HAP. FUNDING: Basilea Pharmaceutica Ltd., Basel, Switzerland.