Very early postoperative troponin increase and clinical outcome in patients admitted to the recovery room after noncardiac surgery with suspected cardiac events.

We assessed the prognostic meaning of very early (<6 h) troponin increase after noncardiac surgery in a population of patients admitted to the recovery room, for whom troponin measurements were taken because of a suspected cardiac event. Among a total of 296 patients, abnormal troponin was found in 24 (8.1%). Ten patients in this group (41.7%) and 27 among those with normal troponin (9.9%) experienced cardiovascular death, myocardial infarction, or decompensated heart failure at one month (p < 0.0001). Troponin was independently associated with a two-fold risk of events (p < 0.0001). In these patients, very early troponin measurement in the recovery room may help to identify patients at risk of cardiovascular events.

Blood flow maintenance by cardiac massage during cardiopulmonary resuscitation: Classical theories, newer hypotheses, and clinical utility of mechanical devices.

The mechanisms by which closed chest cardiac massage produces and maintains blood flow during cardiopulmonary resuscitation are still debated. To date, two main theories exist: the "cardiac pump", which assumes that blood flow is driven by direct cardiac compression and the "chest pump", which hypothesizes that blood flow is caused by changes in intrathoracic pressure. Newer hypotheses including the "atrial pump", the "lung pump", and the "respiratory pump" were also proposed. We reviewed studies supporting these different theories as well as the clinical evidences on the utility of mechanical devices proposed to optimize cardiopulmonary resuscitation, in view of their pathophysiological assumptions with regard to the underlying theory. On the basis of current evidence, a single theory is probably not sufficient to explain how cardiac massage produces blood flow. This suggests that different simultaneous mechanism might be involved. The relative importance of these mechanisms depends on several factors, including delay from collapse to starting of resuscitation, compression force and rate, body habitus, airway pressure, and presenting electrocardiogram. The complexity of the physiologic events occurring during cardiopulmonary resuscitation, together with the need of adequate training for a correct and prompt utilization of mechanical devices, might also partially explain the disappointing results of these devices in most clinical studies.

Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome a pilot study.

PURPOSE: Speckle tracking echocardiography is a novel echocardiographic technique to assess RV myocardial function but no data are so far available in patients with acute respiratory distress syndrome (ARDS), and we aimed at assessing the feasibility of 2 dimensional (2D) speckle tracking echocardiography and the prognostic role of RV free wall speckle tracking strain in 30 consecutive patients with moderate-severe ARDS MATERIALS AND METHODS: In an observational prospective study, 30 consecutive patients with moderate-severe ARDS were enrolled. Echocardiography was performed within 12 hours from ICU admission. RESULTS: Mortality rate was 33% (10/30). Non-survivors showed lower values of pH (7.32 ± 0.09, P = 0.03) and higher troponin I levels (0.32 (0.08-0.46), P = 0.04), NT-pro BNP (3091 (2662-7128), P = 0.009), and SAPS II (60.3 ± 9.6, P < 0.001). At echocardiographic examination, non-survivors showed lower values of TAPSE (18.3 ± 3, P = 0.034) and higher systolic pulmonary arterial pressure (49.6 ± 16, P = 0.05). Two patients (6.6%) did not show valid acoustic windows. Only three patients showed normal values of RV strain free wall (22%, 25%, and 28% absolute values, respectively), among whom one patient died. When compared to survivors, non-survivors showed significantly lower values of RV strain free wall (-10.4 ± 0.10, P < 0.001). CONCLUSIONS: In mechanically ventilated moderate-severe ARDS, 2D speckle tracking is feasible even though difficult acoustic windows are common. Further studies are needed to confirm our findings in a larger cohort of patients.

Clinical impact of recovery room on post-operative walking performance in elderly patients submitted to hip surgery: a real-world analysis.

BACKGROUND: Strategies aimed at favouring functional recovery after surgery for hip fracture may be of clinical importance. AIMS: To test the clinical utility of a recovery room (RR) in terms of postoperative walking performance in an elderly population submitted to hip fracture surgery. METHODS: Postoperative walking performance at rollator was assessed in 242 consecutive orthogeriatric patients able to follow the institutional physiotherapy protocol starting on day 1 after hip surgery. Group 1 (n = 186, age 86.0 ± 9.3 years, 24.7% male) was admitted to the RR for postoperative monitoring, whereas Group 2 (n = 56, age 85.2 ± 5.7 years, 23.2% male) was directly admitted to the ward. The best performance observed during the first three postoperative days was considered. RESULTS: Group 1 showed a better walking performance than Group 2, with a 50% lower probability of walking < 5 m (relative risk 0.51, p = 0.0005) and a two-fold higher probability of walking > 10 m (relative risk 2.10, p = 0.0005). Multivariable analysis confirmed a favourable independent effect of the RR stay on walking performance (ß = 0.205, p = 0.005). DISCUSSION: Admission to the RR in elderly patients submitted to hip fracture surgery could have an independent beneficial effect on postoperative walking functional recovery. This beneficial effect could probably depend on the possibility of ensuring a more rapid management of postoperative issues CONCLUSIONS: These findings support the clinical utility of a RR implementation in facilities where hip surgery in elderly subjects is routinely performed.

Comparison of three sites to check the pulse and count heart rate in hypotensive infants.

BACKGROUND: Current international guidelines state that heart rate counted at the brachial pulse must be absent or <60 b x min(-1) to diagnose cardiac arrest. Some data suggest that this site may not be the best to check cardiac activity. Hypotension is a likely real scenario of the need for chest compressions in infants. We compared the performance of three sites of pulse palpation (brachial, carotid, and femoral) for detecting and counting heartbeat in hypotensive infants. METHODS: In an operating theater of a pediatric teaching hospital in Italy, we studied 40 anesthetized hypotensive infants just prior to surgery, checked by two doctors and two nurses by a cross-sectional, repeated-measures study design. Each examiner, blind to the monitoring data of the patient, was asked to find the infant's arterial pulse within 10 s and count heart rate for 15 s. During each examination, the order of the three sites was randomized. RESULTS: Among successful detections, femoral pulse palpation resulted as the most successful, rapid, and accurate site to detect and count heart rate in hypotensive infants. CONCLUSIONS: Femoral palpation proved to be the best site for detecting heartbeat and counting heart rate in hypotensive infants. These findings challenge the current guidelines. More data are needed, but the current standard of brachial pulse assessment is debatable.

Attitudes of children with leukemia toward repeated deep sedations with propofol.

Procedural sedation is generally recommended for children requiring repeated painful diagnostic or therapeutic procedures. A child with leukemia undergoes an average of 20 procedures such as lumbar puncture and bone marrow aspiration through the course of illness. No data are currently available about the psychological impact of repeated sedations on children. The objective of this study was to evaluate the attitudes of patients with leukemia toward repeated deep sedations using propofol. A questionnaire addressing sedation-related distress was given to 30 children with leukemia. Procedure-related distress was evaluated using the Amended Observational Scale of Behavioural Distress. Another questionnaire concerning the same issues was given to an historical group of 39 children who had undergone painful procedures without sedation in previous years. Fear and distress were significantly reduced in the sedation group compared with the historical one. Fear of sedation was reported by 17% of children of this group. Distressed behavior was observed in 27%. In conclusion, sedation-related distress was observed in a subgroup of patients; in these cases, specific strategies could be considered to reduce sedation-related distress.

Tremors and chorea induced by trimethoprim-sulfamethoxazole in a child with Pneumocystis pneumonia.

A 1.5-year-old girl developed high frequency tremors and chorea after receiving a dose of 120 mg/kg/d trimethoprim-sulfamethoxazole (TMP-SMX) for the treatment of Pneumocystis pneumonia. The child was human immunodeficiency virus-negative but immunocompromised because of prolonged immunosuppressive therapy. These symptoms disappeared 3 days after TMP-SMX was discontinued. Pediatricians should be aware of tremors and chorea among the potential adverse effects of high doses of TMP-SMX.

Heartbeat assessment in infants: a comparison of four clinical methods.

OBJECTIVE: To compare the performance of four clinical methods (apex ear auscultation; brachial, carotid, and femoral pulse palpation) for detecting and counting heart beat in infants. DESIGN: Cross-sectional, repeated-measures study design. Prospective data collection. SETTING: A postanesthesia care unit of a pediatric teaching hospital in Italy. PATIENTS: Fifty-six normotensive sedated infants, aged 1-12 mos, were evaluated by 14 pediatric basic life support (PBLS)-qualified health professionals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The proportion of successful heartbeat detections ranged from 60% with carotid pulse palpation to 98% with apex auscultation. Among successful detections, apex auscultation proved to be the most rapid way to detect heart rate (median, 4 secs) and the most accurate with a median discrepancy of 8 beats/min (vs. 12 with the other methods) from the electrocardiographic results. Differences between apex auscultation and pulse palpation were statistically significant (p < .0001). In contrast, no significant differences were found among the three methods of pulse checking. CONCLUSIONS: Apex listening is the most successful, rapid, and accurate method to detect and count the heartbeat by PBLS-certified professionals in normotensive infants without instruments. Pulse checking remains important for assessing the effectiveness of circulation. Palpating the brachial, carotid, or femoral pulse is equally effective.

Deep sedation with propofol by nonanesthesiologists: a prospective pediatric experience.

BACKGROUND: The need to perform procedural sedation for children has increased in recent years, and so has the experience of nonanesthesiologists in this field. The use of propofol increases the success of satisfactory deep sedation, but it can produce rapid and profound decreases in level of consciousness and cardiorespiratory function. Data are needed to assess the safety of this drug outside an anesthesiology setting. OBJECTIVE: To assess safety and efficacy of procedural sedation with propofol in a pediatric ward of a tertiary-care pediatric teaching hospital with trained personnel and monitoring facilities. METHODS: Patients admitted to the hospital who needed invasive procedures underwent procedural sedation by the pediatric sedation unit with intravenous propofol. A training protocol was developed to educate nurses and residents. RESULTS: We performed 1059 procedures. Sedation was achieved in all procedures, and all but 1 were successfully performed. No patient required intubation. Transient desaturation resolving spontaneously occurred in 134 (12.7%) of 1059 patients. Major desaturation requiring a short course of ventilation occurred in 4 (0.8%) of 483 patients undergoing upper endoscopies, in 1 (0.3%) of 287 patients undergoing painful procedures, and in none of the 289 patients undergoing colonoscopies. Laryngospasm occurred in 10 (2.1%) of 483 patients undergoing upper endoscopies. CONCLUSIONS: In this experience, the use of propofol with concurrent oxygen administration allowed sedations in children with no significant complications for colonoscopies and painful procedures. Complications in the group of upper endoscopies appear too high for recommending propofol in a sedation unit with residents in attendance. This protocol of procedural sedation by nonanesthesiologists allowed a significant increase in the number of procedures performed with sedation and saved anesthesiology resources.

Motion sickness and postoperative vomiting in children.

BACKGROUND: Motion sickness is considered an important risk factor for postoperative nausea and vomiting in children. The aim of this study was to verify the impact of motion sickness on the incidence of vomiting after routine surgery in children, and to compare the incidence of vomiting, after combined regional/general anaesthesia, using either halothane or sevoflurane. METHODS: We prospectively studied 420 children (369 males and 51 females) who received general anaesthesia and inguinal field block for common paediatric surgery. The children were randomly allocated into one of two groups (halothane or sevoflurane). In the 200 children in the first group (H), general anaesthesia was induced and maintained with halothane, whereas in the 220 children in the second group (S), anaesthesia was induced and maintained with sevoflurane. RESULTS: There were 79 children with a prior history of motion sickness (MS+) and 341 without such a history (MS-). In the MS+ population, the incidence of vomiting was similar in both H and S groups, being around 33%. However, repeated episodes of vomiting in MS+ children were more frequent when halothane was used. In the MS- group, the incidence of vomiting was significantly greater in the H group (19%) than in the S group (8%). CONCLUSIONS: In the postoperative period, we found that MS+ children vomit more than MS- children, regardless of the inhalation anaesthetic used. However, MS- children displayed a higher incidence of vomiting when halothane was used rather than sevoflurane.