Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in o... more Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m(2) scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (pre...
Background To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS)... more Background 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. Methods Patients were ventilated according to the ARDS Network protocol at baseline (pre-OLA). OLA consisted in a recruitment maneuver followed by a decremental positive end-expiratory pressure trial. Respiratory mechanics, gas exchange, electrical impedance tomography (EIT), cardiac index, and stroke volume variation were measured at baseline and 20 min after OLA implementation (post-OLA). Esophageal pressure was used for lung and chest wall elastance partitioning. The tomographic lung image obtained at the fifth intercostal space by EIT was divided in two ventral and two dorsal regions of interest (ROIventral and ROIDorsal). Results Fifteen consecutive patients were studied. The OLA increased arterial oxy...
ABSTRACT Background: In this prospective physiological observational study, we applied a strategy... more ABSTRACT Background: In this prospective physiological observational study, we applied a strategy to estimate the end-expiratory pleural pressure (Ppl,ee) using esophageal manometry to measure the esophageal pressure (Pes) directly. The estimated Ppl,ee was used to assess the end-expiratory transpulmonary pressure (PL,ee), in order to obtain a parameter to target PEEP, thereby minimizing alveolar collapse and resulting hypoxemia at end expiration during normal and one lung ventilation (OLV) in supine and lateral decubitus in Thoracic Surgery. Material and methods: After Ethical Committee approval was obtained, we enrolled patients with age ≥ 18 ys, scheduled for thoracic surgery and OLV with double-lumen tube in lateral decubitus. Exclusion criteria: ASA > III, haemodynamic instability, ARDS. Haemodynamics, gas exchange and respiratory mechanics data were recorded at three time points: two lung ventilation in supine position (T1), two lung ventilation in lateral (T2) and one lung ventilation in lateral position (T3). We applied a factor to correct absolute Pes values to estimate the Ppl,ee, by subtracting the Pes value obtained at the relaxation volume of the respiratory system (Vr) af ter manual disconnection from the ventilator, from the Pes value at the end of an expiratory occlusion. PL,ee was obtained as airway pressure at the end of the expiratory occlusion minus Ppl,ee. Result and discussion: 8 consecutive patients undergoing to thoracic surgery were included. At T1 Ppl,ee was 1.31±0.37 cmH2O, and increased overtime (3.06 ± 0.23 at T2 and 3.87 ± 0.43 at T3; p< 0.01 vs T1), while PL,ee decreased (2.88 ± 0.36 cmH2O at T1, 0.2 ± 0.33 at T2, -0.36 ± 0.47 at T3; p< 0.01 vs T1).Conclusion: Our preliminary results show that the lateral position and the lung exclusion induce an increase in Ppl,ee and a reduction in PL,ee. We need further studies to determine if the estimation of Ppl,ee on the basis of the Vr method could allow PEEP titration to target an PL,ee of 0 cmH2O in order to avoid atelectrauma during thoracic surgery.
International journal of immunopathology and pharmacology
We studied the effects of Propofol, Desflurane, and Sevoflurane on the systemic redox balance in ... more We studied the effects of Propofol, Desflurane, and Sevoflurane on the systemic redox balance in patients undergoing laparohysterectomy. We measured blood concentration of glutathione (GSH), plasma antioxidant capacity (Trolox Equivalent Antioxidant Capacity-TEAC), and lipid peroxidation products (malondialdehyde (aMDA) and 4-hydroxynonenal (aHNE) protein adducts). Sixty patients were randomly placed into three groups of twenty people each. In Group P anesthesia was induced with Propofol 2 mg/kg and maintained with 12-10-8 mg/kg/min; in Groups S and D anesthesia was induced with 3 mg/kg Sodium Thiopental and maintained with 2 percent Sevoflurane and 6 percent Desflurane, respectively. Blood samples were collected prior to induction (T0 bas), 60min and 24h postoperatively (T1 60 and T2 24 h). In Group P, GSH increased on T1 60 and returned to baseline on T24h, while TEAC remained unmodified; in Groups S, GSH and TEAC decreased on T1 60 in Group D, on T1 60 there was a slight decrease...
The "bone cement implantation syndrome" is a rare but severe complication observed espe... more The "bone cement implantation syndrome" is a rare but severe complication observed especially during the insertion of cemented prostheses in hip and knee replacement surgery. Several mechanisms are involved: effects of methylmethacrilate, embolism of fat, air and bone marrow, and release of tissue thromboplastin during acetabular and femoral reaming. Aim of this study was to detect embolic events, right heart impairment, hemodynamic and respiratory changes during hip and knee replacement surgery. Prospective study, between February-May 2001. Orthopedic Operative room. Twenty-one patients who underwent total hip or knee arthroplasty under general anesthesia. Patients were divided in methylmethacrylate cemented prostheses groups (CEM, n=10) and totally uncemented prostheses (NON CEM, n=11). Standard anesthesia monitoring and omniplane TEE were performed. TEE probe was positioned in order to obtain "inflow-outflow" views of right heart. Measurements were obtained af...
To evaluate the effects of positive end expiratory pressure (PEEP) on intrathoracic and extrathor... more To evaluate the effects of positive end expiratory pressure (PEEP) on intrathoracic and extrathoracic blood volumes in patients with acute respiratory failure (ARF). In 4 ARF patients, we have measured cardiac output (CI), intrathoracic blood volume (ITBVI), global end-diastolic ventricular volume (GEDVI), pulmonary (PBVI) and total (TBVI) blood volumes, during application of two PEEP levels (0 and 10 cm H2O). These measurements have been performed by PULSION COLD Z-021 system, using the double indicator dilution technique (thermal and dye dilution). PEEP application caused a significant reduction in CI (from 3.8 +/- 0.4 to 2.9 +/- 0.1 1/min/m2) and ITBVI (from 888 +/- 48 to 698 +/- 25 ml/m2). The reduction in intrathoracic blood volume was associated with a significant reduction in GEDVI and PBVI. After PEEP application, there was a significant reduction in TBVI (from 2437 +/- 135 to 1984 +/- 49 ml/m2). PEEP application decreases cardiac index, mainly through a preload reduction, a...
The combination of sedative and analgesic drugs is increasingly being used during minimally invas... more The combination of sedative and analgesic drugs is increasingly being used during minimally invasive surgery. The authors compared the clinical efficacy of two different fentanyl regimens, in combination with midazolam, for sedation analgesia in patients undergoing office-based plastic surgery procedures under local anesthesia. One-hundred patients were randomized into two groups of 50 subjects each. Group F1 received a fentanyl bolus of 0.7 microg/kg before infiltration with local anaesthetics; group F2 received the same bolus plus 0.6 microg/kg fentanyl every 45 minutes. All patients received a midazolam bolus of 0.05 mg/kg plus continuous infusion 0.08 mg/kg per hour. High-quality analgesia was obtained in every group, without significant differences between the two fentanyl regimens. Group F2 was associated with lower intraoperative mean blood pressure and SpO2 values compared with group F1. No differences were detected between the two groups in perioperative side effects or postoperative pain. Higher doses of opioid did not improve the quality of perioperative patient comfort but acted synergistically with the sedative drugs, amplifying the hemodynamic and respiratory side effects.
Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in o... more Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m(2) scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (pre...
Background To test the hypothesis that in early, mild, acute respiratory distress syndrome (ARDS)... more Background 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. Methods Patients were ventilated according to the ARDS Network protocol at baseline (pre-OLA). OLA consisted in a recruitment maneuver followed by a decremental positive end-expiratory pressure trial. Respiratory mechanics, gas exchange, electrical impedance tomography (EIT), cardiac index, and stroke volume variation were measured at baseline and 20 min after OLA implementation (post-OLA). Esophageal pressure was used for lung and chest wall elastance partitioning. The tomographic lung image obtained at the fifth intercostal space by EIT was divided in two ventral and two dorsal regions of interest (ROIventral and ROIDorsal). Results Fifteen consecutive patients were studied. The OLA increased arterial oxy...
ABSTRACT Background: In this prospective physiological observational study, we applied a strategy... more ABSTRACT Background: In this prospective physiological observational study, we applied a strategy to estimate the end-expiratory pleural pressure (Ppl,ee) using esophageal manometry to measure the esophageal pressure (Pes) directly. The estimated Ppl,ee was used to assess the end-expiratory transpulmonary pressure (PL,ee), in order to obtain a parameter to target PEEP, thereby minimizing alveolar collapse and resulting hypoxemia at end expiration during normal and one lung ventilation (OLV) in supine and lateral decubitus in Thoracic Surgery. Material and methods: After Ethical Committee approval was obtained, we enrolled patients with age ≥ 18 ys, scheduled for thoracic surgery and OLV with double-lumen tube in lateral decubitus. Exclusion criteria: ASA > III, haemodynamic instability, ARDS. Haemodynamics, gas exchange and respiratory mechanics data were recorded at three time points: two lung ventilation in supine position (T1), two lung ventilation in lateral (T2) and one lung ventilation in lateral position (T3). We applied a factor to correct absolute Pes values to estimate the Ppl,ee, by subtracting the Pes value obtained at the relaxation volume of the respiratory system (Vr) af ter manual disconnection from the ventilator, from the Pes value at the end of an expiratory occlusion. PL,ee was obtained as airway pressure at the end of the expiratory occlusion minus Ppl,ee. Result and discussion: 8 consecutive patients undergoing to thoracic surgery were included. At T1 Ppl,ee was 1.31±0.37 cmH2O, and increased overtime (3.06 ± 0.23 at T2 and 3.87 ± 0.43 at T3; p< 0.01 vs T1), while PL,ee decreased (2.88 ± 0.36 cmH2O at T1, 0.2 ± 0.33 at T2, -0.36 ± 0.47 at T3; p< 0.01 vs T1).Conclusion: Our preliminary results show that the lateral position and the lung exclusion induce an increase in Ppl,ee and a reduction in PL,ee. We need further studies to determine if the estimation of Ppl,ee on the basis of the Vr method could allow PEEP titration to target an PL,ee of 0 cmH2O in order to avoid atelectrauma during thoracic surgery.
International journal of immunopathology and pharmacology
We studied the effects of Propofol, Desflurane, and Sevoflurane on the systemic redox balance in ... more We studied the effects of Propofol, Desflurane, and Sevoflurane on the systemic redox balance in patients undergoing laparohysterectomy. We measured blood concentration of glutathione (GSH), plasma antioxidant capacity (Trolox Equivalent Antioxidant Capacity-TEAC), and lipid peroxidation products (malondialdehyde (aMDA) and 4-hydroxynonenal (aHNE) protein adducts). Sixty patients were randomly placed into three groups of twenty people each. In Group P anesthesia was induced with Propofol 2 mg/kg and maintained with 12-10-8 mg/kg/min; in Groups S and D anesthesia was induced with 3 mg/kg Sodium Thiopental and maintained with 2 percent Sevoflurane and 6 percent Desflurane, respectively. Blood samples were collected prior to induction (T0 bas), 60min and 24h postoperatively (T1 60 and T2 24 h). In Group P, GSH increased on T1 60 and returned to baseline on T24h, while TEAC remained unmodified; in Groups S, GSH and TEAC decreased on T1 60 in Group D, on T1 60 there was a slight decrease...
The "bone cement implantation syndrome" is a rare but severe complication observed espe... more The "bone cement implantation syndrome" is a rare but severe complication observed especially during the insertion of cemented prostheses in hip and knee replacement surgery. Several mechanisms are involved: effects of methylmethacrilate, embolism of fat, air and bone marrow, and release of tissue thromboplastin during acetabular and femoral reaming. Aim of this study was to detect embolic events, right heart impairment, hemodynamic and respiratory changes during hip and knee replacement surgery. Prospective study, between February-May 2001. Orthopedic Operative room. Twenty-one patients who underwent total hip or knee arthroplasty under general anesthesia. Patients were divided in methylmethacrylate cemented prostheses groups (CEM, n=10) and totally uncemented prostheses (NON CEM, n=11). Standard anesthesia monitoring and omniplane TEE were performed. TEE probe was positioned in order to obtain "inflow-outflow" views of right heart. Measurements were obtained af...
To evaluate the effects of positive end expiratory pressure (PEEP) on intrathoracic and extrathor... more To evaluate the effects of positive end expiratory pressure (PEEP) on intrathoracic and extrathoracic blood volumes in patients with acute respiratory failure (ARF). In 4 ARF patients, we have measured cardiac output (CI), intrathoracic blood volume (ITBVI), global end-diastolic ventricular volume (GEDVI), pulmonary (PBVI) and total (TBVI) blood volumes, during application of two PEEP levels (0 and 10 cm H2O). These measurements have been performed by PULSION COLD Z-021 system, using the double indicator dilution technique (thermal and dye dilution). PEEP application caused a significant reduction in CI (from 3.8 +/- 0.4 to 2.9 +/- 0.1 1/min/m2) and ITBVI (from 888 +/- 48 to 698 +/- 25 ml/m2). The reduction in intrathoracic blood volume was associated with a significant reduction in GEDVI and PBVI. After PEEP application, there was a significant reduction in TBVI (from 2437 +/- 135 to 1984 +/- 49 ml/m2). PEEP application decreases cardiac index, mainly through a preload reduction, a...
The combination of sedative and analgesic drugs is increasingly being used during minimally invas... more The combination of sedative and analgesic drugs is increasingly being used during minimally invasive surgery. The authors compared the clinical efficacy of two different fentanyl regimens, in combination with midazolam, for sedation analgesia in patients undergoing office-based plastic surgery procedures under local anesthesia. One-hundred patients were randomized into two groups of 50 subjects each. Group F1 received a fentanyl bolus of 0.7 microg/kg before infiltration with local anaesthetics; group F2 received the same bolus plus 0.6 microg/kg fentanyl every 45 minutes. All patients received a midazolam bolus of 0.05 mg/kg plus continuous infusion 0.08 mg/kg per hour. High-quality analgesia was obtained in every group, without significant differences between the two fentanyl regimens. Group F2 was associated with lower intraoperative mean blood pressure and SpO2 values compared with group F1. No differences were detected between the two groups in perioperative side effects or postoperative pain. Higher doses of opioid did not improve the quality of perioperative patient comfort but acted synergistically with the sedative drugs, amplifying the hemodynamic and respiratory side effects.
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Papers by G. Cinnella