As compared with a practice of nonprotective mechanical ventilation, the use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical outcomes and reduced health care utilization. (IMPROVE ClinicalTrials.gov number, NCT01282996.).

Summary. Background: Reagent-supported thromboelastometry with the rotation thrombelastography (e.g. ROTEM Ò ) is a whole blood assay that evaluates the visco-elastic properties during blood clot formation and clot lysis. A hemostatic monitor capable of rapid and accurate detection of clinical coagulopathy within the resuscitation room could improve management of bleeding after trauma. Objectives: The goals of this study were to establish whether ROTEM correlated with standard coagulation parameters to rapidly detect bleeding disorders and whether it can help to guide transfusion. Methods: Ninety trauma patients were included in the study. At admission, standard coagulation assays were performed and ROTEM parameters such as clot formation time (CFT) and clot amplitude (CA) were obtained at 15 min (CA 15 ) with two activated tests (INTEM, EXTEM) and at 10 min (CA 10 ) with a test analyzing specifically the fibrin component of coagulation (FIBTEM). Results: Trauma induced significant modifications of coagulation as assessed by standard assays and ROTEM. A significant correlation was found between prothrombin time (PT) and CA 15 -EXTEM (r ¼ 0.66, P < 0.0001), between activated partial thromboplastin time and CFT-INTEM (r ¼ 0.91, P < 0.0001), between fibrinogen level and CA 10 -FIB-TEM (r ¼ 0.85, P < 0.0001), and between platelet count and CA 15 -INTEM (r ¼ 0.57, P < 0.0001). A cutoff value of CA 15 -EXTEM at 32 mm and CA 10 -FIBTEM at 5 mm presented a good sensitivity (87% and 91%) and specificity (100% and 85%) to detect a PT > 1.5 of control value and a fibrinogen less than 1 g L )1, respectively. Conclusions: ROTEM is a point-ofcare device that rapidly detects systemic changes of in vivo coagulation in trauma patients, and it might be a helpful device in guiding transfusion.

The ultrasonographic measurement of antral CSA could be an important help for the anesthesiologist in minimizing the risk of pulmonary aspiration of gastric contents due to general anesthesia.

IntroductionSeptic shock remains a major health care problem worldwide. Sepsis-induced immune alterations are thought to play a major role in patients' mortality and susceptibility to nosocomial infections. Programmed death-1 (PD-1) receptor system constitutes a newly described immunoregulatory pathway that negatively controls immune responses. It has recently been shown that PD-1 knock-out mice exhibited a lower mortality in response to experimental sepsis. The objective of the present study was to investigate PD-1-related molecule expressions in septic shock patients.MethodsThis prospective and observational study included 64 septic shock patients, 13 trauma patients and 49 healthy individuals. PD-1-related-molecule expressions were measured by flow cytometry on circulating leukocytes. Plasmatic interleukin (IL)-10 concentration as well as ex vivo mitogen-induced lymphocyte proliferation were assessed.ResultsWe observed that septic shock patients displayed increased PD-1, PD-Ligand1 (PD-L1) and PD-L2 monocyte expressions and enhanced PD-1 and PD-L1 CD4+ T lymphocyte expressions at day 1-2 and 3-5 after the onset of shock in comparison with patients with trauma and healthy volunteers. Importantly, increased expressions were associated with increased occurrence of secondary nosocomial infections and mortality after septic shock as well as with decreased mitogen-induced lymphocyte proliferation and increased circulating IL-10 concentration.ConclusionsThese findings indicate that PD-1-related molecules may constitute a novel immunoregulatory system involved in sepsis-induced immune alterations. Results should be confirmed in a larger cohort of patients. This may offer innovative therapeutic perspectives on the treatment of this hitherto deadly disease.

No abstract

European Society of Anaesthesiology.

As compared to the continuation of the empirical antimicrobial treatment, a strategy based on de-escalation of antibiotics resulted in prolonged duration of ICU stay. However, it did not affect the mortality rate.

of the congenital esophageal anomalies. A GT is kept in place during surgery so the surgeon can identify the proximal pouch. Intubation can be performed after inhaled or IV induction or rarely with the infant awake. Two methods to prevent severe gastric distension after positive pressure ventilation are positioning of the ETT in relation to the fistula and preoperative gastrostomy under local anesthesia. The ETT is advanced to the right main bronchus and gradually withdrawn to a position above the carina where breath sounds can be auscultated. Gastrostomy may provide a low-pressure escape route for gas, thus increasing flow through the fistula and compromising pulmonary ventilation. A Fogarty balloon catheter placed into the fistula and inflated will occlude the fistula, or a Fogarty catheter can be introduced retrogradely through the gastrostomy into the distal esophagus. For children having antireflux procedures, RSII is often used.The algorithm presented by the authors should be considered a basic framework to be amended and expanded as new information, approaches, and strategies are developed and show clinical efficacy. COMMENTAnesthesiologists pride themselves on being experts at airway management, and the literature contains a plethora of articles on endotracheal intubation, airway devices, and medications to facilitate intubation. There is, however, a dearth of information and evidence pertaining to GTs that may be passed either via the nasal or oral route. Although RSII and awake tracheal intubation are frequently used anesthetic approaches for the management of patients at risk for aspiration of esophageal or gastric contents, some of these vulnerable patients have a GT placed preoperatively, but there are no clinical guidelines to indicate which patients should have a GT placed before induction of anesthesia or how the GT should be managed during induction and the perioperative period. This helpful review article attempts to address these gaps.The use of CP is virtually routine during RSII, and the application of this technique has been critically reviewed by Loganathan and Liu. 1 Although the value of CP when there is either an NGT or oral GT in place has been questioned, it has been shown that a GT may actually improve the effectiveness of CP by "occupying the portion of the upper esophageal sphincter that is not compressed by cricoid pressure." 2 Clearly, we have many unanswered questions regarding the application of CP, and future research should be directed toward enhancing the quality of CP and when to release or avoid using this maneuver altogether. In addition, we have many unresolved issues regarding GT use that deserve further exploration, especially with regard to pediatric patients of all ages. 3 The current authors, however, deserve our gratitude for initiating this conversation. Comment by Kathryn E. McGoldrick, MD Disclosure: The author declares no conflict of interest.REFERENCES 1. Loganathan N, Liu EH. Cricoid pressure: ritual or effective measure? Singapore Med J. 2012;53:620-622. 2. R...