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system. By using POCUS in patients with COVID-19, disease pathologies ranging from pneumonia and acute respiratory distress syndrome to systolic heart failure and acute myocardial injury could be identified and monitored, while minimizing personnel and equipment exposure and personal protective equipment use. In anticipation of a large burden of COVID-19 cases, UW acquired additional handheld ultrasound machines, some of which were provided free of charge by the manufacturers. Additionally, ultrasound simulators and mannequins were obtained to provide standardized training in image acquisition and interpretation for trainees. 5 Images obtained using handheld ultrasound machines would be uploaded to the picture archiving and communication system for image archiving. These images would therefore be virtually available, including to the echocardiography laboratory, which could provide support and feedback for POCUS users and provide guidance for potential subsequent imaging. Our efforts have been positively received by clinicians across the UW system, as reflected by increasing participation in simulator training and implementation of the POCUS protocol. Our goal is to fully use POCUS during the COVID-19 pandemic to deliver highquality care while ensuring the safety of patients and health care workers. We hope to not only continue this collaboration among the various subspecialties but also report findings from the application of this protocol in the near future.

Background. Patients who undergo high-risk surgery represent a large amount of post-operative ICU-admissions. These patients are at high risk of experiencing postoperative complications. Renal Resistive Index was found to be related with renal dysfunction, hypertension, and posttraumatic hemorrhagic shock, probably due to vasoconstriction. We explored whether Renal Resistive Index (RRI), measured after awakening from general anesthesia, could have any relationship with postoperative complications. Methods. In our observational, stratified dual-center trial, we enrolled patients who underwent general anesthesia for high-risk major surgery. After awakening in recovery room (or during awakening period in subjects submitted to cardiac surgery) we measured RRI by echo-color-Doppler method. Primary endpoint was the association of altered RRI (>0.70) and outcome during the first postoperative week. Results. 205 patients were enrolled: 60 (29.3%) showed RRI > 0.70. The total rate of adverse event was 27 (18.6%) in RRI ≤ 0.7 group and 19 (31.7%) in RRI > 0.7 group (P = 0.042). Significant correlation between RRI > 0.70 and complications resulted in pneumonia (P = 0.016), septic shock (P = 0.003), and acute renal failure (P = 0.001) subgroups. Patients with RRI > 0.7 showed longer ICU stay (P = 0.001) and lasting of mechanical ventilation (P = 0.004). These results were confirmed in cardiothoracic surgery subgroup. RRI > 0.7 duplicates triplicates the risk of complications, both in general (OR 2.03 93 95% CI 1.02–4.02, P = 0.044) and in cardiothoracic (OR 2.62 95% CI 1.11–6.16, P = 0.027) population. Furthermore, we found RRI > 0.70 was associated with a triplicate risk of postoperative septic shock (OR 3.04, CI 95% 1.5–7.01; P = 0.002).

During carotid cross-clamping, an excessive rise of blood pressure is not necessary to guarantee safe values of rSO2. On the contrary, hypertension could expose the patient to risk of cardiac accident. So we have modified our intraoperative strategy avoiding controlled hypertension for normotensive management during carotid clamping.

During SARS-CoV-2 pandemic, several subjects were treated in our intensive care unit (ICU) because of acute respiratory failure following COVID-19 pneumonia. Most of them required mechanical ventilation and someone in prone position (PP) too, because of acute respiratory distress syndrome (ARDS). During PP, trans-esophageal echocardiography (TEE) is not always easy, mainly due to the forced position of the neck of the patient. Moreover, during a pandemic, given the great number of patients needing treatment, TEE probes and monitoring devices are not widely available. Then, trans-thoracic echocardiography (TTE) plays a crucial role as it is non-invasive, repeatable, and available every time it is needed. Moreover, it can be safely performed also in prone position (TTEp). According to in-hospital protocol, TTEp was performed using the apical-four-chamber (A-4-C) view in 8 patients. We temporarily deflated the lower thoracic section of the air-mattress to place the probe between the mattress surface and the thorax of the patient. We collected both TEE and hemodynamics data. The main result of our retrospective analysis is that TTE can be performed in patients in prone positioning and is reliable and repeatable; the single apicalfour-chamber view provides sufficient data to evaluate the cardiac performance in case of scarce availability of hemodynamic monitoring devices, like in a pandemic setting. TTE may be a helpful tool for cardiac performance evaluation and diagnosis not only in supine or anterolateral positioning like in echocardiographic lab, but also in subjects admitted to ICU due to ARDS needing of mechanical ventilation in prone positioning.

Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients’ management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist’s point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.

Lactatemia during liver resection depends on the duration of PM, bleeding and the duration of the operation. Normal liver may expose the patient to the risk of hyperlactatemia.

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