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.).

Continuous intravenous administration of lidocaine during and after abdominal surgery improves patient rehabilitation and shortens hospital stay.

Continuous preperitoneal administration of 0.2% ropivacaine at 10 ml/h during 48 h after open colorectal resection reduced morphine consumption, improved pain relief, and accelerated postoperative recovery.

Age and prior use of psychotropic agents are associated with postoperative morphine dose requirements. Whether ABCB1 polymorphisms might predict morphine side effects remains to be determined.

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 The ETT is advanced to the right main bronchus and gradually withdrawn to a position above the carina where breath sounds can be auscultated.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...

No abstract

Lidocaine is an amide local anaesthetic initially used intravenously as an antiarrhythmic agent. At some point it was proposed that intravenous lidocaine (IVL) had an analgesic effect that could be potentially beneficial in perioperative settings. Since these preliminary reports, a large body of evidence confirmed that IVL had anti-inflammatory and opiate-sparing effects, a combination of characteristics leading to an array of effects such as a decrease in postoperative pain and opiate consumption, and a reduction in the duration of digestive ileus. Additional studies demonstrated IVL to possess antithrombotic, antimicrobial and antitumoral effects. Beneficial effects of IVL have been characterized in abdominal surgery but remain controversial in other types of surgeries. Because the quality of evidence was limited, due to inconsistency, imprecision and study quality, recent conclusions from meta-analysis pooling together all types of surgery stated the uncertainty about IVL benefits. Additional indications such as the prevention of propofol-induced injection pain, prevention of hyperalgesia, protection against bronchial reactivity by bronchotracheal relaxation during surgery, and the increase in depth of general anaesthesia have since emerged. IVL is rapidly distributed in the body and metabolized by the liver. With the commonly recommended doses, lidocaine's therapeutic index remains very high and the plasma concentrations stay largely below the cardiotoxic and neurotoxic threshold levels, a notion that may be used by clinicians to draw conclusions on the benefit-risk profile of IVL in comparison to other analgesic strategies. The purpose of this review is to address the pharmacokinetic and pharmacodynamic properties of lidocaine in healthy and pathological conditions.

Liver fibrosis is produced by myofibroblasts of different origins. In culture models, rat myofibroblasts derived from hepatic stellate cells (HSCs) and from periductal portal mesenchymal cells, show distinct proliferative and immunophenotypic evolutive profiles, in particular regarding desmin microfilament (overexpressed vs shut-down, respectively). Here, we examined the contributions of both cell types, in two rat models of cholestatic injury, arterial liver ischemia and bile duct ligation (BDL). Serum and (immuno)histochemical hepatic analyses were performed at different time points (2 days, 1, 2 and 6 weeks) after injury induction. Cholestatic liver injury, as attested by serum biochemical tests, was moderate/ resolutive in ischemia vs severe and sustained in BDL. Spatio-temporal and morphometric analyses of cytokeratin-19 and Sirius red stainings showed that in both models, fibrosis accumulated around reactive bile ductules, with a significant correlation between the progression rates of fibrosis and of the ductular reaction (both higher in BDL). After 6 weeks, fibrosis was stabilized and did not exceed F2 (METAVIR) in arterial ischemia, whereas micronodular cirrhosis (F4) was established in BDL. Immuno-analyses of a-smooth muscle actin and desmin expression profiles showed that intralobular HSCs underwent early phenotypic changes marked by desmin overexpression in both models and that the accumulation of fibrosis coincided with that of a-SMA-labeled myofibroblasts around portal/septal ductular structures. With the exception of desmin-positive myofibroblasts located at the portal/septal-lobular interface at early stages, and of myofibroblastic HSCs detected together with fine lobular septa in BDL cirrhotic liver, the vast majority of myofibroblasts were desmin-negative. These findings suggest that both in resolutive and sustained cholestatic injury, fibrosis is produced by myofibroblasts that derive predominantly from portal/periportal mesenchymal cells. While HSCs massively undergo phenotypic changes marked by desmin overexpression, a minority fully converts into matrix-producing myofibroblasts, at sites, which however may be important in the healing process that circumscribes wounded hepatocytes.