European Society of Anaesthesiology.

IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H 2 O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H 2 O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with SpO 2 Յ92% for >1 minute). RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, −2.3% [95% CI, −5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, −8.6% [95% CI, −11.1% to 6.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.

Purpose This study aimed to evaluate the effect of preoperative carbohydrate oral (CHO) loading on the postoperative metabolic and inflammatory response, perioperative discomfort and surgical clinical outcomes in open colorectal surgery compared with a conventional fasting protocol. Methods Fifty patients were randomly allocated to either the intervention group (CHO), to receive preoperative oral carbohydrate supplementation, or the control group (FAST), to undergo preoperative fasting. Insulin resistance, insulin sensitivity, the Glasgow Prognostic Score (GPS) and IL-6 levels were analysed at 06 h on the day of surgery (T 1 ), 6 h after surgery (T 2 ) and at 06 h on postoperative day 1 (T 3 ) and postoperative day 2 (T 4 ). Thirst, hunger, dry mouth, weakness, anxiety and pain were assessed using the visual analogue scale (VAS) prior to anaesthesia induction and at 0-4, 4-8, 8-12 and 12-24 h after surgery. Surgical clinical outcomes included the return of gastrointestinal function, time to independent ambulation and postoperative discharge day. Results Postoperative insulin resistance was 30% lower (p < 0.03) and insulin sensitivity was 15% higher (p < 0.05) in the CHO group than in the FAST group. The GPS was lower in the CHO group at T 1 (p < 0.001), T 3 (p < 0.01) and T 4 (p < 0.004). IL-6 serum levels were lower at the analysed postoperative time points in the CHO group (p < 0.001). The VAS well-being score was lower in the intervention group (p < 0.001); however, the VAS pain score was not significantly different between the groups. The evaluated surgical outcomes appeared earlier in the CHO group (p < 0.001). Conclusion A preoperative CHO drink reduced the postoperative metabolic and inflammatory response and improved subjective well-being and surgical clinical outcomes but did not diminish the VAS pain score.

Aim:The aim of this study was to investigate a relationship between seasonal variation and incidence of type A acute aortic dissection (AAD) and spontaneous abdominal aneurysm rupture (rAAA) in Canton Tuzla, Bosnia and Herzegovina.Patients and methods:A total of 81 cases, 41 AAD and 40 of ruptured AAA were identified from one center over a 6-year, from 2008 till 2013. In 2012 were admitted (45.6% or 36 patients).Results:Seasonal analysis showed that 19(23.4%) patients were admitted in spring, 15(18.5) in summer, 26(32%) in autumn and 21(25.9) in winter. The most frequent period was autumn/winter with 47 or 58% patients. A causal link between atmospheric pressure (AP) and incidence of rAAA and AAD on seasonal and monthly basis was found.

Sepsis is a life-threatening organ dysfunction caused by an unregulated response of a host. Septic shock is its most severe form. It is manifested by a drop in blood pressure, which decreases tissue perfusion pressure, causing hypoxia that is characteristic of shock. Sepsis is still one of the leading causes of mortality worldwide. Its incidence has increased since the first consensus definitions were established in 1991. Raising sepsis awareness, its significance and the need for better treatment, has led to an improvement in in defining sepsis and the development of guidelines for its treatment. The first guidelines were published in 2004, the second 2008, the third 2013, the fourth 2016, and the last revised guidelines appeared in 2021. This paper will describe the previous and new definitions of sepsis and septic shock, the previous guidelines for the recognition and treatment, and the latest recommendations for treatment. Timely diagnosis is crucial for the outcomes for patients with sepsis and septic shock. The fact is that the sepsis care bundles have been modified to increasingly shorter time determinants, which emphasizes the importance of emergency physicians, who frequently first recognize and begin emergency treatment of septic patients.

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Background and importance Patients aged 65 and above constitute a large and growing part of emergency department (ED) visits in western countries. Objective The primary aim of this European prospective study was to determine the epidemiologic characteristics of elderly patients presenting to EDs across Europe. Our secondary objective was to determine the hospitalization rate, characteristics, and in-hospital mortality rates of geriatric patients presenting to EDs. Design setting and participants An observational prospective cohort study over seven consecutive days between 19 October and 30 November 2020, in 36 EDs from nine European countries. Patients aged 65 years and older presenting to EDs with any complaint during a period of seven consecutive days were included. Outcome measures Data were collected on demographics, the major presenting complaint, the presenting vital signs, comorbidities, usual medication, and outcomes after the ED, including disposition, in-hospital outcome, and the final hospital diagnosis. The patients were stratified into three groups: old (65–74 years), older (75–84 years), and oldest age (>85 years). Main results A total of 5767 patients were included in the study. The median age of the patients was 77 (interquartile range: 71–84) years. The majority presented with a non-traumatic complaint (81%) and about 90% of the patients had at least one comorbid disease and were on chronic medication. An ED visit resulted in subsequent hospital admission in 51% of cases, with 9% of patients admitted to an intensive care unit. Overall in-hospital mortality was 8%, and ED mortality was 1%. Older age was associated with a higher female proportion, comorbidities, need for home care service, history of previous falls, admission rates, length of ED, and hospital stay. Conclusion The characteristics of ED elderly patients and their subsequent hospital stay are reported in this prospective study.

Background: Occupational burnout syndrome generally develops in individuals of helping professions and is considered to result from long-standing stress. Burnout syndrome is characterized by loss of interest, fatigue, or frustration, the negative consequences of which affect the individual's performance, thus being a major factor that influences the quality of work. Objectives: The aim of the study was to assess the existence of burnout syndrome in medical staff working at hospital emergency department. Methods: The study included 120 subjects working at emergency departments. The following two questionnaires were used: Copenhagen Burnout Inventory and Copenhagen Psychosocial Questionnaire. Likert scale was employed on scoring the answers offered in the questionnaires. Statistical analysis was performed using the exploratory factor analysis, analysis of variance, Bonferroni test, and Pearson correlation coefficient. The level of statistical significance was set at p < 0.05. Results: Study results revealed that the subjects suffer mostly from the symptoms of fatigue due to occupational burnout and exhaustion at the end of the day. The prevalence of burnout syndrome was highest among subjects with 11-15 years work in emergency department, while lower risk was recorded in those nurses and physicians who reported a higher level of social support, sense of community, and feedback information. Conclusion: Results of the study confirmed the existence of burnout syndrome in medical staff working at hospital emergency department, with the highest prevalence recorded in those working at this department for more than 11 years. The main burnout symptoms reported by study subjects were fatigue, exhaustion at the end of the day, and feeling that they were giving more than they were receiving in return. Burnout syndrome was found to be less common among those nurses and physicians who reported a higher level of social support, sense of community, and feedback information.