Background: The authors tested the hypothesis that during laparoscopic surgery, Trendelenburg position and pneumoperitoneum may worsen chest wall elastance, concomitantly decreasing transpulmonary pressure, and that a protective ventilator strategy applied after pneumoperitoneum induction, by increasing transpulmonary pressure, would result in alveolar recruitment and improvement in respiratory mechanics and gas exchange. Methods: In 29 consecutive patients, a recruiting maneuver followed by positive end-expiratory pressure 5 cm H 2 O maintained until the end of surgery was applied after pneumoperitoneum induction. Respiratory mechanics, gas exchange, blood pressure, and cardiac index were measured before (T BSL ) and after pneumoperitoneum with zero positive end-expiratory pressure (T preOLS ), after recruitment with positive end-expiratory pressure (T postOLS ), and after peritoneum desufflation with positive end-expiratory pressure (T end ). Results: Esophageal pressure was used for partitioning respiratory mechanics between lung and chest wall (data are mean ± SD): on T preOLS , chest wall elastance (E cw ) and elastance of the lung (E L ) increased (8.2 ± 0.9 vs. 6.2 ± 1.2 cm H 2 O/L, respectively, on T BSL ; P = 0.00016; and 11.69 ± 1.68 vs. 9.61 ± 1.52 cm H 2 O/L on T BSL ; P = 0.0007). On T postOLS , both chest wall elastance and E L decreased (5.2 ± 1.2 and 8.62 ± 1.03 cm H 2 O/L, respectively; P = 0.00015 vs. T preOLS ), and PaO 2 /inspiratory oxygen fraction improved (491 ± 107 vs. 425 ± 97 on T preOLS; P = 0.008) remaining stable thereafter. Recruited volume (the difference in lung volume for the same static airway pressure) was 194 ± 80 ml. Pplat RS remained stable while inspiratory transpulmonary pressure increased (11.65 + 1.37 cm H 2 O vs. 9.21 + 2.03 on T preOLS ; P = 0.007). All respiratory mechanics parameters remained stable after abdominal desufflation. Hemodynamic parameters remained stable throughout the study. Conclusions:In patients submitted to laparoscopic surgery in Trendelenburg position, an open lung strategy applied after pneumoperitoneum induction increased transpulmonary pressure and led to alveolar recruitment and improvement of E cw and gas exchange. LAPAROSCOPY is a well-established procedure for pelvic gynecologic surgery often performed in Trendelenburg position.1,2 To facilitate laparoscopic surgical manipulation, a pneumoperitoneum is usually induced through carbon dioxide inflation. Both the increase in abdominal pressure as a result of carbon dioxide inflation and the head down body position have been shown to impair the respiratory function during the procedure, mainly inducing atelectasis formation in the dependent lung regions. 1,[3][4][5][6] The resulting decrease in functional residual capacity poses Address correspondence to Dr. Cinnella: Departmentt of Anesthesia and Intensive Care, Policlinico 'Riuniti' -University of Foggia, Viale Pinto 1 -71100 Foggia, Italy. g.cinnella@unifg.it. Information on purchasing reprints may be found at www.anesthesiology.org...

IntroductionHip fractures represent one of the most important causes of morbidity and mortality in elderly people. Anxiety and depression affect their quality of life and increase pain severity, and have adverse effects on functional recovery. Recent World Health Organization guidelines emphasize that therapeutic regimes need to be individualized and combined with psychological support. This study was launched with the primary endpoint of assessing if and to what extent client-centered therapy affects the perception of pain, reduces anxiety and depression, and increases the quality of life of elderly patients with hip fracture.Materials and methodsForty patients were admitted to the Orthopedic and Trauma Surgery ward for hip fracture. Patients were randomly divided into two subgroups: (1) case (group C), had to receive patient-centered counseling throughout the hospitalization; and (2) control (group NC), receiving the analgesic treatment without receiving counseling. Short Form-36-item Health Survey Questionnaire, State–Trait Anxiety Inventory, and Hamilton Rating Scale for Depression scores were recorded before any treatment, at discharge, and after 30 days. Pain levels were evaluated by means of Visual Analog Scale every 12 hours during the hospitalization from the day of surgery until day 5.ResultsThe hierarchical clustering analysis identified before any treatment were two clusters based on different physical functioning perceptions and role limitations, which were due to physical and emotional problems. Counseling did have a positive impact on quality of life on all patients, but in a more relevant way if patients were low functioning upon admittance to the ward. Anxiety and depression decreased in patients undergoing counseling, and their pain levels were lower than among patients not receiving it.ConclusionThis study reveals that hip fracture patients can be clustered on the basis of Short Form-36 baseline scores. Counseling affects the evolution of mental and physical status in these patients, and the major benefit is reported in patients whose quality of life perception is worse after the trauma. Decreasing anxiety and depression levels, as well as more satisfying pain management, assessed by means of specific tests, confirm the effectiveness of counseling in elderly patients with hip fracture.

Background:The authors tested the hypothesis that during laparoscopic surgery, Trendelenburg position and pneumoperitoneum may worsen chest wall elastance, concomitantly decreasing transpulmonary pressure, and that a protective ventilator strategy applied after pneumoperitoneum induction, by increasing transpulmonary pressure, would result in alveolar recruitment and improvement in respiratory mechanics and gas exchange. Methods: In 29 consecutive patients, a recruiting maneuver followed by positive end-expiratory pressure 5 cm H 2 O maintained until the end of surgery was applied after pneumoperitoneum induction. Respiratory mechanics, gas exchange, blood pressure, and cardiac index were measured before (T BSL ) and after pneumoperitoneum with zero positive end-expiratory pressure (T preOLS ), after recruitment with positive end-expiratory pressure (T postOLS ), and after peritoneum desufflation with positive end-expiratory pressure (T end ). Results: Esophageal pressure was used for partitioning respiratory mechanics between lung and chest wall (data are mean ± SD): on T preOLS , chest wall elastance (E cw

Using transesophageal Doppler no differences in hemodynamic parameters could be detected between balanced general anesthesia with either caudal levobupivacaine or remifentanil infusion. Both techniques showed good hemodynamic stability with only minor changes from baseline over time which are unlikely to be of clinical significance except possibly in patients with preexisting cardiovascular compromise. Other studies with noninvasive monitoring in a larger population are required to better understand the consequences of caudal blockade on CO and on regional blood flow in infants.