Papers by Enrico Giustiniano
J Anesth Analg Crit Care. 2025; 13;5:7, 2025
Background Intraoperative hypotension (IOH) during non-cardiac surgery is closely associated with... more Background Intraoperative hypotension (IOH) during non-cardiac surgery is closely associated with postoperative complications. Hypotensive events are more likely during major open vascular surgery. We prospectively investigated whether our institutional algorithm of cardiocirculatory management, which included the Hypotension Prediction Index (HPI), a predictive model of hypotension of the Hemosphere ™ platform (Edwards Lifescience, Irwin, CA, USA), was able to reduce the incidence and severity of intraoperative hypotension during open abdominal aortic aneurysm repair. Methods A multi-center observational study was conducted at
We reviewed the comparative trials of the Flotrac/Vigileo TM versus the thermodilution method, pu... more We reviewed the comparative trials of the Flotrac/Vigileo TM versus the thermodilution method, published in the last decade. The results about the agreement between the two methods measuring cardiac output are contrasting. We also noticed that almost the whole pertinent literature include studies conducted without a correct statistical design, particularly about the sample size. For this reason, we consider that results of the published studies do not permit any conclusion about the agreement between pulse contour analysis for cardiac output measurement and thermodilution method.
Digestive Surgery, Oct 26, 2017
Perioperative fluid-therapy is a still a debated issue. In hepatic surgery, volume load must be s... more Perioperative fluid-therapy is a still a debated issue. In hepatic surgery, volume load must be strictly monitored to assure both a safe hemodynamics and low central venous pressure (CVP) to limit the backflow bleeding. Retrospectively, we compared intraoperative fluid management before and after the adoption of a semi-invasive hemodynamic monitoring. We compared patients submitted to liver resection monitored by FloTrac/VigileoTM (group A) vs. patients who did not (group B). We searched for differences about hemodynamics, fluid therapy and outcome. Three hundred fifty-five patients underwent hepatic resection due to neoplasm: group A - n = 179 and group B - n = 176. At the end of the resection, patients of group A showed a higher mean arterial pressure (MAP) than group B (74 ± 12 vs. 49.4 ± 8 mm Hg, respectively; p &amp;amp;lt; 0.001). Cardiac index and stroke volume variation in group A were within a normal range. Fluid input was higher in group B than in group A (12.0 ± 3.4 vs. 7.6 ± 3.1 mL/kg/h, respectively; p &amp;amp;lt; 0.001) and fluid balance was significantly different: group A -400 ± 1,527 vs. group B 326 ± 1,527 mL (p &amp;amp;lt; 0.001). Group B showed a greater number of cases complicated outcomes (36 vs. 20; p = 0.014). Considering only those subjects who were able to reach their hemodynamic targets (MAP ≥65 mm Hg and CVP ≤7 mm Hg), we found similar data. Patients who received a monitored fluid therapy experienced a safer outcome.
SOJ anesthesiology & pain management, 2015
WA, USA) was used to value cardiac performance, but particularly to monitor the endoprosthesis re... more WA, USA) was used to value cardiac performance, but particularly to monitor the endoprosthesis release and its "landing" on aortic wall. BGA was tested when considered appropriate. Postoperative analgesia consisted of Paracetamol 1g i.v bolus every 6 hours and wound infiltration with L-Bupivacaine 3.75mg/ml (20ml) before cutaneous suturing.
Journal of Anesthesia and Clinical Research, 2012
We report a case of postoperative renal failure in a patient submitted to cardiac surgery operati... more We report a case of postoperative renal failure in a patient submitted to cardiac surgery operation. Usually we adopt the renal resistivity index as a guide for the treatment, particularly about the titration of vasoactive drugs. We consider that renal resistivity index may be a simple and safe support for therapy-guiding in this kind of patients.
Journal of Vascular Surgery, Aug 1, 2021
BACKGROUND While appreciated for its long-term benefits, open repair of AAA is associated with a ... more BACKGROUND While appreciated for its long-term benefits, open repair of AAA is associated with a significant peri-operative burden. "Enhanced recovery" and "fast-track" protocols improved surgical outcomes in many specialties but remain scarcely applied in the vascular field. METHODS Based on the applied peri-operative protocol in a single Center experience, three consecutive study groups were identified among 394 consecutive patients undergoing elective AAA open repair in the last 12 years. Group A included 66 patients who underwent traditional surgery, group B comprised of 225 patients treated according to a partially adopted peri-operative protocol, and group C consisted of 103 patients, operated in line with a complete peri-operative protocol. The aim of the study was to evaluate the impact of the peri-operative protocol on recovery time by measuring complication rates, analgesic and antiemetic control, return of bowel function and ambulation, as well as length of hospitalization. RESULTS The study groups had similar baseline characteristics. A significant improvement was noted in the complication rates (p-value 0.019) and hospitalization time (p-value <0.001) following a complete implementation of the peri-operative protocol, where the median hospitalization time was 3 days. No mortality and no readmissions within 30 post-operative days were recorded in this group. There was an improvement in pain levels, as well as post-operative nausea and vomiting control (p-value <0.001). CONCLUSIONS Peri-operative protocol implementation in AAA open repair is feasible; the clinical outcomes may be improved when strictly adhering to the protocol. All the applied peri-operative management interventions appear to have a synergic effect on shortening the recovery time.
Journal of Anesthesia, Feb 14, 2023
Despite increasing use of immunosuppressants and anti-tumor necrosis factor (TNF) agents, approxi... more Despite increasing use of immunosuppressants and anti-tumor necrosis factor (TNF) agents, approximately half of Crohn's disease (CD) patients still require surgery within 10 years after diagnosis. Surgery is not curative as postoperative relapse is very frequent in the absence of prophylactic treatment. Screening for known risk factors for postoperative recurrence allows patients to be stratified in order to consider appropriate therapy. A subsequent endoscopic evaluation and reassessment of treatment is currently the best strategy. Analyses of pooled data indicate that 5-aminosalicylic acid and thiopurines have only slight efficacy to prevent postoperative recurrence in CD. Nitroimidazole antibiotics are modestly effective, but long-term toxicity limits their use in clinical practice. Recently, anti-TNF agents have demonstrated the best efficacy profile to prevent endoscopic recurrence after surgery. As new treatment algorithms evolve towards increasing use of anti-TNF agents, this drives increased costs of management. However, this may be offset by the more widespread use of biosimilar versions of the anti-TNF agents. The increasing number of patients with previous exposure to numerous immunosuppressants and biologics at the time of surgery is a new challenge in postoperative management of CD, for which further data on new biologics are eagerly awaited.
Journal of Anesthesia & Critical Care: Open Access, Jun 23, 2015
We report the results of an observational analysis about the post-intensive care outcome in high-... more We report the results of an observational analysis about the post-intensive care outcome in high-risk patients submitted to major oncologic surgery who needed of intensive care surveillance and/or treatment during the 1 st postoperative week. Given the acute kidney injury is a poor prognostic factor and is one of the most frequent post-surgical complication, we measured renal resistive index by color-Doppler ultrasound within six hours from the ICU admittance of 146 patients submitted to major surgery due to neoplasm, hypothesizing that high RRI may be correlated with mortality. We found a significant difference of renal resistive index in patients who died compared to survived subjects: 0.74+0.06 vs 0.66+0.08, p<0.001. Furthermore, RRI>0.70 may be a reasonable cutoff value to predict a significant increase of mortality risk.
Reviews on Recent Clinical Trials, Jul 1, 2012
We reviewed the comparative trials of the Flotrac/VigileoTM versus the thermodilution method, pub... more We reviewed the comparative trials of the Flotrac/VigileoTM versus the thermodilution method, published in the last five years. The results about the agreement between the two methods measuring cardiac output are contrasting. We also noticed that almost the whole pertinent literature include studies conducted without a correct statistical design, particularly about the sample size. For this reason we consider that results of the published studies about the agreement between pulse contour analysis for cardiac output measurement and thermodilution method may be not reliable.
International journal of anesthetics and anesthesiology, Mar 31, 2016
Background: Incidence of difficult tracheal intubation in elective surgery population varies in a... more Background: Incidence of difficult tracheal intubation in elective surgery population varies in a wide range, with estimated pooled frequency of 6.8%. Unanticipated difficult intubation has been reported in 1.5 8.5% of all general anesthesia. Among devices providing indirect laryngoscopy, Truview EVO2 ® offers advantages in terms of glottic exposure, short training, and low cost. Methods: Retrospective review of unexpected difficult intubation among 24.500 patients scheduled for elective surgery under general anesthesia over a 44 months period. Direct laryngoscopy was first performed in all patients, thus, in case of any difficulty encountered, an alternative device was utilized. Incidence and characteristics of difficult intubation are reported. Preoperative airway evaluation parameters have been correlated with intubation difficulty. Results: Difficult tracheal intubation (DTI) was observed in 0.4% (90 patients). Truview laryngoscope has been used in 59 of 90 patients and succeeded in achieving intubation in 75% of cases. Among risk factors for difficult intubation, neither Mallampati class nor Body Mass Index (BMI) were shown to have high predictive value. An El-Ganzouri Risk Index (EGRI) score of 3 has been estimated to represent the cut-off value between easy and difficult intubation. Truview laryngoscope represents a useful tool in case of unexpected difficult intubation, and could be eventually introduced in a difficult airway management algorithm without burden on Unit costs and staff training. DTI predictive scores have been applied in clinical practice but still lack in cut-off values validation. As in our experience the risk score failed in predicting difficult airway, we speculate that the Anesthesiologist's confidence with one or more alternative intubation devices could obviate the need for predictive scores. Patients with pharyngo-laryngeal or neck tumors, maxillofacial or cervical spine injury were excluded. Given the retrospective observational nature of the study, the specific written informed consent was not obtained. Preoperative airway assessment was routinely evaluated by El-Ganzouri Risk Index (EGRI) consisting in: mouth opening (> or < 4cm); thyro-mental distance (> 6.
Journal of Anesthesia and Clinical Research, 2015
We retrospectively investigated whether inferior-vena-cava diameter variations due to mechanical ... more We retrospectively investigated whether inferior-vena-cava diameter variations due to mechanical ventilation, correlates with fluid regimen and outcome in hepatic resection. We analyzed data from 91 cases of liver resection during which inferior vena cava collapsibility was measured in duplicate, before and after the resection phase of the operation (IVCI1 and IVCI2). IVCI was calculated according to the following formula: [IVCDmax-IVCDmin]/[0.5 × (IVCDmax+IVCDmin)], where IVCDmax and IVCDmin stand for the maximal and minimal IVCD within one a respiratory cycle. IVCI variation (ΔIVCI) was defined as: (IVCI pre-resection-IVCI post-resection)/IVCI pre-resection. Fluid management focused to maintain CVP <6 mmHg during the parenchymal dissection in an effort to reduce the backflow bleeding and limit the blood loss. Therefore, fluid administration included a volume input 3-5 ml/kg/h of crystalloid solutions from the induction of anesthesia until parenchymal dissection was concluded. Additional fluid administration was at the judgment of the anesthesiologist. Then we searched for any correlation between IVCI and other hemodynamic parameters, fluid regimen administration and the post-operative outcome. Results: Among 91 patients enrolled in the study, 57 (63%) were male and 34 (37%) female aged from 34 to 85 years (median 62 years). The median ASA was 2 (range 1-3). The median operation time was 374 min (range 150-720). Liver transaction was accomplished employing the Pringle maneuver and the median total liver ischemic time was 82 min (range 9-182). After liver resection ending many variables differed significantly from starting values: IVCI from 0.26 ± 0.21 to 0.18 ± 0.16 (p<0.001); HR from 68 ± 14 to 78 ± 13 bpm (p<0.001); CI from 2.6 ± 0.7 to 3.0 ± 0.8 L/min/m2 (p<0.001). All BGA values changed significantly (p<0.001). Serum lactate concentration showed a significant increase during the parenchymal dissection changing from 0.95 ± 0.5 to 4.1 ± 2.0 mmol/L (p<0.001). Serum hemoglobin lowered from 11.3 ± 1.7 g/dl to 9.8 ± 1.8 g/dl (p<0.001). In contrast, CVP and SVV did not change significantly. Both IVCI1 and IVC2 showed a weak correlation with CI (r=-0.166 and r=-0.087), CVP (r=-0.049 and r=-0.083) and SVV (r=0.138 and r=0.121). According to postoperative outcome patients were divided in two groups: Group 1 (complicated) and Group 2 (non-complicated). The IVCI resulted not significantly different between two groups (0.12 ± 0.11 vs 0.16 ± 0.13; p=0.105) which were homogeneous for global fluid regimen (7.25 ± 2.63 ml/kg/h vs 7.98 ± 2.93 ml/kg/h; p=0.341). Conclusions: Although retrospectively, it seems clear that, during hepatic resection, IVCI is not sensible to fluid administration and is not correlated with postoperative outcome.
EJVES vascular forum, 2022
Case reports in anesthesiology, 2013
We report a comparison of two cases regarding subjects who underwent thoracoabdominal aorta aneur... more We report a comparison of two cases regarding subjects who underwent thoracoabdominal aorta aneurysmectomy. During the procedure we monitored cerebrospinal fluid lactate concentration. One patient experienced postoperative paraplegia and his cerebrospinal fluid lactate concentration was much higher than that in the other case, whose postoperative outcome was uneventful. Consequently we consider that monitoring the lactate concentration in cerebrospinal fluid during thoracic aorta surgical procedures may be a helpful tool to predict the ischemic spine-cord injury allowing for trying to recover it precociously.
Seminars in Vascular Surgery
Nisi F, Carenzo L, Ruggieri N, Reda A, Pascucci MG, Pignataro A, Civilini E, Piccioni F, Giustini... more Nisi F, Carenzo L, Ruggieri N, Reda A, Pascucci MG, Pignataro A, Civilini E, Piccioni F, Giustiniano E. The anesthesiologist&#39;s perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance. Semin Vasc Surg. 2023 Jun;36(2):363-379. doi: 10.1053/j.semvascsurg.2023.04.017. Epub 2023 Apr 29. PMID: 37330248.
EJVES Vascular Forum, 2022
International Journal of Anesthetics and Anesthesiology, 2016
Background: Incidence of difficult tracheal intubation in elective surgery population varies in a... more Background: Incidence of difficult tracheal intubation in elective surgery population varies in a wide range, with estimated pooled frequency of 6.8%. Unanticipated difficult intubation has been reported in 1.5 8.5% of all general anesthesia. Among devices providing indirect laryngoscopy, Truview EVO2 ® offers advantages in terms of glottic exposure, short training, and low cost. Methods: Retrospective review of unexpected difficult intubation among 24.500 patients scheduled for elective surgery under general anesthesia over a 44 months period. Direct laryngoscopy was first performed in all patients, thus, in case of any difficulty encountered, an alternative device was utilized. Incidence and characteristics of difficult intubation are reported. Preoperative airway evaluation parameters have been correlated with intubation difficulty. Results: Difficult tracheal intubation (DTI) was observed in 0.4% (90 patients). Truview laryngoscope has been used in 59 of 90 patients and succeeded in achieving intubation in 75% of cases. Among risk factors for difficult intubation, neither Mallampati class nor Body Mass Index (BMI) were shown to have high predictive value. An El-Ganzouri Risk Index (EGRI) score of 3 has been estimated to represent the cut-off value between easy and difficult intubation. Truview laryngoscope represents a useful tool in case of unexpected difficult intubation, and could be eventually introduced in a difficult airway management algorithm without burden on Unit costs and staff training. DTI predictive scores have been applied in clinical practice but still lack in cut-off values validation. As in our experience the risk score failed in predicting difficult airway, we speculate that the Anesthesiologist's confidence with one or more alternative intubation devices could obviate the need for predictive scores. Patients with pharyngo-laryngeal or neck tumors, maxillofacial or cervical spine injury were excluded. Given the retrospective observational nature of the study, the specific written informed consent was not obtained. Preoperative airway assessment was routinely evaluated by El-Ganzouri Risk Index (EGRI) consisting in: mouth opening (> or < 4cm); thyro-mental distance (> 6.
Minerva Anestesiologica
Bstract iNtroDUctioN: the management of thoracic paravertebral block (tPVB) and erector spine pla... more Bstract iNtroDUctioN: the management of thoracic paravertebral block (tPVB) and erector spine plane block (esPB) in patients treated with anticoagulant or antiplatelet therapy is based on limited clinical data, mostly from single case reports. Scientific societies and organizations do not provide strong detailed indications about the limitations of these regional anesthesia techniques in patients receiving antithrombotic therapy. this review summarizes evidence regarding tPVB and esPB in patients under antithrombotic therapy. eViDeNce acQUsitioN: a literature review from PubMed/MeDliNe, eMBase, cochrane, google scholar and Web of science databases was conducted from 1999 to 2022 to identify articles concerning tPVB and esPB for cardiothoracic surgery or thoracic procedures in patients under anticoagulant or antiplatelet therapy. eViDeNce sYNtHesis: a total of 1704 articles were identified from the initial search. after removing duplicates and not-pertinent articles, 15 articles were analyzed. the results demonstrated a low risk of bleeding for tPVB and minimal or absent risk for esPB. Ultrasound guidance was extensively used to perform esPB, but not for tPVB. coNclUsioNs: although the low level of evidence available, tPVB and esPB are reasonably safe options in patients ineligible for epidural anesthesia due to antithrombotic therapy. the few published studies suggest that esPB offers a risk profile safer than TPVB and the use of ultrasound guidance minimizes any complication. Since the literature available does not allow us to draw definitive conclusions, future adequately-powered trials are warranted to determine the indications and the safety of tPVB and esPB in patients receiving anticoagulant or antiplatelet therapy. (Cite this article as: Nisi F, sella N, Di gregorio g, lubian M, giustiniano e, rosboch gl, et al. the safety of thoracic paravertebral block and erector spinae plane block in patients treated with anticoagulant or antiplatelet therapy. a narrative review of the evidence. Minerva anestesiol 2023 Jul 05.
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Papers by Enrico Giustiniano