With improvements in healthcare, the survival of preterm babies has increased significantly and these preterm and ex-preterm babies often present for various surgical interventions. Previously, it was believed that due to the immaturity of the nervous system, these preterm babies do not experience or feel pain and consequently inadequate or no anaesthesia was administered to them. Recent work has shown that as early as the 13th to 20th week of gestation, there is perception of pain. Evoked potentials and cerebral glucose metabolism offer evidence of functional maturity and responses such as changes in pulse and blood pressure, crying, and grimacing have been quantified for circumcisions done without anaesthesia [1]. Determination of gestational age is important to assess risks for morbidity and mortality in neonates.In view of the immature physiology of the preterm and ex preterm neonate, these patients present a great challenge to the anaesthesiologist. The various factors that increase morbidity and mortality in these patients are usually consequent to the immaturity of the various body systems and the associated congenital defects.Central nervous systemPeri/intra-ventricular (PVH-IVH) hemorrhage remains a significant cause of both morbidity and mortality in infants who are born prematurely. Sequelae of PVH-IVH include life-long neurological deficits, such as cerebral palsy, developmental delay, and seizures [2]. Because PVH-IVH can occur without clinical signs, screening and serial examinations are necessary for the diagnosis. The preterm neonate is at a greater risk for intracranial hemorrhage which may be due to changes in blood flow, blood pressure, and various other factors including serum osmolality [3].Respiratory systemThe respiratory bronchioles formation and production of surfactant begins by 24 weeks’ gestation, at which stage extra uterine survival is possible, though surfactant concentrations may remain inadequate until 36 weeks. The fetal lung structure and immature functional capacity are at greatest risk of respiratory distress, need for oxygen and positive-pressure ventilation, and admission for intensive care. These patients have a greater incidence of bronchopulmonary dysplasia (BPD) and chronic lung disease (CLD). Respiratory distress syndrome is caused by surfactant deficiency and is inversely related to gestational age affecting 90% of infants born at 26 weeks’ gestation. Anaesthesia may cause low lung volumes and ventilation/perfusion mismatch. The combination of immature structural development, disease and anaesthesia increases the chance of hypoxia and an anaesthetic technique based on mechanical ventilation with the use of positive end-expiratory pressure should avoid this complication. The risks of oxygen toxicity and barotraumas should also be considered during anaesthesia and the goal should be to maintain adequate oxygenation and ventilation, with the minimum oxygen concentration and peak inspiratory pressure necessary [4-6].Apnoea of prematurityApnoeic spell is defined as a pause in breathing of more than 20 seconds or one of less than 20 seconds associated with bradycardia and/or cyanosis [2]. The incidence of apnoea is related to the gestational as well as post conceptional age. An infant born at a lower post conceptional stage is more likely to have apnoea than one with same post conceptional age but born later. This risk is approximately 45% at 48 weeks post conceptional age up to 60 weeks. This risk reduces with increase in duration of post conceptual age upto 60 weeks post conceptional age [7]. Aponea in premature infants is exacerbated by hypoxia, sepsis, intracranial haemorrhage, metabolic abnormalities, hypo/hyperthermia, upper airway obstruction, heart failure, anaemia, vasovagal reflexes and drugs, including prostaglandins and anaesthetic agents [8]. Apnoeic spells are treated by stimulation, bag-mask ventilation, addressing underlying abnormalities, the use of respiratory stimulants such as caffeine or theophylline, neonatal CPAP or ventilation [9-11]. These infants therefore require careful post operative monitoring and HDU (High Dependency Unit) stay for at least 24hrs and should not be anaesthetized as outpatients even if regional anaesthesia has been administered. In fact some workers suggest that wherever possible, anaesthesia should be delayed until the ex premature infant is older than 52 weeks post conceptional age [12].Cardiovascular systemThe premature infant is at greater risk of cardiovascular compromise during anaesthesia and surgery than the term infant. They have poor diastolic function, the left ventricle is less compliant and cardiac output depends more on the heart rate than in the term infant. Premature babies have small absolute blood volumes, therefore relatively minor blood loss during surgery can rapidly lead to hypovolaemia, hypotension and shock. Autoregulation is not well developed in premature babies and the heart rate may not increase with hypovolaemia. Also, anaesthesia blunts the baroreflexes in premature infants, further limiting the ability to compensate for hypovolaemia [6].There may be associated cardiac congenital defects. Patent ductus arteriosus (PDA) is almost a normal finding in the preterm ( >50% incidence) with significant left-to-right shunting and risk for the development of congestive heart failure, IVH, necrotizing enterocolitis (NEC), renal insufficiency, pulmonary edema, or hemorrhage due to PDA and retinopathy of prematurity (ROP). Various treatment strategies for closure of a PDA include careful fluid administration, diuretics and prostaglandin synthetase inhibitors (PSI) such as Indomethacin or Ibuprofen. Surgical PDA ligation is considered when medical treatment had either failed or is contraindicated [13-15].Temperature Regulation, Skin and Body SurfaceThe epidermis is thinner in the preterm below 32 wks. As a result, they have increased susceptibility to damage from the most trivial trauma and tendency for greater fluid loss through the skin. Thermoregulation in the neonate is limited and easily overwhelmed by environmental conditions. There is a great potential for heat loss  and limited heat production through brown fat metabolism. The preterm baby is particularly vulnerable as the immature skin is thin and allows major heat (and evaporative fluid) losses. The principle of anaesthesia in these infants is for minimal handling in a warm environment [2].Haematologic systemNewborns born at 26 to 28 weeks have lower hemoglobin levels (13-15gm/dl) than term newborns, 70-80% of which maybe fetal haemoglobin. The blood volume is 100 to 110ml per kg. Preterm newborns are deficient in both vitamin K and vitamin K–dependent coagulation factors and may also have a relatively low platelet count [16-18].Renal functionFunctional capacity is related to gestational age. The limited capacity of renal tubules to reabsorb bicarbonate accounts for the ‘normal’ acidosis seen in newborns. The ability to retain sodium effectively does not develop until 32 weeks. The distal tubular response to aldosterone is low until 34 weeks and antidiuretic hormone levels in the premature neonate are high. These factors predispose to hyponatraemia. The total body water in the preterm infant is higher than in a term neonate (75–85% of body weight) and is inversely related to the gestational age. The marked transepidermal permeability due to skin immaturity and a relatively large body surface area leads to 15-fold increase in the evaporative water loss during the first few days of life as compared with term babies [19].Gastrointestinal functionNecrotizing enterocolitis (NEC) with bowel wall necrosis and possible perforation can occur in these babies, which can further lead to systemic sepsis. Bowel perforation may be the result of administration of indomethacin and corticosteroids. Gastro-oesophageal reflux is common, not only because of neurological immaturity but also results from an underdeveloped and incompetent lower oesophageal sphincter leading to laryngospasm, laryngitis, tracheitis, apnoea, chronic cough, otitis media, and asthma. It should be treated aggressively to minimize upper and lower respiratory complications in these populations who are already predisposed to pulmonary dysfunction .Glucose homeostasisLiver stores of glycogen (and iron) are made up primarily in the last trimester of fetal life and consequently preterm neonates have very limited glycogen stores. Also, ketogenesis and lipolysis capability are limited. It is therefore critical to carefully monitor serum glucose during anesthesia more so because all the clinical signs of hypoglycemia may not be evidenced during general anaesthesia. Currently we know that preterm newborns require the same glucose levels as term infants. Hyperglycaemia should be avoided as a hyperosmolar state can lead to intraventricular haemorrhage (IVH), osmotic diuresis, and dehydration .The other factors that increase morbidity and mortality in the preterm are the associated congenital anomalies and considerations regarding use of high concentrations of oxygen.Anaesthetic management of the preterm neonateThe anaesthesiologist is usually called to administer anaesthesia in the preterm for the following situations:PDA ligation (20–30% incidence in moderately premature neonates)Laparotomy for NEC or spontaneous bowel perforationLaparotomy for reanastomosis of bowel or relief of adhesionsInguinal hernia repair Fundoplication for unresolving and symptomatic oesophageal refluxVascular access under X-ray controlViterectomy or laser surgery for retinopathy of prematurityCSF drainage or ventriculoperitoneal shunt insertion for obstructive hydrocephalus after intraventricular haemorrhageCT and MRI scanning to evaluate cerebral damageThe most commonly performed surgery is the repair of inguinal hernia, appearing in 38% of infants whose birth weight is between 751g and 1000g and in 16% of those whose birth weight is between 1001g and 1250g. Inguinal hernia require early surgical repair because of the risk of bowel incarceration and vascular compromise in bowel and gonadal tissue . In addition, preterm newborns may be born with the other coexisting congenital anomalies as term infants that require urgent or emergent surgery such as intestinal atresia, gastroschisis, omphalocele, and esophageal atresia with or without tracheoesophageal fistula or congenital diaphragmatic hernia.Preanaesthetic EvaluationPreoperative assessment should include parental consultation with the description of a likely deterioration in pulmonary function necessitating postoperative ventilatory support. The infant's antenatal history, gestational age, and weight are prerequisite information for surgical procedures [23]. A detailed complete system examination should be carried out with special reference to upper airway appearance and possibility of difficult intubation.The routine investigations - Haemoglobin, haematocrit, platelets, and the coagulation profile should be within acceptable limits. Preoperative serum electrolyte and glucose levels will help guide requirements in theatre. An ABG, X-ray chest and an echocardiogram are desirable prior to surgery. Cross-matched blood must be available so that transfusion can be given whenever the blood loss is more than 10% of blood volume during the surgery [20].Periods of preoperative fasting must be taken into account to calculate fluid deficits that need replacement intraoperatively. Neonates undergoing elective surgery can be fed until 4 hours before anaesthesia and then given clear fluids until 2 hours before surgery. Breast milk and Formula feeds are considered in the same category as solids [19]. If surgery is delayed for extended periods, IV fluids must be given, or if time permits, additional clear oral fluids are given. Some babies may be receiving total parenteral nutrition to provide their maintenance fluid, glucose, and electrolyte requirements. A detailed preanaesthetic check should be performed with special reference to detection and correction of fluid and electrolyte deficits.Premedication is usually avoided as there may be a dramatic respiratory depressant response to the drugs. However, atropine (10–20 mg kg) can be considered to preempt transient bradycardia, although these are less frequent during anaesthesia with newer inhalation agents. All babies should receive vitamin K before operation.Practical Points for the conduct of anaesthesia in a preterm neonateSome modifications for the conduct of anaesthesia may be required for these very tiny patients.Monitoring SpO2: Two pulse oximeters should be used; the first saturation probe is placed on the right hand  and the other on a lower limb . These oximeters should be of the “neonatal” variety, with less adhesive to minimize skin damage.Blood pressure: Proper size and application is important since repeated noninvasive blood pressure measurement can fracture very poorly ossified, calcium-deficient bones. The definition of a normal systemic blood pressure is problematic in the extremely low gestational age newborn. A safe “rule of thumb” is to treat the mean arterial blood pressure if it is below the gestational age + 5 mm Hg. Treatment options are variable and include IV fluid, or vasopressors .ECG: Adhesive on electrocardiogram (ECG) stickers can damage the skin. Removal of adhesive tape or monitors can damage the skin akin to a partial thickness burn. After delivery, the skin of preterm newborns does mature rapidly and achieves greater thickness within a few weeksEtCO2: Because of very small tidal volumes and low maximum expiratory flow rate, end-tidal CO2 measurement will be rendered less accurate but is important nonetheless [24].IBP: Invasive blood pressure or central venous pressure measurement, although desirable, is so technically challenging and potentially dangerous that often these are not employed. If an umbilical artery line is in place, rapid sampling and flushing can lead to disastrous consequences [24].Temperature monitoring: It is important and intraoesophageal temperature can be monitored using a combined stethoscope and temperature probe. But this may itself pose a risk as sometimes perforation is possible despite meticulous and careful placement of rectal or esophageal probes [24].OT preparation Staffing: Extra personnel and help may be required. An experienced operating department practitioner is essential.Equipment: All equipment including a Mapleson F circuit for hand ventilation, anaesthetic machine, ventilator, breathing circuits, infusion pumps, and laryngoscopes should be prechecked. Electrical supply for infusion pumps must be assured, especially if inotropic support is to be continued. A pressure controlled ventilator capable of delivering small tidal volumes with PEEP is essential. Airway: Securing the airway is difficult in these very tiny babies and proper-sized equipment and endotracheal tubes and masks should be available and ready. These patients generally arrive to the OT already intubated, thus the anaesthetic plan should include postoperative mechanical ventilation. A “000” face mask, “0” Miller blades and 0-sized laryngeal mask airways (LMAs) should be available, as well as endotracheal tubes of 2.5, 3.0 and 3.5 mm outer diameter (OD) with appropriately sized stylets. OT temperature: Premature infants have a greater tendency for heat loss. The ambient OT temperature must be kept around 27 C. Patient should be kept warm by using a warming mattress and a warm air blanket. Inspired gases should be heated and humidified with a paediatric heat-moisture exchanger. I.V. fluids, blood, and blood products should be warmed and used. Irrigation fluid must be warmed. Other ways to keep the patient warm include application of the waterproof surgical drape to the non-involved areas.Positioning: The majority of preterm neonates requiring emergency surgery are likely to be intubated and ventilated and transported in a dedicated transfer incubator. The baby must be carefully but expeditiously transferred to the operating table taking care to avoid accidental disconnections and decannulations. In the smallest of neonates and especially when 360 access to the patient is required by the surgeon (e.g. laser surgery for retinopathy), access can be improved by removing the head and foot ends of the operating table.General anaesthesiaTraditionally, general anaesthesia (GA) has been administered in the preterm and ex preterm neonates. The advantages of GA are better control over the respiratory and cardiovascular parameters.There is considerable controversy currently over the long-term CNS effects of many anaesthetic medications such as midazolam, nitrous oxide, isoflurane and ketamine. There have been reports of choreaform movements with long-term administration of midazolam in newborns, and for this reason many NICUs no longer use this medication to sedate preterm newborns receiving mechanical ventilation .Moderate concentrations of volatile agents can be used to minimize increase in PVR and to avoid decrease in systemic arterial pressure. Also inhaled nitric oxide can be used for the same. Although halothane has shown to cause postoperative complications, the newer shorter acting agents, desflurane may be particularly useful for recovery in a preterm infant prone for respiratory depression and apnoea .Rapid sequence inductions can be challenging as even a short period of apnoea can cause detrimental desaturations, and mechanical pressure over the cricoid area can render the anatomy unrecognizable. Its use in children is questioned in contemporary practice. The tracheal length is 4 cm in a preterm neonate; therefore, the tube length should be carefully adjusted and secured. As a guide 1, 2, 3, and 4 kg babies should have the TT positioned at the gum margin at the 7, 8, 9, and 10 cm marks. The TT should allow a positive pressure breath with a small leak at 20–25 cm H2O pressure. Opioids have a long record of safety in preterm and fentanyl is advised as part of balanced anaesthesia in those with potential or overt pulmonary hypertension on ventilator therapy .There is concern that even brief exposure to high oxygen levels is associated with increased morbidity and mortality in premature infants; fluctuations in oxygen levels should be avoided and oxygen saturation maintained between 88-95%, not exceeding 95%. Newborn resuscitation should be carried out with room air rather than 100% oxygen [30].Tachycardia and hypertension can be detrimental in the presence of underdeveloped cerebral auto regulation. And hence careful titration of anaaesthetic and narcotic analgesic agents is necessary. For those who will be extubated after operation, minimal use of opioids combined with local anesthetic techniques and acetaminophen is beneficial, while planned postoperative ventilation indicates an opioid-based technique.Sale et al, in their study on preterm infants under 37 weeks gestation and under 47weeks post conceptional age undergoing inguinal herniotomy suggested that light GA with sevoflurane or desflurane , controlled ventilation and caudal block is the current best technique for high risk preterm neonates [31].In these patients, hypoglycemia should be anticipated and managed accordingly at a rate of 8 to 10 mg/kg/minute. This can be achieved by administering 10% dextrose at a rate of 110 to 120 ml/kg/day [32]. Glucose levels should be checked frequently, either by finger-stick using a glucometer or as part of an arterial blood gas measurement.The blood volume of an 800-g newborn is 95 to 100 ml. Even what appears to be a small amount of bleeding is significant to such a small patient. Replacement of blood products must be done promptly but also slowly . A 10-mL syringe of packed cells (PBRC) rapidly delivered into the vascular system over less than 1 minute will increase the blood volume by 10%. This is analogous to administering 2 units of PRBC to an adult over 1 minute. It is also very important that the blood products be warmed to minimize hypothermia in these patients.Regional anaesthesiaIn view of the high incidence of postoperative apnoea in preterm infants undergoing anaesthesia, a number of investigators have postulated a safe operating period that does not commence until a postmenstrual age of greater than 44 weeks, or even greater than 60 weeks. In addition to a suggested safe period of operation, awake regional anaesthesia has been suggested to reduce the incidence of post-operative apnoea, with an even lower incidence observed when no sedation is used. Prophylactic caffeine has also been used to prevent postoperative apnoea following general anaesthesia .Studies have indicated that regional anaesthesia is not to be considered as a sole anaesthesia method for premature infants, but is beneficial as a supportive element when combined with GA. Smaller fractions of GA are required when regional anaesthesia is used along with it. Titration is recommended to ensure maximum effectiveness using minimal amounts of anaesthesia. In this category, as for GA, a cardiovascular complication is common, regardless of the combination used .Regional anaesthetic techniques are popular due to the lack of exposure to volatile agents, omission of use of opiates in the postoperative period, uncomplicated execution and guarantee of excellent surgical conditions especially for inguinal hernia repair .Preterm neonates can be managed successfully with spinal, caudal or combined spinal/caudal block for surgery. Regional techniques without sedation have been reported to have a reduced incidence of postoperative respiratory complications and may be more suitable than GA in the very young. However spinal anaesthesia in a preterm may be technically more difficult. In the study by Cavern et al, there were more technical failures in the spinal group. For every seven infants having a spinal anaesthetic, one failed to achieve accurate placement of the spinal needle. For every three patients having a spinal anaesthetic, one experienced an anaesthetic agent failure, requiring additional anaesthetic agent .Spinal anaesthesia has been used successfully for inguinal hernia surgery in the preterm and ex pretem neonate and has shown to reduce the incidence of postoperative adverse events. Due to a larger volume of CSF and the increased surface area of nerve roots, a higher dose of local anaesthetics are required and the duration of action is also lesser as compared to older children and adults . However haemodynamics are maintained by the low vasomotor tone and decreased vagal activity.Caudal epidural anaesthesia can be employed safely and effectively either as single bolus dose or in the continuous form, via catheter. The advantage of using epidural catheter is that the level and duration of anaesthesia can be extended. Also lower volume of drugs can be used [42-44].Gunter et al, evaluated the efficiency of several concentrations of bupivacaine (0.125 to 0.25%) for caudal anaesthesia in patients between 1 and 8 years of age, submitted to inguinal herniotomy. In this study, all the concentrations proved to be effective when associated with general inhalation anaesthesia with halothane and nitrous oxide. Caudal anaesthesia has been used successfully with light GA with newer inhalation agents .Various other blocks like ilio-inguinal nerve blocks have been used successfully. Topical anaesthetics have been used to reduce pain in premature infants during eye examination for retinopathy of prematurity [46].Post operative analgesiaThe aims of postoperative analgesia are to recognize pain, to minimize moderate and severe pain safely, to prevent pain where it is predictable, to bring pain rapidly under control and to continue pain control after discharge from hospital [47]. Pain is prevented using multi-modal analgesia, based on four classes of analgesics, namely local anaesthetics, opioids, non-steroidal antiinflammatory drugs (NSAIDs), and acetaminophen (paracetamol).Opioids, because of their dramatic response on the respiratory system and tendency to cause postoperative apnoea, are not recommended for post operative analgesia in preterm and ex-preterm neonates. Local anaesthetics, NSAIDs, and acetaminophen (paracetamol) are generally preferred. However, most NSAIDS are not suitable for use in infants less than 6 months of age. Paracetamol is the only analgesic that can be safely used for postoperative analgesia in preterm infants [47-48].In particular, a local/regional analgesic technique may be employed for all surgical cases unless there is a specific reason or an indication not to do so. Various field blocks like Ilioinguinal block for hernia surgery and Intercostal nerve blocks for PDA ligation can be used to supplement analgesia and manage postoperative pain in the preterm neonate [2].ConclusionAnaesthetizing a preterm neonate requires constant vigilance, rapid recognition of events and trends, and swift intervention.The anaesthetic considerations in the preterm neonate are based on the physiological immaturity of the various body systems, associated congenital disorders, poor tolerance of anesthetic drugs and considerations regarding use of high concentrations of oxygen.Clearly, the benefit of providing adequate anaesthesia and analgesia must be carefully balanced against the significant risk of cardio respiratory depression in this fragile population.Titration of anaesthetics to a desired effect, while carefully monitoring the cardio respiratory status, is the goal. Premature and ex-premature infants may have dramatic responses to narcotics and potent inhaled anaesthetics. They have wide variability in their responses to anaesthetics and sedatives, and frequently experience exaggerated and unpredictable effects not observed in older infants and children.Recently, the use of regional anaesthesia has shown to be safe and effective. It can reduce the complications and various adverse events generally associated with GA.Source of Support: NilConflict of Interest: None declared


The aim of this study was to determine the diagnostic values of kidney shear wave velocity (SWV) and bone morphogenetic protein-7 (BMP-7), and their correlation in the diagnosis of early diabetic kidney disease.2, n = 50). Fifty healthy volunteers were recruited to serve as controls (control group). The levels of serum BMP-7 were detected, and virtual touch tissue quantification was used to detect the renal SWV value in all study subjects. Correlations between groups as well as SWV and BMP-7 were analyzed.A total of 150 patients with type 2 diabetes mellitus were divided into three equal groups based on the urinary albumin-creatinine ratio (ACR): normal albuminuria , microalbuminuria , and macroalbuminuria  ≥30 ml/min/1.73 mP < 0.01 between each other for BMP-7 and SWV). Moreover, no significant differences between the normo- and control groups were observed for either BMP-7 or SWV (both P > 0.05). In addition, a significant correlation was found between SWV and BMP-7, with a coefficient of -0.569 (P < 0.05).Serum BMP-7 and SWV were significantly and progressively decreased and increased, respectively, during the development of renal disease, from the normo- to the micro- and to the macro- groups (all The determination of SWV together with serum BMP-7 may play an important role in the diagnosis of diabetic kidney disease. Diabetic kidney disease (DKD), which is caused by glomerulosclerosis and renal interstitial fibrosis, is one of the most severe complications of type 2 diabetes mellitus (T2DM). As it usually has a poor prognosis, early diagnosis is crucial for the treatment of DKD with T2DM. It has been well established that renal fibrosis, as a precursor to end-stage renal disease, plays an essential role in the development of chronic kidney disease. Fibrosis causes the kidney to stiffen. To detect the extent of fibrosis or stiffness in renal tissue, virtual touch tissue quantification (VTQ) has been widely recommended, which is an ultrasound imaging technique that detects the elasticity/stiffness of tissues or organs –4. UltraBone morphogenetic protein-7 (BMP-7), one of the endogenous hormones in the kidney, is a major inhibiting factor of the profibrotic transforming growth factor beta (TGF-β) and has a strong antifibrotic activity,12. In aWe have previously studied VTQ to determine renal injury in T2DM and demonstrated that the shear wave velocity (SWV) increases as renal injury progresses. HoweverThis was a single-center study that prospectively enrolled 175 T2DM patients from the Endocrinology and Nephrology Departments of the Affiliated Hospital of Qingdao University from January 2012 to January 2013. This study was approved by the Human Research Ethics Committee of our hospital, and written informed consent was obtained from all the subjects involved in this study.The inclusion criteria for patient enrolment in this study were in-hospital patients with T2DM, diagnosed based on the Standards of Medical Care in Diabetes–2010, with or2.The DKD patients were divided into the following three groups according to the urinary ACR: normoalbuminuria (normo-group), ACR < 30 mg/g creatinine, including 29 male and 21 female patients (mean age ± standard deviation (SD), 48.65 ± 16.83 years old, range: 33–62 years old); microalbuminuria (micro- group), 30 ≤ ACR < 300 mg/g creatinine, including 25 male and 25 female patients ; macroalbuminuria (macro- group), ACR ≥ 300 mg/g creatinine, including 27 male and 23 female patients . The control group consisted of 50 age-matched healthy volunteers , who visited the medical centers of the Affiliated Hospital of Qingdao University for an annual health checkup, were randomly selected based on the normal clinical characteristics of blood pressure, blood glucose, blood lipids, renal function, and renal ultrasound. The estimated glomerular filtration rates (eGFRs) varied among the groups ; however2). The Cockcroft-Gault formula used was CCr (ml/min) = (140-age) × weight (kg) / [72 × serum creatinine (mg/dL))] × . The improved MDRD formula used was eGFR  = 186 × (Scr)-1.154 × (age)-0.203 × .The weight and height of the participants were measured to calculate the body mass index (BMI). The blood pressure was measured at the right brachial artery in a seated position after a 15-min rest, and the mean value of three measurements was obtained. Venous blood, after an 8- to 12-h fast, was collected to measure HbA1C, fasting blood glucose, lipids, creatinine, urinary nitrogen, and albumin. All assays were performed according to routine procedures in the Biochemical Laboratory of the Affiliated Hospital of Qingdao University. The normal reference ranges for fasting blood glucose, HbA1C, and blood pressure were selected as less than 6.9 mM, 7.0%, and 130/80 mmHg, respectively. The urinary albumin excretion rate was presented as the ACR , which was confirmed with at least two separate urine samples. The evaluation of GFR was calculated by the Cockcroft-Gault formula, then verified by the Chinese People-improved MDRD formula for endogenous creatinine clearance (CCr) >30 ml/min, 1.73 mAll abdominal ultrasonography and SWV measurements were performed by a qualified radiologist with 15 years of relevant experience using a Siemens ACUSON S2000 US system  equipped with a 3.5–5.5 MHz linear array transducer (4C1). The radiologists performed the examination had no knowledge of the clinical information of the study subjects. All subjects were initially screened by conventional ultrasonography for kidney evaluation. Patients were excluded if they had pathological conditions that may have affected measurements  or other abnormalities outside of the kidney but within the abdomen. If there were no pathological findings in the kidneys or other solid organs in the abdomen, then the subjects were included in the normal group. The cortex and medulla thicknesses were measured in the lower pole of the kidney (the perpendicular distance from the apex of the pyramid to the capsule of the kidney), and the average of the bilateral kidney was measured in the region of interest . An acoustic push pulse was transmitted immediately in the middle of the kidney cortex. Scanning was continued in the coronal section without pressure, and the scanning direction was constantly kept vertical with the kidney. Three valid measurements were obtained for each kidney at the same portion of the mid-pole, as parallel as possible to the radically arranged tubular system. The results were expressed as meters per second (m/sec), and the mean of three SWV values was used for the statistical analysis.A 3-ml sample of venous blood was obtained after the subjects had fasted for 8–12 h. After the sample was left standing for 30 min, it was centrifuged for 5 min, the serum was separated, and aliquots were stored at -70°C until use. The BMP-7 serum concentration were determined by enzyme-linked immunosorbent assay (ELISA) using BMP-7 (human) ELISA Kit  according to the manufacturer’s instructions. One hundred μL serum was mixed with the assay buffer and incubated at room temperature for 45 min. The reaction OD was measured spectrometrically at 450 nm.2 test was used for categorical variables; and cortical thickness and clinical characteristics except for gender were analyzed by one-way analysis of variance and the least significant difference test for pair-wise comparisons, respectively. Differences were considered significant at P < 0.05. The ACR, BMP-7, and SWV were analyzed by the Kruskal-Wallis test and then the Mann-Whitney test for pairwise comparisons. Differences were considered to be significant at P < 0.01. Spearman analysis was used to determine the relationship between the SWV and ACR in DKD.SPSS version 17.0 software  was used for all statistical analyses. Continuous variables were expressed as mean ± standard deviation; the χThrough an initial screening, 326 subjects were excluded from the present study population, including 103 patients with nondiabetic renal diseases accompanying T2DM; 119 patients with a systemic disease/condition that could influence the albumin-creatinine ratio (ACR) as assessed by the medical history or examination; 79 patients taking medications that could affect renal function; and 25 patients with an anatomical distance between the body surface and kidney cortex greater than 5.0 cm.P > 0.05). However, the cortical thickness values were the lowest in the macroalbuminuria group among the three DKD groups (P < 0.01).Gender, age, fasting blood glucose, HbA1C, blood lipids, blood pressure, BMI, and medulla thickness of the patients are listed in P < 0.01). In addition, the serum BMP-7 level in the macro- group was significantly less than that in the micro- group (P < 0.01); and that in the micro- group was significantly less than that in the normo- group (P < 0.01). Moreover, the serum BMP-7 level in the micro- and macro- groups was significantly less than that in the control group (both P < 0.01); but there was no significant difference between the normo- and the control groups (P > 0.05) (see Both the micro- and macro- groups had a significantly higher ACR compared to the normo- group (.05) see .P < 0.01). However, there was no significant difference between the normo- and the control groups . We propose that a better clinical diagnosis of the degree of DKD is feasible by a combination of SWV and BMP-7 detections accompanied with the conventional diagnostic methods.The present study showed that the SWV values increased and the BMP-7 levels decreased as the renal function decreased in patients with early DKD. In addition, there was a significant negative correlation between the two values  and that the differences between the normo- and micro- or macro- groups, and the micro- and the macro- groups were significant , suggesting that early DKD could cause significant renal pathological changes and lead to an increased in renal stiffness. With a significant negative correlation between the SWV and the ACR in the DKD groups, we suggest that an increased renal SWV could be related to the degree of renal dysfunction in early DKD. Therefore, renal SWV could be effectively used to diagnose early stages of DKD. The fact that no significant difference was observed in the SWV values between the normo- and the control groups may, at least partially, support that SWV values are relevant to the morphological condition, as no significant anatomical or chemical pathology change is expected between the normo- group and the control group. However, it has been reported that the SWV value can also be affected by renal blood flow. A lower SWV value was obtained in patients with a high brachial-ankle pulse wave velocity, an index of arterial stiffness[The elasticity of the kidney as determined by the SWV may be helpful in the early diagnosis of diabetic kidney damage. As a nostiffness. As SWV As there may be a discrepancy between ACR and eGFR in the assessment of renal function, especially at the early stage of the disease, albuminuria and symptomatic treatment have been the main clinical focus (up to end-stage kidney disease), so we selected ACR as an effective assessment parameter in our study on early DKD. However, a cohort study may be required to demonstrate that the combination of SWV and BMP-7 with ACR and/or eGFR as a confounder would be superior to that with ACR and/or eGFR alone in the diagnosis and assessment of the stage of early DKD. In addition, this study could not determine the relationship of the SWV and/or BMP-7, with the degree of renal damage in the absence of histological classification. However, a histopathological approach will be our next research priority to explore such a relationship.In conclusion, we analyzed the SWV values and BMP-7 levels in patients with early DKD and demonstrated their usefulness in assessing the extent of renal damage. The SWV and serum BMP-7 level were correlated not only with each other, but also with ACR, and they significantly increased and decreased, respectively, as renal function declined. Combining the detection of SWV and serum BMP-7 level with conventional diagnostic methods may have a greater diagnostic value in the determination of the DKD stage than current methods.


Pressure-support ventilation, is widely used in critically ill patients; however, the relative contribution of patient’s effort during assisted breathing is difficult to measure in clinical conditions. Aim of the present study was to evaluate the performance of ultrasonographic indices of diaphragm contractile activity (respiratory excursion and thickening) in comparison to traditional indices of inspiratory muscle effort during assisted mechanical ventilation.2O). The right hemidiaphragm was evaluated by B- and M-mode ultrasonography to record respiratory excursion and thickening. Airway, gastric and oesophageal pressures, and airflow were recorded to calculate indices of respiratory effort .Consecutive patients admitted to the ICU after major elective surgery who met criteria for a spontaneous breathing trial with pressure support ventilation were enrolled. Patients with airflow obstruction or after thoracic/gastric/esophageal surgery were excluded. Variable levels of inspiratory muscle effort were achieved by delivery of different levels of ventilatory assistance by random application of pressure support  during tidal breathing. No correlation was found between either diaphragm or esophageal pressure–time product and diaphragm excursion , nor was diaphragm excursion correlated to diaphragm thickening  during tidal breathing.In patients undergoing in assisted mechanical ventilation, diaphragm thickening is a reliable indicator of respiratory effort, whereas diaphragm excursion should not be used to quantitatively assess diaphragm contractile activity.The online version of this article (doi:10.1186/s13054-015-0894-9) contains supplementary material, which is available to authorized users. The diaphragm is the main muscle that powers breathing. Impaired function of the diaphragm can lead to respiratory complications and often prolongs the duration of mechanical ventilation . Converses)) and abdominal (or gastric (Pga)) pressures and variables derived from those measurements [The relative contribution of the patient’s effort during assisted breathing is difficult to measure in clinical conditions, and the diaphragm, the major muscle of inspiratory function, is inaccessible to direct clinical assessment. Several methods have been used in the research setting to assess diaphragmatic contractile activity . Among turements . HoweverBedside ultrasonography, which is already crucial in several aspects of critically illness , has beeThe vast majority of reports addressing these ultrasonic indices were performed in spontaneously breathing patients ,17-19, aComitato Etico dell’Azienda Ospedaliera San Paolo di Milano) approved the study protocol (#13864/2013) and patients gave their written consent to participate during pre-anesthetic assessment before surgery.This study was conducted in accordance with the amended Declaration of Helsinki. The local ethics committee  according to the clinical needs. Local guidelines for sedation of postoperative patients prescribe the use of an intravenous (iv) continuous infusion of propofol, starting at 1.5 mg/kg*h and titrated to obtain a Richmond agitation-sedation scale (RASS) score of 0/-1. Analgesia is provided as a 6- to 8-ml/h continuous epidural infusion of bupivacaine 0.125% + fentanyl 2-mcg/ml solution, aiming at a verbal numerical rating <4 or a behavioral pain scale <7. If epidural analgesia is not feasible, patients receive 0.5 to 1 mg/kg*h continuous iv infusion of morphine + iv acetaminophen 1 g three/four times per day.2/FIO2) ≥150 mmHg, respiratory rate <35/min, maximal inspiratory pressure < −20 cmH2O, respiratory rate/tidal volume ratio <105 breaths/(min*l) [Patients were enrolled when judged by the attending physician to be eligible for a test of weaning from mechanical ventilation, following the local weaning guidelines, that is, adequate cough, absence of excessive tracheobronchial secretion, clinical stability, heart rate (HR) <140/min, systolic blood pressure between 90 and 140 mmHg, arterial partial pressure of oxygen/inspired oxygen fraction  level >20 cmH2O, body temperature >38°C or <35°C, deep sedation state (as defined by a RASS score < −1), intrinsic PEEP, or history of chronic obstructive pulmonary disease (COPD). Patients after thoracic, gastric or esophageal surgery were also excluded.Exclusion criteria were any of the following: hemodynamic instability requiring vasopressors, gas exchange impairment requiring positive end-expiratory pressure (PEEP) >10 cmHFlow was measured using a heated Fleisch number one pneumotachograph  connected to a pressure transducer , placed between the endotracheal tube and the ventilator Y connector. Airway pressure (Paw) was measured using a similar pressure transducer.es and Pga were measured using a double-balloon, graduated feeding catheter  [es was changing in concert with Paw when making efforts against a closed airway [di), the main determinant of the force generated by that muscle independently of any accessory muscle and elastic recoil of the system, was obtained by electronic subtraction of Pes from the Pga signal [es and Pga were displayed on a dedicated multiparametric monitor , collected at a sampling rate of 100 Hz, and recorded on a personal computer for subsequent analysis using dedicated software .P, Italy) , which wd airway . Transdia signal  over tenes or Pdi signal from the onset of their negative (for Pes) or positive (for Pdi) deflection to the end of inspiratory flow [The esophageal and transdiaphragmatic pressure-time product  per breath and per minute were obtained by measuring the area under the Pory flow .The airway pressure decrease in the first 100 ms after the onset of inspiration following an end-expiratory occlusion (P0.1)  was measwhere Pel,rsi is the elastic recoil pressure of the respiratory system at the end of inspiration, measured as the airway pressure plateau value during an end-inspiratory occlusion maneuver, and PS is pressure support.Ultrasonography was performed by the same trained operator (DL) using an LogiQ7  equipped with a high resolution 10-MHz linear probe and a 7.5-MHz convex phased-array probe. Images were recorded for subsequent computer-assisted quantitative analysis performed by a trained investigator (AG), unaware of the ventilatory condition.The convex probe was placed below the right costal margin along the mid-clavicular line, so that the ultrasound beam was perpendicular to the posterior third of the corresponding hemi-diaphragm, as previously described . PatientDiaphragm thickness was assessed in the zone of apposition of the diaphragm to the rib cage. The linear probe was placed above the right 10th rib in the mid-axillary line, as previously described . The infTwenty recordings (from separate patients) were randomly selected to assess reproducibility: the same sets of recordings were analyzed twice by the same ultrasonographer (DL) and twice by a different ultrasonographer (AG). Repeated measurements obtained in each patient from the same ultrasonographer were used for intra-observer reproducibility, and measurements obtained in the same patient by the two ultrasonographers were used for inter-observer reproducibility.2 were set before the beginning of the study according to local guidelines, and were not modified throughout the study. Sedation was not modified either. In each patient, three levels of PS were applied in random sequence: 0, 5 and 15 cmH2O. Each level was applied for a minimum of 30 minutes, with the recording phase starting from the 20th minute to allow for a steady-state. Tidal Volume (Vt) and respiratory rate (RR) were recorded in each step, as well as P0.1 and PMI. During each of the three steps arterial blood gas analysis was performed, and arterial blood pressure (ABP) and HR were recorded. Diaphragm ultrasound scanning was also performed, and airway, esophageal and gastric pressure and flow were recorded. At the end of the recording phase PS was changed to that of the following step.Patients were in the semi-recumbent position throughout the study. PEEP and FIO2O was not tolerated for over-assistance . Figure 2O pressure support step (PS0).The protocol was allowed to be stopped, and PS increased to the pre-study value to allow patients to rest for at least 30 minutes whenever they developed one of the following signs of respiratory distress: RR >35 breaths/min, a peripheral pulse oximeter oxygen saturation (SpO2) < 90%, HR >140 beats/min or variation >30% from baseline, ABP >180 mmHg, diaphoresis or anxiety. Conversely, PS level was lowered to the value before the beginning of the study if PS 15 cmHb coefficient. Reproducibility was expressed by the intra-class correlation coefficient [P-values <0.05 were considered statistically significant.Data were analyzed using Stata 11 . Normality was assessed by the Shapiro-Francia test. Results are reported as mean ± standard deviation if normally distributed, or median (25 to 75th percentiles) otherwise. Comparison of variables over the different steps was performed by repeated-measures analysis of variance or the Friedman test with post-hoc comparison, as needed. Correlation was assessed using Pearson’s or Spearman’s method according to the distribution of the variable. To deal with the longitudinal structure of our dataset (patients with repeated measurements over time), regression analysis was conducted by building a linear mixed model for repeated measures based on each patient. In this case, the extent of the association between variables was expressed as the fficient  and the fficient . The lat2 were set by the attending physician and remained constant during the whole study (as per study protocol). The values of PEEP and FIO2 were 6.8 ± 1.6 cmH2O and 0.53 ± 0.11, respectively. All patients tolerated the study protocol well, and none developed signs of respiratory distress or over-assistance. All patients were successfully weaned from mechanical ventilation and discharged alive.During the study period, 114 patients met the inclusion criteria; 79 were excluded from the study . Of the 35 remaining patients 10 more were excluded because of technical/organizational issues . Twenty-five consecutive patients were then enrolled; all presented an adequate ultrasonographic window. Patients’ demographics and clinical data are shown in Table es during the dynamic occlusion test . Adequate intra- and interobserver reproducibility for diaphragmatic thickness and respiratory displacement was found, as shown in Additional file The calibration procedure for the esophageal balloon was strongly correlated between Paw and PTable Figure Measurements of inspiratory effort and ultrasound measurements are reported in Table b coefficient = 0.032, P = 0.900 and −0.005, p = 0.720, respectively) , P0.1 , RR  or Vt .Ultrasonographic TF of the diaphragm also significantly changed and decreased with increasing ventilator support, whereas diaphragmatic excursion was unaltered. No correlation was found between diaphragm excursion and PTPes or PTPdi   and P0.1 . Negative correlation was found between TF and Vt . No correlation was found between diaphragm TF and excursion .Diaphragm TF significantly correlated with PTPes and PTPdi . Similarly, no relationship was found between diaphragm thickness at end-expiration and the level of PEEP .Because in our patient population PEEP was selected by the attending physician based on clinical criteria and thus, could differ among patients, we analyzed the effect of different levels of PEEP on the values of diaphragm end-expiratory thickness and thickening fraction at every PS level. No significant correlation was found between TF and the level of PEEP (PS15: The main findings of this work can be summarized as follows: in a population of post-surgical patients during assisted tidal breathing, a parallel reduction was found between ultrasonographic assessment of diaphragm thickening and indices of respiratory muscle effort when different amounts of respiratory effort were achieved by titration of pressure support. On the contrary, no correlation was found between indices of muscle effort and diaphragm excursion, nor was the latter correlated to diaphragm thickening.PSV is a commonly used ventilation mode, both as stand-alone ventilatory support in acute respiratory failure and/or during the weaning phase of mechanical ventilation . HoweverVarious non-invasive indices have been suggested to adjust the level of support, such as clinical assessment of accessory muscle activity , RR and 2O, as that value was shown to take over the major part of the work of breathing in postoperative patients without pre-existing pulmonary diseases [As in other similar physiologic studies ,33,34 wediseases . We evaldiseases , with midiseases .Diaphragm excursion has been extensively studied as an index of diaphragmatic contractile activity ,13,18,19As expected for our case-mix, we observed a normally functioning diaphragm in all patients, as testified by the absence of need for prolonged mechanical ventilation or difficult weaning and a thickening fraction well above the 20% cutoff during PS0 . HoweverOne of our hypotheses was that diaphragm thickening would be a more accurate index of diaphragm contractile activity than excursion during pressure-support ventilation, as thickening should only be influenced by active contraction. We found a significant correlation between thickening fraction and both PTPes and PTPdi. Although most evidence regarding the role of ultrasonographic assessment of diaphragm thickening relates to studies performed on spontaneously breathing patients ,17-19, iAnother interesting finding of our study is the negative correlation between TF and Vt. In spontaneously breathing patients, TF was shown to be positively related to tidal volume . HoweverOn the other hand, an apparently counterintuitive finding was that despite a relevant increase in TV between PS0 and PS15, diaphragmatic excursion remained almost constant. The most likely explanation is that with higher levels of PS a higher portion of the TV is distributed to the non-dependent lung region due to better compliance of this area, as recently shown with electrical impedance tomography analysis ,42. AnotA common drawback of ultrasonography is its operator dependence. We therefore assessed the intraobserver and interobserver reproducibility of both diaphragmatic excursion and thickness. We found an overall good repeatability of our assessments, with intra-class correlation coefficients well above 0.75, usually considered to indicate good agreement . The coe2O. To date, there is no evidence about feasibility and accuracy of diaphragmatic ultrasonography in the presence of elevated levels of PEEP, when the increase in lung volume might cause a displacement of the superior edge of the zone of apposition [Some other limitations of this study need to be acknowledged. We studied a relatively small population; however, this was comparable with that included in similar physiological studies ,34. Furtposition .In conclusion, we found that in postoperative patients undergoing assisted spontaneous breathing diaphragm thickening was a good indicator of changes of inspiratory muscle effort in response to modifications of the PS level. We suggest that the use of diaphragm excursion is of little help during PSV and should not be used to quantitatively assess diaphragm contractile activity. Further studies are warranted to assess if this holds true in a greater number of patients with different diseases.Diaphragm ultrasonography is a simple, non-invasive method of quantification of diaphragm contractile activity.During spontaneous ventilation, the assessment of diaphragm respiratory excursion may help to identify patients with diaphragm dysfunction; however, during assisted mechanical ventilation, the role of excursion in the functional evaluation of diaphragm contractile activity is far less clear. Little is known about the role of diaphragm thickening.In this physiologic, clinical pilot study we found that diaphragm excursion was not correlated to any index of muscle effort under varying levels of muscle loading; we also found that diaphragm thickening was a good indicator of changes of inspiratory muscle effort in response to modifications of the support level.Monitoring of diaphragm contractile activity during the weaning phase should be performed with diaphragm thickening, and the suggested cutoffs for diaphragm dysfunction, as far as diaphragmatic excursion is concerned, should not be considered valid during assisted mechanical ventilation.


Objective. This study aims to explore the usage of intraocular pressure measurements as the early indicator of the increase in intra-abdominal pressure. Methods. In this prospective study, 40 patients undergoing elective surgery were included. Patients were divided into four groups of 10 patients. The control group (Group C) was not subjected to laparoscopic intervention. Laparoscopic surgery was, respectively, performed with an intra-abdominal pressure of 9, 12, and 15 mmHg in Groups L (low), M (medium), and H (high pressure). Intraocular pressure was measured binocularly in each patient at three different times  using a contact tonometer. Results. Patients' gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, and operative times were not different among the groups. No complications occurred with either the surgery or measurement of intraocular pressure. Intubation was associated with a severe rise in IOP (P < 0.05). An increase in intraocular pressure was seen in groups M and H (P < 0.05). Conclusion. Intraocular pressure was increased in the groups with an intra-abdominal pressure of 12 mmHg or more. Measuring the intraocular pressure might be a useful method to estimate the intra-abdominal pressure. This trial is registered with NCT02319213. The adverse effects of intra-abdominal hypertension (IAH) on other systems were first revealed with the recognition of the relationship between IAH and oliguria. The influence of IAH on cardiovascular, renal, and the pulmonary system became definite through the publications in the first half of the 20th century .The normal pressure of the abdominal cavity is almost equal to atmospheric pressure. However, the pressure increases 5–7 mmHg with the respiratory cycle. Pressures which constantly develop above 12 mmHg are defined as IAH.Intra-abdominal pressure might be measured invasively through a port placed in the abdomen, the transvesical route, the transgastric route, or the inferior vena cava. The transvesical method is the most common one as it costs less, and it might be easily applied and learned , 3. MeasIn our study, we aimed to determine the IAP increase by means of measuring the IOP as an alternative to transvesical measurement and to introduce a more practical measurement method for clinical use. The advantages of IOP measurement are the absence of infection risk, easy comprehension, and the nonexistence of costs other than tonometry.2 or less were included in the study in accordance with the American Society of Anesthesiologists (ASA) I-II status. Exclusion criteria were preexisting eye disease, cardiovascular or neuromuscular disease, difficult intubation, and the use of any antihypertensive agents. A complete ophthalmologic evaluation of each patient was performed before the surgery by the same physician from the Ophthalmology Department.After the approval of the institutional Ethics Committee (no. 08-38) and obtaining of informed consent, 40 adult patients between 18 and 55 years old with a body mass index (BMI) of 30 kg/mn = 10), 12 mmHg (n = 10), and 15 mmHg (n = 10). IAP in control group patients was accepted as “zero” in the measurements made without insufflation. Measurement of IOP was performed for both eyes three times: firstly (time 1): postanesthesia induction and 30 seconds prior to the intubation, secondly (time 2): 1 minute after the intubation, and lastly (time 3): 45 minutes after the insufflation. IOP was measured by the same physician from the Ophthalmology Department using the Perkins Hand-Held Applanation Tonometer .The patients were divided into four groups with 10 subjects in each. The control group consisted of the patients who had undergone a surgery for inguinal hernia. The study groups were comprised of patients who had undergone laparoscopic cholecystectomy, which allows direct and the most accurate intra-abdominal pressure monitorization. In these cases, the pressure values were monitored from the insufflator monitor and the abdomen was insufflated with 9 mmHg  was used for standard monitoring including electrocardiography, pulse oximetry, heart rate, noninvasive blood pressure, and neuromuscular transmission.2O, and EtCO2 at 35–40 mmHg on mechanical ventilation .Patients who had received premedication the previous night and one hour before the operation were administered 1 mcg/kg Remifentanil, 0.5 mg/kg Atracurium, 1-2 mg/kg Propofol for induction, and 0.25 mcg/kg Remifentanil. Additionally, 1 MAC desflurane was used for maintenance of anesthesia. Standardization was attempted by keeping the respiratory rate at 10–12/min, the tidal volume at 8–20 mL/kg, PEEP at 3 cmHt-test was used in the dependent groups in order to determine the difference between the measurements. A P level of <0.05 was accepted as it was statistically significant.The data were evaluated by using the SPSS v13.0 program . A normality analysis was performed. As the data were consistent with a normal distribution, variance analysis was used for the repeated measurements and the post hoc Tukey test was used for multiple comparisons. The Bonferroni correction 2. There was not any statistical difference between the groups in terms of age, sex, and BMI. The demographic data are shown in The mean age of 40 patients  was 41.4 ± 8.2 years (range 19–55). The mean operative time was 54.2 ± 11.6 minutes and the ASA scores were I and II. The body mass index was 25.3 ± 1.8 (22–30) kg/mThe control group consisted of patients who had undergone an operation for inguinal hernia. All the patients in the study group underwent standard four-port laparoscopic cholecystectomy. There were no complications from the surgery or measurement of IOP. As the IOP values of the right and left eyes did not show a statistically significant difference, analysis was performed on 40 measured values.The mean IOP in the four groups showed similar values before intubation (time 1) and a similar rise after endotracheal intubation (time 2) (6.4 ± 3.7 mmHg). Furthermore, 12 mmHg or more pressured (Groups M and H) pneumoperitoneum induction led to a significant rise in IOP averaging 8.5 ± 3.4 mmHg. The IOP values of medium and high pressure group at all the measurement points (times 2-3) were higher than the preintubation levels (time 1). However, the IOP values of groups C and L and time 3 measurements were, respectively, decreased from 27% to 25% compared with the time 1 measurements . Time 1,Prevalence of IAH has been reported as 18–58.8% regardless of the cause of hospitalization in patients hospitalized in the intensive care unit . IAH musIndirect measurement of IAP might be performed through several methods . The mosIn previous studies, IAP was found to be significantly affected by the body mass index and previous operations . In this2O (1 mmHg = 1.36 cmH2O) as the limit value. In that study, the intracranial pressures of the patients with 20 cmH2O intraocular pressures were found to be above 20 cmH2O. The intracranial pressures of the patients whose IOPs were below 20 cmH2O were found to be normal [Elevated intracranial pressure could impair venous blood flow of the eye, and intraocular pressure increases , 21. LasIt is known that pathologic changes gradually develop in all of the organs after the IAP exceeds 12 mmHg . In our Measurement of the intraocular pressure may be an alternative method to estimate the IAP in order to reduce the frequency of other indirect measurement methods. Although the findings of our study confirm the hypothesis that 12 mmHg and more intra-abdominal pressure values reflect the IOP, further research is needed. The sample size was limited and IAP values were not high, thus limiting the power of the study, because the study was designed on a healthy population in terms of abdominal hypertension. Nevertheless, our preliminary findings should act as a stimulus for further studies involving larger samples and higher intra-abdominal pressure.


Acute kidney injury is frequently observed at the intensive care unit, after surgery, and after toxic drug administration. A rise in serum creatinine and a fall in urine output are consequences of much earlier injury to the most sensitive part of tubular cells located at the proximal tubule. The aim of the present study was to investigate the course of two cell-cycle arrest urinary biomarkers compared to serum creatinine in four clinical settings: ischemic reperfusion injury, cardiac failure, severe acute kidney injury, and chemotherapy-induced kidney injury.A recently developed bedside test known as NephroCheck measures two urinary parameters: insulin-like growth factor binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinase-2 (TIMP-2). The test is based on a sandwich immunoassay technique. The final test output, labeled AKIRisk, is shown as a numeric result.This report revealed that [IGFBP7] · [TIMP-2] in urine rise rapidly prior to any change in serum creatinine. A unique feature of all four clinical settings is that a rapid decline predicts the recovery of kidney function. Besides, a subclinical kidney injury might be detected by the test.This bedside test detects biomarkers of renal injury. A rapid decline in AKIRisk was associated with the restoration of kidney function, whereas a prolonged high AKIRisk score was associated with end-stage renal disease. However, the dynamics seem to differ, depending on the cause and the extent of injury. Further studies will be needed to clarify the issue.The online version of this article (doi:10.1186/s12882-015-0203-5) contains supplementary material, which is available to authorized users. Acute kidney injury (AKI) is common in patients at the intensive care unit and after surgery , 2. IndeA novel test method, known as NephroCheck™, measures two small tubular cell-derived molecules, [IGFBP7] · [TIMP-2]. According to recently published data, this test possesses the highest sensitivity for detecting AKI at an early stage , 14. GivIGFBP7 and TIMP-2 are markers of cell cycle arrest and possibly apoptosis, inflammation, and tubular cell repair , 16. TheWe evaluated the applicability of the test method in selected patients at our nephrology inpatient ward who were deemed susceptible to AKI, including those with preexisting CKD. The following entities were included: kidney injury following IRI during kidney transplantation (TX), AKI due to cardiac failure, severe AKI, and chemotherapy-induced kidney injury related to cisplatin. The course of [IGFBP7] · [TIMP-2] were monitored in comparison to serum creatinine.n = 52) and the oncology ward (n = 17) of the University Hospital of Vienna from 2013 to 2014. Inclusion criteria were the following: age over 18 years, clinical signs of comorbidities constituting a high risk of AKI or evident AKI. Only patients admitted to the intensive care unit and the nephrology inpatient clinic were selected for testing. These included kidney transplant recipients for the evaluation of ischemic reperfusion injury. Preexistent chronic kidney disease was no exclusion criterion in the nephrology group.Sixty-nine consecutive patients were tested at the nephrology inpatient ward . The patients’ clinical data, demographics, medical history, medication and laboratory data were obtained from their medical files and the databases of the hospital. Representative patients  were selected. Twelve patients were chosen for the report; a further four cases have been described in the supplement  or death.Analyses of urine samples for the biomarker combination of [IGFBP7] · [TIMP-2] were performed with NephroCheck™, a tool designed by a California-based biotechnology company . The Astute140TM meter is a device based on a fluorescence labeling technique, which detects fluorescent signals from the immunoassay and calculates concentrations of IGFBP7 and TIMP-2 from the inserted cartridge. The device converts the measured signals into a single number, defining the relative risk of the patient developing AKI. The final result, known as the AKIRisk score, is obtained within 20 min. Quality controls were performed as recommended and provided by the manufacturer.Urine samples were tested immediately for all patients at the nephrology department. For those at the oncology department, a maximum delay of 2 h occurred between collection and testing. In case immediate analysis was not possible, the samples were frozen at −20 °C after centrifugation and stored. Frozen samples were thawed and warmed to room temperature, and the NephroCheck™ test was performed immediately.Owing to the wide range of clinical settings, the patients’ data are presented in four groups consisting of individual case reports and graphic demonstrations in numeric order #1- #12) depicted in Fig. - #12 depPatient #1: A 66-year-old man received a cadaver kidney organ with a cold ischemia time of 12 h. After transplantation the patient was observed briefly at the intermediate intensive care unit and then transferred to the internal ward, where urine output monitoring was started. The patient had been anuric for the preceding 6 months, requiring constant hemodialysis (HD). Oliguria was observed from day 1 to 4, followed by a phase of polyuria starting on day 5 with a decrease in sCr. Interestingly, the AKIRisk score on the NephroCheck™ test was high (1.6) when the patient’s initial urine output started, and fell rapidly to levels below 0.06 prior to the phase of polyuria. Two weeks after transplantation the patient needed a transplant nephrectomy due to rupture of the renal artery.Patient #2: A 38-year-old man, oliguric and on dialysis for the last 2 years, received a cadaver kidney organ from a 15-year-old female non-heart-beating donor. After transplantation the patient was observed briefly at the surgery ward and then transferred to the internal ward (day 1) for further monitoring. The patient was oliguric to anuric during day 1–16. Donor organ perfusion and urinary tract morphology were monitored on a daily basis. Hemodialysis had to be performed three times from day 12 to day 19 post-transplantation. The patient needed stenting of the ureteral ostium to the bladder on day 12, and percutaneous drainage of the transplanted kidney pelvis. A percutaneous kidney biopsy revealed tubular cell damage, but no signs of graft rejection. TIMP-2 staining of tubular cells obtained from the urinary sediment on day 25 is shown in the supplement , throughout the observation period.2 day1, cisplatin 75 mg/m2 day1 and 5-fluorouracil 750 mg/m2/24 h by continuous infusion on days 1–5. About 3000 ml of fluid substitution was given along with each cisplatin administration.The following three case reports concern patients undergoing chemotherapy based on cisplatin. The DCF regimen, consisting of docetaxel, cisplatin and 5-fluorouracil, was administered in the following doses: docetaxel 75 mg/mPatient #10: A 41-year-old patient, initially diagnosed with gastric cancer, showed a significant rise in AKIRisk levels to 4 after the first administration of cisplatin during the first cycle on day 2 of the first cycle. This fell to below 0.5 during further treatment. Serum creatinine levels were slightly increased at the end of each cycle.Patient #11: A 54-year-old man with esophageal cancer tolerated the regimen well. His AKIRisk score rose to higher ranges after the administration of cisplatin during each cycle, with peak levels of 2.6 on day 2 during the second cycle. A marginal increase in sCr was noted, but sCr remained in the normal range. His treatment was changed after three cycles because of cisplatin-induced neuropathy.Patient #12: A 57-year-old man with cancer of the hypopharynx was admitted to the hospital for chemotherapy. During the first and second cycles of cisplatin his AKIRisk score increased to 2.7 on day 3 of cycle 1. Concurrently sCr was slightly elevated after the first 2 cycles, but remained within normal range.The present report describes the dynamics and applicability of a novel and rapid urine-based diagnostic method for evaluating the risk of imminent kidney failure, compared to serum creatinine levels. Acute kidney injury as such is known to be a poor prognostic factor in terms of mortality . We concOf patients with AKI and CKD, patient #4 had a prolonged high AKIRisk score with falling sCr levels. These unexpected dynamics might be explained by the patient’s stage of CKD and her previous history of intermittent kidney replacement therapy at the intensive care unit 1 month earlier.The course of disease seems to differ from patient to patient. As shown by other authors as well, repair mechanisms might contribute to the patients’ levels of secretion . Kidney With regard to toxic kidney injury due to chemotherapy, the increase in AKIRisk levels was followed by a marginal increase in serum creatinine. This was noted in patient #7, whose high AKIRisk score resulted in a slight increase in serum creatinine 72 h later. The toxic effects either occur in a small population of nephrons or are of such a small magnitude that they do not result in clinically measurable pathologies. However, earlier studies have clearly shown that marginal changes in serum creatinine might be related to toxic injury, which is relevant with regard to the patient’s subsequent life span . NephrolThe brisk kinetics of [IGFBP7] · [TIMP-2] after tubular cell injury during surgery or ischemic reperfusion was clearly seen in the majority of our patients. However, this might be different in CKD patients, especially in those with diabetic nephropathy (patient #4). Injury under these conditions might induce a more prolonged cascade of cell cycle arrest, causing signaling, which induces further fibrosis and vascular rarefication , 26.The very brisk and rapid dynamics of these parameters is associated with limitations in terms of method. Timely detection of tubular cell injury might require frequent testing, especially at the intensive care unit. Further studies are needed to evaluate the applicability of the test in the very complex and varying patterns of acute kidney injury.One of the limitations of the study and the test method is that it is still unclear why patients responding with high NephroCheck levels after chemotherapy do not show an immediate rise in sCr. However, our own observations regarding tubular-cell-derived urinary proteins show that the presence of subclinical tubular cell injury does not necessarily result in elevated sCr levels. One patient (#9) had prolonged high levels and eventually went into RRT. The secretion of [IGFBP7] · [TIMP-2] in this patient might have been connected to his renal disease.As the present investigation was not performed for the purpose of test validation, no conclusions can be drawn in regard of risk stratification. However, the time point of NephroCheck testing is obviously crucial. Further research should be focused on the various types of disease and the corresponding AKIRisk scores.Nephrocheck was tested in 69 patients, in different settings of acute kidney injury. The dynamics of this test are compared to serum creatinine in the present report. A brisk decline in AKIRisk levels was indicative of the restoration of kidney function to a previous stage. However, the patients’ AKIRisk dynamics varied. One limitation of the study is the wide spectrum of disease entities and comorbidities in the individual patients. Future studies should be focused on specific disease entities.


Context: It is well known that patients with chronic kidney disease (CKD) have a strong risk of cardiovascular disease (CVD). However, the excess risk of cardiovascular disease in patients with CKD is only partially explained by the presence of traditional risk factors, such as hypertension and diabetes mellitus.Evidence Acquisitions: Directory of Open Access Journals (DOAJ), Google Scholar, PubMed, EBSCO and Web of Science has been searched.Results: Chronic kidney disease even in its early stages can cause hypertension and potentiate the risk for cardiovascular disease. However, the practice of intensive blood pressure lowering was criticized in recent systematic reviews. Available evidence is inconclusive but does not prove that a blood pressure target of less than 130/80 mmHg as recommended in the guidelines improves clinical outcomes more than a target of less than 140/90 mmHg in adults with CKD.Conclusions: The association between CKD and CVD has been extensively documented in the literature. Both CKD and CVD share common traditional risk factors, such as smoking, obesity, hypertension, diabetes mellitus, and dyslipidemia. However, cardiovascular disease remains often underdiagnosed und undertreated in patients with CKD. It is imperative that as clinicians, we recognize that patients with CKD are a group at high risk for developing CVD and cardiovascular events. Additional studies devoted to further understand the risk factors for CVD in patients with CKD are necessary to develop and institute preventative and treatment strategies to reduce the high morbidity and mortality in patients with CKD. It is well known that patients with chronic kidney disease (CKD) have a strong risk of cardiovascular disease (CVD) . HoweverDirectory of Open Access Journals (DOAJ), Google Scholar, PubMed, EBSCO and Web of Science has been searched.The association between CKD and CVD was first reported by Dr. Bright in 1836 . Impairm2 and CKD stage4  compared with subjects with normal kidney function . Patientet al., have shown that hypertension increases the incidence of CVD in subjects with CKD more than in patients with normal kidney function  (Hypertension is a strong risk factor for the development of CKD. Kokubo function . The preout CKD) ,23.CKD even in its early stages can cause hypertension and potentiate the risk for CVD. However, the practice of intensive blood pressure lowering was criticized in recent systematic reviews. Available evidence is inconclusive but does not prove that a blood pressure target of less than 130/80 mmHg as recommended in the guidelines improves clinical outcomes more than a target of less than 140/90 mmHg in adults with CKD .In 2012, Canadian hypertension education program guidelines made a significant change to its target BP for patients with non-diabetic chronic kidney disease, increasing the target from <130/80 mmHg to <140/90 mmHg, whereas those with kidney disease and concomitant diabetes continue to have a target of <130/80 mmHg  has been demonstrated in multiple studies -29. Amon2 ,32. Howe2 .Diabetes mellitus is the most common cause of CKD worldwide . The proet al. have shown that even the prescription of statins, β blockers, and antiplatelet agents is less frequent for patients with acute myocardial infarct and CKD even though the treatment benefits have been recommended and by the 2012 European guidelines on cardiovascular disease prevention  have higher rates of comorbidities, conduction abnormalities, and anterior infarctions compared with individuals without CKD . Cardiacevention ,44. NeveTo prevent CVD events in patients with CKD, treatment should be initiated during the early stages of CKD. The presence of albuminuria is a predictive factor for the progression of CKD and is associated with an increased risk of CVD, even in the setting of normal renal function . Among pThe association between CKD and CVD has been extensively documented in the literature. Both CKD and CVD share common traditional risk factors, such as smoking, obesity, hypertension, diabetes mellitus, and dyslipidemia. However, cardiovascular disease remains often underdiagnosed und undertreated in patients with CKD. It is imperative that as clinicians, we recognize that patients with CKD are a group at high risk for developing CVD and cardiovascular events. Additional studies devoted to further understand the risk factors for CVD in patients with CKD are necessary to develop and institute preventative and treatment strategies to reduce the high morbidity and mortality in patients with CKD.All authors wrote the manuscript equally.The author declared no competing interests.This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors


New onset diabetes mellitus after transplant (NODAT) has been described in 4-25% of kidney transplant recipients. It is not only a major factor leading to dysfunction and deterioration of the allograft, but also has a significant impact on cardiovascular risk and patient survival. Several risk factors have been linked to this condition such as age, class of immunosupressive drug, obesity and family history of diabetes. However this has been poorly studied in our population.To identify the prevalence and the major risk factors associated with NODAT after kidney transplantation in our population.We performed a retrospective evaluation of patients who underwent kidney transplant from 1994 to 2014 and were not diabetic before the procedure. The prevalence of NODAT was established through the ADA criteria. Clinical and epidemiologic data were retrieved by review of medical charts and analised with SPSS 17.0. A p≤0.05 was considered significant. Results: A total of 109 patients were studied  Their mean age was 52 (±9.7) yrs. old (range: 27 to 72). Among them, 35 developed NODAT . Those who developed NODAT were older than others . NODAT was more common in those who underwent hemodialysis before the transplant  and that used imunossupressive therapy with mycophenolate . BMI before transplantation (p=0.671), gender (p=1.0), ethnicity , type of organ donor , family history of diabetes  and use of other imunossupressive drugs, like tacrolimus , sirolimus , cyclosporine (p=1.0) and corticosteroid , were not associated with NODAT in our patients. The majority of patients using corticosteroids  used prednisone dosage ≤ 5 mg/day. In patients who developed NODAT, 2,8% used sulfonylureas alone, 14,3% used metformin alone, 5,7% used DPP4 inhibitors, 2,8% used sulfonylureas and insulin, 17,1% used metformin with insulin and 22,8% used insulin alone.NODAT occurs in aproximately one third of patients that underwent kidney transplant in our population. The development of diabetes in these individuals is associated with older age at the time of surgery, hemodialysis before transplant and surprisingly with use of mycophenolate. This finding could be explained by the more common use of this drug in our center than in others.


Inappropriately cuffed tracheal tubes can lead to inadequate ventilation or silent aspiration, or to serious tracheal damage. Cuff pressures are of particular importance during aeromedical transport as they increase due to decreased atmospheric pressure at flight level. We hypothesised, that cuff pressures are frequently too high in emergency and critically ill patients but are dependent on providers’ professional background.Tracheal cuff pressures in patients intubated before arrival of a helicopter-based rescue team were prospectively recorded during a 12-month period. Information about the method used for initial cuff pressure assessment, profession of provider and time since intubation was collected by interview during patient handover. Indications for helicopter missions were either Intensive Care Unit (ICU) transports or emergency transfers. ICU transports were between ICUs of two hospitals. Emergency transfers were either evacuation from the scene or transfer from an emergency department to a higher facility.2O; range, 8-120 cmH2O. There was no difference between patient characteristics and tracheal tube-size or whether anaesthesia personnel or non-anaesthesia personnel inflated the cuff (30 (24.8/70.0) cmH2O vs. 50 (28.0/90.0) cmH2O); p = 0.113.This study included 101 patients scheduled for aeromedical transport. Median cuff pressure measured at handover was 45 (25.0/80.0) cmH2O in emergency transfers vs. 30 (20.0/45.8) cmH2O in inter-ICU transports; p < 0.001. For cuff pressure assessment by the intubating team, a manometer had been applied in 2 of 59 emergency transfers and in 20 of 34 inter-ICU transports (method was unknown for 4 cases each). If a manometer was used, median cuff pressure was 27 (20.0/30.0) cmH2O, if not 70 (47.3/102.8) cmH2O; p < 0.001.With regard to mission type , median cuff pressure was different: 58 (30.0/100.0) cmHCuff pressures in the pre-hospital setting and in intensive care units are often too high. Interestingly, there is no significant difference between non-anaesthesia and anaesthesia personnel. Acceptable cuff pressures are best achieved when a cuff pressure manometer has been used. This method seems to be the only feasible one and is recommended for general use. For emergency patients, tracheal intubation with a cuffed tube remains the gold standard for securing the airway. Compared with other airway tools, only cuffed tracheal tubes are able to prevent aspiration. In addition, for controlled ventilation, air leakage must be minimised. This is especially important during the transfer and relocation of patients. In emergency situations, the risk of over-inflation is high -3. TherePossible damage from inappropriately high cuff pressures is a well-known hazard in long-term (days) ventilated patients but is a less recognised problem in short-term (hours) intubated patients. Nevertheless, a recent publication demonstrated that mucosal damage also occurs in short-term 1-3 hours) intubated patients . Emergen-3 hours In addition, cardiac output and blood pressure in emergency patients are often compromised, and low capillary pressure has been shown to influence tracheal mucosal perfusion ,14 resulBecause situations in emergency and critically ill patients are more complex and team compositions are often not as well-rehearsed as in elective hospital intubation settings, we hypothesised that cuff pressures are frequently too high and depend on the provider’s professional background.The study was approved by the local Institutional Review Board (Ethikkommission beider Basel) as a quality assurance investigation. Requirement for written informed consent was waived by the Institutional Review Board.This prospective observational study occurred over a 12-month period. Inclusion criteria included all mechanically ventilated patients scheduled for aeromedical transport and intubated with a cuffed tracheal tube. Exclusion criteria were: (i) patients who were intubated by the study group; (ii) devices other than regular tracheal tubes ; (iii) technical problems (e.g. incompatibilities between the cuff pilot and the cuff-pressure manometer or damaged tube cuffs); and (iv) patients in whom the study setting seemed unsuitable due to safety concerns .2O.Initial cuff pressures were measured before loading the patient into the helicopter, using a commercially available cuff-pressure manometer . As all emergency physicians working on the helicopter were anaesthesiologists familiar with the manometer from their anaesthesia practice, no formal training was required. Cuff pressure was considered “elevated” if the value was ≥30 cmHThe local team present at the handover was questioned about the professional background of the person who had inflated the cuff (anaesthesia vs. non-anaesthesia personnel and physician vs. nurse/paramedic staff). In addition, the technique used for cuff inflation was recorded, specifically if cuff pressure was measured or if it was estimated clinically.2O. Besides this intervention, there was no further change in patient management.For safety reasons, after measurement by the investigating helicopter team, cuff pressure was adjusted to 25 cmHThe study was performed in cooperation with Swiss Air-Rescue . The helicopter base was located at the Euro-Airport Basel and serves the tri-border region of Switzerland, Germany and France. The helicopter emergency medical services crew consisted of a pilot, a paramedic-flight assistant and a board certified anaesthesiologist or anaesthesiologist at certification level with an additional board-certification in pre-hospital emergency medicine.The following parameters were assessed: cuff pressure before helicopter take off; type of mission  or “ICU transfers” ); time between intubation and the initial cuff pressure measurement; tube size and insertion depth (tip to teeth in cm); and patient characteristics .Data were recorded using printed forms and later transferred into a Microsoft Excel® 2000 worksheet .Data were analysed using IBM SPSS Statistics 19.0 . Data are presented as descriptive statistics (median (25/75 percentiles); mean ± SD). Mann-Whitney U test was used for comparison between continuous variables. Chi-square tests were used for categorical data. Values of p < 0.05 were considered significant.After exclusion based on the specified criteria, data of 101 patients were included in the study . There was no difference in cuff pressures dependent on patient characteristics  or tracheal tube diameter. Values of initial cuff pressure were not different if anaesthesia personnel (nurse or anaesthesiologist) or non-anaesthesia personnel (nurse or physician) had inflated the cuffs (median 30 (24.8/70.0) vs. 50 (28.0/90.0) cmH2O, mean 46 ± 31.5 vs. 60 ± 35.1 cmH2O); p = 0.113.Median initial cuff pressure measured was 45 (25.0/80.0) cmH2O for emergency transfers vs. 30 (20.0/45.8) cmH2O for ICU transfers (mean 64 ± 36.4 vs. 38 ± 24.5 cmH2O); p < 0.001.Mission type significantly influenced cuff pressure values: 58 (30.0/100.0) cmH2O) was found in patients intubated within one hour of measuring (Table 2O (mean 56 ± 35.7 and 51 ± 35.4 cmH2O), respectively.Duration between tracheal intubation and patient handover was 40 ± 41.1 minutes  in emergency transfers and 97 ± 167.4 minutes  in ICU transfers. The highest percentage of elevated cuff pressures ; a specific volume of air was inflated in 14 cases (14%); the palpatory method was used in 10 cases (10%); and the acoustic method was used in one case. In 46 patients (46%), cuff pressures had not been checked by any method, and in 8 cases the referring person could not provide any information on the type of measurement, if any. ICU transfers showed a higher percentage of “measurement”  compared with emergency transfers , for 4 patients in each group the technique was unknown.2O, if not 70 (47.3/102.8) cmH2O (mean 27 ± 8.7 vs. 65 ± 35.6 cmH2O); p < 0.001. Apart from one cuff pressure evaluated using the acoustic method, manometer measurement was the only method with a median cuff pressure <30 cmH2O.Different methods of checking showed different cuff pressure values Figure . If a main vitro study simulating flight-level changes in an altitude chamber [Tracheal tube cuff pressures in patients intubated prior to aeromedical transport are generally too high. This finding is independent of patient characteristics, tube diameter and time since intubation. In particular, professional background of those who performed intubation had no influence. Contrary to expectation, anaesthesia personnel did not reliably control the appropriateness of the cuff inflation. Cuff pressures were much higher in emergency transfers than in ICU transfers. Elevated cuff pressures in tracheally intubated patients prior to emergency transfer have been demonstrated in the prehospital and the emergency department setting -3,15,16. chamber . If not 2O [Tracheal mucosal blood flow has been shown to be impaired at cuff pressures ≥30 cmH2O . Animal 2O . As many2O . In a ra2O .A recent multicentre study recorded cuff pressures in an operating room setting and showed much higher than optimal values if pressure was estimated by clinical judgement alone . In addiFor brief procedures lasting only a few hours, most anaesthesiologists pay little attention to tube cuff inflation pressure . SeveralIn our study, cuff pressures were not controlled at all in nearly half of the cases. In “controlled” cases, the most frequent technique for assessment was measuring using a manometer, followed by insufflating a “specific volume of air”, “palpatory” and “acoustic” methods, whereupon measurements had been performed prior to almost all ICU transfers. Techniques other than direct measurement are unreliable in the prehospital setting.Acceptable cuff pressures are best achieved by using a manometer.There are several limitations to this study. During the study period, about half of all mechanically-ventilated, aeromedically-transported patients could not be included Figure . Nearly Tracheal tube cuff pressures in patients intubated prior to aeromedical transport are too high. In our study, cuff pressures were not controlled at all in nearly half of cases. Awareness about this circumstance seems to be absent from daily practice in emergency situations; this seems to apply to anaesthesia personnel, too. We, therefore, recommend the mandatory routine use of a cuff pressure manometer to avoid inappropriately high cuff pressures. Use of a 5 ml syringe may be a perferable pragmatic alternative to the traditional 10 ml syringe. Acknowledging the dangerous increase of cuff pressures during subsequent airborne transport, medical teams responsible for transfer of intubated patients must monitor tracheal tube cuff pressures and adjust the pressures appropriately.The authors declare that they have no competing interests.FH helped analyse the data and write the manuscript, and performed the statistical analysis. MZ is responsible for the study design, helped analyse the data, and write the manuscript. MB helped collect and analyse the data. WU participated in the study design, helped collect and analyse the data and write the manuscript. All authors read and approved the final manuscript.