Minerva anestesiologica最新文献

This article examines how clinical reasoning about the critical patient is currently treated and draws attention to some critical issues already often highlighted in the literature. Traditional approaches to clinical reasoning, even when applied to critical patients, prioritize identifying structured diseases. In contrast, the critical care setting demands an alternative approach that aligns with the intensivist's goal of supporting or substituting vital organ functions. In this manuscript, we emphasized the reasons that make it primary for intensivists to obtain a diagnosis of function in order to act therapeutically. Moreover, we highlighted the challenges posed by diagnostic errors, often attributed to cognitive biases and shortcomings in clinical reasoning, which can adversely affect patient outcomes and resource utilization. We also discussed the complexities of clinical decision-making in emergency medical services, where physicians must perform rapid actions in the face of incomplete information and high uncertainty. We underscore the limitations of traditional information technology tools in facilitating practical clinical reasoning, advocating for the integration of relevant data that directly informs on organ function and pathophysiological mechanisms. This discourse emphasizes a deep understanding of physiology and pathophysiology as foundational for practical clinical reasoning in critical care. Finally, we propose a structured assessment method that prioritizes pinpointing the compromised organ function, elucidating the pathophysiological mechanism responsible, hypothesizing potential causes, and testing these hypotheses to guide therapeutic interventions. This approach aligns clinical reasoning with the intensivist's goal: supporting and restoring vital functions in the critically ill patient.

Background: This research aimed to assess the analgesic efficacy of ultrasound-guided rhomboid intercostal block (RIB) or serratus plane block (SPB) versus IV opioid among modified radical mastectomy (MRM) patients.

Methods: One hundred and five female patients aged 18-65 years with American Society of Anesthesiologists (ASA) physical status II-III scheduled for unilateral MRM were randomly allocated into three equal groups: 1) control group (received IV basal analgesia); 2) SPB group (received ipsilateral SPB); and 3) RIB group (received ipsilateral RIB).

Results: Visual Analogue Scale (VAS) was significantly increased in control group compared to SPB group at Post-Anesthesia Care Unit (PACU) (1 [1-2], 0 [0-1]), 2 h (4 [3-4], 0 [0-1]), and 4 h (3 [3-4], 2 [1-2]) postoperative in control and SPB groups, respectively; and in comparison with RIB group at PACU (0 [0-1]), 2 h (1 [0-1]), 4 h, (1 [1-2]), 6 h (1 [1-2]), and 8 h (2 [1-2]), postoperative. VAS was significantly increased in SPB group at 6 h (4 [3-4]), and 8 h (4 [3.25-4]), compared to RIB group with P<0.0001. Time of first analgesic requirement (minutes) was significantly delayed in RIB (720 [480-720]) and SPB (360 [360-360]) groups in comparison with control group (60 [60-120]) and in RIB group in comparison with SPB group. The total postoperative 24 h morphine consumption (mg) was significantly increased in control group (15.69±1.64) when compared to SPB (9.6±1.42) and RIB (6.51±1.36) groups and in SPB group when compared to RIB group.

Conclusions: Both rhomboid intercostal and serratus anterior plane blocks were efficient for analgesia after modified radical mastectomy. However, RIB had better analgesic efficacy compared to SPB.

Background: Acute kidney injury (AKI) is a major health burden after cardiac surgery. Renal vasoconstriction and venous congestion can be assessed via transesophageal echocardiography (TEE). The primary objective is to determine feasibility of measuring intraoperative Renal resistive index (RRI) and portal vein pulsatility fraction (PF) by TEE. The secondary objectives are to determine the association between RRI and/or PF and postoperative AKI, Intensive Care Unit (ICU) length of stay, hospital length of stay, and 30-day mortality.

Methods: This is a prospective observational study at a single center University setting in adult patients undergoing elective cardiac surgery. Intraoperative RRI and PF measurements were obtained prior to CPB, after CPB, and after chest closure.

Results: Eighty patients met eligibility criteria and consented. Overall feasibility rate was 91% (73/80), RRI measured in 96% (77/80) and PF measured in 94% (75/80). Further analyses was conducted in 69 patients. RRI prior to CPB significantly correlated with AKI ([OR][95% CI] 2.15 [1.07-4.33], P=0.03) with an AUC of 0.68 ([95%CI] 0.55-0.81, P=0.02). Post-chest closure RRI>0.75 significantly correlated with AKI ([OR][95% CI] 3.54 [1.18-10.62], P=0.02). Combination of the three timepoints significantly associated with AKI ([AUC][95% CI] 0.71 [0.58-0.84], P=0.007). PF did not significantly correlate with AKI.

Conclusions: This study demonstrates high feasibility for obtaining intraoperative TEE measurement of RRI and PF and significant correlation between postoperative AKI with pre CPB RRI, post chest closure RRI, and the combination of RRI at the three timepoints.

Background: Epidural block may be facilitated by ultrasound (US), particularly in pediatrics. Our goal was to compare pre-procedural US with traditional palpation for epidural block in pediatrics undergoing midabdominal urological procedures.

Methods: A total of 110 patients (1 to 12 years of age) with physical status Class I and II were enrolled in this study. Patients were randomly assigned to 2 equal groups (US and palpation; 55 subjects in each group) using the permuted block randomization method with randomly selected block sizes of four and six. Study subjects and outcomes evaluators were blinded to the study group. The primary outcome was the rate of successful epidural block at the first needle pass.

Results: There was a significant increase in success rate of the epidural block at the first needle pass in US group compared with the palpation group, 80% and 47.3% respectively, 95% Confidence Interval (2.379-8.35), P value ˂0.001. The epidural space detection time was shorter significantly in the US group compared to the palpation group. The procedural complications (unintentional vascular puncture and epidural puncture) did not occur in the 2 groups.

Conclusions: Preprocedural US facilitated epidural block in pediatrics undergoing mid-abdominal urological operations compared with conventional techniques.

Introduction: Remimazolam, a recently approved drug for surgical sedation and general anesthesia, has been compared with propofol in previous studies regarding its efficacy as a general anesthetic. However, the question of whether remimazolam demonstrates non-inferiority to propofol in postoperative subjective quality of recovery (QoR) among patients under general anesthesia has not been definitively answered.

Evidence acquisition: PubMed, Embase, and Cochrane Library databases were systematically searched for all published randomized controlled trials (RCTs) comparing the efficacy of remimazolam and propofol. The primary outcome assessed was the quality of recovery (QoR-15, QoR-40) on postoperative days (POD) 1-3. Secondary outcomes included the duration until consciousness recovery, extubation time, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay.

Evidence synthesis: The analysis involved 10 RCTs with a total of 1077 patients. Remimazolam showed comparable QoR scores to propofol on POD1 (nine trials, standardized mean difference [SMD]: 0.14, 95% confidence interval [CI]: -0.15 to 0.44, P=0.34), POD 2 (two trials, SMD: 0.09, 95% CI: -0.18 to 0.36, P=0.5), and POD 3 (four trials, SMD: 0.17, 95% CI: -0.51 to 0.85, P=0.62). Subgroup and sensitivity analyses confirmed the robustness of these findings. Furthermore, no significant differences were observed in recovery time for consciousness, extubation duration, incidence of PONV, or length of hospital stay between the remimazolam and propofol groups.

Conclusions: Remimazolam is similar to propofol in terms of postoperative subjective QoR for patients receiving general anesthesia.

Background: Shoulder arthroscopy, a standard orthopedic procedure, often results in severe postoperative pain, leading to high opioid consumption and delayed recovery. Various analgesic methods, including peripheral nerve blocks, manage this pain. The pericapsular nerve group block is a relatively new technique whose efficacy in shoulder surgeries has yet to be extensively studied. This study aimed to assess the impact of the pericapsular nerve group block on postoperative recovery quality following shoulder arthroscopy, as measured by the Quality of Recovery-15 score.

Methods: A randomized, prospective, controlled, multicenter study was conducted with 60 patients undergoing unilateral shoulder arthroscopy. Participants were allocated to either Group P (patients receiving the pericapsular nerve group block and multimodal analgesia) or Group C (patients receiving only multimodal analgesia). The primary outcome measured was the Quality of Recovery-15 score 24 hours post-surgery. Secondary outcomes included postoperative numeric rating scale scores, the requirement for rescue analgesia, time to first rescue analgesia, postoperative complications, the necessity for antiemetics, and patient satisfaction.

Results: The median Quality of Recovery-15 score was significantly higher in Group P compared to Group C (120±10 vs. 89±11; P<0.001). Additionally, Group P exhibited lower pain scores at rest and during movement, a decreased need for rescue analgesia, and an extended duration before the first rescue analgesia was required. Postoperative nausea and vomiting were less common in Group P, and patient satisfaction scores were notably higher in this group.

Conclusions: The pericapsular nerve group block significantly enhances postoperative recovery quality, reduces pain and opioid consumption, and improves patient satisfaction without significant complications.

Introduction: This network meta-analysis (NMA) was performed to assess the relative efficacy and safety of various regional analgesic techniques used in patients undergoing partial nephrectomy or nephrectomy.

Evidence acquisition: Randomized controlled trials (RCTs) evaluating different regional analgesia techniques in patients underwent partial nephrectomy or nephrectomy were retrieved from databases, including PubMed, Embase, Web of Science, and the Cochrane Library, from inception to January 2024. The NMA was made by using Stata 15.1 softwares. The certainty of evidence was assessed by using CINeMA.

Evidence synthesis: We included 27 trials with 1852 patients and 14 techniques. Postoperative resting pain scores within 24 hours were decreased by erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), intrathecal morphine (IM), retrolaminar block (RLB). Postoperative movement pain scores within 24 hours were decreased by ESPB, TPVB, lateral quadratus lumborum block (QLB-L), transversus abdominis plane block. Postoperative opiates consumption within 24 hours were decreased most by QLB-L, followed by transmuscular QLB (QLB-TM), TPVB, and IM. Postoperative nausea and vomiting (PONV) were decreased by RLB, anterior QLB approach at the lateral supra-arcuate ligament (QLB-LSAL). Length of hospital stay were decreased by TPVB, ESPB.

Conclusions: This available evidence suggests that ESPB and TPVB are more likely to reduce pain scores within 24 hours and shorten the length of hospital stay. QLB-L and QLB-TM are more likely to reduce the cumulative opiates consumption within 24 hours. RLB and QLB-LSAL are more likely to decrease the incidence of PONV. The wound infiltration (WI), intraperitoneal instillation (IPI), and WI+IPI are less likely to be effective.