Minerva anestesiologica最新文献

Spinal anesthesia is a fundamental and widely adopted technique in modern clinical practice. However, its application in patients with abnormal spinal anatomy remains contentious due to heightened risks of technical failure, neurological injury, and hemodynamic instability. This review synthesizes recent advances in the use of spinal anesthesia in this complex patient population, providing clinical insights and practical recommendations derived from a comprehensive analysis of over 40 studies retrieved from the PubMed and Web of Science databases. Findings suggest that subarachnoid block may offer higher success rates than epidural block in patients with a history of spinal surgery. Among individuals with scoliosis, the failure rate of neuraxial block was markedly higher in those with a Cobb angle greater than 50° (26.9%) compared to those with milder deformities (7.5%). Furthermore, symmetrical bilateral spread of local anesthetics was more frequently observed in patients with left-sided scoliosis (52.9%) than in those with right-sided curvature (28.1%). To optimize puncture success, a needle insertion angle of 4.1±2.45° from the midline is recommended for patients with Cobb angles less than 50°, and 9.14±2.45° for those with Cobb angles exceeding 50°. In cases of ankylosing spondylitis, the paramedian approach, in combination with electromagnetic needle tracking systems such as SonixGPS^®, has shown improved procedural efficacy. Despite these promising developments, large-scale, multicenter clinical trials are urgently required to establish standardized protocols, refine anesthetic dosing strategies, and reduce the incidence of neurological complications in patients with altered spinal anatomy.

Hemoglobin (Hb) is a critical component of arterial oxygen content, and thus of oxygen delivery to the brain. As a result, anemia is a major concern in patients with acute brain injury such as traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage (aSAH), or intracranial hemorrhage (ICH). In these patients, anemia has been associated with higher mortality and worse neurological outcomes. However, the safety and benefit of red blood cell (RBC) transfusion remained uncertain in observational studies. Until recently, there was limited evidence to guide the optimal transfusion threshold: whether to adopt a liberal or a restrictive RBC transfusion strategy. In 2024, three randomized controlled trials compared liberal (Hb threshold 9-10 g·dL^-1) vs. restrictive (Hb threshold 7-8 g·dL^-1) transfusion strategies in patients with aSAH (SAHARA), TBI (HEMOTION), or mixed acute brain injury (TRAIN). Of these, only TRAIN demonstrated a significant benefit for the liberal strategy (Hb 9 g·dL^-1) over the restrictive one (Hb 7 g·dL^-1) in improving 6-month neurological outcomes. HEMOTION showed a non-significant trend favoring the liberal strategy (Hb 10 g·dL^-1). When combined in meta-analyses, these findings suggest adopting a more liberal transfusion threshold (9-10 g·dL^-1) in patients with acute brain injury, especially those with TBI. Moving forward, a personalized transfusion strategy - guided by clinical context, timing, and neuromonitoring - may offer the best approach for this hypoxia-sensitive population.

Background: To compare the safety and efficacy of ultrasound-guided pericapsular nerve group (PENG) block and anterior quadratus lumborum block (AQLB) in elderly patients undergoing total hip arthroplasty (THA).

Methods: This randomized, controlled trial included 93 patients aged 65 years or older with traumatic hip fractures, scheduled for elective unilateral THA under general anesthesia. Patients were randomized into three groups: PENG group (N.=31), AQLB group (N.=31), and a control group (N.=31), which received only opioid analgesia. The primary outcome was total morphine consumption within the first 24 hours postoperatively. Secondary outcomes included intraoperative fentanyl use, time to first rescue analgesia, block failure rate, pain scores at rest and during movement, motor recovery (muscle strength and hip flexion), time to first ambulation, and length of hospital stay. Additional assessments involved intraoperative hemodynamic monitoring, block-related and morphine-related complications, as well as block performance time and duration of surgery.

Results: The AQLB group showed the least total morphine consumption (median 6.0 mg), followed by the PENG group (median 8.0 mg), with a significant difference between the two groups (P=0.035). Both PENG and AQLB groups showed a significantly lower total morphine consumption than the control group (median=12.0 mg). The Numeric Pain Rating Scale at rest showed significant differences between "AQLB versus Control" till four hours postoperative, and between "PENG versus Control" at all-time points except at six, eight, and 18 hours. The AQLB group showed the lowest scores for the manual muscle test for the quadriceps and Iliopsoas muscles and for the range of motion with significant differences between AQLB and PENG. Furthermore, the time to first walk was significantly longer among the AQLB group (median 24 h) in comparison to the PENG group (median 8 h). The PENG displayed the shortest hospital stay period (2.13 days), followed by the control group (2.94 days), and then the AQLB group (3.16 days), with significant differences.

Conclusions: While the PENG block facilitated earlier mobilization and shorter hospital stays, the AQLB offered superior analgesia and reduced opioid consumption. Both techniques proved effective, with the choice depending on clinical priorities such as pain control versus early recovery.

During assisted ventilation in patients with hypoxemic respiratory failure and acute respiratory distress syndrome (ARDS), achieving a balance between ventilator support and patient effort is essential. Contemporary approaches favor light sedation and limited use of neuromuscular blocking agents: most recent evidence would suggest that spontaneous breathing should be encouraged for as long as possible, provided that excessive inspiratory effort does not injure the lungs or the diaphragm. While spontaneous breathing is beneficial in case of mild-moderate hypoxemia, it may become injurious in moderate-to-severe patients (PaO2/FiO2 <150 mmHg), especially in cases of low respiratory system compliance. Monitoring drive, effort, patient-ventilator interaction, respiratory mechanics and lung stress helps detect and manage harmful inflation patterns, preventing self-inflicted lung injury. By analyzing the first effort against an end-expiratory occlusion, we can assess the respiratory drive intensity from the negative deflection of airway pressure in the first 100 ms (P0.1 ‒ optimal range: 1-4 cmH2O), and the inspiratory effort from the maximum negative deflection (ΔPocc ‒ optimal range: 5-14 cmH2O). Plateau pressure can be measured to estimate total lung stress and calculate respiratory system compliance and driving pressure: driving pressure values above 12 cmH2O are associated to increased mortality. These measurements can be performed bedside without additional equipment, and should be integrated for comprehensive understanding of patient's individual respiratory mechanics and workload. In this narrative review, we provide a practical overview of these monitoring techniques and their physiological rationale, aiming to guide safe and effective maintenance of spontaneous breathing during invasive ventilation in hypoxemic patients.