Anaesthesia Critical Care & Pain Medicine最新文献

Introduction: Peritonitis is a frequent cause of sepsis in the intensive care unit (ICU) and is characterized by substantial microbiological variability, including multidrug-resistant organisms (MDROs).

Method: We conducted a retrospective, multicenter cohort study including ICU patients diagnosed with intra-abdominal infection across 4 hospitals 2020-2022). The primary objective was to describe clinico-biological features, and microbiological characteristics according to the setting of the peritonitis (Community peritonitis (CP), early nosocomial peritonitis (ENP), or late nosocomial peritonitis (LNP)). Additionally, we analyzed 90-day survival using Kaplan-Meier curves and multivariable Cox regression.

Results: Among the 392 patients included in the study period, 195 experienced a CP, 88 an ENP, and 109 an LNP. Extended-spectrum beta-lactamase-producing bacteria were identified in 24 patients (6.1%), and carbapenem-resistant bacteria in 5 patients (1.3%). MDRO rates differed significantly: carbapenem-resistant bacteria were more frequent in LNP patients (3.7% vs. 0.0% in CP and 0.5% in ENP; p = 0.03), and cephalosporinase-producing bacteria were more common in nosocomial settings (40.4% in LNP vs. 19.0% in CP; p < 0.001). Ninety-day mortality was 34.7% overall and did not differ across settings (p = 0.345). Age and SAPS II were independently associated with mortality. Finally, appropriate empirical antimicrobial therapy was not associated with improved 90-day survival (p = 0.128).

Conclusion: Through this large cohort study of ICU patients with peritonitis, we observed a low prevalence of MDRO. Our findings challenge the relevance of broad-spectrum empirical therapy in low-MDRO regions and underscore the need for tailored antimicrobial stewardship strategies.

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common and serious complication, significantly increasing postoperative morbidity and mortality. We aimed to evaluate whether intraoperative peripheral perfusion index (PPI) was associated with the risk of major adverse kidney events, as defined by MAKE30, as well as CSA-AKI and 30-day mortality METHODS: In this retrospective observational cohort, we studied patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Hemodynamic data were extracted from intraoperative monitors at 1-minute intervals. Multivariable logistic regression was used, adjusting for acute kidney injury risk factors and intraoperative MAP and central venous pressure (CVP). Sensitivity analyses included post-CPB periods and LASSO-based variable selection.

Results: We analyzed 446 adult patients. Lower intraoperative PPI values were significantly associated with an increased risk of MAKE30. For every 15 minutes spent with a PPI < 0.5, the odds of MAKE30 increased by 49% (OR 1.49; 95% CI 1.27-1.76; p <  0.001). Similarly, for every 15 minutes with a PPI < 1.5, the odds increased by 18% (OR 1.18; 95% CI 1.08-1.28; p <  0.001). The duration of time with PPI values below 0.5 and 1.5 was also significantly associated with CSA-AKI and mortality. Sensitivity analyses confirmed that these associations were robust.

Conclusion: Low intraoperative PPI is independently associated with an increased risk of MAKE30, CSA-AKI, and 30-day mortality following cardiac surgery with CPB. Future prospective studies should investigate whether interventions aimed at optimizing PPI through goal-directed therapy can improve postoperative outcomes.

Background: Severe respiratory failure is the leading cause of intensive care unit (ICU) admission and mortality in critically ill COVID-19 patients. However, whether active viral replication persists in the lower respiratory tract of these patients and contributes to lung injury remains unclear.

Methods: We conducted a prospective cohort study of 159 critically ill COVID-19 patients requiring invasive mechanical ventilation (IMV). A bronchoalveolar lavage (BAL) sample was collected within 24 hours of intubation. SARS-CoV-2 RNA load (N1, N2, E, and subgenomic E) and the expression of 18 host immune-related genes were assessed. A replication-competent virus was detected using a Vero cell culture assay by inoculating cells with BAL samples and monitoring cytopathic effects. SARS-CoV-2 replication was confirmed by RT-qPCR. Association of virological and immunological factors with time from symptom onset to IMV initiation was evaluated using multivariable linear regression.

Results: SARS-CoV-2 RNA was detected in 84.3% of BAL samples, and 71.7% were positive for subgenomic E RNA. Replication-competent virus was confirmed in 60% of the samples. High RNA levels and SARS-CoV-2 culture positivity were independently associated with shorter time from symptom onset to IMV initiation, with culture positivity showing the strongest association. Gene expression profiling revealed a marked suppression of innate immune effectors, despite robust expression of type I and type III interferons. CXCL10 and PDL1 were the only genes independently associated with shorter time from symptom onset to IMV initiation.

Conclusions: At the time of IMV initiation, patients with early respiratory failure showed high levels of SARS-CoV-2 RNA and evidence of active viral replication in the lower respiratory tract. This group represents a distinct virological phenotype that could benefit from therapeutic interventions targeting pulmonary viral replication.

Registration: Sub-study of the CIBERESUCICOVID project (NCT04457505).

Background: Understanding the challenges in resource-limited settings is crucial for improving the quality of care, building capacity, and facilitating international collaboration in neurosurgical care. We conducted this survey with the aim of assessing and describing the current practices, challenges, training, and infrastructure associated with neuroanaesthesia across LMICs, to identify key gaps.

Methods: This cross-sectional survey collected data on training, education, details about clinical practice, agents used, availability of equipment and resources, and challenges involved. Data were analysed using descriptive statistics, and comparisons were made across different geographical regions (and economic strata [low-income countries (LICs), lower middle-income countries (LoMICs), and upper middle-income countries (UMICs)].

Results: A total of 453 anaesthesiologists from 38 LMICs took the survey. About 54.9% (133/242) of respondents from UMICs reported the presence of an academic program for training in neuroanaesthesia, while 67.2% (45/67) of respondents from LICs do not have any facility for neuroanaesthesia training. Approximately 40.4% (183/453) of respondents have a recognized neuroanaesthesia course available at their institute. The availability of dedicated neuroanaesthetists was limited (69/453; 15.2%). Only 46.8% (212/453) of respondents were satisfied with the availability of critical neuroanaesthesia tools, and variation was observed across LMICs (p < 0.001). The presence of a dedicated quality improvement program was reported by only 16.8% of the respondents.

Conclusion: This survey provides useful insight about the unmet needs and the opportunities for strengthening neuroanaesthesia practice in the LMICs.

Background: Although flexible bronchoscopy is considered the gold standard for awake tracheal intubation in patients with anticipated difficult airways (DA), videolaryngoscopy (VL) has emerged as a reliable alternative. The primary objective of this multicenter study was to evaluate the overall success rate of awake tracheal intubation using VL in patients with suspected DA.

Methods: We conducted a prospective, observational cohort study including all awake tracheal intubations performed with VL over a 3-year period in three hospitals. Data collected included the type of VL used (Airtraq®, C-MAC D-Blade®, or McGrath®X3), procedural success, number of intubation attempts, operator-perceived difficulty, and procedure-related complications.

Results: A total of 312 awake tracheal intubations were performed during the study period, with an overall success rate of 94.9% (296/312). In 298 patients, VL was the first intubation technique used in the operating room, with a success rate of 95% (283/298). No differences were found between non-channeled (95%) and channeled VLs (94.9%; p = 0.984). First-attempt success was achieved in 68.1% of patients (69.9% with non-channeled vs 61% with channeled VL; p = 0.235). The procedure was rated as easy or slightly difficult in 82.6% of cases (82% vs 84.8%; p = 0.425). The most frequent complication was impaired glottic visualization due to secretions (8.1%).

Conclusions: Videolaryngoscopy is an effective and safe alternative for awake tracheal intubation in patients with suspected difficult airways, achieving high success rates with few complications. No significant differences were observed between channeled and non-channeled devices.

Background: Children with severe obstructive sleep apnea (OSA) are at high risk for respiratory complications following adenotonsillectomy, necessitating overnight observation. We assessed the feasibility of noninvasive respiratory volume monitoring in the postoperative period to predict low minute ventilation (MV) and respiratory events on the first postoperative night.

Methods: We conducted a prospective observational exploratory study of children under 18 years of age with severe OSA undergoing adenotonsillectomy with planned postoperative admission. The primary outcome was the occurrence of low MV events on the ward, defined as predicted MV < 40% for at least 2 minutes, measured using a noninvasive respiratory volume monitor (RVM).

Results: We enrolled 60 children (77% male, median age 6 [4.5] years, 55% non-white, 55% Hispanic, median apnea-hypopnea index 31 [33] events per hour). The RVM sensor was not tolerated overnight in only 5 patients (8%). Low MV events occurred in 33% (19/58) in the postanesthesia care unit (PACU) and 62% (34/55) on the ward. Patients who had PACU events were more likely to have ward events (odds ratio [OR] 4.26; 95% CI 0.98-18.55). Increasing age increased ward events (OR 1.25 per year; 95% CI 1.02-1.52) while history of asthma was protective (OR 0.15; 95% CI 0.02-0.87).

Conclusions: This exploratory study suggests that PACU low MV events may predict subsequent events on the ward in children with severe OSA undergoing adenotonsillectomy. The RVM demonstrated good feasibility and should be tested in future studies to predict ventilatory derangements on the first postoperative night.

Objectif: To provide recommendations for eco-responsible optimization of choice and use of medicines and medical devices.

Design: A committee of 16 experts brought together by CERES and from SPFDM/Euro-Pharmat, SFAR, SFCR, SFED, SF2H, SFPC, SFR, SF2S has been set up. A policy for declaring links of interest was applied and respected throughout the process of creating the reference system. Similarly, it has not provided any funding from a company marketing a health product (drug or medical device). The committee had to respect and follow the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

Methods: The recommendations were formulated by identifying 4 different fields: practice of care (optimization of medicines and medical devices), packaging (reduction of the environmental impact of medical devices), organization of care (integration of environmental criteria) and waste management (reduction, sorting and recovery). Each question was formulated according to the PICO (Patients, Intervention, Comparison, Outcome) format. The analysis of the literature and the recommendations were carried out according to the GRADE® methodology.

Results: The experts' synthesis work resulted in 46 recommendations validated after one round of voting. For all questions, since the GRADE grid ® method could not be applied in full, the recommendations were formulated in the form of expert opinions.

Conclusion: From a strong agreement between experts, we were able to formulate 46 recommendations for eco-responsible optimization of the choice and use of medicines and medical devices.

Background: Perioperative respiratory adverse events (PRAE) are a main cause of morbidity and mortality in paediatric anaesthesia. Clinicians need to be able to predict their patients' risk of PRAE to plan their care. Clinical risk prediction tools have been developed to assist with pre-operative risk stratification; however, validation outside the contexts of their development is limited. In this study, we test the ability of common risk prediction tools to identify patients at high risk of PRAE in general anaesthesia.

Methods: In this post-hoc secondary analysis, six risk prediction scores were evaluated in 12,364 cases of general anaesthesia in children. Area Under the Receiver Operator Characteristic curves (AUC) were calculated for each as the primary measure of predictive performance, along with Positive Predictive Value and Negative Predictive Value.

Results: The rate of PRAE in our sample of 12,364 cases was 11.9% for any PRAE or 2.0% for severe PRAE (bronchospasm and/or laryngospasm). Although each of the tools assessed was positively associated with the occurrence of PRAE, we found poor to moderate predictive ability for each of the risk prediction tools assessed. AUCs ranged from 0.562-0.649 for the prediction of any PRAE, and 0.509-0.614 for the prediction of severe PRAE. The best performing tool was the OLDS score (AUC 0.649) adapted from Lee 2018, which selected predictor variables based upon the beliefs of clinicians rather than on data mining or statistical significance thresholds.

Conclusion: The discriminative ability of existing PRAE risk prediction tools was poor in our test group. These scales would need to be carefully adjusted for use in clinical environments other than those in which they were developed. There remains a gap for a well-validated and user-friendly PRAE prediction tool to fit into clinical practice.

Registration: Australian and New Zealand Clinical Trials Registration (ACTRN12624000018516).