Journal of Anesthesia, Analgesia and Critical Care (Online)最新文献

The Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) developed a good clinical practice document providing consensus-based statements on the monitoring of respiratory variables during weaning from invasive mechanical ventilation in adult patients. The aim was to summarize key parameters and available monitoring techniques to support healthcare professionals in daily clinical practice. The statements and supporting rationales were drafted by a panel of 10 experts to assist clinicians in selecting appropriate monitoring tools for the various respiratory functions involved during assisted ventilation. A total of 13 statements were issued, grouped into 8 items (rationale for monitoring, choice of the level of assistance, monitoring of respiratory patterns, respiratory effort, diaphragm functionality, respiratory drive, patient-ventilator synchrony, discontinuation of invasive assisted ventilation). The panel's work offers a practical bedside tool designed to optimize monitoring while acknowledging the heterogeneity of practices and equipment across Italian intensive care units.

Background: Fascia, once viewed as a passive structural tissue, is now recognized as a biologically active interface integral to musculoskeletal stability, force transmission, proprioception, and nociception. Despite the increasing clinical use of fascial plane blocks, the microanatomy of fasciae relevant to regional anesthesia remains poorly characterized. Understanding their histological features-including innervation, vascularization, and microstructure-is critical to optimizing anesthetic efficacy and elucidating mechanisms of pain and tissue response.

Methods: This systematic review was prospectively registered on the Open Science Framework (reference: yk4ua, 19 September 2025) and reported according to PRISMA guidelines. MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to September 2025 without language or date restrictions. Eligible studies included histological or microanatomical investigations of human fascial planes relevant to regional anesthesia (e.g., pectoral, thoracolumbar, abdominal, and fascia lata). Data were extracted independently by multiple reviewers, and study quality was assessed using the Anatomical Quality Assessment (AQUA) tool. Findings were synthesized qualitatively by anatomical region.

Results: Seventeen studies met inclusion criteria, encompassing fasciae from the thoracic, abdominal, lumbar, and lower limb regions. Fasciae exhibited considerable structural heterogeneity but shared a multi-layered organization of dense and loose connective tissue laminae rich in type I collagen. The fascia lata and thoracolumbar fascia demonstrated highly ordered collagen fiber orientation, multilaminar organization, and dense innervation, whereas thinner fasciae (e.g., pectoral fascia) showed simpler single-layer structures with fewer neural and vascular elements. Hyaluronic acid content ranged from 29 to 35 µg/g, with fasciacytes identified as the principal secretory cells. Nerve fibers-often associated with vessels and collagen bundles-were consistently present across all deep fasciae, with regional variations in density and mechanoreceptor type. Pathological changes, such as thickening, increased vascularization, and inflammatory infiltration, were reported in chronic pain states.

Conclusions: The fascia should be viewed as a dynamic, active tissue network rather than a passive sheath. Methodological limitations-including small sample sizes, regional heterogeneity, and histological artifacts-restrict current understanding. Future multimodal studies integrating histology, imaging, and biomechanics are warranted to clarify how fascial microstructure affects anesthetic diffusion, pain modulation, and postoperative recovery.

Background: Volatile anesthetics have been suggested to exert neuroprotective effects in patients with subarachnoid hemorrhage caused by a ruptured cerebral aneurysm. However, their effects on functional outcomes remain unverified. We assessed the association between volatile anesthetics and functional outcomes in patients with subarachnoid hemorrhage.

Methods: Using data from the Japanese Diagnosis Procedure Combination inpatient database, patients with subarachnoid hemorrhage, aged = 18 years, and undergoing any procedures for aneurysm treatment were selected. Patients were categorized into those who received volatile anesthetics and those who did not. The primary outcome was a composite of in-hospital death or impaired functional outcome at discharge. The secondary outcomes included in-hospital mortality, postoperative cerebral infarction, postoperative acute hydrocephalus, tracheostomy, hospital stay, and total healthcare costs. After 1:1 propensity-score matching, a generalized linear model or linear model was applied for each outcome, with cluster-robust standard error adjustment. Interaction analysis was also conducted for the primary outcome and in-hospital mortality.

Results: Overall, 35,097 matched pairs were generated. No significant difference was noted in the primary outcome between the two groups (total intravenous anesthetics: 44.5%; volatile anesthetics: 44.1%; odds ratio 0.99, 95% confidence interval [CI] 0.93-1.06, p = 0.84). However, in-hospital mortality differed significantly between the groups (total intravenous anesthetics: 9.3%; volatile anesthetics: 8.7%; odds ratio 0.89, 95% CI 0.82-0.97, p < 0.01). Other secondary outcomes showed no significant group differences. Interaction analysis indicated that volatile anesthetics worsened outcomes among patients with impaired consciousness at admission.

Conclusions: Volatile anesthetic use was not associated with improved functional outcomes in patients with subarachnoid hemorrhage. In patients presenting with impaired consciousness, volatile anesthetics were associated with poorer outcomes, although this finding should be interpreted with caution, given the observational nature of the study.

Ultrasound-guidance increases success rate and reduces complications compared to traditional palpation for radial artery catheterization. However, in special groups of patients, such as pediatric, older, obese, hypotensive population, and patients with chronic kidney disease (CKD), ultrasound-guided arterial cannulation can still be improved. The current available evidence revealed some techniques for improvement of success rate, in consideration of various modifiable factors during the procedure. In this narrative review, we summarized and illustrated techniques in four different aspects related to plane-needle relationship, ultrasound probe, patient's artery, and insertion needle, which may provide inspiration for better practice in the future.

Objective: To validate a predictive risk score of early aggressive pharmacokinetic/pharmacodynamic (PK/PD) target non-attainment with continuous infusion (CI) piperacillin/tazobactam or meropenem in a retrospective cohort of critically ill patients having documented Gram-negative infections.

Methods: Critically ill adult patients receiving treatment of documented Gram-negative infections with CI piperacillin-tazobactam or meropenem and undergoing first real-time beta-lactam therapeutic drug monitoring (TDM) instance within 72 h from starting standard dosing regimens were retrospectively included. A receiving operating characteristic (ROC) curve analysis was performed by using the proposed predictive score as the test variable and early aggressive PK/PD target non-attainment as the state variable. Area under the curve (AUC) and 95% confidence interval were calculated. The identified cut-off risk values were used for stratifying patients and assessing the impact on clinical/microbiological outcome in each sub-cohort of patients receiving targeted monotherapy.

Results: Overall, 209 and 203 patients receiving CI piperacillin-tazobactam and meropenem were included, respectively. Early aggressive PK/PD target non-attainment was reported in 33 cases (15.8%) receiving piperacillin-tazobactam and in 8 (3.9%) of those treated with meropenem. A score threshold ≥ 2 points for piperacillin-tazobactam (AUC 0.81; 95% CI 0.75-0.86; p < 0.0001) and ≥ 3 points for patients treated with meropenem (AUC 0.96; 95% CI 0.93-0.99; p < 0.0001) were significantly associated with early aggressive PK/PD target non-attainment. Patients achieving the cut-off predictive score showed a significant higher microbiological failure rate in both piperacillin-tazobactam (56.3% vs. 28.6%, p = 0.044) and meropenem sub-cohorts (50.0% vs. 10.4%, p = 0.028).

Conclusions: Our findings suggest that the proposed predictive cut-off risk score may represent a valuable tool for identifying promptly critically ill patients at high risk of early aggressive PK/PD target non-attainment with CI piperacillin-tazobactam or meropenem for whom a more intensified CI dosing regimens should be promptly applied bedside.

Background: Proximal Femur Fractures (PFF) are common among the elderly and can lead to significant disability. Anesthesiological management typically involves Spinal Anesthesia (SA) or Peripheral Nerve Blocks (PNBs). This study aimed to compare the efficacy and safety of SA and PNBs in elderly patients undergoing surgical fixation of PFF. The primary outcome was the comprehensive assessment of intraoperative hemodynamic instability.

Methods: A monocentric, patient-, surgeon-, and assessor-blind randomized study was conducted at the University 'Federico II' Hospital of Naples from December 2023 to June 2024. Patients diagnosed with PFF and scheduled for surgery were randomized to receive either Selective Spinal Anesthesia (SSA) (hypobaric bupivacaine 0.5% 7.5 mg and sufentanil 5 µg) or PNBs (femoral, lateral femoral cutaneous, obturator, and sciatic nerve blocks). The study evaluated the efficacy and safety of locoregional procedures by analyzing intraoperative and postoperative adverse events, as well as the effectiveness of analgesia.

Results: The PNB group showed a significantly lower incidence of intraoperative hemodynamic instability (16.7% vs 43.4%, p = 0.048) compared to the SSA group. Bradycardia was also less frequent in the PNB group (10% vs 33.3%, p = 0.028). Although repeated hypotensive episodes occurred in both groups, mean MAP, TWA-MAP and TWA-hypotension remained within safe limits, with brief episode durations and no need for pharmacological intervention. Mobilization was slower in the PNB group; however, these patients experienced a shorter hospital stay. No differences were observed in the need for analgesic rescue doses or in the incidence of postoperative complications, including PONV, DVT, MI, or neurological injury. Pain scores were slightly higher in the SSA group at 6 and 24 h, though the differences were not clinically meaningful. Both groups showed significant increases in NRS and PAINAD scores over time compared to baseline. Motor and sensory block onset was slower and duration longer in the PNB group, while SSA produced a faster onset and earlier resolution. Surgeon satisfaction, as well as estimated and actual surgical durations, were comparable between groups.

Conclusions: PNBs offer an alternative to SSA by providing better intraoperative hemodynamic stability, a lower incidence of postoperative delirium, and improved postoperative analgesia.

Trial registration: This study is registered with Clinicaltrials.gov, number (NCT06155903), registered July, 2, 2023, https://clinicaltrials.gov/study/NCT06155903.

Background: Traumatic brain injury (TBI) remains a leading cause of death and disability worldwide. Beyond the primary insult, excessive sympathetic activation contributes to secondary brain injury and poor outcomes. Beta-blockers may attenuate this hyperadrenergic surge and provide neuroprotective benefits, but their efficacy in improving long-term functional recovery remains uncertain.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating beta-blockers in adults with acute TBI. We searched MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and ClinicalTrials.gov for RCTs comparing beta-blockers with placebo, usual care, or non-adrenergic comparators. Our primary outcome was long-term functional outcome, assessed with the Glasgow Outcome Scale (GOS) or its Extended version (GOS-E). Secondary outcomes included mortality, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and adverse events.

Results: Seven RCTs (n = 559) met inclusion; six (n = 445) contributed data to meta-analyses. Only two trials (n = 259) reported functional outcomes. Beta-blockers did not significantly reduce the risk of unfavorable neurological outcome (RR 0.81; 95% CI 0.57-1.15; very low certainty). In contrast, beta-blocker therapy was associated with a reduction in mortality (RR 0.57; 95% CI 0.39-0.82; 6 trials, n = 440; low certainty) and a shorter duration of mechanical ventilation (-1.58 days; 95% CI -2.91 to -0.26; 2 trials, n = 85; low certainty). No effect was observed on ICU or hospital stay. Adverse event reporting was sparse, but no consistent safety concerns were identified.

Conclusions: In adults with acute TBI, beta-blockers did not decrease unfavorable long-term neurological outcomes but were associated with lower mortality and shorter duration of mechanical ventilation. Given the small number of trials and very low certainty of evidence, definitive conclusions cannot be drawn, and routine use cannot be recommended. A large, well-designed RCT is needed to establish the efficacy and safety of beta-blockers in this population.

Systematic review registration: PROSPERO CRD42024565361.

Critically ill patients in Intensive Care Units are at high risk of developing invasive candidiasis (IC). Delay in diagnosis and suboptimal management contribute to high mortality rates, highlighting the need for an appropriate and patient-tailored approach. The Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) convened a multidisciplinary panel, involving intensivists, infectious disease specialists, microbiologists, and pharmacologists, to develop consensus-based statements on the diagnosis and management of IC in critically ill patients. The panel formulated 13 statements addressing key aspects of care, including identification of major risk factors for IC, the role of biomarkers to support therapeutic decision-making, and optimal selection of antifungal agents based on pharmacokinetic/pharmacodynamic (PK/PD) considerations and site-specific characteristics. The document also provides guidance on the use of therapeutic drug monitoring (TDM) to optimize antifungal efficacy. Special attention is given to infections in specific anatomical sites, such as the peritoneal cavity, central nervous system, eye, and biofilm-associated infections, where drug penetration and activity must be carefully considered. This multidisciplinary statement offers a practical framework aimed at improving clinical decision-making for the management of invasive candidiasis in critically ill patients.

Background: Despite serving over 10 million inhabitants, neurocritical care across the Lombardy region of Italy (from here on Lombardia) remains fragmented and insufficiently mapped, underscoring the need for a structured regional network. This study aimed to evaluate current resources and explore pathways for integration and development.

Methods: In 2024, along with other initiatives, a web-based survey was performed, focusing on hospitals with neurosurgical capabilities and intensive care units (ICUs) to identify variations in service delivery and adherence to evidence-based practices, guiding quality improvement across centers.

Results: Responses were obtained from 19 acute care hospitals with neurosurgical facilities within the regional health service. Ten hospitals (52%) host dedicated neuro-ICUs, including five (26%) that also admit pediatric patients, accounting for a total of 85 beds. In the remaining nine hospitals (47%), neurocritical care is delivered within general ICUs without dedicated beds. Continuous in-house neurosurgical coverage is available in 9 centers (47%), while the others rely on a 24/7 on-call model. All 19 centers (100%) report 24/7 availability of neurologists and neuroradiologists, either in-house or on call. However, access to advanced diagnostic and monitoring technologies remains heterogeneous across sites. Participating centers identified a clear need for standardized protocols and clinical pathways to improve care quality and support evidence-based practices. Priority areas defined by the clinicians include neuroprognostication, end-of-life care and donor management, pediatric neurocritical care, neurointerventional procedures, management of delayed cerebral ischemia following subarachnoid hemorrhage, and post-discharge follow-up. To address these gaps, several multidisciplinary working groups have been established.

Conclusion: Neurocritical care in Lombardia remains highly heterogeneous, with bed availability significantly below international benchmarks. The establishment of a regional network seeks to enhance the quality and equity of care for neurocritical patients, while also fostering clinical research, data sharing, and multidisciplinary collaboration across centers.

Background: A wide gap exists between the number of patients awaiting organ transplantation and the availability of donor organs. For most vital organs, no artificial substitutes are available, resulting in the death of approximately 3-4% of patients on transplant waiting lists. Deceased organ donation occurs through one of two pathways: donation after brain death (DBD) or after controlled circulatory death (cDCD). In the absence of documented consent during the patient's lifetime, many countries rely on family members to make the decision, placing an emotional burden on them during a time of acute grief. Data on family attitudes toward organ donation, particularly in relation to the mode of death (DBD vs. cDCD), remains limited. This study aimed to examine the frequency of family refusal in the context of deceased organ donation and assess whether it differs between DBD and cDCD cases.

Methods: This retrospective, single-center observational study analyzed 6 years of hospital data (2019-2024) from five intensive care units at a tertiary university hospital in Varese, Italy. All patients, regardless of age, who were eligible for deceased organ donation through either DBD or cDCD were included.

Results: A total of 158 patients were evaluated for donation (135 DBD; 23 cDCD). Documented opt-in consent, as recorded in the national donor registry, was available for 41 patients (20%), while 3 had registered their refusal. Two patients were ineligible for donation; for the remaining 112 patients (71%), consent was sought from family members. Family refusal occurred in 28 cases (25% of the 112 families asked for consent). No significant difference in consent rates was observed between DBD and cDCD pathways (DBD: 73/98 vs. cDCD: 11/14; p = 0.74).

Conclusions: Family refusal was the leading reason for missed donation opportunities among patients without documented opt-in consent, accounting for one in four cases. The donation pathway (DBD vs. cDCD) did not significantly influence family decision-making. Given ongoing organ shortages and high wait-list mortality, strategies are needed to support family decisions and to promote the formal registration of opt-in consent among citizens.