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

Background: Maternal acute kidney injury (AKI) represents a severe and preventable complication of pregnancy, contributing significantly to maternal and perinatal morbidity and mortality worldwide. Marked disparities persist between low- and middle-income countries (LMICs) and high-income countries (HICs), particularly regarding access to renal replacement therapy (RRT) and critical care support. We aimed to estimate the global incidence among obstetric ICU admissions, risk factors, and outcomes of maternal AKI requiring intensive care, with a specific focus on the burden and prognostic impact of RRT.

Methods: This systematic review and meta-analysis followed the PRISMA 2020 guidelines. PubMed, Embase, Scopus, and Web of Science were searched up to April 2025 for original studies reporting incidence, etiology, and outcomes of maternal AKI in intensive care units (ICUs). Random-effects models were used to pool incidence rates and outcome measures across studies.

Results: Eleven studies comprising 3,494 critically ill obstetric patients from seven countries were included. The pooled global incidence of maternal AKI was 2,813 per 10,000 obstetric ICU admissions (95% CI: 1,5-4,5), with the highest rates in African (5,909/10,000) and Western Pacific (2,912/10,000) regions. The predominant etiologies were hypertensive disorders of pregnancy (including HELLP syndrome), obstetric hemorrhage, and sepsis. Among AKI patients, 20.4% required RRT (95% CI: 11.7-33.2), and mortality was 19.4% (95% CI: 12.3-29.2). Renal recovery occurred in 81.8%, while persistent dysfunction was observed in 18.2% of survivors. A strong correlation was found between RRT use and mortality (Spearman's ρ = 0.71, p = 0.047).

Conclusions: Among obstetric patients admitted to intensive care units, maternal AKI represents a substantial clinical burden, with a significant proportion of affected women requiring RRT-a marker of disease severity strongly associated with increased mortality. Despite generally favorable renal recovery among survivors, profound regional disparities persist. These estimates apply exclusively to obstetric ICU admissions and should not be extrapolated to the general pregnant population. Early identification, standardized diagnostic criteria, and equitable access to renal replacement therapies remain critical priorities to improve maternal outcomes in intensive care settings.

Background and aims: The incidence of diaphragmatic-palsy following interscalene brachial plexus block (IBPB) is almost 100% where the drug volume plays a significant role. We compared the incidence of hemidiaphragmatic paresis and the success rate following IBPB using three different volumes of local anaesthetics.

Methods: Ninety patients undergoing shoulder and arm surgeries under ultrasound-guided IBPB were randomly allocated into three groups: Group A (10 ml), Group B (15 ml), and Group C (20 ml). The drug administered was 0.75% ropivacaine with 50 mcg dexmedetomidine. The diaphragm excursion was measured before and 30 min after the block on the side of surgery. The incidence of diaphragmatic palsy and its severity were noted. The success rate following block, the onset of sensory blockade, duration of postoperative analgesia, and adverse effects were observed in all three groups. The statistical analysis was done using SPSS software.

Results: The demographic data, duration of surgery, and success rate following block were statistically insignificant. The hemidiaphragmatic paresis (< 25%, 25-75%, > 75%) in Group A (29,1,0), Group B (17,13,0), and Group C (15,8,7) was statistically significant (P value < 0.001). The onset of sensory blockade was Group A (7.06 ± 0.73 min), Group B (6.23 ± 0.72 min), and Group C (4.61 ± 0.63 min) with a P value < 0.001. The duration of postoperative analgesia in Group A (440 ± 48.42 min), Group B (429 ± 44.48 min), and Group C (411 ± 51.37 min) was statistically insignificant (P value-0.072). Five patients in Group C developed hoarseness of voice postoperatively, which was managed conservatively.

Conclusion: Low volume ultrasound guided interscalene block (10 ml) is associated with a lower incidence of hemidiaphragmatic paresis with a similar success rate and duration of postoperative analgesia. Higher volume of the drug yields a faster onset of the sensory blockade.

Background: Underweight critical care patients are at an increased risk of in-hospital mortality. This vulnerability is attributed to the lack of physiological reserve, which may increase the risk of reintubation in these patients. However, the association between underweight and reintubation remains unclear. We aimed to assess the association between a lower body mass index (BMI) and the risk of reintubation in mechanically ventilated patients.

Methods: We performed a retrospective cohort study using data from the Japanese Intensive care PAtient Database (JIPAD). We included adult patients who received mechanical ventilation for at least 24 h from intensive care unit (ICU) admission between 2018 and 2023. The primary outcome was reintubation, which was defined as the reimplementation of mechanical ventilation within 72 h after extubation. BMI was categorized into five groups: underweight (< 18.5 kg/m²), slightly underweight (18.5-21.9 kg/m²), normal weight (22.0-24.9 kg/m²), overweight (25.0-29.9 kg/m²), and obesity (≥ 30.0 kg/m²). We examined the relationship between BMI and reintubation and using a multivariable logistic regression analysis. We adjusted for established reintubation risk factor as a fixed effect, and facilities as a random effect. Additionally, we performed age-stratified subgroup analysis.

Results: Of the 41,016 eligible patients from 131 ICUs, the mean BMI was 23.4 kg/m², and the overall reintubation rate within 72 h was 5.9% (2,436 patients). This rate was the highest in the underweight group (8.4%) and the lowest in the obesity group (4.3%). Using normal weight as the reference, being underweight correlated with a higher risk of reintubation (adjusted odds ratio 1.58, [95% confidence interval 1.39-1.80]), whereas being obese correlated with a lower risk of reintubation (adjusted odds ratio, 0.69 [95% confidence interval: 0.57-0.84]). In the subgroup analysis stratified by age category, being underweight was associated with an increased risk of reintubation.

Conclusion: A lower BMI was associated with an increased risk of reintubation. This relationship remained consistent in the age-stratified subgroup analysis. The present results indicate that a lower BMI needs to be considered an important factor when assessing an underweight patient's risk of reintubation.

Background: Admission to an Intensive Care Unit (ICU) constitutes a sudden and emotionally impactful event for both the critically ill patient and their family. Prognostic uncertainty is frequently associated with elevated levels of anxiety, depression, and stress within the family. In the Portuguese context, the association between the patient's clinical status and the emotional state of their next of kin remains insufficiently explored. This study aimed to analyze that relationship.

Methods: A cross-sectional study was conducted in an adult ICU in central Portugal, using a convenience sample of 130 dyads of critically ill patients and their next of kin. Data were collected between September 2024 and February 2025. The emotional state of the next of kin was assessed using the Depression, Anxiety, and Stress Scales-21 (DASS-21), validated for the Portuguese population. The patients' clinical status was evaluated using the Coma Recovery Assessment Instrument of the University of Aveiro, the Glasgow Coma Scale, the Richmond Agitation-Sedation Scale, and pain scales. Statistical analysis included Spearman's rank correlation, Mann-Whitney U tests, Kruskal-Wallis H tests, and linear regression.

Results: The mean age of the patients was 65.7 ± 13.0 years, and 56.2% were male. The next of kin had a mean age of 53.3 ± 14.5 years, and 63.8% were female. Stress was the most frequently reported symptom, followed by depression and anxiety. Statistically significant negative associations were found between the emotional state of next of kin and the patients' clinical consciousness scores (p < 0.001). Next of kin of patients undergoing invasive mechanical ventilation or receiving therapeutic infusions showed higher levels of emotional distress. Furthermore, female next of kin, spouses, and direct descendants were associated with higher emotional vulnerability. Ventilatory support and the relationship to the patient were identified as factors independently associated with emotional distress, together accounting for approximately 27% of the observed variability in emotional symptoms.

Conclusions: The emotional state of the next of kin is significantly associated with the clinical status of the critically ill patient. These findings highlight vulnerable subgroups and underscore the potential role of nursing professionals in the early identification of emotional distress. Such identification may facilitate the planning of targeted supportive strategies, which have been associated in the literature with an attenuated emotional burden and a potential reduction in the risk of Post-Intensive Care Syndrome-Family and long-term psychological problems.

Introduction: Intra-abdominal hypertension (IAH) is a common complication in critically ill patients and is associated with increased mortality. While acute kidney injury (AKI) and respiratory impairment are also linked to IAH, their roles as mediators of mortality remain unclear. This study aimed to evaluate the associations between IAH and mortality, with a focus on AKI and pulmonary parameters as potential mediators.

Methods: This retrospective cohort study utilized the MIMIC-IV database and included adult patients admitted to the intensive care unit (ICU) with intra-abdominal pressure measurements. Patients with previous advanced kidney disease or early kidney replacement therapy (KRT) were excluded. Time-varying exposure to IAH, AKI status, and respiratory parameters were analyzed via marginal structural models (MSMs) and a mediational g-formula to assess the effects of mediation on mortality.

Results: Among the 555 patients, IAH was associated with mortality HR 2.20 (95% CI 1.54-2.56) and stage 3 AKI emerged as a significant mediator of IAH-associated mortality, accounting for almost half (41.5%, p < 0.001) of the excess mortality. KRT was associated with a protective effect, reducing the hazard ratio for mortality by 16.6%. Although the need for mechanical ventilation per se mediated a statistically significant but small effect of IAH on mortality (4.2%), no respiratory parameters, including driving pressure, demonstrated a significant mediating role.

Conclusion: Severe acute kidney injury (stage 3) is a key mediator of IAH-related mortality in critically ill patients, whereas KRT was associated with a protective effect. The absence of an important mediating role for respiratory parameters suggests that the relationship between IAH and mortality is driven primarily by renal mechanisms. However, pulmonary impairment may not have been fully captured by the variables studied, particularly in a retrospective study. Unmeasured aspects of pulmonary dysfunction could still contribute to mortality.

Background: The SIS-NET ICU study aimed to describe the epidemiology of severe community-acquired pneumonia (CAP) among patients admitted to Italian intensive care units (ICUs). This study also aimed to describe the clinical and microbiological characteristics, outcomes, and treatments received by the included patients.

Methods: We conducted a prospective, observational, multicenter study. We included patients consecutively admitted to the ICUs of 13 participating centers during the study period for acute respiratory failure due to CAP. The study period spanned from January to November 2025. The analyses aimed to describe the epidemiological and clinical characteristics, diagnostic pathways, factors associated with ICU mortality, and type of respiratory support during the ICU stay.

Results: We included a cohort of 150 patients with a mean age of 63 years and a male predominance (61%). The occurrence rate of CAP in the participating ICUs was 2.5%. Streptococcus pneumoniae, Haemophilus influenzae, Influenza A and Respiratory Syncytial Virus were the predominant isolated microorganisms. The average APACHE II score was 17 (SD 7.9) and the median SOFA score was 7 (SD 3.9). The comorbidity burden was substantial. A high proportion of patients was managed with non-invasive respiratory supports. Rapid microbiological testing methods were early adopted in 63% of patients, with substantial impact on antimicrobial therapy decisions. Each 10-year increase in age was associated with a 54% increase in the odds of death (aOR 1.54, 95% CI 1.06-2.35; p = 0.02) and immunosuppressed status was associated with higher odds of death (aOR 3.13, 95% CI 1.04-9.63; p = 0.04). Polymicrobial infection showed a trend towards higher mortality (aOR 2.47, 95% CI 0.94-6.89; p = 0.06), although this association did not reach conventional statistical significance.

Conclusions: Our study demonstrated the predominance of common pathogens as microbiological isolates in patients with severe CAP in Italy. Age, and immunosuppressed status were independently associated with a higher odds of mortality.

Background: Laparoscopic bariatric surgery is effective for weight loss but often requires opioids for postoperative pain management, possibly increasing complications. Intraperitoneal local anaesthetic (IPLA) instillation may help to reduce pain and opioid use, though its efficacy remains unclear. This systematic review and meta-analysis aims to evaluate the impact of IPLA on postoperative pain management and opioid consumption in patients undergoing laparoscopic bariatric surgery.

Methods: Following PRISMA guidelines, a systematic search of PubMed, Scopus, Web of Science and Cochrane Library (up to July 31, 2024) identified randomized controlled trials (RCTs) comparing IPLA with placebo or other analgesics. Primary outcomes were postoperative pain scores; secondary outcomes included opioid consumption, hospital length of stay (LOS) and incidence of postoperative nausea and vomiting (PONV). Risk of bias was assessed using Cochrane RoB2, and a random-effects model was used for statistical analysis.

Results: Eight RCTs (n = 875) showed IPLA significantly reduced pain in the first 4 h (SMD: - 1.46, 95% CI: - 2.08 to - 0.85, p < 0.001) and 4-8 h postoperatively (SMD: - 1.16, 95% CI: - 1.94 to - 0.37, p < 0.001), with no effect beyond 8 h. IPLA reduced additional analgesic use (RR: 0.41, 95% CI: 0.25-0.66, p < 0.001) but without significant impact on LOS or PONV. Due to heterogeneity in opioid consumption reporting, a pooled analysis was not feasible.

Conclusion: IPLA effectively reduces early postoperative pain and opioid demand in laparoscopic bariatric surgery, though long-term benefits remain uncertain. Further high-quality RCTs are needed to establish optimal administration techniques and assess their broader clinical benefits.

Background: An international observational study was conducted to describe the preferred techniques for obstetric analgesia and anesthesia in the Czech Republic (CZE) and Slovakia (SVK), as well as during the period after the COVID-19 pandemic. In this article, the authors present only results about analgesia during vaginal delivery.

Objective: To determine whether modes of obstetric analgesia are adequate and in line with the needs of women in labor and current trends.

Study design: An international multicentric observational study.

Setting: A total of 149 centers were invited to participate; 64 from CZE and 22 from SVK supplied the electronic case report form for obstetric analgesia (prepared by the steering committee); the study period was November 2022.

Study population: Patients who underwent vaginal delivery.

Intervention: Labor analgesia during vaginal delivery.

Main outcome measurers: Modes of labor analgesia and complication rates.

Results: In CZE, of the total number of births, 5914 were born, 1552 (26.2%) of which were cesarean deliveries. In Slovakia, the total number of births was 2030, of which 684 (33.7%) were cesarean deliveries. Obstetric analgesia was administered by an anesthesiologist to 1331 (23.3%) parturients, 900 (20.6%) in the CZE group and 431 (32%) in the SVK group. In most cases, 1280 (96.5%) epidural analgesia was used; 874 (97.4%) parturients were in the CZE, and 406 (94.2%) parturients were in the SVK. Complications from epidural analgesia occurred in 74 (5.8%) parturients.

Conclusion: This study describes the limited use of epidural analgesia in CZE (20.0%) and SVK (30.2%), which are associated with a low incidence of complications. Regularly performed audits or national registers would provide relevant data for describing daily practices.

Trial registration: The study was registered at http://www.

Clinicaltrials: gov. NCT04912791. June 2, 2021 Trial Overview Official Title: Obstetric Anaesthesia and Analgesia Month Attributes - in COVID-19 (OBAAMA-COV) Sponsor: Brno University Hospital, Czech Republic Condition Studied: Obstetric anesthesia care during the COVID‑19 pandemic Study Type: Observational national survey across the Czech Republic and Slovakia.

Background: Fluid accumulation is common in critically ill patients and has been associated with adverse outcomes. However, its impact on postoperative outcomes in cardiac surgery remains unclear.

Purpose: To assess the association between perioperative fluid accumulation and clinical outcomes in adults undergoing cardiac surgery.

Methods: We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials. PubMed, Embase, and the Cochrane Library were searched through February 2025. Eligible studies enrolled adults (≥ 18 years) undergoing cardiac surgery and compared liberal versus restrictive fluid strategies or fluid-positive versus fluid-restrictive states. Outcomes included all-cause mortality, acute kidney injury (AKI), hospital and intensive care unit (ICU) length of stay, duration of mechanical ventilation, ICU readmission, and postoperative atrial fibrillation (POAF). Certainty of evidence was assessed using the GRADE framework.

Results: Eighteen studies (15,052 patients) were included. In pooled analyses, fluid accumulation was associated with increased mortality (OR 1.65; 95% CI 1.03-2.63; p = 0.04), and fluid restriction was associated with decreased hospital stay (MD -1.02 days; 95% CI -1.67 to -0.37; p = 0.002). Bayesian analysis supported these findings, showing a 98.8% probability that restrictive fluid strategies reduce mortality and a 98.6% probability of shorter hospital stay. For AKI, the Bayesian model showed an 84.7% probability of benefit despite non-significant frequentist results. No significant associations were found for POAF, ICU stay, mechanical ventilation duration, or ICU readmissions. The certainty of evidence was low for randomized evidence and very low for observational data when assessed with GRADE.

Conclusions: Perioperative fluid accumulation may be associated with worse postoperative outcomes, but the certainty of evidence is limited by heterogeneity and methodological variability across studies. These findings should be interpreted as hypothesis-generating and underscore the need for high-quality randomized trials to clarify safe fluid exposure thresholds and the role of individualized perioperative fluid management.

Background: Intra-abdominal infections are complex and potentially life-threatening conditions frequently requiring intensive care admission and are associated with highly variable mortality driven by disease severity, host response, comorbidities, and antimicrobial resistance. Outcomes depend on timely diagnosis, effective surgical source control, appropriate antimicrobial therapy, and a coordinated multidisciplinary approach addressing both the infectious and systemic inflammatory components of the disease.

Material and method: This was a prospective, observational nationwide study. We included all adult patients admitted to the hospital with complicated abdominal infections requiring ICU admission. The aim of this study was to describe the epidemiology and outcomes of patients admitted to the hospital with intra-abdominal infections (IAIs) requiring an intensive care unit (ICU) admission in 23 Italian hospitals.

Results: A total of 784 patients admitted to the hospital with complicated IAIs requiring ICU admission were enrolled. Overall, in-hospital mortality among ICU patients was 23.9%. Septic shock (36.2%) and sepsis (35.9%) were the main reasons for ICU admission. Community-acquired infections accounted for 64.8% of cases, and adequate source control was achieved in 61.5% of patients. Re-operation was required in 21%. The most frequently isolated pathogens were Escherichia coli (23.1%), followed by Enterococcus spp. (15.4%). Empiric antibiotic therapy was prescribed in more than 80% of patients (median duration ranging from 8.1 to 19.3 days). Piperacillin-tazobactam was the most commonly used antibiotic. In multivariable logistic regression analysis, increasing age (OR 1.04 per year, 95% CI 1.03-1.06), immunosuppression (OR 1.99, 95% CI 1.09-3.66), serious cardiovascular disease (OR 1.91, 95% CI 1.20-3.05), re-operation (OR 2.30, 95% CI 1.34-3.96), inadequate source control (OR 0.39, 95% CI 0.22-0.71), peritonitis (OR 0.39, 95% CI 0.23-0.66), and healthcare-associated infections (OR 1.83, 95% CI 1.10-3.04) were independently associated with in-hospital mortality. Duration of antibiotic therapy, malignancy, and delay in initial intervention were not significantly associated with mortality.

Conclusion: Septic shock remains the leading cause of ICU admission in patients with IAIs. Patients with immunosuppression, serious cardiovascular comorbidities, requirement for re-operation, inadequate source control, peritonitis, and healthcare-associated infections were at significantly higher risk of in-hospital mortality. Overall, our study reinforces the multifactorial nature of mortality in critically ill patients with intra-abdominal infections, highlighting modifiable factors (source control, timely intervention) that can be targeted to improve outcomes.