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

Cardiac surgery with cardiopulmonary bypass (CBP) is essential for different cardiac procedures in order to perform surgery with a clear sight field.To safely perform surgery with CPB and preserve brain, kidney, and patient tissue from ischemic damage, cold cardioplegia, and mild to deep hypothermia are induced during the operation.Cryoglobulinemia is a hematological/infective-related disease (in certain cases idiopathic) in which temperature-dependent antibodies tend to aggregate and form emboli in the vascular system causing tissue damage if exposed to low temperature.The patient with cryoglobulinemia (known and unknown) can be at risk of a major ischemic event during CPB and induced hypothermia.This article's aim is to evaluate the present scientific literature in order to understand how, in years, the therapeutic or preventive approach, is evolving, and to analyze and make improvements to the management of a cryoglobulinemic patient who must undergo elective or emergency cardiac surgery.In the last part of our article, we expose our single-center experience during a 32-month-long period of survey.In all cases, our medical team (anesthesiologists, perfusionists, and cardiac surgeons) opted for a normothermic cardiopulmonary bypass to lower the risk of cryoglobulin-associated complications.In our experience, along with therapeutic intervention to lower the cryoglobulin titer, normothermic management of cardiopulmonary bypass is as safe as hypothermic management.Notwithstanding our results, further studies with a larger population are needed to confirm this perioperative management in a cardiac surgery setting.

Background: Despite being a useful strategy for providing respiratory support to patients with advanced or terminal illnesses, non-invasive ventilation (NIV) requires in-depth investigation in several key aspects.

Objectives: This bibliometric analysis seeks to comprehensively examine the existing research on the subject. Its goal is to uncover valuable insights that can inform the prediction trajectory of studies, guide the implementation of corrective measures, and contribute to the improvement of research networks.

Methods: A comprehensive review of literature on NIV in the context of palliative care was conducted using the Web of Science core collection online database. The search utilized the key terms "non-invasive ventilation" and "palliative care" to identify the most relevant articles. All data were gathered on November 7, 2023. Relevant information from documents meeting the specified criteria was extracted, and Journal Citation Reports™ 2022 (Clarivate Analytics) served as the data source. The analysis employed literature analysis and knowledge visualization tools, specifically CiteScope (version 6.2.R4) and VOSviewer (version 1.6.20).

Results: A dataset with bibliometric findings from 192 items was analyzed. We found a consistent upward of the scientific output trend over time. Guidelines on amyotrophic lateral sclerosis management received the highest number of citations. Most documents were published in top-ranked journals. Less than one-third of the documents pertain to clinical studies, especially retrospective analyses (25%). Key topics such as "decision making", and "communication" were less addressed.

Conclusions: Given the substantial clinical implications, further high-quality studies on this subject are recommended. Encouraging international collaborations is needed. Despite the growing volume of documents in the field, this bibliometric analysis indicates a decline in collaborative networks.

Severe infections frequently require admission to the intensive care unit and cause life-threatening complications in critically ill patients. In this setting, severe infections are acknowledged as prerequisites for the development of sepsis, whose pathophysiology implies a dysregulated host response to pathogens, leading to disability and mortality worldwide.Vitamin D is a secosteroid hormone that plays a pivotal role to maintain immune system homeostasis, which is of paramount importance to resolve infection and modulate the burden of sepsis. Specifically, vitamin D deficiency has been widely reported in critically ill patients and represents a risk factor for the development of severe infections, sepsis and worse clinical outcomes. Several studies have demonstrated the feasibility, safety and effectiveness of vitamin D supplementation strategies to improve vitamin D body content, but conflictual results support its benefit in general populations of critically ill patients. In contrast, small randomised clinical trials reported that vitamin D supplementation may improve host-defence to pathogen invasion via the production of cathelicidin and specific cytokines. Nonetheless, no large scale investigations have been designed to specifically assess the impact of vitamin D supplementation on the outcome of critically ill septic patients admitted to the intensive care unit.

Background: Erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) are regional anesthesia techniques that have shown favorable results in pain management following thoracic surgeries; however, their relative superiority is unclear. This review (PROSPERO: CRD42023443018) aims to compare the analgesic efficacy of ESPB and SAPB in patients undergoing thoracic surgeries through the pooled analysis of co-primary outcomes: postoperative oral-morphine-equivalent (mg) consumption in 24 h and pain scores (static) at 24 h.

Methods: A literature search was conducted across PubMed, Cochrane Library, and Google Scholar to identify randomized controlled trials (RCTs) from inception to May 2023, comparing ESPB and SAPB in thoracic surgeries. Statistical pooling was done using Review Manager 5.4.1. Bias assessment employed the Cochrane Collaboration Risk-of-Bias 2.0 tool. The strength of evidence was assessed using the guidelines from the GRADE working group.

Results: Nine RCTs (485 patients) were included in the study. Postoperative pain scores (static) at 24 h (mean difference (MD) =  - 0.31 [- 0.57, 0.05], p = 0.02) and postoperative oral-morphine-equivalent (mg) consumption in 24 h (MD =  - 19.73 [- 25.65, - 13.80], p < 0.00001) were significantly lower in the ESBP group. However, the MDs did not exceed the set threshold for clinical importance. No significant differences were observed in the opioid-related adverse effects and block-related complications.

Conclusion: Our statistically significant results imply that ESPB has superior analgesic efficacy compared to SAPB; however, this difference is clinically unimportant. The safety profile of the two blocks is comparable; hence, current evidence cannot define the relative superiority of one block over the other. Our findings warrant further research with standardized methodologies and a longer duration of analgesic efficacy assessment to yield robust evidence for better clinical applications.

Background: In-hospital cardiac arrest/periarrest is a recognised trigger for consideration of admission to the intensive care unit (ICU). We aimed to investigate the rates of ICU admission following in-hospital cardiac arrest/periarrest, evaluate the outcomes of such patients and assess whether anticipatory care planning had taken place prior to the adult resuscitation team being called.

Methods: Analysis of all referrals to the ICU page-holder within our district general hospital is between 1st November 2018 and 31st May 2019. From this, the frequency of adult resuscitation team calls was determined. Case notes were then reviewed to determine details of the events, patient outcomes and the use of anticipatory care planning tools on wards.

Results: Of the 506 referrals to the ICU page-holder, 141 (27.9%) were adult resuscitation team calls (114 periarrests and 27 cardiac arrests). Twelve patients were excluded due to health records being unavailable. Admission rates to ICU were low - 17.4% for cardiac arrests (4/23 patients), 5.7% (6/106) following periarrest. The primary reason for not admitting to ICU was patients being "too well" at the time of review (78/129 - 60.5%). Prior to adult resuscitation team call, treatment escalation plans had been completed in 27.9% (36/129) with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms present in 15.5% of cases (20/129). Four cardiac arrest calls were made in the presence of a valid DNACPR form, frequently due to a lack of awareness of the patient's resuscitation status.

Conclusions: This study highlights the significant workload for the ICU page-holder brought about by adult resuscitation team calls. There is a low admission rate from these calls, and, at the time of resuscitation team call, anticipatory planning is frequently either incomplete or poorly communicated. Addressing these issues requires a collaborative approach between ICU and non-ICU physicians and highlights the need for larger studies to develop scoring systems to aid objective admission decision-making.

Background: The connection between academic career advancement and publishing research articles is important, as it can impact promotion and compensation decisions. Gender bias in academic publishing is a known issue, with studies showing low numbers in key roles in female representation. This article aims to analyze the ratio of women to men as first and last authors in the Regional Anesthesia & Pain Medicine (RAPM) journal and explore other factors such as the mentorship effect and representation in regional anesthesia associations.

Main body: We examined the RAPM articles from 1976 to 2023 evaluating the gender of first and last authors. We analyzed the trend over the years and also analyze the subset of original articles. A further analysis was conducted to analyze the relationship between the first and last author's gender. Additionally, regional anesthesia societies were contacted to gather data on the gender of their members. We included 5650 articles; most of them were first authored by men (72.9-87.7%). There was a positive trend over time for female first authorship but not for last authorship. The analysis also revealed a mentorship effect in recent years for both overall articles and the subgroup of original articles. The representation of women within regional anesthesia societies contrasted with the representation of women as last authors in original articles.

Conclusions: Our findings raise important questions about gender bias in academic publishing highlighting the need for increased representation and opportunities for women in the field of regional anesthesia.

Background: The intraoperative period is often characterized by hemodynamic instability, and intraoperative hypotension is a common complication. The optimal mean arterial pressure (MAP) target in hypertensive patients is still not clear. We hereby describe the protocol and detailed statistical analysis plan for the high versus standard blood pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: the HISTAP randomized clinical trial. The HISTAP trial aims at addressing whether the use of a higher intraoperative MAP target in high-risk hypertensive surgical patients scheduled for elective abdominal surgery would improve postoperative outcomes, as compared to the standard and recommended perioperative MAP, by using a composite outcome including a 30-day mortality from surgical intervention and at least one major organ dysfunction or new onset of sepsis and septic shock occurring 7 days after surgery.

Methods: The HISTAP trial is an investigator-initiated, pragmatic, parallel-grouped, randomized, stratified, analyst-blinded trial with adequate allocation sequence generation, and allocation concealment. We will allocate 636 patients to a MAP target ≥ 80 mmHg (treatment group) or to a MAP target ≥65 mmHg (control group). The primary outcome is a composite outcome including a 30-day mortality from the operation and major organ complications. Secondary outcomes are mortality at 30 days, intensive care unit (ICU) length of stay, ICU readmission, Sequential Organ Failure Assessment (SOFA) scores recorded up to postoperative day 7, overall intraoperative fluid balance, vasopressors use, and the need for reoperation. An unadjusted χ² test will be used for the primary outcome analysis. A Cox proportional hazards model will be used to adjust the association between the primary outcome and baseline covariates.

Conclusions: The HISTAP trial results will provide important evidence to guide clinicians' choice regarding the intraoperative MAP target in high-risk hypertensive patients scheduled for elective abdominal surgery.

Background: Systemic infection has always been considered a relative contraindication to neuraxial anesthesia, despite the fact that infectious complications are relatively uncommon. Pregnancy-related physiological changes and coronavirus disease (COVID-19) neurotropic features may facilitate the virus' entry into the central nervous system. The principal aim of this study was to test the safety of spinal anesthesia in "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2)-positive pregnant women and to examine cerebrospinal fluid (CSF) characteristics.

Methods: We conducted a prospective observational single-center study in asymptomatic or paucisymptomatic consecutive pregnant SARS-CoV-2 patients who underwent spinal anesthesia for cesarean section. Women with severe infection were excluded because they underwent general anesthesia. At the time of spinal anesthesia, we collected CSF samples, and then we performed a chemical-physical analysis to look for signs of inflammation and for SARS-CoV-2 genome.

Results: We included 26 women. No spinal anesthesia complications were reported in the perioperative period and after 2 months. All CSF samples were crystal clear, and all physical-chemical values were within physiological ranges: the median concentration of CSF/plasma glucose ratio was 0.66, IQR 0.5500 (0.6000-0.7100), and the average CSF protein concentration value was 23.2 mg/dl (SD 4.87). In all samples, genomes of SARS-CoV-2 and other neurotropic viruses were not detected.

Conclusions: Spinal anesthesia was safe in SARS-CoV-2 pregnant women with mild disease; no clinical maternal complications were detected, and no CSF changes indicative of inflammatory or infectious diseases that would compromise the safety of the procedure were found.

Background: Parasternal intercostal blocks (PSB) have been proposed for postoperative analgesia in patients undergoing median sternotomy. PSB can be achieved using two different approaches, the superficial parasternal intercostal plane block (SPIP) and deep parasternal intercostal plane block (DPIP) respectively.

Methods: We designed the present prospective, observational cohort study to compare the analgesic efficacy of the two approaches. Cardiac surgical patients who underwent full sternotomy from January to September 2022 were enrolled and divided into three groups, according to pain control strategy: morphine, SPIP, and DPIP group. Primary outcomes were was postoperative pain evaluated as absolute value of NRS at 12 h. Secondary outcomes were the NRS at 24 and 48 h, the need for salvage analgesia (both opioids and NSAIDs), incidence of postoperative nausea and vomiting, time to extubation, mechanical ventilation duration, and bowel disfunction.

Results: Ninety-six were enrolled. There was no significant difference in terms of median Numeric Pain Rating Scale at 24 h and at 48 h between the study groups. Total postoperative morphine consumption was 1.00 (0.00-3.00), 2.00 (0.00-5.50), and 15.60 mg (9.60-30.00) in the SPIP, DPIP, and morphine group, respectively (SPIP and DPIP vs morphine: p < 0.001). Metoclopramide consumption was lower in SPIP and DPIP group compared with morphine group (p = 0.01). There was no difference in terms of duration of mechanical ventilation and of bowel activity between the study groups. Two pneumothorax occurred in the DPIP group.

Conclusions: Both SPIP and DPIP seem able to guarantee an effective pain management in the postoperative phase of cardiac surgeries via full median sternotomy while ensuring a reduced consumption of opioids and antiemetic drugs.