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

Efficiency in the operating room is often considered either in terms of clinical excellence or in terms of performance optimization through managerial approaches. However, these dichotomous models-clinician-centered versus engineer-led-fail to capture the complexity of modern surgical care. This paper therefore proposes a multidisciplinary model in which the anesthetist plays a central role, acting as an integrator of clinical needs and organizational logistics. As new technologies emerge, they should support a comprehensive vision that combines patient-centered care with organizational and technological considerations. This approach should complement, rather than replace, clinical judgment.

Background: Post-extubation sore throat (PEST), cough, and hoarseness are common complications of tracheal intubation. Several agents and techniques have been postulated to reduce their occurrence.

Aim: This study sought to compare the effects of intravenous and intra-cuff magnesium sulphate on the incidence and severity of PEST, cough and hoarseness of voice.

Materials and methods: This was a randomised single-blind study involving 90 surgical patients requiring endotracheal intubation. Patients were randomised into 3 groups: A (control), B (intra-cuff magnesium sulphate) and C (intravenous magnesium sulphate). Participants in Group A had the endotracheal tube cuff (ETTc) inflated with air to a pressure of 25 cmH₂O whilst those in Group B had the ETTc inflated with 2 g of magnesium sulphate solution and the pressure adjusted to 25 cmH₂O with top-ups of 0.9% normal saline. Participants in Group C had the ETTc filled with air to a pressure of 25 cmH₂O and received 2 g of intravenous magnesium sulphate in 20 ml of 0.9% normal saline perfused over 10 min immediately prior to the induction of general anaesthesia. The occurrence of PEST, cough and hoarseness of voice were recorded at 0, 4, 8, 12 and 24 h after surgery.

Results: The incidence of PEST on swallowing in the intra-cuff magnesium sulphate group compared to the intravenous magnesium sulphate group at 4, 8, and 12 h post-operatively were 51.7% vs 12.5%, 51.7% vs 18.8% and 51.7% vs 21.9% respectively. Compared to intra-cuff magnesium sulphate, intravenous magnesium sulphate significantly reduced the incidence and severity of PEST during swallowing at 4, 8, and 12 h. The incidence of PEST at rest in the intra-cuff magnesium sulphate group compared to the intravenous magnesium sulphate group at 0, 4, 8, 12 and 24 h post-operatively were 13.8% vs 9.4%, 20.7% vs 6.3%, 17.2% vs 6.3%, 13.8% vs 3.1% and 13.8% vs 3.1% respectively. Compared to intra-cuff magnesium sulphate, intravenous magnesium sulphate reduced the incidence of PEST at rest, though this was not statistically significant over first 24 h postoperative period. Intravenous magnesium sulphate had significantly lower PEST severity scores at rest at 12 h only compared to intra-cuff magnesium sulphate. There was no statistically significant difference in the incidence and severity of cough and hoarseness between the study groups.

Conclusion: Intravenous magnesium sulphate given at induction was found to be better compared to intra-cuff magnesium sulphate in lowering the incidence and severity of post-extubation sore throat on swallowing but not at rest. However, it does not significantly reduce the incidence or severity of post-extubation cough or hoarseness.

Trial registration: PACTR202211634990263.

Background: Boarding of critically ill patients in the emergency department (ED) is an emerging problem that increases mortality. We have developed a "CREM Unit (critical emergency medicine unit)" led by an anesthetist-intensivist who manages critical patients directly in the ED. This study aims to assess whether the CREM Unit is an effective model for mitigating the boarding of critical patients in the ED and the impact of this on mortality.

Method: This is a retrospective observational study. We collected all patients assigned to the CREM Unit from January 1, 2019, to December 31, 2021. As our primary endpoints, we calculated ED boarding rate and the impact of boarding time on mortality. As a secondary endpoint, we compared observed 28-day mortality to Simplified Acute Physiology Score (SAPS II) predicted mortality.

Results: Patients managed by the CREM unit were 127 in 2019, 181 in 2020, and 206 in 2021, with a clear upward trend, for a total of 514 patients (p < 0.001). Overall boarding rate was 13.9%, and length of stay in ED was not associated with an increased mortality (p = 0.399). Observed mortality was compared with expected mortality, estimated from the SAPS II score for a group of inpatients (n = 295). Moreover, the median value of SAPS II for inpatients was 54 (40.5-69.0), with an expected mortality of 55.3%, while the observed mortality was 36.8% (95% CI 31.9% to 42.1%, p < 0.0001).

Conclusions: Over the years, the number of patients assigned to the CREM Unit has grown steadily. These data suggest that the CREM Unit cares for a significant number of critically ill patients and could have a well-defined role both in keeping their boarding low and may contribute to reducing its impact on mortality.

Background: The purpose of this study was to perform a 1-year follow-up after ICU discharge and evaluate post-intensive care syndrome (PICS) in both COVID (GroupCov) and NON COVID (GroupNCov) patients.

Methods: All consecutive patients discharged from our Intensive Care Unit (ICU) from June to December 2022 were prospectively screened. Scheduled in-person visits were carried on 3, 6, and 12 months after ICU discharge to evaluate physical, cognitive, and mental health status using different scale evaluations (SF-36, Barthel Index, ISI score, PCL-5 score, MNA-sf score, Fatigue Severity Score, MoCA Test, HADS and GDS) by means of standardized questionnaires.

Results: Eighty patients (50 GroupCov vs 30 GroupNCov) were initially included, but some patients did not attend all follow-up visits. At 1-year follow-up, 60 patients (30 COVID-19 and 30 non-COVID) completed all evaluations. Both groups showed PICS, but GroupCov had a better nutritional status, better outcomes in physical evaluations, and a better perception of Quality of Life (QoL) and mental health status, but a worse cognitive assessment in the MoCA Test. Moreover, heterogeneity analysis showed that GroupNCov patients had the same trend during follow-up, while in GroupCov different trends were observed over time, especially a worse nutritional state, often found in older patients, that was related to a longer hospital stay and worse psychophysical outcomes.

Conclusions: This study shows that PICS in SARS-COV2 patients is not always homogeneous, and that different clusters of psychophysical patterns may develop over time. Although our study was only observational, it seems from our preliminary results that performing a follow-up could be the basis for a secondary prevention and to develop new therapeutic strategies after patients discharge from ICU.

Background: Burnout (BO) is a serious issue affecting professionals across various sectors, leading to adverse psychological and occupational consequences, even in anesthesiologists. Machine learning, particularly neural networks, can offer effective data-driven approaches to identifying BO risk more accurately. This study aims to develop and evaluate different artificial dense neural network (DNN)-based models to predict BO based on occupational, psychological, and behavioral factors.

Methods: A dataset (300 Italian anesthesiologists) comprising workplace stressors, psychological well-being indicators, and demographic variables was used to train DNN models. Model performance was measured using standard evaluation metrics, including accuracy, precision, recall, and F1 score. Statistical tests were adopted to assess differences in prediction across the DNNs.

Results: The best neural architecture achieved a predictive accuracy of 0.68, with key contributors to BO including workload, emotional exhaustion, job dissatisfaction, and lack of work-life balance. Despite substantial differences among the six implemented algorithms, no significant variation in prediction performance was observed.

Conclusion: Psychological distress scores are significantly higher in the high-risk BO group, suggesting greater anxiety, depression, and overall distress in this category. While challenges remain, continued advancements in artificial intelligence and data science promise more effective and personalized mental health care solutions.

Trial registration: Not applicable.

Background: Sleep-disordered breathing and obstructive sleep apnea syndrome are two diseases of relevant clinical and research interest, especially in the pediatric field. However, there are gaps in knowledge regarding these diseases.

Methods: We performed a survey that was administered electronically, via the SurveyMonkey platform, to 15,000 Italian anesthesiologists registered on the SIAARTI mailing list for a period of 4 months (April-July 2021).

Results: A total of 223 anesthesiologists completed the questionnaire (1.48%), 143 female and 79 male. Pediatric anesthetists generally responded more correctly than the general anesthesiology population.

Conclusion: The topic of pediatric OSA is a topic on which to invest in training of anesthesiologists, and the OSAKA-PedAn questionnaire is a valid tool to test the level of basic competence and that achieved.

Background: Cesarean delivery is one of the most common surgeries performed worldwide. Given the unavoidable use of general anesthesia in some situations, and the potential for complications, we performed a multicenter national survey in order to investigate aspects related to the use of general anesthesia for cesarean delivery.

Methods: This multicenter national survey questionnaire study was performed from October 2020 to March 2021. After Institutional Review Board waiver, we surveyed 25 eligible medical centers with an active obstetric anesthesia unit. The survey covered issues related to general anesthesia: preoperative management, personnel, induction, maintenance and emergence phases of anesthesia, intraoperative and postoperative pain management, protocol use, availability of difficult airway algorithm, and complications that are related to cesarean delivery under general anesthesia.

Results: A total of 113 participants among the 25 medical centers participated in the study. Routine pharmacological aspiration prophylaxis use was reported by 100/113 (88.5%). Administration of opiates during induction before fetal delivery was in 16.8%. We found only 27/113 (23.9%) of respondents ventilate their patients during RSI. Routine use of depth of anesthesia monitoring was reported by 21/113 (18.6%) respondents. Routine postoperative intravenous patient-controlled analgesia (IV-PCA) use with morphine was reported by 6/113 (5.3%) respondents.

Conclusions: In this national survey, we emphasize the importance of the presence of highly qualified anesthesiologic personnel during the surgery, benefit from the use of short-acting opiates during induction, availability of videolaryngoscope, ventilation of the patient during RSI, and availability of institutional difficult airway protocols. We observe underuse of intraoperative anesthesia-depth monitoring and poor postoperative pain control.

The accurate prediction of volume responsiveness is fundamental to goal-directed fluid administration. Targeted fluid administration during surgery is critical to avoid hypervolemia or hypovolemia and their associated postoperative complications. Recently, lung-protective ventilation strategies with tidal volumes of less than 8 mL/kg of ideal body weight have been recommended as standard practice during surgeries. Nevertheless, these reduced tidal volumes diminish the reliability of dynamic indices, such as pulse pressure variation, for predicting volume responsiveness. To address this limitation, the tidal volume challenge has proven to be a reliable method. This challenge involves increasing the tidal volume from 6 to 8 mL/kg of ideal body weight and observing the impact on hemodynamic parameters. Multiple studies have validated the efficacy of this test in both surgical patients and critically ill patients in the intensive care unit. The tidal volume challenge effectively improves the accuracy of predicting fluid responsiveness by increasing both sensitivity and specificity. Established threshold values for changes in pulse pressure variation and stroke volume variation offer precise clinical recommendations. However, additional cohorts and randomized controlled trials are imperative to validate the efficacy of the tidal volume challenge and advance fluid management strategies.