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

Background: Previous studies have demonstrated that perioperative use of lidocaine effectively reduces opioid requirements in various surgical procedures. Our objective was to evaluate the effect of postoperative intravenous lidocaine infusion on opioid consumption following pelvic bone tumor surgery.

Methods: This single center randomized controlled trial in a tertiary teaching hospital containing a total of 70 patients, aged 18 to 65 years, with American Society of Anesthesiologists(ASA) physical status classifications of I to III, who were scheduled to undergo pelvic bone tumor surgery. Participants were randomly assigned in a 1:1 ratio to either the lidocaine group(L Group) or the control group(C Group). The L Group received lidocaine for postoperative analgesia, whereas the C Group was administered a placebo saline infusion.The primary outcome was postoperative opioid consumption. Secondary outcomes included the time to first bowel movement, the incidence of postoperative nausea and vomiting(PONV), and pain scores at rest and during movement on postoperative days.

Results: A significant difference was observed in the cumulative 72-h morphine equivalent consumption between the L Group (n = 33) and the C Group (n = 33). Patients in the L Group required significantly less morphine equivalent consumption compared to the C Group (13 (0-52) mg vs. 25 (14-85) mg, P = 0.043). Additionally, the proportion of patients experiencing breakthrough pain was significantly lower in the L Group compared to the C Group (33.33% vs. 75.76%, P = 0.001). No significant differences were noted between the groups in secondary outcomes, including the incidence of PONV, numerical pain scores at rest or during movement, time to first bowel evacuation, or time to first oral intake.

Conclusion: Postoperative intravenous lidocaine infusion is effective in reducing opioid consumption and the incidence of breakthrough pain following pelvic bone tumor surgery.

Trial registration: This single-center, prospective RCT was registered with the Chinese Clinical Trial Registry (ChiCTR2100051207, 15/09/2021). The first research participant was enrolled in September 20, 2021.

Objective: To identify potential differences in lung microbiota according to clinical severity, age, and gender in pneumonia patients compared to controls.

Design: Pilot study.

Setting: Single center (Azienda Ospedaliera Universitaria Dulbecco, Catanzaro, Italy).

Patients: Thirty-three individuals-11 ICU patients requiring invasive mechanical ventilation, 11 non-ICU patients, and 11 cadaver controls without lung disease.

Interventions: Bronchoalveolar lavage sample collection and analysis via microbiological cultures and metagenomic sequencing.

Measurements and main results: Bacteroidota and Verrucomicrobiota phyla were more abundant in older (≥65 years) ICU and non-ICU patients versus controls. Massilia timonae showed a significantly lower relative abundance at the group level in cases compared to controls, potentially increasing infection susceptibility. Higher microbiota diversity was observed in older patients.

Conclusions: Alterations in lung microbiota composition were observed in pneumonia patients, with differences that appeared more evident in older patients. Microbiota phenotyping may offer novel insights into pneumonia pathophysiology and pulmonary dysbiosis.

Introduction: Vascular access devices (VADs) play a critical role in clinical practice, facilitating the administration of medications, fluid therapy, and parenteral nutrition. Nevertheless, improper selection of VADs can result in various complications, escalate healthcare costs, and significantly impact patients' experience. This study seeks to evaluate the appropriateness of VAD selection in contemporary clinical practice.

Methods: A prospective observational pilot study was conducted between September 1st and December 31st, 2023, in two medical wards at Careggi University Hospital, Florence, Italy. Data on VAD type, insertion, maintenance, and complications were collected. The primary outcome was the appropriate selection of central VADs (CVADs) and peripheral VADs (PVADs) as recommended by the most recent international guidelines and consensus documents.

Results: A total of 322 VADs were inserted in the considered period, out of which 23 (7.1%) were CVADs and 299 (92.9%) were PVADs. Peripherally Inserted Central Catheter (PICC, n = 10; 43.5%) was the most represented CVAD, followed by ports (n = 6; 26%), Centrally Inserted Central Catheters (CICC, n = 4; 17.4%), and Femorally Inserted Central Catheters (FICC, n = 3; 13%). Short peripheral cannulas (SPC) were the most represented PVADs (n = 257; 86%), followed by long peripheral cannulas (LPC) (32; 10.7%), and midline (MC) (n = 10; 3.3%). CVADs were appropriate in 82.6% of cases, whereas PVADs' appropriateness fell to 43.1%. Overall, 47 VAD failures were observed: 6 (26.1%) CVADs and 41 (13.7%) PVADs.

Conclusion: This study found a high prevalence of inappropriate VAD selection in hospitalised patients, especially among PVADs, although with no increased risk of complications. Further studies are needed to address effective strategies for improving the selection of VADs.

Background: Clinical effectiveness of high-flow nasal therapy (HFNT) over conventional oxygen therapy (COT) in patients with mild COVID-19-related acute hypoxaemic respiratory failure (AHRF) remains uncertain. The COVID-HIGH trial did not demonstrate statistically significant benefits of HFNT over COT. However, the trial was slightly underpowered, and the event rate lower-than-expected. Bayesian methods provide deeper insight by incorporating prior knowledge and quantifying uncertainty intuitively. This analysis aimed to quantify the probability of benefit or harm associated with HFNT, adopting a Bayesian approach.

Methods: We performed a Bayesian reanalysis of the COVID-HIGH trial (NCT, which randomised 364 patients with PaO₂/FiO₂ between 200-300 mmHg to receive HFNT or COT. The primary outcome was escalation of respiratory support (continuous positive airway pressure, noninvasive ventilation or invasive mechanical ventilation) within 28 days. A key secondary outcome was clinical recovery at day 14. Bayesian logistic models with noninformative and informative priors were used to estimate the posterior probability of treatment effects.

Results: Escalation of respiratory support occurred in 23.6% (HFNT) versus 30.2% (COT) (risk difference - 6.6%, 95% CI - 15.1 to 2.1; p = 0.14). Across a wide range of priors, the posterior probability mass on the beneficial side remained high, generally > 70%, while the proportion on the harm side remained consistently low at ≤ 6% for all models, underscoring a favourable benefit-risk profile. The acute respiratory failure meta-analysis model (OR 0.76, 95% CrI 0.60-0.97), the COVID-19 randomised evidence model (OR 0.76, 95% CrI 0.60-0.97), the COVID-19 observational evidence model (OR 0.60, 95% CrI 0.45-0.80), and the COVID-19 Bayesian meta-analysis mixed evidence model (OR 0.66, 95% CrI 0.52-0.86) showed posterior probability mass on the beneficial side of 70%-94%. Clinical recovery at day 14 occurred in 61.5% (HFNT) versus 53.3% (COT), with 61-73% of posterior probability mass on the clinical benefit side.

Conclusions: This Bayesian re-analysis of the COVID-HIGH trial suggests that HFNT likely reduces escalation of respiratory support and improves clinical recovery in patients with COVID-19 pneumonia and mild hypoxaemia, although the magnitude of benefit remains uncertain and sensitive to prior assumptions.

Trial registration: The trial was prospectively registered in ClinicalTrials.gov on December 7, 2020 (NCT04655638).

Background: To determine whether norepinephrine improves the left ventricle systolic function in early septic shock patients.

Methods: Single-center, prospective, observational study in critically ill patients over a 2-year period in Italy. Hypotensive patients were included within 24 hours from the diagnosis of septic shock; preload responsiveness was excluded by a passive leg raising test. The main objective was the augmentation of the left ventricular outflow tract velocity time integral (LVOT-VTI) induced by the increase of norepinephrine infusion dosage.

Results: Thirty patients were included in the final analysis, with a median age and SAPS II score of 67 (51-77) years and 49 (41-65), respectively. All patients were mechanically ventilated, 25 (83%) invasively and 5 (17%) non-invasively. The time elapsed between septic shock diagnosis and inclusion was 8 (3-17) hours. The norepinephrine infusion dose was increased from 0.3 (0.2-0.6) to 0.6 (0.4-0.9) µg kg^-1 min^-1, p < 0.01. The LVOT-VTI improved from 14 (11-17) to 17 (13-20) cm, p < 0.01. Conversely, the left ventricle ejection fraction (LVEF) did not change (p = 0.54). The end-systolic left ventricle elastance and the arterial elastance augmented from 1.02 (0.64-1.78) to 1.64 (0.98-2.22) mmHg ml^-1-p < 0.01-and from 1.71 (1.28-2.03) to 2.01 (1.71-2.82) mmHg ml^-1-p < 0.01, respectively; hence, the ventriculoarterial coupling decreased from 1.75 (1.15-2.29) to 1.29 (0.99-1.78), p < 0.01. An improvement of the left ventricle systolic indices was recorded also in the 15 (50%) patients with baseline depressed LVEF.

Conclusions: Norepinephrine improved the left ventricle systolic function and the ventriculoarterial coupling in septic shock patients.

Background: Robotic-assisted gynecologic (RAS) surgery offers enhanced precision, ergonomics, and visualization compared with open (OP) and laparoscopic (LAP) approaches. However, it introduces distinct anesthetic challenges related to patient positioning, airway access, and postoperative recovery and analgesia. This review aims to evaluate perioperative outcomes across four domains: intraoperative anesthetic management, postoperative recovery, pain control strategies, and surgical performance.

Methods: We performed a systematic review of the current literature on adult women undergoing robotic-assisted gynecologic surgery under general anesthesia. Data on perioperative outcomes across the aforementioned domains were extracted via standardized selection, extraction, and bias assessment methods.

Results: A total of 479 papers were included in the study following screening of over 10,000 citations. Intraoperatively, airway complications were infrequently reported; however, a few cases of increased pulmonary pressures and hypercapnia emerged. Postoperatively, RAS was associated with shorter hospital stay (mean 2.52 days RAS vs. 1.85 LAP vs. 5.11 OP) and faster return to daily activities (mean 11.4 days RAS vs. 13.6 LAP vs. 13.2 OP), but evidence for validated quality of recovery scores was lacking. Pain intensity and analgesic requirements were found to be lower after RAS than after OP and sometimes LAP, with inconsistent findings across studies. Surgical outcomes favored RAS, showing reduced blood loss (mean 154 mL RAS vs. 149 LAP vs. 358 OP), lower conversion and major complications rates than other approaches. Oncologic metrics-including lymph node yield and R0 resection-were comparable across approaches. Overall study quality was limited by a moderate to serious risk of bias across most outcomes.

Conclusion: Robotic-assisted gynecologic surgery is a feasible and safe alternative to laparoscopic and open approaches, with advantages in selected surgical outcomes and potential benefits in postoperative pain and recovery. However, further high-quality randomized studies are needed to confirm these benefits.

Systematic review registration: PROSPERO CRD420251105240.

Background: Postoperative neurocognitive disorders are common and associated with adverse clinical outcomes. Existing preventive interventions are limited; the Wash In/Wash Out technique (or "wave-like awakening") might reduce the risk of postoperative neurocognitive complications. Therefore, this trial evaluated the effect of the Wash In/Wash Out technique on emergence agitation after sevoflurane-based anesthesia.

Methods: In this multicenter, double-blind, randomized trial, adult patients undergoing elective open abdominal surgery under general anesthesia with sevoflurane were randomly assigned to either an intervention group (wave-like awakening group) or a control group (standard emergence from general anesthesia). In the intervention group, sevoflurane was intermittently discontinued and immediately resumed in three consecutive cycles before awakening. The primary outcome was the incidence of emergence agitation (EA), defined as a Richmond Agitation-Sedation Scale score ≥  +2 during emergence.

Results: Between March 2021 and February 2025, 202 patients were enrolled across three centers. The frequency of the primary endpoint was markedly low at just 1.5%, well below the anticipated rate. We found no difference in the rate of emergence agitation which occurred in 2/101 (2%) of patients in the intervention group and 1/101 (1%) in the control group (relative risk (RR), 2.00; 95% confidence interval (CI), 0.18-21.71; p > 0.999), delirium (5.9% vs. 8.9%; RR, 0.67; 95% CI, 0.25-1.82; p = 0.421), or delayed neurocognitive recovery (7.9% vs. 10.9%; RR, 0.72; 95% CI, 0.30-1.72; p = 0.470). A composite of the three postoperative neurologic complications was 13/101 (13%) vs. 19/101 (19%) (p = 0.25). We found that the median duration of delirium was shorter in the intervention group (1 [1; 1] days) than in the control group (2 [2; 3] days). No adverse event was noted.

Conclusions: In this multicenter randomized controlled trial, the Wash In/Wash Out strategy was feasible and safe but we cannot exclude clinically relevant benefit or harm on the incidence of emergence agitation due to the low event rates. We found a reduction in delirium duration in adult patients undergoing elective abdominal surgery under sevoflurane anesthesia which should be considered hypothesis generating.

Trial registration: ClinicalTrials.gov NCT04765488. Registered 15 February 2021.