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

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.

Invasive intracranial pressure (ICP) monitoring is considered the gold standard for the management of patients with an acute brain injury and at risk of developing intracranial hypertension (IH). However, invasive devices (e.g., intraparenchymal probe or external ventricular drain) are expensive, not available worldwide, and might be associated with some risks. Recently, a consensus for the monitoring and management of traumatic brain injury (TBI) patients when invasive ICP is not available (B-ICONIC) was developed. This approach is based on repeated neurological evaluation, neuroimaging, and the use of non-invasive ICP monitoring tools, such as transcranial Doppler, automated pupillometry, and ultrasound optic nerve sheath diameter measurement, to titrate interventions aiming at controlling ICP. Despite this clinical algorithm was mainly proposed for low and middle-income countries where invasive ICP is not widely implemented, a potential application of this approach may exist even in healthcare facilities where direct ICP monitoring is available. This includes patients who may have contraindications to invasive monitoring, such as coagulopathy, as well as those in whom ICP monitoring is not routinely implemented, such as individuals with post-anoxic brain injury or acute liver failure, for the reported occurrence of cerebral edema and potential risk of IH in these cases. Therefore, the aim of this manuscript is to propose the extension of the B-ICONIC algorithm to a wider population, regardless of the decision to insert an ICP sensor, and to guide their management using this multimodal approach.

Background: Weaning from mechanical ventilation (MV) is an important step for lowering the risk of ventilator-related complications. Currently, pressure support ventilation (PSV) remains the most common weaning mode, whereas proportional assist ventilation (PAV/PAV +) has been proposed as an alternative with better weaning outcomes. We conducted this meta-analysis to compare the efficacy of PAV/PAV + and PSV in adult patients who were weaning from invasive MV.

Methods: Randomized controlled trials (RCTs) comparing PAV/PAV + with PSV were identified through major databases up to September 2025. The primary outcomes were weaning success and the reintubation rate; the secondary outcomes included mortality, duration of weaning, and duration of MV. We analyzed the outcomes via RevMan 5.4, with the risk ratio (RR) and mean difference (MD) as the effect measures.

Results: Seven RCTs encompassing 1,059 patients were included. The rates of weaning success were comparable between PAV/PAV + and PSV (RR 1.08; 95% CI, 1.00-1.16). PAV/PAV + was associated with a significantly lower risk of reintubation (RR 0.64; 95% CI, 0.42-0.97). There were no significant differences in mortality (RR 0.95; 95% CI, 0.72-1.25), duration of weaning (MD 5.59 h; 95% CI, - 12.56 to 23.74), or total ventilation duration (MD - 8.21 h; 95% CI, - 74.96 to 58.55).

Conclusions: We found no significant difference between PAV/PAV + and PSV regarding weaning success, mortality, duration of weaning, or duration of MV. PAV/PAV +, on the other hand, was linked to a decreased rate of reintubation, suggesting a potential benefit in critically ill patients. However, the lack of high-quality evidence precludes any strong conclusions until further large-scale studies confirm these results.

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 Venous Excess Ultrasound (VExUS) score integrates inferior vena cava diameter and venous Doppler findings to quantify congestion. Findings are conflicting regarding whether higher VExUS grades reflect worse cardiac function. We conducted a systematic review and meta-analysis to evaluate echocardiographic changes across different VExUS grades and their clinical significance.

Methods: The systematic review and meta-analysis were performed in accordance with the PRISMA guidelines, including hospitalized patients assessed with the VExUS score and echocardiography. The primary outcome was the association between high VExUS (grades 2-3) and TAPSE. Secondary outcomes explored the association between VExUS and other echocardiographic parameters in different subpopulations. Eligible studies were randomized or observational. The risk of bias was assessed using the ROBINS-I tool.

Results: Eight studies were included in the primary outcome analysis. Patients with high VExUS scores had significantly lower TAPSE values compared to those with low scores, with a pooled mean difference of -2.35 mm (95% CI -3.27 to -1.42; p < 0.00001). Moderate heterogeneity was observed (I² = 61%), but the overall effect remained robust. Secondary outcomes showed consistent associations between high VExUS scores and reduced cardiac output, stroke volume, RV S', and LVOT VTI. However, in a sensitivity analysis excluding studies enrolling patients with heart failure, no significant association was observed between higher VExUS scores and right ventricular dysfunction. Moreover, the pooled mean values of right heart parameters (TAPSE, S', and RV FAC) in patients with VExUS 2-3 remained within normal physiological ranges, suggesting preserved right ventricular function despite venous congestion.

Conclusion: This systematic review and meta-analysis demonstrate that patients with venous congestion, as assessed by the VExUS score, may exhibit lower values of echocardiographic parameters of right ventricular function. This association is observed particularly in the subgroup of patients with known cardiac dysfunction and is not present in patients without heart failure. These findings suggest that the VExUS score should be primarily interpreted as a marker of established systemic venous congestion, rather than as an indicator of intrinsic right ventricular systolic impairment.