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

Background: Intraoperative hypotension (IOH) during non-cardiac surgery is associated with increased risk of postoperative complications, including acute kidney injury, myocardial injury, stroke, and mortality. Artificial intelligence-based predictive hemodynamic monitoring using the Hypotension Prediction Index (HPI), combined with goal-directed therapy (GDT), has been proposed to reduce IOH. However, its effectiveness in major maxillofacial and otolaryngologic surgery remains unclear. The purpose of the study was to assess whether HPI-guided management or classical GDT reduces IOH compared to standard care in patients undergoing major maxillofacial and otolaryngologic surgery.

Methods: In this randomized controlled pilot trial at a university hospital, 75 patients were allocated to one of three groups: control (n = 25), HPI-guided GDT (n = 25), or classical GDT without HPI (n = 25). In the control group, the advanced hemodynamic monitoring was blinded to the anesthesiologist. IOH was defined as mean arterial pressure (MAP) < 65 mmHg for > 1 min. Primary endpoints were the number and total duration of IOH episodes. Secondary endpoints included the time-weighted average MAP < 65 mmHg (TWA65) and postoperative complications.

Results: Seventy-four patients were analyzed. The HPI group showed significantly fewer IOH episodes (median 3.0 vs. 7.0; p = 0.02) and shorter IOH duration (7.0 min vs. 46.0 min; p < 0.01) compared to control. No significant difference was observed between the classical GDT and control groups. Secondary outcomes were comparable across all groups.

Conclusions: HPI-guided hemodynamic management significantly reduces the frequency and duration of IOH in major head and neck surgery. Larger studies are needed to evaluate effects on clinical outcomes.

Trial registration: The trial was registered on clinicaltrials.gov (NCT04151264) on 14th October 2019.

Background: High cervical spinal diseases (C1-C4), resulting in paralysis of the respiratory muscles, makes the person dependent on invasive mechanical ventilation (IMV) for life support. Although effective from a ventilatory point of view, IMV is associated with increased morbidity and mortality; ventilated patients have higher rates of respiratory complications, a significant reduction in life expectancy, and above all, a serious psychological repercussion with estrangement from the world. Diaphragmatic pacing system (DPS) is a well-established technique capable of restoring paraphysiological ventilation.

Aim of the study: A narrative review of the case history and their follow-up of 13 patients dependent on life support ventilation who have been implanted since 2011 in the Neurocritical Care Unit of the Niguarda Hospital, Milan.

Results: Diaphragmatic pacing system was successful implanted in all the patients: of them 9 were affected by traumatic cervical SCI, 2 by Arnold Chiari sequelae, 1 due to a spontaneous ischemia. One patient with Pompe disease was included although his pathophysiology primarly affects the diaphragm instead the high cervical spine tract. During the 14 years follow-up, 92% of patients (12/13) used DPS and in 42 % of them (5/12 patients) we were able to be disconnected from IMV for at least 12 h. One of the patients (7.7%) was completely weaned from IMV and the tracheostomy was finally removed. One patient needed hospitalization for a respiratory complication. All the patients perceived their quality of life to be excellent or good.

Discussion: The long-term follow-up of 13 patients with DPS suggests that the implant could be a potential long-term alternative to IMV, particularly in terms of quality of life. The diaphragmatic stimulator protects from IMV associated respiratory complications, therefore reducing hospitalization. Allowing spontaneous breathing for a variable number of hours enables the caregiver to support the individual more effectively, facilitating their reintegration into daily social and work activities. Diaphragmatic pacing system does not eliminate the disability but allows for more independent years of life with a greater possibility of social reintegration.

Objective: This observational study aims to describe the characteristics and management of paediatric head-injured patients across different paediatric age groups, compared with adults.

Design: Secondary analysis of the CENTER-TBI study.

Setting: 65 centers in Europe between December 2014 and December 2017.

Patients: Patients with traumatic brain injury (TBI) admitted to the hospital were divided into different age groups: paediatrics (pTBI, age ≤ 17 years), adults (18-65 years), and elderly (> 65 years). Paediatrics were further subdivided into three groups: toddlers (from 0 to 4 years), children (from 5 to 12 years), and adolescents (from 13 to 17 years).

Interventions: None.

Measurements and main results: 3,661 patients were included in the analysis (2,138 admitted to the intensive care unit (ICU) and 1,523 to the ward). Among these, 227 were paediatric (27 toddlers [0-4 years], 65 children [5-12 years], and 135 adolescents [13-17 years]). Most pTBI patients admitted to the ICU presented with mild injuries (Glasgow Coma Scale [GCS] 13-15; 66%), although severe injuries (GCS ≤ 8) were more common in adolescents (23.8%). Susceptibility to neuroworsening and seizures was low in the paediatric group (6% and 3.5%, respectively). Intracranial pressure monitoring was performed in 52 (39.4%) of 132 paediatric ICU patients. Paediatric patients received less intensive therapy targeted to the intracranial pressure (ICP) control particularly in toddlers. Age below 18 years was associated with a lower risk of poor neurological outcomes at six months, particularly in adolescents and children (odds ratio (OR) = 0.31, 95% confidence interval (CI) = 0.15-0.58 p < 0.001 and OR = 0.29, 95% CI = 0.09-0.71, p < 0.001, respectively). In toddlers, the association was not statistically significant (OR = 0.48, 95% CI = 0.07-1.94, p = 0.4).

Conclusions: Paediatric TBI differs significantly from non-paediatric cases, with predominantly mild injuries, lower neuroworsening rates, and less intensive management, especially in younger children. Outcomes at six months are generally more favorable in paediatric patients, emphasizing the need for age-specific management strategies in TBI care.

Thoracic wall surgery is frequently associated with severe and multifactorial postoperative pain, including somatic, visceral, and neuropathic components. Inadequate pain control can impair respiratory function, delay mobilization, prolong hospitalization, and contribute to the development of chronic postsurgical pain. Traditional techniques, such as thoracic epidural and paravertebral blocks, have shown efficacy; however, their complexity and risk profiles limit their widespread use. In recent years, ultrasound-guided fascial plane blocks have gained prominence because of their favorable safety profile, ease of use, and suitability for incorporation into multimodal analgesia strategies. This narrative review provides an overview of the anatomical rationale, mechanisms of action, and clinical applications of fascial plane blocks of the thoracic wall, namely the interpectoral and pectoserratus, serratus anterior, erector spinae, and parasternal intercostal plane blocks. These techniques have demonstrated promising results in breast, thoracic, and cardiac surgeries, with analgesic outcomes comparable to those of conventional methods in many studies. Although evidence suggests a favorable safety profile and potential for opioid-sparing effects, further high-quality research is required to confirm their efficacy across diverse patient populations and surgical contexts. As clinical experience and data continue to accumulate, thoracic wall fascial plane blocks are emerging as important components of modern perioperative pain management strategies.

Background: The data available at the national level in Italy regarding elective neurosurgical and neuroradiological procedures are limited. This survey aimed to explore clinical practices across Italian centers, focusing on anesthetic strategies, monitoring, and postoperative management.

Methods: A nationwide survey was conducted, collecting data from centers performing elective craniotomies and interventional neuroradiology. Questions addressed procedural volumes, anesthesia type, monitoring tools, and intraoperative and postoperative management.

Results: Among 49 responding centers, 21 were high-volume (>150 craniotomies/year). Intravenous anesthesia was the preferred anesthesia method, though not uniformly applied across volume groups. Awake craniotomy was rarely performed, even in high-volume centers. Bispectral Index™ monitoring was reported in 71.7% of centers, but without correlation to center volume. Anti-epileptic prophylaxis was routinely used in 73.9% of high-volume centers. Practices regarding intraoperative awakening and postoperative computer tomography scans varied widely: 53.5% performed them routinely in the postoperative period. In addition, 42.5% of physicians still adopted delayed awakening for neuroprotection purposes. Intensive care unit admission was not universally applied, reflecting a growing trend toward selective monitoring and enhanced recovery protocols.

Discussion: Large-volume centers do not always align with the best evidence available, albeit the limitation in the literature. In many centers, there is still indiscriminate use of anti-epileptic prophylaxis, admission to the critical care unit after craniotomy, and computed tomography in conscious patients in the immediate postoperative period: habits and preferences, however, for which there are no clear and consistent answers in the literature.

Conclusions: This survey reveals significant heterogeneity in the anesthetic and perioperative practices across Italian centers, independent of surgical volume. The absence of a dedicated national database limits broader analysis. Establishing such a registry could guide protocol standardization, training, and resource optimization in elective neurosurgical and neuroradiological care.

Background: To characterize current clinical practices and outcomes associated with the use of the extracorporeal blood purification (EBP) device Oxiris® in critically ill patients.

Methods: This was a prospective clinical registry database that analyzed patients treated with Oxiris®. Three different clusters of critically ill patients were identified: Group A-patients with chronic kidney disease and systemic inflammation who required postoperative support of renal function; Group B-patients requiring immunomodulation without definitive indications for renal support; Group C-patients with abdominal septic shock necessitating both postoperative renal support and immunomodulation. The primary endpoint was the comparison between mortality rates predicted by the Simplified Acute Physiology Score II (SAPS II) and observed mortality rates 4 days after EBP initiation.

Results: Observed 4-day mortality rates were markedly lower than SAPS II-predicted rates: 16.7% vs. 41% in Group A, 30.8% vs. 77% in Group B, and 21.3% vs. 83% [66;89] in Group C. Early mortality was significantly associated with baseline hemodynamic instability (vasopressor requirement, OR = 3.62 [1.59-9.80], p = 0.005) and a lower PaO₂/FiO₂ ratio (OR = 0.99 [0.98-0.99], p = 0.001).

Conclusions: The removal of inflammatory mediators and microbial components is an emerging therapeutic target for Oxiris® use. Oxiris® may offer therapeutic benefit through the removal of inflammatory mediators in critically ill patients with severe systemic inflammation and renal failure. Although observed mortality was lower than historical estimates, these findings must be interpreted cautiously given the lack of a control group and the limitations of SAPS II. Controlled trials are needed to confirm its clinical impact.

Trial registration: The study was registered on ClinicalTrials.gov (Identifier: NCT03807414; Registration Date: June 28, 2019).

The Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) developed a good clinical practice document providing consensus-based statements on the monitoring of respiratory variables during weaning from invasive mechanical ventilation in adult patients. The aim was to summarize key parameters and available monitoring techniques to support healthcare professionals in daily clinical practice. The statements and supporting rationales were drafted by a panel of 10 experts to assist clinicians in selecting appropriate monitoring tools for the various respiratory functions involved during assisted ventilation. A total of 13 statements were issued, grouped into 8 items (rationale for monitoring, choice of the level of assistance, monitoring of respiratory patterns, respiratory effort, diaphragm functionality, respiratory drive, patient-ventilator synchrony, discontinuation of invasive assisted ventilation). The panel's work offers a practical bedside tool designed to optimize monitoring while acknowledging the heterogeneity of practices and equipment across Italian intensive care units.

Background: Fascia, once viewed as a passive structural tissue, is now recognized as a biologically active interface integral to musculoskeletal stability, force transmission, proprioception, and nociception. Despite the increasing clinical use of fascial plane blocks, the microanatomy of fasciae relevant to regional anesthesia remains poorly characterized. Understanding their histological features-including innervation, vascularization, and microstructure-is critical to optimizing anesthetic efficacy and elucidating mechanisms of pain and tissue response.

Methods: This systematic review was prospectively registered on the Open Science Framework (reference: yk4ua, 19 September 2025) and reported according to PRISMA guidelines. MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to September 2025 without language or date restrictions. Eligible studies included histological or microanatomical investigations of human fascial planes relevant to regional anesthesia (e.g., pectoral, thoracolumbar, abdominal, and fascia lata). Data were extracted independently by multiple reviewers, and study quality was assessed using the Anatomical Quality Assessment (AQUA) tool. Findings were synthesized qualitatively by anatomical region.

Results: Seventeen studies met inclusion criteria, encompassing fasciae from the thoracic, abdominal, lumbar, and lower limb regions. Fasciae exhibited considerable structural heterogeneity but shared a multi-layered organization of dense and loose connective tissue laminae rich in type I collagen. The fascia lata and thoracolumbar fascia demonstrated highly ordered collagen fiber orientation, multilaminar organization, and dense innervation, whereas thinner fasciae (e.g., pectoral fascia) showed simpler single-layer structures with fewer neural and vascular elements. Hyaluronic acid content ranged from 29 to 35 µg/g, with fasciacytes identified as the principal secretory cells. Nerve fibers-often associated with vessels and collagen bundles-were consistently present across all deep fasciae, with regional variations in density and mechanoreceptor type. Pathological changes, such as thickening, increased vascularization, and inflammatory infiltration, were reported in chronic pain states.

Conclusions: The fascia should be viewed as a dynamic, active tissue network rather than a passive sheath. Methodological limitations-including small sample sizes, regional heterogeneity, and histological artifacts-restrict current understanding. Future multimodal studies integrating histology, imaging, and biomechanics are warranted to clarify how fascial microstructure affects anesthetic diffusion, pain modulation, and postoperative recovery.

Background: Volatile anesthetics have been suggested to exert neuroprotective effects in patients with subarachnoid hemorrhage caused by a ruptured cerebral aneurysm. However, their effects on functional outcomes remain unverified. We assessed the association between volatile anesthetics and functional outcomes in patients with subarachnoid hemorrhage.

Methods: Using data from the Japanese Diagnosis Procedure Combination inpatient database, patients with subarachnoid hemorrhage, aged = 18 years, and undergoing any procedures for aneurysm treatment were selected. Patients were categorized into those who received volatile anesthetics and those who did not. The primary outcome was a composite of in-hospital death or impaired functional outcome at discharge. The secondary outcomes included in-hospital mortality, postoperative cerebral infarction, postoperative acute hydrocephalus, tracheostomy, hospital stay, and total healthcare costs. After 1:1 propensity-score matching, a generalized linear model or linear model was applied for each outcome, with cluster-robust standard error adjustment. Interaction analysis was also conducted for the primary outcome and in-hospital mortality.

Results: Overall, 35,097 matched pairs were generated. No significant difference was noted in the primary outcome between the two groups (total intravenous anesthetics: 44.5%; volatile anesthetics: 44.1%; odds ratio 0.99, 95% confidence interval [CI] 0.93-1.06, p = 0.84). However, in-hospital mortality differed significantly between the groups (total intravenous anesthetics: 9.3%; volatile anesthetics: 8.7%; odds ratio 0.89, 95% CI 0.82-0.97, p < 0.01). Other secondary outcomes showed no significant group differences. Interaction analysis indicated that volatile anesthetics worsened outcomes among patients with impaired consciousness at admission.

Conclusions: Volatile anesthetic use was not associated with improved functional outcomes in patients with subarachnoid hemorrhage. In patients presenting with impaired consciousness, volatile anesthetics were associated with poorer outcomes, although this finding should be interpreted with caution, given the observational nature of the study.

Ultrasound-guidance increases success rate and reduces complications compared to traditional palpation for radial artery catheterization. However, in special groups of patients, such as pediatric, older, obese, hypotensive population, and patients with chronic kidney disease (CKD), ultrasound-guided arterial cannulation can still be improved. The current available evidence revealed some techniques for improvement of success rate, in consideration of various modifiable factors during the procedure. In this narrative review, we summarized and illustrated techniques in four different aspects related to plane-needle relationship, ultrasound probe, patient's artery, and insertion needle, which may provide inspiration for better practice in the future.