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

Background: Septic shock is a fatal infection-induced syndrome causing severe organ dysfunction and high mortality. The study aimed to comprehensively evaluate the effects of continuous versus intermittent bolus hydrocortisone treatment in patients with septic shock, addressing all relevant primary and secondary outcomes.

Methods: PubMed, Embase, Scopus, and Web of Science were systematically searched from inception to June 1, 2025, with additional manual sources. Eligible studies included randomized controlled trials and cohort studies of adults with septic shock comparing continuous infusion versus intermittent bolus hydrocortisone. This review followed PRISMA guidelines. Risk of bias was assessed using the Cochrane RoB 2 tool for RCTs and ROBINS-I for cohort studies. Certainty of evidence was graded via the GRADE framework. Primary outcomes were ICU, hospital, and 28-day mortality. Secondary outcomes included 7-day shock reversal, ICU-acquired weakness, ICU and hospital length of stay, vasopressor-free days, duration of vasopressor therapy, and metabolic complications.

Results: This study included 14 studies comparing continuous infusion and intermittent bolus administration of hydrocortisone in patients with septic shock. The findings indicated no significant differences in ICU mortality, hospital mortality, or 28-day mortality between the two groups. However, continuous infusion was associated with significantly improved 7-day shock reversal, reduced risk of hypokalemia, and lower glycemic variability. No significant differences were found between the groups in terms of ICU and hospital length of stay, insulin requirements, and other variables.

Conclusion: These findings suggest that continuous infusion may provide clinical benefits in specific aspects of the management of septic shock patients.

Trial registration: PROSPERO CRD420251069956.

Background: Prone positioning is recommended for patients with acute respiratory distress syndrome not only to improve oxygenation, but also to reduce lung stress, and lower mortality. The association between improved oxygenation during prone position and reduced mortality is still controversial. In previous studies, oxygenation improvement during the first prone positioning cycle was linked to lower intensive care unit (ICU) mortality, especially with prolonged duration. However, physiological data during subsequent cycles were lacking. This study aims to explore the association between ICU mortality and physiological responses to prone positioning-such as arterial oxygenation, dead space, and respiratory mechanics-and to assess how the cumulative time spent in prone or supine positions across all studied cycles influences outcomes.

Methods: International registry including adult patients who underwent prone positioning for acute hypoxemic respiratory failure due to COVID-19. We measured the difference for arterial partial pressure of oxygen to inspired fraction of oxygen ratio (PaO2/FiO2) and ventilatory ratio between baseline supine position and at either the end of cycle of prone position (Delta-PP) or re-supination (Delta-PostPP), focusing on the cycles following the first one.

Results: We included 1523 patients from 53 centers. Both Delta-PP and Delta-PostPP for PaO2/FiO2 were significantly higher in ICU survivors than in ICU non-survivors for all the analyzed prone positioning cycles (p ≤ 0.001 for all comparisons). Delta-PP and Delta-PostPP for ventilatory ratio were significantly lower in ICU survivors than in ICU non-survivors for all the analyzed prone positioning cycles (p < 0.05 for all comparisons). No difference in the overall time spent in prone position was found between ICU survivors and non-survivors [61 (38, 84) h vs 58 (32, 85) h, respectively, p = 0.175]. The cumulative length of prone position was associated with ICU mortality only for the second prone positioning cycle [OR (95% CI) 0.986 (0.978, 0.994)]. No significant association was observed between the time spent in supine position and ICU mortality for all the analyzed prone positioning cycles.

Conclusions: ICU survivors consistently demonstrated better oxygenation and more stable ventilatory ratio across studied prone positioning cycles, whereas non-survivors showed worsening oxygenation when returning supine and increased ventilatory ratio. Additionally, extending the duration of prone position beyond the second cycle may not significantly impact mortality.

Background: Accurate nociception monitoring may optimize opioid administration during total knee arthroplasty. We aimed to evaluate whether the quantium nociception index (qNOX)-guided remifentanil infusion reduces opioid consumption and improves postoperative analgesia.

Methods: In this single-blind randomized trial, 84 patients undergoing total knee arthroplasty received either qNOX-guided (M group, n = 42) or conventional remifentanil infusion (R group, n = 42). Primary outcome was the incidence of Visual Analogue Scale (VAS) ≥ 5 within 40 min postoperatively. Secondary outcomes included intraoperative remifentanil/propofol consumption, Quality of Recovery (QoR)-15 questionnaire, postoperative nausea and vomiting, hospital stay, and hemodynamic stability.

Results: M group demonstrated the following: Lower resting VAS ≥ 5 incidence (16.7% vs. 55.6%; relative risk [RR] 0.30, 95% CI 0.15 to 0.63; P = 0.023). The qNOX-guided strategy also led to a significant reduction in intraoperative remifentanil consumption (0.071 vs. 0.083 µg·kg⁻¹·min⁻¹; P = 0.001) and a faster time to extubation (median 16 vs. 18 min; P = 0.009). No differences were observed in propofol consumption, QoR-15 scores, or the incidence of postoperative nausea and vomiting.

Conclusion: qNOX-guided analgesia reduces intraoperative remifentanil requirements, accelerates recovery, and improves early postoperative pain control without increasing adverse events.

Trial registration: Chinese Clinical Trial Registry, ChiCTR2500107430. Registered August 11th, 2025, retrospectively registered.

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.