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

Objective: To validate a predictive risk score of early aggressive pharmacokinetic/pharmacodynamic (PK/PD) target non-attainment with continuous infusion (CI) piperacillin/tazobactam or meropenem in a retrospective cohort of critically ill patients having documented Gram-negative infections.

Methods: Critically ill adult patients receiving treatment of documented Gram-negative infections with CI piperacillin-tazobactam or meropenem and undergoing first real-time beta-lactam therapeutic drug monitoring (TDM) instance within 72 h from starting standard dosing regimens were retrospectively included. A receiving operating characteristic (ROC) curve analysis was performed by using the proposed predictive score as the test variable and early aggressive PK/PD target non-attainment as the state variable. Area under the curve (AUC) and 95% confidence interval were calculated. The identified cut-off risk values were used for stratifying patients and assessing the impact on clinical/microbiological outcome in each sub-cohort of patients receiving targeted monotherapy.

Results: Overall, 209 and 203 patients receiving CI piperacillin-tazobactam and meropenem were included, respectively. Early aggressive PK/PD target non-attainment was reported in 33 cases (15.8%) receiving piperacillin-tazobactam and in 8 (3.9%) of those treated with meropenem. A score threshold ≥ 2 points for piperacillin-tazobactam (AUC 0.81; 95% CI 0.75-0.86; p < 0.0001) and ≥ 3 points for patients treated with meropenem (AUC 0.96; 95% CI 0.93-0.99; p < 0.0001) were significantly associated with early aggressive PK/PD target non-attainment. Patients achieving the cut-off predictive score showed a significant higher microbiological failure rate in both piperacillin-tazobactam (56.3% vs. 28.6%, p = 0.044) and meropenem sub-cohorts (50.0% vs. 10.4%, p = 0.028).

Conclusions: Our findings suggest that the proposed predictive cut-off risk score may represent a valuable tool for identifying promptly critically ill patients at high risk of early aggressive PK/PD target non-attainment with CI piperacillin-tazobactam or meropenem for whom a more intensified CI dosing regimens should be promptly applied bedside.

Background: Proximal Femur Fractures (PFF) are common among the elderly and can lead to significant disability. Anesthesiological management typically involves Spinal Anesthesia (SA) or Peripheral Nerve Blocks (PNBs). This study aimed to compare the efficacy and safety of SA and PNBs in elderly patients undergoing surgical fixation of PFF. The primary outcome was the comprehensive assessment of intraoperative hemodynamic instability.

Methods: A monocentric, patient-, surgeon-, and assessor-blind randomized study was conducted at the University 'Federico II' Hospital of Naples from December 2023 to June 2024. Patients diagnosed with PFF and scheduled for surgery were randomized to receive either Selective Spinal Anesthesia (SSA) (hypobaric bupivacaine 0.5% 7.5 mg and sufentanil 5 µg) or PNBs (femoral, lateral femoral cutaneous, obturator, and sciatic nerve blocks). The study evaluated the efficacy and safety of locoregional procedures by analyzing intraoperative and postoperative adverse events, as well as the effectiveness of analgesia.

Results: The PNB group showed a significantly lower incidence of intraoperative hemodynamic instability (16.7% vs 43.4%, p = 0.048) compared to the SSA group. Bradycardia was also less frequent in the PNB group (10% vs 33.3%, p = 0.028). Although repeated hypotensive episodes occurred in both groups, mean MAP, TWA-MAP and TWA-hypotension remained within safe limits, with brief episode durations and no need for pharmacological intervention. Mobilization was slower in the PNB group; however, these patients experienced a shorter hospital stay. No differences were observed in the need for analgesic rescue doses or in the incidence of postoperative complications, including PONV, DVT, MI, or neurological injury. Pain scores were slightly higher in the SSA group at 6 and 24 h, though the differences were not clinically meaningful. Both groups showed significant increases in NRS and PAINAD scores over time compared to baseline. Motor and sensory block onset was slower and duration longer in the PNB group, while SSA produced a faster onset and earlier resolution. Surgeon satisfaction, as well as estimated and actual surgical durations, were comparable between groups.

Conclusions: PNBs offer an alternative to SSA by providing better intraoperative hemodynamic stability, a lower incidence of postoperative delirium, and improved postoperative analgesia.

Trial registration: This study is registered with Clinicaltrials.gov, number (NCT06155903), registered July, 2, 2023, https://clinicaltrials.gov/study/NCT06155903.

Critically ill patients in Intensive Care Units are at high risk of developing invasive candidiasis (IC). Delay in diagnosis and suboptimal management contribute to high mortality rates, highlighting the need for an appropriate and patient-tailored approach. The Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) convened a multidisciplinary panel, involving intensivists, infectious disease specialists, microbiologists, and pharmacologists, to develop consensus-based statements on the diagnosis and management of IC in critically ill patients. The panel formulated 13 statements addressing key aspects of care, including identification of major risk factors for IC, the role of biomarkers to support therapeutic decision-making, and optimal selection of antifungal agents based on pharmacokinetic/pharmacodynamic (PK/PD) considerations and site-specific characteristics. The document also provides guidance on the use of therapeutic drug monitoring (TDM) to optimize antifungal efficacy. Special attention is given to infections in specific anatomical sites, such as the peritoneal cavity, central nervous system, eye, and biofilm-associated infections, where drug penetration and activity must be carefully considered. This multidisciplinary statement offers a practical framework aimed at improving clinical decision-making for the management of invasive candidiasis in critically ill patients.

Background: Traumatic brain injury (TBI) remains a leading cause of death and disability worldwide. Beyond the primary insult, excessive sympathetic activation contributes to secondary brain injury and poor outcomes. Beta-blockers may attenuate this hyperadrenergic surge and provide neuroprotective benefits, but their efficacy in improving long-term functional recovery remains uncertain.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating beta-blockers in adults with acute TBI. We searched MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and ClinicalTrials.gov for RCTs comparing beta-blockers with placebo, usual care, or non-adrenergic comparators. Our primary outcome was long-term functional outcome, assessed with the Glasgow Outcome Scale (GOS) or its Extended version (GOS-E). Secondary outcomes included mortality, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and adverse events.

Results: Seven RCTs (n = 559) met inclusion; six (n = 445) contributed data to meta-analyses. Only two trials (n = 259) reported functional outcomes. Beta-blockers did not significantly reduce the risk of unfavorable neurological outcome (RR 0.81; 95% CI 0.57-1.15; very low certainty). In contrast, beta-blocker therapy was associated with a reduction in mortality (RR 0.57; 95% CI 0.39-0.82; 6 trials, n = 440; low certainty) and a shorter duration of mechanical ventilation (-1.58 days; 95% CI -2.91 to -0.26; 2 trials, n = 85; low certainty). No effect was observed on ICU or hospital stay. Adverse event reporting was sparse, but no consistent safety concerns were identified.

Conclusions: In adults with acute TBI, beta-blockers did not decrease unfavorable long-term neurological outcomes but were associated with lower mortality and shorter duration of mechanical ventilation. Given the small number of trials and very low certainty of evidence, definitive conclusions cannot be drawn, and routine use cannot be recommended. A large, well-designed RCT is needed to establish the efficacy and safety of beta-blockers in this population.

Systematic review registration: PROSPERO CRD42024565361.

Background: Despite serving over 10 million inhabitants, neurocritical care across the Lombardy region of Italy (from here on Lombardia) remains fragmented and insufficiently mapped, underscoring the need for a structured regional network. This study aimed to evaluate current resources and explore pathways for integration and development.

Methods: In 2024, along with other initiatives, a web-based survey was performed, focusing on hospitals with neurosurgical capabilities and intensive care units (ICUs) to identify variations in service delivery and adherence to evidence-based practices, guiding quality improvement across centers.

Results: Responses were obtained from 19 acute care hospitals with neurosurgical facilities within the regional health service. Ten hospitals (52%) host dedicated neuro-ICUs, including five (26%) that also admit pediatric patients, accounting for a total of 85 beds. In the remaining nine hospitals (47%), neurocritical care is delivered within general ICUs without dedicated beds. Continuous in-house neurosurgical coverage is available in 9 centers (47%), while the others rely on a 24/7 on-call model. All 19 centers (100%) report 24/7 availability of neurologists and neuroradiologists, either in-house or on call. However, access to advanced diagnostic and monitoring technologies remains heterogeneous across sites. Participating centers identified a clear need for standardized protocols and clinical pathways to improve care quality and support evidence-based practices. Priority areas defined by the clinicians include neuroprognostication, end-of-life care and donor management, pediatric neurocritical care, neurointerventional procedures, management of delayed cerebral ischemia following subarachnoid hemorrhage, and post-discharge follow-up. To address these gaps, several multidisciplinary working groups have been established.

Conclusion: Neurocritical care in Lombardia remains highly heterogeneous, with bed availability significantly below international benchmarks. The establishment of a regional network seeks to enhance the quality and equity of care for neurocritical patients, while also fostering clinical research, data sharing, and multidisciplinary collaboration across centers.

Background: A wide gap exists between the number of patients awaiting organ transplantation and the availability of donor organs. For most vital organs, no artificial substitutes are available, resulting in the death of approximately 3-4% of patients on transplant waiting lists. Deceased organ donation occurs through one of two pathways: donation after brain death (DBD) or after controlled circulatory death (cDCD). In the absence of documented consent during the patient's lifetime, many countries rely on family members to make the decision, placing an emotional burden on them during a time of acute grief. Data on family attitudes toward organ donation, particularly in relation to the mode of death (DBD vs. cDCD), remains limited. This study aimed to examine the frequency of family refusal in the context of deceased organ donation and assess whether it differs between DBD and cDCD cases.

Methods: This retrospective, single-center observational study analyzed 6 years of hospital data (2019-2024) from five intensive care units at a tertiary university hospital in Varese, Italy. All patients, regardless of age, who were eligible for deceased organ donation through either DBD or cDCD were included.

Results: A total of 158 patients were evaluated for donation (135 DBD; 23 cDCD). Documented opt-in consent, as recorded in the national donor registry, was available for 41 patients (20%), while 3 had registered their refusal. Two patients were ineligible for donation; for the remaining 112 patients (71%), consent was sought from family members. Family refusal occurred in 28 cases (25% of the 112 families asked for consent). No significant difference in consent rates was observed between DBD and cDCD pathways (DBD: 73/98 vs. cDCD: 11/14; p = 0.74).

Conclusions: Family refusal was the leading reason for missed donation opportunities among patients without documented opt-in consent, accounting for one in four cases. The donation pathway (DBD vs. cDCD) did not significantly influence family decision-making. Given ongoing organ shortages and high wait-list mortality, strategies are needed to support family decisions and to promote the formal registration of opt-in consent among citizens.

Background: Intermittent aspiration of subglottic secretions (IASS) is commonly used to alleviate retention on the cuff, but inappropriate subglottic secretion drainage may lead to adverse effects, and fewer studies have been conducted on active subglottic airway humidification to improve the safety and effectiveness of IASS.

Methods: A randomized controlled trial was conducted from August 2023 to July 2024, involving 90 patients with flushable tracheostomy tubes: 48 patients received 30-min pre-drainage active humidification (intervention group), while 42 patients received sterile water flush (control group). The outcomes included vital signs, secretion viscosity, cuff pressure, inspired and exhaled tidal volume, catheter blockage, occult blood positivity, and the incidence of ventilator-associated pneumonia (VAP).

Results: The control group demonstrated a higher incidence of occult blood positivity (23.81% vs. 8.33%), blockage rate of the drainage catheter (19.05% vs. 4.17%), and Δcuff pressure (2.90 ± 1.39 cmH₂O vs. 1.48 ± 0.99 cmH₂O), with all comparisons yielding p < 0.05. Furthermore, the reduction rate of the viscosity of subglottic secretion was lower in the control group than in the intervention group (9.52% vs. 64.58%, p < 0.01). Although ΔVTe and VT_leak of the intervention group were significantly increased, no significant differences were observed in ΔSpO2, ΔPETCO2, or the incidence of VAP.

Conclusion: Active subglottic airway humidification prior to IASS significantly reduces the positive rate of occult blood (OB) tests, the incidence of drainage catheter blockage, and secretion viscosity, with the exception of the incidence of VAP. It also stabilizes cuff pressure with minimal fluctuation. Although the intervention is associated with a decrease in exhaled tidal volume, it has no significant impact on pulse oxygen saturation or end-tidal carbon dioxide pressure.

Non-steroidal anti-inflammatory drugs (NSAIDs) are integral to multimodal analgesic strategies after non-cardiac surgery, aimed at minimizing opioid exposure. Although their analgesic and anti-inflammatory efficacy is well established, emerging evidence raises concerns that perioperative NSAID use may increase the risk of postoperative atrial fibrillation (POAF). Mechanistic studies suggest multiple pathways for this association, including cyclooxygenase inhibition, renin-angiotensin-aldosterone system activation, oxidative stress, and autonomic dysregulation. In this context, perioperative clinicians face the challenge of optimizing pain control while mitigating cardiovascular risk. This review synthesizes preclinical, translational, and clinical data to delineate the potential impact of NSAIDs on POAF risk after non-cardiac surgery, providing a framework for evidence-informed perioperative management.