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

Background: Managing donors after brain death (DBD) is a complex task, but intensivists are believed to play a crucial role in optimizing organ perfusion to enhance organ procurement. This survey aims to gather important data on the practical management of DBD in Italy and to identify areas for potential improvement.

Methods: This national survey was conducted online and distributed to all members of the Italian Society of Anesthesia, Analgesia, and Intensive Care (SIAARTI). The questionnaire consisted of 30 questions covering aspects such as the respondents' region of work, level of experience, and workplace characteristics. Clinical questions focused on hemodynamic monitoring and management in the ICU, fluid therapy, mechanical ventilation practices, nutritional habits, and management of endocrine disorders. Additionally, the survey examined practices during the brain death determination process and the organizational procedures involved in organ procurement in the operating room. The data collected were analyzed using descriptive statistics to provide a comprehensive overview of the current practices in DBD management in Italy.

Results: From May 4 to August 30, 2024, 364 valid responses have been considered. 63% of respondents reported that they have written guidelines or diagnostic and therapeutic care pathways (PDTA) for DBD, while 34.5% indicated that such pathways do not exist. Nearly 49% of the respondents rely exclusively on standard hemodynamic monitoring techniques. By contrast, 42% incorporate cardiac ultrasound along with both basic and advanced invasive hemodynamic monitoring methods. Norepinephrine was chosen as the preferred treatment by 64.5% of participants. 58% of respondents used balanced crystalloids, while both normal saline and human albumin were used by 20% of them. Most participants implemented protective mechanical ventilation strategies (tidal volume ≤ 6 mL/kg and PEEP ≤ 10cmH₂O). Nutrition practices varied significantly among respondents. Additionally, 41% reported that they almost always administered hormonal replacement therapy, while 38% used it only in case of hemodynamic instability. In the assessment of brain death, 43% of physicians performed an apnea test using continuous positive airway pressure without disconnecting the ventilation circuit. The most commonly administered medications during surgery included neuromuscular blocking agents (43%), opioids (42%), inhaled anesthetics (25.5%), propofol (11.5%), and none of the above (3.8% ).

Conclusions: This survey reflects the current practices of SIAARTI members when managing DBD. It highlights several areas for improvement, particularly the need for written guidelines and PDTA to be readily accessible at every procurement site. Additionally, while protective mechanical ventilation is generally well understood, there is considerable variability in hemodynamic manage

Background: Spinal anesthesia is the preferred technique for elective cesarean delivery; however, it is frequently associated with spinal anesthesia-induced hypotension. To mitigate this, prophylactic vasopressors have become a cornerstone of obstetric anesthesia practice. Despite their use, hypotension may still occur, prompting the exploration of adjunctive maneuvers to enhance hemodynamic stability and reduce vasopressor requirements. This study hypothesized that passive leg elevation would reduce the need for noradrenaline during cesarean delivery under spinal anesthesia.

Methods: In this randomized controlled trial, we evaluated the effect of 30-degree leg elevation on noradrenaline requirements. Noradrenaline was administered as a variable infusion, ranging from 0.05 to 0.14 µg/kg/min. Participants were randomly assigned to either the control group or the leg elevation group. The primary outcome was the average noradrenaline requirement in each group.

Results: A total of 80 healthy pregnant patients were included in the final analysis, with 40 patients in each group. The mean noradrenaline requirement was significantly lower in the leg elevation group compared to the control group (0.067 ± 0.01 vs. 0.079 ± 0.01 µg/kg/min, respectively; p < 0.05). Additionally, the incidence of hypotension was reduced in the leg elevation group (20%) compared to the control group (40%).

Conclusion: Among healthy parturients undergoing elective cesarean section, passive leg elevation significantly reduced noradrenaline requirements and was associated with a lower incidence of hypotension. This simple maneuver may serve as a valuable adjunct to pharmacologic prophylaxis in spinal anesthesia.

Trial registration: The study was registered by the principal investigator (M. Helmy) at ClinicalTrials.gov under the identifier NCT06822699 on February 7, 2025.

Background: Elderly patients undergoing surgery for hip fractures are at high risk for perioperative Major Adverse Cardiac Events (MACE), which can markedly compromise postoperative outcomes. This study aims to develop a machine learning (ML) based, interpretable tool to predict MACE using clinical and ultrasound-based variables in this population.

Methods: We analyzed data from 877 patients in the multicenter LUSHIP study, incorporating demographics, Revised Cardiac Risk Index (RCRI), functional status, and preoperative lung ultrasound (LUS) scores. Multiple ML models were trained and validated using bootstrap resampling. The final ensemble meta-model combined GBM (Gradient Boosting Machine) and GLMNET (Elastic-Net Regularized Generalized Linear Models).

Results: The ensemble model achieved an AUROC of 0.86, with sensitivity and specificity of 0.72 and 0.83, respectively. These results significantly improve over traditional tools such as the Revised Cardiac Risk Index (RCRI), particularly when used alone. A significant contribution of this work is the integration of lung ultrasound (LUS) as a non-invasive, bedside biomarker, which notably improved risk prediction compared to the performance of the individual LUS marker alone (AUC = 0.78). Relevant predictors for the ML model are LUS score, RCRI score, and patient age. A web-based Shiny application was developed to enable real-time personalized risk estimation.

Conclusion: This interpretable ML model improves perioperative cardiac risk stratification and profiling in elderly hip fracture patients and may guide targeted preventive strategies and resource allocation.

Trial registration: CT04074876.

Background: Low cardiac output syndrome (LCOS) is a life-threatening complication following cardiac surgery. We explored the predictive value of transesophageal echocardiography (TEE)-measured global longitudinal strain (GLS) and strain rate (SR) to establish clinically relevant thresholds for both GLS and SR to subsequently develop a predictive model for LCOS.

Methods: A trained anesthesiologist performed standard TEE after general anesthesia induction and before establishment of cardiopulmonary bypass. GLS and SR were obtained using 2D speckle tracking. The occurrence of LCOS after mitral surgery was the primary outcome. Predictive accuracy was assessed using receiver operating characteristic (ROC) curves and Youden index. A multivariable logistic regression model was internally validated via bootstrapping. Associations between GLS categories (< - 19.1 vs > - 19.1%) and outcomes were evaluated using inverse probability of treatment weighting (IPTW).

Results: In 126 included patients, LCOS occurred in 31 (25%) instances. Optimal cut-offs to predict LCOS were > - 19.1% for GLS (area under the curve [AUC], 0.79; P < 0.001) and ≤ - 0.98 s^-1 for SR (AUC, 0.66; P = 0.01). Predictors for LCOS were GLS > - 19.1%, tricuspid annular plane systolic excursion (TAPSE), ejection fraction (EF), and creatinine clearance (CrCl). The model showed strong performance (R², 0.580; c-statistic, 0.898; optimism-corrected R² = 0.517 and AUC 0.77). GLS > - 19.1% was also associated with time on mechanical ventilation (P = 0.015), length of ICU (P = 0.004), and hospital stay (P < 0.001). After IPTW-weighted analyses, patients with GLS > - 19.1% had significantly higher odds of developing postoperative LCOS (odds ratio, 5.48; 95% confidence interval, 1.63-18.5; P = 0.006).

Conclusions: We found that GLS, TAPSE, EF, and CrCl were independent predictors of postoperative LCOS in patients undergoing mitral surgery. Among them, a GLS value > - 19.1% was associated with higher odds of LCOS.

Clinical trial number: ClinicalTrials.gov, NCT04045340, date of registration: 02.08.2019.

Background: Postoperative nausea and vomiting (PONV) are among the most common postoperative complications affecting children. In adult patients, cigarette smoking significantly reduces the incidence of PONV, although the mechanism underlying this effect is unclear. Here we aimed to investigate whether environmental tobacco smoke exposure influenced the PONV incidence among children.

Methods: This monocentric retrospective study included 1348 children (1-15 years of age), who underwent endoscopic adenoidectomy under general anaesthesia, between 22 March 2017 and 26 June 2023. Data for this study were obtained from the patient's medical records and from a telephone conversation with their parent.

Results: Our analysis revealed that the PONV incidence was significantly lower in children exposed to environmental tobacco smoke (ETS), compared to in children who were not passive smokers (13.9% vs 22.1%; p < 0.001). Children of non-smoking parents were at a higher risk of developing PONV (OR: 1.82; 95% CI: 1.31-2.58).

Conclusions: Although exposure to ETS has many undesirable consequences, it is also associated with a lower incidence of PONV. Conversely, children without ETS exposure are at a higher risk of PONV development and should receive proactive pharmacological prophylaxis.

Background: Surgery for severe scoliosis (SS) is usually performed in the prone position. Changes in respiratory mechanics related to position and positive end expiratory pressure (PEEP) titration during anesthesia of SS are understudied. We aimed to investigate the effect of prone position and PEEP on the respiratory mechanics of scoliotic children undergoing spine surgery.

Methods: Prospective, crossover study performed in two pediatric hospitals (Montevideo, Uruguay-Centro Hospitalario Pereira Rossell- and Milano, Italy-Vittore Buzzi Children's Hospital). Shortly after intubation, pulmonary mechanics measurements were performed using inspiratory and expiratory breath holds during volume-controlled ventilation with a set tidal volume (TV) of 8 ml/kg and a respiratory rate adjusted to maintain normocapnia. Measurements of peak (PIP), plateau (P_PLAT) and total PEEP (tPEEP) were obtained at three levels of applied PEEP: 0 (ZEEP), 5, and 10 cmH₂O both in supine (baseline) and prone positions. Driving pressure (∆P: P_PLAT-tPEEP) was calculated to obtain static respiratory system compliance (Crs: TV/∆P). Crs and pressures were analyzed using a mixed linear regression model with a random subject effect in their relationship with position and PEEP.

Results: Sixty-nine patients were enrolled. Crs was negatively associated with Cobb angle in all the cohorts. Only in secondary scoliosis, it was positively associated with body mass index. Crs was also negatively correlated with the prone position and positively correlated with increasing PEEP levels. The interaction between PEEP and position was studied and showed no significance.

Conclusions: Crs is influenced by the severity of scoliosis and the nutritional status during spine surgery. The addition of PEEP improves Crs and reduces ∆P in the supine position, but both worsen in the prone position. These changes can be related to the effects of position on chest wall compliance.