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

Background: Malignant hyperthermia (MH) syndrome is a rare pharmacogenetic disorder that can be highly life-threatening if diagnosis and treatment are delayed. The purpose of this study is to assess the knowledge and current practices of Italian anesthesiogists in managing malignant hyperthermia episodes.

Methods: We conducted a national survey. Data were collected via an online questionnaire distributed by the Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Responses were collected over 15 weeks between July 15 and October 15, 2024, using an online General Data Protection Regulation-compliant platform.

Results: A total of 395 anesthetists completed the survey. The majority are employed in public (35%) and university hospitals (26%), with an average of 20 years of professional experience. MH had been managed at least once by 31% of respondents, and 70% of them declared they always report adverse reactions. In over 90% of cases, preventive measures (removal of trigger drugs, ventilator wash-out, perioperative care) are identified, although only 49% reported having an internal protocol in place at their institution. In most centers (89%), non-anesthesiologists are responsible for the storage and supply of dantrolene and only 66% of respondents correctly identify sterile water as its appropriate solvent.

Discussion: Our results highlight the need for broader standardization of MH management. Despite limitation in sample size and difference in geographical and hospital setting, the survey reveals a discrepancy between clinical practice and recommended strategies. Although the need for preventive measures as a mean to avoid episodes of MH is widely recognized, there continues to be too much ambiguity on what the exact protocol should be in these situations, leaving room to develop an unequivocal approach that allows the optimal treatment for episodes of MH.

Background: During pregnancy, labor, and postpartum, physiological changes such as weight gain, hormonal fluctuations, or fluid retention may cause airway edema and soft tissue swelling. These factors impact Mallampati Classification, a predictive tool to investigate airway. A higher Mallampati class indicates a high-risk obstetric population. This systematic review explores the airway and Mallampati modification during the different pregnancy periods. Understanding the airway changes in pregnancy is critical to safely intubate, avoid adverse outcomes in maternal care and support clinical practice.

Methodology: Research started using five databases, from the beginning to January 2025: Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrial.gov, with the following search terms: "Mallampati", "Mallampati grading", "Airway", "Airway changes", "Airway Obstruction", "pregnancy", "Delivery, Obstetric", "Anesthesia, Obstetrical". Articles included only studies covering a change in the Mallampati classification in pregnancy, labor, or postpartum. All the studies that did not concern airway changes in pregnancy or did not include a Mallampati classification were excluded. The quality of the included studies was assessed using a modified Newcastle-Ottawa Scale.

Results: Ten articles met the inclusion criteria. Significant changes in Mallampati class during pregnancy, labor, and post-partum were evidenced. Grades III and IV of Mallampati Classification increased during pregnancy, reaching 51.7% at delivery, compared to 10.3% pre-pregnancy. Increased proportions of MMC III/IV were observed among women with hypertensive and preeclampsia conditions when compared with the normotensive population. During the postpartum, the Mallampati class partially receded toward pre-pregnancy levels, with approximately 82% returning to baseline within 36 to 48 h.

Conclusion: These findings evidenced the pregnancy-related airway changes and their dynamic process, highlighting the need for close vigilance, especially during labor in high-risk populations.

Systematic review registration: PROSPERO CRD42025635304.

Critically ill patients frequently require analgesic and sedative medications to manage pain, agitation, and the stress associated with their condition. The onset of Acute Kidney Injury (AKI) can complicate the pharmacokinetics of these drugs, requiring careful dose adjustments to prevent adverse effects. Additionally, Kidney Replacement Therapy (KRT) may further influence drug metabolism and clearance. As renal dysfunction may alter the elimination of these medications, a comprehensive understanding of their pharmacologic profiles and the impact of KRT is essential for optimizing pain and sedation management in critically ill patients. In particular, this review explores the challenges and strategies involved in dosing analgesic and sedative drugs in critically ill patients with AKI undergoing various KRT modalities, including intermittent hemodialysis (IHD), continuous kidney replacement therapy (CKRT), and prolonged intermittent kidney replacement therapy (PIKRT). Moreover, this narrative review is aimed at summarizing existing evidence on pharmacokinetic alterations, clearance rates and eventual dose adjustments in critically ill patients with AKI undergoing various KRT modalities. Special emphasis is placed on the effects of different KRT modalities on drug elimination and associated therapeutic implications, seeking to provide healthcare professionals with evidence-based guidelines for the safe and effective administration of analgesics and sedatives in this complex, high-risk patient population.

Background: Artificial intelligence (AI) is increasingly applied in emergency, critical, and perioperative medicine, yet its implementation remains limited and fragmented. Variability in digital maturity, governance, and clinical readiness continues to challenge large-scale adoption.

Methods: A multidisciplinary expert consensus was conducted to identify key priorities for the safe and effective integration of AI in high-acuity settings. The consensus process included an independent literature review, group discussion, and blinded online voting. Priorities that reached at least 70% agreement on a 9-point Likert scale were considered consensual.

Results: Three priorities reached the predefined consensus threshold: 1. Digitalization and sharing of healthcare data (92.3% agreement): Digitalize the Emergency, Critical, and Perioperative Department patient journey by adopting a shared standard structure for electronic medical records that is optimized for data sharing and interoperability. 2. Efficacy and validation of AI models (93.4% agreement): Use only AI models that have demonstrated impact on patient outcomes, decision-making processes, or risk stratification validated through prospective studies or randomized clinical trials. 3. AI education of healthcare professionals (100% agreement): Healthcare professionals must acquire a digital health literacy level appropriate for their specific role, with individuals with leadership and management roles having more in-depth knowledge.

Conclusions: The consensus identifies three strategic priorities to guide the integration of AI in high-acuity settings. Together, they outline a pragmatic roadmap for translating AI potential into safe and clinically meaningful practice.

Optimizing mechanical ventilation in patients with acute brain injury (ABI) presents a complex clinical challenge, requiring a delicate balance between minimizing secondary cerebral injury and preventing ventilator-induced lung injury (VILI). The intricate interplay between respiratory and cerebral physiology mandates an individualized approach to ventilatory management. Core goals include maintaining normoxia and normocapnia to avert cerebral ischemia from hypoxia or hypocapnia while avoiding intracranial hypertension associated with hypercapnia. However, evidence guiding the ideal tidal volume and positive end-expiratory pressure (PEEP) settings in this population remains limited, particularly regarding their impact on cerebral perfusion pressure and oxygen delivery. Advanced neuromonitoring modalities-such as transcranial Doppler ultrasound and brain tissue oxygen tension (PbtO₂) monitoring-offer critical real-time data to inform ventilation strategies. Additionally, emerging technologies, including automated and adaptive modes of ventilation, show promise in enhancing patient-ventilator synchrony and gas exchange. This narrative review synthesizes current physiological principles, discusses the challenges inherent in protecting both the brain and lungs, and explores the evolving role of precision ventilation strategies supported by multimodal monitoring. Integrating these approaches may improve neurological and respiratory outcomes and help close the evidence gaps in ABI management.

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.