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

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.

Background: Heart failure (HF) leads to venous congestion (VC), leading to organ dysfunction. Traditional VC assessments include pulmonary artery catheterization and IVC ultrasound. Newer tools like venous excess ultrasound (VExUS) and femoral venous doppler (FVD) quantify VC severity. We aimed to compare FVD with VExUS score to predict organ dysfunction and its progression in acute HF patients.

Methods: We conducted a 6-month prospective study in a 36-bed Cardiac ICU, enrolling 111 adults with acute decompensated HF. We evaluated FVD and VExUS to predict organ dysfunction and its progression. Key parameters were recorded on ICU admission and Day 3. We followed up patients at 90-days using the MAKE-90 criteria. Sensitivity, specificity, and predictive values of FVD and VExUS were calculated and compared using McNemar's test.

Results: VC was higher in the organ dysfunction group, with higher VExUS scores (55% vs. 31%, p = 0.018) and FVD-defined congestion (85% vs. 57%, p = 0.002). This group also revealed worse LUS, lower TAPSE:PASP ratios, more severe AKI, higher creatinine, and increased use of non-invasive ventilation (all p < 0.01). Mortality (39% vs. 24%) and MAKE-90 events (56% vs. 39%) were higher but not statistically significant. FVD had higher sensitivity but lower specificity than VExUS in detecting AKI, and lung congestion. VExUS had higher specificity for RV coupling and organ dysfunction; FVD correlated more with organ dysfunction.

Conclusion: FVD and VExUS provide complementary insights into venous congestion, reinforcing the need for an integrated approach rather than reliance on a single modality. A multimodal strategy combining these tools with clinical and biochemical markers may offer a more precise framework for guiding management in acute heart failure.

Trial registration: This trial was registered with Clinical Trial Registry-India ( https://www.ctri.nic.in/ ), Trial No-CTRI/2023/10/058186 on 3/10/2023.

The selection of the appropriate size of a double-lumen tube (DLT) is a critical yet often underestimated aspect of thoracic anaesthesia. The present narrative review evaluates traditional and emerging methods for determining DLT size, including anthropometric formulas, chest X-rays, CT scans, and ultrasonography. Despite the prevalence of height- and gender-based predictions, mounting evidence underscores their restricted correlation with airway anatomy. Chest X-rays and CT scans have been shown to offer more accurate estimations of tracheobronchial dimensions, while ultrasound has been identified as a promising bedside tool. Recent meta-analytic evidence and technological advancements, including 3D reconstruction and AI-based modelling, may support a more personalised and safer approach. It is recommended that a pragmatic, image-guided strategy be employed to minimise airway trauma, improve lung isolation, and optimise patient outcomes.

Background: To analyze risk factors for adverse outcomes in a nationally representative sample of pediatric cancer patients admitted to the PICU.

Methods: An observational study composed of a 2-year retrospective phase and a 2-year prospective phase was conducted before and during PICU admission in Italian PICUs.

Results: We included 518 patients, median age 7.2 years (IQR 2.5-12.6). Main diagnosis: solid tumors (51%) and acute lymphoblastic leukemia (23%). Nineteen percent underwent stem cell transplantation (HSCT). Main causes of admission were respiratory failure (33%) and neurological impairment (24%). In-PICU mortality was 15%, higher in HSCT (41%) and non-solid cancer (25%). Pre-PICU mortality risk factors included HSCT (OR 3.48, 95%CI 1.5-8.11), higher Pediatric Overall Performance Category (POPC) (OR 1.72, 95%CI 1.23-2.42), and Pediatric Index of Mortality 3 (PIM-3) score (OR 1.03, 95%CI 1.01-1.06). In-PICU mortality risk factors included multiple organ failure (MOF) (OR 4.83, 95%CI 1.66-15.71), and cardiac arrest (OR 82.16, 95%CI 14.19-1594.61). The use of MV does not appear to be associated with increased mortality. Longer PICU LOS was associated with pre-admission acute respiratory distress syndrome (p < 0.001), renal failure (p = 0.024), POPC (p = 0.007) and PIM 3 (p < 0.001), and in-PICU use of total parenteral nutrition (p = 0.036), and duration of mechanical ventilation (MV) (p < 0.001).

Conclusions: HSCT, non-solid tumor, higher PIM-3, and POPC on admission, MOF, and history of cardiac arrest were associated with poorer outcome. The use of MV does not appear to be associated with increased mortality.

Trial registration: ClinicalTrials.gov ID NCT04581655, October 7, 2020.

Although it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. Pregnant patients should receive treatment based on nonpregnant guidelines, with special adjustments for diagnosis, staging, oncology, and obstetrics. This situation is particularly concerning for the health of a long-awaited foetus, especially after medical intervention to aid fertilization. To ensure the baby's safety, it is best to conclude the pregnancy as soon as possible in many cases. We know this is not always possible. This case report discusses the application of the pecto-serratus plane block (PSP) in a patient at seven months gestation undergoing breast quadrantectomy due to the abrupt onset of breast cancer. This study is limited as it involves only one patient. However, it highlights the relevance of locoregional anaesthesia in para-physiological states such as pregnancy.

Background: Videolaryngoscopy has significantly improved the management of unanticipated difficult airways and replaced other intubation techniques. The goal of this study was to identify the indications for using videolaryngoscopy and fiberoptic bronchoscopy for adult patients, where direct laryngoscopy is the standard intubation technique.

Methods: Over a one-year period from January to December 2018, anesthesiologists were surveyed on their reasons for using a videolaryngoscope or fiberoptic bronchoscope for tracheal intubations. Additionally, retrospective data on all direct laryngoscopy intubations were collected for the same period from the anesthesia information management system.

Results: Out of 6251 tracheal intubations with direct laryngoscopy and 502 with videolaryngoscopy or fiberoptic bronchoscopy, data from 450 (89.6%) cases were collected. We excluded 46 cases where videolaryngoscopy and fiberoptic bronchoscopy were used for non-airway management reasons, resulting in 404 cases for analysis. Videolaryngoscopy was initially used in 356 (88.1%) patients. The primary reasons for using videolaryngoscopy or fiberoptic bronchoscopy were anticipated difficult intubation (218, 54.0%) and cervical pathology (109, 27.0%). Among the 42 cases of unanticipated failed direct laryngoscopy, videolaryngoscopy was used in 41 cases and fiberoptic bronchoscopy in 1 case. The overall rate of unanticipated failed direct laryngoscopy was 0.7%.

Conclusions: The routine use of videolaryngoscopy and fiberoptic bronchoscopy for anticipated difficult tracheal intubations led to a very low incidence of unanticipated failed tracheal intubations with direct laryngoscopy. Therefore, routinely using more expensive videolaryngoscopes for all intubations would prevent only very small numbers of unanticipated failed direct laryngoscopic intubations and is not financially justified.

Introduction: Refusal of organ donation is influenced by a range of interconnected factors spanning donor characteristics, family dynamics, and intensive care unit (ICU) practices. This study explores the impact of donor or centre-related variables on organ donation refusal rates in Italian ICUs, among potential donors without expressed will.

Methods: We conducted a retrospective analysis of 12,930 potential donors registered in the North Italian Transplant Program registry from 01/01/2010 to 31/03/2025. A linear mixed-effects model was applied to account for donor characteristics (age, timing and cause of death, geographic origin) and ICU-level variability with refusal of organ donation.

Results: In multivariate analysis geographic origin was an independent predictor of refusal - particularly for donors from North Africa and Middle East (OR 9.59, IQR 6.25 - 14.72; p-value < 0.001), Asia (OR 7.76, IQR 5.69-10.57; p-value < 0.001), Africa (OR 6.81, IQR 4.44 - 10.45; p-value < 0.001) and eastern European (OR 2.65, IQR 2.17 - 3.23; p-value < 0.001). Also, time from event to death over 48 h was associated with higher refusal rate (OR 3.37, IQR 2.52 - 4.50, p-value < 0.001). In contrast, traumatic brain injury (OR 0.85, IQR 0.74 - 0.98; p-value 0.023) was protective. Finally, inter-ICU variability had a significant impact on refusal rates, as indicated by a Median Odds Ratio of 1.38. However, the multivariate model demonstrated weak predictive ability for organ donation refusal (AUC = 0.66).

Conclusions: This study identifies several factors independently associated with organ donation refusal. However, the overall predictive ability based on available variables remains limited. To enable individualized interventions and effectively reduce refusal rates, more comprehensive and prospective data collection is warranted.

Objectives: Surviving Sepsis Campaign (SSC) defined Sepsis as "life-threatening organ dysfunction caused by a dysregulated host response to infection" (De Backer D et al, Crit Care Med, n.d.). Sepsis remains one of the leading causes of morbidity and mortality (17-65% (De Oliveira DC, Arq Bras Cardiol Sociedade Brasileira de Cardiologia - SBC 94:352-6, 2010)) worldwide and it still remains a challenge to be defined and for which an appropriate treatment is desired (Chiu and Legrand, Curr Opin Anaesthesiol 34:71-6, 2021). Different studies have been conducted on genes coding for inflammatory cytokines whose could predispose to the development of sepsis [e.g., IL-10 PD1 and WT1] (Gupta DL et al, Infectious Process Sepsis, 202).

Design: This multicentric observational prospective study aims to evaluate blinding the genetic expression kinetics of different molecules involved in the inflammatory process, IL10, PD1 and WT1, to search for a possible molecular predictive marker of sepsis.

Setting: Nine University teaching Hospitals in Italy take part in this study in collaboration with the Department of Applied Science (DISBA) of the University of Basilicata.

Participants: One hundred sixty-two patients, under elective cardiac and on pump surgery were enrolled in the study.

Interventions: From each patient 4 blood samples were collected during and at the end of the surgery, following the study design.

Measurements and main results: We observed, 30 min after the start of the surgery, lower gene expression levels of IL10 and PD1 in septic patients compared to non-septic (p < 0.05), but considering all the timepoint there are differences in gene expression modulation between the groups.

Conclusion: These results confirmed the dysregulated immune response in septic patients compared to non-septic, highlight how a measurement of the gene expression could help to optimize procedures and pay attention to more susceptible patients.