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

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.

Background: Spinal cord stimulation is a validated approach for managing chronic pain syndromes. The stimulator placement typically requires sedation, and an awake phase is needed to ensure optimal lead positioning. We describe a novel multimodal sedation approach using target-controlled infusions of propofol, remifentanil, and dexmedetomidine, combined with boluses of ketamine, guided by electroencephalography and nociception-antinociception balance monitoring.

Methods: This retrospective, single-center cohort study reviewed all spinal cord stimulator procedures, including both trials and permanent implants. A standardized anesthetic protocol, administered by a single anesthesiologist, included target controlled infusions of propofol, remifentanil, and dexmedetomidine, with additional boluses of ketamine. Processed electroencephalogram guided sedation depth, and antinociception was assessed using the Analgesia Nociception Index. Data collected included drug doses, time to intraoperative awakening, hemodynamic stability, and airway management.

Results: A total of 25 procedures (11 trials, 14 permanent implants) were analyzed in 21 patients, with 4 patients undergoing both procedures. All patients received the same four-drug regimen. The median (interquartile range) minimum and maximum effect-site concentrations of propofol required to achieve an adequate level sedation (level - 4 of the Richmond Agitation-Sedation Scale) were 1 (0.5) µg/mL and 1.5 (0.8) µg/mL, respectively. The median (interquartile range) minimum and maximum effect-site remifentanil concentrations needed to achieve sufficient antinociception (Analgesia Nociception Index between 50 and 70) were 0.5 (0.3) ng/mL and 1.2 (0.4) ng/mL, respectively. The median (interquartile range) minimum and maximum effect-site concentrations of dexmedetomidine required to achieve adequate antinociception were 0.3 (0.1) ng/mL and 0.5 (0.1) ng/mL, respectively. The median (interquartile range) dose of ketamine was 25 (20) mg. The ketamine dose used during the implant was significantly higher than during the trial procedure (30 (30) vs. 20 (10) mg), p = 0.006. The average time to intraoperative awakening was 114 ± 56 s, and there was no significant difference between the trial and implant groups.

Conclusions: This study demonstrates the feasibility and safety of a multimodal sedation protocol for the placement of a spinal cord stimulator, combining propofol, remifentanil, dexmedetomidine, and ketamine, guided by electroencephalogram and nociception-antinociception monitoring.

Background: Opioid-free anesthesia (OFA) is an innovative approach to anesthesia management aimed at enhancing both the safety and the quality of perioperative outcomes. The efficacy and safety of these approaches are uncertain. The aim of our work was to compare the effectiveness and safety of different OFA regimens to opioid-based anesthesia (OBA).

Study design and methods: We conducted a systematic review and frequentist random-effects network meta-analysis of randomized controlled trials (RCTs). The primary outcome measure was the intensity of postoperative pain at 24 h, expressed in terms of numerical rating scale (NRS), visual analogue scale (VAS), or verbal rating scale (VRS) scores. The SUCRA was used to determine the likelihood that an intervention was ranked as the best. The certainty of the evidence was assessed according to the GRADE methodology for Network Meta-analysis (NMA).

Results: A total of 42 RCTs were included, for a total of 4666 patients. We have addressed the variety of available interventions. The random-effects network meta-analysis comparing OBA and different OFA regimens showed no difference in the pain intensity at 24 h. We performed the GRADE assessment for each comparison between each OFA regimen and OBA as a comparator. The certainty of evidence for the primary outcome ranges from moderate to very low among the different comparisons.

Conclusions: We have identified a significant heterogeneity in OFA regimens evaluated and a moderate to high risk of bias in over 70% of studies reporting the primary outcome. No OFA regimens showed a statistically significant effect over OBA in reducing postoperative pain within the first 24 h following surgery. Current evidence does not support the superiority of the analgesic efficacy of OFA in the immediate postoperative period compared to the use of opioids.

Trial registration: This study is registered in PROSPERO with the registration number CRD42024529236 (May 3, 2024).