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

Background: Pulmonary shunt refers to the passage of venous blood into the arterial blood system bypassing the alveoli-blood gas exchange. Pulmonary shunt is defined by a drop in the physiologic coupling of lung ventilation and lung perfusion. This may consequently lead to respiratory failure.

Main body: The pulmonary shunt assessment is often neglected. From a mathematical point of view, pulmonary shunt can be assessed by estimating the degree of mixing between oxygenated and deoxygenated blood. To compute the shunt, three key components are analyzed: the oxygen (O₂) content in the central venous blood before gas exchange, the calculated O₂ content in the pulmonary capillaries after gas exchange, and the O₂ content in the arterial system, after the mixing of shunted and non-shunted blood. Computing the pulmonary shunt becomes of further importance in patients on extracorporeal membrane oxygenation (ECMO), as arterial oxygen levels may not directly reflect the gas exchange of the native lung.

Conclusion: In this review, the shunt analysis and its practical clinical applications in different scenarios are discussed by using an online shunt simulator.

Background: The efficacy of the erector spinae plane (ESP) block in mitigating postoperative pain has been shown for a range of thoracic and abdominal procedures. However, there is a paucity of literature investigating its impact on postoperative analgesia as well as its influence on weaning and subsequent recovery in comparison to thoracic epidural analgesia (TEA) in median sternotomy-based approach for open-cardiac surgeries and hence the study.

Methods: Irrespective of gender or age, 74 adult patients scheduled to undergo open cardiac surgery were enrolled and randomly allocated into two groups: the Group TEA (thoracic epidural block) and the Group ESP (bilateral Erector Spinae Plane block). The following variables were analysed prospectively and compared among the groups with regard to pain control, as determined by the VAS Scale both at rest (VAS_R) and during spirometry (VAS_S), time to extubation, quantity and frequency of rescue analgesia delivered, day of first ambulation, length of stay in the intensive care unit (ICU), and any adverse cardiac events (ACE), respiratory events (ARE), or other events, if pertinent.

Results: Clinical and demographic variables were similar in both groups. Both groups had overall good pain control, as determined by the VAS scale both at rest (VAS_R) and with spirometry (VAS_S) with Group ESP demonstrating superior pain regulation compared to Group TEA during the post-extubation period at 6, 9, and 12 h, respectively (P > 0.05). Although statistically insignificant, the postoperative mean rescue analgesic doses utilised in both groups were comparable, but there was a higher frequency requirement in Group TEA. The hemodynamic and respiratory profiles were comparable, except for a few arrhythmias in Group TEA. With comparable results, early recovery, fast-track extubation, and intensive care unit (ICU) stay were achieved.

Conclusions: The ESP block has been found to have optimal analgesic effects during open cardiac surgery, resulting in a decreased need for additional analgesic doses and eliminating the possibility of a coagulation emergency. Consequently, it presents itself as a safer alternative to the potentially invasive thoracic epidural analgesia (TEA).

Background: Septic shock, a critical condition characterized by organ failure, presents a substantial mortality risk in intensive care units (ICUs), with the 28-day mortality rate possibly reaching 40%. Conventional management of septic shock typically involves the administration of antibiotics, supportive care for organ dysfunction, and, if necessary, surgical intervention to address the source of infection. In recent decades, extracorporeal blood purification therapies (EBPT) have emerged as potential interventions aimed at modulating the inflammatory response and restoring homeostasis in patients with sepsis. Likewise, sequential extracorporeal therapy in sepsis (SETS) interventions offer comprehensive organ support in the setting of multiple organ dysfunction syndrome (MODS). The EROICASS study will assess and describe the utilization of EBPT in patients with septic shock. Additionally, we will evaluate the potential association between EBPT treatment utilization and 90-day mortality in septic shock cases in Italy.

Methods: The EROICASS study is a national, non-interventional, multicenter observational prospective cohort study. All consecutive patients with septic shock at participating centers will be prospectively enrolled, with data collection extending from intensive care unit (ICU) admission to hospital discharge. Variables including patient demographics, clinical parameters, EBPT/SETS utilization, and outcomes will be recorded using a web-based data capture system. Statistical analyses will encompass descriptive statistics, hypothesis testing, multivariable regression models, and survival analysis to elucidate the associations between EBPT/SETS utilization and patient outcomes.

Conclusions: The EROICASS study provides valuable insights into the utilization and outcomes of EBPT and SETS in septic shock management. Through analysis of usage patterns and clinical data, this study aims to guide treatment decisions and enhance patient care. The implications of these findings may impact clinical guidelines, potentially improving survival rates and patient outcomes in septic shock cases.

Aim: To assess the feasibility of a fast-track anesthesia protocol for hepatopancreatobiliary cancer surgery.

Methods: Retrospective analysis of consecutive sample of patients who underwent hepatopancreatic surgery for cancer for a period of 12 months in a high volume cancer center. Blended anesthesia was performed for most patients who were then observed in a recovery room area until achieving a safety score.

Results: Data of 163 patients were examined. Fifty-six and 107 patients underwent surgery for pancreatic cancer and liver surgery for primary tumor or metastases, respectively. Most patients were ASA 3. The mean durations of anesthesia and surgery were 322 min (SD 320) and 296 min (SD 133), respectively. Extubation was performed in the operating room in 125 patients. Post-operatory invasive ventilation was maintained in the recovery room in fifteen patients for a mean duration of 72.7 min (SD148.2). Only one patient was admitted to intensive care for 15 h. NIV was performed in three patients for a mean duration of 73.3 min (SD 15.3). The mean recovery room staying was 79 min (SD 80). The mean hospital postoperative stay was a mean of 8.1 days (SD 5.7). No complications were found in 144 patients. Globally, mortality rate was 3%.

Conclusion: A program of fast-track anesthesia with a short stay in recovery room allowed to achieve a good outcome, limiting the costs of intensive care admission.

Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.

Background: Preoperative fasting before elective pediatric surgery is a matter of ongoing debate. The objectives of this study were to evaluate the compliance to a recently implemented preoperative fasting protocol (clear fluids until 1 hour from the induction of anesthesia), to identify predictors of prolonged preoperative fasting time, and to determine whether duration of preoperative fasting was associated with adverse outcomes.

Methods: Retrospective single-center study in an operating theater of a tertiary pediatric hospital.

Results: In a 6-month period, 1820 consecutive patients were analyzed. The data collected in the questionnaire reporting the time of last food, milk and/or liquid intake, and eventual reasons for nonadherence was analyzed. Median (interquartile range) preoperative fasting time was 186 (110-345) min. In 502 patients (27.6%), duration of preoperative fasting to clear fluid ranged from 60 to 119 min, whereas in 616 (34%) it was 120-240 min. The reasons for not respecting fasting time rules are mostly related to communication issues or unwillingness by the patients. A significant difference in fasting times was evident between infants and children older than 10 years (188, 105-290 vs. 198, 115-362; p = 0.02). Fasting times were significantly shorter in the inpatient group and in the first scheduled patients of the morning. Clear fluids fasting times were significantly longer in patients with hypovolemia complications than in those without, 373 (185-685) vs. 180 (110-330) min (p < 0.0001). Longer fasting times to clear fluids, younger age, and scheduled surgery time were independently associated with the odds of experiencing complications.

Conclusions: In this single pediatric center study, median clear fluids fasting time was three times higher (180 min) than those recommended by the preoperative fasting protocol. Compliance to the protocol was observed in approximately 1 out of 4 patients (27.6%). Longer fasting times were associated with an increased risk of complications, which might be due to dehydration and/or hypovolemia.

Background: Peripheral nerve injuries (PNI) have been associated with prone positioning (PP) in mechanically ventilated (MV) patients with COVID-19 pneumonia. The aims of this retrospective study were to describe PNI prevalence 3 months (M3) after intensive care unit (ICU) discharge, whether patients survived COVID-19 or another critical illness, and to search for risk factors of PNI.

Results: A total of 55 COVID (62 [54-69] years) and 22 non-COVID (61.5 [48-71.5] years) patients were followed at M3, after an ICU stay of respectively 15 [9-26.5] and 13.5 [10-19.8] days. PNI symptoms were reported by 23/55 (42.6%) COVID-19 and 8/22 (36%) non-COVID-19 patients (p = 0.798). As the incidence of PNI was similar in both groups, the entire population was used to determine risk factors. The MV duration predicted PNI occurrence (OR (CI95%) = 1.05 (1.01-1.10), p = 0.028), but not the ICU length of stay, glucocorticoids, or inflammation biomarkers.

Conclusion: In the present cohort, PNI symptoms were reported in at least one-third of the ICU survivors, in similar proportion whether patients suffered from severe COVID-19 or not.

Background: Thoracic surgery is a high-risk surgery especially for the risk of postoperative pulmonary complications. Postoperative residual paralysis has been shown to be a risk factor for pulmonary complications. Nevertheless, there are few data in the literature concerning the use of neuromuscular blocking agent antagonists in patients undergoing lung surgery.

Methods: Seventy patients were randomized in three Italian centers to receive sugammadex or neostigmine at the end of thoracic surgery according to the depth of the residual neuromuscular block. The primary outcome was the time from reversal administration to a train-of-four ratio (TOFR) of 0.9. Secondary outcomes were the time to TOFR of 1.0, to extubation, to postanesthesia unit (PACU) discharge, postoperative complications until 30 days after surgery, and length of hospital stay.

Results: Median time to recovery to a TOFR of 0.9 was significantly shorter in the sugammadex group compared to the neostigmine one (88 vs. 278 s - P < 0.001). The percentage of patients who recovered to a TOFR of 0.9 within 5 min from reversal administration was 94.4% and 58.8% in the sugammadex and neostigmine groups, respectively (P < 0.001). The time to extubation, but not the PACU stay time, was significantly shorter in the sugammadex group. No differences were found between the study groups as regards postoperative complications and length of hospital stay. The superiority of sugammadex in shortening the recovery time was confirmed for both deep/moderate and shallow/minimal neuromuscular block.

Conclusions: Among patients undergoing thoracic surgery, sugammadex ensures a faster recovery from the neuromuscular block and earlier extubation compared to neostigmine.