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

Background: Sleep-disordered breathing and obstructive sleep apnea syndrome are two diseases of relevant clinical and research interest, especially in the pediatric field. However, there are gaps in knowledge regarding these diseases.

Methods: We performed a survey that was administered electronically, via the SurveyMonkey platform, to 15,000 Italian anesthesiologists registered on the SIAARTI mailing list for a period of 4 months (April-July 2021).

Results: A total of 223 anesthesiologists completed the questionnaire (1.48%), 143 female and 79 male. Pediatric anesthetists generally responded more correctly than the general anesthesiology population.

Conclusion: The topic of pediatric OSA is a topic on which to invest in training of anesthesiologists, and the OSAKA-PedAn questionnaire is a valid tool to test the level of basic competence and that achieved.

Background: Cesarean delivery is one of the most common surgeries performed worldwide. Given the unavoidable use of general anesthesia in some situations, and the potential for complications, we performed a multicenter national survey in order to investigate aspects related to the use of general anesthesia for cesarean delivery.

Methods: This multicenter national survey questionnaire study was performed from October 2020 to March 2021. After Institutional Review Board waiver, we surveyed 25 eligible medical centers with an active obstetric anesthesia unit. The survey covered issues related to general anesthesia: preoperative management, personnel, induction, maintenance and emergence phases of anesthesia, intraoperative and postoperative pain management, protocol use, availability of difficult airway algorithm, and complications that are related to cesarean delivery under general anesthesia.

Results: A total of 113 participants among the 25 medical centers participated in the study. Routine pharmacological aspiration prophylaxis use was reported by 100/113 (88.5%). Administration of opiates during induction before fetal delivery was in 16.8%. We found only 27/113 (23.9%) of respondents ventilate their patients during RSI. Routine use of depth of anesthesia monitoring was reported by 21/113 (18.6%) respondents. Routine postoperative intravenous patient-controlled analgesia (IV-PCA) use with morphine was reported by 6/113 (5.3%) respondents.

Conclusions: In this national survey, we emphasize the importance of the presence of highly qualified anesthesiologic personnel during the surgery, benefit from the use of short-acting opiates during induction, availability of videolaryngoscope, ventilation of the patient during RSI, and availability of institutional difficult airway protocols. We observe underuse of intraoperative anesthesia-depth monitoring and poor postoperative pain control.

The accurate prediction of volume responsiveness is fundamental to goal-directed fluid administration. Targeted fluid administration during surgery is critical to avoid hypervolemia or hypovolemia and their associated postoperative complications. Recently, lung-protective ventilation strategies with tidal volumes of less than 8 mL/kg of ideal body weight have been recommended as standard practice during surgeries. Nevertheless, these reduced tidal volumes diminish the reliability of dynamic indices, such as pulse pressure variation, for predicting volume responsiveness. To address this limitation, the tidal volume challenge has proven to be a reliable method. This challenge involves increasing the tidal volume from 6 to 8 mL/kg of ideal body weight and observing the impact on hemodynamic parameters. Multiple studies have validated the efficacy of this test in both surgical patients and critically ill patients in the intensive care unit. The tidal volume challenge effectively improves the accuracy of predicting fluid responsiveness by increasing both sensitivity and specificity. Established threshold values for changes in pulse pressure variation and stroke volume variation offer precise clinical recommendations. However, additional cohorts and randomized controlled trials are imperative to validate the efficacy of the tidal volume challenge and advance fluid management strategies.

Spinal cord injury (SCI) causes temporary or permanent changes and alterations in patients' motor, sensory, or autonomic function, significantly impacting their quality of life and requiring clear goals and optimization of anesthesia and perioperative care for acute and chronic spinal cord injuries. SCI results from various etiologies and involving two principal pathophysiological mechanisms: primary and secondary injury. The first is result of the traumatic event, with irreversible neuronal damage, the second is generated as a consequence and in the minutes after the first and can continue for weeks or months causing degenerative damage to the spinal cord. It is in the secondary lesion where the objectives of anesthetic and perioperative management should be focused, especially in acute lesion. A conscientious and detailed preoperative evaluation allows to identify, injury level, evolution time, airway evaluation, cervical stability, hemodynamic status, ventilatory function and associated injuries must be determined. It is important to differentiate potential hemodynamic alterations and types of shock to prevent, especially in injuries greater than T6 and if necessary, provide early management in order to maintain adequate spinal cord perfusion. The objective of this review is to identify the pathophysiological mechanisms of spinal cord injury and the secondary systemic alterations and complications, as well as to establish specific optimization objectives during anesthetic management and perioperative care, which could reduce injury progression, prevent and control potential complications, and improve the quality of life of patients with this condition.

Background: The impact of anaesthesia on lung function during paediatric surgery remains an area of active investigation. Understanding respiratory mechanics under different anaesthetic approaches is crucial for optimising pulmonary management in this vulnerable population.

Objective: To assess ventilation distribution changes during different phases of anaesthesia in paediatric patients, using electrical impedance tomography (EIT).

Methods: This observational study included 76 paediatric surgical patients-57 under controlled mechanical ventilation (CMV) and 19 breathing spontaneously. EIT assessed lung ventilation at multiple timepoints (T1-T6), analyzing regional distribution (ROIs) and center of ventilation (CoV).

Results: In the CMV group, ventilation progressively shifted toward ventral lung regions (p < 0.0001 from T1 to T2, T3, T4, T5) with a contemporaneously reduced ventilation switching from T1 to T2 (p = 0.005), T3 (p < 0.0001), T4 (p = 0.001), and T5 (p < 0.0001). Ventilation normalised upon restoration of spontaneous breathing at the end of surgery. In the same group, CoV shifted toward non-dependent lung regions from T1 to T2, T3, T4, and T5 (p < 0.0001) and returned to baseline at T6. Overall, no modifications were observed in the spontaneous breathing group.

Conclusions: In paediatric surgical patients, contrariwise to spontaneous breath where no modifications occurred, CMV induced a progressive redistribution of ventilation towards the ventral lung regions, at the expense of the dorsal zones. These changes were reversible with the recovery of spontaneous breathing.

Trial registration: NCT06370507.

Background: The ultrashort-acting properties and organ-independent metabolism of remifentanil may be advantageous in mechanical ventilation management. Unlike fentanyl, which accumulates over time and may prolong sedation, remifentanil enables more predictable titration and rapid weaning. This study aimed to determine the effect of remifentanil on shortening the duration of mechanical ventilation in comparison with fentanyl in adult intensive care unit (ICU) patients.

Methods: A systematic review and meta-analysis was conducted, including randomised controlled trials (RCTs) and observational studies from MEDLINE, Cochrane, EMBASE, ICTRP, and ClinicalTrials.gov, from inception to July 2024. Studies comparing remifentanil with fentanyl in mechanically ventilated ICU patients were included, whereas those that used only remifentanil or fentanyl intraoperatively were excluded. The primary outcome was ventilation duration, with a minimal important difference (MID) of 90 min. A random-effects meta-analysis was performed and the certainty of evidence was assessed using the GRADE approach. The risk of bias was evaluated using RoB 2.0 and ROBINS-I tools.

Results: We included 18 studies (14 RCTs and 4 observational studies). Ten studies (8 RCTs and 2 observational studies; 901 patients) were analysed. Remifentanil may reduce ventilation duration compared to fentanyl (8 RCTs: MD -6.70 h, 95% CI -14.36 to 0.97; low certainty; 2 observational studies: MD -21.26 h, 95% CI -37.29 to -5.24; low certainty).

Conclusions: Remifentanil may reduce the duration of mechanical ventilation, potentially improving patient outcomes. However, owing to the low certainty of the evidence and study heterogeneity, further high-quality RCTs are required to validate these findings.

Trial registration: PROSPERO 2024 and CRD42024557414.

Background: Changes in cerebrospinal fluid (CSF) in patients with aneurysmal subarachnoid hemorrhage (aSAH) have not been fully elucidated, yet they are critical and may potentially be associated with the risk of complications. The aim of this study is to characterize the biochemical properties of CSF and examine the temporal changes in aSAH patients with and without post-aSAH complications such as vasospasm and shunt-dependent hydrocephalus.

Methods: This prospective observational longitudinal cohort study involved collecting CSF and arterial blood samples from SAH patients requiring an external ventricular drain at four different timepoints following the initial event (1-3, 4-7, 8-13, and 14-20 days after aSAH). A control group that comprised patients with idiopathic normal pressure hydrocephalus undergoing CSF sampling was included.

Results: A total of 20 SAH patients and 20 controls were enrolled. We observed significantly higher levels of hemoglobin (Hb), proteins, lactate, and cell concentrations in the CSF of aSAH patients compared to the control group (p < 0.001), with no corresponding differences in serum levels. Furthermore, a progressive decline in CSF Hb, proteins, and cells levels was noted over the days following the hemorrhage (p = 0.029, p = 0.005, and p = 0.010, respectively). Patients that developed vasospasm exhibited a lower CSF glucose/lactate ratio (p < 0.001) and reduced CSF sodium levels (p = 0.045), while patients that developed shunt-dependent hydrocephalus exhibited higher plasmatic and CSF glucose levels (p = 0.013 and p = 0.003, respectively) and lower CSF Hb/proteins ratio (p < 0.001).

Conclusions: Patients with aSAH exhibit changes in the biochemical profile of the CSF, which evolve over time following the acute event. Parameters such as CSF glucose/lactate ratio and CSF Hb/proteins ratio could potentially provide valuable insights not only into the pathophysiology of aSAH but also into patient risks of post-hemorrhagic complications, such as vasospasm and hydrocephalus.