Anaesthesiology intensive therapy最新文献

Introduction: Spinal anesthesia (SA) is preferred for hip fracture surgery but can be difficult due to severe preoperative pain. This study compared prespinal analgesic techniques for improving the ease of SA and postoperative analgesia in neck of femur fractures.

Material and methods: In a prospective, randomized, double-blind trial, 210 patients aged ≥ 60 years undergoing internal fixation of fractured neck of femur under SA were allocated to three groups. Group A received a femoral nerve block (FNB), Group B a pericapsular nerve group (PENG) block, and Group C intravenous fentanyl 1 µg kg-1 10 minutes before SA. For FNB and PENG, 20 mL of 0.25% bupivacaine was used.

Results: The PENG group had the lowest Ease of Spinal Anesthesia (EOSA) score (median 7 [IQR 7-8]) vs. FNB 8 (7-9) and fentanyl 9 (9-10) (P < 0.001). Pain during positioning and puncture was lowest with PENG (P < 0.001). Time to first rescue analgesia was longest with PENG (8.8 ± 2.03 h, 95% CI: 8.3-9.3) compared with FNB (5.9 ± 1.5 h, 95% CI: 5.5-6.4) and fentanyl (4.2 ± 0.7 h, 95% CI: 4.0-4.4) (P < 0.001). Immediate postoperative visual analog scale (VAS) scores at 6 and 12 hours were lower with PENG; differences at 24 hours and 30 days were not significant. Hemodynamics and complication rates were largely similar across groups.

Conclusions: In hip-fracture patients, ultrasound-guided PENG and FNB improved the ease of SA and reduced postoperative opioid use, with PENG showing the greatest benefit.

Background: The PREVENT-MINS trial investigated whether perioperative heart rate reduction with ivabradine could prevent myocardial injury after noncardiac surgery (MINS). Although ivabradine modestly reduced heart rate, it did not reduce the incidence of MINS in the intention-to-treat analysis. This per-protocol analysis of the PREVENT-MINS trial, with a post-hoc biomarker substudy, evaluated whether perioperative iva-bradine modifies postoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations, a marker of perioperative cardiovascular risk.

Methods: This analysis included 2008 participants who received ≥ 1 dose of study drug, underwent surgery, and had NT-proBNP and troponin measured (ivabradine: n = 1,001; placebo: n = 1,007). Postoperative NT-proBNP levels and changes from baseline (ΔNT-proBNP) were compared by treatment allocation. Clinical outcomes and safety endpoints from the parent trial were evaluated. Analysis of covariance (ANCOVA) assessed ivabradine's effect on postoperative NT-proBNP after adjustment for baseline values and clinical covariates.

Results: MINS occurred in 17.7% of ivabradine-treated vs. 15.7% of placebo patients (RR 1.13; 95% CI: 0.93-1.37; P = 0.23). Median postoperative NT-proBNP was higher with ivabradine than with placebo (418.0 vs. 333.5 pg mL-1; P < 0.001), as were ΔNT-proBNP values (215.1 vs. 154.0 pg mL^-1; P < 0.001). After adjustment for baseline and relevant clinical covariates, ivabradine was independently associated with an approximately 82% increase in postoperative NT-proBNP (Δlog = 0.59 ± 0.19; 95% CI: 26-164).

Conclusions: Ivabradine did not reduce the incidence of MINS and was associated with greater postoperative NT-proBNP release. Perioperative heart rate reduction with ivabradine may elevate markers of cardiac stress without measurable clinical benefit.

Compartment syndrome (CS) arises from increased pressure within a confined space, compromising organ function due to reduced blood flow and subsequent tissue hypo-xia and ischemia. Thoracic compartment syndrome (TCS), a subset of CS, occurs in diverse surgical and medical conditions, particularly cardiac surgery, chest trauma, and critical care scenarios, significantly contributing to morbidity and mortality. However, the absence of a standardized definition hinders timely diagnosis and treatment. This study systematically explores the clinical presentation, pathophysiology, and causes of TCS, aiming to establish a comprehensive definition to guide diagnosis and research. A multi-stage review process was employed. Two independent reviewers screened titles, abstracts, and full texts of studies identified through databases such as PubMed, Scopus, Embase, Google Scholar, and SpringerLink, complemented by gray literature searches in NTIS and EAGLE. Inclusion criteria focused on adult patients, excluding pediatric and obstetric populations. The search spanned all relevant studies published up to December 20, 2024. TCS remains under-recognized yet poses significant risks in critically ill patients. This article proposes a definition grounded in evidence and pathophysiological insights to aid diagnosis and future investigations into this life-threatening condition.

Assessing pain in non-communicative patients remains challenging in anaesthesia and intensive care. When self-report is unavailable, clinicians infer nociception from behaviour and physiology. Behavioural scales such as the Behavioral Pain Scale and the Critical-Care Pain Observation Tool are simple and reproducible, supporting consistent practice; however, performance declines with deep sedation, neuromuscular blockade, or severe neurological injury. Where behavioural cues are absent or unreliable, physiological and neurophysiological signals provide partial information. Autonomic indicators, including heart rate variability, the Surgical Pleth Index, pupillometry, and skin conductance, capture sympathetic responses to noxious stimuli rather than perceived pain and are sensitive to drugs, haemodynamic instability, shivering, and agitation. Electroencephalography and functional near-infrared spectroscopy identify cortical responses to nociceptive input, yet clinically useful thresholds remain context dependent, and most applications are research-based. Emerging machine-learning systems that integrate behaviour and physiology show promise, but models validated in the operating room are not automatically applicable in the intensive care unit and require new external validation with potential recalibration. Evidence is generally stronger intraoperatively than in intensive care, and paediatric data are limited. No instrument directly measures subjective pain when self-report is absent. Available tools index nociception through behavioural and physiological correlates and must be interpreted within the clinical context.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are now recognized as important but often underdiagnosed contributors to cardiovascular instability in critically ill patients. Recent studies have clarified the mechanisms by which elevated intra-abdominal pressure (IAP) reduces venous return, raises intrathoracic pressure, and impairs both preload and contractility while increasing afterload. These pathophysiological changes can compromise organ perfusion even at modest IAP elevations, and the interplay between cardiovascular, renal, and hepatic dysfunction has led to the concept of the cardio-abdomino-renal syndrome. Advances in monitoring have shifted practice away from static pressure indices such as central venous and pulmonary artery occlusion pressures. Emerging evidence supports the use of abdominal perfusion pressure, mean perfusion pressure, and volumetric indices obtained by transpulmonary thermodilution, alongside echocardiography and ultrasound-based venous congestion assessment. These tools enable individualized resuscitation strategies, balancing fluid therapy with the risks of exacerbating IAH. The purpose of this review is to synthesize recent evidence on the cardiovascular consequences of IAH and ACS, highlight evolving monitoring techniques, and outline current approaches to management. By integrating updated concepts into clinical practice, early recognition and targeted interventions may mitigate multi-organ dysfunction and improve patient outcomes.

Background: Cricoid pressure (CP) is commonly used during rapid sequence induction and intubation to prevent regurgitation and aspiration of gastric contents. However, its effectiveness and safety have been questioned. Paratracheal pressure (PP) has emerged as a potential alternative. This study aimed to compare the adverse effects of PP versus CP on the glottic view during direct laryngoscopy.

Material and methods: This randomized, double-blind, non-inferiority trial included 200 adult patients undergoing general anaesthesia. Participants were randomly assigned to receive either PP or CP during anaesthesia induction. The primary endpoint was the incidence of deteriorated laryngoscopic view, assessed by a blinded observer using the modified Cormack-Lehane grade with a non-inferiority margin of -10%. Secondary endpoints included the percentage of the glottic opening score, ease of mask ventilation, changes in ventilation volume and peak inspiratory pressure (PIP) during mechanical mask ventilation, ease of tracheal intubation, and resistance during tube advancement.

Results: PP was found to be non-inferior to CP regarding the incidence of deteriorated laryngoscopic view (0% vs. 20%; absolute risk difference, -20%; 2-sided 95% CI, -26.68 to -13.32; P < 0.001). Mask ventilation was easier with PP (OR, 0.60; 95% CI, 0.15-2.17; P = 0.284). The increase in PIP was significantly smaller in the paratracheal group (0.47 (0.31-0.63) vs. 1.46 (1.22-1.69); P = 0.002).

Conclusions: PP is non-inferior to CP concerning its effect on the glottic view during direct laryngoscopy. Additionally, PP may facilitate easier mask ventilation and reduce PIP during mechanical ventilation, making it a viable alternative to cricoid pressure.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is predominantly performed in high-volume centres with extensive experience, which may limit its adoption by new facilities. However, data from the Extracorporeal Life Support Organization registry indicate that ECPR is often performed in small-volume centres, suggesting potential for its successful implementation. The aim of the study was to assess the first-year periprocedural results and patient outcomes after launching an ECPR programme in a newly established referral centre.

Methods: Data from 22 consecutive patients (median age 44.5 years, 77.3% male) who underwent ECPR for out-of-hospital cardiac arrest between May 2023 and May 2024 were retrospectively analysed. The most frequent aetiologies were acute myocardial infarction (31.8%) and pulmonary embolism (22.7%). Periprocedural characteristics, complications, and survival and neurological outcomes at 3 months were assessed.

Results: The median cannulation time was 15.5 minutes (IQR: 15.0-20.0) and median time from cardiac arrest to extracorporeal membrane oxygenation flow was 59.5 minutes (IQR: 40.0-78.8). At 3-month follow-up, the survival rate reached 31.8% (7 patients), and a favourable neurological outcome (a score of 1 or 2 on the Cerebral Performance Category Scale) occurred in 27.3% of the study group (6 patients). The cannulation success rate was 100%. In one case, cannulation was complicated by a perforation of the right femoral artery, necessitating endovascular repair.

Conclusions: The preliminary results from the first year of our ECPR programme indicate that initiation of such an advanced resuscitative strategy in a newly established centre is achievable, with acceptable short-term clinical and neurological outcomes.

Anaesthesia in children seems to be still a challenge for anaesthetists, who usually anaesthetize adult patients in everyday practice. The principles in the field of pediatric anaesthesiology in Poland are regulated by the regulation of the Minister of the Health on the organizational standard as well as requirements regarding the equipment and staff skills, taking into account the safety and quality of the comprehensive perioperative care in hospitals where those procedures are performed in children. The most important rule in the perioperative care is ERAS concept i.e. improving the results of surgical treatment through a comprehensive approach to child in the perioperative period. Some components of this concept apply to anesthetic field such as shortening fasting time, avoiding pharmacological premedication, multimodal analgesia, prevention nausea and vomiting or emergence delirium. This article presents the updated consensus statement of the Section of Paediatric Anaesthesiology and Intensive Therapy of the Polish Society of Anaesthesiology and Intensive Therapy on anesthesia in children over 3 years of age, regarding general and specific recommendations in selected surgical specialties. We hope that this statement, which is a continuation of the statement for children under 3 years, will be of interest to anaesthetists who perform anaesthesia in children and adolescents.

The anaesthesia of a young child under 3 years of age is a challenge for every anaesthetist. The peculiarities of this group of patients, particularly neonates and infants, resulting primarily from differences in both physiology, anatomy and the immaturity of individual organs which translate into different pharmacokinetics and pharmacodynamics of the drugs used in anaesthesiology, underlie the significantly more frequently recorded critical events during anaesthesia compared with the adult patient population. Concerned about the safety of children undergoing anaesthesia and aiming to ensure the highest possible quality and uniform standard of anaesthetic services, the Expert Panel of the Section of Paediatric Anaesthesiology and Intensive Care has prepared a Section position paper on anaesthesia in children under 3 years of age.