Challenges of the Regional Anesthetic Techniques in Intensive Care Units - A Narrative Review.

Effective pain management is vital for critically ill patients, particularly post-surgery or trauma, as it can mitigate the stress response and positively influence morbidity and mortality rates. The suboptimal treatment of pain in Intensive Care Unit (ICU) patients is often due to a lack of education, apprehensions about side effects, and improper use of medications. Hence, the engagement of pain management and anesthesiology experts is often necessary. While opioids have been traditionally used in pain management, their side effects make them less appealing. Local anesthetics, typically used for anesthesia and analgesia in surgical procedures, have carved out a unique and crucial role in managing pain and other conditions in critically ill patients. This work aims to offer a comprehensive overview of the role, advantages, challenges, and evolving practices related to the use of local anesthetics in ICUs. The ability to administer local anesthetics continuously makes them a suitable choice for controlling pain in the upper and lower extremities, with fewer side effects. Epidural analgesia is likely the most used regional analgesic technique in the ICU setting. It is primarily indicated for major abdominal and thoracic surgeries, trauma, and oncology patients. However, it has contraindications and complications, so its use must be carefully weighed. Numerous challenges exist regarding critically ill patients, including renal and hepatic failure, sepsis, uremia, and the use of anticoagulation therapy, which affect the use of regional anesthesia for pain management. Appropriate timing and indication are crucial to maximizing the benefits of these methods. The advent of new technologies, such as ultrasonography, has improved the safety and effectiveness of neuraxial and peripheral nerve blocks, making them feasible options even for heavily sedated patients in ICUs.

Total Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging - Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?

Background: Since its debut, as reported by the first published studies, COVID-19 has been linked to life-threatening conditions that needed vital assistance and admission to the intensive care unit. Skeletal muscle is a core element in an organism's health due to its ability to keep energy balance and homeostasis. Many patients with prolonged hospitalization are characterized by a greater probability prone to critical illness myopathy or intensive care unit-acquired weakness. Objective: The main aim of this study was to assess the skeletal muscle in a COVID-19 cohort of critically ill patients by measuring the psoas area and density. Material and methods: This is a retrospective study that included critically ill adult patients, COVID-19 positive, mechanically ventilated, with an ICU stay of over 24 hours, and who had 2 CT scans eligible for psoas muscle evaluation. In these patients, correlations between different severity scores and psoas CT scans were sought, along with correlations with the outcome of the patients. Results: Twenty-two patients met the inclusion criteria. No statistically significant differences were noticed regarding the psoas analysis by two blinded radiologists. Significant correlations were found between LOS in the hospital and in ICU with psoas area and Hounsfield Units for the first CT scan performed. With reference to AUC-ROC and outcome, it is underlined that AUC-ROC is close to 0.5 values, for both the psoas area and HU, indicating that the model had no class separation capacity. Conclusion: The study suggested that over a short period, the psoas muscle area, and the psoas HU decline, for both the left and the right sight, in adult COVID-19 patients in ICU conditions, yet not statistically significant. Although more than two-thirds of the patients had a negative outcome, it was not possible to demonstrate an association between the SARS-COV2 infection and psoas muscle impairment. These findings highlight the need for further larger investigations.

Assessment of the Diaphragm Thickness Decrease in Critically Ill COVID-19 Patients: Could Computed Tomography Be of Aid Regarding Diaphragm Muscle Mass?

INTRODUCTION: The diaphragm has a significant clinical value on respiratory performance. There is little literature on the use of thorax computed tomography for the purpose of identifying alterations in diaphragm thickness in critically ill patients diagnosed with COVID-19. The present study aims to investigate dynamic changes in muscle thickness and its association with clinical outcomes. METHODS: A single-center retrospective observational study was conducted in a tertiary intensive care unit (ICU). The study comprised adult patients with severe COVID-19 who were admitted to the ICU and underwent two thorax CT scans. We measured diaphragmatic thickness at the level of the celiac truncus. RESULTS: The average reduction in thickness of the dynamic diaphragm was found to be -0.58 mm for the right diaphragm and -0.54 mm for the left diaphragm. The diaphragm thickness exhibited a substantial decrease on both the right and left sides in both CT scans (p=0.02). A negative correlation coefficient was observed for both the right and left diaphragm. The criterion indicating a poor prognosis for the right diaphragm was a value greater than -0.175, whereas it was more significant for the left diaphragm than -0.435. The cut-off values indicated a high risk of prolonged mechanical ventilation and an increased risk of ICU mortality. CONCLUSION:  CT diaphragm evaluation in mechanically ventilated COVID-19 patients has the possibility of becoming a reliable tool for predicting muscle modifications.

Airway Ultrasound for Anesthesia and in Intensive Care Patients-A Narrative Review of the Literature.

Ultrasound is an everyday diagnostic tool. In anesthesia and intensive care, it has a role as an adjuvant for many procedures, including the evaluation of the airway. Ultrasound airway evaluation can help predict a difficult airway, visualize the proper positioning of an intubation cannula, or evaluate the airway post-intubation. Protocols need to be established for the better integration of ultrasound in the airway evaluation, however until a consensus is reached in this respect, the ultrasound is a reliable aid in anesthesia and intensive care.

Survey on Anxiety and Post-Traumatic Stress Disorder in Intensive Care Personnel during the COVID-19 Pandemic in a Medically Under-Resourced Country.

The COVID-19 pandemic has increased the need for intensive care personnel. Romania has a low number of physicians per inhabitant. The stress of pandemics upon an already weak medical health system triggered some psychological effects upon burnt-out personnel. The main objective is to provide an insight into the psychological status of Romanian ICU personnel by evaluating their level of anxiety. The secondary objectives aim to identify the level of post-traumatic stress disorder and anxiety in different groups and to identify the personnel most affected psychologically. This study enrolled adult responders from the ICU of Târgu Mureș Emergency Clinical County Hospital, Romania, participating voluntarily. The evaluation tests were the State-Trait Anxiety Inventory and Post-Traumatic Stress Test. Out of the 126 eligible participants, 87 adult employees were enrolled-with a 69% response rate. The study comprised three groups: doctors, nurses, and auxiliary personnel. All three groups scored for moderate anxiety symptoms. COVID-19-related anxiety was strongly correlated with age and number of working years in all groups. Increased PTSD scores were observed in doctors and nurses. All ICU personnel who dealt with COVID-19 patients presented with moderate anxiety and post-traumatic stress disorder symptoms. The years of ICU experience had a positive impact on anxiety symptoms.

Cardio Protective Effects of Lipid Emulsion against Ropivacaine-Induced Local Anesthetic Systemic Toxicity-An Experimental Study.

Inadvertent intravascular injection of local anesthetics (LA) during regional anesthesia causes Local Anesthetic Systemic Toxicity (LAST). Theories of lipid rescue in the case of LAST proved that the administration of lipids in LAST has beneficial effects. One possible mechanism of action is based on the lipophilic properties of LA which allow plasma-free LA to be bound by the molecules of Lipid Emulsion (LE). The association LA-LE is shuttled towards organs such as liver and the kidneys, and the half-life of LA is shortened. The main objective of this experimental study was to assess the possible cardio-prophylactic effect of LE administration before the induction of LAST by intravenous administration of Ropivacaine. This was an experimental, interventional, prospective, and non-randomized study. The subjects were divided into groups and received, under general anesthesia, LE 20% first 0.3-0.4 mL, followed by 0.1 mL Ropivacaine 2 mg/mL, or Ropivacaine alone. At the end of the experiment, the subjects were sacrificed, and tissue samples of kidney, heart and liver were harvested for histopathological examination. LE, when administered as prophylaxis in Ropivacaine-induced LAST, had protective cardiac effects in rats. The LE known side effects were not produced if the substance was administered in the low doses used for LAST prophylaxis.

The role of interleukin-6 as an early predictor of sepsis in a murine sepsis model.

AIM: Evaluating the role of interleukin-6 (IL-6) as an early predictor of sepsis in a murine model. MATERIALS AND METHODS: The study divided 26 Wistar rats into two experimental groups in which sepsis was induced through the intraperitoneal injection of different Escherichia coli cultures [Group 1: Extended-spectrum beta-lactamase (ESBL)-producing culture and Group 2: Standardized ATCC35218 culture] and a control group. IL-6 levels were determined at 5 and 24 hours post-inoculation and immunohistochemistry (IHC) was performed on tissue samples from the sacrificed animals. RESULTS: Mean plasma IL-6 levels in Group 1 peaked at 5 hours [37.4 pg∕mL; standard deviation (SD) = 2.4 pg∕mL] and decreased at 24 hours (34 pg∕mL; SD=3.2 pg∕mL) after inoculation. IL-6 levels in Group 1 were elevated compared to Group 2, at 5 hours (33.7 pg∕mL; SD=3.3 pg∕mL; p=0.019) and non-significantly so at 24 hours (32.5 pg∕mL; SD=2.4 pg∕mL; p=0.233). The results did not show an increase over control levels at either 5 hours (37.6 pg∕mL; SD=3.4 pg∕mL) or 24 hours (40.8 pg∕mL; SD=2.9 pg∕mL) after inoculation. The IHC shows a varying degree of IL-6 expression across all organ types studied. No statistically significant correlations were found between the tissue level quantification of IL-6 and serum values at 24 hours in either group. CONCLUSIONS: For an early stage of infection/inflammation, serum levels of IL-6 are not correlated with tissue-level inflammation disproving a potential role of IL-6 as a very precocious diagnostic and predictor test. Accumulation of IL-6 in lung, kidney and spleen tissue can be observed from the beginning of inflammation.