Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations.

Aim: This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background: NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods: Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results: Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion: Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article: Karim HMR, Sarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938-948.

Slow ventricular tachycardia in a 91-year-old man with implantable cardioverter-defibrillator and acute respiratory failure.

Slow ventricular tachycardia (VT) in patients with devices such as an implantable cardioverter - defibrillator (ICD) is more common than in the rest of the population. The incidence in elderly patients with an ICD remains largely unknown. In younger patients, slow VT is generally asymptomatic or associated with limited clinical relevance. It may be efficiently and safely terminated by anti-tachycardia pacing. We present a case of slow VT in a 91-year-old man with ICD with type 1 acute respiratory failure and drowsiness. Very elderly patients who have poor cardiac reserve and minor deterioration in cardiac function can face serious consequences such as ventricular fibrillation, cardiac arrest, and sudden cardiac death. The persistent ventricular rhythm may have a deleterious effect on their haemodynamic status, with potential aggravation of symptoms of heart failure and further impairment of ventricular function.

Caring for critically ill oldest old patients: a clinical review.

Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their life expectancy and the impact of multimorbidity. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.

Non-invasive ventilation for very old patients with limitations to respiratory care in half-open geriatric ward: experience on a consecutive cohort of patients.

INTRODUCTION: A leading role for non-invasive ventilation (NIV), as comfort treatment or palliative care, is actually recognized for very old patients suffering from ARF. NIV was frequently used in both ICU and respiratory ICU (RICUs) for very old patients and it is associated with a reduced rate of endotracheal intubations and mortality. This study aims to evaluate the effects of NIV, performed in a setting of half-open geriatric ward with family support, in a cohort of very old patients with ARF and DNI decision. METHODS: A consecutive cohort of 20 very old patients with DNI decision was admitted in our 26-bed geriatric ward during a 6 months' period. DNI decision was obtained in emergency room with an intensive care physician supported by a psychologist. Pressure support ventilation was the first choice of NIV. NIV has been performed by three adequately trained geriatricians, with one of them experienced in ICU, and in close collaboration with intensive care physicians. Arterial blood gases, to assess the response to ventilation, were obtained after 1, 6 and 12 h. NIV settings were modified according to arterial blood gas analyses or respiratory fatigue, if needed. RESULTS: Therefore, 75% of patients were discharged home and 12 out of 20 patients had home respiratory support. PaO2/FiO2 ratio and pH increased while PaCO2 decreased during the 12 h of NIV with statistical significance. At the admission, alive patients had PaCO2 significantly lower than dead patients. After 12 h, alive patients had a better pH than dead patients. Dead patients experienced more complication than survivors. CONCLUSION: Very old DNI patients with ARF could be treated with NIV in half-open geriatric ward with trained physicians and nurses. The presence of family members may improve patients' comfort and reduce anxiety level even at the end of life. Further studies are needed to address the effective role of NIV in very old patients with DNI decisions.

Latent tuberculosis reactivation in the setting of SARS-Cov-2 infection: The analysis of the radiologic features that help the diagnosis.

In Italy tuberculosis is a relatively rare disease and people coming from developing nations are usually affected. The radiological findings are variable and depend on the tuberculosis activity, if primary or post-primary. In literature, few data are reported about the co-existence of COVID-19 and lung tuberculosis. In this case report, authors describe the imaging features of latent lung tuberculosis in a patient with SARS-CoV-2 disease. The important role of CT imaging in identifying and diagnosing other infectious lung diseases presenting in the setting of the polymorphism and severity of SARS-CoV-2 disease is also discussed.

Noninvasive ventilation: education and training. A narrative analysis and an international consensus document.

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries.

Who gets to decide for the older patient with a limited decision-making capacity: a review of surrogacy laws in the European Union.

Family members of older incompetent patients are increasingly playing an essential role in the decision-making process relating to medical treatment. Furthermore, rights of patients and carers and the extent of their legal involvement vary widely across the European Union. Starting with an illustrative case within the Italian legal framework, this review focuses on statutory laws in the European Union to analyse the role and the rights of surrogates on behalf of older incompetent patients. The authors have identified two main essential areas of surrogate's law in Europe, in the absence of the advance directives: the role of family members automatically accepted as surrogates by law and a legal representative appointed by a court.

Effects of demographic and environmental variables on cognitive performance in a rural community sample of elderly people living in Southern Italy.

BACKGROUND AND AIMS: The aim of our study was to understand how demographic and environmental factors may be associated with cognitive functions in a rural population of Southern Italy, with a very high percentage of elderly persons with little formal education. MATERIALS AND METHODS: From the population registry of San Marcellino (province of Caserta), out of 1089 persons aged over 60 years, a random sample of 300 residents received a door-to-door visit. Two hundred and twenty-six subjects were judged as not having significant cognitive impairment, on the basis of their personal history and Clinical Dementia Rating score (< 1). They were administered the Mini Mental State Examination (MMSE). RESULTS: A positive statistically significant correlation was observed between MMSE score and education, but not between MMSE score, age and gender. Normative data showed that 90% of the normal population from this area had an adjusted MMSE score of more than 16.20, a value far below the traditional cut-off score of 23/24 for diagnosis of dementia. Subjects living with their families showed better performance than persons living alone or only with spouses. CONCLUSIONS: This finding is consistent with other epidemiologic surveys, and suggests the possible role of ecological and environmental factors in preventing or compensating cognitive decline, at least in persons coming from homogeneous rural areas. Low social demands in a protective family environment do not stimulate high intellectual performance, and signs of dementia may not be recognized by persons living in this context until the patient reaches a severe stage of disease.