Exposure to severe hyperoxemia worsens survival and neurological outcome in patients supported by veno-arterial extracorporeal membrane oxygenation: A meta-analysis.

BACKGROUND: Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a rescue treatment in refractory cardiogenic shock (CS) or refractory cardiac arrest (CA). Exposure to hyperoxemia is common during VA-ECMO, and its impact on patient's outcome remains unclear. METHODS: We conducted a systematic review (PubMed and Scopus) and meta-analysis investigating the effects of exposure to severe hyperoxemia on mortality and poor neurological outcome in patients supported by VA-ECMO. When both adjusted and unadjusted Odds Ratio (OR) were provided, we used the adjusted one. Results are reported as OR and 95% confidence interval (CI). Subgroup analyses were conducted according to VA-ECMO indication and hyperoxemia thresholds. RESULTS: Data from 10 observational studies were included. Nine studies reported data on mortality (n = 5 refractory CA, n = 4 CS), and 4 on neurological outcome. As compared to normal oxygenation levels, exposure to severe hyperoxemia was associated with higher mortality (nine studies; OR: 1.80 [1.16-2.78]; p = 0.009; I2 = 83%; low certainty of evidence) and worse neurological outcome (four studies; OR: 1.97 [1.30-2.96]; p = 0.001; I2 = 0%; low certainty of evidence). Magnitude and effect of these findings remained valid in subgroup analyses conducted according to different hyperoxemia thresholds (>200 or >300 mmHg) and VA-ECMO indication, although the association with mortality remained uncertain in the refractory CA population (p = 0.13). Analysis restricted to studies providing adjusted OR data confirmed an increased likelihood of poorer neurological outcome (three studies; OR: 2.11 [1.32-3.38]; p = 0.002) in patients exposed to severe hyperoxemia but did not suggest higher mortality (five studies; OR: 1.68 [0.89-3.18]; p = 0.11). CONCLUSIONS: Severe hyperoxemia exposure after initiation of VA-ECMO may be associated with an almost doubled increased probability of poor neurological outcome and mortality. Clinical efforts should be made to avoid severe hyperoxemia during VA-ECMO support.

Non-Invasive Monitoring during Caesarean Delivery: Prevalence of Hypotension and Impact on the Newborn.

BACKGROUND: The aim of our study was to investigate the prevalence of perioperative hypotension after spinal anesthesia for cesarean section using non-invasive continuous hemodynamic monitoring and its correlation with neonatal well-being. METHODS: We included 145 patients. Spinal anesthesia was performed with a combination of hyperbaric bupivacaine 0.5% (according to a weight/height scheme) and fentanyl 20 µg. Hypotension was defined as a mean arterial pressure (MAP) < 65 mmHg or <60 mmHg. We also evaluated the impact of hypotension on neonatal well-being. RESULTS: Perioperative maternal hypotension occurred in 54.5% of cases considering a MAP < 65 mmHg and in 42.1% with the more conservative cut-off (<60 mmHg). Severe neonatal acidosis occurred in 1.4% of neonates, while an Apgar score ≥ 9 was observed in 95.9% at 1 min and 100% at 5 min. CONCLUSIONS: Continuous non-invasive hemodynamic monitoring allowed an early detection of maternal hypotension leading to a prompt treatment with satisfactory results considering neonatal well-being.

Anesthesiological management of Brugada syndrome patients: A systematic review.

Brugada syndrome (BrS) is a major risk factor for sudden cardiac death and ventricular tachyarrhythmias. Several drugs are contraindicated in patients with BrS, including some commonly administered drugs during anesthesia or in the perioperative period; however, there is still a paucity of evidence regarding BrS and common anesthetic pharmaceuticals. We conducted a systematic literature search (PubMed, updated October 10, 2022), including all studies reporting pharmacological management of BrS patients during anesthesia or intensive care, with a specific focus on proarrhythmic effects and possible pharmacological interactions in the context of BrS. The search revealed 44 relevant items, though only three original studies. Two randomized controlled studies were identified, one comparing propofol and etomidate for the induction of general anesthesia and one investigating lidocaine with or without epinephrine for local anesthesia; there was also one prospective study without a control group. The other studies were case series (n = 5, for a total of 19 patients) or case reports (n = 36). Data are reported on a total population of 199 patients who underwent general or local anesthesia. None of the studies evaluated BrS patients in the intensive care unit (ICU). We found the studies focusing on the pharmacological management of BrS patients undergoing general or local anesthesia to be of generally poor quality. However, it appears that propofol can be used safely, without an increase in arrhythmic events. Regional anesthesia is possible, and lidocaine might be preferred over longer-acting local anesthetics. Considering the quality of the included studies and their anecdotal evidence, it seems increasingly important to conduct large multicenter studies or promote international registries with high-quality data on the anesthesiological management of these patients.

Red Blood Cell Transfusion Guided by Hemoglobin Only or Integrating Perfusion Markers in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis.

OBJECTIVE: Strategies for red blood cell (RBC) transfusion in patients undergoing cardiac surgery have been traditionally anchored to hemoglobin (Hb) targets. A more physiologic approach would consider markers of organ hypoperfusion. DESIGN: The authors conducted a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials (RCTs). SETTING: Cardiac surgery. PARTICIPANTS: Adult patients. INTERVENTION: RBC transfusion targeting only Hb levels compared with strategies combining Hb values with markers of organ hypoperfusion. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were the number of RBC units transfused, the number of patients transfused at least once, and the average number of transfusions. Secondary outcomes were postoperative complications, intensive care (ICU) and hospital lengths of stay, and mortality. Only 2 RCTs were included (n = 257 patients), and both used central venous oxygen saturation (ScvO2) as a marker of organ hypoperfusion (cut-off: <70% or ≤65%). A transfusion protocol combining Hb and ScvO2 reduced the overall number of RBC units transfused (risk ratio [RR]: 1.57 [1.33-1.85]; p < 0.0001, I2 = 0%), and the number of patients transfused at least once (RR: 1.33 [1.16-1.53]; p < 0.0001, I2 = 41%), but not the average number of transfusions (mean difference [MD]: 0.18 [-0.11 to 0.47]; p = 0.24, I2 = 66%), with moderate certainty of evidence. Mortality (RR: 1.29, [0.29-5.77]; p = 0.73, I2 = 0%), ICU length-of-stay (MD: -0.06 [-0.58 to 0.46]; p = 0.81, I2 = 0%), hospital length-of-stay (MD: -0.05 [-1.49 to 1.39];p = 0.95, I2 = 0%), and all postoperative complications were not affected. CONCLUSIONS: In adult patients undergoing cardiac surgery, a restrictive protocol integrating Hb values with a marker of organ hypoperfusion (ScvO2) reduces the number of RBC units transfused and the number of patients transfused at least once without apparent signals of harm. These findings were preliminary and warrant further multicentric research.

Telemedicine in Patients Affected by Chronic Liver Disease: A Scoping Review of Clinical Outcomes and the Devices Evaluated.

For patients with chronic liver disease (CLD), telemedicine is emerging as a useful tool to prevent liver decompensation or hospitalization, allowing access to and the decentralization of care, even for patients with limited resources. However, research and attendant evidence are still lacking; thus, this review aims to systematically explore the topic of telemonitoring for CLD to describe the currently used tools and clinical outcomes. The review was conducted by using key terms on PubMed/EMBASE and searching for observational studies or clinical trials (according to PRISMA recommendations) that were published between 6 April 2013 and 6 April 2023 to keep the technological framework limited to the last 10 years. The studies were described and grouped according to the aim of telemonitoring, the underlying disease, and the tools adopted to achieve remote monitoring. A total of 32 articles met the inclusion criteria. Of these, 11 articles report the successful use of a telehealth program to support and improve access to care in the management of HCV-related cirrhosis, eight articles examine the efficacy of telemedicine for remote monitoring interventions to prevent or decrease the risk of decompensation in high-risk patients, and five articles examine improvements in the physical performance and quality of life of cirrhotic patients through telehealth rehabilitation programs. Four studies were completed during the recent COVID-19 pandemic. Telehealth has the potential to provide and expand treatment access and reduce barriers to care for the most disadvantaged patients and might be able to reduce the need for hospital readmission for CLD, though most practice to test feasibility is still in the pilot stage.

Tracheal intubation while wearing personal protective equipment in simulation studies: a systematic review and meta-analysis with trial-sequential analysis.

BACKGROUND: Tracheal intubation in patients with coronavirus disease-19 is a high-risk procedure that should be performed with personal protective equipment (PPE). The influence of PPE on operator's performance during tracheal intubation remains unclear. METHODS: We conducted a systematic review and meta-analysis of simulation studies to evaluate the influence of wearing PPE as compared to standard uniform regarding time-to-intubation (TTI) and success rate. Subgroup analyses were conducted according to device used and operator's experience. RESULTS: The TTI was prolonged when wearing PPE (eight studies): Standard Mean Difference (SMD) -0.54, 95% Confidence Interval [-0.75, -0.34], p <  0.0001. Subgroup analyses according to device used showed similar findings (direct laryngoscopy, SMD -0.63 [-0.88, -0.38], p < 0.0001; videolaryngoscopy, SMD -0.39 [-0.75, -0.02], p =  0.04). Considering the operator's experience, non-anesthesiologists had prolonged TTI (SMD -0.75 [-0.98, -0.52], p < 0.0001) while the analysis on anesthesiologists did not show significant differences (SMD -0.25 [-0.51, 0.01], p = 0.06). The success rate of tracheal intubation was not influenced by PPE: Risk Ratio (RR) 1.02 [1.00, 1.04]; p = 0.12). Subgroup analyses according to device demonstrated similar results (direct laryngoscopy, RR 1.03 [0.99, 1.07], p = 0.15, videolaryngoscopy, RR 1.01 [0.98, 1.04], p =  0.52). Wearing PPE had a trend towards negative influence on success rate in non-anesthesiologists (RR 1.05 [1.00, 1.10], p = 0.05), but not in anesthesiologists (RR 1.00 [0.98, 1.03], p = 0.84). Trial-sequential analyses for TTI and success rate indicated robustness of both results. CONCLUSIONS: Under simulated conditions, wearing PPE delays the TTI as compared to dressing standard uniform, with no influence on the success rate. However, certainty of evidence is very low. Performing tracheal intubation with direct laryngoscopy seems influenced to a greater extent as compared to videolaryngoscopy. Similarly, wearing PPE affects more the non-anesthesiologists subgroup as compared to anesthesiologists.

Continuous Erector Spinae Plane Block as Postoperative Analgesic Technique for Robotic-Assisted Thoracic Surgery: A Case Series.

INTRODUCTION: The erector spinae plane block (ESPB) is a recently implemented analgesic technique initially reported for thoracic analgesia and subsequently adopted for both intra- and postoperative pain management. Thoracic surgery is among the most painful surgical procedures, even when conducted with minimally invasive approach. Robotic-assisted thoracic surgery (RATS) challenges the traditional analgesic regimens as one of its aims is to decrease the patient's length of stay (LOS) whilst achieving optimal postoperative pain management. Furthermore, there is lots of growing evidence on the impact of poorly controlled postoperative pain (PP) on the development of chronic post-surgical pain (CPSP). In these case series, we aim to describe our preliminary experience of postoperative pain management with continuous ESPB in the field of RATS. CASE SERIES PRESENTATION: In eight consecutive patients undergoing elective RATS procedure, we performed the ESPB after surgery with an initial bolus of local anesthetic followed by catheter insertion for continuous infusion. The infusion of local anesthetic lasted for the first two postoperative days. The effectiveness of the ESPB was evaluated through serial pain assessment with numeric rate scale (NRS) score, both at rest and during movement every 6 hours. Any analgesic rescue drug prescription was reported. We noted that the ESPB strongly reduced the prescription of opioids and of rescue analgesic. In our series, only one patient needed opioids during the first two postoperative days, and no rescue analgesic administration was noted in the remaining cases. CONCLUSION: We report a small but promising experience regarding postoperative pain management with continuous ESPB performed after RATS. We implemented the ESPB before surgery. Larger studies on postoperative pain management with continuous regional blocks in thoracic surgery are warranted.

Self-citation policies and journal self-citation rate among Critical Care Medicine journals.

BACKGROUND: Inappropriate authors' self-citation (A-SC) is a growing mal-practice possibly boosted by the raising importance given to author's metrics. Similarly, also excessive journals' self-citation (J-SC) practice may factitiously influence journal's metrics (impact factor, IF). Evaluating the appropriateness of each self-citation remains challenging. MAIN BODY: We evaluated the presence of policies discouraging A-SC in Critical Care Medicine (CCM) journals with IF. We also calculated the J-SC rate of these journals. In order to evaluate if J-SC rates are influenced by the focus of interest of CCM journals, we separated them in three sub-categories ("multidisciplinary", "broad" or "topic-specific" CCM journals). We analyzed 35 CCM journals and only 5 (14.3%) discouraged excessive and inappropriate A-SC. The median IF was higher in CCM journals with A-SC policies [4.1 (3-12)] as compared to those without [2.5 (2-3.5); p = 0.02]. The J-SC rate was highly variable (0-35.4%), and not influenced by the presence of A-SC policies (p = 0.32). However, J-SC rate was different according to the focus of interest (p = 0.01): in particular, it was higher in "topic-specific" CCM journals [15.3 (8.8-23.3%)], followed by "broad" CCM [11.8 (4.8-17.9%)] and "multidisciplinary" journals [6.1 (3.6-9.1%)]. CONCLUSIONS: A limited number of CCM journals have policies for limiting A-SC, and these have higher IF. The J-SC rate among CCM journals is highly variable and higher in "topic-specific" interest CCM journals. Excluding self-referencing practice from scientific metrics calculation could be valuable to tackle this scientific malpractice.