Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anaesthesia for elective surgery: a systematic review and meta-analysis.

BACKGROUND: Many RCTs have evaluated the influence of intraoperative tidal volume (tV), PEEP, and driving pressure on the occurrence of postoperative pulmonary complications, cardiovascular complications, and mortality in adult patients. Our meta-analysis aimed to investigate the association between tV, PEEP, and driving pressure and the above-mentioned outcomes. METHODS: We conducted a systematic review and meta-analysis of RCTs from inception to May 19, 2022. The primary outcome was the incidence of postoperative pulmonary complications; the secondary outcomes were intraoperative cardiovascular complications and 30-day mortality. Primary and secondary outcomes were evaluated stratifying patients in the following groups: (1) low tV (LV, tV 6-8 ml kg-1 and PEEP ≥5 cm H2O) vs high tV (HV, tV >8 ml kg-1 and PEEP=0 cm H2O); (2) higher PEEP (HP, ≥6 cm H2O) vs lower PEEP (LP, <6 cm H2O); and (3) driving pressure-guided PEEP (DP) vs fixed PEEP (FP). RESULTS: We included 16 RCTs with a total sample size of 4993. The incidence of postoperative pulmonary complications was lower in patients treated with LV than with HV (OR=0.402, CI 0.280-0.577, P<0.001) and lower in DP than in FP group (OR=0.358, CI 0.187-0.684, P=0.002). Postoperative pulmonary complications did not differ between HP and LP groups; the incidence of intraoperative cardiovascular complications was higher in HP group (OR=1.385, CI 1.027-1.867, P=0.002). The 30-day mortality was not influenced by the ventilation strategy. CONCLUSIONS: Optimal intraoperative mechanical ventilation is unclear; however, our meta-analysis showed that low tidal volume and driving pressure-guided PEEP strategies were associated with a reduction in postoperative pulmonary complications.

Telemedicine in Cancer Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Telemedicine is defined as the delivery of medical services through a variety of telecommunication tools. This novel approach can fit the needs of cancer patients who cannot often reach clinics due to their disabling symptoms. In this population of patients, pain is undoubtedly the most important symptom which dramatically affects the quality of life. Our work aimed to investigate the effectiveness of telemedicine in the management of cancer pain in order to assess the feasibility of a combination between telemedicine and traditional in-person visits; we also propose a model of integration of these two approaches. METHODS: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework to conduct our study. Quality assessment and risk of bias were performed according Cochrane criteria. Results were reported as mean differences and summarized using forest plots. We performed a trial sequential analysis (TSA) to assess the conclusiveness of our results. RESULTS: Pain severity score and pain interference were lower for patients treated with telemedicine compared to those undergoing classical management (mean difference: -0.408; P =< .001 and -0.492; P = .004, respectively). TSA confirmed that our results were statistically significant and pointed out the need of other studies to reach the required sample size. PROSPERO registration: CRD42022333260. CONCLUSIONS: Telemedicine can be effectively used to manage cancer pain. This novel approach will certainly have a revolutionary economic and organizational impact on health care systems in the next future. Furthermore, the model herein proposed could help set up an algorithm to safely and efficiently implement telemedicine.

Association of Hypoactive and Hyperactive Delirium With Cognitive Function After Critical Illness.

OBJECTIVES: Delirium, a heterogenous syndrome, is associated with worse long-term cognition after critical illness. We sought to determine if duration of motoric subtypes of delirium are associated with worse cognition. DESIGN: Secondary analysis of prospective multicenter cohort study. SETTING: Academic, community, and Veteran Affairs hospitals. PATIENTS: Five-hundred eighty-two survivors of respiratory failure or shock. INTERVENTIONS: We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale daily during hospitalization. We defined a day with hypoactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score less than or equal to 0 and a day with hyperactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score greater than 0. At 3 and 12 months, we assessed global cognition with the Repeatable Battery for the Assessment of Neurologic Status and executive function with the Trail Making Test Part B. We used multivariable regression to examine the associations between days of hypoactive and hyperactive delirium with cognition outcomes. We allowed for interaction between days of hypoactive and hyperactive delirium and adjusted for baseline and in-hospital covariates. MEASUREMENTS AND RESULTS: Hypoactive delirium was more common and persistent than hyperactive delirium (71% vs 17%; median 3 vs 1 d). Longer duration of hypoactive delirium was associated with worse global cognition at 3 (-5.13 [-8.75 to -1.51]; p = 0.03) but not 12 (-5.76 [-9.99 to -1.53]; p = 0.08) months and with worse executive functioning at 3 (-3.61 [-7.48 to 0.26]; p = 0.03) and 12 (-6.22 [-10.12 to -2.33]; p = 0.004) months; these associations were not modified by hyperactive delirium. Hyperactive delirium was not associated with global cognition or executive function in this cohort. CONCLUSIONS: Longer duration of hypoactive delirium was independently associated with worse long-term cognition. Assessing motoric subtypes of delirium in the ICU might aid in prognosis and intervention allocation. Future studies should consider delineating motoric subtypes of delirium.

A Brief Informant Screening Instrument for Dementia in the ICU: The Diagnostic Accuracy of the AD8 in Critically Ill Adults Suspected of Having Pre-Existing Dementia.

BACKGROUND/AIM: The diagnostic accuracy of brief informant screening instruments to detect dementia in critically ill adults is unknown. We sought to determine the diagnostic accuracy of the 2- to 3-min Ascertain Dementia 8 (AD8) completed by surrogates in detecting dementia among critically ill adults suspected of having pre-existing dementia by comparing it to the Clinical Dementia Rating Scale (CDR). METHODS: This substudy of BRAIN-ICU included a subgroup of 75 critically ill medical/surgical patients determined to be at medium risk of having pre-existing dementia (Informant Questionnaire on Cognitive Decline in the Elderly [IQCODE] score ≥3.3). We calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and AUC for the standard AD8 cutoff of ≥2 versus the reference standard CDR score of ≥1 for mild dementia. RESULTS: By the CDR, 38 patients had very mild or no dementia and 37 had mild dementia or greater. For diagnosing mild dementia, the AD8 had a sensitivity of 97% (95% CI 86-100), a specificity of 16% (6-31), a PPV of 53% (40-65), an NPV of 86% (42-100), and an AUC of 0.738 (0.626-0.850). CONCLUSIONS: Among critically ill patients judged at risk for pre-existing dementia, the 2- to 3-min AD8 is highly sensitive and has a high NPV. These data indicate that the brief tool can serve to rule out dementia in a specific patient population.

Obstetric Admissions in ICU in a Tertiary Care Center: A 5-Years Retrospective Study.

BACKGROUND AND AIM: Obstetric patients admitted to intensive care unit (ICU) represent a challenge to physicians. The purpose of this study is to evaluate the incidence, characteristics, and mortality of pregnant and postpartum patients requiring ICU admission. MATERIALS AND METHODS: A retrospective cohort study was performed between January 2008 and December 2013 at the University Hospital Federico II of Naples including pregnant and puerperal women until the 42nd day of postpartum and admitted to ICU. RESULTS: Patients admitted with an obstetric diagnosis had a higher incidence of at least one previous cesarean section, were treated more with hysterectomy, had an increasing incidence of hemodynamic instability, had more postpartum admission, had a higher TISS-28 score, and required more endotracheal intubation than patients admitted with non-obstetrics diagnosis. CONCLUSION: A shared approach including a close collaboration between ICU and obstetric ward may be useful to reduce ICU admission and to improve maternal and foetal outcomes. HOW TO CITE THIS ARTICLE: Vargas M, Marra A, Buonanno P, Iacovazzo C, Schiavone V, Servillo G. Obstetric Admissions in ICU in a Tertiary Care Center. A 5-years Retrospective Study. Indian J Crit Care Med 2019;23(5):213-219.

Co-Occurrence of Post-Intensive Care Syndrome Problems Among 406 Survivors of Critical Illness.

OBJECTIVES: To describe the frequency of co-occurring newly acquired cognitive impairment, disability in activities of daily livings, and depression among survivors of a critical illness and to evaluate predictors of being free of post-intensive care syndrome problems. DESIGN: Prospective cohort study. SETTING: Medical and surgical ICUs from five U.S. centers. PATIENTS: Patients with respiratory failure or shock, excluding those with preexisting cognitive impairment or disability in activities of daily livings. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: At 3 and 12 months after hospital discharge, we assessed patients for cognitive impairment, disability, and depression. We categorized patients into eight groups reflecting combinations of cognitive, disability, and mental health problems. Using multivariable logistic regression, we modeled the association between age, education, frailty, durations of mechanical ventilation, delirium, and severe sepsis with the odds of being post-intensive care syndrome free. We analyzed 406 patients with a median age of 61 years and an Acute Physiology and Chronic Health Evaluation II of 23. At 3 and 12 months, one or more post-intensive care syndrome problems were present in 64% and 56%, respectively. Nevertheless, co-occurring post-intensive care syndrome problems (i.e., in two or more domains) were present in 25% at 3 months and 21% at 12 months. Post-intensive care syndrome problems in all three domains were present in only 6% at 3 months and 4% at 12 months. More years of education was associated with greater odds of being post-intensive care syndrome free (p < 0.001 at 3 and 12 mo). More severe frailty was associated with lower odds of being post-intensive care syndrome free (p = 0.005 at 3 mo and p = 0.048 at 12 mo). CONCLUSIONS: In this multicenter cohort study, one or more post-intensive care syndrome problems were present in the majority of survivors, but co-occurring problems were present in only one out of four. Education was protective from post-intensive care syndrome problems and frailty predictive of the development of post-intensive care syndrome problems. Future studies are needed to understand better the heterogeneous subtypes of post-intensive care syndrome and to identify modifiable risk factors.

Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review.

OBJECTIVES: The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population. DATA SOURCES: We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed. STUDY SELECTION AND DATA EXTRACTION: Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes. DATA SYNTHESIS: Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12-43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62-76%, specificity of 74-98%, positive predictive value of 63-91%, negative predictive value of 70-94%, and reliability kappa of 0.64-0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival. CONCLUSIONS: These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients.

Videolaryngoscopy versus Fiberoptic Bronchoscopy for Awake Tracheal Intubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: In recent years, videolaryngoscopy has increasingly been utilized as an alternative to fiberoptic bronchoscopy in awake intubation. Nonetheless, it remains uncertain whether videolaryngoscopy represents a viable substitute for fiberoptic bronchoscopy. We conducted this systematic review with a meta-analysis to compare videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. Methods: We systematically searched for all randomized controlled trials (RCTs) comparing videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. The Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE were systematically queried through August 2023. Our primary outcome measure was the duration of intubation. Secondary outcomes encompassed the rate of successful intubation on the initial attempt, failed intubation, patient-reported satisfaction, and any complications or adverse events potentially stemming from the intubation procedure. The Cochrane Risk of Bias Tool for RCTs was employed to evaluate all studies for evidence of bias. The GRADE approach was utilized to gauge the certainty of the evidence. Results: Eleven trials involving 873 patients were ultimately included in our review for data extraction. Meta-analysis demonstrated that videolaryngoscopy decreased the duration of intubation compared to fiberoptic bronchoscopy (SMD -1.9671 [95% CI: -2.7794 to -1.1548] p < 0.0001), a finding corroborated in subgroup analysis by the type of videolaryngoscope (SMD -2.5027 [95% CI: -4.8733 to -0.1322] p = 0.0385). Additionally, videolaryngoscopy marginally lowered the risk of experiencing a saturation below 90% during the procedure (RR -0.7040 [95% CI: -1.4038 to -0.0043] p = 0.0486). No statistically significant disparities were observed between the two techniques in terms of failed intubation, initial successful intubation attempt, or sore throat/hoarseness. With regard to patient-reported satisfaction, a pooled analysis was precluded due to the variability in evaluation methods employed across the trials to assess this outcome. Lastly, trial sequential analysis (TSA) conducted for intubation time (primary outcome) affirmed the conclusiveness of this evidence; TSA performed for secondary outcomes failed to yield conclusive evidence, indicating the necessity for further trials. Conclusions: Videolaryngoscopy for awake tracheal intubation diminishes intubation time and the risk of experiencing a saturation below 90% compared to fiberoptic bronchoscopy.

The Effects of the Pericapsular Nerve Group Block on Postoperative Pain in Patients with Hip Fracture: A Multicenter Study.

BACKGROUND: An adequate early mobilization followed by an effective and pain-free rehabilitation are critical for clinical and functional recovery after hip and proximal femur fracture. A multimodal approach is always recommended so as to reduce the administered dose of analgesics, drug interactions, and possible side effects. Peripheral nerve blocks should always be considered in addition to spinal or general anesthesia to prolong postoperative analgesia. The pericapsular nerve group (PENG) block appears to be a less invasive and more effective analgesia technique compared to other methods. METHODS: We conducted multicenter retrospective clinical research, including 98 patients with proximal femur fracture undergoing osteosynthesis surgery within 48 h of occurrence of the fracture. Thirty minutes before performing spinal anesthesia, 49 patients underwent a femoral nerve (FN) block plus a lateral femoral cutaneous nerve (LCFN) block, and the other 49 patients received a PENG block. A non-parametric Wilcoxon-Mann-Whitney (α = 0.05) test was performed to evaluate the difference in resting and dynamic numerical rating scale (NRS) at 30 min, 6 h, 12 h, and 24 h. RESULTS: the PENG block administration was more effective in reducing pain intensity compared to the FN block in association with the LFCN block, as seen in the resting and dynamic NRS at thirty minutes and 12 h follow-up. CONCLUSION: the PENG block was more effective in reducing pain intensity than the femoral nerve block associated with the lateral femoral cutaneous nerve block in patients with proximal femur fracture undergoing to osteosynthesis.

The spectrum of psychological disorders in family members of patients suffering from delirium associated with critical illness: a prospective, observational study.

During intensive care unit admission, relatives of critically ill patients can experience emotional distress. The authors hypothesized that families of patients who are diagnosed with intensive care unit (ICU) delirium experience more profound depression and anxiety disorders related to stress than do families of patients without delirium. We performed a prospective observational single-center study including families of adult patients (age above 18 years) hospitalized in a 17-bed ICU of a university hospital for at least 48 h who completed research questionnaires at day 2 after admission and day 30 after initial evaluation using dedicated questionnaires (HADS, CECS, IES, PTSD-C). A total of 98 family members of patients hospitalized in the ICU were included in the final analysis (50 family members whose relatives were CAM-ICU positive (DEL+), and 48 family members of patients without delirium (DEL-)). No statistically significant differences in demographics and psychosocial data were found between the groups. In the follow-up 30 days after the first conversation with a family member, the mean PTSD score for the relatives of patients with delirium was 11.02 (Me = 13.0; SD = 5.74), and the mean score for nondelirious patients' family members was 6.42 (Me = 5.5; SD = 5.50; p < 0.001). A statistically significant increase in IES scores for family members of patients with delirium was observed for total PTSD (p = 0.001), IES-intrusion (p < 0.001), and IES-hyperarousal (p = 0.002). The prevalence of anxiety symptoms, depression, and posttraumatic stress disorder (PTSD) was higher in families of patients diagnosed with ICU delirium within 48 h of admission to the ICU. No factors increasing the depth of these disorders in family members of patients with ICU delirium were identified. Taking appropriate actions and thus providing families with appropriate support will contribute to the understanding of unfavorable emotional states, including anxiety, stress, depression, anger, agitation, or avoidance.

Timing of Tracheostomy in ICU Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: The ideal timing for tracheostomy in critically ill patients is still debated. This systematic review and meta-analysis examined whether early tracheostomy improves clinical outcomes compared to late tracheostomy or prolonged intubation in critically ill patients on mechanical ventilation. Methods: We conducted a comprehensive search of randomized controlled trials (RCTs) assessing the risk of clinical outcomes in intensive care unit (ICU) patients who underwent early (within 7-10 days of intubation) versus late tracheostomy or prolonged intubation. Databases searched included PubMed, Embase, and the Cochrane Library up to June 2023. The primary outcome evaluated was mortality, while secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), ICU length of stay, and duration of mechanical ventilation. No language restriction was applied. Eligible studies were RCTs comparing early to late tracheostomy or prolonged intubation in critically ill patients that reported on mortality. The risk of bias was evaluated using the Cochrane Risk of Bias Tool for RCTs, and evidence certainty was assessed via the GRADE approach. Results: This systematic review and meta-analysis included 19 RCTs, covering 3586 critically ill patients. Early tracheostomy modestly decreased mortality compared to the control (RR -0.1511 [95% CI: -0.2951 to -0.0070], p = 0.0398). It also reduced ICU length of stay (SMD -0.6237 [95% CI: -0.9526 to -0.2948], p = 0.0002) and the duration of mechanical ventilation compared to late tracheostomy (SMD -0.3887 [95% CI: -0.7726 to -0.0048], p = 0.0472). However, early tracheostomy did not significantly reduce the duration of mechanical ventilation compared to prolonged intubation (SMD -0.1192 [95% CI: -0.2986 to 0.0601], p = 0.1927) or affect VAP incidence (RR -0.0986 [95% CI: -0.2272 to 0.0299], p = 0.1327). Trial sequential analysis (TSA) for each outcome indicated that additional trials are needed for conclusive evidence. Conclusions: Early tracheostomy appears to offer some benefits across all considered clinical outcomes when compared to late tracheostomy and prolonged intubation.

Potential Role of Focal Microvibration (Equistasi®) in the Management of Chronic Pain: A Pilot Study.

INTRODUCTION: Chronic pain is one of the leading causes of medical consultation with a dramatic psychophysical and socioeconomic impact. Focal microvibration (Equistasi®) is a revolutionary technology that converts the thermal energy of the skin into vibration. Equistasi® was shown to be effective in the treatment of gait and balance dysfunction in many pathological conditions such as Parkinson's disease and multiple sclerosis. Our aim was to explore the efficacy of focal microvibration in the management of chronic pain. METHODS: We randomized 60 patients with pain of different origin into two groups: an experimental group (group E) treated with Equistasi, and a control group (group C) treated with standard pharmacological therapy. Pain, disability, and working capacity were evaluated by Brief Pain Inventory (BPI), Oswestry Disability Index (ODI), and Work Ability Index (WAI) at the baseline and after 7 (T7), 15 (T15), 30 (T30), 60 (T60), and 90 (T90) days. RESULTS: According to BPI, average and worst pain in the last 24 h significantly decreased in group E at T15 and this result persisted up to T90; pain interference on general activity, mood, waling ability, normal work, relations with other people, sleep, and enjoyment of life decreased in group E with a significant improvement from T15. Lifting activity and work ability in relation to demands also significantly improved in group E. No significant changes in BPI, ODI, and WAI scores were recorded in group C during the follow-up. CONCLUSIONS: Focal microvibration can be an effective tool for managing chronic pain in combination with other therapies.