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PURPOSE: The use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) by patients undergoing surgery and procedures requiring anesthesia has become a topic of significant concern for perioperative providers because of the potential increased risk of aspiration resulting from the medication's effect of delaying gastric emptying. There is currently a lack of high-quality data regarding the safety of GLP-1 RAs in patients undergoing surgery, which has led to variations in practice. SOURCE: We performed an internet search of society-endorsed statements and guidelines related to perioperative management of GLP-1 RAs, focusing on the top 20 countries with the largest anesthesiology societies determined by membership data from the World Federation of Societies of Anesthesiologists. We excluded articles and websites that were not in English. PRINCIPAL FINDINGS: Our search revealed endorsed statements from fourteen major anesthesiology, endocrinology, and gastroenterology societies. There was considerable variation between societies in the recommendations and guidance for withholding these medications before surgery, the duration of withholding, assessment of the need for avoiding deep sedation or general anesthesia, use of rapid sequence intubation, need for prolonged fasting periods and clear fluid before a nil per os period, recognition of signs and symptoms for aspiration risk, the management of glucose in the perioperative period, and the use of point-of-care ultrasound for risk assessment. CONCLUSION: Society-endorsed statements and guidelines provide varying recommendations on the perioperative management of GLP-1 RAs. The insights gained from this comparative analysis may help guide clinical practice, develop institutional practice guidelines, and direct future research efforts.
RéSUMé: OBJECTIF: L'utilisation d'agonistes des récepteurs (AR) du peptide-1 de type glucagon (GLP-1) par les personnes bénéficiant d'une intervention chirurgicale et de procédures nécessitant une anesthésie est devenue un sujet de préoccupation important pour les prestataires de soins périopératoires en raison de l'augmentation du risque potentiel d'aspiration résultant de l'effet du médicament, qui provoque un retard de la vidange gastrique. Il existe actuellement un manque de données de haute qualité concernant l'innocuité des AR GLP-1 chez les patient·es bénéficiant d'une intervention chirurgicale, ce qui a mené à des variations dans la pratique. SOURCES: Nous avons réalisé une recherche sur Internet des déclarations et lignes directrices approuvées par les sociétés médicales concernant la prise en charge périopératoire des AR GLP-1, en nous concentrant sur les 20 pays comptant les plus grandes sociétés d'anesthésiologie, déterminées par les données sur les membres de la Fédération mondiale des sociétés d'anesthésiologistes. Nous avons exclu les articles et les sites Web qui n'étaient pas en anglais. CONSTATATIONS PRINCIPALES: Nos recherches ont révélé des déclarations approuvées par quatorze grandes sociétés d'anesthésiologie, d'endocrinologie et de gastro-entérologie. Il y avait des variations considérables entre les sociétés en matière de recommandations et de directives concernant l'abstention de ces médicaments avant la chirurgie, la durée de l'abstention, l'évaluation de la nécessité d'éviter la sédation profonde ou l'anesthésie générale, l'utilisation de l'intubation en séquence rapide, la nécessité de périodes de jeûne prolongées et de liquides clairs avant une période nil per os, la reconnaissance des signes et symptômes du risque d'aspiration, la prise en charge de la glycémie pendant la période périopératoire et l'utilisation de l'échographie ciblée pour l'évaluation des risques. CONCLUSION: Les déclarations et les lignes directrices approuvées par les sociétés médicales fournissent des recommandations variées sur la prise en charge périopératoire des AR GLP-1. Les connaissances acquises grâce à cette analyse comparative pourraient aider à orienter la pratique clinique, à élaborer des lignes directrices de pratique institutionnelles et à guider les efforts de recherche futurs.
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Traditionally, patients with obesity have been deemed ineligible for extracorporeal life support (ELS) therapies such as extracorporeal membrane oxygenation (ECMO), given the association of obesity with chronic health conditions that contribute to increased morbidity and mortality. Nevertheless, a growing body of literature suggests the feasibility, efficacy, and safety of ECMO in the obese population. This review provides an in-depth analysis of the current literature assessing the effects of obesity on outcomes among patients supported with ECMO (venovenous [VV] ECMO in noncoronavirus disease 2019 and coronavirus disease 2019 acute respiratory distress syndrome, venoarterial [VA] ECMO, and combined VV and VA ECMO), offer a possible explanation of the current findings on the basis of the obesity paradox phenomenon, provides a framework for future studies addressing the use of ELS therapies in the obese patient population, and provides guidance from the literature for many of the challenges related to initiating, maintaining, and weaning ELS therapy in patients with obesity.
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Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório , Humanos , Estudos Retrospectivos , Obesidade/complicações , Obesidade/terapia , Síndrome do Desconforto Respiratório/terapiaRESUMO
Heart failure (HF) remains a public health concern affecting millions of individuals worldwide. Despite recent advances in device-related therapies, the prognosis for patients with chronic HF remains poor with significant long-term risk of morbidity and mortality. Left ventricular assist devices (LVADs) have transformed the landscape of advanced HF management, offering circulatory support as destination therapy or as a bridge for heart transplantation. Among the latest generation of LVADs, the HeartMate 3 has gained popularity due to improved clinical outcomes and lower risk of serious adverse events when compared with previous similar devices. The ELEVATE (Evaluating the HeartMate 3 with Full MagLev Technology in a Post-Market Approval Setting) Registry and the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) trial represent landmark investigations into the performance and comparative effectiveness of the HeartMate 3 LVAD. This review provides a comprehensive synthesis of the safety and efficacy of the 2-year and 5-year HeartMate LVAD outcomes, highlighting key findings, methodological considerations, implications for clinical practice, and future directions.
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BACKGROUND: Inhaled nitric oxide (NO) is a selective pulmonary vasodilator. In-vitro studies report that NO donors can inhibit replication of SARS-CoV-2. This multicenter study evaluated the feasibility and effects of high-dose inhaled NO in non-intubated spontaneously breathing patients with Coronavirus disease-2019 (COVID-19). METHODS: This is an interventional study to determine whether NO at 160 parts-per-million (ppm) inhaled for 30 min twice daily might be beneficial and safe in non-intubated COVID-19 patients. RESULTS: Twenty-nine COVID-19 patients received a total of 217 intermittent inhaled NO treatments for 30 min at 160 ppm between March and June 2020. Breathing NO acutely decreased the respiratory rate of tachypneic patients and improved oxygenation in hypoxemic patients. The maximum level of nitrogen dioxide delivered was 1.5 ppm. The maximum level of methemoglobin (MetHb) during the treatments was 4.7%. MetHb decreased in all patients 5 min after discontinuing NO administration. No adverse events during treatment, such as hypoxemia, hypotension, or acute kidney injury during hospitalization occurred. In our NO treated patients, one patient of 29 underwent intubation and mechanical ventilation, and none died. The median hospital length of stay was 6 days [interquartile range 4-8]. No discharged patients required hospital readmission nor developed COVID-19 related long-term sequelae within 28 days of follow-up. CONCLUSIONS: In spontaneous breathing patients with COVID-19, the administration of inhaled NO at 160 ppm for 30 min twice daily promptly improved the respiratory rate of tachypneic patients and systemic oxygenation of hypoxemic patients. No adverse events were observed. None of the subjects was readmitted or had long-term COVID-19 sequelae.
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Tratamento Farmacológico da COVID-19 , Hospitalização , Óxido Nítrico/administração & dosagem , Pneumonia Viral/tratamento farmacológico , Respiração/efeitos dos fármacos , Administração por Inalação , COVID-19/complicações , COVID-19/virologia , Relação Dose-Resposta a Droga , Humanos , Óxido Nítrico/farmacologia , Óxido Nítrico/uso terapêutico , Pneumonia Viral/complicaçõesRESUMO
Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with suspected or confirmed COVID-19 infection.
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Manuseio das Vias Aéreas , Infecções por Coronavirus/terapia , Pneumonia Viral/terapia , COVID-19 , Hospitalização , Humanos , PandemiasRESUMO
Critically ill patients with COVID-19 are at increased risk for thrombotic complications which has led to an intense debate surrounding their anticoagulation management. In the absence of data from randomized controlled clinical trials, a number of consensus guidelines and recommendations have been published to facilitate clinical decision-making on this issue. However, substantive differences exist between these guidelines which can be difficult for clinicians. This review briefly summarizes the major societal guidelines and compares their similarities and differences. A common theme in all of the recommendations is to take an individualized approach to patient management and a call for prospective randomized clinical trials to address important anticoagulation issues in this population.
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Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/terapia , Infecções por Coronavirus/complicações , Estado Terminal , Pneumonia Viral/complicações , Guias de Prática Clínica como Assunto , Trombose/etiologia , Trombose/terapia , Betacoronavirus , COVID-19 , Humanos , Pandemias , SARS-CoV-2RESUMO
This review highlights the ultrasound findings reported from a number of studies and case reports and discusses the unifying findings from coronavirus disease (COVID-19) patients and from the avian (H7N9) and H1N1 influenza epidemics. We discuss the potential role for portable point-of-care ultrasound (PPOCUS) as a safe and effective bedside option in the initial evaluation, management, and monitoring of disease progression in patients with confirmed or suspected COVID-19 infection.
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Betacoronavirus/patogenicidade , Infecções por Coronavirus/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Pneumonia Viral/diagnóstico por imagem , Sistemas Automatizados de Assistência Junto ao Leito , Testes Imediatos , Ultrassonografia , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19 , Infecções por Coronavirus/terapia , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Feminino , Humanos , Controle de Infecções , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Vírus da Influenza A Subtipo H1N1/patogenicidade , Subtipo H7N9 do Vírus da Influenza A/patogenicidade , Influenza Humana/diagnóstico por imagem , Influenza Humana/virologia , Pulmão/virologia , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/efeitos adversos , Exposição Ocupacional/prevenção & controle , Pandemias , Pneumonia Viral/terapia , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , SARS-CoV-2 , Ultrassonografia/efeitos adversosAssuntos
Betacoronavirus , Infecções por Coronavirus/fisiopatologia , Impedância Elétrica , Pneumonia Viral/fisiopatologia , Sistemas Automatizados de Assistência Junto ao Leito , Ventilação Pulmonar/fisiologia , Tomografia/métodos , Idoso , COVID-19 , Humanos , Pulmão/diagnóstico por imagem , Pulmão/fisiopatologia , Masculino , Pandemias , SARS-CoV-2Assuntos
Infecções por Coronavirus , Pandemias , Pneumonia Viral , Betacoronavirus , COVID-19 , Humanos , SARS-CoV-2 , UltrassonografiaRESUMO
Ultrasound evaluation of the upper airway has emerged as an essential instrument for clinicians, offering real-time assessment that can help to guide interventions and improve patient outcomes. This review aims to provide health care providers with a practical approach to performing ultrasound evaluation of the upper airway, covering basic physics relevant to upper airway ultrasound, the identification of key anatomical structures, and elucidating its various clinical applications, such as prediction of difficult airway, confirmation of endotracheal intubation, and guidance for surgical airway procedures and airway blocks. We also discuss evidence-based training programs, limitations, and future directions of ultrasound imaging of the upper airway.
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Intubação Intratraqueal , Humanos , Intubação Intratraqueal/métodos , Ultrassonografia/métodosRESUMO
BACKGROUND: Electroconvulsive therapy (ECT) is a procedure commonly used to treat a number of severe psychiatric disorders, including pharmacologic refractory depression, mania, and catatonia by purposefully inducing a generalized seizure that results in significant hemodynamic changes as a result of an initial transient parasympathetic response that is followed by a marked sympathetic response from a surge in catecholamine release. While the physiologic response of ECT on classic hemodynamic parameters such as heart rate and blood pressure has been described in the literature, real-time visualization of cardiac function using point-of-care ultrasound (POCUS) during ECT has never been reported. This study utilizes POCUS to examine cardiac function in two patients with different ages and cardiovascular risk profiles undergoing ECT. METHODS: Two patients, a 74-year-old male with significant cardiovascular risks and a 23-year-old female with no significant cardiovascular risks presenting for ECT treatment, were included in this study. A portable ultrasound device was used to obtain apical four-chamber images of the heart before ECT stimulation, after seizure induction, and 2 min after seizure resolution to assess qualitative cardiac function. Two physicians with expertise in echocardiography reviewed the studies. Hemodynamic parameters, ECT settings, and seizure duration were recorded. RESULTS: Cardiac standstill was observed in both patients during ECT stimulation. The 74-year-old patient with a significant cardiovascular risk profile exhibited a transient decline in cardiac function during ECT, while the 23-year-old patient showed no substantial worsening of cardiac function. These findings suggest that age and pre-existing cardiovascular conditions may influence the cardiac response to ECT. Other potential contributing factors to the cardiac effects of ECT include the parasympathetic and sympathetic responses, medication regimen, and seizure duration with ECT. This study also demonstrates the feasibility of using portable POCUS for real-time cardiac monitoring during ECT. CONCLUSION: This study reports for the first time cardiac standstill during ECT stimulation visualized using POCUS imaging. In addition, it reports on the potential differential impact of ECT on cardiac function based on patient-specific factors such as age and cardiovascular risks that may have implications for ECT and perioperative anesthetic management and optimization.
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Eletroconvulsoterapia , Parada Cardíaca , Masculino , Feminino , Humanos , Adulto Jovem , Adulto , Idoso , Eletroconvulsoterapia/efeitos adversos , Eletroconvulsoterapia/métodos , Sistemas Automatizados de Assistência Junto ao Leito , Encéfalo , Hemodinâmica/fisiologia , ConvulsõesRESUMO
Diagnostic errors are prevalent in critical care practice and are associated with patient harm and costs for providers and the healthcare system. Patient complexity, illness severity, and the urgency in initiating proper treatment all contribute to decision-making errors. Clinician-related factors such as fatigue, cognitive overload, and inexperience further interfere with effective decision-making. Cognitive science has provided insight into the clinical decision-making process that can be used to reduce error. This evidence-based review discusses ten common misconceptions regarding critical care decision-making. By understanding how practitioners make clinical decisions and examining how errors occur, strategies may be developed and implemented to decrease errors in Decision-making and improve patient outcomes.
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Volume resuscitation is a cornerstone of modern anesthesia care. Finding the right balance to avoid inadequate or excess volume administration is often difficult to clinically discern and can lead to negative consequences. Pulse pressure variation is often intraoperatively used to guide volume resuscitation; however, this requires an invasive arterial line and is generally only applicable to patients who are mechanically ventilated. Unfortunately, without a pulmonary artery catheter or another costly noninvasive device, performing serial measurements of cardiac output is challenging, time-consuming, and often impractical. Furthermore, noninvasive measures such as LVOT VTI require significant technical expertise as well as access to the chest, which may not be practical during and after surgery. Other noninvasive techniques such as bioreactance and esophageal Doppler require the use of costly single-use sensors. Here, we present a case report on the use of corrected carotid flow time (ccFT) from a portable, handheld ultrasound device as a practical, noninvasive, and technically straightforward method to assess fluid responsiveness in the perioperative period, as well as the inpatient and outpatient settings.
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Background: Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room (OR) and non-operation room sites. There are no guidelines or expert consensus focused on the assessment of the difficult airway before, so this expert consensus is developed to provide guidance for airway assessment, making this process more standardized and accurate to reduce airway-related complications and improve safety. Methods: Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology (CSA) met to discuss the first draft and then this was sent to 15 international experts for review, comment, and approval. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is used to determine the level of evidence and grade the strength of recommendations. The recommendations were revised through a three-round Delphi survey from experts. Results: This expert consensus provides a comprehensive approach to airway assessment based on the medical history, physical examination, comprehensive scores, imaging, and new developments including transnasal endoscopy, virtual laryngoscopy, and 3D printing. In addition, this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway. Conclusions: This consensus applies to anesthesiologists, critical care, and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.
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OBJECTIVES: Experimental models suggest that prone position and positive end-expiratory pressure (PEEP) homogenize ventral-dorsal ventilation distribution and regional respiratory compliance. However, this response still needs confirmation on humans. Therefore, this study aimed to assess the changes in global and regional respiratory mechanics in supine and prone positions over a range of PEEP levels in acute respiratory distress syndrome (ARDS) patients. DESIGN: A prospective cohort study. PATIENTS: Twenty-two intubated patients with ARDS caused by COVID-19 pneumonia. INTERVENTIONS: Electrical impedance tomography and esophageal manometry were applied during PEEP titrations from 20 cm H2O to 6 cm H2O in supine and prone positions. MEASUREMENTS: Global respiratory system compliance (Crs), chest wall compliance, regional lung compliance, ventilation distribution in supine and prone positions. MAIN RESULTS: Compared with supine position, the maximum level of Crs changed after prone position in 59% of ARDS patients (n = 13), of which the Crs decreased in 32% (n = 7) and increased in 27% (n = 6). To reach maximum Crs after pronation, PEEP was changed in 45% of the patients by at least 4 cm H2O. After pronation, the ventilation and compliance of the dorsal region did not consistently change in the entire sample of patients, increasing specifically in a subgroup of patients who showed a positive change in Crs when transitioning from supine to prone position. These combined changes in ventilation and compliance suggest dorsal recruitment postpronation. In addition, the subgroup with increased Crs postpronation demonstrated the most pronounced difference between dorsal and ventral ventilation distribution from supine to prone position (p = 0.01), indicating heterogeneous ventilation distribution in prone position. CONCLUSIONS: Prone position modifies global respiratory compliance in most patients with ARDS. Only a subgroup of patients with a positive change in Crs postpronation presented a consistent improvement in dorsal ventilation and compliance. These data suggest that the response to pronation on global and regional mechanics can vary among ARDS patients, with some patients presenting more dorsal lung recruitment than others.