Guidelines for inhaled sedation in the ICU.

INTRODUCTION AND OBJECTIVES: Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY: Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS: The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION: The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.

Monitorización de las presiones de la vía aérea con la modalidad de flujo continuo en cirugía toracoscópica pediátrica. Estudio en modelo animal / Airway pressure monitoring by the continuous flow method in paediatric thoracoscopic surgery. A study in an animal model

Objetivo. Comparar las presiones en la vía aérea obtenidas antes del tubo endotraqueal con las intratraqueales en la modalidad ventilatoria de flujo continuo, en cirugía toracoscópica para ventilación unipulmonar, en modelo pediátrico en animales. Material y métodos. Estudio prospectivo observacional simple. Se emplearon 10 cerdos Large White, con un peso de 4,6±0,8kg. Los animales se ventilaron en modo neonatal (flujo continuo) con un respirador Temel Supra. Mediante traqueotomía realizamos un sellado completo del sistema respiratorio para usar tubos sin neumotaponamiento especiales que permiten el registro traqueal de presiones sin interferir en la ventilación. Se realizó colapso del pulmón derecho por videotoracoscopia y se mantuvo durante 120min. Las variables se analizaron en 10 tiempos: inicio y 5min en bipulmonar, tras el colapso en los tiempos 5, 15, 30, 60, 90 y 120min, y 5 y 15min tras la reexpansión pulmonar. Registramos la presión basal, pico, meseta y teleespiratoria en la boca del animal e intratraqueal. Resultados. La media de la presión pico en la boca del animal en ventilación unipulmonar fue de 23,38mmHg y traqueal de 21,24mmHg, mientras que la media de la presión meseta en la boca de animal en ventilación unipulmonar fue de 21,88mmHg y traqueal de 21,39mmHg, respectivamente, con diferencias significativas en todas (p<0,05). Encontramos diferencias estadísticamente significativas (p<0,05) para la presión pico y meseta al comparar el registro en la boca del animal con el registro traqueal, siendo la diferencia en valor absoluto mayor para el registro de presión pico. Conclusiones. Los parámetros de presiones registrados en la boca del animal fueron asumibles para la cirugía, manteniéndose una adecuada estabilidad respiratoria y hemodinámica. Podemos afirmar que la modalidad de flujo continuo según el estudio de presiones puede ser idónea para este tipo de cirugía, y que el registro en la boca del animal (paciente) para la presión pico no refleja lo que realmente ocurre en el alvéolo, pero sí podemos tener una aproximación clínica adecuada para la presión meseta(AU)

Objective. To compare the airway pressures obtained before the endotracheal tube with the intratracheal ones in the continuous flow ventilation mode, in thoracoscopic surgery for one lung ventilation, in a paediatric model in animals. Material and methods. A simple prospective observational study was conducted. Ten Large White pigs weighing 4.6±0.8kg were used. The animals were ventilated in neonatal mode (continuous flow) with a Temel Supra ventilator. Using tracheotomy, we completely sealed the respiratory system in order to use tubes without special endotracheal cuffs, which would enable tracheal pressures to be registered without interfering with ventilation. Collapse of the right lung was performed by videothoracoscopy and was maintained for 120min. The variables were measured at 10 time periods: start and 5min with both lungs, after collapse at 5, 15, 30, 60, 90 and 120min, and 5 and 15min after lung re-expansion. We recorded the baseline, peak, plateau and positive end expiratory pressure in the mouth of the animal and intratracheal. Results. The mean peak pressure in the mouth of the animal in one lung ventilation was 23.38mmHg and tracheal ventilation was 21.24mmHg, while the mean plateau pressure in the mouth of the animal in one lung ventilation it was 21.88mmHg and tracheal was 21.39mmHg, respectively, with significant differences in all of them (P<.05). We found statistically significant differences (P<.05) for peak and plateau pressure on comparing the record in the animal mouth with the tracheal record. The difference in absolute value was higher for the peak pressure record. Conclusions. The pressure parameters recorded in the animal mouth were acceptable for surgery, with a suitable respiratory and haemodynamic stability being maintained. We can state that the continuous flow mode according to the pressures study may be suitable for this type of surgery, and that the mouth of the animal (patient) record for the peak pressure does not reflect what really happens in the alveoli, but we can give a suitable clinical estimate for the plateau pressure(AU)

[Airway pressure monitoring by the continuous flow method in paediatric thoracoscopic surgery. A study in an animal model]. / Monitorización de las presiones de la vía aérea con la modalidad de flujo continuo en cirugía toracoscópica pediátrica. Estudio en modelo animal.

OBJECTIVE: To compare the airway pressures obtained before the endotracheal tube with the intratracheal ones in the continuous flow ventilation mode, in thoracoscopic surgery for one lung ventilation, in a paediatric model in animals. MATERIAL AND METHODS: A simple prospective observational study was conducted. Ten Large White pigs weighing 4.6 ± 0.8 kg were used. The animals were ventilated in neonatal mode (continuous flow) with a Temel Supra ventilator. Using tracheotomy, we completely sealed the respiratory system in order to use tubes without special endotracheal cuffs, which would enable tracheal pressures to be registered without interfering with ventilation. Collapse of the right lung was performed by videothoracoscopy and was maintained for 120 min. The variables were measured at 10 time periods: start and 5 min with both lungs, after collapse at 5, 15, 30, 60, 90 and 120 min, and 5 and 15 min after lung re-expansion. We recorded the baseline, peak, plateau and positive end expiratory pressure in the mouth of the animal and intratracheal. RESULTS: The mean peak pressure in the mouth of the animal in one lung ventilation was 23.38 mmHg and tracheal ventilation was 21.24 mmHg, while the mean plateau pressure in the mouth of the animal in one lung ventilation it was 21.88 mmHg and tracheal was 21.39 mmHg, respectively, with significant differences in all of them (P<.05). We found statistically significant differences (P<.05) for peak and plateau pressure on comparing the record in the animal mouth with the tracheal record. The difference in absolute value was higher for the peak pressure record. CONCLUSIONS: The pressure parameters recorded in the animal mouth were acceptable for surgery, with a suitable respiratory and haemodynamic stability being maintained. We can state that the continuous flow mode according to the pressures study may be suitable for this type of surgery, and that the mouth of the animal (patient) record for the peak pressure does not reflect what really happens in the alveoli, but we can give a suitable clinical estimate for the plateau pressure.

Propuesta de un programa de formación usando un modelo experimental para el manejo anestésico del trasplante hepático / Proposed experimental model to provide training in the management of anesthesia in liver transplantation

Objetivos: Proponemos y evaluamos un programa de entrenamiento para anestesiólogos, en modelo porcino, para aumentar la calidad del manejo anestésico durante el trasplante hepático. Material y método: Cinco anestesiólogos, facultativos especialistas de área, sin experiencia previa en el manejo anestésico del trasplante hepático que no trabajan en centros donde se realiza la cirugía de trasplante hepático, realizaron el programa de entrenamiento y evaluación de manera voluntaria, anestesiando cinco animales cada uno. La cirugía se realizó bajo anestesia total balanceada, realizando monitorización hemodinámica, ventilatoria, determinación bioquímica, gasometrías arteriales y coagulación. Para evaluar a los alumnos se utilizaron criterios publicados previamente, considerando su habilidad para mantener al paciente estable. Fueron evaluados en los tiempos T1 (basal), T2-15 min fase preanhepática, T3-final fase preanhepática, T4-15 min fase anhepática, T5-final fase anhepática, T6-15 min fase postanhepática, T7-final fase postanhepática. Los alumnos completaron una encuesta al finalizar el programa para valorar su utilidad. Los cambios en la puntuación de los criterios de calidad fueron analizados utilizando ANOVA. Resultados: Durante la fase postimplantación, los cambios metabólicos (acidosis) y cardiacos (hipotensión y bradicardia) fueron las alteraciones más críticas a las que tuvieron que hacer frente los alumnos. Se evidenció un incremento significativo en las habilidades de los alumnos para hacer frente a los cambios hemodinámicos y metabólicos (p < 0,05). Todos los alumnos expresaron su preferencia por la realización de un entrenamiento previo en modelo porcino. Conclusiones: Utilizando este modelo de entrenamiento, los cambios hemodinámicos y fisiológicos que acontecen durante el trasplante, fueron entendidos y manejados. En nuestra opinión, la realización de un programa de formación en modelo porcino permite al anestesiólogo adquirir experiencia y habilidad para el manejo anestésico del trasplante hepático(AU)

Objetive: To propose and evaluate the use of a porcine model for training in how to manage and improve the quality of anesthesia during liver transplantation. Material and Methods: Five trained anesthesiologists who had no previous experience in managing anesthesia during liver transplantation and who did not work in hospitals where the procedure was performed volunteered for the training course and evaluated it. Each trainee anesthetized 5 animals. Surgery was performed under total balanced anesthesia with monitoring of hemodynamics, ventilation, biochemistry, arterial blood gases, and coagulation. Previously set criteria were used to evaluate the trainees' skill in maintaining patient stability. Their work was assessed 7 times: at baseline, 15 minutes into the preanhepatic phase, at the end of the preanhepatic stage, 15 minutes into the anhepatic phase, at the end of the anhepatic phase, 15 minutes into the postanhepatic phase, and at the end of the postanhepatic phase. After completing the course, the trainees filled in a questionnaire to evaluate its usefulness. Analysis of variance was applied to score changes in anesthetic quality criteria. Results: After implantation, changes in metabolic (acidosis) and cardiac (hypotension and bradycardia) status were the most critical abnormalities the trainees faced. Their skill in coping with hemodynamic and metabolic changes improved significantly (P<.05). All participants expressed a preference for receiving training in a porcine model before providing anesthesia in this surgical setting. Conclusions: Under this training model, the anesthesiologists understood and were able to manage the hemodynamic and physiologic changes that develop during a liver transplant procedure. We believe that training using a porcine model allows an anesthesiologist to acquire experience and skill in this setting(AU)

[Proposed experimental model to provide training in the management of anesthesia in liver transplantation]. / Propuesta de un programa de formación usando un modelo experimental para el manejo anestésico del trasplante hepático.

OBJECTIVE: To propose and evaluate the use of a porcine model for training in how to manage and improve the quality of anesthesia during liver transplantation. MATERIAL AND METHODS: Five trained anesthesiologists who had no previous experience in managing anesthesia during liver transplantation and who did not work in hospitals where the procedure was performed volunteered for the training course and evaluated it. Each trainee anesthetized 5 animals. Surgery was performed under total balanced anesthesia with monitoring of hemodynamics, ventilation, biochemistry, arterial blood gases, and coagulation. Previously set criteria were used to evaluate the trainees' skill in maintaining patient stability. Their work was assessed 7 times: at baseline, 15 minutes into the preanhepatic phase, at the end of the preanhepatic stage, 15 minutes into the anhepatic phase, at the end of the anhepatic phase, 15 minutes into the postanhepatic phase, and at the end of the postanhepatic phase. After completing the course, the trainees filled in a questionnaire to evaluate its usefulness. Analysis of variance was applied to score changes in anesthetic quality criteria. RESULTS: After implantation, changes in metabolic (acidosis) and cardiac (hypotension and bradycardia) status were the most critical abnormalities the trainees faced. Their skill in coping with hemodynamic and metabolic changes improved significantly (P<.05). All participants expressed a preference for receiving training in a porcine model before providing anesthesia in this surgical setting. CONCLUSIONS: Under this training model, the anesthesiologists understood and were able to manage the hemodynamic and physiologic changes that develop during a liver transplant procedure. We believe that training using a porcine model allows an anesthesiologist to acquire experience and skill in this setting.

Propuesta de un programa de formación usando un modelo experimental para el manejo anestésico del trasplante hepático / Proposed experimental model to provide training in the management of anesthesia in liver transplantation

Objetivos: Proponemos y evaluamos un programa de entrenamiento para anestesiólogos, en modelo porcino, para aumentar la calidad del manejo anestésico durante el trasplante hepático. Material y método: Cinco anestesiólogos, facultativos especialistas de área, sin experiencia previa en el manejo anestésico del trasplante hepático que no trabajan en centros donde se realiza la cirugía de trasplante hepático, realizaron el programa de entrenamiento y evaluación de manera voluntaria, anestesiando cinco animales cada uno. La cirugía se realizó bajo anestesia total balanceada, realizando monitorización hemodinámica, ventilatoria, determinación bioquímica, gasometrías arteriales y coagulación. Para evaluar a los alumnos se utilizaron criterios publicados previamente, considerando su habilidad para mantener al paciente estable. Fueron evaluados en los tiempos T1 (basal), T2-15 min fase preanhepática, T3-final fase preanhepática, T4-15 min fase anhepática, T5-final fase anhepática, T6-15 min fase postanhepática, T7-final fase postanhepática. Los alumnos completaron una encuesta al finalizar el programa para valorar su utilidad. Los cambios en la puntuación de los criterios de calidad fueron analizados utilizando ANOVA. Resultados: Durante la fase postimplantación, los cambios metabólicos (acidosis) y cardiacos (hipotensión y bradicardia) fueron las alteraciones más críticas a las que tuvieron que hacer frente los alumnos. Se evidenció un incremento significativo en las habilidades de los alumnos para hacer frente a los cambios hemodinámicos y metabólicos (p < 0,05). Todos los alumnos expresaron su preferencia por la realización de un entrenamiento previo en modelo porcino. Conclusiones: Utilizando este modelo de entrenamiento, los cambios hemodinámicos y fisiológicos que acontecen durante el trasplante, fueron entendidos y manejados. En nuestra opinión, la realización de un programa de formación en modelo porcino permite al anestesiólogo adquirir experiencia y habilidad para el manejo anestésico del trasplante hepático(AU)

Objetive: To propose and evaluate the use of a porcine model for training in how to manage and improve the quality of anesthesia during liver transplantation. Material and Methods: Five trained anesthesiologists who had no previous experience in managing anesthesia during liver transplantation and who did not work in hospitals where the procedure was performed volunteered for the training course and evaluated it. Each trainee anesthetized 5 animals. Surgery was performed under total balanced anesthesia with monitoring of hemodynamics, ventilation, biochemistry, arterial blood gases, and coagulation. Previously set criteria were used to evaluate the trainees' skill in maintaining patient stability. Their work was assessed 7 times: at baseline, 15 minutes into the preanhepatic phase, at the end of the preanhepatic stage, 15 minutes into the anhepatic phase, at the end of the anhepatic phase, 15 minutes into the postanhepatic phase, and at the end of the postanhepatic phase. After completing the course, the trainees filled in a questionnaire to evaluate its usefulness. Analysis of variance was applied to score changes in anesthetic quality criteria. Results: After implantation, changes in metabolic (acidosis) and cardiac (hypotension and bradycardia) status were the most critical abnormalities the trainees faced. Their skill in coping with hemodynamic and metabolic changes improved significantly (P<.05). All participants expressed a preference for receiving training in a porcine model before providing anesthesia in this surgical setting. Conclusions: Under this training model, the anesthesiologists understood and were able to manage the hemodynamic and physiologic changes that develop during a liver transplant procedure. We believe that training using a porcine model allows an anesthesiologist to acquire experience and skill in this setting(AU)

Manejo anestésico de un paciente con displasia arritmogénica de ventrículo derecho, ascitis y colitis ulcerosa para una cirugía abdominal mayor / Patient with right ventricular arrhythmogenic dysplasia, ascites and ulcerative colitis: anesthetic management during major abdominal surgery

Presentamos el caso de un varón de 43 años con colitis ulcerosa y displasia arritmogénica de ventrículo derecho con deterioro de la función ventricular y portador de un desfibrilador automático implantable programado para pancolectomía por transformación adenomatosa de pólipos de colon. Se discuten aspectos básicos sobre la displasia arritmogénica de ventrículo derecho, su manejo y monitorización de cara a una cirugía mayor abdominal y el manejo perioperatorio de un enfermo con un desfibrilador automático implantable, con especial atención a la influencia de las interferencias electromagnéticas que pueden alterar su funcionamiento en un contexto quirúrgico. Por último se detallan los datos de la historia de un enfermo asintomático que deben hacer sospechar la presencia de una displasia arritmogénica de ventrículo derecho

A 43-year-old man with ulcerative colitis was scheduled for pancolectomy owing to adenomatous transformation of polyps. The patient had right ventricular arrhythmogenic dysplasia, with deteriorating ventricular function, and carried an automatic implantable defibrillator. We discuss the general features of arrhythmogenic right ventricular dysplasia and its implications for management and monitoring during major abdominal surgery. Perioperative management of a patient with an implantable defibrillator is also discussed, with special attention to the influence of electromagnetic interference that can affect how the device functions during surgery. Finally, we list signs that should lead to suspicion of arrhythmogenic right ventricular dysplasia in an asymptomatic patient

[Anesthetic management for thoracoscopic repair of type I esophageal atresia with continuous-flow single-lung ventilation]. / Manejo anestésico en la corrección toracoscópica de atresia de esófago tipo I con ventilación unipulmonar con modalidad de flujo continuo.

We describe a continuous flow mode of ventilation for repair of type I esophageal atresia in an infant. This type of atresia is defined by distal stenosis of the esophagus with a proximal blind pouch and no connection to the tracheobronchial tree. In traditional repair procedures the surgical approach is by thoracotomy, but newer videoassisted thoracoscopic techniques have introduced novel challenges to ventilatory mechanics in these low-weight infants. The literature contains little discussion of the anesthetic management or respiratory mechanics of these patients. Trying to maintain adequate tidal volume and oxygenation while thoracoscopic maneuvers take place increases the risk of barotrauma. Single-lung ventilation with a continuous flow respirator was effective in the case we report.

Manejo anestésico en la corrección toracoscópica de atresia de esófago tipo I con ventilación unipulmonar con modalidad de flujo continuo / Anesthetic management for thoracoscopic repair of type I esophageal atresia with continuous flow ventilation of a single lung

Describimos el modo de ventilación con flujo continuo para la reparación de un caso de atresia de esófago tipo I en un lactante. Este tipo de atresia se caracteriza por estenosis esofágica distal, con bolsón proximal sin fístula en el árbol bronquial. Las técnicas clásicas quirúrgicas realizan la reparación por toracotomía, pero la nueva introducción de técnicas videotoracoscópicas para este tipo de cirugía establece un nuevo reto en la mecánica ventilatoria de estos lactantes de bajo peso. La literatura es escasa en el manejo anestésico y de la mecánica ventilatoria de estos pacientes. Intentar mantener un adecuado volumen de ventilación, junto con una adecuada oxigenación añadido a la toracoscopia aumenta el riesgo de barotrauma. Con ventilación unipulmonar y con modalidad de flujo continuo se consiguió ventilar a este paciente eficazmente

We describe a continuous flow mode of ventilation for repair of type I esophageal atresia in an infant. This type of atresia is defined by distal stenosis of the esophagus with a proximal blind pouch and no connection to the tracheobronchial tree. In traditional repair procedures the surgical approach is by thoracotomy, but newer videoassisted thoracoscopic techniques have introduced novel challenges to ventilatory mechanics in these low-weight infants. The literature contains little discussion of the anesthetic management or respiratory mechanics of these patients. Trying to maintain adequate tidal volume and oxygenation while thoracoscopic maneuvers take place increases the risk of barotrauma. Single-lung ventilation with a continuous flow respirator was effective in the case we report

[Patient with right ventricular arrhythmogenic dysplasia, ascites and ulcerative colitis: anesthetic management during major abdominal surgery]. / Manejo anestésico de un paciente con displasia arritmogénica de ventrículo derecho, ascitis y colitis ulcerosa para una cirugía abdominal mayor.

A 43-year-old man with ulcerative colitis was scheduled for pancolectomy owing to adenomatous transformation of polyps. The patient had right ventricular arrhythmogenic dysplasia, with deteriorating ventricular function, and carried an automatic implantable defibrillator. We discuss the general features of arrhythmogenic right ventricular dysplasia and its implications for management and monitoring during major abdominal surgery. Perioperative management of a patient with an implantable defibrillator is also discussed, with special attention to the influence of electromagnetic interference that can affect how the device functions during surgery. Finally, we list signs that should lead to suspicion of arrhythmogenic right ventricular dysplasia in an asymptomatic patient.