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.

Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions / Coloides versus cristaloides em fluidoterapia guiada por objetivos, revisão sistemática e metanálise. Demasiadamente cedo ou demasiadamente tarde para obter conclusões / Coloides versus cristaloides en fluidoterapia guiada por objetivos, revisión sistemática y metaanálisis. Demasiado pronto o demasiado tarde para obtener conclusiones

Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality.

Foram feitos múltiplos ensaios clínicos em fluidoterapia guiada por objetivos (FGO), muitos deles com o uso de coloides para aprimoramento da pré-carga. Após a decisão da Agência Europeia de Medicamentos, existe ainda controvérsia sobre seu uso, seus benefícios e sua possível contribuição para a falência renal. O objetivo desta revisão sistemática e metanálise é comparar o uso de coloides de última geração, derivados de milho, com cristaloides em FGO para determinar as complicações e a mortalidade associadas.

Se han realizado múltiples ensayos clínicos en fluidoterapia guiada por objetivos (FGO), muchos de ellos con el uso de coloides para la optimización de la precarga. Tras la decisión de la Agencia Europea del Medicamento, existe cierta controversia en cuanto a su utilización, beneficios y su posible contribución al fallo renal. El objetivo de esta revisión sistemática y metaanálisis es comparar el uso de coloides de última generación, derivados del maíz, con cristaloides en FGO para determinar las complicaciones y la mortalidad asociadas.

Analgesic efficacy of the ultrasound-guided blockade of the transversus abdominis plane - a systematic review / Eficácia analgésica do bloqueio ecoguiado do plano transverso do abdome - revisão sistemática / Eficacia analgésica del bloqueo del plano transverso del abdomen ecoguiado-revisión sistemática

The transverse abdominal plan blockade is a block of abdominal wall that has diffused rapidly in the clinical practice as part of a multimodal analgesia for abdominal surgery. The performance of the ultrasound-guided technique has allowed the lowering of potential complications, as well as new approaches that were carried out according to the descriptions, and the prospective studies would make it possible to utilize the transverse abdominal plan blockade in different surgical interventions; however, the results obtained in randomized clinical trials are inconsistent.

El bloqueo del plano transverso del abdomen (TAP) es un bloqueo de pared abdominal que se ha extendido rápidamente en la práctica clínica como parte de analgesia multimodal en cirugía abdominal. La realización de la técnica ecoguiada ha permitido disminuir las potenciales complicaciones, así como nuevos abordajes que según las descripciones realizadas y los estudios de extensión permitirían utilizar el TAP en distintas intervenciones quirúrgicas; sin embargo, los resultados obtenidos en ensayos clínicos aleatorizados (ECA) son inconsistentes.

Analgesic efficacy of the ultrasound-guided blockade of the transversus abdominis plane - a systematic review.

BACKGROUND: The transverse abdominal plan blockade is a block of abdominal wall that has diffused rapidly in the clinical practice as part of a multimodal analgesia for abdominal surgery. The performance of the ultrasound-guided technique has allowed the lowering of potential complications, as well as new approaches that were carried out according to the descriptions, and the prospective studies would make it possible to utilize the transverse abdominal plan blockade in different surgical interventions; however, the results obtained in randomized clinical trials are inconsistent. OBJECTIVES: To prepare a systematic review aiming to determine the efficacy of the ultrasound-guided transverse abdominal plan blockade for different surgical interventions, as well as the indications according to the approaches and their influences. METHODS: Two research approaches, one manual, and the other in Pubmed returned 28 randomized clinical trials where intervention with ultrasound-guided transverse abdominal plan blockades was performed to compare the analgesic efficacy in contrast to another technique in adults, published between 2007 and October 2013, in English or Spanish, with Jadad score>1, according to the inclusion criteria for this review. The authors analyzed independently all the randomized clinical trials. CONCLUSIONS: The transverse abdominal plan blockades have been shown to be an effective technique in colorectal surgery, cesarean section, cholecystectomy, hysterectomy, appendectomy, donor nephrectomy, retropubic prostatectomy, and bariatric surgery. However, the data found in randomized clinical trial are not conclusive, and as a result, it is necessary to develop new and well designed randomized clinical trial, with enough statistical power to compare different approaches, drugs, doses, and volumes for the same intervention, aiming to answer the current questions and their effects in the habitual clinical practice.

Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions.

INTRODUCTION: Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to renal failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids in GDFT to determine associated complications and mortality. METHODS: A bibliographic research was carried out in MEDLINE PubMed, EMBASE and Cochrane Library, corroborating randomized clinical trials where crystalloids are compared to colloids in GDFT for major non-cardiac surgery in adults. RESULTS: One hundred thirty references were found and among those 38 were selected and 29 analyzed; of these, six were included for systematic review and meta-analysis, including 390 patients. It was observed that the use of colloids is not associated with the increase of complications, but rather with a tendency to a higher mortality (RR [95% CI] 3.87 [1.121-13.38]; I(2)=0.0%; p=0.635). CONCLUSIONS: Because of the limitations of this meta-analysis due to the small number of randomized clinical trials and patients included, the results should be taken cautiously, and the performance of new randomized clinical trials is proposed, with enough statistical power, comparing balanced and unbalanced colloids to balanced and unbalanced crystalloids, following the protocols of GDFT, considering current guidelines and suggestions made by groups of experts.

[Analgesic efficacy of the ultrasound-guided blockade of the transversus abdominis plane - a systematic review]. / Eficácia analgésica do bloqueio ecoguiado do plano transverso do abdome - revisão sistemática.

BACKGROUND: The transverse abdominal plan blockade (TAP) is a block of abdominal wall that has diffused rapidly in the clinical practice as part of a multimodal analgesia for abdominal surgery. The performance of the ultrasound-guided technique has allowed the lowering of potential complications, as well as new approaches that according to the descriptions carried out and the prospective studies would make it possible to utilize the TAP in different surgical interventions; however, the results obtained in randomized clinical trials (RCTs) are inconsistent. OBJECTIVES: To prepare a systematic review aiming to determine the efficacy of the ultrasound-guided TAP for different surgical interventions, as well as the indications according to the approaches and their influences. METHODS: Two research approaches, one manual, and the other in Pubmed returned 28 RCT where an intervention with ultrasound-guided TAP were performed to compare the analgesic efficacy in contrast to another technique in adults, published between 2007 and October 2013, in English or Spanish, with Jadad score > 1, according to the inclusion criteria for this review. The authors analyzed independently all the RCT. CONCLUSIONS: The TAP have been shown to be an effective technique in colorectal surgery, cesarean section, cholecystectomy, hysterectomy, appendectomy, donor nephrectomy, retropubic prostatectomy, and bariatric surgery. However, the data found in RCT are not conclusive, and as a result, it is necessary to develop new and well designed RCT, with enough statistical power to compare different approaches, drugs, doses, and volumes for the same intervention, aiming to answer the current questions and their effects in the habitual clinical practice.

[Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw conclusions]. / Coloides versus cristaloides em fluidoterapia guiada por objetivos, revisão sistemática e metanálise. Demasiadamente cedo ou demasiadamente tarde para obter conclusões.

INTRODUCTION: Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to kidney failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids, in GDFT, to determine complications and mortality associated associated. METHODS: A bibliographic research was carried out in Medline, Pubmed, Embase and Cochrane Library, corroborating randomized clinical trials in those crystalloids are compared to colloids in GDFT for mayor non-cardiac surgery in adults. RESULTS: One hundred thirty references were found, among those 38 were selected, and 29 analyzed; of these, 6 were included for systematic review and meta-analysis, including 390 patients. It was perceived that the use of colloids it not associated with the increase of complications, but rather with a tendency to a higher mortality (RR [95% IC] 3.87 [1.121, 13, 38]); I(2)=0.0%; p=0.635). CONCLUSIONES: Due to this meta-analysis' limitations for small number of randomized clinical trials and patients included, the results should be taken cautiously, and it is proposed to carry out new randomized clinical trials, with enough statistical power, comparing balanced and non-balanced colloids to balanced and non-balanced crystalloids, following the protocols of GDFT, respecting current guidelines and suggestions made by groups of experts.

Diseño de una vía clínica para el tratamiento quirúrgico del carcinoma gástrico a partir del análisis del proceso / Design of a clinical pathway for the surgical treatment of gastric cancer based on an analysis of the process

Introducción: Las vías clínicas son herramientas de gran utilidad para la sistematización y la mejora de los procesos asistenciales. Se presenta la metodología para la gestión del proceso asistencial en el tratamiento quirúrgico del cáncer gástrico mediante la evaluación previa del proceso y el desarrollo de una vía clínica. Material y método: Estudio descriptivo, retrospectivo y transversal. Se revisaron las historias clínicas de los pacientes intervenidos por adenocarcinoma gástrico durante el período 1998-2000. Se analizaron las características clínicas, la calidad científico-técnica, la efectividad clínica y el consumo de recursos. Toda esta información, junto con la revisión bibliográfica sobre el tema, se utilizó para diseñar una vía clínica para la mejora del proceso. Resultados: Los puntos fuertes fueron: intervalo correcto entre el diagnóstico y el tratamiento quirúrgico (mediana, 27 días), baja tasa de complicaciones mayores (18,1%) y mortalidad (1,8%). Las áreas susceptibles de mejora fueron: valoración anestésica ambulatoria (23,5%), estancia media hospitalaria (mediana, 21 días), obtención del consentimiento informado (53,5%), cumplimiento del protocolo de profilaxis antibiótica (62,5%) y tromboembólica (78,5%), consumo de antibióticos (55,3%) y nutrición parenteral (96,4%), realización de tomografía computarizada abdominal preoperatoria (83,9%), número insuficiente de ganglios aislados (mediana, 14), índice de transfusiones (61,8%) y aplicación de una encuesta de satisfacción. Con toda esta información se diseñaron los documentos de la vía clínica y se definieron indicadores y estándares de calidad adaptados a la realidad de la unidad quirúrgica

Introduction: Clinical pathways are highly useful tools for the systematization and improvement of clinical processes. We present the methodology for the management of the surgical treatment of gastric cancer, through a prior analysis of the process and design of a clinical pathway. Material and method: A descriptive, retrospective, cross sectional study was performed. The medical records of patients who underwent surgery for gastric adenocarcinoma from 1998-2000 were reviewed. Clinical characteristics, scientific-technical quality, clinical effectiveness, and resource use were analyzed. All this information, together with a review of the literature on the topic, was used to design a clinical pathway to improve the process. Results: The following strengths were identified: appropriate interval between diagnosis and surgical treatment (median 27 days), low index of major complications (18.1%) and mortality (1.8%). Areas requiring improvement were outpatient anesthetic evaluation (23.5%), mean length of hospital stay (median 21 days), obtaining of informed consent (53.5%), application of thromboembolic (78.5%) and antibiotic prophylactic protocols (62.5%), use of antibiotic (55.3%) and parenteral nutrition (96.4%), performance of preoperative abdominal computed tomography (83.9%), insufficient number of isolated nodes (median 14), transfusion rate (61.8%), and application of the patient satisfaction survey. The above information was used to design the clinical pathway documents and define the quality indicators and standards according to the real situation of the surgical unit

Colorectal cancer relapse: allelic alterations associated with tumour marker overexpression.

The objective of the present study was to assess the prognostic value of allelic alterations in comparison with clinical prognostic factors (age and gender, clinical stage, lymph node involvement, tissue tumour marker expression) and clinical outcomes (disease relapse and overall survival time) in colorectal cancer patients. Polymerase chain reaction was performed on the DNA of 72 colorectal samples (from 36 colorectal cancer patients) using primers D17S513 and D17S514. Carbohydrate antigen 19-9 (CA 19-9) marker was determined in tumour sections by enzyme immunoassay. Tumours were considered to exhibit allelic alterations if the microsatellite region adjacent to the p53 locus in chromosome 17 either gained or lost repeated sequences. Allelic alterations were detected in 44% of tumour samples. Patients with more than 3 involved lymph nodes had more frequent allelic alterations (p < 0.002). The allelic alteration status was compared with tumour CA 19-9 expression, which showed statistically significantly higher values within the allelic alterations group (p < 0.005). Multivariate analyses confirmed that tumours with allelic alterations had a higher probability of disease relapse (odds ratio 7.3, p = 0.01). This is the first report showing an association between allelic alteration and overexpression of a tissue tumour marker protein and established risk factors. These results could be considered useful additional prognostic information for colorectal cancer.

An unusual expression of hyperplastic gastropathy (Menetrier type) in twins.

Menetrier's disease is an uncommon condition of unknown aetiology. We describe two cases of male identical twins with haematemesis aged 29 and 35 years that exhibited a similar and particular form of this hyperplastic gastropathy. Their stomachs showed confluent polypoid mucosal projections affecting mainly the gastric fundus and the antrum. To the best of our knowledge, only four previous cases have been reported in a familial setting, and this is the first documented example of an occurrence in twins. These two cases suggest the possibility of a genetic predisposition for this condition.

Funduplicación de Nisen por laparoscopia y gastrostomía endoscópica en niños: informe de un caso / Laparoscopic Nissen funduplication and endoscopic gastrostomy in children: a case report

Se describe el caso clínico de una paciente femenina de siete años de edad, con retraso psicomotor, trastorno en el mecanismo de la deglución y enfermedad por reflujo gastroesofágico, con neumopatía crónica secundaria a broncoaspiración, la cual fue sometida a funduplicación de Nissen por vía laparoscópica y gastrostomía endoscópica. Analizamos las indicaciones de la intervención, la técnica quirúrgica y las variaciones de la misma, con respecto a los pacientes adultos