Ultrasound mapping of soft tissue vascular anatomy proximal to the larynx: a prospective cohort study.

Background: Bleeding incidents during percutaneous dilatational tracheostomy are concerning, and most cases occur in patients with unrecognized and unanticipated anatomical variations in the vascular anatomy. However, the extent of this variation remains unclear. To address this knowledge gap, our study aimed to comprehensively map laryngeal vascular anatomy in a cohort of adult patients. Methods: Ultrasound assessments of the soft tissue in the neck were performed, spanning from the thyroid cartilage to the third tracheal ring and extending 2 cm laterally on both sidesperformed. We subdivided this area into 12 zones comprising four medial and eight lateral sections. A pre-planned form was used to document the presence of arteries or veins in each zone. The results are reported as odds ratios, 95% CIs, and corresponding P-values. Results: Five-hundred patients were enrolled from August 14, 2023, to November 13, 2023, at the University Hospital of Padua. Arteries and veins were identified in all investigated zones (varying from a minimum of 1.0%-46.4%). The presence of invessels progressively increased from the cricothyroid membrane to the third tracheal ring and from the midline to the paramedian laryngeal area. Conclusions: Given the prevalence of arteries and veins, particularly in areas where tracheostomies are commonly performed, we strongly advocate for routine ultrasound assessments before such procedures are performed.

Rehabilitation approaches in West Nile Virus survivors: a systematic review.

INTRODUCTION: Periodic increases in West Nile virus (WNV) infections have been documented. Proper rehabilitative management is essential for these patients, who may experience limitations in daily activities even after the resolution of the acute infection. Since there are currently no globally accepted guidelines, our aim is to conduct a best-evidence synthesis on rehabilitative management for patients with neuroinvasive WNV. EVIDENCE ACQUISITION: We screened the literature with two independent researchers conducting searches on PubMed, Embase, SCOPUS, and Google Scholar databases for WNV-related studies in the field of rehabilitation. Suitable studies were identified and selected through a rigorous process. The review includes original research articles published up to August 15, 2023. EVIDENCE SYNTHESIS: Despite the potential for bias in the studies, the literature suggests that a comprehensive and interdisciplinary rehabilitation program, which includes physical therapy with neuromotor and respiratory interventions, occupational therapy, neurocognitive interventions, and speech therapy for dysphagia and communication issues, can lead to functional improvement in WNV patients. This program should be tailored to address each patient's specific challenges, and the duration of the rehabilitation program may vary depending on the individual patient's needs. CONCLUSIONS: Even if additional research with larger cohorts and higher evidence levels is needed for a comprehensive understanding of WNV patient rehabilitation, an early and comprehensive rehabilitation approach addressing respiratory, neuromuscular, and cognitive aspects appears effective for WNV patient recovery.

Examining gender bias in regional anesthesia academic publishing: a 50-year bibliometric analysis.

BACKGROUND: The connection between academic career advancement and publishing research articles is important, as it can impact promotion and compensation decisions. Gender bias in academic publishing is a known issue, with studies showing low numbers in key roles in female representation. This article aims to analyze the ratio of women to men as first and last authors in the Regional Anesthesia & Pain Medicine (RAPM) journal and explore other factors such as the mentorship effect and representation in regional anesthesia associations. MAIN BODY: We examined the RAPM articles from 1976 to 2023 evaluating the gender of first and last authors. We analyzed the trend over the years and also analyze the subset of original articles. A further analysis was conducted to analyze the relationship between the first and last author's gender. Additionally, regional anesthesia societies were contacted to gather data on the gender of their members. We included 5650 articles; most of them were first authored by men (72.9-87.7%). There was a positive trend over time for female first authorship but not for last authorship. The analysis also revealed a mentorship effect in recent years for both overall articles and the subgroup of original articles. The representation of women within regional anesthesia societies contrasted with the representation of women as last authors in original articles. CONCLUSIONS: Our findings raise important questions about gender bias in academic publishing highlighting the need for increased representation and opportunities for women in the field of regional anesthesia.

Enhancing study quality assessment: an in-depth review of risk of bias tools for meta-analysis-a comprehensive guide for anesthesiologists.

BACKGROUND: Yearly, a multitude of randomized controlled trials are published, overwhelming clinicians with conflicting information; this data saturation leads to confusion and hinders clinicians' everyday decision-making. Hence, it is crucial to assess the quality and reliability of the evidence in order to consolidate it. Through this synthesis, clinicians can guarantee that their decisions are informed by solid evidence. Meta-analysis, a statistical technique, can effectively combine data from multiple studies to furnish accurate and dependable evidence for clinical practice and policy decisions. Nonetheless, the reliability of the obtained results depends on the use of high-quality evidence. MAIN BODY: Risk of bias is an assessment mandatory while performing a meta-analysis and is used to have an overview of the quality of the studies from which data are extracted. Several tools have been developed and are used to perform the risk of bias assessment. In this statistical round, we will provide an overview of the most used tools for both the randomized (Cochrane Risk of Bias 2 and Jadad) and the nonrandomized (Risk Of Bias In Non-randomized Studies and Newcastle-Ottawa Scale) clinical trials. CONCLUSION: We provided an overview of the most used risk of bias tools used in meta-analysis.

Erector Spinae Plane Block and Chronic Pain: An Updated Review and Possible Future Directions.

Chronic pain is a common, pervasive, and often disabling medical condition that affects millions of people worldwide. According to the Global Burden of Disease survey, painful chronic conditions are causing the largest numbers of years lived with disability worldwide. In America, more than one in five adults experiences chronic pain. Erector spinae plane block is a novel regional anesthesia technique used to provide analgesia with multiple possible uses and a relatively low learning curve and complication rate. Here, we review the erector spinae plane block rationale, mechanism of action and possible complications, and discuss its potential use for chronic pain with possible future directions for research.

Pupillary dynamics predict long-term outcome in a cohort of acute traumatic brain injury coma patients.

OBJECTIVE: Examining the size and reactivity of the pupils of traumatic brain injury coma patients is fundamental in the Neuro-intensive care unit (ICU). Pupil parameters on admission predict long-term clinical outcomes. However, little is known about the dynamics of pupillary parameters and their potential value for outcome prediction. METHODS: This study applied a time-course analysis of pupillary signals (size and photo-reactivity) in acute traumatic brain injury coma patients (n = 20) to predict outcome at 6 months. RESULTS: The time course of pupillary signals was informative in discriminating favorable (F) versus unfavorable (U) outcomes, with the highest correlation within the 1st week notwithstanding pharmacological sedation. Patients with favorable outcome at 6 months showed more consistent in time isochoric and photo-reactive pupils. In contrast, patients with an unfavorable outcome showed more variable measures that tended to stabilize toward pathological values. INTERPRETATION: Time-dependent tracking of pupils' size and reactivity is a promising application for ICU monitoring and long-term prognosis. These findings support the usefulness of automatic tools for the dynamic, quantitative, and objective measurements of pupils.

Single-Shot Regional Anesthesia for Bariatric Surgery: a Systematic Review and Network Meta-Analysis.

PURPOSE: Laparoscopic bariatric surgeries can cause intense postoperative pain. Opioid medication can alleviate the pain but can have harmful side effects especially in patients with obstructive sleep apnea. To promote early recovery, enhanced recovery after surgery guideline advises minimizing opioid use and opting for alternative analgesics. This paper aims to investigate the effect of regional anesthesia techniques through a systematic review and network meta-analysis. Primary outcome is postoperative morphine equivalent consumption at 24 h. METHODS: Search was conducted in the following databases: PubMed, CENTRAL, Scopus, and EMBASE, from the inception until 10 January 2023. The eligibility criteria were determined by PICOS, including postoperative opioid consumption, pain scores, time to ambulate, use of additional analgesics, and adverse events. The quality assessment was performed using the Risk of Bias 2 Tool, and the certainty of evidence was assessed using the GRADE approach. Funnel plots were used to evaluate publication bias. RESULTS: We included 22 studies in quantitative synthesis. A review of 12 studies found that all techniques had a lower mean consumption of opioids compared to placebo or no intervention, with TAP block having the greatest reduction. The quality of evidence for postoperative pain, PONV, time to deambulate, and use of rescue analgesics, was rated as moderate, with TAP block being the most effective intervention. There was no publication bias in any outcome. CONCLUSIONS: TAP block is superior to other regional anesthesia techniques in reducing opioid consumption, pain, PONV, and use of rescue analgesics in bariatric surgery. However, further research is needed.

General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis.

PURPOSE: Endovascular treatment for stroke patients usually requires anesthesia care, with no current consensus on the best anesthetic management strategy. Several randomized controlled trials and meta-analyses have attempted to address this. In 2022, additional evidence from three new trials was published: the GASS trial, the CANVAS II trial, and preliminary results from the AMETIS trial, prompting the execution of this updated systematic review and meta-analysis. The primary objective of this study was to evaluate the effects of general anesthesia and conscious sedation on functional outcomes measured with the modified Rankin scale (mRS) at three months. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials investigating conscious sedation and general anesthesia in endovascular treatment. The following databases were examined: PubMed, Scopus, Embase, and the Cochrane Database of Randomized Controlled Trials and Systematic Reviews. The Risk of Bias 2 tool was used to assess bias. In addition, trial sequence analysis was performed on the primary outcome to estimate if the cumulative effect is significant enough to be unaffected by further studies. RESULTS: Nine randomized controlled trials were identified, including 1,342 patients undergoing endovascular treatment for stroke. No significant differences were detected between general anesthesia and conscious sedation with regards to mRS, functional independence (mRS, 0-2), procedure duration, onset to reperfusion, mortality, hospital length of stay, and intensive care unit length of stay. Patients treated under general anesthesia may have more frequent successful reperfusion, though the time from groin to reperfusion was slightly longer. Trial sequential analysis showed that additional trials are unlikely to show marked differences in mean mRS at three months. CONCLUSIONS: In this updated systematic review and meta-analysis, the choice of anesthetic strategy for endovascular treatment of stroke patients did not significantly impact functional outcome as measured with the mRS at three months. Patients managed with general anesthesia may have more frequent successful reperfusion. TRIAL REGISTRATION: PROSPERO (CRD42022319368); registered 19 April 2022.

RéSUMé: OBJECTIF: Le traitement endovasculaire pour les patient·es victimes d'un accident vasculaire cérébral (AVC) nécessite généralement des soins d'anesthésie, mais il n'existe actuellement aucun consensus sur la meilleure stratégie de prise en charge anesthésique. Plusieurs études randomisées contrôlées et méta-analyses ont tenté d'aborder cette question. En 2022, des données probantes supplémentaires provenant de trois nouvelles études ont été publiées : l'étude GASS, l'étude CANVAS II et les résultats préliminaires de l'étude AMETIS, ce qui a motivé la réalisation de cette revue systématique et méta-analyse mises à jour. L'objectif principal de cette étude était d'évaluer les effets de l'anesthésie générale et de la sédation consciente sur les devenirs fonctionnels mesurés avec l'échelle de Rankin modifiée (mRS) à trois mois. MéTHODE: Nous avons réalisé une revue systématique avec méta-analyse d'études randomisées contrôlées portant sur la sédation consciente et l'anesthésie générale dans le traitement endovasculaire. Les bases de données suivantes ont été examinées : PubMed, Scopus, Embase et la base de données Cochrane des études randomisées contrôlées et des revues systématiques. L'outil Risque de biais 2 a été utilisé pour évaluer le biais. De plus, une analyse séquentielle des études a été effectuée sur le critère d'évaluation principal afin d'estimer si l'effet cumulatif était suffisamment significatif pour ne pas être affecté par d'autres études. RéSULTATS: Neuf études randomisées contrôlées ont été identifiées, incluant 1342 patient·es bénéficiant d'un traitement endovasculaire pour un AVC. Aucune différence significative n'a été détectée entre l'anesthésie générale et la sédation consciente en ce qui concerne la mRS, l'indépendance fonctionnelle (mRS, 0-2), la durée de l'intervention, le moment d'apparition de la reperfusion, la mortalité, la durée de séjour à l'hôpital et la durée de séjour en unité de soins intensifs. Les patient·es traité·es sous anesthésie générale pourraient avoir une reperfusion réussie plus fréquente, bien que le temps entre l'aine et la reperfusion était légèrement plus long. L'analyse séquentielle des études a montré qu'il est peu probable que d'autres études montrent des différences marquées dans la mRS moyenne à trois mois. CONCLUSION: Dans cette revue systématique et méta-analyse mises à jour, le choix de la stratégie anesthésique pour le traitement endovasculaire des personnes victimes d'un AVC n'a pas eu d'impact significatif sur les devenirs fonctionnels mesurés avec la mRS à trois mois. La réussite de la reperfusion pourrait être plus fréquente chez les patient·es pris·es en charge par anesthésie générale. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022319368); enregistrée le 19 avril 2022.

Reliability of Third Ventricle Assessment by Transcranial Ultrasound: A Computational Model of the Effect of Insonation Angle.

INTRODUCTION: Transcranial sonography (TCS) is a bedside examination which is currently used in multiple neurocritical care settings. Third ventricle ultrasound is usually a simple technique, though a large insonation angle could lead to an overestimation of third ventricular diameter. The aim of this study was to use a mathematical model to evaluate the impact of probe inclination on the false positive rate when using TCS to evaluate third ventricle enlargement. METHODS: Using R software, we simulated a pool of 100,000 fictitious patients with a normal third ventricle size (diameter from 0 to 9 mm) in daily follow-up for ventricle enlargement for 30 consecutive days using TCS. Each day, a different, random insonation angle (α) was generated and a corresponding measured diameter calculated as: measured diameter=real diameter/cos α. If the measured diameter was >9.0 mm, the simulation registered a "misdiagnosis" episode and the simulation loop was interrupted; otherwise, the simulation continued to its thirtieth iteration. RESULTS: Of the 100,000 "patient" simulations, 30,905 (30.9%) had an erroneous TCS diagnosis of ventricular enlargement. Angles of insonation >35 degrees contributed to 79.3% of the total misdiagnoses of ventricular enlargement (false positive rate, 3.71%), whereas misdiagnosis was rare when the insonation angle was ≤15 degrees (1.30% of the total misdiagnoses; false positive rate, 0.06%). CONCLUSION: Using probe inclinations <15 degrees, erroneous diagnosis of third ventricular enlargement was rare. Our results suggest that TCS has a low rate of false positives when the angle of insonation is minimized.

Inappropriate Citation of Retracted Articles in Anesthesiology and Intensive Care Medicine Publications.

BACKGROUND: Retracted articles represent research withdrawn from the existing body of literature after publication. Research articles may be retracted for several reasons ranging from honest errors to intentional misconduct. They should not be used as reliable sources, and it is unclear why they are cited occasionally by other articles. This study hypothesized that several mechanisms may contribute to citing retracted literature and aimed to analyze the characteristics of articles citing retracted literature in anesthesiology and critical care. METHODS: Using the Retraction Watch database, we retrieved retracted articles on anesthesiology and intensive care medicine up to August 16, 2021, and identified the papers citing these retracted articles. A survey designed to investigate the reasons for citing these articles was sent to the corresponding authors of the citing papers. RESULTS: We identified 478 retracted articles, 220 (46%) of which were cited at least once. We contacted 1297 corresponding authors of the papers that cited these articles, 417 (30%) of whom responded to our survey and were included in the final analysis. The median number of authors in the analyzed articles was five, and the median elapsed time from retraction to citation was 3 yr. Most of the corresponding authors (372, 89%) were unaware of the retracted status of the cited article, mainly because of inadequate notification of the retraction status in journals and/or databases and the use of stored copies. CONCLUSIONS: The corresponding authors were generally unaware of the retraction of the cited article, usually because of inadequate identification of the retracted status in journals and/or web databases and the use of stored copies. Awareness of this phenomenon and rigorous control of the cited references before submitting a paper are of fundamental importance in research.

A Comparison Between Enteral and Intravenous Nimodipine in Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis.

Our objective was to compare the effectiveness of intravenous and enteral nimodipine in preventing poor outcome from delayed cerebral ischemia in patients with subarachnoid hemorrhage. We performed a systematic search and a network meta-analysis using the following databases: PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Google Scholar. Risk of Bias 2 tool was used to assess risk of bias of included studies. A ranking among methods was performed on the basis of the frequentist analog of the surface under the cumulative ranking curve. Published studies that met the following population, intervention, comparison, outcomes and study (PICOS) criteria were included: patients with subarachnoid hemorrhage aged 15 years or older (P); nimodipine, intravenous and oral formulation (I); placebo or no intervention (C); poor outcome measured at 3 months (defined as death, vegetative state, or severe disability), case fatality at 3 months, delayed cerebral ischemia, delayed ischaemic neurologic deficit, and vasospasm measured with transcranial Doppler or digital subtraction angiography (O); and randomized controlled trials (S). No language or publication date restrictions were applied. Ten studies were finally included, with a total of 1527 randomly assigned patients. Oral and intravenous nimodipine were both effective in preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. Neither treatment was effective in improving case fatality. Evolving clinical protocols over a 30-year period and the risk of bias of the included studies may limit the strength of our results. Enteral and intravenous nimodipine may have a similar effectiveness in terms of preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. More research may be needed to fully establish the role of intravenous nimodipine in current clinical practice.

Preoperative dexmedetomidine and intraoperative bradycardia in laparoscopic cholecystectomy: a meta-analysis with trial sequential analysis.

BACKGROUND: While laparoscopic surgical procedures have various advantages over traditional open techniques, artificial pneumoperitoneum is associated with severe bradycardia and cardiac arrest. Dexmedetomidine, an imidazole derivative that selectively binds to α2-receptors and has sedative and analgesic properties, can cause hypotension and bradycardia. Our primary aim was to assess the association between dexmedetomidine use and intraoperative bradycardia during laparoscopic cholecystectomy. METHODS: We performed a systematic review with a meta-analysis and trial sequential analysis using the following PICOS: adult patients undergoing endotracheal intubation for laparoscopic cholecystectomy (P); intravenous dexmedetomidine before tracheal intubation (I); no intervention or placebo administration (C); intraoperative bradycardia (primary outcome), intraoperative hypotension, hemodynamics at intubation (systolic blood pressure, mean arterial pressure, heart rate), dose needed for induction of anesthesia, total anesthesia requirements (both hypnotics and opioids) throughout the procedure, and percentage of patients requiring postoperative analgesics and experiencing postoperative nausea and vomiting and/or shivering (O); randomized controlled trials (S). RESULTS: Fifteen studies were included in the meta-analysis (980 patients). Compared to patients that did not receive dexmedetomidine, those who did had a higher risk of developing intraoperative bradycardia (RR: 2.81, 95% CI [1.34, 5.91]) and hypotension (1.66 [0.92,2.98]); however, they required a lower dose of intraoperative anesthetics and had a lower incidence of postoperative nausea and vomiting. In the trial sequential analysis for bradycardia, the cumulative z-score crossed the monitoring boundary for harm at the tenth trial. CONCLUSIONS: Patients undergoing laparoscopic cholecystectomy who receive dexmedetomidine during tracheal intubation are more likely to develop intraoperative bradycardia and hypotension.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)-Part 1.

BACKGROUND: Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts' recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm. METHODS: A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. RESULTS: Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided. CONCLUSIONS: This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician's decision-making and not to mandate a standard of practice.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)-part 2.

BACKGROUND: Questions remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance regarding this topic. Specifically, in this manuscript (part 2), we aim to provide a list of experts' recommendations regarding the management of SAH patients in a center with neurosurgical/neuroendovascular facilities after aneurysm treatment. METHODS: A multidisciplinary consensus panel composed by 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. RESULTS: A total of 33 statements were discussed, voted, and approved. Consensus was reached on 30 recommendations (28 strong and 2 weak). In 3 cases, where consensus could not be agreed upon, no recommendation was provided. CONCLUSIONS: This consensus provides practical recommendations (and not mandatory standard of practice) to support clinician's decision-making in the management of SAH patients in centers with neurosurgical/neuroendovascular facilities after aneurysm securing.