Nociception level index variations in ICU: curarized vs non-curarized patients - a pilot study.

PURPOSE: Pain is a major physiological stressor that can worsen critical medical conditions in many ways. Currently, there is no reliable monitoring tool which is available for pain monitoring in the deeply sedated ± curarized critically ill patients. This study aims to assess the effectiveness of the multiparameter nociception index (NOL®) in the critical care setting. We compared NOL with traditionally used neurovegetative signs and examined its correlation with sedation depth measured by bispectral index (BIS®) electroencephalographic (EEG) monitoring. METHODS: This retrospective monocentric cohort study was conducted in a general intensive care unit, including patients who required moderate-to-deep levels of sedation with or without continuous neuromuscular blockade. The performance of NOL was evaluated both in the entire studied population, as well as in two subgroups: curarized and non-curarized patients. RESULTS: NOL demonstrated greater accuracy than all other indicators in pain detection in the overall population. In the non-curare subgroup, all indices correctly recognized painful stimulation, while in the patients subjected to neuromuscular blocking agent's infusion, only NOL properly identified nociception. In the former group, EEG's relation to nociception was on the border of statistical significance, whereas in the latter BIS showed no correlation with NOL. CONCLUSION: NOL emerges as a promising device for pain assessment in the critical care setting and exhibits its best performance precisely in the clinical context where reliable pain assessment methods are most lacking. Furthermore, our research confirms the distinction between sedation and analgesia, highlighting the necessity for distinct monitoring instruments to accurately assess them.

Neuraxial Anesthesia for Combined Left Nephrectomy and Left Hemicolectomy in a One-Lung Patient.

Monopulmonary patients undergoing major abdominal surgery represent a high-risk population. While general anesthesia is typically the standard approach, mechanical ventilation can cause significant complications, particularly in patients with pre-existing lung conditions. Tailored anesthesia strategies are essential to mitigate these risks and preserve respiratory function. We present the case of a 71-year-old female with a history of prior right pneumonectomy for lung cancer. She was scheduled for combined left nephrectomy and left hemicolectomy laparotomic surgery because of extended colon cancer. The patient was prepared according to the local Enhanced Recovery After Surgery (ERAS) protocol and underwent thoracic neuraxial anesthesia with sedation maintaining spontaneous breathing, so avoiding general anesthesia and mechanical ventilation. Anesthesia in the surgical field was effective, and no respiratory problems occurred intraoperatively. The patient's rapid recovery and early discharge underscore the success of our "tailored anesthesia strategy." Our experience highlights the feasibility and benefits of tailored anesthesia in monopulmonary patients undergoing major abdominal surgery. By avoiding general anesthesia and mechanical ventilation, we mitigated risks and optimized patient outcomes, emphasizing the importance of individualized approaches in high-risk surgical populations.

A GAVeCeLT consensus on the indication, insertion, and management of central venous access devices in the critically ill.

Central venous access devices are essential for the management of critically ill patients, but they are potentially associated with many complications, which may occur during or after insertion. Many evidence-based documents-consensus and guidelines-suggest practical recommendations for reducing catheter-related complications, but they have some limitations. Some documents are not focused on critically ill patients; other documents address only some special strategies, such as the use of ultrasound; other documents are biased by obsolete concepts, inappropriate terminology, and lack of considerations for new technologies and new methods. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to offer an updated compendium of the main strategies-old and new-that should be adopted for minimizing catheter-related complications in the adult critically ill patient. The project has been planned as a consensus, rather than a guideline, since many issues in this field are relatively recent, and few high-quality randomized clinical studies are currently available, particularly in the area of indications and choice of the device. Panelists were chosen between the Italian vascular access experts who had published papers on peer-reviewed journals about this topic in the last few years. The consensus process was carried out according to the RAND/University of California at Los Angeles (UCLA) Appropriateness Methodology, a modification of the Delphi method, that is, a structured process for collecting knowledge from groups of experts through a series of questionnaires. The final document has been structured as statements which answer to four major sets of questions regarding central venous access in the critically ill: (1) before insertion (seven questions), (2) during insertion (eight questions), (3) after insertion (three questions), and (4) at removal (three questions).

Ventajas de la utilización de la ecografía como guía para la colocación de accesos vasculares en pediatría / Advantages of applying ultrasound as guidance for central vascular access in pediatric care

Está demostrado que la guía por ecografía para los accesos vasculares incrementa la seguridad y la eficacia durante el cateterismo venoso central en los adultos. Se han informado resultados similares en la población pediátrica para la canalización de la vena yugular interna, pero se dispone de escasos datos sobre el uso de esta tecnología para la canalización de las venas subclavia y femoral. Los metanálisis actuales no han favorecido la utilización de puntos de referencia de superficie en relación con la canalización guiada por ecografía. La guía por ultrasonografía incrementa la tasa de resultados positivos en el primer intento, reduce las complicaciones y es rentable. El acceso venoso central más difundido en pacientes pediátricos es la vena yugular interna, pero pueden utilizarse las venas subclavia, braquiocefálica y femoral. Se necesita un abordaje metodológico de esta técnica y un extenso entrenamiento en ecografía para la realización de este procedimiento en pacientes pediátricos.