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Background/Objectives: Elevated glycemic variability (GV) has been associated with postoperative morbidity. Traditional preoperative fasting guidelines may contribute to high GV by driving the body into catabolism. Enhanced recovery after surgery (ERAS) protocols that include a preoperative carbohydrate load (PCL) reduce hospital length of stay and healthcare costs; however, it remains unclear whether PCL improves GV in surgical patients. The aim of this retrospective study was to determine the effect of a PCL on postoperative GV in diabetic and non-diabetic patients having gynecological surgery. Methods: Retrospective data were collected on patients who had gynecological surgery before and after the rollout of an institutional ERAS protocol that included PCL ingestion. The intervention group included patients who underwent surgery in 2019 and were enrolled in the ERAS protocol and, therefore, received a PCL. The control group included patients who underwent surgery in 2016 and, thus, were not enrolled in the protocol. The primary endpoint was GV, calculated by the coefficient of variance (CV) and glycemic lability index (GLI). Results: A total of 63 patients in the intervention group and 45 in the control were analyzed. GV was not statistically significant between the groups for CV (19.3% vs. 18.6%, p = 0.65) or GLI (0.58 vs. 0.54, p = 0.86). Postoperative pain scores (4.5 vs. 5.2 p = 0.23) and incentive spirometry measurements (1262 vs. 1245 p = 0.87) were not significantly different. A subgroup analysis of patients with and without type 2 diabetes mellitus revealed no significant differences in GV for any of the subgroups. Conclusions: This retrospective review highlights the need for additional GV research, including consensus agreement on a gold standard GV measurement. Large-scale prospective studies are needed to test the effectiveness of the PCL in reducing GV. [ABSTRACT FROM AUTHOR]

Background: The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice. Methods: A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume. Results: A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377). Conclusion: Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction. [ABSTRACT FROM AUTHOR]

Despite significant advances in medical imaging, thrombolytic therapy, and mechanical thrombectomy, acute ischemic strokes (AIS) remain a major cause of mortality and morbidity globally. Targeted temperature management (TTM) has emerged as a potential therapeutic intervention, aiming to mitigate neuronal damage and improve outcomes. This literature review examines the efficacy and challenges of TTM in the context of an AIS. A comprehensive literature search was conducted using databases such as PubMed, Cochrane, Web of Science, and Google Scholar. Studies were selected based on relevance and quality. We identified key factors influencing the effectiveness of TTM such as its timing, depth and duration, and method of application. The review also highlighted challenges associated with TTM, including increased pneumonia rates. The target temperature range was typically between 32 and 36 °C, with the duration of cooling from 24 to 72 h. Early initiation of TTM was associated with better outcomes, with optimal results observed when TTM was started within the first 6 h post-stroke. Emerging evidence indicates that TTM shows considerable potential as an adjunctive treatment for AIS when implemented promptly and with precision, thereby potentially mitigating neuronal damage and enhancing overall patient outcomes. However, its application is complex and requires the careful consideration of various factors. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) incurs substantial health and economic burden, as it is the leading reason for death and disability globally. Endocrine abnormalities are no longer considered a rare complication of TBI. The reported prevalence is variable across studies, depending on the time frame of injury, time and type of testing, and variability in hormonal values considered normal across different studies. The present review reports evidence on the endocrine dysfunction that can occur after TBI. Several aspects, including the pathophysiological mechanisms, clinical consequences/challenges (in the acute and chronic phases), screening and diagnostic workup, principles of therapeutic management, and insights on future directions/research agenda, are presented. The management of hypopituitarism following TBI involves hormonal replacement therapy. It is essential for health care providers to be aware of this complication because at times, symptoms may be subtle and may be mistaken to be caused by brain injury itself. There is a need for stronger evidence for establishing recommendations for optimum management so that they can be incorporated as standard of care in TBI management. [ABSTRACT FROM AUTHOR]

The letter in the Journal of Anesthesia discusses the advantages of neuraxial anesthesia for cesarean delivery in patients with placenta accreta spectrum (PAS). A retrospective study compared neuraxial (NA) and general (GA) anesthesia in 425 patients, finding that NA resulted in lower periprocedural bleeding, reduced need for blood transfusions, shorter operation time, and postoperative length of stay. However, the study lacks details on anesthetic drugs used, neonatal and maternal adverse events, group assignment criteria, and methods for estimating blood loss, highlighting the need for further research in this area. [Extracted from the article]

Objective: The optimal target for blood glucose concentration in critically ill patients is unclear. We will perform a systematic review and meta-analysis with aggregated and individual patient data from randomized controlled trials, comparing intensive glucose control with liberal glucose control in critically ill adults. Data sources: MEDLINE®, Embase, the Cochrane Central Register of Clinical Trials, and clinical trials registries (World Health Organization, clinical trials.gov). The authors of eligible trials will be invited to provide individual patient data. Published triallevel data from eligible trials that are not at high risk of bias will be included in an aggregated data meta-analysis if individual patient data are not available. Methods: Inclusion criteria: randomized controlled trials that recruited adult patients, targeting a blood glucose of = 120mg/dL (= 6.6mmol/L) compared to a higher blood glucose concentration target using intravenous insulin in both groups. Excluded studies: those with an upper limit blood glucose target in the intervention group of > 120mg/dL (> 6.6mmol/L), or where intensive glucose control was only performed in the intraoperative period, and those where loss to follow-up exceeded 10% by hospital discharge. Primary endpoint: In-hospital mortality during index hospital admission. Secondary endpoints: mortality and survival at other timepoints, duration of invasive mechanical ventilation, vasoactive agents, and renal replacement therapy. A random effect Bayesian meta-analysis and hierarchical Bayesian models for individual patient data will be used. Discussion: This systematic review with aggregate and individual patient data will address the clinical question, 'what is the best blood glucose target for critically ill patients overall?'. [ABSTRACT FROM AUTHOR]

Cocaine consumption has increased over the last decade. The potent sympathomimetic effects of the drug can lead to serious neurovascular complications in the form of ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). This systematic review and meta-analysis were designed to describe the clinical features and outcomes of patients suffering from IS, ICH, or SAH occurring in the context of cocaine use. The PubMed, Embase, Cochrane, and Web of Science libraries were queried in December 2022. Studies were included if they provided information regarding the epidemiology, clinical presentation, or outcomes in cocaine-associated strokes. Odds ratios (OR) were pooled using a random-effects model. A total of 36 papers were included. Strokes associated with cocaine use were more prevalent in younger populations and those of African American descent. Cocaine use increased the odds of IS, ICH, or SAH (OR = 5.05, p < 0.001). The odds of mortality (OR = 1.77, p = 0.0021), vasospasm (OR = 2.25, p = 0.0037), and seizures (OR = 1.61, p < 0.001) were also worse when strokes were associated with cocaine use. In addition to counseling patients on the benefits of drug cessation, clinicians should remain vigilant of the potential complications in patients who are hospitalized with cocaine-associated strokes. [ABSTRACT FROM AUTHOR]

Background: Lung recruitment maneuvers (LRMs) have been demonstrated to be effective in avoiding atelectasis during general anesthesia in the pediatric population. Performing these maneuvers is safe at the systemic hemodynamic and respiratory levels. Aims: We aimed to evaluate the impact of a stepwise LRM and individualized positive end-expiratory pressure (PEEP) on cerebral hemodynamics in an experimental neonatal model. Methods: Eleven newborn pigs (less than 72 h old, 2.56 ± 0.18 kg in weight) were included in the study. The LRM was performed under pressure-controlled ventilation with a constant driving pressure (15 cmH2O) in a stepwise increasing PEEP model. The target peak inspiratory pressure (PIP) was 30 cmH2O and the PEEP was 15 cmH2O. The following hemodynamic variables were monitored using the PICCO® system: mean arterial pressure (MAP), central venous pressure (CVP), and cardiac output (CO). The cerebral hemodynamics variables monitored were intracranial pressure (ICP) (with an intraparenchymal Camino® catheter) and cerebral oxygen saturation (rSO2) (with the oximetry monitor INVOS 5100® system). The following respiratory parameters were monitored: oxygen saturation, fraction of inspired oxygen, partial pressure of oxygen, end-tidal carbon dioxide pressure, Pmean, PEEP, static compliance (Cstat), and dynamic compliance (Cdyn). Results: All LRMs were safely performed as scheduled without any interruptions. Systemic hemodynamic stability was maintained during the lung recruitment maneuver. No changes in ICP occurred. We observed an improvement in rSO2 after the maneuver (+5.8%). Conclusions: Stepwise LRMs are a safe tool to avoid atelectasis. We did not observe an impairment in cerebral hemodynamics but an improvement in cerebral oxygenation. [ABSTRACT FROM AUTHOR]

Mechanical thrombectomy (MT) has become a standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Recent evidence suggests that general anesthesia (GA) and mechanical ventilation do not lead to inferior neurologic outcomes if compared to non-GA. However, the guidelines lack specific recommendations for ventilation targets during MT under GA. This systematic review aims to identify ventilation strategies correlating with better neurological outcomes in AIS patients undergoing MT, particularly focusing on oxygenation and carbon dioxide (CO2) targets. A systematic search of multiple databases was conducted to identify human studies reporting the correlation between ventilation strategies and neurological outcomes in MT for AIS. Eligible studies included clinical trials, observational studies, and case–control studies. Out of 157 studies assessed, 11 met the inclusion criteria. Five studies investigated oxygenation targets, while six studies explored CO2 targets. The published studies highlighted the controversial role of supplemental normobaric oxygen therapy and its potential association with worse outcomes. Regarding CO2 targets, the studies identified a potential association between end tidal CO2 levels and functional outcomes, with hypocapnia being unfavorable. This systematic review demonstrates that the current available evidence still lacks strength to suggest specific ventilation targets, but it highlights the potential risks of hyperoxia and hypocapnia in this specific cohort of patients. [ABSTRACT FROM AUTHOR]

This systematic review presents clinical evidence on the association of heart rate variability with outcome prediction in intracerebral and subarachnoid hemorrhages. The literature search led to the retrieval of 19 significant studies. Outcome prediction included functional outcome, cardiovascular complications, secondary brain injury, and mortality. Various aspects of heart rate recording and analysis, based on linear time and frequency domains and a non-linear entropy approach, are reviewed. Heart rate variability was consistently associated with poor functional outcome and mortality, while controversial results were found regarding the association between heart rate variability and secondary brain injury and cardiovascular complications. [ABSTRACT FROM AUTHOR]

Background: Neurocognitive alterations in the perioperative period might be caused by a wide variety of factors including pain, blood loss, hypotension, hypoxia, micro- and macroemboli, cardiopulmonary bypass (CPB), reperfusion damage, and surgery itself, and all are risk factors for developing postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). The objective of this study was to evaluate the effect of ketamine on neurocognitive dysfunction after anesthesia. Methods: We conducted a meta-analysis of randomized controlled trials (RCTs) comparing ketamine use (experimental group) with placebo (controls). Results: The model favors the control group over the experimental group in terms of frequency of hallucinations (the risk ratio with 95% CI is 1.54 [1.09, 2.19], p-value = 0.02), the number of patients readmitted within 30 days (RR with 95% CI is 0.25 [0.09, 0.70]), and the number of adverse events (overall RR with 95% CI is 1.31 [1.06, 1.62]). In terms of morphine consumption, the model favors the experimental group. Conclusion: There was no statistically significant difference in incidences of postoperative delirium, vasopressor requirement, and fentanyl consumption between the ketamine and control groups. However, hallucinations were more frequently reported in the ketamine group. [ABSTRACT FROM AUTHOR]

Background: Although slack is an asset to resilient hospitals, it is usually explicitly discussed only in terms of the quantity and quality of beds and staff. This paper expands this view by addressing slack in four infrastructures of intensive care units (ICUs) (physical space, electricity supply, oxygen supply, and air treatment) during the COVID pandemic. Methods: The study occurred in a leading private hospital in Brazil, aiming at the identification of slack in four units originally designed as ICUs and two units adapted as ICUs. Data collection was based on 12 interviews with healthcare professionals, documents, and comparison between infrastructures and regulatory requirements. Results: Twenty-seven instantiations of slack were identified, with several indications that the adapted ICUs did not provide infrastructure conditions as good as the designed ones. Findings gave rise to five propositions addressing: relationships intra and inter infrastructures; the need for adapted ICUs that match as closely as possible the designed ICUs; the consideration of both clinical and engineering perspectives in design; and the need for the revision of some requirements of the Brazilian regulations. Conclusions: Results are relevant to both the designers of the infrastructures and to the designers of clinical activities as these must take place in fit-for-purpose workspaces. Top management might also benefit as they are the ultimate responsible for decision-making on whether or not to invest in slack. The pandemic dramatically demonstrated the value of investing in slack resources, creating momentum for this discussion in health services. [ABSTRACT FROM AUTHOR]

This article discusses the use of statins in the prevention of delayed cerebral ischemia (DCI) in patients with subarachnoid hemorrhage (SAH) caused by a ruptured cerebral aneurysm. While the most recent guidelines do not recommend statins for this purpose, a randomized trial in 2014 found that taking a statin did not improve outcomes for SAH patients. However, a network meta-analysis suggested that certain statin agents may reduce the risk of DCI, although the certainty of evidence was low to moderate. It is important to note that the use of 80 mg of simvastatin is off-label in Europe and North America, and the common side effects of statins, such as liver dysfunction and myositis, may be particularly relevant in sepsis. Further research is needed to determine the efficacy of statins in preventing DCI in SAH patients. [Extracted from the article]

Background: Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH. Methods: We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations. Results: Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found. Conclusions: Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed. [ABSTRACT FROM AUTHOR]

Introduction: Altered levels of cerebrospinal fluid (CSF) glucose and lactate concentrations are associated with poor outcomes in acute brain injury patients. However, no data on changes in such metabolites consequently to therapeutic interventions are available. The aim of the study was to assess CSF glucose-to-lactate ratio (CGLR) changes related to therapies aimed at reducing intracranial pressure (ICP). Methods: A multicentric prospective cohort study was conducted in 12 intensive care units (ICUs) from September 2017 to March 2022. Adult (> 18 years) patients admitted after an acute brain injury were included if an external ventricular drain (EVD) for intracranial pressure (ICP) monitoring was inserted within 24 h of admission. During the first 48–72 h from admission, CGLR was measured before and 2 h after any intervention aiming to reduce ICP ("intervention"). Patients with normal ICP were also sampled at the same time points and served as the "control" group. Results: A total of 219 patients were included. In the intervention group (n = 115, 53%), ICP significantly decreased and CPP increased. After 2 h from the intervention, CGLR rose in both the intervention and control groups, although the magnitude was higher in the intervention than in the control group (20.2% vs 1.6%; p = 0.001). In a linear regression model adjusted for several confounders, therapies to manage ICP were independently associated with changes in CGLR. There was a weak inverse correlation between changes in ICP and CGRL in the intervention group. Conclusions: In this study, CGLR significantly changed over time, regardless of the study group. However, these effects were more significant in those patients receiving interventions to reduce ICP. [ABSTRACT FROM AUTHOR]

Introduction: Cardiac arrest is a significant cause of premature mortality and severe disability. Despite the death rate steadily decreasing over the previous decade, only 22% of survivors achieve good clinical status and only 25% of patients survive until their discharge from the hospital. The objective of this scoping review was to review relevant AI modalities and the main potential applications of AI in resuscitation. Methods: We conducted the literature search for related studies in PubMed, EMBASE, and Google Scholar. We included peer-reviewed publications and articles in the press, pooling and characterizing the data by their model types, goals, and benefits. Results: After identifying 268 original studies, we chose 59 original studies (reporting 1,817,419 patients) to include in the qualitative synthesis. AI-based methods appear to be superior to traditional methods in achieving high-level performance. Conclusion: AI might be useful in predicting cardiac arrest, heart rhythm disorders, and post-cardiac arrest outcomes, as well as in the delivery of drone-delivered defibrillators and notification of dispatchers. AI-powered technologies could be valuable assistants to continuously track patient conditions. Healthcare professionals should assist in the research and development of AI-powered technologies as well as their implementation into clinical practice. [ABSTRACT FROM AUTHOR]

Impairment in neurocognitive functions ranges between delayed neurocognitive recovery (DNR) and postoperative neurocognitive disorders (pNCD). Incidence varies from 11% after noncardiac surgery to 60% after cardiac surgery. Insulin receptors (IRs) signaling pathway in the central nervous system (CNS) could be a possible pathophysiological mechanism of anesthesia-induced DNR/pNCD and perioperative intranasal insulin administration could be a preventive approach. This hypothesis is supported by the following evidence: effects of IRs-CNS signaling pathway on neuromodulation; higher incidence of DNR/pNCD in patients with insulin resistance; neurotoxicity of IRs signaling pathways after anesthetic exposure; improvement of neurocognitive impairment after insulin exposure. This narrative review was conducted after a literature search of PubMed, EMBASE and SCOPUS online medical data performed in May 2022. Perioperative intranasal insulin is shown to be protective and future studies should address: the role of insulin as a neuromodulator; its integration into neuroprotection approaches; patient populations that might benefit from this approach; a well-defined protocol of intranasal insulin administration in a perioperative background and other disciplines; and possible collateral effects. [ABSTRACT FROM AUTHOR]

Moderate and severe traumatic brain injury (TBI) are major causes of disability and death. In addition, when TBI occurs during pregnancy, it can lead to miscarriage, premature birth, and maternal/fetal death, engendering clinical and ethical issues. Several recommendations have been proposed for the management of TBI patients; however, none of these have been specifically applied to pregnant women, which often have been excluded from major trials. Therefore, at present, evidence on TBI management in pregnant women is limited and mostly based on clinical experience. The aim of this manuscript is to provide the clinicians with practical suggestions, based on 10 rules, for the management of moderate to severe TBI during pregnancy. In particular, we firstly describe the pathophysiological changes occurring during pregnancy; then we explore the main strategies for the diagnosis of TBI taking in consideration the risks related to mother and fetus, and finally we discuss the most appropriate approaches for the management in this particular condition. Based on the available evidence, we suggest a stepwise approach consisting of different tiers of treatment and we describe the specific risks according to the severity of the neurological and systemic conditions of both fetus and mother in relation to each trimester of pregnancy. The innovative feature of this approach is the fact that it focuses on the vulnerability and specificity of this population, without forgetting the current knowledge on adult non-pregnant patients, which has to be applied to improve the quality of the care process. [ABSTRACT FROM AUTHOR]

The best mode of delivering enteral nutrition (EN) in the intensive care unit (ICU) is still debated: several consensus guidelines (American Society for Parenteral and Enteral Nutrition [ASPEN] and the European Society for Parental and Enteral Nutrition [ESPEN]) suggest that EN in ICU should be preferably delivered continuously rather intermittently, but some authors highlight that the first is unphysiological. The aim of this systematic review (SR) is to summarize available clinical evidence related to safety and efficacy of continuous EN (C‐EN) or intermittent EN (I‐EN) in patients in the ICU, in relation to appropriated supply on nutrition status, gastrointestinal symptoms or tolerance, and risks on respiratory tract infections. A literature search of PubMed, EMBASE, and Google Scholar was performed comparing C‐EN vs I‐EN, and 4196 published studies were screened. Nineteen studies were selected for this SR reporting types of ICU, nutrition protocols, and study period. Effects of C‐EN vs I‐EN were presented according to the impact on nutrition status, digestive tract, and respiratory tract. The contrasting results confirmed that the optimal delivering mode of EN remains controversial. Future studies dedicated to identifying the benefits and limitations of C‐EN or I‐EN should be realized. [ABSTRACT FROM AUTHOR]

This document is a comment on a study titled "Singleton pregnancy using in vitro fertilization or intracytoplasmic sperm injection does not increase risk of bleeding in cesarean delivery: a retrospective cohort study." The authors of the comment express interest in the study and discuss its findings. The study compared bleeding risk during and after cesarean delivery in women who conceived using assisted reproductive technology (ART) with those who conceived spontaneously. The authors found no statistically significant difference in bleeding between the two groups. However, they note that previous studies have shown an increased risk of complications, including postpartum hemorrhage, in ART pregnancies. The authors also raise concerns about the study's methodology, including the selection criteria for the control group and the method used to measure blood loss. They suggest that pre-operative and post-operative hemoglobin levels could provide more accurate information on blood loss. The authors declare no conflicts of interest. [Extracted from the article]

This document is a reply to a comment on a systematic review titled "Remote Monitoring of Chronic Critically Ill Patients after Hospital Discharge: A Systematic Review." The original objective of the review was to explore the potential application of remote monitoring in chronic critically ill patients with brain injuries after hospital discharge. However, due to the high heterogeneity of the patient population and the inclusion of patients with various conditions, there was not enough evidence to support the initial objective. The review highlighted limitations and suggested closer collaboration between different professionals to address these issues. The document also mentioned the existing issues associated with using remote monitoring technologies and the potential improvements in device quality and functionality. More original studies are needed to support the initial objective of the review. The authors welcome further comments and suggestions for future directions. [Extracted from the article]

The evaluation of new therapeutic resources against coronavirus disease 2019 (COVID‐19) represents a priority in clinical research considering the minimal options currently available. To evaluate the adjuvant use of systemic oxygen‐ozone administration in the early control of disease progression in patients with COVID‐19 pneumonia. PROBIOZOVID is an ongoing, interventional, randomized, prospective, and double‐arm trial enrolling patient with COVID‐19 pneumonia. From a total of 85 patients screened, 28 were recruited. Patients were randomly divided into ozone‐autohemotherapy group (14) and control group (14). The procedure consisted in a daily double‐treatment with systemic Oxygen–ozone administration for 7 days. All patients were treated with ad interim best available therapy. The primary outcome was delta in the number of patients requiring orotracheal‐intubation despite treatment. Secondary outcome was the difference of mortality between the two groups. Moreover, hematological parameters were compared before and after treatment. No differences in the characteristics between groups were observed at baseline. As a preliminary report we have observed that one patient for each group needed intubation and was transferred to ITU. No deaths were observed at 7–14 days of follow up. Thirty‐day mortality was 8.3% for ozone group and 10% for controls. Ozone therapy did not significantly influence inflammation markers, hematology profile, and lymphocyte subpopulations of patients treated. Ozone therapy had an impact on the need for the ventilatory support, although did not reach statistical significance. Finally, no adverse events related to the use of ozone‐autohemotherapy were reported. Preliminary results, although not showing statistically significant benefits of ozone on COVID‐19, did not report any toxicity. [ABSTRACT FROM AUTHOR]

Rationale: Initial reports of case fatality rates (CFRs) among adults with coronavirus disease (COVID-19) receiving invasive mechanical ventilation (IMV) are highly variable.Objectives: To examine the CFR of patients with COVID-19 receiving IMV.Methods: Two authors independently searched PubMed, Embase, medRxiv, bioRxiv, the COVID-19 living systematic review, and national registry databases. The primary outcome was the "reported CFR" for patients with confirmed COVID-19 requiring IMV. "Definitive hospital CFR" for patients with outcomes at hospital discharge was also investigated. Finally, CFR was analyzed by patient age, geographic region, and study quality on the basis of the Newcastle-Ottawa Scale.Measurements and Results: Sixty-nine studies were included, describing 57,420 adult patients with COVID-19 who received IMV. Overall reported CFR was estimated as 45% (95% confidence interval [CI], 39-52%). Fifty-four of 69 studies stated whether hospital outcomes were available but provided a definitive hospital outcome on only 13,120 (22.8%) of the total IMV patient population. Among studies in which age-stratified CFR was available, pooled CFR estimates ranged from 47.9% (95% CI, 46.4-49.4%) in younger patients (age ≤40 yr) to 84.4% (95% CI, 83.3-85.4%) in older patients (age >80 yr). CFR was also higher in early COVID-19 epicenters. Overall heterogeneity is high (I2 >90%), with nonsignificant Egger's regression test suggesting no publication bias.Conclusions: Almost half of patients with COVID-19 receiving IMV died based on the reported CFR, but variable CFR reporting methods resulted in a wide range of CFRs between studies. The reported CFR was higher in older patients and in early pandemic epicenters, which may be influenced by limited ICU resources. Reporting of definitive outcomes on all patients would facilitate comparisons between studies.Systematic review registered with PROSPERO (CRD42020186997). [ABSTRACT FROM AUTHOR]

Background: SARS-Cov2 infection may trigger lung inflammation and acute-respiratory-distress-syndrome (ARDS) that requires active ventilation and may have fatal outcome. Considering the severity of the disease and the lack of active treatments, 14 patients with Covid-19 and severe lung inflammation received inhaled adenosine in the attempt to therapeutically compensate for the oxygen-related loss of the endogenous adenosine→A2A adenosine receptor (A2AR)-mediated mitigation of the lung-destructing inflammatory damage. This off label-treatment was based on preclinical studies in mice with LPS-induced ARDS, where inhaled adenosine/A2AR agonists protected oxygenated lungs from the deadly inflammatory damage. The treatment was allowed, considering that adenosine has several clinical applications. Patients and treatment: Fourteen consecutively enrolled patients with Covid19-related interstitial pneumonitis and PaO2/FiO2 ratio<300 received off-label-treatment with 9 mg inhaled adenosine every 12 hours in the first 24 hours and subsequently, every 24 days for the next 4 days. Fifty-two patients with analogue features and hospitalized between February and April 2020, who did not receive adenosine, were considered as a historical control group. Patients monitoring also included hemodynamic/hematochemical studies, CTscans, and SARS-CoV2-tests. Results: The treatment was well tolerated with no hemodynamic change and one case of moderate bronchospasm. A significant increase (> 30%) in the PaO2/FiO2-ratio was reported in 13 out of 14 patients treated with adenosine compared with that observed in 7 out of52 patients in the control within 15 days. Additionally, we recorded a mean PaO2/FiO2-ratio increase (215 ± 45 vs. 464 ± 136, P = 0.0002) in patients receiving adenosine and no change in the control group (210±75 vs. 250±85 at 120 hours, P>0.05). A radiological response was demonstrated in 7 patients who received adenosine, while SARS-CoV-2 RNA load rapidly decreased in 13 cases within 7 days while no changes were recorded in the control group within 15 days. There was one Covid-19 related death in the experimental group and 11in the control group. Conclusion: Our short-term analysis suggests the overall safety and beneficial therapeutic effect of inhaled adenosine in patients with Covid-19-inflammatory lung disease suggesting further investigation in controlled clinical trials. [ABSTRACT FROM AUTHOR]

Background: Obesity and steatosis are associated with COVID-19 severe pneumonia. Elevated levels of pro-inflammatory cytokines and reduced immune response are typical of these patients. In particular, adipose tissue is the organ playing the crucial role. So, it is necessary to evaluate fat mass and not simpler body mass index (BMI), because BMI leaves a portion of the obese population unrecognized. The aim is to evaluate the relationship between Percentage of Fat Mass (FM%) and immune-inflammatory response, after 10 days in Intensive Care Unit (ICU).Methods: Prospective observational study of 22 adult patients, affected by COVID-19 pneumonia and admitted to the ICU and classified in two sets: (10) lean and (12) obese, according to FM% and age (De Lorenzo classification). Patients were analyzed at admission in ICU and at 10th day.Results: Obese have steatosis, impaired hepatic function, compromise immune response and higher inflammation. In addition, they have a reduced prognostic nutritional index (PNI), nutritional survival index for ICU patients.Conclusion: This is the first study evaluating FM% in COVID-19 patient. We underlined obese characteristic with likely poorly prognosis and an important misclassification of obesity. A not negligible number of patients with normal BMI could actually have an excess of adipose tissue and therefore have an unfavorable outcome such as an obese. Is fundamental personalized patients nutrition basing on disease phases. [ABSTRACT FROM AUTHOR]

Background: Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice.Methods: European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537.Results: In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%).Conclusion: Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents. [ABSTRACT FROM AUTHOR]

Time and Type of Administered Fluids during Cesarean Section Might Not Matter for Hemodynamic Outcomes, but There Are Significant Patient Safety Concerns Regarding Colloid Use in Parturients. The authors concluded that both fluid-loading techniques are "appropriate" for women undergoing cesarean delivery. We read the article by Theodoraki K and colleagues entitled 'Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter' with interest [[1]]. [Extracted from the article]