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BACKGROUND: The COVID-19 pandemic has provided an unprecedented scenario to deepen knowledge of surge capacity (SC), assessment of which remains a challenge. This study reports a large-scale experience of a multi-hospital network, with the aim of evaluating the characteristics of different hospitals involved in the response and of measuring a real-time SC based on two complementary modalities (actual, base) referring to the intensive care units (ICU). METHODS: Data analysis referred to two consecutive pandemic waves (March-December 2020). Regarding SC, two different levels of analysis are considered: single hospital category (referring to a six-level categorization based on the number of hospital beds) and multi-hospital wide (referring to the response of the entire hospital network). RESULTS: During the period of 114 days, the analysis revealed a key role of the biggest hospitals (>Category-4) in terms of involvement in the pandemic response. In terms of SC, Category-4 hospitals showed the highest mean SC values, irrespective of the calculation method and level of analysis. At the multi-hospital level, the analysis revealed an overall ICU-SC (base) of 84.4% and an ICU-SC (actual) of 106.5%. CONCLUSIONS: The results provide benchmarks to better understand ICU hospital response capacity, highlighting the need for a more flexible approach to SC definition.

Anesthesia, perioperative and critical care medicine are specific areas where registries, biobanks and big data are gaining a leading role in increasing knowledge and improving patients' care. The adoption of these robust data infrastructures - aimed at bridling, manipulating, aggregating, and linking patients' multiparametric data - supports anesthesiologists and intensive care physicians in several aspects of bedside practice and clinical research. Indeed, registries-integrated calculators may promote the concept of personalized medicine acting as "sniffers," electronic alarm systems, or decision support systems. Artificial intelligence applied to large databases or meta-registries may further increase dramatically this functionality, identify associations among thousands of different and only apparently uncorrelated variables. From a research perspective, large datasets are increasingly mined to create observations about medical care beyond prospective randomized clinical trials enrolling thousands of patients, often only presumably homogeneous ore well-balanced. Registries in this context may effectively explore the association between patients' management and patients' outcomes with a negligible impact on ethical issues, limited costs, and easy management. Finally, registries may promote self-evaluation and continuous quality improvement in the field of perioperative and critical care medicine. In a different way, the role of biobanks primarily relies on translational medical research. These allow rapidly creating pools of biological samples available for epidemiological description, pathophysiological definition, and treatment effectiveness verification, basically acting as an accelerator of knowledge production in critical care and perioperative medicine. Nowadays, registries and biobanks are thus routine tools for anesthesiologists and critical care physicians.

Periodic dose assessment is quintessential for dynamic dose adjustment and quality control of continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury (AKI). The flows‐based methods to estimate dose are easy and reproducible methods to quantify (estimate) CRRT dose at the bedside. In particular, quantification of effluent flow and, mainly, the current dose (adjusted for dialysate, replacement, blood flows, and net ultrafiltration) is routinely used in clinical practice. Unfortunately, these methods are critically influenced by several external unpredictable factors; the estimated dose often overestimates the real biological delivered dose quantified through the measurement of urea clearance (the current effective delivered dose). Although the current effective delivered dose is undoubtedly more precise than the flows‐based dose estimation in quantifying CRRT efficacy, some limitations are reported for the urea‐based measurement of dose. This article aims to describe the standard of practice for dose quantification in critically ill patients with AKI undergoing CRRT in the intensive care unit. Pitfalls of current methods will be underlined, along with solutions potentially applicable to obtain more precise results in terms of (a) adequate marker solutes that should be used in accordance with the clinical scenario, (b) correct sampling procedures depending on the chosen indicator of transmembrane removal, (c) formulas for calculations, and (d) quality controls and benchmark indicators., The periodic dose assessment is quintessential for dynamic dose adjustment and quality control of continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury (AKI). The effluent flow quantification and the current dose, easy and reproducible flows‐based dose estimations to quantify the CRRT dose at the bedside, are influenced by external unpredictable factors. Thus, the current effective delivered dose, commonly quantified through the urea clearance measurement, is often overestimated. Limitations related to the urea as it is used as the marker solute could be overcome using different marker solutes (X solutes).

Background: The literature is full of papers reporting side effects of progestogens in cats; however, they are, in fact, safe drugs, as discussed in this article. Gonadotropin-releasing hormone (GnRH) agonists and melatonin are additionally a practical solution for controlling cyclicity in queens, but they also have some contraindications and need to be used carefully. Clinical relevance: Mastering the use of reproductive drugs allows feline practitioners to handle many more clinical situations than can be solved using surgery. It is not necessary to be a specialist in reproduction to be able to halt cyclicity in a valuable breeding queen using hormones. Equipment and technical skills: A sound knowledge of appropriate dosages and criteria for patient selection for all reproductive drugs currently used in feline reproduction is the best guarantee of owner satisfaction and of ensuring the queen’s health. Availability of a serum progesterone assay, either in-house or via an external laboratory, is also important, in order to confirm a queen is at an appropriate stage of the reproductive cycle for treatment. Audience: This article is aimed principally (but not exclusively) at veterinarians working with cat breeders and whose clientele is increasingly interested in alternative methods of controlling reproduction in pet queens. Surgery is no longer the only choice, and practitioners who manage to keep abreast of new developments will be able to address clients’ needs in a modern, professional way. Evidence base: This review draws on a vast body of scientific evidence-based literature. Previously, personal (and sometimes misinformed) opinions, such as the proposed dangerous side effects of progestogens, have been perpetuated in the scientific literature. The papers cited in this review have therefore been carefully scrutinised to distinguish reliable information based on controlled studies from non-evidence-based information.

Multiple organ failure following a septic event derives from immune dysregulation. Many of the mediators of this process are humoral factors (cytokines), which could theoretically be cleared by direct adsorption through a process called hemoperfusion. Hemoperfusion through devices, which bind specific molecules like endotoxin or theoretically provide non-specific adsorption of pro-inflammatory mediators has been attempted and studied for several decades with variable results. More recently, technological evolution has led to the increasing application of adsorption due to more biocompatible and possibly more efficient biomaterials. As a result, new indications are developing in this field, and novel tools are available for clinical use. This narrative review will describe current knowledge regarding technical concepts, safety, and clinical results of hemoperfusion. Finally, it will focus on the most recent literature regarding adsorption applied in critically ill patients and their indications, including recent randomized controlled trials and future areas of investigation. Clinical trials for the assessment of efficacy of hemoperfusion in septic patients should apply the explanatory approach. This includes a highly selected homogenous patient population. Enrichment criteria such as applying genetic signature and molecular biomarkers allows the identification of subphenotypes of patients. The intervention must be delivered by a multidisciplinary team of trained personnel. The aim is to maximize the signals for efficacy and safety. In a homogenous cohort, confounding uncontrolled variables are less likely to exist. Trials with highly selected populations have a high internal validity but poor generalizability. The parallel design described in the figure is robust and usually is required by regulatory agencies for the approval of a new treatment. Allocation concealment and randomization are key to minimize bias such as confirmation bias, observer bias. The intervention should be delivered following a strict protocol. Deviations from the protocol might negatively influence the potential effects of the therapies. Surrogates such as cytokine measurement are adequate primary outcomes in phase 3 trials with small sample size because there is a higher likelihood of finding positive results concerning surrogate markers than in respect with clinical outcomes. Once a trial shows positive results concerning surrogate markers, a rationale for another phase 3 trial exploring clinical outcomes is built, justifying the allocation of financial sources to the intended trial.

First isolated in China in early 2020, Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the novel coronavirus responsible for the ongoing pandemic of Coronavirus Disease 2019 (COVID-19). The disease has been spreading rapidly across the globe, with the largest burden falling on China, Europe, and the United States. COVID-19 is a new clinical syndrome, characterized by respiratory symptoms with varying degrees of severity, from mild upper respiratory illness to severe interstitial pneumonia and acute respiratory distress syndrome, aggravated by thrombosis in the pulmonary microcirculation. Three main phases of disease progression have been proposed for COVID-19: an early infection phase, a pulmonary phase, and a hyperinflammation phase. Although current understanding of COVID-19 treatment is mainly derived from small uncontrolled trials that are affected by a number of biases, strong background noise, and a litany of confounding factors, emerging awareness suggests that drugs currently used to treat COVID-19 (antiviral drugs, antimalarial drugs, immunomodulators, anticoagulants, and antibodies) should be evaluated in relation to the pathophysiology of disease progression. Drawing upon the dramatic experiences taking place in Italy and around the world, here we review the changes in the evolution of the disease and focus on current treatment uncertainties and promising new therapies.

The enhanced recovery after surgery (ERAS) pathway is an evidence-based approach to the use of care elements along the patient perioperative pathway. All care elements that may impact on clinically relevant outcomes have been considered and reviewed. The combined ERAS actions allow a quicker return to bowel function, oral feeding, nutritional and metabolic equilibrium, normal activity and ultimately to achieve better outcomes. Because of the multi factorial approach and the commitment of all the professionals caring for the patient, it is necessary to have the engagement of all disciplines, such as surgery, anesthesiology, clinical nutrition, nursing, physiatry, involved. ERAS is a dynamic process and new evidence are constantly integrated into the program. The primary endpoint of this review is to give updated information on the key ERAS actions to achieve optimal perioperative nutritional and metabolic care.

Introduction: In clinical reports on coronavirus disease 2019 (COVID-19), the incidence of acute kidney injury (AKI) is extremely variable, although AKI is described as an independent risk factor for mortality. A meta-analysis was performed to clarify the incidence and the impact of COVID-19-related AKI on mortality. Methods: All trials reporting the incidence of AKI in COVID-19 patients were searched using MEDLINE, the Cochrane Library, and EMBASE databases (last update April 26, 2020). Results: Ten trials with a sample of 5,166 patients were included. AKI occurred in 947 out of 5,166 (18.3%) patients. AKI incidence was higher in severe cases: 62/305 severe patients developed AKI (20%) versus 27/1,268 nonsevere patients (2%) (p = 0.00001). AKI occurred in 475 out of 915 (52%) deceased patients versus 183 out of 2,678 (7%) survivors (p = 0.00001). Continuous renal replacement therapy was significantly more frequent in severe cases and in dead patients. Conclusion: A significant increase in mortality rate was observed in COVID patients who developed AKI, and AKI incidence was also higher in severe cases. Any supportive strategies to protect kidney could represent valuable intervention to reduce mortality in severe COVID-19 patients.

Arterial blood pressure (BP) is a fundamental cardiovascular variable, is routinely measured in perioperative and intensive care medicine, and has a significant impact on patient management. The clinical reference method for BP monitoring in high-risk surgical patients and critically ill patients is continuous invasive BP measurement using an arterial catheter. A key prerequisite for correct invasive BP monitoring using an arterial catheter is an in-depth understanding of the measurement principle, of BP waveform quality criteria, and of common pitfalls that can falsify BP readings. Here, we describe how to place an arterial catheter, correctly measure BP, and identify and solve common pitfalls. We focus on 5 important steps, namely (1) how to choose the catheter insertion site, (2) how to choose the type of arterial catheter, (3) how to place the arterial catheter, (4) how to level and zero the transducer, and (5) how to check the quality of the BP waveform.

Background The “END-of-Life ScorING-System” (ENDING-S) was previously developed to identify patients at high-risk of dying in the ICU and to facilitate a practical integration between palliative and intensive care. The aim of this study is to prospectively validate ENDING-S in a cohort of long-term critical care patients. Materials and methods Adult long-term ICU patients (with a length-of-stay> 4 days) were considered for this prospective multicenter observational study. ENDING-S and SOFA score were calculated daily and evaluated against the patient’s ICU outcome. The predictive properties were evaluated through a receiver operating characteristic (ROC) analysis. Results Two hundred twenty patients were enrolled for this study. Among these, 21.46% died during the ICU stay. ENDING-S correctly predicted the ICU outcome in 71.4% of patients. Sensitivity, specificity, positive and negative predictive values associated with the previously identified ENDING-S cut-off of 11.5 were 68.1, 72.3, 60 and 89.3%, respectively. ROC-AUC for outcome prediction was 0.79 for ENDING-S and 0.88 for SOFA in this cohort. Conclusions ENDING-S, while not as accurately as in the pilot study, demonstrated acceptable discrimination properties in identifying long-term ICU patients at very high-risk of dying. ENDING-S may be a useful tool aimed at facilitating a practical integration between palliative, end-of-life and intensive care. Trial registration Clinicaltrials.gov Identifier: NCT02875912; First registration August 4, 2016.

The increasing prevalence of multi-drug-resistant bacteria responsible for bloodstream infections (BSIs) makes therapeutic choices progressively more complex. Fast microbiology quickly detects the presence of pathogens and clinically relevant determinants of antibiotic resistance, offering the potential for early administration of antibiotics. In this retrospective observational study, we comparatively evaluated the performances of FilmArray and the current standard method using blood samples collected from intensive care unit (ICU) patients with suspected BSI. A full agreement with the standard was observed in 97/102 samples (95.1 ± 4.2%), a mismatch in 3/102 samples (2.9 ± 3.2%) and detection failure in 2/102 cases (1.96 ± 2.7%). Statistical analysis demonstrated a near-perfect/perfect level of agreement between the two methods, with an overall degree of agreement of 95%. The high performance demonstrated by the FilmArray could allow a "watch and wait" approach helping clinicians in decision-making processes related to choice and initiation of the antimicrobial therapy, thus avoiding ineffective and excessive use of drugs.

Funder: Università degli Studi di Brescia, BACKGROUND: The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. METHODS: A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology. Panelists were assigned four domains (techniques for electroencephalography [EEG] monitoring, patient selection, use of the EEG monitors, competency, and training the principles of pEEG monitoring) from which a list of questions and statements was created to be addressed. A Delphi method based on iterative approach was used to produce the final statements. Statements were classified as highly appropriate or highly inappropriate (median rating ≥ 8), appropriate (median rating ≥ 7 but < 8), or uncertain (median rating < 7) and with a strong disagreement index (DI) (DI < 0.5) or weak DI (DI ≥ 0.5 but < 1) consensus. RESULTS: According to the statements evaluated by the panel, frontal pEEG (which includes a continuous colored density spectrogram) has been considered adequate to monitor the level of sedation (strong consensus), and it is recommended by the panel that all sedated patients (paralyzed or nonparalyzed) unfit for clinical evaluation would benefit from DOS monitoring (strong consensus) after a specific training program has been performed by the ICU staff. To cover the gap between knowledge/rational and routine application, some barriers must be broken, including lack of knowledge, validation for prolonged sedation, standardization between monitors based on different EEG analysis algorithms, and economic issues. CONCLUSIONS: Evidence on using DOS monitors in ICU is still scarce, and further research is required to better define the benefits of using pEEG. This consensus highlights that some critically ill patients may benefit from this type of neuromonitoring.

An accurate assessment of preoperative risk may improve use of hospital resources and reduce morbidity and mortality in high-risk surgical patients. This study aims at implementing an automated surgical risk calculator based on Artificial Neural Network technology to identify patients at risk for postoperative complications. We developed the new SUMPOT based on risk factors previously used in other scoring systems and tested it in a cohort of 560 surgical patients undergoing elective or emergency procedures and subsequently admitted to intensive care units, high-dependency units or standard wards. The whole dataset was divided into a training set, to train the predictive model, and a testing set, to assess generalization performance. The effectiveness of the Artificial Neural Network is a measure of the accuracy in detecting those patients who will develop postoperative complications. A total of 560 surgical patients entered the analysis. Among them, 77 patients (13.7%) suffered from one or more postoperative complications (PoCs), while 483 patients (86.3%) did not. The trained Artificial Neural Network returned an average classification accuracy of 90% in the testing set. Specifically, classification accuracy was 90.2% in the control group (46 patients out of 51 were correctly classified) and 88.9% in the PoC group (8 patients out of 9 were correctly classified). The Artificial Neural Network showed good performance in predicting presence/absence of postoperative complications, suggesting its potential value for perioperative management of surgical patients. Further clinical studies are required to confirm its applicability in routine clinical practice.

Cardiac output (CO) is a key hemodynamic variable that can be minimally invasively estimated by pulse wave analysis. Multi-beat analysis is a novel pulse wave analysis method. In this prospective observational clinical method comparison study, we compared CO estimations by multi-beat analysis with CO measured by intermittent pulmonary artery thermodilution (PATD) in adult patients treated in the intensive care unit (ICU) after off-pump coronary artery bypass surgery (OPCAB). We included patients after planned admission to the ICU after elective OPCAB who were monitored with a radial arterial catheter and a pulmonary artery catheter. At seven time points, we determined CO using intermittent PATD (PATD-CO; reference method) and simultaneously recorded the radial arterial blood pressure waveform that we later used to estimate CO using multi-beat analysis (MBA-CO; test method) with the Argos monitor (Retia Medical; Valhalla, NY, USA). Blood pressure waveforms impaired by inappropriate damping properties or artifacts were excluded. We compared PATD-CO and MBA-CO using Bland–Altman analysis accounting for repeated measurements, the percentage error, and the concordance rate derived from four-quadrant plot analysis (15% exclusion zone). We analyzed 167 CO values of 31 patients. Mean PATD-CO was 5.30 ± 1.22 L/min and mean MBA-CO was 5.55 ± 1.82 L/min. The mean of the differences between PATD-CO and MBA-CO was 0.08 ± 1.10 L/min (95% limits of agreement: − 2.13 L/min to + 2.29 L/min). The percentage error was 40.7%. The four-quadrant plot-derived concordance rate was 88%. CO estimation by multi-beat analysis of the radial arterial blood pressure waveform (Argos monitor) shows reasonable agreement compared with CO measured by intermittent PATD in adult patients treated in the ICU after OPCAB.

Pulse wave analysis enables stroke volume to be estimated from an arterial blood pressure waveform. Multi-beat analysis is a novel pulse wave analysis method. We aimed to investigate cardiac output (CO) estimations using multi-beat analysis of the radial arterial blood pressure waveform in patients undergoing off-pump coronary artery bypass surgery (OPCAB) using intermittent pulmonary artery thermodilution (PATD) as the reference method. This was a prospective clinical method comparison study. In 58 patients, we measured CO using PATD (PATD-CO; reference method) and simultaneously recorded the radial arterial blood pressure waveform that we used for off-line estimation of CO based on multi-beat analysis (MBA-CO; test method) using the Argos CO monitor (Retia Medical; Valhalla, NY, USA). The final analysis was performed using 572 paired CO measurements. We performed Bland–Altman analysis accounting for multiple observations per patient. To describe the ability of the test method to track changes in CO over time we computed four-quadrant plots using a central exclusion zone of 15% and calculated the concordance rate. Mean PATD-CO was 4.13 ± 1.26 L/min and mean MBA-CO was 4.31 ± 1.25 L/min. The mean of the differences between PATD-CO and MBA-CO was − 0.20 L/min with a standard deviation of ± 1.14 L/min and 95% limits of agreement of − 2.48 to + 2.08 L/min. The concordance rate for CO changes between PATD-CO and MBA-CO was 89%. CO estimations using multi-beat analysis (Argos monitor) show reasonable agreement and trending ability compared with PATD-CO as the reference method in adult patients during OPCAB.

Background Assessment of fluid responsiveness is problematic in intensive care unit (ICU) patients, in particular for those undergoing modes of partial support, such as pressure support ventilation (PSV). We propose a new test, based on application of a ventilator-generated sigh, to predict fluid responsiveness in ICU patients undergoing PSV. Methods This was a prospective bi-centric interventional study conducted in two general ICUs. In 40 critically ill patients with a stable ventilatory PSV pattern and requiring volume expansion (VE), we assessed the variations in arterial systolic pressure (SAP), pulse pressure (PP) and stroke volume index (SVI) consequent to random application of 4-s sighs at three different inspiratory pressures. A radial arterial signal was directed to the MOSTCARE™ pulse contour hemodynamic monitoring system for hemodynamic measurements. Data obtained during sigh tests were recorded beat by beat, while all the hemodynamic parameters were averaged over 30 s for the remaining period of the study protocol. VE consisted of 500 mL of crystalloids over 10 min. A patient was considered a responder if a VE-induced increase in cardiac index (CI) ≥ 15% was observed. Results The slopes for SAP, SVI and PP of were all significantly different between responders and non-responders (p

Cardiorenal syndrome (CRS) describes a specific acute and chronic clinical picture in which the heart or the kidney are primarily dysfunctioning and secondarily affect each other. CRS is divided into five classes: acute and chronic CRS, acute and chronic renocardiac syndromes, and secondary dysfunction of heart and kidneys. This article specifically details the classification and the epidemiology, some risk factors, and the pathophysiology of CRS. Some emerging aspects of CRS are also discussed, such as CRS in patients with end-stage heart failure, with mechanical ventricular assistance, and after heart transplantation. Finally, some aspects of pediatric CRS are detailed.

Background: International data on the epidemiology, ventilation practice, and outcomes in patients undergoing abdominal robotic-assisted surgery (RAS) are lacking. The aim of the study was to assess the incidence of postoperative pulmonary complications (PPCs), and to describe ventilator management after abdominal RAS. Methods: This was an international, multicentre, prospective study in 34 centres in nine countries. Patients ≥18 yr of age undergoing abdominal RAS were enrolled between April 2017 and March 2019. The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score was used to stratify for higher risk of PPCs (≥26). The primary outcome was the incidence of PPCs. Secondary endpoints included the preoperative risk for PPCs and ventilator management. Results: Of 1167 subjects screened, 905 abdominal RAS patients were included. Overall, 590 (65.2%) patients were at increased risk for PPCs. Meanwhile, 172 (19%) patients sustained PPCs, which occurred more frequently in 132 (22.4%) patients at increased risk, compared with 40 (12.7%) patients at lower risk of PPCs (absolute risk difference: 12.2% [95% confidence intervals (CI), 6.8–17.6%]; P

Background The fluid challenge response in surgical patients can be predicted by functional haemodynamic tests. Two tests, the mini-fluid challenge (mini-FC) and end-expiratory occlusion test (EEOT), have been assessed in a few small single-centre studies with conflicting results. In general, functional haemodynamic tests have not performed reliably in predicting fluid responsiveness in patients undergoing laparotomy. Objective This trial is designed to address and compare the reliability of the EEOT and the mini-FC in predicting fluid responsiveness during laparotomy. Design Prospective, multicentre study. Setting Three university hospitals in Italy. Patients A total of 103 adults patients scheduled for elective laparotomy with invasive arterial monitoring. Interventions The study protocol evaluated the changes in the stroke volume index (SVI) 20 s (EEOT20) and 30 s (EEOT30) after an expiratory hold and after a mini-FC of 100 ml over 1 min. Fluid responsiveness required an increase in SVI at least 10% following 4 ml kg-1 of Ringer's solution fluid challenge infused over 10 min. Main outcome measurements Haemodynamic data, including SVI, were obtained from pulse contour analysis. The area under the receiver operating characteristic curves of the tests were compared with assess fluid responsiveness. Results Fluid challenge administration induced an increase in SVI at least 10% in 51.5% of patients. The rate of fluid responsiveness was comparable among the three participant centres (P = 0.10). The area under the receiver operating characteristic curves (95% CI) of the changes in SVI after mini-FC was 0.95 (0.88 to 0.98), sensitivity 98.0% (89.5 to 99.6) and specificity 86.8% (75.1 to 93.4) for a cut-off value of 4% of increase in SVI. This was higher than the SVI changes after EEOT20, 0.67 (0.57 to 0.76) and after EEOT30, 0.73 (0.63 to 0.81). Conclusion In patients undergoing laparotomy the mini-FC reliably predicted fluid responsiveness with high-sensitivity and specificity. The EEOT showed poor discriminative value and cannot be recommended for assessment of fluid responsiveness in this surgical setting. Trial registration NCT03808753.

Background The best fluid replacement strategy and the role of albumin in immunocompromised patients with sepsis is unclear. Methods We performed a secondary analysis of immunocompromised patients enrolled in the ALBIOS trial which randomized patients with severe sepsis or septic shock to receive either 20% albumin (target 30 g per liter or more) and crystalloid or crystalloid alone during ICU stay. Results Of 1818 patients originally enrolled, 304 (16.4%) were immunocompromised. One-hundred-thirty-nine (45.7%) patients were randomized in the albumin while 165 (54.2%) in the crystalloid group. At 90 days, 69 (49.6%) in the albumin group and 89 (53.9%) in the crystalloids group died (hazard ratio - HR - 0.94; 95% CI 0.69–1.29). No differences were observed with regards to 28-day mortality, SOFA score (and sub-scores), length of stay in the ICU and in the hospital, proportion of patients who had developed acute kidney injury or received renal replacement therapy, duration of mechanical ventilation. Albumin was not independently associated with a higher or lower 90-day mortality (HR 0.979, 95% CI 0.709–1.352) as compared to crystalloid. Conclusion Albumin replacement during the ICU stay, as compared with crystalloids alone, did not affect clinical outcomes in a cohort of immunocompromised patients with sepsis.

Vasopressors and inotropic agents are widely used in critical care. However, strong evidence supporting their use in critically ill patients is lacking in many clinical scenarios. Thus, the Italian Society of Anesthesia and Intensive Care (SIAARTI) promoted a project aimed to provide indications for good clinical practice on the use of vasopressors and inotropes, and on the management of critically ill patients with shock. A panel of 16 experts in the field of intensive care medicine and hemodynamics has been established. Systematic review of the available literature was performed based on PICO questions. Basing on available evidence, the panel prepared a summary of evidences and then wrote the clinical questions. A modified semi-quantitative RAND/UCLA appropriateness method has been used to determine the appropriateness of specific clinical scenarios. The panel identified 29 clinical questions for the use of vasopressors and inotropes in patients with septic shock and cardiogenic shock. High level of agreement exists among the panel members about appropriateness of inotropes/vasopressors' use in patients with septic shock and cardiogenic shock.

The best timing of orotracheal intubation and invasive ventilation in COVID-19 patients with acute respiratory distress syndrome is unknown. The use of non-invasive ventilation, a life-saving technique in many medical conditions, is debated in patients with ARDS since prolonged NIV and delayed intubation may be harmful. Shortage of intensive care beds and ventilators during a respiratory pandemic can trigger a widespread use of early non-invasive ventilation in many hospitals but which is the best way to ventilate patients with severe bilateral pneumonia and severely increased spontaneous ventilation is controversial. Moreover, viral spreading to health-care workers and other hospitalized patients is an issue for any device used to administer oxygen. Even if protective mechanical ventilation is currently the gold standard for the management of acute respiratory distress syndrome, tracheal intubation is not without risks and is associated with delirium, hemodynamic instability, immobilization and post intensive care syndrome. Both invasive and non-invasive ventilation are associated with advantages and limitations that should be carefully considered when patients with COVID-19-ARDS need our attention. In the absence of strong evidence , in this review we highlight all the pro and con of these two different approaches.

Hemodynamic instability associated with acute renal replacement therapy (aRRT, HIRRT) and/or with acute kidney injury (AKI) is frequently observed in the intensive care unit; it affects patients’ renal recovery, and negatively impacts short- and long-term mortality. A thorough understanding of mechanisms underlying HIRRT and AKI-related hemodynamic instability may allow the physician in adopting adequate strategies to prevent their occurrence and reduce their negative consequences. The aim of this review is to summarize the main alterations occurring in patients with AKI and/or requiring aRRT of those homeostatic mechanisms which regulate hemodynamics and oxygen delivery. In particular, a pathophysiological approach has been used to describe the maladaptive interactions between cardiac output and systemic vascular resistance occurring in these patients and leading to hemodynamic instability. Finally, the potential positive effects of aRRT on these pathophysiological mechanisms and on restoring hemodynamic stability have been described.

This CIRSE Standards of Practice document provides best practices for the safe administration of procedural sedation and analgesia for interventional radiology procedures in adults. The document is aimed at health professionals involved in the provision of sedation and analgesia during interventional radiology procedures. The document has been developed by a writing group consisting of physicians with internationally recognised expertise in interventional radiology, and analgesia and sedation.

Background Beat-to-beat stroke volume (SV) results from the interplay between left ventricular function and arterial load. Fluid challenge induces time-dependent responses in cardiac performance and peripheral vascular and capillary characteristics. Objective To assess whether analysis of the determinants of the haemodynamic response during fluid challenge can predict the final response at 10 and 30 min. Design Observational multicentric cohort study. Setting Three university ICUs. Patients 85 ICU patients with acute circulatory failure diagnosed within the first 48 h of admission. Intervention(s) The fluid challenge consisted of 500 ml of Ringer's solution infused over 10 min. A SV index increase at least 10% indicated fluid responsiveness. Main outcome measures The SV, pulse pressure variation (PPV), arterial elastance, the systolic-dicrotic pressure difference (SAP-Pdic) and cardiac cycle efficiency (CCE) were measured at baseline, 1, 2, 3, 4, 5, 10, 15 and 30 min after the start of the fluid challenge. All haemodynamic data were submitted to a univariable logistic regression model and a multivariable analysis was then performed using the significant variables given by univariable analysis. Results The multivariable model including baseline PPV, and the changes of arterial elastance at 1 min and of the CCE and SAP-Pdic at 5 min when compared with their baseline values, correctly classified 80.5% of responders and 90.7% of nonresponders at 10 min. For the response 30 min after starting the fluid challenge, the model, including the changes of PPV, CCE, SAP-Pdic at 5 min and of arterial elastance at 10 min compared with their baseline values, correctly identified 93.3% of responders and 91.4% of nonresponders. Conclusion In a selection of mixed ICU patients, a statistical model based on a multivariable analysis of the changes of PPV, CCE, arterial elastance and SAP-Pdic, with respect to baseline values, reliably predicts both the early and the late response to a standardised fluid challenge. Trial registration ACTRN12617000076370.

Background Systemic inflammation in COVID-19 often leads to multiple organ failure, including acute kidney injury (AKI). Renal replacement therapy (RRT) in combination with sequential extracorporeal blood purification therapies (EBP) might support renal function, attenuate systemic inflammation, and prevent or mitigate multiple organ dysfunctions in COVID-19. Aim Describe overtime variations of clinical and biochemical features of critically ill patients with COVID-19 treated with EBP with a hemodiafilter characterized by enhanced cytokine adsorption properties. Methods An observational prospective study assessing the outcome of patients with COVID-19 admitted to the ICU (February to April 2020) treated with EBP according to local practice. Main endpoints included overtime variation of IL-6 and multiorgan function-scores, mortality, and occurrence of technical complications or adverse events. Results The study evaluated 37 patients. Median baseline IL-6 was 1230 pg/ml (IQR 895) and decreased overtime (p p = 0.001). The reduction in serum IL-6 concentrations correlated with the improvement in organ function, as measured in the decrease of SOFA score (rho = 0.48, p = 0.0003). Median baseline SOFA was 13 (IQR 6) and decreased significantly overtime (p p = 0.001). Compared to the expected mortality rates, as calculated by APACHE IV, the mean observed rates were 8.3% lower after treatment. The best improvement in mortality rate was observed in patients receiving EBP early on during the ICU stay. Premature clotting (running Conclusions EBP with heparin-coated hemodiafilter featuring cytokine adsorption properties administered to patients with COVID-19 showed to be feasible and with no adverse events. During the treatment, patients experienced serum IL-6 level reduction, attenuation of systemic inflammation, multiorgan dysfunction improvement, and reduction in expected ICU mortality rate.

Through the years, technology has evolved rapidly, along with great developments in medical devices, particularly in the field of neurointensive care. This has allowed us to delve into new levels of detail and precision, which would not be possible with clinical examination alone. Pupillary reflexes, for example, carry considerable weight on prognostication of the brain-injured patient, yet assessment is of a poor quality. With automated infrared pupillometry now available, clinicians are able to assess this reflex quantitatively. Brain ultrasound, developing from transcranial Doppler into transcranial color-coded duplex Doppler ultrasonography, has become of paramount importance in the assessment of intracranial blood flow, early diagnosis of vasospasm, and estimation of cerebral perfusion pressure and intracranial pressure. Moreover, B-mode can enable the physician to visualize space-occupying lesions such as hematomas and midline shift and to monitor the effectiveness of brain-protective medical interventions. Electroencephalography (EEG) is a complex field, and too few intensivists are able to apply it. However, its diagnostic potential for seizures, depth of sedation evaluation, and need for analgesia remains unparalleled. More simple forms of cerebral function monitoring technology can now provide a more simplified version of EEG, allowing us to titrate sedation and analgesia and diagnose subclinical seizure activity during anesthesia or in the ICU. In this chapter, we propose what we consider as essential noninvasive multimodality neuromonitoring.

Background: The current effective delivered dose is a quality indicator for continuous renal replacement therapy. Its periodic assessment might enable physicians to deliver personalised treatments. Yet, its quantification as by extracorporeal urea clearance (Cl) is cumbersome and thus often neglected in routine practice. The aim of this in vitro study is to demonstrate the non-inferior effectiveness of assessing the current effective delivered dose using a simpler, cheaper and faster approach based on measurement of fluoride rather than urea extracorporeal Cl. Methods: We compared urea and fluoride removal in 3 post-dilution continuous veno-venous haemofiltration (CVVH) and 3 continuous veno-venous haemodialysis (CVVHD) in vitro experimental models. Experiments ran for 180 min, using 3 L of human blood, heparin anticoagulation and a machine dose of 30 mL/kg/h. Urea and fluoride were measured in the inflow, outflow and effluent lines to compare sieving coefficients (SC), saturation coefficients (SA) and transmembrane Cls. Results: In CVVH, the median SC values were 1.06 (1.02–1.07) and 1.02 (1.01–1.04) for fluoride and urea, respectively (discrepancy of 4.3%), while transmembrane convective Cls were 31.28 (30.01–31.31) mL/kg/h and 30.30 (29–31.85) mL/kg/h (discrepancy of 3.13%), respectively. In CVVHD, the median SA values were 1.01 (0.96–1.02) and 1 (0.95–1.01) for fluoride and urea, respectively (discrepancy of 1.6%), while transmembrane dialytic Cls were 30.26 (29.52–31.32) mL/kg/h and 31.16 (30–31.75) mL/kg/h (discrepancy of –2.97%), respectively. Conclusion: Fluoride transmembrane removal was close to that observed with urea, in terms of SC, SA and transmembrane Cl. Fluoride seems as much accurate as urea in assessing the current effective delivered dose during both CVVH and CVVHD and might therefore be adopted for dose measurement. Besides accuracy, fluoride bedside assessment could present many advantages over urea, particularly in terms of availability, costs, time requirement and rapidity of assessment.

The aim of this study was to investigate fetal gastrointestinal motility (FGM) of dogs using ultrasonic imaging and its association with vaginal and rectal temperature, serum progesterone concentrations and fetal heart rate. Pregnant bitches were examined after day 54 of gestation and there were determinations of vaginal and rectal temperature and serum progesterone concentrations. The fetal abdomen was evaluated for 30 s using longitudinal and transversal assessments, and FGM was scored as 0 (no peristalsis) or 1 (evident peristalsis). Number of fetuses with a 1 or 0 score were determined for each bitch (number and the percentage of fetuses with FGM). A total of 135 FGM measurements were recorded. There was FGM in 0/3, 0/6, 1/6 (16.7 %), 3/20 (15 %), 5/18 (27.3 %), 18/28 (64.3 %), 12/17 (70.6 %), 14/22 (63.6 %), 6/9 (66.7 %), 4/6 (66.7 %) fetuses from day -9 until 0 preceding parturition, respectively. In the last 5 days before parturition, 63.3 % of fetuses had FGM. Vaginal and rectal temperature were strongly and positively correlated (P 0.001). Vaginal temperature was positively correlated with progesterone concentrations and fetal heart rate (P 0.01), and there was a small negative correlation with FGM (r = -0.331, P 0.05). Due to ease of data collection, the assessment of FGM is a valuable procedure for evaluation of fetal maturity in dogs. Vaginal and rectal temperatures are reliable variables to be assessed during the last week of pregnancy for estimating the time of parturition.

Background: In a previous trial, in-line filtration significantly prevented postoperative phlebitis associated with short peripheral venous cannulation. This study aims to describe the cost-effectiveness of in-line filtration in reducing phlebitis and examine patients’ perception of in-hospital vascular access management with and without in-line filtration. Methods: We analysed costs associated with in-line filtration: these data were prospectively recorded during the previous trial. Furthermore, we performed a follow-up for all the 268 patients enrolled in this trial. Among these, 213 patients responded and completed 6 months after hospital discharge questionnaires evaluating the perception of and satisfaction with the management of their vascular access. Results: In-line filtration group required 95.60€ more than the no-filtration group (a mean of € 0.71/patient). In terms of satisfaction with the perioperative management of their short peripheral venous cannulation, 110 (82%) and 103 (76.9%) patients, respectively, for in-line filtration and control group, completed this survey. Within in-line filtration group, 97.3% of patients were satisfied/strongly satisfied; if compared with previous experiences on short peripheral venous cannulation, 11% of them recognised in-line filtration as a relevant causative factor in determining their satisfaction. Among patients within the control group, 93.2% were satisfied/strongly satisfied, although up to 30% of them had experienced postoperative phlebitis. At the qualitative interview, they recognised no difference than previous experiences on short peripheral venous cannulation, and mentioned postoperative phlebitis as a common event that ‘normally occurs’ during a hospital stay. Conclusion: In-line filtration is cost-effective in preventing postoperative phlebitis, and it seems to contribute to increasing patient satisfaction and reducing short peripheral venous cannulation–related discomfort

Sepsis-induced acute kidney injury (SI-AKI) represents the first cause of AKI in ICUs, and renal replacement therapy (RRT) is frequently applied in advanced AKI stages. The debate between 'rescue' indications for RRT start in patients with severe AKI (acidosis, hyperkalemia, uremia, oliguria/anuria, volume overload) and a proactive RRT initiation is still ongoing. In addition, current SI-AKI pathophysiologic theory has identified the toxic effects of soluble middle-molecules released during sepsis and inflammation (pathogen and damaged associated molecular patterns).The purpose of the present review is to summarize the recent literature on RRT for patients with SI-AKI. Supportive or replacement measures for severe stages of renal dysfunction and blood purification techniques for sepsis syndrome will be reviewed.Anticipated RRT for SI-AKI does not seem to improve survival or renal recovery. There is no clinical advantage by delivering continuous RRT at high doses for blood purification purposes. Similarly, specific applications with dedicated devices and membranes have yielded no clinical benefit in these patients, so far.In the present review, the recent insights and results from large randomized and nonrandomized trials in the area of RRT applied both as supportive measures for kidney failure and blood purification techniques are described.

Innovation in continuous renal replacement therapies (CRRT) utilized to treat acute kidney injury (AKI) and sepsis, has brought new machines and techniques. Part of these new advances are due to the availability of innovative biomaterials and the construction of membranes with larger pores and wide distribution of pore sizes. This includes the creation of a new generation of high cut-off membranes whose utilization in clinical practice is promising for the wide spectrum of solutes that are removed during extracorporeal therapies.However, the enlargement of pore diameters brings some loss of albumin during treatment and this effect is still under evaluation, since there is a possibility that this is detrimental for the patient. A thorough review of the available clinical literature is reported in this paper with a reappraisal of the potential application of these new technologies.

Background During a fluid challenge, the changes in cardiac performance and peripheral circulatory tone are closely related to the position of the ventricle on the Frank-Starling curve. Some patients have a good haemodynamic response to a fluid challenge, others hardly any response. The early haemodynamic effects of a fluid challenge could predict the final response before the entire fluid volume has been administered. Objective To assess whether a multivariate logistic regression model, including pulse pressure variation (PPV), cardiac cycle efficiency (CCE), arterial elastance and the difference between the dicrotic pressure and both systolic and mean arterial pressure (SAP - Pdic and MAP - Pdic) can predict cardiac responsiveness early during a fluid challenge in comparison with the standard procedure described elsewhere. Design Observational study. Setting Elective surgical patients undergoing laparotomy, enrolled in two Italian University Hospitals. Patients Fifty adult surgical patients, ventilated with a lung protective strategy, were enrolled and data from 46 were analysed. Interventions A fluid challenge consisting of 500 ml of crystalloid infused over 10 min. Main outcome measures and analysis The changes in CCE, arterial elastance, SAP - Pdic and MAP - Pdic were compared using analysis of variance. A multivariate logistic regression analysis utilising baseline values and the first minute measuring a variation statistically significant for the considered variables. Results At baseline, PPV correctly identified 70% of patients (89% of non-responders; 42% of responders). The model, including baseline PPV, ΔCCE and ΔSAP - Pdic, correctly identified the efficiency of fluid challenge in 87% of patients (84.2% of responders; 92.5 of non-responders) after 5 min from fluid challenge infusion. Conclusion In this pilot study conducted in a population of surgical patients mechanically ventilated with a VT less than 8 ml kg, a dynamic model of fluid challenge assessment, including PPV, ΔCCE and ΔSAP - Pdic, enhances the prediction of fluid challenge response after 5 min of a 10-min administration. Trial registration ACTRN12616001479493.

To evaluate the feasibility and safety of the MIRUS system (Pall International, Sarl, Fribourg, Switzerland) for sedation with sevoflurane for postsurgical ICU patients and to evaluate atmospheric pollution during sedation.Prospective interventional study.Surgical ICU. February 2016 to December 2016.Postsurgical patients requiring ICU admission, mechanical ventilation, and sedation.Sevoflurane was administered with the MIRUS system targeted to a Richmond Agitation Sedation Scale from -3 to -5 by adaptation of minimum alveolar concentration.Data collected included Richmond Agitation Sedation Scale, minimum alveolar concentration, inspired and expired sevoflurane fraction, wake-up times, duration of sedation, sevoflurane consumption, respiratory and hemodynamic data, Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment, and laboratory data and biomarkers of organ injury. Atmospheric pollution was monitored at different sites: before sevoflurane delivery (baseline) and during sedation with the probe 15 cm up to the MIRUS system (S1) and 15 cm from the filter-Reflector group (S2). Sixty-two patients were enrolled in the study. No technical failure occurred. Median Richmond Agitation Sedation Scale was -4.5 (interquartile range, -5 to -3.6) with sevoflurane delivered at a median minimum alveolar concentration of 0.45% (interquartile range, 0.4-0.53) yielding a mean inspiratory and expiratory concentrations of 0.79% (SD, 0.24) and 0.76% (SD, 0.18), respectively. Median awakening time was 4 minutes (2.2-5 min). Median duration of sevoflurane administration was 3.33 hours (2.33-5.75 hr), range 1-19 hours with a mean consumption of 7.89 mL/hr (SD, 2.99). Hemodynamics remained stable over the study period, and no laboratory data indicated liver or kidney injury or dysfunction. Median sevoflurane room air concentration was 0.10 parts per million (interquartile range, 0.07-0.15), 0.17 parts per million (interquartile range, 0.14-0.27), and 0.15 parts per million (interquartile range, 0.07-0.19) at baseline, S1, and S2, respectively.The MIRUS system is a promising and safe alternative for short-term sedation with sevoflurane of ICU patients. Atmospheric pollution is largely below the recommended thresholds (5 parts per million). Studies extended to more heterogeneous population of patients undergoing longer duration of sedation are needed to confirm these observations.

Dynamic parameters of fluid responsiveness (FR), namely aortic blood flow velocity variation (delta V peak), left ventricular velocity-time integral variation (delta VTI), stroke volume variation, and pulse pressure variation (PPV) have demonstrated good diagnostic performance for the prediction of response to fluid loading in mechanically ventilated critically ill adult patients. We aimed to evaluate these parameters in children undergoing cardiac surgery. A retrospective observational study of mechanically ventilated patients weighing less than 20 kg who received a volume expansion (VE) of 10 ml/kg after sternal closure was conducted. A 10% cardiac index (CI) increase divided patients into 7 responders (R) and 9 non-responders (NR). Transesophageal echocardiography and Pressure Recording Analytical Method data were retrieved. The percentage CI increase was 18.6 (12)% in R and 2.9 (5.7)% in NR (p = 0.037). Prior to VE, delta V peak, delta VTI, PPV, and SPV differed between R and NR (p = 0.045, 0.043, 0.048, 0,037 and 0.044, respectively). Systolic (p = 0.004), diastolic (p = 0.002), mean blood pressure (p = 0.003), delta V peak (p = 0.03), delta VTI (p = 0.04), CI (p = 0.01), PPV (p = 0.04), SPV (p = 0.04), and dP/dt max (maximal pressure-to-time ratio) (p = 0.02) changed the following VE in R patients. Delta V peak decreased after VE in NR patients (p = 0.004). Delta VTI and PPV showed the highest predictive values, with area under receiver operator characteristic curves of 0.76 (p = 0.049) and 0.76 (p = 0.045), respectively. Delta VTI and PPV were revealed to be potential predictors of FR in ventilated children after cardiac surgery. Their combined evaluation could be useful for fluid management after sternal closure.

Purpose of review The current review analyzes the current pharmacologic approaches in cardiac surgery-associated acute kidney injury and renal replacement/support therapies. Recent findings Hemodynamic management and promising therapies, including atrial natriuretic peptide, calcium sensitizer inodilators, and mesenchymal stem cells have been discussed. Encouraging results from pre-emptive renal replacement therapies have been also addressed. Summary Cardiac surgery is responsible for the highest risk of renal dysfunction with respect to other surgical settings. A number of different and coacting insults, including toxins, renal hypoperfusion, ischemia-reperfusion injury, and systemic inflammation, are leading causes of this frequent complication. Intense research is ongoing on the treatment of established cardiac surgery-associated acute kidney injury and, in this view, a holistic approach including preoperative data, risk stratification, prevention, timely diagnosis, and aggressive intervention can limit the burdening consequences of renal dysfunction in these patients. Although no specific pharmacologic and nonpharmacologic strategy can be currently recommended outside clinical research, the prompt identification of renal dysfunction and the application of multimodal treatments are fundamental aspects. Right ventricular dysfunction and increased central venous pressure, frequently affecting cardiac surgery patients, potentially lead to congestive renal dysfunction. Hemodynamic management covers a central role in these cases.

Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve cardiac output and oxygen delivery (goal-directed therapy, GDT), may improve outcome. However, an italian survey has revealed that hemodynamic protocols are applied by only 29.1% of anesthesiologists. aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.

Individual response to sedatives and hypnotics is characterized by high variability and the identification of a personalized dose during anesthesia in the operating room and during sedation in the intensive care unit may have beneficial effects. Although the brain is the main target of general intravenous and inhaled anesthetic agents, electroencephalography (EEG) is not routinely utilized to explore cerebral response to sedation and anesthesia probably because EEG trace reading is complex and requires encephalographers' skills. Automated processing algorithms (processed EEG, pEEG) of raw EEG traces provide easy-to-use indices that can be utilized to optimize anesthetic management. A large number of high-quality studies and the recommendations of international scientific societies have confirmed the deleterious consequences of inadequate or excessively deep anesthesia (and sedation) level. In this context, anesthesia in the operating rooms and moderate/deep sedation in intensive care units driven by pEEG monitors could become a standard practice in the near future. The aim of the present review was to provide an overview of current knowledge and debate on available technologies for pEEG monitoring and their role in clinical practice for anesthesia and sedation.

Sleep disturbances are very common and associated with severe complications in patients admitted to intensive care units (ICU). Commonly, sedatives like propofol or benzodiazepines have been demonstrated to increase sleep duration but worsen sleep architecture. Dexmedetomidine seems to positively affect both sleep aspects.The present study aimed to investigate sleep characteristics in non-intubated patients admitted to intensive care unit. The subgroups consisted of those without sedation (NO-DEX), and those which received dexmedetomidine infusion (DEX), titrated to a Richmond Agitation-Sedation Scale target of -1/-2, were also explored. An auto-staged electroencephalographer was used to measure sleep duration and architecture. The Richard-Campbell-Sleep questionnaire was administered to all patients.A multivariate analysis conducted in the overall population showed that dexmedetomidine infusion was the only variable independently associated with N2 increase (p 0.001). DEX (n = 36) versus NO-DEX (n = 36) group showed longer N2 stage [68.9% (57.5-80.9) versus 49.5% [35.7-61.4]; p 0.0003]; longer Total Sleep Time [6.5 h (5.7-7.7) versus 3.4 h (1.8-4.9); p 0.0001, and higher Sleep Efficiency [84.2% (71.3-92.6) versus 47.7% (23.4-60.9); p 0.0001]; shorter N1 (percentage of Total Sleep Time) [10.5% (7.8-20.0) and 38.8% (25.6-50.3); p 0.0001]; longer N3 stage [13.6% (1.9-23.3) versus 4.3% (0.4-14.0); p = 0.058]; fewer Cortical Arousals [15 episodes/hour (8.1-24.6) versus 48.7 episodes/hour (29.7-80.4); p 0.0001]. The questionnaire showed better values in DEX-group in all explored items (p 0.0001).Abnormal sleep is common in intensive care unit patients who have not received sedation. Dexmedetomidine, titrated to reach an appropriate sedation level, may optimize sleep duration and architecture.

Monitoring of intraoperative core temperature is strongly recommended to reduce the risk of perioperative thermic imbalance and related complications. The zero-heat-flux sensor (3M Bair Hugger Temperature monitoring system, ZHF), measures core temperature in a non-invasive manner. This study was aimed at comparing accuracy and precision of the ZHF sensor compared to the esophageal thermometer. Patients scheduled for major elective abdominal or urologic surgery were considered eligible for enrollment. Core body temperature was measured using both an esophageal probe (TESO) and a ZHF sensor (TZHF) every 15 min from induction until the end of general anaesthesia. A Bland–Altman plot for repeated measures was performed. The proportion of measurements within ± 0.5 °C was estimated; from a clinical point of view, a proportion greater than 90% was considered sufficiently accurate. Lin’s concordance correlation coefficient (CCC) for repeated measures were calculated. To evaluate association between the two methods, a generalized estimating equation (GEE) simple linear regression model, was elaborated. A GEE multiple regression model was also performed in order to adjust the estimate of the association between measurements from surgical and patient’s features. Ninety-nine patients were enrolled. Bland–Altman plot bias was 0.005 °C with upper and lower limits of agreement for repeated measures of 0.50 °C and − 0.49 °C. The percentage of measurements within 0.5 °C of the reference value was 97.98% (95% confidence interval 92.89–99.75%), indicating a clinically sufficient agreement between the two methods. This was also confirmed by a CCC for repeated measures of 0.89 (95% CI 0.80 to 0.94). The GEE simple regression model (slope value of 0.77) was not significantly influenced by any patient or surgical variables. According to GEE multiple regression model results, the explored patient- and surgery-related variables did not influence the association between methods. ZHF sensor has shown a clinically acceptable accuracy and precision for body core temperature monitoring during elective major surgery. Clinical trial number: NCT03820232.

Introduction Proper management of patients undergoing robotic-assisted urologic and gynecologic surgery must consider a series of peculiarities in the procedures for anesthesiology, critical care medicine, respiratory care, and pain management. Although the indications for robotic-assisted urogynecologic surgeries have increased in recent years, specific guidance documents are still lacking. Evidence acquisition A multidisciplinary group including anesthesiologists, gynecologists, urologists, and a clinical epidemiologist systematically reviewed the relevant literature and provided a set of recommendations and unmet needs on peculiar aspects of anesthesia in this field. Evidence synthesis Nine core contents were identified, according to their requirements in urogynecologic robotic-assisted surgery: patient position, pneumoperitoneum and ventilation strategies, hemodynamic variations and fluid therapy, neuromuscular block, renal surgery and prevention of acute kidney injury, monitoring the Department of anesthesia, postoperative delirium and cognitive dysfunction, prevention of postoperative nausea and vomiting, and pain management in endometriosis. Conclusions This consensus document provides guidance for the management of urologic and gynecologic patients scheduled for robotic-assisted surgery. Moreover, the identified unmet needs highlight the requirement for further prospective randomized studies.

Background: Technical factors at the moment of catheter insertion might have a role in peripherally inserted central catheter–related thrombotic risk. We performed a systematic review and meta-analysis to define the actual rate of peripherally inserted central catheter–related symptomatic deep vein thrombosis in patients in whom catheter insertion was performed according to ultrasound guidance, appropriate catheter size choice, and proper verification of tip location. Methods: We searched Medline, Embase, and Cochrane Library. Only prospective observational studies published in peer-reviewed journals after 2010 up to November 2018 reporting peripherally inserted central catheter–related deep vein thrombosis rate were included. All studies were of adult patients who underwent peripherally inserted central catheter insertion. Results were restricted to those studies which included in their methods ultrasound guidance for venipuncture, catheter tip location, and a catheter size selection strategy. Random-effect meta-analyses and arcsine transformation for binomial data were performed to pool deep vein thrombosis weighted frequencies. Results: Of the 1441 studies identified, 15 studies involving 5420 patients and 5914 peripherally inserted central catheters fulfilled our inclusion criteria. The weighted frequency of peripherally inserted central catheter–related deep vein thrombosis was 2.4% (95% confidence interval = 1.5–3.3) and remained low in oncologic patients (2.2%, 95% confidence interval = 0.6–3.9). Thrombotic rate was higher in onco-hematologic patients (5.9%, 95% confidence interval = 1.2–10). Considerable heterogeneity (I2 = 74.9) was observed and all studies were considered at high risk of attrition bias. Conclusions: A proper technique is crucial at the moment of peripherally inserted central catheter insertion. Peripherally inserted central catheter–related deep vein thrombosis rate appears to be low when evidence-based technical factors are taken into consideration during the insertion procedure.

Objectives Ventricular-arterial coupling represents the interaction between the left ventricle and the arterial system. Ventricular-arterial coupling is measured as the ratio between arterial elastance and ventricular end-systolic elastance. Scant information is available in critically ill children about these variables. The aim of this study was to prospectively assess ventricular-arterial coupling after pediatric cardiac surgery and evaluate its association with other commonly recorded hemodynamic parameters. Design Single-center retrospective observational study. Setting Pediatric cardiac surgery operating room. Patients Children undergoing corrective cardiac surgery. Interventions Hemodynamic monitoring with transesophageal echocardiography. Measurements and main results Twenty-seven patients with biventricular congenital heart disease, who underwent elective cardiac surgery with cardiopulmonary bypass, were enrolled before operating room discharge. Chen single-beat modified method was applied to calculate ventricular-arterial coupling. The median arterial elastance and end-systolic elastance values were 5.9 mm Hg/mL (2.2-9.3 mm Hg/mL) and 4.3 mm Hg/mL (1.9-8.3 mm Hg/mL), respectively. The median ventricular- arterial coupling was 1.2 (1.1-1.6). End-systolic elastance differences between patients with a ventricular-arterial coupling below (low ventricular-arterial coupling) and above (high ventricular-arterial coupling) the median value were -5.2 (95% CI, -6.28 to -0.7; p = 0.008). Differently, arterial elastance differences were -2.1 (95% CI, -5.7 to 1.6; p = 0.19). Ventricular-arterial coupling showed a significant association with pre-ejection time (r, 0.44; p = 0.02), total ejection time (r, -0.41; p = 0.003), cardiac cycle efficiency (r, -0.46; p = 0.02), maximal delta pressure over delta time (r, -0.44; p = 0.02), ejection fraction (r, -0.57; p = 0.01), and systemic vascular resistances indexed (0.56; p = 0.003). After adjustment, total ejection time (p = 0.001), pre-ejection time (p = 0.02), and ejection fraction (p = 0.001) remained independently associated with ventricular-arterial coupling. Conclusions Median ventricular-arterial coupling values in children after cardiac surgery appear high (above 1). Uncoupling was particularly evident in high ventricular-arterial coupling patients who showed the lowest end-systolic elastance values (but not significantly different arterial elastance values) compared with low ventricular-arterial coupling. Ventricular-arterial coupling appears to be inversely proportional to pre-ejection time, total ejection time, and ejection fraction.

In pediatric cardiac surgery patients, when an artifact due to overdamping or to underdamping is suspected to affect the invasive arterial blood pressure (IABP) measure and waveform, a check against non-invasive blood pressure (NIBP) could be useful. In this study, we aimed to retrospectively analyze the differences between IABP (single site) and NIBP, measured at four limbs in children admitted to pediatric cardiac intensive care unit. Overall, 51 patients were enrolled for a total of 546 measurements. Average differences between IABP and NIBP measurements were relatively high with 42% of differences laying within the benchmark value of ± 5 mmHg. Differences on the measures on one limb vs. the others for systolic, diastolic, and mean arterial pressures were not significant (p = 0.16, 0.98, and 0.89, respectively). The systolic invasive–non-invasive differences were generally negative and diastolic and mean ones were generally positive. Correlations of clinical variables with arterial pressures at different sites were rather weak: age was associated with increased IABP–NIBP differences, whereas heart rate and vasoactive-inotropic score showed inverse correlation with IABP–NIBP deltas. Average systolic, diastolic, and mean IABP–NIBP differences of 45 patients without underdamping artifacts were not significantly different compared to those of 6 patients with underdamping (p = 0.17, 0.84, and 0.08, respectively). In conclusion, a wide bias can be detected in post-cardiac surgery children between IABP and NIBP pressures in more than half of measurements, with underdamping/resonance incidence being relatively low. Measurement of both methods without a limb preference should be considered in cardiac surgery children.

OBJECTIVES Our aim was to verify whether the cardiac index (CI) estimated by the pressure recoding analytical method (PRAM) was associated with clinical metabolic indexes of tissue perfusion and mechanical ventilation duration in paediatric patients undergoing cardiac surgery on cardiopulmonary bypass (CPB) for congenital heart disease and whether it could therefore be considered a clinically reliable monitoring method. METHODS A retrospective study was conducted in a paediatric cardiac intensive care unit (PCICU), applying PRAM, a minimally invasive advanced haemodynamic monitoring system (MostCare®, Vygon, Vytech), for the first 24 postoperative hours. Haemodynamic and clinical average values were analysed as time-weighted average values at four postoperative time points (during the first 2 h from PCICU admission, from the 3rd to the 6th, from the 7th to the 12th and from the 13th to the 24th postoperative hours) and correlated with respective variables recorded and averaged at the same time points. RESULTS Forty consecutive patients were enrolled. Median (interquartile range) age, CPB time and Aristotle score were 85 (47-200) days, 157 (112-185) minutes and 8.9 (7.5-10), respectively. CI values at the four time points were 2.89 (2.67-3.19), 2.94 (2.60-3.17), 2.84 (2.64-3.26) and 2.93 (2.58-3.46) l/min/m2, respectively. CI values correlated with lactate levels (r: -0.2; P = 0.01), systolic pressure (r: 0.34, P = 0.0001), heart rate (r: -0.4; P = 0.0001), vasoactive inotropic score (r: -0.3; P = 0.0001) and diuretic dose (r: -0.2; P = 0.01). In patients with low cardiac output syndrome (diagnosed according to clinical metabolic indexes), CI values estimated by PRAM were significantly lower than those of patients without signs of low cardiac output syndrome (P = 0.0001): 3.0 vs 2.8 (95% CI of difference -0.05 to 0.67), 3.1 vs 2.7 (95% CI of difference 0.13-0.85), 3.2 vs 2.7 (95% CI of difference 0.11-0.83) and 3.2 vs 2.7 (95% CI of difference 0.08-0.81) l/min/m2, respectively. Patients with a CI equal to or above 3 l/min/m2, compared with others, showed a significantly lower increase in creatinine levels from PCICU arrival to postoperative day 1: 0.07 (-0.1 to 0.2) vs 0.21 (0.05-0.3) mg/dl (P = 0.0016). Prediction of mechanical ventilation duration was independently associated only with CI (b: -3.4; r: -0.39; P = 0.04) in a multivariable model after adjustment for Aristotle score, vasoactive inotrope score, cross-clamp time, creatinine levels at PCICU admission and patient's age. CONCLUSIONS CI estimated by PRAM after paediatric cardiac surgery was reliably associated with clinical indicators of tissue perfusion, with vasoactive and diuretic drug requirements, and predicted longer mechanical ventilation duration.