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BACKGROUND: In the last decades, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has been gaining in popularity for intraoperative support during lung transplant (LT), being advocated for routinely use also in uncomplicated cases. Compared to off-pump strategy and, secondarily, to traditional cardiopulmonary bypass (CPB), V-A ECMO seems to offer a better hemodynamic stability and oxygenation, while data regarding blood product transfusions, postoperative recovery, and mortality remain unclear. This systematic review and network meta-analysis aims to evaluate the comparative efficacy and safety of V-A ECMO and CPB as compared to OffPump strategy during LT. METHODS: A comprehensive literature search was conducted across multiple databases (PubMed Embase, Cochrane, Scopus) and was updated in February 2024. A Bayesian network meta-analysis (NMA), with a fixed-effect approach, was performed to compare outcomes, such as intraoperative needing of blood products, invasive mechanical ventilation (IMV) duration, intensive care unit (ICU) length of stay (LOS), surgical duration, needing of postoperative ECMO, and mortality, across different supports (i.e., intraoperative V-A (default (d) or rescue (r)) ECMO, CPB, or OffPump). FINDINGS: Twenty-seven observational studies (6113 patients) were included. As compared to OffPump surgery, V-A ECMOd, V-A ECMOr, and CPB recorded a higher consumption of all blood products, longer IMV durations, prolonged ICU LOS, surgical duration, and higher mortalities. Comparing different extracorporeal supports, V-A ECMOd and, secondarily, V-A ECMOr overperformed CPB in nearly all above mentioned outcomes, except for RBC transfusions. The lowest rate of postoperative ECMO was recorded after OffPump surgery, while no differences were found comparing different extracorporeal supports. Finally, older age, male gender, and body mass index ≥ 25 kg/m2 negatively impacted on RBC transfusions, ICU LOS, surgical duration, need of postoperative ECMO, and mortality, regardless of the intraoperative extracorporeal support investigated. INTERPRETATION: This comparative network meta-analysis highlights that OffPump overperformed ECMO and CPB in all outcomes of interest, while, comparing different extracorporeal supports, V-A ECMOd and, secondarily, V-A ECMOr overperformed CPB in nearly all above mentioned outcomes, except for RBC transfusions. Older age, male gender, and higher BMI negatively affect several outcomes across different intraoperative strategies, regardless of the intraoperative extracorporeal support investigated. Future prospective studies are necessary to optimize and standardize the intraoperative management of LT.

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

Abstract Introduction The need for a standardized core curriculum in regional anesthesia has become essential, particularly with the integration of ultrasound revolutionizing and exponentially increasing clinical practice and possibilities. In fact, numerous novel techniques, often overlapping, can confuse practitioners. This study aims to establish a core curriculum for upper limb, lower limb, paraspinal and fascial plane blocks for residency training, addressing potential educational gaps caused by the multitude of techniques, through a Delphi consensus process involving recognized Italian regional anesthesia experts. Methods A steering committee was formed in order to select a panel of experts in regional anesthesia. A three-round Delphi consensus was planned: two rounds of electronic voting and a final round of mixed electronic voting and round table discussion. The consensus was defined as ≥ 75% agreement for inclusion and lower than ≤ 25% agreement for exclusion from the core curriculum list. Techniques reaching the 50% threshold were included with low consensus. Results Twenty-nine techniques were selected to be included in the ultrasound-guided regional anesthesia core curriculum. Twenty-two were included with strong consensus: Upper limb: interscalene brachial plexus block, supraclavicular brachial plexus block, infraclavicular brachial plexus block, axillary brachial plexus block, intermediate cervical plexus block Lower limb: femoral nerve block, pericapsular nerve group block, adductor canal block, sciatic nerve block (transgluteal approach, infragluteal approach, and at the popliteal fossa), ankle block Paraspinal/fascial plane blocks: erector spinae plane block, deep serratus anterior plane block, superficial pectointercostal plane block, interpectoral plane block, pectoserratus plane block, rectus sheath block, ilioinguinal iliohypogastric nerves block, transversus abdominis plane block (with subcostal and midaxillary approaches) The remaining seven techniques were included with low consensus: superficial cervical plexus block, lumbar plexus block, fascia iliaca block (suprainguinal approach), anterior quadratus lumborum block, lateral quadratus lumborum block, paravertebral block, and serratus anterior plane block. Conclusions This curriculum aims to standardize training and ensure that residents acquire the essential skills required for effective and safe practice regardless of the residents’ subsequent specialization. By incorporating these techniques, educational programs can provide a structured and consistent approach to regional anesthesia, enhancing the quality of patient care and improving outcomes.

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

Abstract Background Transversus abdominis plane (TAP) block has been utilized to alleviate pain following laparoscopic cholecystectomy (LC). However, the optimal timing of administration remains uncertain. This study aimed to compare the efficacy of pre-operative and postoperative TAP blocks as analgesic options after LC. Methods A frequentist network meta-analysis of randomized controlled trials (RCTs) was conducted. We systematically searched PubMed (via the National Library of Medicine), EMBASE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science up to March 2023. The study included RCTs that enrolled adult patients (≥ 18 years) who underwent LC and received either pre-operative or postoperative TAP blocks. The primary outcome assessed was 24-hour postoperative morphine consumption (mg). Additionally, pain rest scores within 3 hours, 12 hours, and 24 hours, as well as postoperative nausea and vomiting (PONV), were considered as pre-specified secondary outcomes. Results A total of 34 trials with 2317 patients were included in the analysis. Postoperative TAP block demonstrated superiority over the pre-operative TAP block in reducing opioid consumption (MD 2.02, 95% CI 0.87 to 3.18, I2 98.6%, p

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

Ischemic stroke, caused by the interruption of the blood supply to the brain, requires prompt medical intervention to prevent irreversible damage. Anesthetic management is pivotal during surgical treatments like mechanical thrombectomy, where precise strategies ensure patient safety and procedural success. This narrative review highlights key aspects of anesthetic management in ischemic stroke, focusing on preoperative evaluation, anesthetic choices, and intraoperative care. A rapid yet thorough preoperative assessment is crucial, prioritizing essential diagnostic tests and cardiovascular evaluations to determine patient frailty and potential complications. The decision between general anesthesia (GA) and conscious sedation (CS) remains debated, with GA offering better procedural conditions and CS enabling continuous neurological assessment. The selection of anesthetic agents—such as propofol, sevoflurane, midazolam, fentanyl, remifentanil, and dexmedetomidine—depends on local protocols and expertise balancing neuroprotection, hemodynamic stability, and rapid postoperative recovery. Effective blood pressure management, tailored airway strategies, and vigilant postoperative monitoring are essential to optimize outcomes. This review underscores the importance of coordinated care, incorporating multimodal monitoring and maintaining neuroprotection throughout the perioperative period.

Background Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach. Methods We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials. Results A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (−1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (−1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV. Conclusions RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

Abstract Background The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery. Methods This systematic review and network meta-analysis involved cardiac surgical patients (age > 18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome. Results The primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 h, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]). Conclusions In this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 h MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better. Trial registration PROSPERO; CRD42022315497.

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

Despite increasing female representation in medical fields, women remain underrepresented in high-impact authorship positions. This study examines gender disparities in authorship of randomized controlled trials in general surgery journals over the past 20 y. Utilizing PubMed and the Journal Citation Reports (Clarivate, 2023), we identified 8810 randomized controlled trials from 117 surgery journals, filtering down to 5694 studies for final analysis. Gender identification was performed using Genderize.io. Results indicate that women accounted for 26.4% of first authorships and 18.7% of last authorships. Logistic regression revealed that a male last author significantly increases the likelihood of a male first author (odds ratio 2.68; 95% confidence interval 2.18-3.32). Over time, there is a positive trend in female authorship, with high correlation coefficients for both first (Spearman's correlation coefficient 0.916, P < 0.005) and last (Spearman's correlation coefficient 0.878, P < 0.005) authors. Interestingly, journal quartiles did not significantly influence the gender of first authors. These findings suggest persistent gender inequity in surgical research authorship, influenced by mentorship dynamics. The study underscores the need for strategies to enhance female representation in academic leadership to foster a more equitable scholarly environment. Limitations include reliance on Genderize.io for gender determination and the focus on general surgery journals, which may omit relevant studies from other domains. Overall, this research highlights incremental progress toward gender equality in surgical academia, advocating for continued efforts to close the gender gap. [ABSTRACT FROM AUTHOR]

Aim: To compare the effectiveness of preventive interventions in reducing reccurrent diabetic foot ulcers. Meta-analysis (MA) was conducted to address clinical questions on this topic of the Italian guidelines on diabetic foot. Methods: This MA includes randomized controlled trials evaluating the effectiveness of various preventive interventions, namely: treatment of pre-ulcerative foot lesions, structured educational programs, psychological interventions and the use of therapeutic footwear to relieve plantar pressure in people with diabetes mellitus and a history of previous ulcers. Results: A total of 731 studies were identified and 14 were considered eligible for the analysis. We found that treatments of pre-ulcerative foot lesions did not provide any statistically significant effects (MH-OR: 0.84 [0.31, 2.33], p = 0.74, I2 = 38%). Conversely, structured educational programs were associated with a trend toward reduction of ulcer recurrence risk (MH-OR: 0.13 [0.01, 1.64], p = 0.10, I2 = 88%). No randomized controlled studies assessing the efficacy of psychological interventions have been retrieved. The use of therapeutic footwears can effectively reduce the risk of reulceration in diabetic patients with an history of previous DFU, in particular prefabricated rigid-soled therapeutic footwears showed a significant reduction of the risk of ulcer recurrence in comparison with semirigid soles (MH-OR: 0.17 [0.05, 0.57], p = 0.004). Conclusions: The study provides low-certainty evidence that, among preventive strategies in patients with previous DFU, rigid-sole therapeutic footwear and structured education programs are capable of reducing the risk of foot re-ulceration. [ABSTRACT FROM AUTHOR]

Abstract Background Opioids are frequently used in the postoperative period due to their analgesic properties. While these drugs reduce nociceptive somatic, visceral, and neuropathic pain, they may also lead to undesirable effects such as respiratory depression, urinary retention, nausea and vomiting, constipation, itching, opioid-induced hyperalgesia, tolerance, addiction, and immune system disorders. Anesthesiologists are in the critical position of finding balance between using opioids when they are necessary and implementing opioid-sparing strategies to avoid the known harmful effects. This article aims to give an overview of opioid-free anesthesia. Main body This paper presents an overview of opioid-free anesthesia and opioid-sparing anesthetic techniques. Pharmacological and non-pharmacological strategies are discussed, highlighting the possible advantages and drawbacks of each approach. Conclusions Choosing the best anesthetic protocol for a patient undergoing cancer surgery is not an easy task and the available literature provides no definitive answers. In our opinion, opioid-sparing strategies should always be implemented in routine practice and opioid-free anesthesia should be considered whenever possible. Non-pharmacological strategies such as patient education, while generally underrepresented in scientific literature, may warrant consideration in clinical practice.

Background The effect of noninvasive respiratory support (NRS), including high-flow nasal oxygen, bi-level positive airway pressure and continuous positive airway pressure (noninvasive ventilation (NIV)), for preventing and treating post-extubation respiratory failure is still unclear. Our objective was to assess the effects of NRS on post-extubation respiratory failure, defined as re-intubation secondary to post-extubation respiratory failure (primary outcome). Secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), discomfort, intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), and time to re-intubation. Subgroup analyses considered “prophylactic” versus “therapeutic” NRS application and subpopulations (high-risk, low-risk, post-surgical and hypoxaemic patients). Methods We undertook a systematic review and network meta-analysis (Research Registry: reviewregistry1435). PubMed, Embase, CENTRAL, Scopus and Web of Science were searched (from inception until 22 June 2022). Randomised controlled trials (RCTs) investigating the use of NRS after extubation in ICU adult patients were included. Results 32 RCTs entered the quantitative analysis (5063 patients). Compared with conventional oxygen therapy, NRS overall reduced re-intubations and VAP (moderate certainty). NIV decreased hospital mortality (moderate certainty), and hospital and ICU LOS (low and very low certainty, respectively), and increased discomfort (moderate certainty). Prophylactic NRS did not prevent extubation failure in low-risk or hypoxaemic patients. Conclusion Prophylactic NRS may reduce the rate of post-extubation respiratory failure in ICU patients.

Abstract Background Since late 2019, a severe acute respiratory syndrome, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread with overwhelming speed causing over 214 million confirmed infections and more than 4.5 million deaths worldwide. In this framework, Italy had the second highest number of SARS-CoV-2 infections worldwide, and the largest number of deaths. A global effort of both the scientific community and governments has been undertaken to stem the pandemic. The aim of this paper is to perform a narrative review of the Italian contribution to the scientific literature regarding intensive care management of patients suffering from COVID-19, being one of the first western countries to face an outbreak of SARS-CoV-2 infection. Main body We performed a narrative review of the literature, dedicating particular attention and a dedicated paragraph to ventilatory support management, chest imaging findings, biomarkers, possible pharmacological interventions, bacterial superinfections, prognosis and non-clinical key aspects such as communication and interaction with relatives. Conclusions Many colleagues, nurses and patients died leaving their families alone. To all of them, we send our thoughts and dedicate these pages.

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