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

Although life-saving in selected patients, ECMO treatment still has high mortality which for a large part is due to treatment-related complications. A feared complication is ischemic stroke for which heparin is routinely administered for which the dosage is usually guided by activated partial thromboplastin time (aPTT). However, there is no relation between aPTT and the rare occurrence of ischemic stroke (1.2%), but there is a relation with the much more frequent occurrence of bleeding complications (55%) and blood transfusion. Both are strongly related to outcome. We will conduct a three-arm non-inferiority randomized controlled trial, in adult patients treated with ECMO. Participants will be randomized between heparin administration with a target of 2-2.5 times baseline aPTT, 1.5-2 times baseline aPTT, or low molecular weight heparin guided by weight and renal function. Apart from anticoagulation targets, treatment will be according to standard care. The primary outcome parameter is a combined endpoint consisting of major bleeding including hemorrhagic stroke, severe thromboembolic complications including ischemic stroke, and mortality at 6 months. We hypothesize that with lower anticoagulation targets or anticoagulation with LMWH during ECMO therapy, patients will have fewer hemorrhagic complications without an increase in thromboembolic complication or a negative effect on their outcome. If our hypothesis is confirmed, this study could lead to a change in anticoagulation protocols and a better outcome for patients treated with ECMO. ClinicalTrials.gov NCT04536272 . Registered on 2 September 2020. Netherlands Trial Register NL7969.

Background High-flow oxygen therapy (HFOT) has been widely used as an effective alternative to invasive mechanical ventilation (IMV) in some critically ill patients with COVID-19 pneumonia. This study aimed to compare different tools, including the respiratory rate and oxygenation (ROX) index, to predict HFOT failure in this setting. Methodology This single-center retrospective observational study was conducted from September to December 2020 and assessed COVID-19 patients who required HFOT as the first treatment at admission; HFOT failure was defined as IMV use. Prognostic scoring tools were as follows: the Sequential Organ Failure Assessment (SOFA), Acute Physiology And Chronic Health Evaluation (APACHE) II, and Simplified Acute Physiology Score (SAPS) III scores; C-reactive protein; lung consolidation percentage on chest CT; mean partial pressure of oxygen in arterial blood (PaO)/fraction of inspired oxygen (FiO) ratio; and ROX index and modified ROX index, calculated using PaO instead of blood oxygen saturation, within the first 24 hours after admission to the intensive care unit (ICU). These scores were analyzed using a multivariate Cox proportional hazard model; optimal cutoffs were computed using the R system for statistical computing. Results The study enrolled 52 patients, 31 (60%) of whom experienced HFOT failure. The best predictors of HFOT failure measured 24 hours after HFOT initiation were as follows: PaO/FiO (threshold 123.6, sensitivity 87%, specificity 81%, hazard ratio [HR] 7.76, and 95% confidence interval [CI] 2.39-17.1); ROX index (threshold 5.63, sensitivity 68%, specificity 95%, HR 6.18, and 95% CI 2.54-13.4); and modified ROX index (threshold 4.94, sensitivity 81%, specificity 90%, HR 8.16, and 95% CI 3.16-21.5) ( < 0.001 for all). Conclusions Early assessment of the ROX index, modified ROX index, and PaO/FiO ratio can adequately predict, with high accuracy, HFOT failure in COVID-19 patients. Because thresholds remain debated and are still no

Background: Although life-saving in selected patients, ECMO treatment still has high mortality which for a large part is due to treatment-related complications. A feared complication is ischemic stroke for which heparin is routinely administered for which the dosage is usually guided by activated partial thromboplastin time (aPTT). However, there is no relation between aPTT and the rare occurrence of ischemic stroke (1.2%), but there is a relation with the much more frequent occurrence of bleeding complications (55%) and blood transfusion. Both are strongly related to outcome. Methods: We will conduct a three-arm non-inferiority randomized controlled trial, in adult patients treated with ECMO. Participants will be randomized between heparin administration with a target of 2–2.5 times baseline aPTT, 1.5–2 times baseline aPTT, or low molecular weight heparin guided by weight and renal function. Apart from anticoagulation targets, treatment will be according to standard care. The primary outcome parameter is a combined endpoint consisting of major bleeding including hemorrhagic stroke, severe thromboembolic complications including ischemic stroke, and mortality at 6 months. Discussion: We hypothesize that with lower anticoagulation targets or anticoagulation with LMWH during ECMO therapy, patients will have fewer hemorrhagic complications without an increase in thromboembolic complication or a negative effect on their outcome. If our hypothesis is confirmed, this study could lead to a change in anticoagulation protocols and a better outcome for patients treated with ECMO. Trial registration: ClinicalTrials.gov NCT04536272. Registered on 2 September 2020.

Elderly surgical population is growing faster than the rate of population ageing. The risk of postoperative complication is higher in this population, the type of complication and the risk indicators are different from younger patients. There is also a huge heterogeneity in the elderly population. The concept of frailty emerges to explain these specific aspects and to risk stratify older patients. The present work intends to help the anaesthesiologist to take into account the concept of frailty at the preoperative visit. We reviewed, in the light of surgical context, the physiopathology of ageing, the definitions of frailty concept, the current existing strategies forperi-operational optimisation and the different frailty assessment tools. Our conclusions are that preoperative frailty assessment is essential in modern perioperative medicine practice and that the Edmonton Frail Scale stands out from other tools even though it cannot yet be considered as a gold standard., SCOPUS: re.j, info:eu-repo/semantics/published

Surgery remains a main part of the treatment of most solid tumors. Paradoxically, rapid disease progression may be a consequence of surgery in patients presenting with a dysregulated inflammatory response, and increased angiogenesis consequent to a suppressed antitumoral immune response. Physicians taking care of cancer patients should be aware of the important findings that indicate that analgesic techniques could play a role in these phenomena.