Aspirin interruption before neurosurgical interventions: A controversial problem

Aspirin is widely used for primary or secondary prevention of ischemic events. At the same time, chronic aspirin consumption can affect blood clot formation during surgical intervention and increase intraoperative blood loss. This is especially important for high-risk surgery, including neurosurgery. Current European Society of Cardiology guidelines recommend aspirin interruption for at least 7 d before neurosurgical intervention, but this suggestion is not supported by clinical evidence. This narrative review presents evidence that challenges the necessity for aspirin interruption in neurosurgical patients, describes options for aspirin effect monitoring and the clinical implication of these methods, and summarizes current clinical data on bleeding risk associated with chronic aspirin therapy in neurosurgical patients, including brain tumor surgery, cerebrovascular procedures, and spinal surgery.

Machine learning in the prediction and detection of new-onset atrial fibrillation in ICU: a systematic review

Atrial fibrillation (AF) stands as the predominant arrhythmia observed in ICU patients. Nevertheless, the absence of a swift and precise method for prediction and detection poses a challenge. This study aims to provide a comprehensive literature review on the application of machine learning (ML) algorithms for predicting and detecting new-onset atrial fibrillation (NOAF) in ICU-treated patients. Following the PRISMA recommendations, this systematic review outlines ML models employed in the prediction and detection of NOAF in ICU patients and compares the ML-based approach with clinical-based methods. Inclusion criteria comprised randomized controlled trials (RCTs), observational studies, cohort studies, and case-control studies. A total of five articles published between November 2020 and April 2023 were identified and reviewed to extract the algorithms and performance metrics. Reviewed studies sourced 108,724 ICU admission records form databases, e.g., MIMIC. Eight prediction and detection methods were examined. Notably, CatBoost exhibited superior performance in NOAF prediction, while the support vector machine excelled in NOAF detection. Machine learning algorithms emerge as promising tools for predicting and detecting NOAF in ICU patients. The incorporation of these algorithms in clinical practice has the potential to enhance decision-making and the overall management of NOAF in ICU settings.

Verbal Glasgow Coma Scale as predictor of persistent disorder of consciousness: Insights for improving accuracy and reliability in clinical practice

This brief report discusses the relationship between verbal function, disorders of consciousness, and neurological follow-up after acute brain injury. It provides valuable insights for improving the accuracy and reliability of Verbal Glasgow Coma Scale scoring in clinical practice. The report addresses the need for standardized training and underlines the importance of physiological stabilization before assessment. Clarity in communication, recognition of non-verbal cues, and serial assessments are emphasized as critical factors to reduce the Verbal Glasgow Coma Scale inconsistencies. It also promotes interdisciplinary collaboration and cultural sensitivity to refine the Verbal Glasgow Coma Scale evaluation, improving the prediction of long-term neurological outcomes after acute brain injury and optimizing effective rehabilitation programs. Possible strategies to implement in the routine clinical practice the provided tips are discussed.

How much does it cost to be fit for operation? The economics of prehabilitation

PURPOSE OF REVIEW

Prehabilitation before elective surgery can include physical, nutritional, and psychological interventions or a combination of these to allow patients to return postoperatively to baseline status as soon as possible. The purpose of this review is to analyse the current date related to the cost-effectiveness of such programs.

RECENT FINDINGS

The current literature regarding the economics of prehabilitation is limited. However, such programs have been mainly associated with either a reduction in total healthcare related costs or no increase.

SUMMARY

Prehabilitation before elective surgery has been shown to minimize the periprocedural complications and optimization of short term follow up after surgical procedures. Recent studies included cost analysis, either based on hospital accounting data or on estimates costs. The healthcare cost was mainly reduced by shortening the number of hospitalization day. Other factors included length of ICU stay, place of the prehabilitation program (in-hospital vs. home-based) and compliance to the program.

European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice

Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.

Preoperative Risk Assessment Before Elective Craniotomy: Are Aspirin, Arrhythmias, Deep Venous Thromboses, and Hyperglycemia Contraindications to Surgery?

OBJECTIVE

Perioperative risk assessment and stratification before craniotomy is necessary to identify and optimize modifiable risk factors. Due to the high costs of diagnostic testing and concerns for delaying surgery, some have questioned whether and when surgery delays are warranted and supported by the current body of literature. The objective of this scoping review was to evaluate the available evidence on the prognostic value of preoperative risk assessment before anesthesia for elective craniotomy.

METHODS

In this scoping review, we reviewed 156 papers that assess preoperative risk assessment before elective craniotomy, of which 27 papers were included in the final analysis.

RESULTS

There is little high-quality evidence to suggest significant risk reduction when 4 common preexisting abnormalities are present: preoperative chronic aspirin therapy, cardiac arrhythmias, deep vein thrombosis, or hyperglycemia.

CONCLUSIONS

The risk of delaying craniotomy should ultimately be weighed against the perceived risks associated the patient's comorbid conditions and should be considered on an individualized basis.

The Predictive Value of the Verbal Glasgow Coma Scale in Traumatic Brain Injury: A Systematic Review

BACKGROUND

Traumatic brain injury (TBI) is a major global health concern, imposing significant burdens on individuals and healthcare systems. The Glasgow Coma Scale (GCS), a widely utilized instrument for evaluating neurological status, includes 3 variables: motor, verbal, and eye opening. The GCS plays a crucial role in TBI severity stratification. While extensive research has explored the predictive capabilities of the overall GCS score and its motor component, the Verbal Glasgow Coma Scale (V-GCS) has garnered less attention.

OBJECTIVE

To examine the predictive accuracy of the V-GCS in assessing outcomes in patients with TBI, with a particular focus on functional outcome and mortality. In addition, we intend to compare its predictive performance with other components of the GCS.

METHODS

A systematic review, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was conducted utilizing the PubMed, Scopus, and Web of Science databases. Inclusion criteria encompassed 10 clinical studies involving patients with TBI, wherein the level of consciousness was assessed using the verbal GCS score. Predominant statistical measures employed were odds ratios (ORs) and area under the curve (AUC).

RESULTS

Recorded findings consistently underscore that lower V-GCS scores are associated with adverse functional outcomes and mortality in patients with TBI. Despite the predictive accuracy of the V-GCS, the Motor Glasgow Coma Scale (M-GCS) emerges as a superior predictor.

CONCLUSION

In the context of TBI outcome prediction, the V-GCS demonstrates its efficacy as a prognostic tool. However, the M-GCS exhibits superior performance compared with the V-GCS. These insights underscore the multifaceted nature of TBI assessment and emphasize the necessity of considering distinct components of the Glasgow Coma Scale for comprehensive evaluation. Further research is warranted to refine and improve the application of these predictive measures in clinical practice.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Targeted Temperature Management for Patients with Acute Ischemic Stroke: A Literature Review

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

Peri-operative night-time work of anaesthesiologists: A qualitative study of critical issues and proposals

BACKGROUND

Qualitative data on the opinions of anaesthesiologists regarding the impact of peri-operative night-time working conditions on patient safety are lacking.

OBJECTIVES

This study aimed to achieve in-depth understanding of anaesthesiologists' perceptions regarding the impact of night-time working conditions on peri-operative patient safety and actions that may be undertaken to mitigate perceived risks.

DESIGN

Qualitative analysis of responses to two open-ended questions.

SETTING

Online platform questionnaire promoted by the European Society of Anaesthesiology and Intensive Care (ESAIC).

PARTICIPANTS

The survey sample consisted of an international cohort of anaesthesiologists.

MAIN OUTCOME MEASURES

We identified and classified recurrent themes in the responses to questions addressing perceptions regarding (Q1) peri-operative night-time working conditions, which may affect patient safety and (Q2) potential solutions.

RESULTS

We analysed 2112 and 2113 responses to Q1 and Q2, respectively. The most frequently reported themes in relation to Q1 were a perceived reduction in professional performance accompanied by concerns regarding the possible consequences of work with fatigue (27%), and poor working conditions at night-time (35%). The most frequently proposed solutions in response to Q2 were a reduction of working hours and avoidance of 24-h shifts (21%), an increase in human resources (14%) and performance of only urgent or emergency surgeries at night (14%).

CONCLUSION

Overall, the surveyed anaesthesiologists believe that workload-to-staff imbalance and excessive working hours were potential bases for increased peri-operative risk for their patients, partly because of fatigue-related medical errors during night-time work. The performance of nonemergency elective surgical cases at night and lack of facilities were among the reported issues and potential targets for improvement measures. Further studies should investigate whether countermeasures can improve patient safety as well as the quality of life of anaesthesia professionals. Regulations to improve homogeneity, safety, and quality of anaesthesia practice at night seem to be urgently needed.

Diagnostic Accuracy of Procalcitonin in Bacterial Infections of the CNS: An Updated Systematic Review, Meta-Analysis, and Meta-Regression

OBJECTIVES

To evaluate diagnostic accuracy of serum and cerebrospinal fluid (CSF) procalcitonin for diagnosing CNS bacterial infections.

DATA SOURCES

We searched MEDLINE, Cochrane Central Register of Controlled Trials, and International Web of Science databases from January 1, 2016, to September 30, 2022.

STUDY SELECTION

Randomized controlled trials and observational studies, either prospective or retrospective, focusing on procalcitonin as a biomarker for CNS infections.

DATA EXTRACTION

We screened and extracted studies independently and in duplicate. We assessed risk of bias using the revised Quality Assessment for Studies of Diagnostic Accuracy tool. Data for diagnostic sensitivity and specificity were pooled using the bivariate or hierarchical model, as appropriate.

DATA SYNTHESIS

Of 5,347 citations identified, 23 studies were included. Overall, CSF procalcitonin showed slightly higher pooled sensitivity, specificity, and positive likelihood ratio compared with serum procalcitonin. In adults, pooled sensitivity of CSF procalcitonin was 0.89 (95% CI, 0.71-0.96), specificity 0.81 (95% CI, 0.66-0.91); pooled sensitivity of serum procalcitonin was 0.82 (95% CI, 0.58-0.94), specificity 0.77 (95% CI, 0.60-0.89). In children, pooled sensitivity of CSF procalcitonin was 0.96 (95% CI, 0.88-0.99), specificity 0.91 (95% CI, 0.72-0.97); pooled sensitivity of serum procalcitonin was 0.90 (95% CI, 0.75-0.97), specificity 0.83 (95% CI, 0.67-0.92). In post-neurosurgical patients, pooled sensitivity of CSF procalcitonin was 0.82 (95% CI, 0.53-0.95), specificity 0.81 (95% CI, 0.63-0.91); pooled sensitivity of serum procalcitonin was 0.65 (95% CI, 0.33-0.88), specificity 0.61 (95% CI, 0.41-0.78). Logistic regression revealed between-study heterogeneity higher for serum than CSF procalcitonin. For the latter, threshold variability was found as source of heterogeneity.

CONCLUSIONS

In children and critical post-neurosurgical patients, CSF procalcitonin gains superior sensitivity and specificity compared with serum procalcitonin. Overall, CSF procalcitonin appears to have a higher pooled positive likelihood ratio compared with serum procalcitonin.

Fatigue among anaesthesiologists in Europe: Findings from a joint EBA/NASC survey

BACKGROUND

Anaesthesiologists deliver an increasing amount of patient care and often work long hours in operating theatres and intensive care units, with frequent on-calls and insufficient rest in between. In the long term, this will negatively influence mental and physical health and well being. As fatigue becomes more prevalent, this has predictable implications for patient safety and clinical effectiveness. 1.

OBJECTIVE

This study aimed to evaluate the prevalence, severity, causes and implications of work-related fatigue amongst specialist anaesthesiologists.

DESIGN

An online survey of specialist anaesthesiologists.

PARTICIPANTS

The survey was sent to anaesthesiologists in 42 European countries by electronic mail.

MAIN OUTCOME MEASURES

Responses from a 36-item online survey assessed work-related fatigue and its impact on anaesthesiologists in European countries.

RESULTS

Work-related fatigue was experienced in 91.6% of the 1508 respondents from 32 European countries. Fatigue was caused by their working patterns, clinical and nonclinical workloads, staffing issues and excessive work hours. Over 70% reported that work-related fatigue negatively impacted on their physical and mental health, emotional well being and safe commuting. Most respondents did not feel supported by their organisation to maintain good health and well being.

CONCLUSION

Work-related fatigue is a significant and widespread problem amongst anaesthesiologists. More education and increased awareness of fatigue and its adverse effects on patient safety, staff well being and physical and mental health are needed. Departments should ensure that their rotas and job plans comply with the European Working Time Directive (EWTD) and introduce a fatigue risk management system to mitigate the effects of fatigue.

Evidence-based literature review: De-duplication a cornerstone for quality

Evidence-based literature reviews play a vital role in contemporary research, facilitating the synthesis of knowledge from multiple sources to inform decision-making and scientific advancements. Within this framework, de-duplication emerges as a part of the process for ensuring the integrity and reliability of evidence extraction. This opinion review delves into the evolution of de-duplication, highlights its importance in evidence synthesis, explores various de-duplication methods, discusses evolving technologies, and proposes best practices. By addressing ethical considerations this paper emphasizes the significance of de-duplication as a cornerstone for quality in evidence-based literature reviews.

Endocrine Dysfunction After Traumatic Brain Injury: An Ignored Clinical Syndrome?

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

Anesthetic management of endovascular neurosurgical procedures in acute ischemic stroke patients: A systematic review of meta-analyses

Restoration of cerebral circulation in the ischemic area is the most critical treatment task for reducing irreversible neuronal injury in ischemic stroke patients. The recanalización of appropriately selected patients became indispensable for improving clinical outcomes and resulted in the widespread revascularization techniques. There is no clear answer as to which anesthetic modality to use in ischemic stroke patients undergoing neuro-endovascular procedures. The purpose of this systematic review is to conduct a qualitative analysis of systematic reviews and meta-analyses (RSs & MAs) comparing general anesthesia and non-general anesthesia methods for cerebral endovascular interventions in acute ischemic stroke patients. We developed a protocol with the inclusion and exclusion criteria for matched publications and conducted a literature search in PubMed and Google Scholar. The literature search yielded 52 potential publications. Ten relevant RSs & MAs were included and analysed in this review. The decision about which anesthesia method to use for endovascular procedures in managing acute ischemic stroke patients should be made based on the patient's personal characteristics, pathophysiological phenotypes, clinical characteristics, and institutional experience.

Reply to Farahani, P.; Wahid, L. Comment on "Viderman et al. Remote Monitoring of Chronic Critically Ill Patients after Hospital Discharge: A Systematic Review. J. Clin. Med. 2022, 11, 1010"

Thank you very much for taking the time to read this systematic review and for sharing your thoughts [...].

Intensive glucose control in critically ill adults: a protocol for a systematic review and individual patient data meta-analysis

OBJECTIVE

The optimal target for blood glucose concentration in critically ill patients is unclear. We will perform a systematic review and meta-analysis with aggregated and individual patient data from randomized controlled trials, comparing intensive glucose control with liberal glucose control in critically ill adults.

DATA SOURCES

MEDLINE®, Embase, the Cochrane Central Register of Clinical Trials, and clinical trials registries (World Health Organization, clinical trials.gov). The authors of eligible trials will be invited to provide individual patient data. Published trial-level data from eligible trials that are not at high risk of bias will be included in an aggregated data meta-analysis if individual patient data are not available.

METHODS

Inclusion criteria: randomized controlled trials that recruited adult patients, targeting a blood glucose of ≤ 120mg/dL (≤ 6.6mmol/L) compared to a higher blood glucose concentration target using intravenous insulin in both groups. Excluded studies: those with an upper limit blood glucose target in the intervention group of > 120mg/dL (> 6.6mmol/L), or where intensive glucose control was only performed in the intraoperative period, and those where loss to follow-up exceeded 10% by hospital discharge.

PRIMARY ENDPOINT

In-hospital mortality during index hospital admission. Secondary endpoints: mortality and survival at other timepoints, duration of invasive mechanical ventilation, vasoactive agents, and renal replacement therapy. A random effect Bayesian meta-analysis and hierarchical Bayesian models for individual patient data will be used.

DISCUSSION

This systematic review with aggregate and individual patient data will address the clinical question, 'what is the best blood glucose target for critically ill patients overall?'Protocol version 0.4 - 06/26/2023PROSPERO registration:CRD42021278869.

Preoperative glycated hemoglobin concentration and early postoperative infections in patients undergoing spinal surgery: A systematic review

Early postoperative infections can affect a significant number of spinal surgery patients. Many studies reported on the features that may associate with elevated risk of infectious complications in this group. Data on the impact of glucose metabolism disorders in this area are well known. At the same time information on the correlation of preoperative HbA1c level and postoperative infections in spinal surgery are still scarce. Furthermore there are no strict recommendations regarding routine HbA1c testing prior to elective surgery. In present SR we aimed to report available clinical evidence on association between preoperative HbA1c and early postoperative infections. We used PubMed and EMBASE database and a set of specific key words (spine surgery AND infections AND HbA1c) to identify eligible studies. The study was registered in PROSPERO database and reported according to PRISMA recommendations. 16 studies were selected for further assessment. Predominance of data indicated a significant correlation between preoperative HbA1c concentration and elevated risk of postoperative infections, as well as higher rate of non - infective complications and worse patients future outcome. Adequately designed future studies on purposely dimensioned sample size are needed to confirm the role of preoperative HbA1c testing in preoperative management of spinal surgery patients.

Cocaine and Ischemic or Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Clinical Evidence

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

Ventilation Targets for Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review

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

Impact of Stepwise Recruitment Maneuvers on Cerebral Hemodynamics: Experimental Study in Neonatal Model

BACKGROUND

Lung recruitment maneuvers (LRMs) have been demonstrated to be effective in avoiding atelectasis during general anesthesia in the pediatric population. Performing these maneuvers is safe at the systemic hemodynamic and respiratory levels.

AIMS

We aimed to evaluate the impact of a stepwise LRM and individualized positive end-expiratory pressure (PEEP) on cerebral hemodynamics in an experimental neonatal model.

METHODS

Eleven newborn pigs (less than 72 h old, 2.56 ± 0.18 kg in weight) were included in the study. The LRM was performed under pressure-controlled ventilation with a constant driving pressure (15 cmH2O) in a stepwise increasing PEEP model. The target peak inspiratory pressure (PIP) was 30 cmH2O and the PEEP was 15 cmH2O. The following hemodynamic variables were monitored using the PICCO® system: mean arterial pressure (MAP), central venous pressure (CVP), and cardiac output (CO). The cerebral hemodynamics variables monitored were intracranial pressure (ICP) (with an intraparenchymal Camino® catheter) and cerebral oxygen saturation (rSO2) (with the oximetry monitor INVOS 5100® system). The following respiratory parameters were monitored: oxygen saturation, fraction of inspired oxygen, partial pressure of oxygen, end-tidal carbon dioxide pressure, Pmean, PEEP, static compliance (Cstat), and dynamic compliance (Cdyn).

RESULTS

All LRMs were safely performed as scheduled without any interruptions. Systemic hemodynamic stability was maintained during the lung recruitment maneuver. No changes in ICP occurred. We observed an improvement in rSO2 after the maneuver (+5.8%).

CONCLUSIONS

Stepwise LRMs are a safe tool to avoid atelectasis. We did not observe an impairment in cerebral hemodynamics but an improvement in cerebral oxygenation.

Time and Type of Administered Fluids during Cesarean Section Might Not Matter for Hemodynamic Outcomes, but There Are Significant Patient Safety Concerns Regarding Colloid Use in Parturients. Comment on Theodoraki et al. Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter. J. Clin. Med. 2023, 12, 1333

We read the article by Theodoraki K and colleagues entitled 'Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter' with interest [...].

Heart Rate Variability for Outcome Prediction in Intracerebral and Subarachnoid Hemorrhage: A Systematic Review

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

Effect of Ketamine on Postoperative Neurocognitive Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Neurocognitive alterations in the perioperative period might be caused by a wide variety of factors including pain, blood loss, hypotension, hypoxia, micro- and macroemboli, cardiopulmonary bypass (CPB), reperfusion damage, and surgery itself, and all are risk factors for developing postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). The objective of this study was to evaluate the effect of ketamine on neurocognitive dysfunction after anesthesia.

METHODS

We conducted a meta-analysis of randomized controlled trials (RCTs) comparing ketamine use (experimental group) with placebo (controls).

RESULTS

The model favors the control group over the experimental group in terms of frequency of hallucinations (the risk ratio with 95% CI is 1.54 [1.09, 2.19], p-value = 0.02), the number of patients readmitted within 30 days (RR with 95% CI is 0.25 [0.09, 0.70]), and the number of adverse events (overall RR with 95% CI is 1.31 [1.06, 1.62]). In terms of morphine consumption, the model favors the experimental group.

CONCLUSION

There was no statistically significant difference in incidences of postoperative delirium, vasopressor requirement, and fentanyl consumption between the ketamine and control groups. However, hallucinations were more frequently reported in the ketamine group.

Preoperative carbohydrate load to reduce perioperative glycemic variability and improve surgical outcomes: A scoping review

The detrimental effects of both diabetes mellitus (DM) and hyperglycemia in the perioperative period are well established and have driven extensive efforts to control blood glucose concentration (BGC) in a variety of clinical settings. It is now appreciated that acute BGC spikes, hypoglycemia, and high glycemic variability (GV) lead to more endothelial dysfunction and oxidative stress than uncomplicated, chronically elevated BGC. In the perioperative setting, fasting is the primary approach to reducing the risk for pulmonary aspiration; however, prolonged fasting drives the body into a catabolic state and therefore may increase GV. Elevated GV in the perioperative period is associated with an increased risk for postoperative complications, including morbidity and mortality. These challenges pose a conundrum for the management of patients typically instructed to fast for at least 8 h before surgery. Preliminary evidence suggests that the administration of an oral preoperative carbohydrate load (PCL) to stimulate endogenous insulin production and reduce GV in the perioperative period may attenuate BGC spikes and ultimately decrease postoperative morbidity, without significantly increasing the risk of pulmonary aspiration. The aim of this scoping review is to summarize the available evidence on the impact of PCL on perioperative GV and surgical outcomes, with an emphasis on evidence pertaining to patients with DM. The clinical relevance of GV will be summarized, the relationship between GV and postoperative course will be explored, and the impact of PCL on GV and surgical outcomes will be presented. A total of 13 articles, presented in three sections, were chosen for inclusion. This scoping review concludes that the benefits of a PCL outweigh the risks in most patients, even in those with well controlled type 2 DM. The administration of a PCL might effectively minimize metabolic derangements such as GV and ultimately result in reduced postoperative morbidity and mortality, but this remains to be proven. Future efforts to standardize the content and timing of a PCL are needed. Ultimately, a rigorous data-driven consensus opinion regarding PCL administration that identifies optimal carbohydrate content, volume, and timing of ingestion should be established.

Slack in the infrastructure of intensive care units: resilience management in the post-pandemic era

BACKGROUND

Although slack is an asset to resilient hospitals, it is usually explicitly discussed only in terms of the quantity and quality of beds and staff. This paper expands this view by addressing slack in four infrastructures of intensive care units (ICUs) (physical space, electricity supply, oxygen supply, and air treatment) during the COVID pandemic.

METHODS

The study occurred in a leading private hospital in Brazil, aiming at the identification of slack in four units originally designed as ICUs and two units adapted as ICUs. Data collection was based on 12 interviews with healthcare professionals, documents, and comparison between infrastructures and regulatory requirements.

RESULTS

Twenty-seven instantiations of slack were identified, with several indications that the adapted ICUs did not provide infrastructure conditions as good as the designed ones. Findings gave rise to five propositions addressing: relationships intra and inter infrastructures; the need for adapted ICUs that match as closely as possible the designed ICUs; the consideration of both clinical and engineering perspectives in design; and the need for the revision of some requirements of the Brazilian regulations.

CONCLUSIONS

Results are relevant to both the designers of the infrastructures and to the designers of clinical activities as these must take place in fit-for-purpose workspaces. Top management might also benefit as they are the ultimate responsible for decision-making on whether or not to invest in slack. The pandemic dramatically demonstrated the value of investing in slack resources, creating momentum for this discussion in health services.

Fatigue amongst anaesthesiology and intensive care trainees in Europe: A matter of concern

BACKGROUND

There is a growing awareness of the effects of fatigue on trainee wellbeing and health. Trainees in anaesthesiology and intensive care work long hours, switching work schedules frequently with insufficient rest. This may have unwanted long-term effects on mental and physical health and emotional well being, resulting in burnout and affecting patient safety.

OBJECTIVE

The study aimed to evaluate the prevalence, severity, causes and effects of work-related fatigue in trainees in anaesthesiology and intensive care.

DESIGN

Online survey of trainees in anaesthesiology and intensive care.

SETTINGS

A total of 31 countries within Europe were included in the survey.

PARTICIPANTS

European anaesthesiology and intensive care trainees who responded to an invitation to take part by electronic mail or through social media.

MAIN OUTCOME MEASURES

Responses from a 29-item online survey to assess the realities within European countries with regards to work-related fatigue.

RESULTS

One thousand and two hundred trainees from 31 European countries answered the survey demonstrating that an alarming number of trainees were fatigued by their working patterns and night shifts. Trainees reported effects on personal well being, safe commuting and potential for clinical errors. Respondents described a lack of support from hospitals and management for recovery during and after night shifts.

CONCLUSION

Fatigue among trainees in anaesthesiology and intensive care has a significant impact on their well being and potentially, on the incidence of clinical errors. Current measures from authorities and hospital management are not sufficient to prevent serious fatigue, and therefore a fatigue risk management system should be considered. Failure to address this issue might lead to a further decline in trainees' wellbeing, their capacity to work in the speciality in the future, and potentially increase patient care errors.

Pre-operative ultrasound prediction of difficult airway management in adult patients: A systematic review of clinical evidence

BACKGROUND

Predicting a difficult airway, including difficult laryngoscopy, intubation or mask ventilation, is paramount in peri-operative management. As clinical predictors are only partially reliable, ultrasound-based measurements might be useful in evaluating anterior neck fat tissues depth.

OBJECTIVES

The aim of this systematic review is to report clinical evidence on pre-operative ultrasound as a predictor of difficult laryngoscopy, difficult intubation or difficult mask ventilation.

DESIGN

A systematic review of randomised controlled trials and observational studies.

DATA SOURCES

The MEDLINE, EMBASE and Google Scholar databases were queried from inception until 28 February 2022.

ELIGIBILITY CRITERIA

Studies involving adult patients who had undergone orotracheal intubation after evaluation with airways ultrasound were considered suitable. Exclusion criteria were a clinical history of difficult airways, cancer or trauma, pregnancy, supraglottic airway devices, video-laryngoscopy. Parameters were classified by reporting their accuracy in discriminating 'difficult' vs. 'not difficult' laryngoscopy, intubation or mask ventilation.

RESULTS

Thirty-one observational studies were included and a total of 41 single parameters and 12 different combinations of clinical and ultrasound parameters were reported. The distance from skin to epiglottis midway with neutral position of head and neck, the distance from hyoid bone to skin surface with a neutral position of head and neck and the hyomental distance extended/neutral ratio are the most associated with difficult laryngoscopy or difficult intubation. A combination of clinical and ultrasound parameters (a modified Mallampati score, the distance from the skin to the epiglottis midway with neutral position of the head and neck, and the USED-MSH score) showed high accuracy. Only two studies reported the role of ultrasound in predicting difficult mask ventilation: the distance from hyoid bone to skin surface with neutral position of head and neck, the thickness of the base of the tongue with hyperextension of the head, and the hyomental distance with hyperextension of the head and active subluxation of the mandible are the parameters with the highest correlation.

CONCLUSIONS

The use of ultrasound parameters might be useful in predicting difficult laryngoscopy or difficult intubation. Several ultrasound parameters and combinations have been associated with difficult laryngoscopy or difficult intubation prediction. The use of scores combining clinical predictors and ultrasound measures are very promising. Data on difficult mask ventilation are scarce and the role of ultrasound is still controversial. Future studies are needed.

CLINICAL TRIAL REGISTRATION

CRD42021250574.

The burden of peri-operative work at night as perceived by anaesthesiologists: An international survey

BACKGROUND

No international data are available on the night working conditions and workload of anaesthesiologists and their opinions about associated risks.

OBJECTIVE

The aim of this international survey was to describe the peri-operative night working conditions of anaesthesiologists and their perception of the impact these conditions have on patient outcomes and their own quality of life.

DESIGN

Cross-sectional survey.

SETTING

Not applicable.

PARTICIPANTS

Anaesthesiologists providing peri-operative care during night shifts responded to an online survey promoted by the European Society of Anaesthesiology and Intensive Care (ESAIC).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Twenty-eight closed questions.

RESULTS

Overall 5292 complete responses were analysed. Of these, 920 were from trainees. The median reported monthly number of night shifts was 4 [IQR 3-6]. An irregular weekly night shift schedule was most common (51%). Almost all the respondents (98%) declared that their centres have no relevant institutional programmes to monitor stress or fatigue. Most respondents (90%) had received no training or information regarding performance improvement methods for night work. Most respondents were of the opinion that sleep deprivation affects their professional performance (71%) and that their fatigue during night work may increase the peri-operative risk for their patients (74%). Furthermore, 81% of the respondents agreed or strongly agreed that night work represents an additional risk per se for patient safety, and 77% stated that their night work affects the quality of their daily life significantly or extremely.

CONCLUSION

Anaesthesiologists commonly perform perioperative night work without appropriate training, education or support on this specific condition. They perceive current practice as adversely affecting their professional performance and the safety of their patients. They also report significant effects on their own quality of life. Adequate training and education for night work may ally some of these concerns and programmes to monitor workers' stress and fatigue should be mandated to assess whether these concerns are justified.

TRIAL REGISTRATION

Not applicable.

Association of preoperative glycated hemoglobin and early postoperative infections after elective craniotomy: a retrospective cohort study

BACKGROUND

The prognostic value of preoperative HbA1c (glycated hemoglobin) testing is controversial. Available evidence provide conflicting results on the role of preoperative HbA1c in predicting of postoperative complications in different surgical sections. The primary aim of this retrospective observational cohort study was to assess the association between preoperative HbA1c and postoperative infections after elective craniotomy.

METHODS

We extracted and analyzed data from internal hospital database on 4564 patients who underwent neurosurgical intervention from January 2017 till May 2022. The primary outcome measure of the study was infections established in the first week after surgery according to the criteria of the Centers for Disease Control and Prevention. Records were stratified by the HbA1c values and types of interventions.

RESULTS

In patients undergone brain tumor removal with preoperative HbA1c ≥6.5% odds of early postoperative infections were increased (OR = 2.08; 95% CI,1.16-3.72, p=0.01). There was no association of HbA1c with early postoperative infections in patients undergone elective cerebrovascular interventions, cranioplasty or minimally invasive procedures. After adjusting for age and gender threshold of significant infection risk in neurooncological patients raised up to HbA1c ≥7.5% with adjusted OR = 2.97; 95% CI,1.37-6.45, p=0.0058.

CONCLUSIONS

In patients undergoing elective intracranial surgery for brain tumor removal preoperative HbA1c ≥7.5% is associated with higher infection rate within the first postoperative week. Future prospective studies need to assess prognostic value of this association for clinical decision-making.

Cerebro-spinal fluid glucose and lactate concentrations changes in response to therapies in patIents with primary brain injury: the START-TRIP study

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.

Artificial Intelligence in Resuscitation: A Scoping Review

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

Comparison of dexmedetomidine and propofol for sedation in awake craniotomy: A meta-analysis

BACKGROUND

Awake craniotomy (AC) is the preferred option for the resection of tumors adjacent to eloquent cortical areas and in cases of intractable epilepsy. It is mostly used to maintain the integrity of the brain during intracranial neurosurgical procedures. Awake craniotomy requires the use of ideal anesthetics, hypnotics, and analgesics to balance sedation, prompt the reversal of sedation, and prevent respiratory depression while maintaining communication between patient and medical team. Although a wide variety of anesthetics and hypnotics have been used for awake craniotomy over the past several decades, the optimal drug for the procedure has yet to be determined. The purpose of this meta-analysis was to compare dexmedetomidine and propofol in terms of intraoperative adverse events (i.e., hypertension, hypotension, nausea, vomiting, respiratory depression), patient and surgeon satisfaction, and procedure duration.

METHODS

We searched PubMed, Google Scholar, and the Cochrane Library for relevant articles published between the inception of these databases and April of 2022. The systematic search yielded 781 articles. After screening, we excluded 778 articles. The remaining three articles reporting 138 patients were selected for meta-analysis.

RESULTS

This meta-analysis showed no statistically significant difference between propofol and dexmedetomidine related to intraoperative adverse events, patient satisfaction, or procedure duration. The only statistically significant result was surgeon satisfaction, which appeared to be higher in the dexmedetomidine group.

CONCLUSIONS

Further high-quality randomized and controlled trials are needed to find a preferred agent for intraoperative sedation in awake craniotomy.

Perioperative risk factors associated with increased incidence of postoperative delirium: systematic review, meta-analysis, and Grading of Recommendations Assessment, Development, and Evaluation system report of clinical literature

BACKGROUND

Systematic reviews to date have neglected to exclusively include studies using a validated diagnostic scale for postoperative delirium and monitoring patients for more than 24 h. Evidence on current risk factors is evolving with significantly heterogeneous study designs, inconsistent reporting of results, and a lack of adjustment for bias.

METHODS

This systematic review and meta-analysis aimed to identify risk factors for postoperative delirium in an adult patient population. Study designs suitable for this review included full-text articles, RCTs, observational studies, cohort studies, and case-control studies. Extracted variables from the 169 (7.4%) selected studies were included in qualitative synthesis, quantitative synthesis, and a postoperative delirium checklist. The 16 variables included in the checklist were selected based on consistency, direction of effect, number of studies, and clinical utility as a reference for future studies.

RESULTS

A total of 576 variables were extracted, but only six were eligible for meta-analysis. Age (mean difference [MD]=4.94; 95% confidence interval [CI], 2.93-6.94; P<0.001), American Society of Anesthesiologists physical status >2 (odds ratio [OR]=2.27; 95% CI, 1.47-3.52; P<0.001), Charlson Comorbidity Index ≥2 (OR=1.9; 95% CI, 1.11-3.25; P=0.0202), and Mini-Mental State Examination (MD=-1.94; 95% CI, -3.6 to -0.27; P=0.0224) were statistically significant.

CONCLUSIONS

Risk factors can assist in clinical decision-making and identification of high-risk patients. Literature analysis identified inconsistent methodology, leading to challenges in interpretation. A standardised format and evidence-based approach should guide future studies.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)–Part 1

Background

Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts’ recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm.

Methods

A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted.

Results

Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided.

Conclusions

This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician’s decision-making and not to mandate a standard of practice.

Severe Intraoperative Hyperglycemia and Infectious Complications After Elective Brain Neurosurgical Procedures: Prospective Observational Study

BACKGROUND

Postoperative infections after brain surgery are a serious complication potentially worsening the outcome of surgical treatment. Severe intraoperative hyperglycemia (SIH) contributes to both infectious and noninfectious postoperative complications. However, there are a lack of data on the incidence of SIH in patients undergoing elective neurosurgical brain procedures and its association with the risk of postoperative infections.

METHODS

A total of 514 patients were prospectively enrolled in this single-center observational cohort clinical study to assess the incidence of SIH (blood glucose concentration [BGC] ≥180 mg/dL) in adult patients undergoing elective brain neurosurgical procedures and its association with postoperative infections. Both nondiabetic and diabetic patients were included in the study. BGC was determined by whole-blood analyses taken at the beginning and at the end of the surgery. Diagnosis of infection (wound, pulmonary, blood stream, urinary tract infection, or central nervous system infection) was established according to US Centers for Disease Control and Prevention (CDC) criteria within the first postoperative week.

RESULTS

SIH was recorded in at least 1 blood sample in 23 patients (4.5%). Infectious complications within the first postoperative week were diagnosed in 40 patients (7.8%). Five of 23 patients (22%) with SIH had postoperative infections, compared with 35 of 491 patients (7%) without SIH (odds ratio [OR] = 3.71; 95% confidence interval [CI], 1.24-11.09; P = .018 after fitting a multiple logistic regression model to adjust for age, body mass index [BMI], and surgery duration). Intraoperative BGC >140 mg/dL was also associated with an increased risk of postoperative infections (OR = 3.10; 95% CI, 1.43-6.75; P = .004). Elevated preoperative glycated hemoglobin (HbA1c) concentration was also associated with postoperative infections in the study population (OR = 2.4; 95% CI, 1.02-6.00; P = .045). Age, BMI, American Society of Anesthesiologists (ASA) physical status, type of surgery, and duration of intervention had no significant association with the postoperative infection rate.

CONCLUSIONS

SIH is associated with a higher risk of infections within the first postoperative week in patients undergoing elective brain neurosurgical procedures. Preoperative HbA1c is a reliable marker of the potential risk both of SIH and postoperative infections in the selected cohort. Future studies need to assess possible improvements in outcome under more precise monitoring and tighter control of perioperative hyperglycemia.

Insulin signaling in the central nervous system, a possible pathophysiological mechanism of anesthesia-induced delayed neurocognitive recovery/postoperative neurocognitive disorder: a narrative review

INTRODUCTION

Impairment in neurocognitive functions ranges between delayed neurocognitive recovery (DNR) and postoperative neurocognitive disorders (pNCD). Incidence varies from 11% after noncardiac surgery to 60% after cardiac surgery.

AREAS COVERED

Insulin receptors (IRs) signaling pathway in the central nervous system (CNS) could be a possible pathophysiological mechanism of anesthesia-induced DNR/pNCD and perioperative intranasal insulin administration could be a preventive approach. This hypothesis is supported by the following evidence: effects of IRs-CNS signaling pathway on neuromodulation; higher incidence of DNR/pNCD in patients with insulin resistance; neurotoxicity of IRs signaling pathways after anesthetic exposure; improvement of neurocognitive impairment after insulin exposure. This narrative review was conducted after a literature search of PubMed, EMBASE and SCOPUS online medical data performed in May 2022.

EXPERT OPINION

Perioperative intranasal insulin is shown to be protective and future studies should address: the role of insulin as a neuromodulator; its integration into neuroprotection approaches; patient populations that might benefit from this approach; a well-defined protocol of intranasal insulin administration in a perioperative background and other disciplines; and possible collateral effects.

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers

BACKGROUND

Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH.

METHODS

We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations.

RESULTS

Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found.

CONCLUSIONS

Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

Fraud and retraction in perioperative medicine publications: what we learned and what can be implemented to prevent future recurrence

Fraud in medical publications is an increasing concern. In particular, disciplines related to perioperative medicine-including anaesthesia and critical care-currently hold the highest rankings in terms of retracted papers for research misconduct. The dominance of this dubious achievement is attributable to a limited number of researchers who have repeatedly committed scientific fraud. In the last three decades, six researchers have authored 421 of the 475 papers retracted in perioperative medicine. This narrative review reports on six cases of fabricated publication in perioperative medicine that resulted in the paper's retraction. The process that led to the unveiling of the fraud, the impact on clinical practice, and changes in regulatory mechanisms of scientific companies and governmental agencies' policies are also presented. Fraud in medical publications is a growing concern that affects perioperative medicine requiring a substantial number of papers to be retracted. The continuous control elicited by readers, by local institutional review boards, scientific journal reviewers, scientific societies and government agencies can play an important role in preserving the 'pact of trust' between authors, professionals and ultimately the relationship between doctors and patients.