Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical appraisal

PURPOSE

Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity.

METHODS

The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool.

RESULTS

A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis.

CONCLUSION

The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.

Femoral-Obturator-Sciatic (FOS) Nerve Block as an Anesthetic Triad for Arthroscopic ACL Reconstruction: Is This the Magic Trick We Were Missing?

Arthroscopic anterior cruciate ligament (ACL) reconstruction with hamstring grafting is a common orthopedic procedure that is associated with moderate-to-severe pain. Peripheral nerve blockade as an anesthetic technique is an appealing option in the era of modern anesthesia. The aim of this narrative review is to document the efficacy and safety of the combination of femoral, obturator, and sciatic (FOS) nerve blocks as an exclusive method for anesthesia in patients undergoing ACL reconstruction. An electronic search of the literature published up to October 2023 was conducted in the Medline, Embase, Cochrane, Web of Science, and Google Scholar databases to find studies on ACL reconstruction and peripheral obturator nerve block. Overall, 8 prospective studies-with a total of 315 patients-published between 2007 and 2022 were included in this review. Ultrasound-guided peripheral FOS nerve blockade is an effective anesthetic technique for ACL reconstruction, offering good perioperative pain management, minimal opioid consumption, and an excellent safety profile. Further well-designed prospective studies are needed to determine the best approach for obturator nerve blockade and the appropriate type and dosage of local anesthetic.

Predicting the Outcome of Patients with Severe COVID-19 with Simple Inflammatory Biomarkers: The Utility of Novel Combined Scores-Results from a European Tertiary/Referral Centre

Background: The clinical significance of combinations of inflammatory biomarkers in severe COVID-19 infection is yet to be proved. Although several studies have evaluated the prognostic value of biomarkers in patients with COVID-19, there are limited data regarding the value of the combination scores that could take full advantage of the prognostic value of several biomarkers and that could account for the heterogeneity of patients with severe COVID-19. We investigated the prognostic value of combination scores of admission values of inflammatory biomarkers in adults with severe COVID-19. Methods: Adults admitted to the Department of Respiratory Medicine of the UHL with severe COVID-19 (April-September 2021, NCT05145751) were included. Demographics, medical history, laboratory tests and outcome (high-flow nasal cannula (HFNC), admission to Intensive Care Unit (ICU) or death) were recorded. The optimal cut-off points of on admission values of C-reactive protein (CRP), CRP to lymphocyte ratio (CLR), lymphocyte to neutrophil ratio (LNR) and derived variation of neutrophil to lymphocyte ratio (dv-NLR (neutrophil/white blood count-lymphocyte)) for the predetermined outcome were defined. Based on the cut-off of CRP, LNR, dv-NLR and CLR, which were found to be predictors for HFNC, 3 scores were defined: CRP and LNR (C-CRP #1), CRP and dv-NLR (C-CRP #2), CRP and CLR (C-CRP #3). Likewise, based on the cut-off of CRP and CLR, which were found to be predictors for death, the score of CRP and CLR (C-CRP #3*) was defined. The combination scores were then classified as: 2 points (both biomarkers elevated); 1 point (one biomarker elevated) and 0 points (normal values). None of the biomarkers was predictive for the ICU admission, so no further analysis was performed. Binomial logistic regression analysis was used to establish the predictive role for each biomarker. Results: One hundred and fifteen patients (60% males, mean age 57.7 years) were included. Thirty-seven (32.2%) patients required HFNC, nine (7.8%) died and eight (7%) were admitted to ICU, respectively. As far as HFNC is concerned, the cut-off point was 3.2 for CRP, 0.231 for LNR, 0.90 for dv-NLR and 0.004 for CLR. Two points of C-CRP #1 and 2 points of C-CRP #3 predicted HFNC with a probability as high as 0.625 (p = 0.005) and 0.561 (p < 0.001), respectively. Moreover, 1 point of C-CRP #2 and 2 points of C-CRP #2 predicted HFNC with a probability of 0.333 and 0.562, respectively. For death, the optimal cut-off point for CRP was 1.11 and for CLR 3.2*1033. Two points of C-CRP #3* with an accuracy of 0.922 predicted mortality (p = 0.0038) in severe COVID-19. Conclusions: The combination scores of CRP and inflammatory biomarkers, based on admission values, are promising predictors for respiratory support using HFNC and for mortality in patients suffering from severe COVID-19 infection.

From flatline to lifeline: A scoping review of the Lazarus phenomenon

BACKGROUND

The Lazarus phenomenon or autoresuscitation (autoROSC) is the return of spontaneous circulation (ROSC) after the termination of the cardiopulmonary resuscitation (CPR) efforts.

PURPOSE

The purpose of the current scoping review is to present the available data in the literature regarding autoROSC.

METHODS

We reviewed four scientific databases to identify all studies which reported autoROSC cases in patients who underwent CPR. We then extracted all information relevant to CPR and autoROSC. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

RESULTS

We identified 66 studies describing 76 autoROSC cases. The majority of cardiac arrests were in-hospital (44, 57.89%). Median time from termination of CPR to autoROSC was 5 min. Regarding the outcome, 52 (77.61%) patients died and 11 (14.47%) patients had intact neurological outcome. A higher mortality rate was identified in patients with respiratory comorbidities. Overall, 24 (31.58%) patients survived.

CONCLUSION

AutoROSC is probably an under-reported event in the medical community. Healthcare professionals should be aware of the phenomenon and actively monitor for it, when appropriate.

Predictors of 30-Day Postoperative Outcome after Elective Endovascular Abdominal Aortic Aneurysm Repair: A Tertiary Referral Center Experience

BACKGROUND

We evaluated the 30-day postoperative outcome after elective endovascular aneurysm repair (EVAR) and the possible predictors for the 30-day postoperative outcome.

MATERIALS

Demographics, medical history, laboratory values, intensive care unit (ICU) admission and 30-day complications classified as major (major adverse cardiovascular events (MACEs), acute kidney injury (AKI) and death of any cause) and minor (postimplantation syndrome (PIS), postoperative delirium (POD), urinary tract infection (UTI) and technical graft failure) were documented (March 2016 to February 2019).

RESULTS

We included 322 patients. The majority were managed under general anesthesia (83%) with femoral cutdown (98.1%). Overall, 121 (37.5%) complications, mostly minor (n = 103, 31.9%), were recorded. In total, 11 patients (3.4%) developed MACEs, 5 (1.6%) experienced AKI and 2 (0.6%) died in the ICU. Moreover, 77 patients (23.9%) suffered from PIS, 11 from POD, 11 from UTI and 4 from technical graft failure. The multivariate logistic regression analysis revealed that aneurysm diameter (p = 0.01) and past smoking (p = 0.003) were predictors for complications. PAD was an independent predictor of MACEs (p = 0.003), preoperative neutrophil to lymphocyte ratio (NLR) of AKI (p = 0.003) and past smoking of PIS (p = 0.008), respectively.

CONCLUSIONS

Our study showed that the 30-day morbidity after EVAR exceeded 35%. However, the majority of complications were minor, and the associated mortality was low. Aneurysm diameter and past smoking were independent predictors for postoperative outcome.

Effect of PM2.5 Levels on ED Visits for Respiratory Causes in a Greek Semi-Urban Area

Fine particulate matter that have a diameter of <2.5 μm (PM2.5) are an important factor of anthropogenic pollution since they are associated with the development of acute respiratory illnesses. The aim of this prospective study is to examine the correlation between PM2.5 levels in the semi-urban city of Volos and Emergency Department (ED) visits for respiratory causes. ED visits from patients with asthma, pneumonia and upper respiratory infection (URI) were recorded during a one-year period. The 24 h PM2.5 pollution data were collected in a prospective manner by using twelve fully automated air quality monitoring stations. PM2.5 levels exceeded the daily limit during 48.6% of the study period, with the mean PM2.5 concentration being 30.03 ± 17.47 μg/m3. PM2.5 levels were significantly higher during winter. When PM2.5 levels were beyond the daily limit, there was a statistically significant increase in respiratory-related ED visits (1.77 vs. 2.22 visits per day; p: 0.018). PM2.5 levels were also statistically significantly related to the number of URI-related ED visits (0.71 vs. 0.99 visits/day; p = 0.01). The temperature was negatively correlated with ED visits (r: −0.21; p < 0.001) and age was found to be positively correlated with ED visits (r: 0.69; p < 0.001), while no statistically significant correlation was found concerning humidity (r: 0.03; p = 0.58). In conclusion, PM2.5 levels had a significant effect on ED visits for respiratory causes in the city of Volos.

Remdesivir-induced Bradycardia is not Associated with Worse Outcome in Patients with COVID-19: A Retrospective Analysis

Background

COVID-19, is primarily a respiratory illness but is known to cause extrapulmonary manifestations, especially on the cardiovascular system. Bradycardia is commonly reported in COVID-19 patients despite no prior history of occurrence, and many studies have shown an association with increased mortality. Multiple case reports have been published showcasing remdesivir potentially causing bradycardia. Our aim was to investigate the incidence of bradycardia in patients receiving remdesivir and examine the association with disease severity and survival outcomes.

Methods

A retrospective study was performed including 160 COVID-19 patients receiving remdesivir for 5 days. Patients’ demographics, comorbidities, medication, vital signs, laboratory tests and outcome were recorded. Bradycardia was defined as a heart rate < 60 beats/min and severe bradycardia < 50 beats/min.

Results

One hundred eighteen (73.8%) patients experienced at least one episode of bradycardia during hospitalisation. Bradycardia was present in 12 (7.5%) patients before treatment with remdesivir. The rate of bradycardia increased up to the 6th day of hospitalisation (40.6%) and subsequently diminished and normalised within 5 days after the last remdesivir dose (5% at Day 10). Severe bradycardia was observed in 13 (7.5%) patients. No difference was observed in ICU admission between groups (bradycardia vs no bradycardia). When we stratified patients according to the outcome of hospitalisation, no significant difference was observed in the occurrence of bradycardia between groups (alive vs dead) [p = 0.853].

Conclusions

Treatment with remdesivir may be associated with new-onset bradycardia in hospitalised patients with COVID-19. However, bradycardia is transient and is not associated with ICU admission and mortality.

Circulating suPAR associates with severity and in-hospital progression of COVID-19

BACKGROUND

COVID-19 disease progression is characterized by hyperinflammation and risk stratification may aid in early aggressive treatment and advanced planning. The aim of this study was to assess whether suPAR and other markers measured at hospital admission can predict the severity of COVID-19.

METHODS

The primary outcome measure in this international, multi-centre, prospective, observational study with adult patients hospitalized primarily for COVID-19 was the association of WHO Clinical Progression Scale (WHO-CPS) with suPAR, ferritin, CRP, albumin, LDH, eGFR, age, procalcitonin, and interleukin-6. Admission plasma suPAR levels were determined using the suPARnostic^® ELISA and suPARnostic^® Turbilatex assays.

RESULTS

Seven hundred and sixty-seven patients, 440 (57.4%) males and 327 (42.6%) females, were included with a median age of 64 years. Log-suPAR levels significantly correlated with WHO-CPS score, with each doubling of suPAR increasing the score by one point (p < .001). All the other markers were also correlated with WHO-CPS score. Admission suPAR levels were significantly lower in survivors (7.10 vs. 9.63, 95% CI 1.47-3.59, p < .001). A linear model (SALGA) including suPAR, serum albumin, serum lactate dehydrogenase, eGFR, and age can best estimate the WHO-CPS score and survival. Combining all five parameters in the SALGA model can improve the accuracy of discrimination with an AUC of 0.80 (95% CI: 0.759-0.836).

CONCLUSIONS

suPAR levels significantly correlated with WHO-CPS score, with each doubling of suPAR increasing the score by one point. The SALGA model may serve as a quick tool for predicting disease severity and survival at admission.

Microcirculation-guided treatment improves tissue perfusion and hemodynamic coherence in surgical patients with septic shock

PURPOSE

Severe sepsis and septic shock may impair microcirculatory perfusion and cause organ dysfunction. The aim of this pilot study was to assess a new microcirculation-guided resuscitation strategy in patients with septic shock undergoing emergency abdominal surgery.

METHODS

A microcirculation-guided treatment algorithm was developed and applied intraoperatively following restoration of systemic hemodynamics. Sublingual microcirculation was monitored with Sidestream DarkField (SDF +) imaging technique. The primary objective was to investigate the change in De Backer score, Consensus Proportion of Perfused Vessels (Consensus PPV), and Consensus PPV (small) and its association with venous-to-arterial carbon dioxide difference (v-aPCO₂).

RESULTS

Thirteen consecutive patients were included in the study. Microcirculation-guided resuscitation resulted in an increase of 0.49 mm^-1 in the De Backer score (p < 0.001), an increase of 2.28% in the Consensus PPV (p < 0.001), and an increase of 2.26% in the Consensus PPV (small) (p < 0.001) for every 30 min of additional intraoperative time. All microcirculation variables were negatively correlated with v-aPCO₂ (rho = - 0.656, adj-p < 0.001; rho = - 0.623; adj-p < 0.001; rho = - 0.597, adj-p < 0.001, respectively) at each intraoperative time point. Lactate levels were negatively correlated with Consensus PPV (rho = - 0.464; adj-p = 0.002) and Consensus PPV (small) (rho = - 0.391, adj-p < 0.001). Survival at 30 days, 90 days, and 1 year were 76.9%, 76.9%, and 61.5%, respectively.

CONCLUSIONS

The intraoperative use of microcirculation-guided resuscitation strategy may improve tissue perfusion and hemodynamic coherence in patients with septic shock.

Watch Out for Burnout in COVID-19: A Greek Health Care Personnel Study

The aim of the current study was to examine the mental well-being of healthcare personnel (HCP) working in COVID-19 units in Greece and to calculate the prevalence of burnout (BO) amongst them. A questionnaire based on the Maslach Burnout Inventory for Medical Personnel was utilized between February 21st, 2021 and March 5th, 2021. A total of 190 HCP responded to the questionnaire, of which 73.7% were nurses and midwives. The mean age of the participants was 38.3 (8.4) years. Overall, 71.6% of the participants had a high BO score, while 20.5% had a moderate and 7.9% had a low BO score. Night shifts in COVID-19 wards and job dissatisfaction were significantly associated with a high BO score ( P = .03 and P < .0001, respectively). The majority of HCP working in COVID-19 wards in Greece is experiencing high levels of overall BO and emotional exhaustion.

Comparison of advanced closed-loop ventilation modes with pressure support ventilation for weaning from mechanical ventilation in adults: A systematic review and meta-analysis

PURPOSE

To compare neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), adaptive support ventilation (ASV) and Smartcare pressure support (Smartcare/PS) with standard pressure support ventilation (PSV) regarding their effectiveness for weaning critically ill adults from invasive mechanical ventilation (IMV).

METHODS

Electronic databases were searched to identify parallel-group randomized controlled trials (RCTs) comparing NAVA, PAV, ASV, or Smartcare/PS with PSV, in adult patients under IMV through July 28, 2021. Primary outcome was weaning success. Secondary outcomes included weaning time, total MV duration, reintubation or use of non-invasive MV (NIMV) within 48 h after extubation, in-hospital and intensive care unit (ICU) mortality, in-hospital and ICU length of stay (LOS) (PROSPERO registration No:CRD42021270299).

RESULTS

Twenty RCTs were finally included. Compared to PSV, NAVA was associated with significantly lower risk for in-hospital and ICU death and lower requirements for post-extubation NIMV. Moreover, PAV showed significant advantage over PSV in terms of weaning rates, MV duration and ICU LOS. No significant differences were found between ASV or Smart care/PS and PSV.

CONCLUSIONS

Moderate certainty evidence suggest that PAV increases weaning success rates, shortens MV duration and ICU LOS compared to PSV. It is also noteworthy that NAVA seems to improve in-hospital and ICU survival.

Sublingual microcirculatory alterations during the immediate and early postoperative period: A systematic review and meta-analysis

BACKGROUND

The incidence of postoperative microcirculatory flow alterations and their effect on outcome have not been studied extensively.

OBJECTIVE

This systematic review and meta-analysis was designed to investigate the presence of sublingual microcirculatory flow alterations during the immediate and early postoperative period and their correlation with complications and survival.

METHODS

A systematic search of PubMed, Scopus, Embase, PubMed Central, and Google Scholar was conducted for relevant articles from January 2000 to March 2021. Eligibility criteria were randomized controlled and non-randomized trials. Case reports, case series, review papers, animal studies and non-English literature were excluded. The primary outcome was the assessment of sublingual microcirculatory alterations during the immediate and early postoperative period in adult patients undergoing surgery. Risk of bias was assessed with the Ottawa-Newcastle scale. Standard meta-analysis methods (random-effects models) were used to assess the difference in microcirculation variables.

RESULTS

Thirteen studies were included. No statistically significant difference was found between preoperative and postoperative total vessel density (p = 0.084; Standardized Mean Difference (SMD): -0.029; 95%CI: -0.31 to 0.26; I2 = 22.55%). Perfused vessel density significantly decreased postoperatively (p = 0.035; SMD: 0.344; 95%CI: 0.02 to 0.66; I2 = 65.66%), while perfused boundary region significantly increased postoperatively (p = 0.031; SMD: -0.415; 95%CI: -0.79 to -0.03; I2 = 37.21%). Microvascular flow index significantly decreased postoperatively (p = 0.028; SMD: 0.587; 95%CI: 0.06 to 1.11; I2 = 86.09%), while no statistically significant difference was found between preoperative and postoperative proportion of perfused vessels (p = 0.089; SMD: 0.53; 95%CI: -0.08 to 1.14; I2 = 70.71%). The results of the non-cardiac surgery post-hoc analysis were comparable except that no statistically significant difference in perfused vessel density was found (p = 0.69; SMD: 0.07; 95%CI: -0.26 to 0.39; I2 = 0%).

LIMITATIONS

The included studies investigate heterogeneous groups of surgical patients. There were no randomized controlled trials.

CONCLUSIONS

Significant sublingual microcirculatory flow alterations are present during the immediate and early postoperative period. Further research is required to estimate the correlation of sublingual microcirculatory flow impairment with complications and survival.

Intentional ingestion of batteries and razor blades by a prisoner: a true emergency?

PURPOSE

Few case studies in the literature report on adult patients with intentional foreign body ingestion. Prisoners deliberately ingest foreign bodies, such as cylindrical alkaline batteries and razor blades, to achieve hospitalization or commit suicide. The purpose of this paper is to present a case of deliberate ingestion of batteries and razor blades by an inmate.

DESIGN/METHODOLOGY/APPROACH

The authors present a case of an incarcerated man in Greece, who intentionally ingested three cylindrical alkaline batteries and three razor blades wrapped in aluminum foil.

FINDINGS

The patient was treated conservatively with serial radiographs and was subsequently discharged without complication. This paper discusses the complications and examine the current guidelines available.

ORIGINALITY/VALUE

To best of authors' knowledge, this is the first report of a simultaneous ingestion of batteries and razor blades.

Pulmonary function testing in COPD: looking beyond the curtain of FEV1

Chronic obstructive pulmonary disease (COPD) management remains challenging due to the high heterogeneity of clinical symptoms and the complex pathophysiological basis of the disease. Airflow limitation, diagnosed by spirometry, remains the cornerstone of the diagnosis. However, the calculation of the forced expiratory volume in the first second (FEV1) alone, has limitations in uncovering the underlying complexity of the disease. Incorporating additional pulmonary function tests (PFTs) in the everyday clinical evaluation of COPD patients, like resting volume, capacity and airway resistance measurements, diffusion capacity measurements, forced oscillation technique, field and cardiopulmonary exercise testing and muscle strength evaluation, may prove essential in tailoring medical management to meet the needs of such a heterogeneous patient population. We aimed to provide a comprehensive overview of the available PFTs, which can be incorporated into the primary care physician's practice to enhance the efficiency of COPD management.

Critical emergency medicine and the resuscitative care unit

Critical emergency medicine is the medical field concerned with management of critically ill patients in the emergency department (ED). Increased ED stay due to intensive care unit (ICU) overcrowding has a negative impact on patient care and outcome. It has been proposed that implementation of critical care services in the ED can negate this effect. Two main Critical Emergency Medicine models have been proposed, the "resource intensivist" and "ED-ICU" models. The resource intensivist model is based on constant presence of an intensivist in the traditional ED setting, while the ED-ICU model encompasses the notion of a separate ED-based unit, with monitoring and therapeutic capabilities similar to those of an ICU. Critical emergency medicine has the potential to improve patient care and outcome; however, establishment of evidence-based protocols and a multidisciplinary approach in patient management are of major importance.

Peripherally Inserted Central Catheter lines for Intensive Care Unit and onco-hematologic patients: A systematic review and meta-analysis

BACKGROUND

It is unclear whether Peripherally Inserted Central Catheter (PICC) lines are associated with lower complication rates as compared to conventional Central Venous Catheters (CVCs), especially in high risk patients.

OBJECTIVE

To compare Central Line Associated Bloodstream Infection (CLABSI) and catheter-related thrombosis rates in Intensive Care Unit (ICU) and onco-hematologic patients with PICC lines and CVCs.

METHODS

We systematically reviewed the PubMed, Cochrane and Google Scholar databases to identify relevant studies. Study quality was evaluated using appropriate assessment tools and the pooled odds ratio (OR) and confidence interval (CI) were calculated. Sensitivity analyses were performed based on meta-analysis method, type of study and prophylaxis implementation.

RESULTS

Thirteen studies were included in our meta-analysis. PICC lines were associated with a significantly higher rate of thrombosis in ICU [OR (95%CI): 2.58(1.80,3.70); P_z<0.00001] and onco-hematologic [OR (95%CI): 2.91(2.11,4.02); P_z<0.00001] patients. CLABSI rates with PICC lines were not significantly different in ICU patients [OR (95%CI): 1.65(0.91,2.99); P_z= 0.1], but significantly lower CLABSI rates were observed in onco-hematologic patients [OR (95%CI): 0.38(0.16,0.91); P_z=0.03]. Sensitivity analyses verified the robustness of our results.

CONCLUSIONS

PICC lines are associated with higher rates of thrombotic events. However, they might be suitable for onco-hematologic patients due to lower CLABSI rates.