Recent proposals to use artificial intelligence (AI) in end-of-life decision-making for incapacitated patients without advance directives have prompted critical reflection by the Ethics Committee of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). This position paper analyzes both general ethical concerns surrounding AI in clinical practice and specific issues raised by the hypothesis of using AI to reconstruct patients' presumed wishes through recorded clinical conversations or analysis of digital footprints. At a general level, major challenges include lack of explainability (the so-called black box problem), risks of bias linked to non-representative training data, environmental sustainability, and the potential erosion of the clinician-patient relationship. In end-of-life contexts, these concerns are amplified. Systematic recording and retrospective analysis of sensitive conversations raise serious questions regarding privacy, data security, informed consent, and the authenticity of communication. Moreover, algorithmic interpretation may fail to capture the complexity of non-verbal communication and the inherently interpretative nature of moral reasoning. The construction of a "social portrait" from digital traces risks oversimplifying personal identity and generating conflicts with family narratives at a particularly vulnerable moment. The Committee further highlights the risk of delegating ethically weighty relational tasks to technological systems, thereby reinforcing a procedural model of medicine and weakening shared decision-making. For these reasons, the proposed use of AI in this domain is considered ethically problematic in its current form. Any future application would require robust governance, transparency, and accountability, ensuring that AI supports rather than undermines authentic care relationships.
Cancer-associated pain affects the majority of patients with advanced disease, involves complex nociceptive, neuropathic, and psychosocial mechanisms, and remains inadequately controlled despite available pharmacological options. Circadian rhythms regulate sleep-wake patterns, hormone secretion, immune function, and nociceptive signaling. Their disruption, common in cancer patients due to disease burden, treatment side effects, and psychological distress, may influence both pain perception and analgesic response. This narrative review examines the interplay between chronobiology and cancer-associated pain, evaluating the biological plausibility and clinical readiness of chronotherapy, the role of non-pharmacological circadian-supportive interventions, and the exploratory contribution of medical cannabis within this framework. Circadian patterns in cancer pain and breakthrough cancer pain are inconsistent at the population level, with discrepancies between clinical reports of late-morning peaks and experimental evidence of nocturnal pain sensitivity, suggesting that observed patterns are largely driven by pharmacokinetic, activity-related, and tumor-specific factors. Opioid pharmacokinetics and pharmacodynamics are influenced by circadian variation, and aligning dosing with individual pain and metabolic patterns may theoretically enhance analgesic efficacy, though prospective evidence remains limited. Opioid therapy itself disrupts circadian organization, reinforcing the value of strategies that simultaneously time drug administration and support circadian stability. Non-pharmacological interventions including sleep hygiene, light therapy, structured exercise, and psychological approaches carry established safety profiles and consistent benefits on quality of life, though their direct analgesic contribution within a chronotherapy framework remains to be established. The endocannabinoid system exhibits circadian rhythmicity, but robust trial data supporting medical cannabis for cancer pain and sleep regulation are absent, and current guidelines maintain a cautious stance. The identification of objective circadian biomarkers is a critical prerequisite before chronotherapy can be evaluated in phase III trials. Circadian biology offers a biologically plausible but insufficiently validated framework for optimizing cancer pain management. Clinicians can already incorporate sleep hygiene measures, morning light exposure, and structured physical activity into existing cancer pain management plans while awaiting higher-level evidence. Future research must prioritize biomarker validation, large-scale RCTs of timed opioid administration, and implementation science to translate chronotherapy from hypothesis to guideline-level practice.
Correction of anemia in the perioperative period is essential to reduce complications, optimise tissue oxygen delivery and improve overall patient outcomes. However, in neurosurgical and neurocritical care settings, the management of preoperative anemia presents unique challenges. The brain is highly sensitive to reductions in oxygen delivery, whereas interventions commonly used to correct anemia, most notably blood transfusions, carry inherent risks that may adversely affect neurological outcomes. Therefore, clinicians must carefully balance the prevention of cerebral hypoxia to avoid treatment-related complications.The prevalence of perioperative anemia in neurosurgical and neurocritical patients is influenced by multiple factors, including advanced age, comorbidities, frailty, malnutrition, chronic anticoagulant or antiplatelet therapy and the type and extent of planned intervention.Patient blood management provides a structured, multimodal approach for optimising oxygen delivery, while reducing exposure to allogeneic blood transfusion. Within this framework, anemia correction represents only one pillar, alongside strategies to minimise perioperative blood loss and enhance physiological tolerance to anemia. In neurosurgical and neurocritical care, patient blood management may include targeted anemia treatment (e.g. iron supplementation, erythropoiesis-stimulating agents or carefully restricted transfusion), management of coagulation disturbances using specific "antidotes" such as tranexamic acid and close monitoring of cerebral oxygenation to individualize transfusion and hemodynamic decisions.Despite the limited standardization of patient blood management pathways in neurosurgery, current evidence suggests that it represents a coherent and physiologically grounded approach that may contribute to improved outcomes in this high-risk patient population.
Acute organ dysfunction is a primary driver of ICU mortality. As clinical scores often act as lagging indicators, early recognition of subclinical endothelial stress may be essential for timely intervention. This exploratory study investigated the association of mid-regional pro-adrenomedullin (MR-proADM)-a stable surrogate of the hormone adrenomedullin-as a potential early indicator of early organ failure. This retrospective, single-center study analyzed a heterogeneous cohort of 26 critically ill patients. Plasma MR-proADM levels were assessed at admission (t0) and daily for 5 days. The primary outcome was the correlation between admission MR-proADM and the 24-h SOFA score. Secondary outcomes included comparisons between septic and non-septic patients and between survivors and non-survivors. Admission MR-proADM showed a moderate correlation with the 24-h SOFA score (rho = 0.488; p = 0.021), with the most prominent associations observed within the cardiovascular and renal SOFA domains. In the septic subgroup, MR-proADM levels were higher than in non-septic patients (10.90 [IQR 5.91-19.00] vs. 1.30 [IQR 0.74-2.53] nmol/L, p < 0.001); ROC analysis yielded an AUC of 0.88 (95% CI 0.73-1.00; p < 0.001), although this estimate should be interpreted descriptively given the small number of septic cases. Despite the low number of mortality events (n = 4), higher admission MR-proADM values were observed in non-survivors than in survivors, although this finding remains preliminary. Furthermore, admission MR-proADM levels showed positive correlations with procalcitonin at each individual timepoint during the first five ICU days (p < 0.001 at each timepoint). Within the limits of this small cohort, MR-proADM might provide a biological window into incipient organ dysfunction. Its possible role in supporting clinical assessment of sepsis and risk stratification-particularly regarding hemodynamic and renal dysfunction-remains strictly hypothesis-generating and requires validation in larger, prospective multicenter studies.
Landiolol enables rapid and titratable heart rate control in perioperative and critically ill patients. In supraventricular tachyarrhythmias and perioperative settings, available studies suggest effective rate control and acceptable hemodynamic tolerance. In sepsis and septic shock with persistent tachycardia, landiolol consistently lowers heart rate without increasing vasopressor requirements; however, randomized evidence does not demonstrate consistent benefits on major clinical outcomes, and current guidelines do not support its routine use. Emerging data on decatecholaminization strategies indicate that combining landiolol with non-adrenergic vasopressors may attenuate catecholamine-related toxicity and improve hemodynamic profiles. Experimental and perioperative studies also suggest potential anti-inflammatory effects through modulation of cytokine release. Overall, current evidence supports landiolol as a potentially useful option for acute heart rate control and selected cases of septic tachycardia. Nevertheless, given the heterogeneity of critically ill populations and the absence of clear outcome benefits in large randomized trials, its use should remain individualized and guided by careful hemodynamic monitoring, with particular attention to appropriate patient selection.
Intrathecal adjuvants are frequently used in spinal anaesthesia for lower-limb surgery to enhance block quality and prolong postoperative analgesia. However, evidence remains fragmented across individual agents. This systematic review with frequentist network meta-analysis aimed to compare the efficacy and safety of intrathecal adjuvants in patients undergoing lower limb orthopaedic surgery to evaluate the effectiveness and safety of intrathecal adjuvants combined with long-acting local anaesthetics for lower limb orthopaedic surgery. A systematic search of PubMed, CENTRAL, and Embase was conducted to retrieve English-language RCTs involving adult patients undergoing lower limb orthopaedic surgery under single-shot spinal anaesthesia. We included trials evaluating any intrathecal drug or placebo added to a long-acting local anaesthetic. Our primary outcome was the duration of effective analgesia, defined as the time to the first analgesic requirement, in hours. We selected randomised controlled trials (RCTs) reported in English. We included 183 RCTs, for a total of 14,431 patients and 27 interventions. Morphine combined with ketorolac, morphine alone followed by diamorphine, clonidine combined with morphine and ketamine combined with midazolam provided the greatest prolongation of effective analgesia. Morphine also significantly reduced pain at 12 h and postoperative opioid consumption with no impact on motor block duration. Dexmedetomidine reduced pain intensity at 12 h but substantially prolonged motor block duration and increased the incidence of bradycardia. Morphine and neostigmine showed an increased risk of postoperative nausea and vomiting, while several interventions increased the risk of pruritus. The certainty of evidence ranged from low to very low due to within-study bias, reporting bias, high heterogeneity, imprecision and incoherence. Considering the body of evidence in an NMA framework, intrathecal morphine appears to offer a potentially favourable efficacy-safety balance. Dexmedetomidine may prolong motor block and increase the risk of bradycardia. The certainty of the evidence was low to very low and needs caution interpretation. PROSPERO CRD42024557751.
Healthcare systems contribute approximately 4.6% of global carbon emissions, with anesthesia and intensive care representing major sources of environmental impact. Although awareness of sustainable practices is increasing, real-world implementation in these fields remains limited. This study aimed to describe knowledge, attitudes, practices, and perceived barriers toward sustainability among Italian anesthesiologists-intensivists. A cross-sectional, web-based survey was conducted among members of the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) between June and July 2025. The questionnaire assessed demographics, clinical practices, environmental behaviors, and perceived barriers to sustainability. Descriptive statistics and an unsupervised clustering approach (Factor Analysis of Mixed Data followed by hierarchical clustering) were applied to identify distinct respondent profiles. A total of 459 responses were analyzed. Overall, 83.4% rated environmental sustainability as "very important," and 95.6% supported the adoption of renewable energy in hospitals. Despite this, 93.1% reported routine use of single-use devices, and only 7.4% worked in departments with a designated sustainability officer. Cluster analysis identified two main groups: the Experienced Generation (older, senior specialists) and the Green Generation (younger, early-career clinicians). While both valued sustainability, the Green Generation more frequently implemented eco-friendly practices, including the use of total intravenous anesthesia (71.2% vs. 57.5%), regional anesthesia (74.1% vs. 64.0%), and reusable/recyclable devices (> 80% vs. < 20%). The most frequently reported barriers to sustainability application were lack of training (76.3%), resistance to change (66.4%), and absence of guidelines (54.7%). Italian anesthesiologists-intensivists demonstrate strong environmental awareness but variable implementation of sustainable practices. Strengthening formal education, institutional leadership, and guideline dissemination is essential to promote widespread adoption of sustainable anesthesia and intensive care practices.
External ventricular drainage (EVD)-associated ventriculitis is a serious complication in neurocritical care. Diagnostic uncertainty and heterogeneous infection prevention and control (IPC) practices may contribute to variable ventriculitis rates and potentially avoidable antibiotic exposure. We evaluated the impact of implementing an interdisciplinary standard operating procedure (SOP) on ventriculitis incidence and antimicrobial stewardship (ABS)-related outcomes. We conducted a retrospective single-centre pre-post study in one intensive care unit (ICU) at Charité-Universitätsmedizin Berlin (2019-2023). Adult patients with EVDs were assigned to a pre-SOP cohort (Group 1) or a post-SOP cohort (Group 2). The SOP comprised standardized IPC protocols, an algorithm-based diagnostic workup and evidence-based anti-infective strategies. The primary endpoint was study-defined EVD-associated ventriculitis, adjudicated retrospectively using uniform criteria. Secondary endpoints included empirical antibiotic initiation, duration of therapy, antibiotic consumption, ICU length of stay (LOS), mortality, and SOP adherence. Cerebrospinal fluid (CSF) parameters and clinical signs were summarized descriptively. A total of 166 patients were included (pre-SOP, Group 1: n = 50; post-SOP, Group 2: n = 116). The study-defined ventriculitis rate decreased from 22% [95% CI 0.13-0.35] to 9.5% [95% CI 0.05-0.16] with an unadjusted OR 0.37 [95% CI 0.13-1.04]; p = 0.053, attenuated with an adjusted OR of 0.50 [95% CI 0.19-1.35]; p = 0.169. Incidence density declined from 21.1 to 12.0 per 1000 EVD days. Empirical antibiotic use fell from 28.0% [95% CI 17.5-41.7] to 12.9% [95% CI 8.0-20.2], corresponding to an unadjusted OR of 0.38 [95% CI 0.17-0.87] and median therapy duration decreased from 16 [95% CI 13.5-18.5] to 10 days [95% CI 6.5-13.5]. ICU LOS shortened by 4 days, while ICU mortality remained unchanged (26% vs. 27%). An interdisciplinary SOP was associated with reduced empirical antibiotic exposure and shorter treatment duration without affecting ICU mortality. The SOP appeared to improve diagnostic consistency and standardization of the workup rather than diagnostic test performance. The study is registered in the German Clinical Trial Register (DRKS ID: 00036075) in February 2025.
Ultrasound evaluation of abdominal muscle activity during cough may provide a practical tool to identify patients at risk of failure of liberation from mechanical ventilation (MV). We aimed to investigate the association between abdominal muscle weakness (AMW), assessed by ultrasound during coughing, and failure of liberation from MV within 48 h after the first liberation attempt, with liberation failure within 7 days as a secondary outcome. We also explored its relationship with diaphragm dysfunction (DD) and ICU-acquired weakness (ICUAW). We conducted a prospective cohort study including intubated or tracheostomized critically ill patients at high risk of failure of liberation from MV, who had been ventilated for at least 48 h, and had successfully completed a spontaneous breathing trial (SBT). Before the liberation attempt, all patients were assessed for AMW, defined as the overall thickening fraction of the abdominal muscles during cough (TFabs) measured by ultrasound. DD was assessed using ultrasound and defined by a diaphragm thickening fraction (TFdi) below 29%, while ICUAW was evaluated using the Medical Research Council scale or the simplified peripheral nerve test in uncooperative patients. A total of 46 patients were included in the study. Nine (20.5%) patients had AMW, ICUAW, and DD simultaneously, whereas 10 (22.9%) had isolated AMW. AMW was not associated with ICUAW (p = 0.28) or DD (p = 0.97). Liberation from MV within 48 h was successful in 30 patients (65.2%) and failed in 16 (34.7%). During the 7-day follow-up, liberation failure occurred in 3 of the 30 patients (10.0%) who remained free from MV within 48 h. Multivariable logistic regression analysis showed a higher probability of liberation failure within 48 h (OR 9.4, CI 1.1-75.2, p = 0.03) and 7 days (OR 14.8, CI 1.6-136.1, p = 0.02) in patients with AMW. ICUAW was associated with liberation failure within 48 h (OR 8.5, CI 1.5-46.8, p = 0.01) and 7 days (OR 20.4, CI 2.7-155.0, p < 0.01), whereas the presence of DD was not related to either outcome. Ultrasound evaluation of abdominal muscle function during cough, together with an assessment of ICUAW, may help identify critically ill patients at risk of failure of liberation from MV and may support clinical assessment of readiness for liberation.
In this study, we sought to evaluate the presence, quality, and accessibility of data sharing statements (DSS) in research articles published in five high-impact anesthesiology journals from 2020 to 2023. Data sharing is foundational to research transparency and reproducibility. As anesthesiology evolves, understanding how DSS are implemented in selected high-impact journals can inform open science efforts within anesthesiology research. We conducted a cross-sectional study of five top-ranked anesthesiology journals selected using 2023 Clarivate Journal Impact Factor (JIF) rankings. Eligible studies (2020-2023) were screened in duplicate using Rayyan, and data were extracted using a structured Google Form. We used a large language model (ChatGPT, GPT-4) to aid in the exploratory thematic development of DSS, with manual validation by investigators. Among 1,123 included articles, DSS prevalence varied by journal and year. In Anaesthesia, Critical Care & Pain Medicine, articles with DSS increased from 15% (4/26) in 2020 to 30% (9/30) in 2023, whereas the prevalence of DSS remained below 8% in Anesthesia & Analgesia. Government-funded studies were more likely to include DSS (β = 0.734, P = 0.047), while higher JIF was negatively associated with DSS inclusion (β = -0.298, P = 0.008). Thematic analysis showed "Conditional Data Availability" was the most frequent DSS type (74%). Of authors contacted, 28% responded, and 14% ultimately agreed to share data for replication. We found that DSS were underused in leading anesthesiology journals. Strengthening journal policies, funder mandates, and education on data sharing practices may promote greater transparency in anesthesia research. Because our analysis focused on a limited sample of journals, findings may not be generalizable to the entire field of anesthesiology. RéSUMé: OBJECTIF: Cette étude visait à évaluer la présence, la qualité et l’accessibilité des déclarations de partage des données (data sharing statements, DSS) dans des articles de recherche publiés entre 2020 et 2023 dans cinq revues d’anesthésiologie à fort facteur d’impact. Le partage des données constitue un fondement de la transparence et de la reproductibilité en recherche. À mesure que l’anesthésiologie évolue, comprendre la mise en œuvre des DSS dans certaines revues à impact élevé peut orienter les initiatives de science ouverte en recherche anesthésiologique. MéTHODE: Nous avons mené une étude transversale portant sur cinq revues d’anesthésiologie parmi les mieux classées, sélectionnées selon le Journal Impact Factor (JIF) 2023 de Clarivate. Les études admissibles (2020–2023) ont été évaluées en double à l’aide de Rayyan, et les données ont été extraites au moyen d’un formulaire structuré Google. Un grand modèle de langage (ChatGPT, GPT-4) a été utilisé pour soutenir l’élaboration thématique exploratoire des DSS, avec validation manuelle par les membres de l’équipe de recherche. RéSULTATS: Parmi les 1123 articles inclus, la prévalence des DSS variait selon la revue et l’année. Dans Anaesthesia, Critical Care & Pain Medicine, la proportion d’articles comportant une DSS est passée de 15 % (4/26) en 2020 à 30 % (9/30) en 2023, tandis que cette proportion demeurait inférieure à 8 % dans Anesthesia & Analgesia. Les études financées par des fonds publics étaient plus susceptibles d’inclure une DSS (β = 0,734; P = 0,047), alors qu’un JIF plus élevé était associé négativement à l’inclusion d’une DSS (β = −0,298; P = 0,008). L’analyse thématique a montré que la « disponibilité conditionnelle des données » constituait le type de DSS le plus fréquent (74 %). Parmi les autrices et auteurs contactés, 28 % ont répondu, et 14 % ont finalement accepté de partager leurs données à des fins de réplication. CONCLUSION: Les DSS demeurent sous-utilisées dans les principales revues d’anesthésiologie. Le renforcement des politiques éditoriales, des exigences des organismes subventionnaires et de la formation aux pratiques de partage des données pourrait favoriser une plus grande transparence en recherche en anesthésie. Étant donné que l’analyse portait sur un échantillon limité de revues, les résultats pourraient ne pas être généralisables à l’ensemble du champ de l’anesthésiologie.
Evidence is lacking to appraise whether radial access should be preferred to femoral access for coronary angiography (CAG) in critically ill patients. Patients admitted to the medical intensive care unit (ICU) of a university hospital over a 5-year period and requiring CAG immediately before or during the ICU stay were retrospectively included. The average treatment effect of the arterial route used for CAG was assessed through a win-ratio methodology with propensity score (PS)-based inverse probability of treatment weighting (IPTW). The primary endpoint was a hierarchical composite outcome of (i) all-cause death, (ii) resuscitated cardiac arrest, (iii) stroke, (iv) myocardial infarction, (v) acute limb ischemia and/or need for vascular surgery on CAG access site and (vi) Bleeding Academic Research Consortium (BARC) type 3 major bleeding, all assessed at day 28. The relationship between access site and the likelihood of all-cause death at day 28 was investigated with a Cox proportional hazard model stratified on the occurrence of cardiac arrest before CAG and adjusted through PS-based IPTW. Among the 235 included patients (116 with femoral access and 119 with radial access), 145 (61.7%) were admitted following cardiac arrest and 116 (49.4%) presented with cardiogenic shock at the time of CAG. The primary composite endpoint occurred in 63.4% of patients with femoral access and 47.7% of patients with radial access in IPT-weighted populations (absolute risk difference 15.6%, 95% confidence interval [CI] 1.4% to 29.8%, P = 0.03; win ratio for femoral versus radial access 0.62, 95% CI 0.40 to 0.98, P = 0.04). Access site complications were more frequent in patients with femoral access while major bleedings were similarly observed in both groups. Femoral access was not associated with day-28 mortality (adjusted hazard ratio 1.43, 95% CI 0.90 to 2.26, P = 0.13). Percutaneous coronary revascularisation and implantation of veno-arterial extra-corporeal membrane oxygenation, when required, were not hastened with femoral access. In this study, the use of a femoral rather than radial approach for CAG in critically ill patients was associated with a higher incidence of access site complications but did not correlate with the hazard of major bleeding or all-cause death at day 28.
Arthroscopic rotator cuff repair is the standard of care for rotator cuff tears. However, postoperative pain and recovery remain a significant clinical challenge. While ultrasound-guided interscalene brachial plexus block with liposomal bupivacaine provides sustained analgesia for up to 72 h, the addition of esketamine intravenous infusion may offer further benefits through enhanced pain control, mood stabilization, and cognitive support. This study aims to evaluate the synergistic effect of this combination on the quality of postoperative recovery in patients undergoing arthroscopic rotator cuff repair. This single center, randomized controlled trial will enroll 278 patients undergoing arthroscopic rotator cuff repair. Participants will be randomly allocated at a 1:1 ratio to either the intervention or control group. The intervention group will receive a combination of an ultrasound-guided interscalene brachial plexus block with liposomal bupivacaine and a continuous intravenous esketamine infusion, while the control group will receive a saline infusion. The primary outcome is the 15-item Quality of Recovery (QoR-15) score at 24 h postoperatively. Secondary outcomes include QoR-15 scores at various time points within 30 days, pain scores, total opioid consumption, need for rescue analgesia, incidence of postoperative delirium, hospital anxiety and depression scale scores, sleep quality, length of hospital stay, and adverse events. Guided by Enhanced Recovery After Surgery principles, this randomized controlled trial investigates a novel combination of liposomal bupivacaine block and esketamine infusion to enhance postoperative recovery after arthroscopic rotator cuff repair. It specifically assesses patient-reported recovery through the QoR-15 score, a validated tool encompassing pain, physical comfort, independence, and psychological well-being. As a single-center initiative, this work represents a pivotal step in generating preliminary evidence for this multimodal strategy. This study has been approved by the Ethics Committee at West China Hospital, Sichuan University (approval no. 2025-1908). The trial was prospectively registered with the Chinese Clinical Trial Registry (ChiCTR2500112854) on November 20, 2025.
Colorectal surgery caries a risk of postoperative morbidity and mortality. Prehabilitation may improve recovery and reduce complications in this population. This umbrella review evaluates the effects of prehabilitation on postoperative outcomes. Google Scholar, PubMed, the Cochrane Library, and HINARI were searched for systematic reviews comparing the effect of prehabilitation with usual care on postoperative complications, length of hospital stays and functional capacity in adults undergoing colorectal surgery. The methodological quality was assessed by using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2). Overlap of primary studies was evaluated using the Corrected Covered Area (CCA), while evidence certainty by Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Heterogeneity was measured using I-squared statistic, and publication bias was examined using funnel plot, Egger's test and Trim and Fill method. This umbrella review included 19 systematic reviews with 27,065 participants, most of which were high quality (n = 13; 68.4%). Overall overlap was slight; however, moderate overlap was observed for postoperative complications, length of hospital stay (LOS), and functional capacity. Prehabilitation was associated with a 21% reduction in postoperative complications (risk ratio (RR) = 0.79, 95% CI: 0.69 to 0.89, I2 = 66.5%) with consistent finding in sensitivity analysis excluding short-duration nutritional interventions. It was also associated with a reduction in LOS of approximately 0.5 days (mean difference (MD) = -0.54 days, 95% CI: -0.87 to -0.20; I2 = 80.4%). Both with low certainty of evidence. Similarly, prehabilitation appeared to improve preoperative and postoperative functional capacity by approximately 25 m (MD = 24.78 m, 95% CI: 11.35 to 38.22, I2 = 67.84%) and 35 m (MD = 34.52 m, 95% CI: 6.44 to 62.60, I2 = 74.63%) respectively with low certainty evidence. Systematic reviews that did not present pooled results suggested that prehabilitation reduced postoperative complications (OR), had no significant effect on length of stay (SMD), and generally improved functional capacity (SMD or narrative synthesis). Prehabilitation in colorectal surgery may reduce postoperative complications, may shorten hospital stay, may improve preoperative and postoperative functional capacity, highlighting faster recovery and improve postoperative quality of life. Findings should be interpreted with caution for the moderate overlap of primary studies, low level certainty, and significant heterogeneity.
Aneurysmal subarachnoid hemorrhage (aSAH) remains a severe condition with high morbidity and mortality. Evidence on sex-related differences in outcomes and complication profiles is inconsistent. We assessed the association between sex and 90-day functional outcome and ICU complications in aSAH patients requiring intensive care. We performed a retrospective secondary analysis of the ATLANREA cohort (NCT02426255), a prospective multicenter ICU registry in western France. Adult patients (≥ 18 years) admitted with aSAH between January 1, 2013, and December 31, 2022, requiring orotracheal intubation within 24 h and for ≥ 24 h, were included. The primary outcome was favourable neurological status at day 90 (Glasgow Outcome Scale-Extended [GOS-E] > 4). A prespecified baseline multivariable logistic model included sex, age, WFNS grade, collapsed Fisher grade and mydriasis. Age subgroup analyses (≤ 42, 43-50, > 50 years) were prespecified as exploratory and complemented by a formal sex × age interaction test. Among 865 patients, 540 (62.4%) were women. Women were older than men (58 [IQR 49-66] vs. 54 [45-63] years; p < 0.001), while WFNS and Fisher grades were similar by sex. Ninety-day GOS-E was available for 682/869 patients (78.8%). Favourable outcome rates were similar in women and men (42.2% vs. 41.4%; p = 0.90). In the baseline complete-case model, sex was not significantly associated with favourable outcome (male OR 0.745, 95% CI 0.517-1.067; p = 0.11), whereas age, higher WFNS grades and mydriasis were independently associated with worse outcome. Sensitivity analyses (best-/worst-case imputation and multiple imputation) suggested a modest sex effect under some assumptions. Ordinal modelling of 8-level GOS-E yielded consistent findings (male OR 0.767, 95% CI 0.568-1.035; p = 0.083). There was no evidence of sex × age interaction (p = 0.585). Vasospasm was more frequent in women (48.9% vs. 41.6%; p = 0.048), whereas men had more secondary pulmonary infections (34.4% vs. 18.9%; p = 0.008). Although sex was not an independent predictor of 90-day neurological outcome in this multicenter cohort of intubated ICU patients with severe aSAH, women were older and had slightly higher vasospasm rates but fewer systemic complications, particularly infections. These findings support incorporating sex and age into future prognostic work and underscore the importance of systemic complications in recovery after severe aSAH. ATLANREA cohort, www. gov , NCT02426255.
Real-world data describing contemporary hyperbaric oxygen therapy (HBOT) practice in Italy are limited. This study aimed to describe current clinical indications and therapeutic modalities of HBOT at the national level. We conducted a multicentre, prospective, observational national study, promoted by Italian Society of Anesthesia Analgesia, Resuscitation and Intensive Care (SIAARTI). We included consecutive patients who underwent HBOT in 10 study centres within a period of 12 weeks, for any treatment indication. The primary outcome of the study was the proportion of treatments by clinical indication and urgency of treatment. Overall, 327 patients were included across 10 centres, of which 73.7% (n = 241) received elective and 26.3% (n = 86) urgent treatments. The most frequent indication was sudden hearing loss (35.8%), followed by carbon monoxide poisoning (19.9%) and soft tissue infection (12.2%). Treatments were delivered at a median of 2.5 ATA, with two oxygen cycles for session and a median of 16 sessions for patients. No serious adverse events occurred. In Italy, HBOT is applied in accordance with national and international guidelines. The most frequent indications to treatment were sudden hearing loss, carbon monoxide poisoning, and soft tissue infections. Treatments had similar characteristics across the centres, with heterogeneity mainly regarding the number of sessions per patient. Not applicable.
The perioperative management of high-risk patients undergoing major noncardiac surgery remains a significant challenge in modern healthcare. Accurate preoperative risk stratification is crucial for optimizing patient outcomes and resource allocation. This narrative review explores the emerging approach of combining natriuretic peptide measurements with the Duke Activity Status Index (DASI) to evaluate cardiac reserve in high-risk surgical patients. We examine the individual roles of natriuretic peptides (primarily B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide) and the DASI in preoperative risk assessment, highlighting their strengths and limitations. The rationale for integrating these two measures is discussed, emphasizing their complementary nature in providing both objective biomarker data and patient-reported functional status. The review synthesizes current evidence supporting this combined approach, including recent studies demonstrating improved risk discrimination compared to traditional methods. We outline a methodology for implementing this integrated assessment, addressing the timing of measurements, interpretation of results, and integration with existing risk stratification tools. Furthermore, we provide guidance on the management of identified high-risk patients, including prehabilitation and optimization strategies. The natriuretic peptide/DASI approach is also positioned within the broader context of perioperative assessment to guide appropriate clinical implementation. The integration of natriuretic peptides and DASI represents a promising strategy for enhancing preoperative cardiac risk assessment in high-risk surgical patients. While further research is needed to refine and validate this approach, it offers a practical and potentially powerful tool for improving perioperative care and patient outcomes.
High-dose norepinephrine (NE) is frequently required in septic shock, but the association of NE dose with outcome remains incompletely characterised. We aimed to evaluate the relationship between NE dosing, mortality and ischemic complications, and to identify clinically relevant NE dose ranges. This retrospective single-centre cohort study included adult patients (≥ 18 years) admitted to the Intensive Care Unit (ICU) between 2016 and 2022 with septic shock on admission, complete data on NE dosing and ICU mortality; patients receiving mechanical circulatory support were excluded. NE dosing variables (initial-dose, highest dose within 24 h, and peak ICU-dose) were collected. Adjusted optimal binning was used to identify NE peak-dose ranges associated with ICU and in-hospital mortality. Multivariable logistic regression was adjusted for age, APACHE II, and SOFA score, and time-dependent Cox models assessed associations with secondary ischemic outcomes. A total of 506 patients were included. Median NE peak-dose was 0.5 [0.2-1.2] µg/kg*min. Four NE peak-dose ranges were identified: 0.05-0.6, 0.61-1.2, 1.2-3.0, and > 3.0 µg/kg*min. ICU and in-hospital mortality increased stepwise across these ranges, from 20.7 and 32.4% in the lowest group to 100% in patients receiving > 3.0 µg/kg*min. This association persisted after exclusion of patients with withdrawal of life-sustaining therapies. Adjusted odds ratios for ICU mortality were 1.88 [0.97-3.64] and 2.55 [1.38-5.57] in the 0.61-1.2 and 1.2-3.0 µg/kg*min groups, respectively. NE peak-dose showed fair discrimination for ICU mortality (AUROC of 0.75), with an optimal Youden threshold of 0.78 µg/kg*min. Most ischemic complications were infrequent and not dose dependent, except for myocardial ischemia and unexpected cardiac arrest, which were significantly associated with higher NE doses. In septic shock, increasing NE peak-doses are associated with a significant stepwise increase in ICU and in-hospital mortality across four distinct dose ranges. Ischemic complications are uncommon and largely independent of NE dose.
High levels of airway pressure and especially positive end-expiratory pressure (PEEP) have been reported to reduce splanchnic perfusion and consequently lead to organ damage. We evaluated the effect of increasing PEEP levels on splanchnic perfusion and intra-abdominal pressure in a prospective clinical-experimental trial. In 20 neurosurgical patients, who were admitted to ICU due to the risk of postoperative complications, we measured the renal and splenic Doppler resistance index (RRI and SRI), intra-abdominal pressure (IAP), and the venous impedance index (VII) at different levels of PEEP (5 to 15 cmH2O) using a non-invasive ultrasound technique. Twenty patients were included in the final analysis. All RRI and SRI values remained within the reference range throughout the protocol, with low measurement variability (SD: RRI 0.06; SRI 0.09; VII 0.22). As PEEP levels increased from 5 to 15 cmH₂O, peak and plateau pressures rose significantly, while driving pressure remained constant. Differences between PEEP levels were not significant for IAP (η2G = 0.011, p = 0.298), RRI (η2G = 0.034, p = 0.253), SRI (η2G = 0.008, p = 0.719), or VII (η2G = 0.015, p = 0.070). No significant correlations with PEEP were found for RRI (r =-0.179, p = 0.081) or SRI (r = -0.130, p = 0.205). Mean arterial pressure was stable (84 ± 11 mmHg) and did not correlate with RRI (r = 0.195, p = 0.106), but correlated with SRI (r = 0.250, p = 0.037) and IAP (r = 0.275, p = 0.022). Exploratory mixed-effects models suggested a modest effect of PEEP on RRI (-0.002, p = 0.036) and a significant effect on VII (-0.007, p = 0.003), though patient-specific factors dominated the variance (R2c = 0.60-0.91). In our cohort of mechanically ventilated, hemodynamically stable, non-fluid-responsive, healthy patients, we found no effect of increasing PEEP levels on intra-abdominal pressure or surrogates of splanchnic perfusion, but an increase in renal venous drainage at higher PEEP levels; these findings warrant confirmation in larger samples. The study was registered in the German clinical trials register (DRKS-ID: DRKS00023895 on 15.02.2021).
Sepsis remains a leading cause of intensive care unit (ICU) mortality globally, with the highest burden observed in low- and middle-income countries where diagnostic capacity, timely referral, and access to organ support are limited. However, commonly used prognostic tools rely on laboratory and monitoring resources that are often unavailable in such settings. This study aimed to identify independent predictors of ICU mortality among adults with sepsis in Lubumbashi, Democratic Republic of the Congo, and to develop a context-adapted prognostic score suitable for resource-constrained environments. We conducted a prospective multicenter cohort study across three ICUs between January 2021 and April 2023. Adults meeting Sepsis-3 criteria were consecutively enrolled. Clinical status, basic laboratory parameters, therapeutic timing, and socioeconomic characteristics were recorded within 24 h of ICU admission. Independent predictors of 28-day mortality were identified using multivariable logistic regression. A simplified point-based prognostic model (SPARS-Basique) was constructed and evaluated for discrimination (AUROC) and calibration, with internal validation using bootstrap resampling (1000 iterations). The outcome of interest was 28-day ICU mortality. A total of 136 patients were included (median age 48 years). ICU mortality was 78%, with most deaths occurring within the first 5 days of admission. Nine variables independently predicted mortality: age ≥ 60 years, low socioeconomic status, absence of health insurance, delay > 5 days before ICU admission, Glasgow Coma Scale ≤ 10, SpO2 < 90%, shock index ≥ 0.9, serum creatinine ≥ 3 mg/dL, and blood glucose ≥ 8 mmol/L. These variables formed the SPARS-Basique score (0-18 points). The model demonstrated strong discrimination (AUROC 0.89; bootstrap-corrected AUROC 0.87) and good calibration. Observed mortality increased across risk groups: 21% (score 0-5), 64% (6-9), and 91% (≥10). Sepsis mortality in Lubumbashi ICUs remains high and is influenced by both biological severity and structural barriers to timely care. The SPARS-Basique score demonstrated good internal performance for early risk stratification of ICU mortality in this cohort. However, as this was an exploratory derivation study in a modest sample, external validation in larger, independent cohorts is required before broader clinical application can be considered.
Intensive care unit (ICU) professionals face high levels of stress, burnout, and work-related psychological strain. However, comprehensive multinational assessments of their well-being-particularly those exploring gender differences and work-life dynamics-are scarce. A cross-sectional survey was conducted by the International Women in Intensive and Critical Care Network (iWIN) between October 2023 and June 2024. The 113-item questionnaire assessed well-being using the WHO-5 Well-Being Index and other validated instruments across eight domains. ICU professionals were recruited via email, professional meetings, and the iWIN website. Descriptive statistics, T-tests, chi-square, and Mann-Whitney U tests were used for analysis. One hundred fifty-eight ICU professionals from diverse roles responded (62% female, 37% male, 1% other). The median WHO-5 score was 68 (IQR 52-80); males reported significantly higher scores than females (72 vs. 60; p = 0.0051). Respondents reported high workload, moderate job autonomy, and frequent stress. Temporary employment was common, with 41.1% considering job transfers. Despite generally positive diversity ratings, gender disparities remained in perceptions of hiring, promotion, and career advancement fairness. This exploratory survey found generally positive well-being among ICU professionals, with a gender difference observed in WHO-5 scores. Concerns related to workload, job insecurity, and career development were also reported. Findings should be interpreted with caution and warrant further investigation.