Intensive Care Society Research Articles

Current state of quality improvement research across cardiac ICUs: a Pediatric Cardiac Intensive Care Society (PCICS) survey.

Outcomes for children with heart disease improved over the past decades. Quality improvement (QI) research in paediatric cardiac critical care is a key driver of improvement. The availability and variability of QI research across the field is unknown. This project represents a step in understanding the role. The Pediatric Cardiac Intensive Care Society (PCICS) can serve to support institutions' needs, drive collaborations, and utilise available infrastructure at member institutions for improvement work. The PCICS Quality Improvement and Safety Committee developed a survey to assess the state of QI research. The survey was disseminated over several months and available via QR code at the World Congress of Pediatric Cardiology and Cardiac Surgery in 2023. Fifty-eight respondents completed the survey representing at least 38 unique institutions. Most respondents participated in QI research (52/58, 90%). Most QI projects were single centre (41% of respondents), and of those, the majority were from a minority of institutions (13 institutions [34% of total institutions]). QI support is available at slightly more than half of units, and 55% (32/58) have access to a QI specialist. QI support and rate of publications is significantly lower for small/medium units as compared to large units. Respondents suggested most interest from PCICS in networking with other members with similar project ideas (50/58, 86%). PCICS member institutions are committed to QI research, with limitations in support, local specialists, and networking. Increasing connectivity and accessibility to QI resources may reduce burden to individual members and institutions to achieve QI research.

Sustainability-national and international initiatives in intensive care and emergency medicine

Climate change with global warming, natural disasters, species extinction and soil erosion is doubly relevant for medicine: On the one hand, heat waves, floods and other natural disasters lead to new disease patterns to which healthcare systems must adapt. On the other hand, the global healthcare system itself contributes to these effects, as it is estimated that the CO2 footprint of all healthcare facilities accounts for around 5% of global greenhouse gas emissions. National and international initiatives to promote sustainability concepts in intensive care and emergency medicine. Research on homepages of national and international (specialist) societies dealing with intensive and emergency care medicine and corresponding PubMed search (sustainability and climate change and emergency or intensive care medicine). Six of the 12national specialist societies surveyed have taken initiatives on sustainability, notable among them the initiative of Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) for anew registration of the S1guideline "Sustainability in intensive care and emergency medicine". On the international scene, the activities of the Australian and New Zealand Intensive Care Society (ANZICS) with numerous publications on the topic of sustainability in intensive care medicine and the practical guide "Abeginners guide to sustainability in intensive care medicine" as well as the European Society of Anaesthesiology and Intensive Care (ESAIC) with aconsensus paper on sustainability should be highlighted. At the national level, initiatives on sustainability (guidelines, working groups, forums) are emerging and are attracting increasing attention and activity. The umbrella organization of German Intensive Care Medicine, the Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), has so far shown no (discernible) activity; there is an urgent need for action here, and health policy and the German Medical Association should also become (even) more involved in reducing the CO2 footprint in the healthcare sector. Internationally, there are anumber of societies and institutions that are promoting the topic of "sustainability", although astronger focus on the area of intensive care and emergency medicine would also be desirable here.

Patient Blood Management in 2023: a Nationwide Survey of Anesthesiologists in Romania following the 2018 Guidelines.

In 2018, Romania established national guidelines for patient blood management (PBM), endorsed by the Romanian Society of Anesthesia and Intensive Care (SRATI) and approved by the Ministry of Health. These guidelines emphasize managing anemia, coagulation issues, and the cautious use of allogeneic transfusions to improve patient outcomes. A national survey was conducted among Romanian anesthesiologists to assess PBM guideline adoption. It included 38 questions addressing PBM strategies, resources, transfusion practices, and barriers to implementation. The survey was distributed via email to the SRATI database. Out of 512 professionals who opened the survey, 74% had adopted some PBM measures, and 97% recognized PBM's efficacy in improving outcomes. However, only 33% of anesthesiologists worked in hospitals with formal PBM groups, and 39% had attended PBM-related educational events. Preoperative anemia management was inconsistent, with only 33.5% routinely treating anemia. Access to diagnostic and therapeutic tools was limited; transferrin saturation testing was available in 27% of cases, and erythropoietin was used in 24%. Despite these limitations, 72% of respondents treated anemia with intravenous iron. The main challenges to implementation included insufficient time for pre-surgical assessments, lack of standardized procedures, and difficulties in surgeon-anesthetist collaboration. The survey highlights the need for systemic improvements in PBM adoption. Recommendations include enhancing organizational structures, standardizing protocols, and improving interdisciplinary collaboration to boost PBM implementation in Romania. While progress has been made, a national program with dedicated funding and auditing could facilitate widespread PBM integration into clinical practice.

Beyond the stereotypes: Artificial Intelligence image generation and diversity in anesthesiology.

Artificial Intelligence (AI) is increasingly being integrated into anesthesiology to enhance patient safety, improve efficiency, and streamline various aspects of practice. This study aims to evaluate whether AI-generated images accurately depict the demographic racial and ethnic diversity observed in the Anesthesia workforce and to identify inherent social biases in these images. This cross-sectional analysis was conducted from January to February 2024. Demographic data were collected from the American Society of Anesthesiologists (ASA) and the European Society of Anesthesiology and Intensive Care (ESAIC). Two AI text-to-image models, ChatGPT DALL-E 2 and Midjourney, generated images of anesthesiologists across various subspecialties. Three independent reviewers assessed and categorized each image based on sex, race/ethnicity, age, and emotional traits. A total of 1,200 images were analyzed. We found significant discrepancies between AI-generated images and actual demographic data. The models predominantly portrayed anesthesiologists as White, with ChatGPT DALL-E2 at 64.2% and Midjourney at 83.0%. Moreover, male gender was highly associated with White ethnicity by ChatGPT DALL-E2 (79.1%) and with non-White ethnicity by Midjourney (87%). Age distribution also varied significantly, with younger anesthesiologists underrepresented. The analysis also revealed predominant traits such as "masculine, ""attractive, "and "trustworthy" across various subspecialties. AI models exhibited notable biases in gender, race/ethnicity, and age representation, failing to reflect the actual diversity within the anesthesiologist workforce. These biases highlight the need for more diverse training datasets and strategies to mitigate bias in AI-generated images to ensure accurate and inclusive representations in the medical field.

Commentary on the ANNEXA-I trial from the guideline group of the European Society of Anaesthesiology and Intensive Care (ESAIC) on the reversal of direct oral anticoagulants in patients with life threatening bleeding

Commentary on the ANNEXA-I trial from the guideline group of the European Society of Anaesthesiology and Intensive Care (ESAIC) on the reversal of direct oral anticoagulants in patients with life threatening bleeding

Management of analgosedation during noninvasive respiratory support: an expert Delphi consensus document developed by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

BackgroundDiscomfort can be the cause of noninvasive respiratory support (NRS) failure in up to 50% of treated patients. Several studies have shown how analgosedation during NRS can reduce the rate of delirium, endotracheal intubation, and hospital length of stay in patients with acute respiratory failure. The purpose of this project was to explore consensus on which medications are currently available as analgosedatives during NRS, which types of patients may benefit from analgosedation while on NRS, and which clinical settings might be appropriate for the implementation of analgosedation during NRS.MethodsThe Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects of the use of analgesics and sedatives during NRS treatment. The methodology applied is in line with the principles of the modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales which were then subjected to blind votes for consensus.ResultsThe use of an analgosedation strategy in adult patients with acute respiratory failure of different origins may be useful where there is a need to manage discomfort. This strategy should be considered after careful assessment of other potential factors associated with respiratory failure or inappropriate noninvasive respiratory support settings, which may, in turn, be responsible for NRS failure. Several drugs can be used, each of them specifically targeted to the main component of discomfort to treat. In addition, analgosedation during NRS treatment should always be combined with close cardiorespiratory monitoring in an appropriate clinical setting.ConclusionsThe use of analgosedation during NRS has been studied in several clinical trials. However, its successful application relies on a thorough understanding of the pharmacological aspects of the sedative drugs used, the clinical conditions for which NRS is applied, and a careful selection of the appropriate clinical setting.

Twenty-Five Years of Pediatric Critical Care Medicine: An Evolving Journey With the World Federation of Pediatric Intensive and Critical Care Societies.

Twenty-Five Years of Pediatric Critical Care Medicine: An Evolving Journey With the World Federation of Pediatric Intensive and Critical Care Societies.

Citation for honorary membership of the Intensive Care Society

Citation for honorary membership of the Intensive Care Society

A survey and analysis of peri-operative quality indicators promoted by National Societies of Anaesthesiologists in Europe: The EQUIP project.

To capture preventable peri-operative patient harm and guide improvement initiatives, many quality indicators (QIs) have been developed. Several National Anaesthesiologist Societies (NAS) in Europe have implemented quality indicators. To date, the definitions, validity and dissemination of such quality indicators, and their comparability with validated published indicators are unknown. The aim of this study was to identify all quality indicators promoted by NAS in Europe, to assess their characteristics and to compare them with published validated quality indicators. A cross-sectional study with mixed methods analysis. Using a survey questionnaire, representatives of 37 NAS were asked if their society provided quality indicators to their members and, if so, to provide the list, definitions and details of quality indicators. Characteristics of reported quality indicators were analysed. The 37 NAS affiliated with the European Society of Anaesthesiology and Intensive Care (ESAIC) at the time. Data collection, translations: March 2018 to February 2020. Representatives of all 37 NAS completed the survey. QIs reported by NAS. Only 12 (32%) of the 37 NAS had made a set of quality indicators available to their members. Data collection was mandatory in six (16.2%) of the 37 countries. We identified 163 individual quality indicators, which were most commonly descriptive (60.1%), anaesthesia-specific (50.3%) and related to intra-operative care (21.5%). They often measured structures (41.7%) and aspects of safety (35.6%), appropriateness (20.9%) and prevention (16.6%). Patient-centred care (3.7%) was not well covered. Only 11.7% of QIs corresponded to published validated or well established quality indicator sets. Few NAS in Europe promoted peri-operative quality indicators. Most of them differed from published sets of validated indicators and were often related to the structural dimension of quality. There is a need to establish a European-wide comprehensive core set of usable and validated quality indicators to monitor the quality of peri-operative care. No registration.

Gender and Race/Ethnicity dynamics in anesthesiology mentorship: results of a European survey

BackgroundMentorship is crucial to career advancement, medical education, and psychosocial support, especially for women and minorities. Although anesthesia mentoring programs have shown promise, there are no survey data regarding mentor-mentee relationship dynamics. This study aimed to explore the dynamics of the anesthesia mentor/mentee relationship.MethodsA open cross-sectional web-based survey was distributed by the European Society of Anesthesiology and Intensive Care and European Society of Regional Anesthesia to European anesthesiologists. Participation was anonymous and consent was obtained. The study evaluated responses relating to preferences, facilitators, and barriers to mentorship relationships along with sociodemographic information.ResultsIn total, 543 anesthesiologists responded to the survey, and 406 (111 mentees, 49 mentors, 193 both, 53 neither) responded to questions regarding mentorship. 184 anesthesiologists identified as woman and 22 as other genders (non-binary, transgender, gender-fluid, and self-described gender). Moreover, 250 anesthesiologists identified as white. Both mentors and mentees indicated that personal compatibility was the most important factor for successful mentorship. Barriers to mentorship included time consumption and perceived lack of interest from the mentor and mentee. Both mentors and mentees benefited from this relationship. The former reported feeling helpful, and the latter supported the development of clinical skills. The mentors indicated that their participation was important for protecting against burnout/exhaustion and impostor syndrome. Participants reported a preference for mentorship programs organized at the departmental level, offered at the start of the anesthesiology education curricula. Women were more likely to feel a ‘lack of interest’ in mentoring them as a barrier (OR = 2.49, P = 0.033). Gender was a barrier for mentors of other genders (OR = 23.9, P = 0.0027) and ethnicity (OR = 48.0, P = 0.0023). White mentees found gender (OR = 0.14, P = 0.021) and ethnicity (OR = 0.11, P = 0.048) to be less important barriers to successful mentorship relationship.ConclusionWhen possible, programs should prioritize matching mentors and mentees based on personal compatibility and experience in the mentee’s area of interest. Addressing the perceived lack of interest in mentoring is essential for promoting diversity, equality, and inclusion within anesthesiology, as well as and uplifting women and minorities.Trial registrationClinicaltrials.gov identifier: NCT05968339, First posted (01/08/2023).

Oxygen therapy in acute hypoxemic respiratory failure: guidelines from the SRLF-SFMU consensus conference

IntroductionAlthough largely used, the place of oxygen therapy and its devices in patients with acute hypoxemic respiratory failure (ARF) deserves to be clarified. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and the French Emergency Medicine Society (Société Française de Médecine d’Urgence, SFMU) organized a consensus conference on oxygen therapy in ARF (excluding acute cardiogenic pulmonary oedema and hypercapnic exacerbation of chronic obstructive diseases) in December 2023.MethodsA committee without any conflict of interest (CoI) with the subject defined 7 generic questions and drew up a list of sub questions according to the population, intervention, comparison and outcomes (PICO) model. An independent work group reviewed the literature using predefined keywords. The quality of the data was assessed using the GRADE methodology. Fifteen experts in the field from both societies proposed their own answers in a public session and answered questions from the jury (a panel of 16 critical-care and emergency medicine physicians, nurses and physiotherapists without any CoI) and the public. The jury then met alone for 48 h to write its recommendations.ResultsThe jury provided 22 statements answering 11 questions: in patients with ARF (1) What are the criteria for initiating oxygen therapy? (2) What are the targets of oxygen saturation? (3) What is the role of blood gas analysis? (4) When should an arterial catheter be inserted? (5) Should standard oxygen therapy, high-flow nasal cannula oxygen therapy (HFNC) or continuous positive airway pressure (CPAP) be preferred? (6) What are the indications for non-invasive ventilation (NIV)? (7) What are the indications for invasive mechanical ventilation? (8) Should awake prone position be used? (9) What is the role of physiotherapy? (10) Which criteria necessarily lead to ICU admission? (11) Which oxygenation device should be preferred for patients for whom a do-not-intubate decision has been made?ConclusionThese recommendations should optimize the use of oxygen during ARF.

Patient safety during transfers from critical care: developing and assessing a checklist.

Critically ill patients often need to be transferred from the intensive care unit (ICU) to the imaging department. This can compromise their safety, not only because of the inherent risk of deterioration but also because of the potential for incidents due to the inadequate preparation of medicines, equipment and monitoring. Using a patient transfer checklist can reduce the risk of human factor errors. This article reports on a quality improvement project conducted at the ICU of an acute hospital trust in the Midlands to develop and evaluate a patient transfer checklist. The checklist was developed based on guidance from the Intensive Care Society and evaluated using retrospective incident reports, an audit of staff compliance and a user survey. Using a transfer checklist in the ICU is likely to reduce patient safety incidents during transfers, but a shift in workplace culture may be needed to enhance incident reporting.

Outcomes for people admitted to Australian and New Zealand intensive care units with primary, exacerbating, or incidental SARS-CoV-2 infections, 2022-23: a retrospective analysis of ANZICS data.

To compare in-hospital mortality and intensive care unit (ICU) length of stay for people admitted to Australian and New Zealand ICUs during 2022-23 with coronavirus disease 2019 (COVID-19) pneumonitis, incidental or exacerbating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, or without SAR-CoV-2 infections. Retrospective cohort study; analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data. Adults (16 years or older) admitted to participating ICUs in Australia or New Zealand, 1 January 2022- 30 June 2023. The primary outcome was in-hospital mortality, the secondary outcome ICU length of stay, each by SARS-CoV-2 infection attribution classification: primary COVID-19; exacerbating SARS-CoV-2 infection (SARS-CoV-2 infection was a contributing factor to the primary cause of ICU admission); incidental SARS-CoV-2 infections (SARS-CoV-2 infection detected during ICU admission but did not contribute to admission diagnosis); no SARS-CoV-2 infection. A total of 207 684 adults were admitted to 195 Australian and New Zealand ICUs during 2022-23; 2674 people (1.3%) had incidental SARS-CoV-2 infections, 4923 (2.4%) exacerbating infections, and 3620 (1.7%) primary COVID-19. Unadjusted in-hospital mortality for people with incidental SARS-CoV-2 infections (288 deaths, 10.8%) was lower than for those with exacerbating infections (928 deaths, 18.8%) or primary COVID-19 (830 deaths, 22.9%), but higher than for patients without SARS-CoV-2 infections (15 486 deaths, 7.9%). After adjusting for illness severity, frailty, geographic region, and type of hospital, mortality was higher for patients with incidental SARS-CoV-2 infections (adjusted odds ratio [aOR], 1.28; 95% confidence interval [CI], 1.10-1.50), exacerbating infections (aOR, 1.35; 95% CI, 1.22-1.48), or primary COVID-19 (aOR, 2.54; 95% CI, 2.30-2.81) than for patients without SARS-CoV-2 infections. After adjusting for diagnosis and illness severity, ICU stays were longer for people with incidental (mean difference, 3.3 hours; 95% CI, 2.4-4.2 hours) or exacerbating infections (0.8 hours; 95% CI, 0.2-1.5 hours) than for those without SARS-CoV-2 infections. Risk-adjusted in-hospital mortality and ICU length of stay are higher for people admitted to intensive care who have concomitant SARS-CoV-2 infections than for people who do not.

2203 Avoiding therapeutic nihilism in critically ill older adults: a single Centre approach to enhanced care in patients with frailty

Abstract Introduction Enhanced care units (ECU) are a novel concept, targeting the gap between ward-level and critical care. They care for patients requiring intensive medical or nursing care, who may not require, desire, or be suitable for, escalation above ward care (Society of Acute Medicine and Intensive Care Society, 2022). The ECU at Barnet Hospital opened in March 2022, and, because of the local population demographic, admits a high number of older patients living with frailty. We aimed to assess the performance of the ECU for this subset of patients. Methods A retrospective audit of electronic records of 75 randomly selected patients admitted to ECU between March and August 2023. Data were gathered on Clinical Frailty Score (CFS) at baseline, comorbidity, escalation status, APACHE II illness severity score, and outcome measures. Results The majority of patients in the sample, 52 of 75 (69.3%), were over 65 years of age with an average of 69.1 years. Baseline frailty score was high, with a modal CFS of 6. Of these patients, 32 (61.5%) had a DNACPR, and 17 (32.7%) had treatment ceiling at ECU level. Illness severity was similar across CFS groups, with a mean APACHE II score of 15.2 (representing a 25% mortality risk). Overall mortality in the over 65 s was 23.1% (12/52), without significant change when stratified by CFS. Mortality in the under 65 s was 8.7% (2/23). Conclusions Acutely unwell patients with frailty may benefit from ECU level care. In our centre, we found no significant increase in mortality linked to a higher frailty score. We suggest that this may represent good case selection by clinicians experienced in working with frailty: admitting patients with more reversibility and targeting therapies towards reversible causes. Limitations remain, especially in assessing illness severity, as the assessment tools are not targeted to this cohort.

Assessment of self-perceived knowledge of key clinical pharmacology concepts and educational needs among European Paediatric Intensive Care Units: an ESPNIC survey

BackgroundKnowledge of clinical pharmacology concepts is essential to improve patients’ outcomes. Scarce data is available on the utilisation of these concepts in the paediatric intensive care unit (PICU). We aimed to investigate the self-perceived knowledge of clinical pharmacology concepts, educational needs and identify priorities for pharmacological research across European PICUs.MethodsFrom July to November 2022 an online survey was distributed to evaluate i) the self-reported knowledge, and ii) application of key pharmacology concepts in clinical practice (using a likert scale from 1 = never apply to 10 = always apply); iii) need for additional education on them; and iv) key areas for future pharmacological research. The survey was distributed to European Society of Paediatric and Neonatal Intensive Care (ESPNIC) members and other European national PICUs societies members.ResultsTwo-hundred-thirty-seven responses from 149 PICUs were collected. 54% of PICUs reported to have a clinical pharmacologist available for consultation during drug prescription and 65% of them regularly contact them during the prescribing process. Among clinical pharmacology concepts the parameter with the highest self-reported knowledge was half-life (99%) and the lowest were pharmacodynamics and volume-of-distribution (92%). The reported median application of these concepts in clinical practice ranged between 5/10 and 7/10. Most of the respondents reported the need for additional education on specific pharmacology concepts. Reported priorities for drug research mostly involved analgesics/sedatives (87%), antimicrobials (86%), and cardiovascular medications (55%).ConclusionsSelf-reported knowledge on clinical pharmacology concepts seems good, but self-perceived clinical application may improve and most of the respondents report a need for additional education. These findings call for concerted multidisciplinary efforts to streamline education and guidelines to fill this gap.

Hypothermia for expanded criteria organ donors in kidney transplantation in France (HYPOREME): a multicentre, randomised controlled trial

Expanded criteria donors help to increase graft availability, but provide organs with an increased risk of delayed graft function. We aimed to investigate whether donor hypothermia decreases the risk of delayed graft function compared with normothermia. We did this multicentre, randomised, controlled, parallel-arm trial at 53 intensive care units and transplant centres in France. We included expanded criteria donors in whom death was diagnosed based on neurological criteria, in compliance with French law, and the recipients of their kidney grafts. Eligible expanded criteria donors were older than 60 years or were aged 50-59 years and had at least two other risk factors (history of hypertension, creatinine >132 μmol/L, or cerebrovascular cause of death). Donors were randomly assigned to hypothermia (34-35°C) or normothermia (36·5-37·5°C). Machine perfusion was used routinely. Randomisation was done using a computer-generated, interactive, web-response system, in permuted blocks (block size six), stratified by centre. Outcome assessors were masked; investigator masking was not feasible. The primary outcome was the proportion of kidney recipients with delayed graft function, defined as renal replacement therapy within 7 days after transplantation, assessed in the modified intention-to-treat (mITT) population, which included all recipients who received at least one kidney from an expanded criteria donor, with the exception of those under guardianship. Secondary outcomes in expanded criteria donors were the number of organs recovered and transplanted, kidney function, body temperature, total volume of fluids administered, blood pressure and need for vasopressors and inotropes, and adverse events (cardiovascular events, metabolic disturbances, and coagulation disorders). Secondary outcomes in kidney recipients were duration of hospital stay, kidney graft function and vital status at day 7, day 28, 3 months, and 1 year after transplantation, and adverse events (infections, cardiovascular events, and surgical complications). Secondary outcomes were assessed in the mITT population. The trial was registered at ClinicalTrials.gov, NCT03098706. Between Nov 9, 2017, and March 3, 2021, 365 donors were randomly assigned, of whom 298 (151 [51%] male, 147 [49%] female) provided kidneys to 526 recipients (323 [61%] male, 203 [39%] female). 251 recipients in the hypothermia group and 275 recipients in the normothermia group were included in the analysis. Graft function was delayed in 40 (16%) of 251 recipients in the hypothermia group and 58 (21%) of 275 recipients in the normothermia group (odds ratio 0·71 [95% CI 0·44-1·13]; p=0·14; absolute difference -5·2% [95% CI 11·8-1·5]). Compared with donors in the normothermia group, donors in the hypothermia group had higher highest mean arterial pressure (115 mm Hg [SD 22] vs 108 mm Hg [20]; p=0·001). 1 year after transplantation, recipients in the hypothermia group had a lower mean creatinine concentration (152·4 μmol/L [SD 59·1] vs 169·7 μmol/L [51·4]; p=0·0351) and a higher mean creatinine clearance (42·3 mL/min/1·73 m2 [15·8] vs 40·5 mL/min/1·73 m2 [17·9]; p=0·0414) than those in the normothermia group. No significant differences between groups were identified for any other secondary outcomes. Hypothermia in expanded criteria donors whose organs were routinely stored using machine perfusion did not decrease the frequency of delayed kidney graft function. However, hypothermia was associated with a lower serum creatinine concentration and a higher creatinine clearance 1 year after transplantation. French Ministry of Health and French Intensive Care Society.

Cardiac biomarkers prior to noncardiac surgery

Cardiac biomarkers, such as high-sensitivity cardiac troponin (hs-cTn) and brain natriuretic peptide (BNP) or N‑terminal prohormone of brain natriuretic peptide (NT-proBNP) are measured perioperatively to improve the prognosis and risk prediction. The European Society of Cardiology (ESC), European Society of Anesthesiology and Intensive Care (ESAIC) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI) have recently published guidelines on the use of cardiac biomarkers prior to surgery. This article provides an overview of the available evidence on perioperative troponin and BNP/NT-proBNP measurements. Current guideline recommendations are presented and discussed. MEDLINE, Cochrane and google.scholar were searched for relevant keywords. Titles and abstracts of identified papers were checked for relevance and published results were summarized. Guideline recommendations from the ESC, ESAIC and DGAI are presented, compared and evaluated based on the available literature. In addition, the significance of new perioperative cardiac biomarkers is discussed based on the existing evidence. The definitions, diagnosis and management of cardiovascular events in the perioperative context differ from those in the nonsurgical setting. The evidence for the measurement of hs-cTn and BNP/NT-proBNP is evaluated differently in the guidelines and the resulting recommendations are partly contradictory. In particular, recommendations for changes in perioperative management based on biomarker measurements diverge. The ESC guidelines propose an algorithm that uses preoperative biomarkers as the basis for additional cardiac investigations. In particular, invasive coronary angiography is recommended for patients with stable chronic coronary syndrome who have no preoperative cardiac symptoms but elevated biomarkers. In contrast, the ESAIC guidelines emphasize that the available evidence is not sufficient to use perioperative biomarker measurements as abasis for achange in perioperative management. Treating physicians should coordinate interdisciplinary (surgery, anesthesiology, cardiology) recommendations for clinical practice based on the aforementioned guidelines. If cardiac biomarkers are routinely determined in high-risk patients, this should be done in accordance with the ESC algorithm.

Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI).

Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others. To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology. An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method. Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability. This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM.

The number of trials investigating the effects of deep neuromuscular blockade (NMB) on surgical conditions and patient outcomes is steadily increasing. Consensus on which surgical procedures benefit from deep NMB (a posttetanic count [PTC] of 1 to 2) and how to implement it has not been reached. The European Society of Anaesthesiology and Intensive Care does not advise routine application but recommends use of deep NMB to improve surgical conditions on indication. This study investigates the optimal dosing strategy to reach and maintain adequate deep NMB during total intravenous anesthesia. Data from three trials investigating deep NMB during laparoscopic surgery with total intravenous anesthesia (n = 424) were pooled to analyze the required rocuronium dose, when to start continuous infusion, and how to adjust. The resulting algorithm was validated (n = 32) and compared to the success rate in ongoing studies in which the algorithm was not used (n = 180). The mean rocuronium dose based on actual bodyweight for PTC 1 to 2 was (mean ± SD) 1.0 ± 0.27 mg · kg-1 ·h-1 in the trials, in which mean duration of surgery was 116 min. An induction dose of 0.6 mg ·kg-1 led to a PTC of 1 to 5 in a quarter of patients after a mean of 11 min. The remaining patients were equally divided over too shallow (additional bolus and direct start of continuous infusion) or too deep; a 15-min wait after PTC of 0 for return of PTC to 1 or higher. Using the proposed algorithm, a mean 76% of all 5-min measurements throughout surgery were on target PTC 1 to 2 in the validation cohort. The algorithm performed significantly better than anesthesiology residents without the algorithm, even after a learning curve from 0 to 20 patients (42% on target, P ≤ 0.001, Cohen's d = 1.4 [95% CI, 0.9 to 1.8]) to 81 to 100 patients (61% on target, P ≤ 0.05, Cohen's d = 0.7 [95% CI, 0.1 to 1.2]). This study proposes a dosing algorithm for deep NMB with rocuronium in patients receiving total intravenous anesthesia.

Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM).

There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence-based guidelines for practicing clinicians to support safe and effective airway management in this setting. An expert multidisciplinary, multi-society working party conducted a systematic review of contemporary literature (January 2012-June 2022), followed by a three-round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury. We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre-oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front-of-neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre-hospital care, military settings and principles in human factors. It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.