Rethink analgo-sedation in digestive endoscopy: the role of scientific societies in tracing training path.

OBJECTIVE: The Italian Society of Anesthesia, Analgesia, Reanimation and Intensive Care Medicine (SIAARTI) and the Italian Society of Digestive Endoscopy (SIED) worked together to produce a joint Good Clinical Practice (GCP) on analgo-sedation in digestive endoscopy and launched a survey to support the document. The aim was to identify and describe the actual clinical practice of sedation in Italian digestive endoscopy units and offer material for a wider and more widespread discussion among anesthetists and endoscopists. SUBJECTS AND METHODS: A national survey was planned, in order to support the statements of the GCP. Twelve thousand and five hundred questionnaires were sent to the members of SIAARTI and SIED in June 2020. RESULTS: A total of 662 forms (5.3%) returned completed. Highly complex procedures are performed according to 70% of respondents; daily anesthesiologist's assistance is guaranteed in 26%, for scheduled sessions in 14.5% and as needed in 8%. 69% of respondents declared not to have a dedicated team of anesthesiologists, while just 5% reported an anesthesiologist in charge. A complete monitoring system was assured by 70% of respondents. Dedicated pathways for COVID-19-positive patients were confirmed in <40% of the answers. With regard to moderate/deep sedation, 90% of respondents stated that an anesthetist decides timing and doses. Propofol was exclusively administered by anesthetists according to 94% of answers, and for 6% of respondents the endoscopist is allowed to administer propofol in presence of a dedicated nurse, but with a readily available anesthetist. Only 32.8% of respondents reported institutional training courses on procedural analgo-sedation. CONCLUSIONS: The need to provide patients scheduled for endoscopy procedures with an adequate analgo-sedation is becoming an increasing concern, well-known in almost all countries, but many factors compromise the quality of patient care. Results of a national survey would give strength to the need for a shared GCP in gastrointestinal endoscopy. Training and certification of non-anesthetist professionals should be one of the main ways to center the objective.

Intensive care medicine: A multidisciplinary competence-based approach

During the Covid-19 pandemic general interest in intensive care medicine emerged as besides a majority of other diseases and conditions also patients with Covid-19 pneumonia were treated by intensivists. This acute demand was taken as the rationale by the European Society of Intensive Care Medicine (ESICM), which represents only a small portion of all intensivists throughout Europe, to launch an initiative to recognize Intensive Care Medicine in Europe as a medical specialty according to Annexe V of the European Directive on the recognition of professional qualifications. The discussion having intensive care medicine as a primary discipline is old and the disadvantages have been clearly stated long ago. Intensive care medicine according to the Multidisciplinary Joint Committee of Intensive Care Medicine (MJCICM) of the European Union of Medical Specialists (UEMS) should be multidisciplinary as this serves our patients best. During the pandemic, we learned that all specialties that cover Intensive Care Medicine in their training were able to treat affected patients and to provide intensivists to additionally built ICUs. Most of them were anaesthesiologists who were set free from the operating theatres because of the cancellation of many elective operations. However, other disciplines that provide high-level ICU care, such as internal medicine, surgery, neurosurgery and cardiac surgery were also recruited to face the pandemic. With a single, primary specialty, this would have not been possible on that scale. Certainly, for all highly trained specialists, free movement throughout Europe is an important goal. Therefore, training in Intensive Care Medicine throughout Europe should be according to a common competence-based curriculum and this training and examination on top of a mother discipline should be recognized as a ‘particular qualifications’ throughout Europe. From our point of view, regarding Intensive Care Medicine, this approach in combination with competence-based training and examination in tandem with a primary discipline allows free movement of our doctors and also serves our patients best, for the future and also for the current and future pandemics. © Anästh Intensivmed 2021;62:513–516 Aktiv Druck & Verlag GmbH.

SARS-COV2 CRITICALLY ILL PAZIENTS: FOCUS ON NUTRITION

Objective SARS-CoV-2 disease is a severe infection that has forced millions of patients to stay in ICU.(2) SARS-CoV-2 pneumonia appears to occur rapidly and is often associated with gastrointestinal disorders that compromise the patient ability to adequately feed, causing a severely malnourished and sarcopenic status.(1) Our hypothesis is that a strategy, based on the use of whey protein, that guarantee a fast achievement of protein and caloric targets, can reduce the duration of ventilation and mortality. Methods and procedures We studied and treated 32 COVID-19 patients from 9/3 to 30/4/2020. The following nutritional targets were followed in all patients ⁃ start of enteral nutrition within 24/48 hours ⁃ protein target> = 1.3 g / kg ⁃ Caloric target 20/25 kcal / kg ⁃ Use of enteral mixtures rich in whey protein ⁃ Daily monitoring of prealbumin Results We observed that the 95% of patients presented a significant increase in prealbumin values (figure1) All patients who achieved a prealbumin value > 20 during hospitalization in ICU had a lower mortality. When the protein target was achieved in 2/3 days the time under mechanical ventilation was reduced ( figure 2-3) Conclusion Although the data are hindered by the small number of patients, in our experience an adequate nutritional support that guarantees a rapid achievement of protein target, reduces ventilation time and mortality.