Haloperidol for preventing delirium in ICU patients: a systematic review and meta-analysis.

OBJECTIVE: Delirium, a common behavioral manifestation of acute brain dysfunction in Intensive Care Unit (ICU), is a significant contributor to mortality and worse long-term outcome. Antipsychotics, especially haloperidol, are commonly administered for the treatment and prevention of delirium in critically ill patients while the evidence for the safety and efficacy of these drugs is still lacking. Therefore, we conducted a systematic review of the benefits of haloperidol for the prevention of delirium in ICU patients. MATERIALS AND METHODS: We made a systematic review and meta-analysis. RESULTS: Eight RCTs with 2806 patients were included. The prophylactic use of haloperidol did not reduce the delirium incidence (RR: 0.90, 95% CI: 0.69-1.71), the duration of delirium (MD: -0.33, 95% CI: -1.25-0.588) and the delirium/coma free days (MD: 0.08, 95% CI: -0.06-0.23). We did not find an increase of extrapyramidal effects (RR: 1.86, 95% CI: 0.30-11.39), QTc prolongation (RR: 1.11, 95% CI: 0.79-1.55) and arrhythmias (RR: 1.26, 95% CI: 0.72-2.19). The use of haloperidol did not increase the ICU (MD: 0.77, 95% CI: -0.28-1.83) and hospital length of stay (MD: -0.57, 95% CI: -1.32-0.18). Haloperidol did not increase the sedation level (RR: 1.88, 95% CI: 0.76-4.63) and mortality (RR: 0.97, 95% CI: 0.83-1.18). CONCLUSIONS: Haloperidol did not reduce the delirium incidence, the delirium duration, the delirium/coma free-days and did not increase the incidence of extrapyramidal effects, arrhythmias, the ICU and hospital length of stays and sedation.

Video vs. direct laryngoscopy for adult surgical and intensive care unit patients requiring tracheal intubation: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This systematic review and meta-analysis aimed to determine whether a specific videolaryngoscopy technique is superior to standard direct laryngoscopy using a Macintosh blade to reduce the risk of difficult intubation in surgical and intensive care unit patients. MATERIALS AND METHODS: We identified all randomized controlled trials comparing videolaryngoscopes (VLSs) to direct laryngoscopy in the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE (from inception to April 2020). The primary outcome was difficult intubation in adult surgical and intensive care unit patients. Secondary outcomes were successful intubation at the first attempt, airway trauma, sore throat, hoarseness, hypoxia, and mortality. RESULTS: We included 97 randomized controlled trials to evaluate 12775 patients. A high risk of bias was found in at least 50% of the included studies for each outcome. VLSs reduced the risk of difficult intubation compared to direct Macintosh laryngoscopy (RR 0.48, 95% CI from 0.35 to 0.65). VLSs increased the rate of successful intubation at the first attempt when compared to direct Macintosh laryngoscopy (RR 1.03, 95% CI from 1.00 to 1.07). Lower risks of airway trauma were found with VLSs (RR 0.69, 95% CI from 0.55 to 0.86). A decreased risk of hoarseness was associated with the use of VLSs (RR 0.67, 95% CI from 0.54 to 0.83). In addition, VLSs did not significantly reduce the risk of hypoxia compared with direct laryngoscopy (RR 0.83, 95% CI from 0.60 to 1.16). CONCLUSIONS: In this systematic review and meta-analysis, we found that the use of VLSs reduced the risk of difficult intubation and slightly increased the ratio of successful intubation at the first attempt among adult patients.

A systematic review of the literature on the role of tracheostomy in COVID-19 patients.

The Coronavirus Disease 2019 (COVID-19) is a viral infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which emerged in East Asia and spread around the world from December 2019. The most severe stage of COVID-19 pathology is characterized by respiratory distress requiring intubation. In specific cases, tracheostomy is indicated to ensure the safety of the procedure. The aim of our study was to analyze the scientific literature identifying the indications for tracheostomy and safety precautions to reduce contamination. We analyzed the literature from February 2003 to April 2020, including papers on pandemics of other coronaviruses, such As Severe Acute Respiratory Syndrome Coronavirus 1 and Middle East Respiratory Syndrome Coronavirus, to obtain a variety of relevant information. We focused on indications for tracheostomy in patients affected by COVID-19 or related viruses and the measures adopted to perform a safe procedure. We included 35 papers, of which 24 (68.57%) discussed guidelines for tracheostomy indications. All 35 studies discussed the procedures for performing tracheostomy safely. Data obtained indicated that the authors generally agreed on safety measures but expressed different opinions about indications. Therefore, we provided guidelines addressing safety recommendations. After the pandemic has been resolved, we plan to conduct an international retrospective study to identify the criteria for tracheostomy indications.

Posterior reversible encephalopathy syndrome: the endothelial hypotheses.

Posterior reversible encephalopathy syndrome (PRES) is characterised by headache, visual disorders, seizures, altered mentation, consciousness disturbances and focal neurological signs. Initially described in patients with pre and eclampsia, severe hypertension, posterior reversible encephalopathy syndrome can occur in other clinical conditions such as infection, sepsis, shock, cancer chemotherapy, autoimmune diseases and hypercalcemia. Pathogenesis of brain lesions in PRES is not full understood and two opposite theories have been proposed. Both models are based on the central role of hypertension. According to the first theory, hypertension could cause a breakdown of the autoregulatory system in cerebral circulation, leading to brain edema. The second theory suggests that hypertension causes activation of autoregulatory system, which finally results in a vasoconstriction of brain vessels with hypoperfusion, ischemia and subsequent fluid leakage. However a large number of patients, with PRES, doesn't show hypertension. We here describe the hypothesis of the crucial role of endothelial dysfunction and activation in PRES pathogenesis. Our hypothesis offers a common pathogenetic mechanism in which every PRES-related condition can be set. In our model, the activation of immune system and the consequent endothelial activation start a molecular cascade which finally causes the production of molecules which alter the normal homeostasis of blood-brain barrier. This alteration consists in a weakening of brain vessel tight junctions, which allows fluid leakage and edema. In this scenario, hypertension would be an epiphenomenon of the underlying mechanism and not the cause and, for this reason, it can be present or not in PRES.