Inferior vena cava distensibility during pressure support ventilation: a prospective study evaluating interchangeability of subcostal and trans­hepatic views, with both M­mode and automatic border tracing.

The Inferior Vena Cava (IVC) is commonly utilized to evaluate fluid status in the Intensive Care Unit (ICU),with more recent emphasis on the study of venous congestion. It is predominantly measured via subcostal approach (SC) or trans-hepatic (TH) views, and automated border tracking (ABT) software has been introduced to facilitate its assessment. Prospective observational study on patients ventilated in pressure support ventilation (PSV) with 2 × 2 factorial design. Primary outcome was to evaluate interchangeability of measurements of the IVC and the distensibility index (DI) obtained using both M-mode and ABT, across both SC and TH. Statistical analyses comprised Bland-Altman assessments for mean bias, limits of agreement (LoA), and the Spearman correlation coefficients. IVC visualization was 100% successful via SC, while TH view was unattainable in 17.4% of cases. As compared to the M-mode, the IVC-DI obtained through ABT approach showed divergences in both SC (mean bias 5.9%, LoA -18.4% to 30.2%, ICC = 0.52) and TH window (mean bias 6.2%, LoA -8.0% to 20.4%, ICC = 0.67). When comparing the IVC-DI measures obtained in the two anatomical sites, accuracy improved with a mean bias of 1.9% (M-mode) and 1.1% (ABT), but LoA remained wide (M-mode: -13.7% to 17.5%; AI: -19.6% to 21.9%). Correlation was generally suboptimal (r = 0.43 to 0.60). In PSV ventilated patients, we found that IVC-DI calculated with M-mode is not interchangeable with ABT measurements. Moreover, the IVC-DI gathered from SC or TH view produces not comparable results, mainly in terms of precision.

Poland's first vascular access team 3-year analysis: Insights and learnings.

BACKGROUND: During the COVID-19 pandemic, Poland saw a surge in interest in midline catheters (MCs) and Long Peripheral Catheters (LPCs) for intravenous therapy. Before this, MCs were not extensively utilised in the country, and there was no formally established Polish vascular access team. MCs, which have been used for years in many countries, are now becoming increasingly common in Poland. This study aimed to analyse the use of MCs in a 3-year perspective of their introduction in daily clinical practice based on a nurse-led Vascular Access Team (VAT). METHODS: The records of adult patients who received intravenous therapy with 727 MCs and 293 LPCs from January 2021 to December 2023 at the University Clinical Centre of the Medical University of Warsaw were analysed. RESULTS: The main indication for cannulation was expected intravenous therapy over 5 days (81.66%, n = 833), of which 71.37% (n = 728) of patients in this group had concomitant difficult intravenous access (DIVA). Over 6 years, centrally inserted central catheters (CICCs) inserted due to DIVA were reduced from n = 108 in 2017 to n = 18 in 2023. The end of intravenous therapy was the reason for the removal of 64.6% of catheters (n = 659), including death and switch to CICCs as well. Complications leading to premature removal accounted for 31.2%, such as: occlusion (14.6%), patient self-removal (7.1%) and thrombosis (3.43%). CONCLUSIONS: The introduction of MCs as a possible option for peripheral venous access reduces the use of CVCs. Developing MCs programmes should be based on investing in staff competencies, which increases success rates. The nurses and physicians should be trained in infusion care to achieve better results in the use of MCs and LPCs. Increasing the competence of nurses in Poland is necessary for the implementation of full-service and top-level functioning of VAT.

Pyruvate dehydrogenase-E1α deficiency presenting as generalized dystonia: A genetic diagnosis with important clinical implications.

Pyruvate dehydrogenase complex (PDC) deficiency is a genetic mitochondrial disease mostly associated with severe lactic acidosis, rapid progression of neurological symptoms and death during childhood. We present a 33-year-old male with PDC deficiency caused by a Val262Leu mutation in PDHA1gene. He demonstrated generalized dystonia affecting trunk and upper extremities and paraparesis as the most significant features, with onset of symptoms at age 8. Brain MRI showed bilaterally increased signal within the globus pallidus, typical of Leigh syndrome. A periodic lactate increase in serum and cerebrospinal fluid was detected. We describe a case of pyruvate dehydrogenase deficiency being diagnosed only 25 years after the onset of symptoms and highlight PDHC deficiency as a possible cause of treatable dystonia in childhood, which may respond well to thiamine and levodopa treatment.

Mortality in patients with septic cardiomyopathy identified by longitudinal strain by speckle tracking echocardiography: An updated systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: Septic cardiomyopathy is associated with poor outcomes but its definition remains unclear. In a previous meta-analysis, left ventricular (LV) longitudinal strain (LS) showed significant prognostic value in septic patients, but findings were not robust due to a limited number of studies, differences in effect size and no adjustment for confounders. METHODS: We conducted an updated systematic review (PubMed and Scopus up to 14.02.2023) and meta-analysis to investigate the association between LS and survival in septic patients. We included studies reporting global (from three apical views) or regional LS (one or two apical windows). A secondary analysis evaluated the association between LV ejection fraction (EF) and survival using data from the selected studies. RESULTS: We included fourteen studies (1678 patients, survival 69.6%) and demonstrated an association between better performance (more negative LS) and survival with a mean difference (MD) of -1.45%[-2.10, -0.80] (p < 0.0001;I2 = 42%). No subgroup differences were found stratifying studies according to number of views used to calculate LS (p = 0.31;I2 = 16%), severity of sepsis (p = 0.42;I2 = 0%), and sepsis criteria (p = 0.59;I2 = 0%). Trial sequential analysis and sensitivity analyses confirmed the primary findings. Grade of evidence was low. In the included studies, thirteen reported LVEF and we found an association between higher LVEF and survival (MD = 2.44% [0.44,4.45]; p = 0.02;I2 = 42%). CONCLUSIONS: We confirmed that more negative LS values are associated with higher survival in septic patients. The clinical relevance of this difference and whether the use of LS may improve understanding of septic cardiomyopathy and prognostication deserve further investigation. The association found between LVEF and survival is of unlikely clinical meaning. REGISTRATION: PROSPERO number CRD42023432354.

Critical care echocardiography: barriers, competencies and solutions. A survey of over 600 participants.

INTRODUCTION: Critical care echocardiography (CCE) is at the core of point-of-care ultrasound (POCUS), and although a list of the necessary competencies has been created, most European countries do not have established training programmes to allow intensivists to gain such competencies. To address barriers to the implementation of CCE, we conducted an online European survey, and analysed the current barriers to this with the aim of providing novel, modern solutions to them including environmental considerations. MATERIAL AND METHODS: A 23-item survey was distributed via email with support from the European Society of Intensive Care Medicine, national societies, and social media. Questions focused on bedside CCE prevalence, competencies, and barriers to its implementation. An additional questionnaire was sent to recognised experts in the field of CCE. RESULTS: A total of 644 responses were recorded. Most respondents were anaesthesia and intensive care physicians [79% ( n = 468)], and younger, with 56% in their first five years after specialization ( n = 358). Most respondents [92% ( n = 594)] had access to an ultrasound machine with a cardiac probe, and 97% ( n = 623) reported being able to acquire basic CCE windows. The most common barriers identified by respondents to the implementation of CCE in practice were a lack of sufficient experience/skill [64% ( n = 343)], absence of formal qualifications [46% ( n = 246)] and lack of a mentor [45% ( n = 243)]. Twenty-eight experts responded and identified a lack of allocated time for teaching as a main barrier [60% ( n = 17)]. CONCLUSIONS: We found that bedside CCE is perceived as a crucial skill for intensive care medicine, especially by younger physicians; however, there remain several obstacles to training and implementation. The most important impediments reported by respondents were inadequate training, absence of formal qualifications and difficulties in finding a suitable mentor.

Echocardiography and Ultrasound Committee statement for the accreditation programme in point-of-care ultrasonography in Poland.

Ultrasonography is becoming an essential part of the management of critically ill patients. There has been a sufficient body of evidence to support the incorporation of point-of-care ultrasound (POCUS) in anaesthesia and intensive care medicine training programme. Recently the European Society of Intensive Care Medicine reco-gnized POCUS as an essential skill for European Intensive Care Medicine specialists and updated Competency Based Training in Intensive Care (CoBaTrICe). Following European training standards, the Ultrasound and Echocardiography Committee of the Polish Society of Anaesthesiology and Intensive Therapy issued this Position Statement for recommendations for the accreditation process in POCUS in Poland.

Fatigue amongst anaesthesiology and intensive care trainees in Europe: A matter of concern.

BACKGROUND: There is a growing awareness of the effects of fatigue on trainee wellbeing and health. Trainees in anaesthesiology and intensive care work long hours, switching work schedules frequently with insufficient rest. This may have unwanted long-term effects on mental and physical health and emotional well being, resulting in burnout and affecting patient safety. OBJECTIVE: The study aimed to evaluate the prevalence, severity, causes and effects of work-related fatigue in trainees in anaesthesiology and intensive care. DESIGN: Online survey of trainees in anaesthesiology and intensive care. SETTINGS: A total of 31 countries within Europe were included in the survey. PARTICIPANTS: European anaesthesiology and intensive care trainees who responded to an invitation to take part by electronic mail or through social media. MAIN OUTCOME MEASURES: Responses from a 29-item online survey to assess the realities within European countries with regards to work-related fatigue. RESULTS: One thousand and two hundred trainees from 31 European countries answered the survey demonstrating that an alarming number of trainees were fatigued by their working patterns and night shifts. Trainees reported effects on personal well being, safe commuting and potential for clinical errors. Respondents described a lack of support from hospitals and management for recovery during and after night shifts. CONCLUSION: Fatigue among trainees in anaesthesiology and intensive care has a significant impact on their well being and potentially, on the incidence of clinical errors. Current measures from authorities and hospital management are not sufficient to prevent serious fatigue, and therefore a fatigue risk management system should be considered. Failure to address this issue might lead to a further decline in trainees' wellbeing, their capacity to work in the speciality in the future, and potentially increase patient care errors.

Real-Time Ultrasound Guidance as Compared With Landmark Technique for Subclavian Central Venous Cannulation: A Systematic Review and Meta-Analysis With Trial Sequential Analysis.

OBJECTIVES: We conducted a systematic review and meta-analysis to assess the effectiveness of real-time dynamic ultrasound-guided subclavian vein cannulation as compared to landmark technique in adult patients. DATA SOURCES: PubMed and EMBASE until June 1, 2022, with the EMBASE search restricted to the last 5 years. STUDY SELECTION: We included randomized controlled trials (RCTs) comparing the two techniques (real-time ultrasound-guided vs landmark) for subclavian vein cannulation. The primary outcomes were overall success rate and complication rate, whereas secondary outcomes included success at first attempt, number of attempts, and access time. DATA EXTRACTION: Independent extraction by two authors according to prespecified criteria. DATA SYNTHESIS: After screening, six RCTs were included. Two further RCTs using a static ultrasound-guided approach and one prospective study were included in the sensitivity analyses. The results are presented in the form of risk ratio (RR) or mean difference (MD) with 95% CI. Real-time ultrasound guidance increased the overall success rate for subclavian vein cannulation as compared to landmark technique (RR = 1.14; [95% CI 1.06-1.23]; p = 0.0007; I2 = 55%; low certainty) and complication rates (RR = 0.32; [95% CI 0.22-0.47]; p < 0.00001; I2 = 0%; low certainty). Furthermore, ultrasound guidance increased the success rate at first attempt (RR = 1.32; [95% CI 1.14-1.54]; p = 0.0003; I2 = 0%; low certainty), reduced the total number of attempts (MD = -0.45 [95% CI -0.57 to -0.34]; p < 0.00001; I2 = 0%; low certainty), and access time (MD = -10.14 s; [95% CI -17.34 to -2.94]; p = 0.006; I2 = 77%; low certainty). The Trial Sequential Analyses on the investigated outcomes showed that the results were robust. The evidence for all outcomes was considered to be of low certainty. CONCLUSIONS: Real-time ultrasound-guided subclavian vein cannulation is safer and more efficient than a landmark approach. The findings seem robust although the evidence of low certainty.

Haemodynamic monitoring in acute heart failure - what you need to know.

Acute heart failure (AHF) is a sudden, life-threatening condition, defined as a gradual or rapid onset of symptoms and/or signs of HF. AHF requires urgent medical attention, being the most frequent cause of unplanned hospital admission in patients above 65 years of age. AHF is associated with a 4-12% in-hospital mortality rate and a 21-35% 1-year mortality rate post-discharge. Considering the serious prognosis in AHF patients, it is very important to understand the mechanisms and haemodynamic status in an individual AHF patient, thus preventing end-organ failure and death. Haemodynamic monitoring is a serial assessment of cardiovascular function, intended to detect physiologic abnormalities at the earliest stages, determine which interventions could be most effective, and provide the basis for initiating the most appropriate therapy and evaluate its effects. Over the past decades, haemodynamic monitoring techniques have evolved greatly. Nowadays, they range from very invasive to non-invasive, from intermittent to continuous, and in terms of the provided parameters. Invasive techniques contain pulmonary artery catheterization and transpulmonary thermodilution. Minimally invasive techniques include oesophageal Doppler and noncalibrated pulse wave analysis. Non-invasive techniques contain echocardiography, bioimpedance, and bioreactance techniques as well as non-invasive pulse contour methods. Each of these techniques has specific indications and limitations. In this article, we aimed to provide a pathophysiological explanation of the physical terms and parameters used for haemodynamic monitoring in AHF and to summarize the working principles, advantages, and disadvantages of the currently used methods of haemodynamic monitoring.

Agreement between subcostal and transhepatic longitudinal imaging of the inferior vena cava for the evaluation of fluid responsiveness: A systematic review.

PURPOSE: Assessment of fluid-responsiveness is a key aspect of daily management in critically ill patients. Non-invasive evaluation of the variation of inferior vena cava (IVC) diameter during ventilation may provide useful information. However, a standard sagittal IVC visualization from the subcostal (SC) region is not always feasible. An alternative method to visualize the IVC is a coronal trans-hepatic (TH) approach. MATERIALS AND METHODS: We performed a systematic search to explore the interchangeability of IVC evaluation with SC and TH views. We searched Medline and EMBASE to identify prospective studies. We did not consider the relationship between axial and sagittal visualization of the IVC. RESULTS: We included seven studies reporting data on IVC evaluation with both SC and TH IVC views. Four studies were conducted on spontaneously breathing patients/volunteers, two on fully mechanically ventilated patients, and one in a mixed population, with large heterogeneity regarding the analyses reported. Limits of agreement between SC and TH were large. Concordance of the IVC collapsibility/distensibility indices are not interchangeable between SC and TH view. Correlation between diameters measured with SC and TH approach and intra/inter-observer correlation produced variable results. CONCLUSIONS: An overview of the included studies suggests that longitudinal TH and SC assessment of IVC size and respiratory variation are not interchangeable. New studies with accurate data reporting and appropriate statistical analysis are needed to define proper cut-offs for fluid responsiveness when using TH approach for IVC visualization.

Reply to Sanfilippo et al. Caution Is Warranted When Assessing Diastolic Function Using Transesophageal Echocardiography. Comment on "Kyle et al. Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study. J. Clin. Med. 2021, 10, 5198".

We thank Sanfilippo and colleagues for their insightful comments about the assessment of diastolic function with transesophageal echocardiography (TEE) [...].

Removal of airway obstruction due to presence of blood clots and the role of tranexamic acid - case report.

During invasive mechanical ventilation, the physiological mechanisms of clearing secretions from the bronchial tree are impaired. Factors affecting this process include inhibition of the cough reflex and ciliary movement in the airways and the use of sedating drugs. The standard clinical practice is the suctioning of the residual secretions in the bronchial tree performed blindly with a suction catheter. Repeated introduction of the catheter may lead to mechanical injury of the respiratory tract mucosa [1].

Pre-operative platelet reactivity is a strong, independent predictor of bleeding complications after branched endovascular thoracoabdominal aortic aneurysm repair.

Endovascular aortic repair (EVAR) an alternative to open surgical repair of thoracoabdominal aortic aneurysm (TAAA). The effect of EVAR on platelet reactivity is unknown. We prospectively determined the effect of branched EVAR (bEVAR) on platelet reactivity in patients with TAAA, and evaluated the predictive value of preoperative platelet reactivity for post-operative bleeding in 50 consecutive patients undergoing elective bEVAR (mean age 70.9 ± 5.7 years, 66% male). Blood samples were collected within 24 hours before bEVAR, after bEVAR and at hospital discharge. Platelet reactivity was assessed with impedance aggregometry using ASPI, ADP and TRAP tests. Platelet reactivity decreased within 24 hours after bEVAR compared to the measurement before bEVAR in all tests (p ≤ 0.04), with a further decrease in hospital discharge in the ADP test (p = .004). Twenty-three patients experienced post-operative bleeding complications (transfusion ≥2 red blood cell [RBC] units). Preoperative platelet reactivity below the cutoff value of 30 AUC units predicted post-operative bleeding with 78% sensitivity and 59% specificity (p = .045). In the multivariable analysis, platelet reactivity was the only independent predictor of postoperative bleeding (OR 6.507, 95% CI 1.227-34.506, p = .028). We conclude that platelet reactivity decreases following bEVAR of TAAA and is a strong and independent predictor for postoperative bleeding complications.

How to Maintain Safety and Maximize the Efficacy of Cardiopulmonary Resuscitation in COVID-19 Patients: Insights from the Recent Guidelines.

Since December 2019, the novel coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has remained a challenge for governments and healthcare systems all around the globe. SARS-CoV-2 infection is associated with increased rates of hospital admissions and significant mortality. The pandemic increased the rate of cardiac arrest and the need for cardiopulmonary resuscitation (CPR). COVID-19, with its pathophysiology and detrimental effects on healthcare, influenced the profile of patients suffering from cardiac arrest, as well as the conditions of performing CPR. To ensure both the safety of medical personnel and the CPR efficacy for patients, resuscitation societies have published modified guidelines addressing the specific reality of the COVID-19 pandemic. In this review, we briefly describe the transmission and pathophysiology of COVID-19, present the challenges of CPR in SARS-CoV-2-infected patients, summarize the current recommendations regarding the algorithms of basic life support (BLS), advanced life support (ALS) and pediatric life support, and discuss other aspects of CPR in COVID-19 patients, which potentially affect the risk-to-benefit ratio of medical procedures and therefore should be considered while formulating further recommendations.

Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study.

Diastolic dysfunction is associated with major adverse outcomes following cardiac surgery. We hypothesized that multisystem endpoints of morbidity would be higher in patients with diastolic dysfunction. A total of 142 patients undergoing cardiac surgical procedures with cardiopulmonary bypass were included in the study. Intraoperative assessments of diastolic function according to the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines using transesophageal echocardiography were performed. Cardiac Postoperative Morbidity Score (CPOMS) on days 3, 5, 8, and 15; length of stay in ICU and hospital; duration of intubation; incidence of new atrial fibrillation; 30-day major adverse cardiac and cerebrovascular events were recorded. Diastolic function was determinable in 96.7% of the dataset pre and poststernotomy assessment (n = 240). Diastolic dysfunction was present in 70.9% (n = 88) of measurements before sternotomy and 75% (n = 93) after sternal closure. Diastolic dysfunction at either stage was associated with greater CPOMS on D5 (p = 0.009) and D8 (p = 0.009), with CPOMS scores 1.24 (p = 0.01) higher than in patients with normal function. Diastolic dysfunction was also associated with longer durations of intubation (p = 0.001), ICU length of stay (p = 0.019), and new postoperative atrial fibrillation (p = 0.016, OR (95% CI) = 4.50 (1.22-25.17)). We were able to apply the updated ASE/EACVI guidelines and grade diastolic dysfunction in the majority of patients. Any grade of diastolic dysfunction was associated with greater all-cause morbidity, compared with patients with normal diastolic function.

Postoperative Analgesia after Open Liver Surgery: Systematic Review of Clinical Evidence.

BACKGROUND: The existing recommendations for after open liver surgery, published in 2019, contains limited evidence on the use of regional analgesia techniques. The aim of this systematic review is to summarize available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery. METHODS: The PUBMED and EMBASE registries were used for the literature search to identify suitable studies. Keywords for the literature search were selected, with the authors' agreement, using the PICOS approach: participants, interventions, comparisons, outcomes, and study design. RESULTS: The literature search led to the retrieval of a total of 800 studies. A total of 36 studies including 25 RCTs, 5 prospective observational, and 7 retrospective observational studies were selected as suitable for this systematic review. CONCLUSIONS: The current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a "blended approach" which includes the use of systemic opioids and the infusion of NSAIDs along with regional techniques. This approach warrants the highest efficacy in terms of pain prevention, including the lower incretion of postoperative "stress hormones", and fewer side effects. Furthermore, concerns about the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out.