Prospective multicenter study of heart rate variability with ANI monitor as predictor of mortality in critically ill patients with COVID-19.

The purpose of this study is to demonstrate that the most critically ill patients with COVID-19 have greater autonomic nervous system dysregulation and assessing the heart rate variability, allows us to predict severity and 30-day mortality. This was a multicentre, prospective, cohort study. Patients were divided into two groups depending on the 30-day mortality. The heart rate variability and more specifically the relative parasympathetic activity (ANIm), and the SDNN (Energy), were measured. To predict severity and mortality multivariate analyses of ANIm, Energy, SOFA score, and RASS scales were conducted. 112 patients were collected, the survival group (n = 55) and the deceased group (n = 57). The ANIm value was higher (p = 0.013) and the Energy was lower in the deceased group (p = 0.001); Higher Energy was correlated with higher survival days (p = 0.009), and a limit value of 0.31 s predicted mortalities with a sensitivity of 71.9% and a specificity of 74.5%. Autonomic nervous system and heart rate variability monitoring in critically ill patients with COVID-19 allows for predicting survival days and 30-day mortality through the Energy value. Those patients with greater severity and mortality showed higher sympathetic depletion with a predominance of relative parasympathetic activity.

Impacts of intrathecal fentanyl on the incidence of postoperative nausea/vomiting: Systematic review and meta-analysis of randomized studies.

Post-operative nausea and vomiting (PONV) is an event of multifactorial origin with an incidence of 30% in the general population. Opioids such as fentanyl are being used as adjuvant to local anesthetic for its antiemetic effect. In this context, with this study we aimed to evaluate the impact of spinal fentanyl as an adjuvant on the incidence of PONV compared with a placebo, and shivering. A systematic search of randomized controlled trials that evaluated the use of spinal fentanyl in the prevention of PONV and shivering was conducted in different databases, of which 32 studies met the inclusion criteria. A total of 2116 patients scheduled for various surgeries, including cesarean section, orthopedic surgery in the lower limb, hysterectomy, and transurethral resection of the prostate, were included in the final analysis. The meta-analysis estimated the relative risk of incidence of PONV in the first 24 hours after surgery and secondary outcomes included the shivering symptom. The use of intrathecal fentanyl was associated with lower incidence of PONV, but not statistically significant when compared to the placebo (RR: 0.74 CI95%: 0.55-1.01 P = 0.06). Subgroup analysis showed a statistically significant reduction in PONV incidences with lower doses between 10 and 15 µg (RR: 0.44 CI95%: 0.35-0.55 P < 0.00001, I2 = 0%) but not with higher doses 20-25 µg. Secondary outcomes showed a decrease in incidence with the use of fentanyl vs the placebo (RR: 0.49, CI95% 0.33-0.72 P = 0.0003). Current evidence shows that the use of spinal fentanyl decreases the incidence of PONV, an effect favored using low doses.

Patient Characteristics Influencing Adherence to Enhanced Recovery Protocols for Colorectal Surgery: a Multicentric Prospective Study.

BACKGROUND: High compliance within enhanced recovery protocols is associated with lower complication rates. Understanding which clinical characteristics make patients more prone to fail adequate adherence to enhanced recovery after surgery guidelines are essential to improve quality care. Our aim was to identify patient characteristics that influence adherence to enhanced recovery protocols in colorectal surgery. METHODS: A total of 1041 patients underwent colorectal surgery under ERPs from September 2017 through December 2017 across 21 institutions in Spain. Demographic, medical, and surgical characteristics of the patients included were extracted to determine their influence on the adherence to enhanced recovery protocols. High adherence was defined as ≥ 73% (median). A univariate analysis was performed initially, followed by multivariable logistic regression analysis. RESULTS: Over 85% of the patients underwent colorectal surgery for cancer resection, of which 12% had metastatic disease. In multivariable model, the presence of coronary artery disease (aOR 1.79, 95% CI 1.12-2.96, p = 0.045) was significantly associated with high adherence to enhanced recovery protocols, while preoperative hypoalbuminemia (aOR 0.55, 95% CI 0.37-0.82, p = 0.003), indication for ostomy (aOR 0.55, 95% CI 0.4-0.75, p < 0.001), and preoperative transfusion (aOR 0.48, 95% CI 0.26-0.91, p = 0.02) were associated with lower adherence. CONCLUSION: In this study, patients that had preoperative transfusions, preoperative hypoalbuminemia, and indication for ostomy were more likely to receive care with less adherence to enhanced recovery protocols elements, while patients with coronary artery disease were more likely to receive more enhanced recovery protocols elements during their hospitalization.

Corrected and Republished: Impacts of intrathecal fentanyl on the incidence of postoperative nausea/vomiting: Systematic review and meta-analysis of randomized studies.

Post-operative nausea and vomiting (PONV) is an event of multifactorial origin with an incidence of 30% in the general population. Opioids such as fentanyl are being used as adjuvant to local anesthetic for its antiemetic effect. In this context, with this study we aimed to evaluate the impact of spinal fentanyl as an adjuvant on the incidence of PONV compared with a placebo, and shivering. A systematic search of randomized controlled trials that evaluated the use of spinal fentanyl in the prevention of PONV and shivering was conducted in different databases, of which 32 studies met the inclusion criteria. A total of 2116 patients scheduled for various surgeries, including cesarean section, orthopedic surgery in the lower limb, hysterectomy, and transurethral resection of the prostate, were included in the final analysis. The meta-analysis estimated the relative risk of incidence of PONV in the first 24 hours after surgery and secondary outcomes included the shivering symptom. The use of intrathecal fentanyl was associated with lower incidence of PONV, but not statistically significant when compared to the placebo (RR: 0.74 CI95%: 0.55-1.01 P = 0.06). Subgroup analysis showed a statistically significant reduction in PONV incidences with lower doses between 10 and 15 µg (RR: 0.44 CI95%: 0.35-0.55 P < 0.00001, I2 = 0%) but not with higher doses 20-25 µg. Secondary outcomes showed a decrease in incidence with the use of fentanyl vs the placebo (RR: 0.49, CI95% 0.33-0.72 P = 0.0003). Current evidence shows that the use of spinal fentanyl decreases the incidence of PONV, an effect favored using low doses.

Clinical Applications of Ultrasonography in Neurocritically Ill Patients.

Ultrasonography is part of the multimodal monitoring of the neurocritical patient. Through transcranial color Doppler ultrasound, carotid-color Doppler ultrasound, and ocular ultrasound it is possible to diagnose and monitor a multitude of pathological conditions, such as cerebrovascular events, vasospasm, Terson syndrome, carotid atheromatosis, and brain death. Furthermore, these techniques enable the monitoring of the intracranial pressure, the cerebral perfusion pressure, and the midline deviation, which allows us to understand the patient's neurocritical pathology at their bedside, in a noninvasive way. Although none of these tools have yet been shown to improve patient prognosis, the dissemination of knowledge and management of neurovascular ultrasonography could significantly improve the comprehensive management of neurocritical patients.

¿Puede el fentanilo intratecal disminuir la aparición de náuseas y vómito en comparación con ondansetrón intravenoso durante cesárea electiva? Revisión sistemática de la literatura y metaanálisis / Can intrathecal fentanyl decrease the occurrence of nausea and vomiting compared with intravenous ondansetron during elective cesarean section? Literature Systematic review and meta-analysis

Elective caesarean section is one of the surgeries with the highest intraoperative incidence of nausea, retching and vomiting (IONV), due, among other causes, to the use of anesthetics during the procedure. Some clinical trials have associated the use of low-dose intrathecal (IT) fentanyl with a lower incidence of nausea, retching and vomiting compared to other anesthetics used during caesarean sections. In this context, the objective of this meta-analysis was to evaluate the decrease in the appearance of nausea and vomiting during elective caesarean section with the application of IT fentanyl when compared with the use of intravenous ondansetron (EV). A systematic search was conducted in the main databases (PubMed, EMBASE, ClinicalTrials.gov, Cochrane Library and Google Scholar) for Randomized Clinical Trials (RCTs) that evaluated the use of IT fentanyl compared to ondansetron EV to decrease the occurrence and incidence of IONV during elective caesarean section. The meta-analysis showed a reduction in the incidence of nausea (RR 0.52, 95% CI 0.29-0.93, P = 0.03), gagging (RR 0.39, 95% CI 0, 18-0.88, P = 0.02) and vomiting (RR 0.26, 95% CI 0.11-0.64, P = 0.003) in the group of patients treated with IT fentanyl compared to the group treated with EV ondansetron. From the results, it is suggested that the administration of 12.5 to 20 µg of IT fentanyl may decrease the incidence of IONV in patients undergoing elective caesarean section, although the importance of more high-quality RCTs is highlighted.

La cesárea electiva es una de las cirugías con mayor incidencia intraoperatoria de náuseas, arcadas y vómito (NAV), debido entre otras causas, al uso de anestésicos durante el procedimiento. Algunos ensayos clínicos han asociado el uso de fentanilo intratecal (IT) a dosis bajas con una menor incidencia de náuseas, arcadas y vómito en comparación con otros anestésicos usados durante las cesáreas. En este contexto el objetivo de este metaanálisis fue evaluar la disminución en la aparición de náuseas y vómito durante cesárea electiva con la aplicación de fentanilo IT al compararlo con el uso de ondansetrón intravenoso (EV). Se realizó una búsqueda sistemática en las principales bases de datos (PubMed, EMBASE, ClinicalTrials.gov, Cochrane Library y Google Scholar) para ensayos clínicos aleatorizados (ECA) que evaluaron el uso del fentanilo IT en comparación con ondansetrón EV para disminuir la aparición e incidencia de IONV durante cesárea electiva. En el metaanálisis se evidenció una reducción en la incidencia de náusea (RR 0,52, 95% IC 0,29-0,93, P = 0,03), arcada (RR 0,39, 95% IC 0,18-0,88, P = 0,02) y vómito (RR 0,26, 95% IC 0,11-0,64, P = 0,003) en el grupo de pacientes tratados con fentanilo IT comparado con el grupo tratado con ondansetrón EV. A partir de los resultados, se sugiere que la administración de 12,5 a 20 µg de fentanilo IT puede disminuir la incidencia de NAV intraoperatorias en pacientes sometidas a cesárea electiva, aunque se resalta la importancia de más ECA de alta calidad.

Ultrasonography and electrical impedance as assessment tools for critical patients in times of COVID-19 / Ultrasonografía e impedancia eléctrica como herramientas de evaluación para pacientes críticos en tiempos de COVID-19

In the COVID-19 outbreak we are living currently, the lung ultrasound can be considered as an advantageous tool to examine patients as it can be easily used by a maximum of two trained operators, at the bedside. Likewise, the Electrical impedance tomography is useful to monitor and optimize the patient's ventilation strategies in real time. Here, we present the impact and implication of ultrasonography and electrical impedance as management tools for treating critical patients in times of COVID-19. Clinical Ultrasound has been used more and more in developing countries in Latin America such as Colombia, Argentina, and Uruguay among others, however it is still underutilized due to different issues amongst we found the absence of equipment or the lack of basic training from the medical staff and poor skills to use the machines despite their availability. The use of lung ultrasound and the Electrical impedance tomography is highlighted as a safe manner to manage COVID-19 patients, not as a replacement of a CT scan, but as an easy-to-use and fast complementary tool.

En la pandemia de COVID-19 que se vive actualmente, la ultrasonografía pulmonar puede considerarse como una herramienta ventajosa para examinar a los pacientes, ya que puede ser utilizada fácilmente al pie de cama por un máximo de dos operadores capacitados. Asimismo, la tomografía de impedancia eléctrica es útil para monitorizar y optimizar las estrategias de ventilación del paciente en tiempo real. Aquí se presenta el impacto y la implicación de la ecografía y la impedancia eléctrica como herramientas de manejo para el tratamiento de pacientes críticos en tiempos de COVID-19. El ultrasonido clínico se ha utilizado cada vez más en países en vías de desarrollo de América Latina como Colombia, Argentina y Uruguay entre otros, sin embargo, aún está infrautilizado debido a diferentes cuestiones entre las que encontramos la ausencia de equipos o la falta de formación básica del personal médico y la poca habilidad para usar las máquinas a pesar de su disponibilidad. Se destaca el uso de la ultrasonografía pulmonar y la tomografía de impedancia eléctrica como una forma segura de manejar a los pacientes con COVID-19, no como un reemplazo de una tomografía computarizada, sino como una herramienta complementaria rápida y fácil de usar.

IPACK block: emerging complementary analgesic technique for total knee arthroplasty / Bloqueo IPACK: Complemento analgésico emergente en artroplastia de rodilla

Abstract Introduction: Pain control in total knee arthroplasty (TKA) is a determining factor in the patient's rehabilitation process. With conventional peripheral blocking techniques for the posterior compartment, foot drop, and distal motor deficit have been reported. The infiltration between popliteal artery and capsule of the knee (IPACK) block is a promising emerging analgesic technique. Objective: To describe analgesic control, opioid consumption, and mobility of patients scheduled for TKA using IPACK block as adjunct analgesic to the femoral block. Methods: We conducted a prospective observational cohort study over a 6-month period in adults taken to TKA. Sociodemographic and anthropometric characteristics, laterality, postoperative pain, and opioid consumption, patient and surgeon satisfaction (Likert), postoperative nausea and vomiting, and walk in the first 24hours, were evaluated and reported with a descriptive analysis. Results: Twenty-seven patients taken to TKA received an IPACK block. The pain score remained in a mild level during the 48 hours of evaluation. In 73% of the cases, an opioid rescue dose was not required; 81% of the patients managed to walk in the first 24 hours. Conclusion: The IPACK block, combined with femoral block and neuraxial anesthesia, turn out to be an excellent analgesic strategy for TKA, achieving adequate pain management, prompt rehabilitation, and early ambulation of the patient.

Resumen Introducción: El control del dolor en artroplastia total de rodilla (ATR) es determinante en el proceso de rehabilitación del paciente. Con las técnicas convencionales de bloqueo periférico para el compartimiento posterior se ha reportado pie caído y déficit motor distal. Por lo anterior, se decidió evaluar en una cohorte las cualidades analgésicas del bloqueo IPACK como una técnica emergente prometedora. Objetivo: Describir el control analgésico, consumo de opioides y movilidad de pacientes programados para ATR usando bloqueo IPACK como adyuvante analgésico al bloqueo femoral. Métodos: Se realizó un estudio de cohorte prospectivo, en adultos llevados a ATR, durante 6 meses. Se evaluaron las características sociodemográficas, antropométricas, lateralidad, dolor postopera torio y consumo de opioides, satisfacción del paciente y del cirujano, náuseas y vómito postoperatorio, caminata en las primeras 48 h. Se informar los resultados de forma descriptiva. Resultados: En total, 27 pacientes a quienes se les realizó ATR obtuvieron bloqueo IPACK. La puntuación del dolor se mantuvo en una escala leve en un rango de 1-3 durante las 48 horas de seguimiento. En el 73% de los casos no se requirió una dosis de opioide de rescate. El 81% de los pacientes logró caminar en las primeras 24 horas. Conclusión: El IPACK, combinado con el bloqueo femoral y la anestesia neuroaxial, resultan ser una excelente estrategia analgésica para logar un adecuado control del dolor en ATR, pronta rehabilitación y deambulación temprana del paciente.

¿Puede el fentanilo intratecal disminuir la aparición de náuseas y vómito en comparación con ondansetrón intravenoso durante cesárea electiva? Revisión sistemática de la literatura y metaanálisis / Can intrathecal fentanyl decrease the occurrence of nausea and vomiting compared with intravenous ondansetron during elective cesarean section? Literature Systematic review and meta-analysis

Elective caesarean section is one of the surgeries with the highest intraoperative incidence of nausea, retching and vomiting (IONV), due, among other causes, to the use of anesthetics during the procedure. Some clinical trials have associated the use of low-dose intrathecal (IT) fentanyl with a lower incidence of nausea, retching and vomiting compared to other anesthetics used during caesarean sections. In this context, the objective of this meta-analysis was to evaluate the decrease in the appearance of nausea and vomiting during elective caesarean section with the application of IT fentanyl when compared with the use of intravenous ondansetron (EV). A systematic search was conducted in the main databases (PubMed, EMBASE, ClinicalTrials.gov, Cochrane Library and Google Scholar) for Randomized Clinical Trials (RCTs) that evaluated the use of IT fentanyl compared to ondansetron EV to decrease the occurrence and incidence of IONV during elective caesarean section. The meta-analysis showed a reduction in the incidence of nausea (RR 0.52, 95% CI 0.29-0.93, P = 0.03), gagging (RR 0.39, 95% CI 0, 18-0.88, P = 0.02) and vomiting (RR 0.26, 95% CI 0.11-0.64, P = 0.003) in the group of patients treated with IT fentanyl compared to the group treated with EV ondansetron. From the results, it is suggested that the administration of 12.5 to 20 µg of IT fentanyl may decrease the incidence of IONV in patients undergoing elective caesarean section, although the importance of more high-quality RCTs is highlighted.

La cesárea electiva es una de las cirugías con mayor incidencia intraoperatoria de náuseas, arcadas y vómito (NAV), debido entre otras causas, al uso de anestésicos durante el procedimiento. Algunos ensayos clínicos han asociado el uso de fentanilo intratecal (IT) a dosis bajas con una menor incidencia de náuseas, arcadas y vómito en comparación con otros anestésicos usados durante las cesáreas. En este contexto el objetivo de este metaanálisis fue evaluar la disminución en la aparición de náuseas y vómito durante cesárea electiva con la aplicación de fentanilo IT al compararlo con el uso de ondansetrón intravenoso (EV). Se realizó una búsqueda sistemática en las principales bases de datos (PubMed, EMBASE, ClinicalTrials.gov, Cochrane Library y Google Scholar) para ensayos clínicos aleatorizados (ECA) que evaluaron el uso del fentanilo IT en comparación con ondansetrón EV para disminuir la aparición e incidencia de IONV durante cesárea electiva. En el metaanálisis se evidenció una reducción en la incidencia de náusea (RR 0,52, 95% IC 0,29-0,93, P = 0,03), arcada (RR 0,39, 95% IC 0,18-0,88, P = 0,02) y vómito (RR 0,26, 95% IC 0,11-0,64, P = 0,003) en el grupo de pacientes tratados con fentanilo IT comparado con el grupo tratado con ondansetrón EV. A partir de los resultados, se sugiere que la administración de 12,5 a 20 µg de fentanilo IT puede disminuir la incidencia de NAV intraoperatorias en pacientes sometidas a cesárea electiva, aunque se resalta la importancia de más ECA de alta calidad.

Perioperative duloxetine for acute postoperative analgesia: a meta-analysis of randomized trials.

BACKGROUND: Multimodal analgesia is a fundamental part of modern surgery and enhanced recovery pathways. Duloxetine, a serotonin and norepinephrine reuptake inhibitor, has been validated for the treatment of chronic neuropathic pain. The evidence for duloxetine as an adjunct for the treatment of acute postoperative pain remains controversial. We conducted a meta-analysis to determine the efficacy of duloxetine in the acute perioperative setting. METHODS: A literature search was conducted in the major databases (PubMed, EMBASE and Google Scholar) for randomized controlled trials (RCTs) evaluating duloxetine compared with placebo control for acute postoperative pain. The primary outcome was postoperative pain assessed at 2, 4, 6, 24 and 48 hours time frames. Secondary outcomes included postoperative opioid administration, as well as side effects, such as postoperative nausea/vomiting (PONV), pruritus, dizziness and headache. RESULTS: 574 patients (n=9 RCTs) were included in the analysis, divided between duloxetine (n=285 patients) and placebo (n=289 patients). Duloxetine use was associated with a significant reduction in pain scores as early as 4 (mean difference (MD) -0.9, 95% CI -1.33 to -0.47) and as late as 48 (MD -0.94, 95% CI -1.56 to -0.33) hours postoperatively compared with placebo. In addition, duloxetine was associated with a significant reduction in opioid administration at 24 (standardized MD (SMD) -2.24, 95% CI -4.28 to -0.19) and 48 (SMD -2.21, 95% CI -4.13 to -0.28) hours as well as a significant reduction in PONV (risk ratio 0.69, 95% CI 0.49 to 0.95, p=0.03) compared with placebo. There was no difference between groups in other side effects. CONCLUSION: Duloxetine, a non-opioid neuromodulator, may provide efficacy for the treatment of acute perioperative pain. Additional prospective studies are required to establish optimal perioperative dosing regimens, role in the setting of a comprehensive multimodal analgesic plan and impact on chronic postsurgical pain. PROSPERO REGISTRATION NUMBER: CRD42019121416.