Minerva anestesiologica
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Minerva anestesiologica · Feb 2019
ReviewThinking outside the box; off-label use of the Bispectral Index (BIS) within context and limitations for conditions other than depth of anesthesia. Light and shadow of the BIS.
Numerous articles appeared in literature using brain function monitors (BFM), such as Bispectral Index (BIS) to assess cerebral cognitive conditions not related to depth of anesthesia. BIS cannot be considered a "true" reflection of the electroencephalography (EEG) signal nor an independent measure of brain function. BIS algorithm was retrospectively derived from EEG changes with incremental doses of γ-amino butyric acid (GABA)ergic anesthetic agents while measuring 3 descriptors. ⋯ Could we use BIS monitor outside the scope of the operating room to "grade" other EEG conditions? Actually the answer to that seems to be a "very cautious" yes. Because BIS is a rather appealing scale from 100 to 0, it is tempting to find numerical cut-off values for conditions that are already clinically graded like West Haven hepatic encephalopathy. Having said that I strongly argue against going as far as using BIS in Critical Care Unit (CCU) setting, there are too much heterogeneity and many disease states in the CCU patients, other than sedatives /hypnotics, that would strongly influence BIS values, in effect rendering BIS not only useless most of the time but can also be misleading.
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Minerva anestesiologica · Feb 2019
ReviewWhy don't multicenter randomized controlled trials (RCT) confirm the positive findings of single center RCTs in acute care? (Zeno's Paradox of the Tortoise and Achilles revisited).
It is a common observation that many multicenter randomized controlled trials (mRCT) performed in critically ill patients do not achieve the positive findings often seen in single center studies (sRCT). This has, of course, relevant consequences for clinical practice, as mRCTs have higher scientific validity compared to sRCTs. The aim of this manuscript was to review and discuss the several potential causes of this phenomenon and to relate them to the future of mRCTs in critical care medicine. ⋯ However, sRCTs are more prone to several bias compared to mRCTs, such as local effect bias, selection and performance bias, detection and reporting bias, analysis and attrition bias, concomitant therapy bias, low fragility index and publication bias. In this sense, it is high time the critical care community should see the positive findings of sRTCs with a very high level of scientific caution, unless they are confirmed by mRCTs. MRCTs represent the final step of the process of evidence-based medicine and in the end (however slowly and painfully) such evidence catches up with sRCT and truly helps changes practice worldwide.
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Minerva anestesiologica · Jan 2019
ReviewA year in review in Minerva Anestesiologica 2018. Critical care. Experimental and clinical studies.
Abstract
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Minerva anestesiologica · Jan 2019
ReviewChoosing wisely: what's the actual role of antimicrobial stewardship in intensive care units?
More than two-thirds of critically ill patients receive an antimicrobial therapy with a percentage between 30% and 50% of all prescribed antibiotics reported to be unnecessary, inappropriate or misused. Since inappropriate prescription of antibiotic drugs concurs to dissemination of the multidrug resistant organisms, a reasoned antibiotics use is crucial especially in Intensive Care Unit (ICU), where up to 60% of the admitted patients develops an infection during their ICU stay. ⋯ Specific interventions, designed tacking into account the peculiarities of the ICU setting, are hence necessary to set-up an "in-ICU-stewardship," including prompt identification of infected patients, selection of appropriate empiric treatments, optimization of dosing and route of administration, improvement of diagnostic techniques, early de-escalation to achieve shorter duration and avoid unnecessary therapies. The present narrative review summarizes the "state of art" about AS programmes and discusses the effects of the interventions possibly applied in ICU setting to optimize the patient's treatment, reduce the micro-organisms resistance and contain the hospital resources utilization.