Minerva anestesiologica
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Minerva anestesiologica · Aug 2016
ReviewNeurally Adjusted Ventilatory Assist (NAVA) in children: a systematic review.
Application of mechanical ventilation in spontaneously breathing children remains a challenge for several reasons: mainly, small tidal volumes and high respiratory rates, especially in the presence of leaks, interfere with patient-ventilator synchrony. Leaks also cause unreliable monitoring of respiratory drive and respiratory rate. Furthermore, ventilator adjustment must take into account that infants have strong vagal reflexes, demonstrate central apnea and periodic breathing, with a high variability in breathing pattern. Neurally-adjusted ventilatory assist (NAVA) is a mode of ventilation whereby the timing and amount of ventilatory assist is controlled by the patient's neural respiratory drive. Since NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized assist, both invasively and non-invasively (NIV-NAVA), to follow the variability in breathing pattern, and to monitor patient respiratory drive, independent of leaks. ⋯ Evidence from a few trials suggests improved comfort, less sedation, and reduced length of stay.
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Minerva anestesiologica · Aug 2016
ReviewBleeding management in patients on new oral anticoagulants.
New oral anticoagulants (NOACs) have been developed in recent years and are increasingly used in clinical practice. Dabigatran is a direct thrombin (factor II) inhibitor while rivaroxaban, apixaban and edoxaban are direct inhibitors of factor Xa. The European Medicines Agency (EMA) currently approves these NOACs for different clinical uses. ⋯ NOACs show a similar or lower incidence of bleeding compared with conventional therapies in phase III trials. In case of bleeding, non-specific reversal strategies are available while specific reversal agents are the subject of ongoing trials. The role of this review is to summarize the current knowledge on NOCAs focusing on bleeding management in the perioperative period.
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Both the optimal caloric intake and the best route of delivery of nutrition to critically ill patients fuel an intense debate. Recently, two large pragmatic, multicenter, controlled, randomized clinical trials evaluated these issues in large cohorts of patients. In the CALORIES Study, the authors compared the parenteral with the enteral route as the most effective way to deliver early (e.g. within 36 hours from admission) nutritional support in critically ill adults in 33 English ICUs (N.=2388). ⋯ In the PermiT Study, 894 enterally fed patients from 7 ICUs were randomized to a restrictive strategy for non-protein calories (e.g. "permissive underfeeding" - 40% to 60% of energy expenditure) or to standard feeding (70 to 100% of energy expenditure) for up to 2 weeks. The primary endpoint (90-day mortality) was similar in both groups (27.2% in the permissive-underfeeding group and 28.9% in the standard-feeding group) without significant differences in feeding intolerance, diarrhea or ICU-acquired infections. We herein discuss how these studies should be interpreted with regard to the existing evidence and propose some practical suggestions for nutrition management in the critically ill patient.
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Minerva anestesiologica · Jul 2016
ReviewMortality as an endpoint in studies in critically ill patients: a reappraisal of definitions.
The recent literature was critically reviewed reporting heterogeneous mortality endpoints in studies involving critically ill patients. Both location- and duration-dependent definitions are used, more or less arbitrarily and sometimes with contradictory results. ⋯ There is no consensus on how mortality should be evaluated in the critically ill. It is argued that trialists should aim at uniformity in outcome evaluation of critical care, in order to allow comparison of studies, and that 28-day mortality should remain the primary endpoint for intervention studies.
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Minerva anestesiologica · Jun 2016
ReviewThe role of anesthesia in the prevention of postoperative delirium: a systematic review.
Postoperative delirium (POD) is defined as an acute neurologic insult characterized by changes in consciousness and cognition, altered perception and a fluctuating course. It leads to poor outcome and increased health care system costs. Considering its high incidence, up to 60%, and the lack of a first-choice treatment, prevention has become a priority. Our aim was to systematically review literature on POD prevention and to identify the role of anesthesia in this context. ⋯ Methodologically robust studies supporting strategies for preventing POD are still lacking. Based on our analysis, anesthesiologists should consider the intraoperative use of a depth of anesthesia monitor and the choice for a lighter sedation when possible. The administration of preventive medications should be considered very carefully. Considering the multifactorial nature of POD, however, the integration of effective preventive strategies into multidisciplinary programs is advisable and should be the target for future research.