Abstracts of the ICARE 2025 79th SIAARTI National Congress

This article has been updated to correct an affiliation in abstract A155 and A156.

Ambulatory anaesthesia and NORA

A1 Clinical innovation in cataract surgery: the impact of a new protocol on suspension rate

C. Ferrari¹, P. Vinciguerra², C. Nigro³, M. Vercesi⁴, R. Ferro⁴, P. Zanotti⁴, F. Zangrandi⁵, M. Lagioia⁶

¹Department of Anesthesia and Intensive Care, Humanitas Research Hospital, Rozzano (MI), Italy; ²Department of Ophthalmology, Humanitas Research Hospital, Rozzano (MI), Italy; ³Department of Non Medical Health Professions, Humanitas Research Hospital, Rozzano (MI), Italy; ⁴Operational Management, Humanitas Research Hospital, Rozzano (MI), Italy; ⁵Quality Direction, Humanitas Research Hospital, Rozzano (MI), Italy; ⁶Medical Direction, Humanitas Pio X, Milan, Italy

Correspondence: C. Ferrari

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A1

Background

Ophthalmic patients (pts) are often elderly with comorbidities that impact on well-being. There are few conditions or test Results that preclude cataract surgery (CS) and there are a few situations where CS should likely be delayed to allow optimization of comorbidities. Delayed CS relates to increased complications and worst quality of life. Cataract procedures are typically done with topical anesthesia and minimal or no sedation and have minimal physiological stress, no blood loss, fluid shifts or need to interrupt chronic medications. Despite this, literature highlights that medical testing and the use of medical consultations before CS continue to increase and many procedures are delayed for clinical reasons (CR), as hypertension (HI) and hyperglycemia (HG), that are not aligned to evidence anymore [1].

Materials and Methods

In our academic hospital more than 2000 pts undergo ambulatory CS every year. At the end of 2023 a multiprofessional team (ophthalmologists, anesthesiologists, nurses, operation and quality managers and the medical direction) started to review the existing perioperative protocol. A specific focus has been made on the criteria for delaying surgery and the suspension rate (SR) for all the scheduled pts has been calculated. The output of this teamwork led to a new institutional protocol that has been implemented at the beginning of 2024, published and fully adopted in May 2024, according to the most recent and updated guidelines and statements. A dashboard and weekly report have been created to monitor clinical and process indicators to enable process control after the implementantion of the new approach.

Results

SR 2023 (2089 pts): any cause 16,52%; CR 8,57% mainly HI and HG. SR 2024 (2460 pts): any cause 8,55%; CR 4,01%.SR 2025 (January-April 830 pts): any cause 6,75%; CR 3,61%.SR differences are statistically significative among the years, HI-HG as suspension criteria dropped closed to zero since 2024.

Conclusions

The adoption of a new perioperative protocol enabled better management of CS pts with a significative reduction in clinical unmotivated suspensions and delayed surgery.

References

1. Sweitzer B, Rajan N, Schell D, Gayer S, Eckert S, Joshi GP. Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg. 2021 Dec 1;133(6):1431-1436

Informed consent was obtained for the publication of this scientific article.

A2 The role of high-flow nasal cannula (HFNC) during bronchoscopy in adult patients with moderate respiratory dysfunctions

G. Cosenza, F. Coppolino, V. Pota, P. Sansone, M.B. Passavanti, M.C. Pace

Department of Woman,Child, General and Specialistic Surgery, University of Campania L.Vanvitelli, Naples, Italy

Correspondence: G. Cosenza

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A2

Background

Patients undergoing bronchoscopy are at risk of developing hypoxemia and serious respiratory complications. High-flow nasal cannula (HFNC) therapy has been proposed as a strategy to prevent hypoxemic events during bronchoscopy. The ability in maintaining oxygenation is given by the high oxygen flow which increases alveolar oxygen concentration and facilitates exchange through a concentration gradient. HFNC can also provide to remove carbon dioxide through a micro-ventilation mechanism via cardiogenic oscillations and gas mixture in the anatomical dead space (1). Further benefits in oxygenation and airway opening are given by a minimum positive pressure administered through the elevated oxygen flow.

Moderate respiratory dysfunction is characterized by a partial impairment of pulmonary function, leading to clinically detectable, though not severe, difficulties in ventilation and gas exchange. This condition may present reduced lung volumes, arterial hypoxemia, or hypercapnia, necessitating clinical evaluation.

Management strategies typically during bronchoscopy include supplemental oxygen or other supportive measures, although mechanical ventilation is generally not required. The objective of our case series is to evaluate the feasibility of HFNC and its ability to maintain adequate oxygenation and ventilation, ensuring patient safety during these procedures.

Materials and Methods

We conducted a case series evaluating the use of HFNC in patients with moderate respiratory dysfunction undergoing flexible bronchoscopy. Informed consent to publish had been obtained. In this context, we present six clinical cases of patients referred for diagnostic flexible bronchoscopy, all of whom exhibited moderate respiratory dysfunction, as evidenced by spirometry showing forced expiratory volume in one second (FEV1) between 50% and 80% of the predicted value. In these patients, we employed the AIRVO 3 high-flow oxygen system, along with end-tidal CO2 (EtCO2), monitoring, as part of their management. All patients had vital parameters monitored (blood pressure (BP), oxygen saturation (SpO2), heart rate (HR)) and intravenous drugs like propofol or midazolam were administered to achieve a Richmond Agitation Sedation Scale (RASS) score of −2/−3, maintaining spontaneous breathing. The primary outcome was to evaluate feasibility and safety of HFNC during bronchoscopy and secondary outcomes were determining respiratory and hemodynamic parameters, and the incidence of complications.

Results

HFNC could guarantee oxygenation and ventilation during the procedure. The median duration of the procedure was of 8 minutes. Vital parameters were maintained into the normal ranges, with a mean SpO2 during bronchoscopy of 97%, and mild increases in EtCO2 were corrected with high oxygen flows. No complications occurred.

Conclusions

HFNC are an interesting strategy in the airway management during bronchoscopy during tubeless anesthesia, guaranteeing both oxygenation and ventilation without complicacies.

References

1. Harde M, Patil M, Sahu A, Deshpande C, Akhilnath R, Pawara K. Transnasal humidified rapid insufflation ventilatory exchange (THRIVE): A game changer in apnoeic anaesthesia for shared airway procedures - A retrospective study. Indian J Anaesth. 2024 Dec;68(12):1075-1080. 10.4103/ija.ija_603_24. Epub 2024 Dec 3. PMID: 39944013; PMCID: PMC11812517.

Informed consent was obtained for the publication of this scientific article

A3 Are preoperative tests always necessary? A preliminary evaluation of a streamlined protocol for minor surgery

S. Cattin¹, R. Cescon^1,2, E. Da Tos^1,2, F. Baratto¹

¹Ospedali Riuniti Padova SUD, Monselice, Italy²Department of Medicine (DIMED), University of Padua, Padua, Italy

Correspondence: S. Cattin

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A3

Background

In our department, we have implemented an internal operating protocol for the preoperative management of patients undergoing minor ambulatory surgery. This protocol is based on the NICE guidelines (2016) [1] and the recommendations of the European Society of Anaesthesiology and Intensive Care (ESAIC) published in the European Journal of Anaesthesiology (2018) [2]. In accordance with these guidelines, routine preoperative investigations—such as blood tests, electrocardiograms (ECG), and chest X-rays—are not required for patients classified as ASA I–III. Exceptions are limited to: (1) patients receiving anticoagulant therapy (e.g., warfarin), for whom a prothrombin time (PT) test is mandated; and (2) patients with known cardiac disease, for whom an ECG is required only if one has not been performed in the previous 6–12 months.

Materials and Methods

We retrospectively reviewed data from patients evaluated at the pre-admission clinic between March and April 2025, all of whom underwent minor surgical procedures. Informed consent to publish had been obtained. A total of 111 patients were managed according to the new protocol, with no preoperative tests performed. As a control group, we analyzed data from 74 patients who underwent similar procedures in April 2024, prior to the implementation of the protocol, when routine testing was still in place. Surgical specialties included Ophthalmology, Orthopedics, Urology, and General Surgery.Adherence to the protocol was assessed as the proportion of patients managed without tests in each specialty: Ophthalmology (100%), Orthopedics (76.9%), Urology (35%), and General Surgery (35.9%).

Results

No statistically significant differences were observed in the incidence of postoperative complications between the two cohorts. In the protocol group (2025): complications were recorded in Ophthalmology (19.1%), Orthopedics (19.1%), General Surgery (17.6%), and Urology (6.5%). In the control group (2024): complication rates were Ophthalmology (26.1%), Urology (13.6%), General Surgery (11.1%), and Orthopedics (0%). All orthopedic complications were localized and would not have been foreseeable through preoperative testing.

Conclusions

The adoption of NICE [1] and ESAIC/EJA [2] guidelines via a structured internal protocol has proven to be a safe and effective strategy for preoperative assessment in minor surgery among ASA I–III patients. These preliminary findings, collected over a one-month period in a setting where the protocol has been active for approximately 18 months, suggest that selected patients can safely undergo surgery without routine preoperative investigations. While adherence varied among specialties, initial outcomes are promising and support the continued rationalization and optimization of preoperative testing practices.

References

1. National Institute for Health and Care Excellence (NICE). Routine preoperative tests for elective surgery. NICE Guideline NG45. London: NICE; 2016. Available at: https://www.nice.org.uk/guidance/ng45

2. Soares D, Wappler F, Thomsen C, et al.; ESA Guidelines Committee. European Society of Anaesthesiology and Intensive Care (ESAIC) guidelines for preoperative evaluation of adults undergoing elective noncardiac surgery. Eur J Anaesthesiol. 2018;35(6):407–465. 10.1097/EJA.0000000000000817

Informed consent was obtained for the publication of this scientific article.

General anesthesia and perioperative medicine

A4 Preliminary evaluation of anesthetic techniques in operative hysteroscopy

L. Vivona¹, G. Parisi², M. Marchese^1,2, E. Hila¹, P. Taccone¹

¹Department of Anaesthesia and Intensive Care, San Giuseppe Hospital, IRCCS MultiMedica, Milan, Italy; ²Department of Pathophysiology and Transplantation, University of Milan, Italy

Correspondence: L. Vivona

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A4

Background

Operative hysteroscopy is a common procedure and may be conducted using different anesthetic techniques. Aim of this study is to evaluate the effect of different anesthesiologic strategies on postoperative recovery and pain control.

Materials and Methods

This is a monocentric retrospective observational study conducted in the gynecologic operating room of San Giuseppe Hospital in Milan, from March 5th to April 28th, 2025. Informed consent was collected at the preadmission visit. Only procedures performed without spinal anesthesia or paracervical block were included, for a total of 31 cases. For each patient, the following data were collected: demographic information, surgical diagnosis, anesthetic technique (balanced anesthesia, TIVA, TIVA-TCI), dosage of administered drugs, awakening time, postoperative pain intensity at 15 minutes after awakening assessed with the Numeric Rating Scale (NRS), a validated and widely adopted tool for clinical pain measurement [1], and intra/postoperative adverse events.

Results

The mean age of the patients was 54 ± 13 years. The most frequently used anesthetic techniques were balanced anesthesia (15 cases) and TIVA (14 cases); 2 patients underwent TIVA-TCI. Drug dosages are reported in table 1. Postoperative pain (NRS), reported in table 2, showed a mean value of 2.00 ± 2.88 in the balanced anesthesia group and 2.86 ± 2.44 in the TIVA group. The most frequent diagnoses were endometrial polyp (n=22), leiomyoma (n=3), and uterine septum (n=2). No major adverse events were recorded. Ketorolac was administered to 26 patients, and paracetamol to 27. A possible association between analgesic administration and NRS could not be evaluated due to heterogeneous co-administration of other analgesic drugs and the absence of a homogeneous control group.

Conclusions

In this preliminary analysis, all anesthetic techniques proved to be safe and well tolerated. Balanced anesthesia showed pain control comparable to TIVA, with a trend toward lower NRS values, consistent with findings reported in the literature [2]. Further data are needed to consolidate these findings and to better assess the impact of individual drugs on postoperative recovery.

References

1. Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, Fainsinger R, Aass N, Kaasa S. Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41(6):1073–1093.

2. Mushambi MC, Williamson K. Anaesthetic considerations for hysteroscopic surgery. Best Pract Res Clin Anaesthesiol. 2002;16(1):35–52.

Informed consent was obtained for the publication of this scientific article.

Table 1 (abstract A4).

Mean (SD) drug dosages by anesthetic technique

Technique	Propofol mg Mean (SD)	Sevoflurane % Mean (SD)	Fentanyl mcg Mean (SD)	Remifentanil mcg/kg/min Mean (SD)
Balanced	216,4 (± 49,3)	1,97 (± 0,54)	87,5 (± 16,3)	-
TIVA	317,3 (± 83,7)	-	95 (± 15,8)	-
TIVA	326,6 (± 56,9)	-	-	0,15 (± 0,13)
TIVA-TCI	395	-	100	-
TIVA-TCI	259	-	-	0,1

Table 2 (abstract A4).

Mean (SD) Postoperative NRS and awakening time by anesthetic technique

Technique	N° of patients	NRS pain score Mean (SD)	Awakening time in minutes Mean (SD)
Balanced	15	2.00 (± 2.88)	12 (± 5)
TIVA	14	2.86 (± 2.44)	9 (± 2)
TIVA-TCI	2	2.50 (± 0.75)	7 (± 2)

A5 Renin-angiotensin system blockers withdrawal worse circadian blood pressure profile in obese patients following bariatric surgery preliminary results from bar-hyp observational study

F. Salvo¹, F. Bruno¹, E. Gallo¹, A. Risoli¹, V. Contardi¹, S. Malerba¹, A. Raineri¹, A. Botto¹, E. Travaglio², A. Aprile², A. Gattolin², I. Blangetti¹

¹Anesthesia and Intensive Care Unit. Regina Montis Regalis Hospital, Mondovì (CN), Italy; ²General surgery Unit. Regina Montis Regalis Hospital, Mondovì (CN), Italy

Correspondence: A. Raineri

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A5

Background

Obesity is a growing global health concern often associated with arterial hypertension(AH) with prevalence exceeding 70% in severe obesity. In this population, nocturnal period is of particular prognostic interest due to high prevalence of AH and diminished physiological blood pressure (BP) fall. While lifestyle and pharmacological intervention can contribute to weight loss, bariatric surgery offers a promising alternative when other strategies fail. The widespread of these procedures presents challenges for anesthesiologist, requiring optimization of cardiovascular risk especially in patients(pts) with extreme obesity. Although the withdrawn of renin angiotensin system blockers(RASb) does not appear to influence postoperative cardiovascular prognosis, data remain uncertain in obese pts undergoing bariatric surgery.

Materials and Methods

We conducted a prospective observational study enrolling 64 patients (F/M 45/19) who underwent sleeve gastrectomy in Regina Montis Regalis Hospital from April 2024 to April 2025. Baseline population characteristics are listed in table 1. Inclusion criteria were age > 18 years and American Society of Anesthesiologists (ASA) score < 4. Data were collected duringe: preoperative anesthesiological consultation, intraoperative period and post-operative hospital stay. Systolic and diastolic mean BP (SBP and DBP respectively in mmHg) were recorded at 5 and 30 minutes interval during the intra and post-operative period respectively; mean nocturnal BP was considered abnormal when SBP > 120 mmHg or DBP > 70 mmHg. 21 pts were on RASb: the decision regarding 24-hours pre-operative withdrawn was based on individual clinical judgment; we analyzed a withdrawn (RASbw n=12) and a continuation group (RASbc n=9). All pts underwent anesthetic procedure according to institutional and enhanced recovery after surgery (ERAS) protocol utilizing balanced anesthesia (desflurane plus remifentanil or fentanyl); post-operative opioids were administered only for rescue beyond mandatory paracetamol and NSAIDs.

Results

Mean age of pts was 46±11 years with a BMI of 44±6 kg/m2; AH was present in 45% (n=29) of cases. During the anesthesiological consultation 36% (n=23) had BP above normal limits, but during the nighttime period the prevalence reached 77% (n=49) with at least one episode of SBP > 160 mmHg in 56% (n=36) of cases. Intra-operative mean BPs were similar between the two RASb strategies, whereas nighttime SBPs and DBPs means were higher in RASbw group (136±13 vs. 120±20 and 79±9 vs. 68±9 respectively, p < 0.05 for both). The transfusion rate and the risk of re-intervention were similar. Among normotensives, nocturnal BP was altered in 74% (n=26) of cases, however mean SBPs and DBPs were similar to hypertensives (126±18 vs. 130±18 and 73±10 vs. 76 ± 10, p = ns for both).

Conclusion

Obese patients following bariatric surgery frequently present poor BP control, especially during the nighttime. Higher BP values were observed with the discontinuation of RASb, however the nocturnal period is altered in most cases also in normotensives. These preliminary findings suggest that these patients should receive a more accurate cardiovascular assessment prior to surgery in order to mitigate perioperative risk.

Ethical Compliance

Territorial ethics committee of Novara approved study protocol. Protocol number 324/CE.

Table 1 (abstract A5).

Baseline characteristics of study population

Characteristics	Baseline (n = 64)
Age, years	45 ± 11
Gender Male, n (%) Female, n (%)	19 (30%) 45 (70%)
BMI, kg/m2	44 ± 6
ASA	2 ± 0.4
OSAS, n (%)	32 (50%)
Arterial Hypertension, n (%)	29 (45%)
Office blood pressure Systolic Diastolic	134 ± 16 82 ± 10
Hemoglobin, g/dl	13.9 ± 1.6
Creatinine, mg/dl	0.7 ± 0.1

A6 Anesthesiological management in patient with fabry’s disease undergoing major orthopedic surgery

V. Contardi¹, A. Raineri¹, S. Malerba¹, Z. Bracco¹, F. Bruno¹, A. Cannone¹, E. Gallo¹, I. Nicoletti¹, F. Salvo¹, P. Valesano¹, I. Blangetti¹, M. Feola²

¹Anesthesia and Intensive Care Unit, Regina Montis Regalis Hospital, Mondovì (CN), Italy; ²Cardiology department, Regina Montis Regalis Hospital, Mondovì (CN), Italy

Correspondence: V. Contardi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A6

Background

Fabry’s disease is a rare, X-linked genetic metabolic disorder characterized by deficient or reduced activity of the enzyme alpha-galactosidase-A (GLA), caused by aberrant gene transcription. This deficiency lead to progressive multiple organ accumulation of glycosphingolipids. Symptoms and clinical signs are various and usually emerge in childhood, however especially in women the disease could be asymptomatic or become evident only in adult age. This disparity is caused by different inactivation of chromosome X. Diagnosis is sometimes challenging and should be considered in patients with inexplicable renal or cardiac conditions; life expectancy is reduced, especially in man, and death often occurs for cardiovascular complications.

Case report

Patient G.E. (72 years old) underwent anesthesiological consultation in our center for elective revision of hip prosthesis. In 2016 she received a diagnosis of hypertrophic asymmetric cardiomyopathy and two years ago echocardiography showed systolic anterior motion (SAM) of mitral valve with moderate insufficiency. Ejection fraction was preserved. Total body sintigraphy excluded amyloid accumulation, but the genetic study revealed heterozygous mutation of the GLA gene correlated with Fabry’s disease. Pre-operative echocardiographic control revealed preserved ejection fraction (65%), intraventricular septum thickness 18 mm and dynamic obstruction with basal peak gradient of 32 mmHg (Valsalva 39 mm Hg) with moderate mitral insufficiency. New York Heart Association class was III. After optimization of metoprolol and disopyramide dosages, basal peak gradient fell to 14 mmHg (Valsalva 33 mmHg). Although orthopedic surgery could be perform with subarachnoid anesthesia, there was an elevate risk of reduce cardiac preload, increase heart rate worsening cardiac compensation, cause of peripheral vasodilatation and autonomic mismatch. Before anesthesia induction, we placed mini-invasive hemodynamic monitoring; then we utilized also trans-esophageal echocardiography. General anesthesia induction was performed with fentanyl 3 mcg/kg, sodium pentothal 4 mg/kg and rocuronium bromide 1 mg/kg; subsequent we utilized desflurane 0.8MAC and continued infusion of remifentanil 0.1mcg/kg/min. During surgery we maintain positive water balance; systolic blood pressure nadir was 95 mmHg 60 minutes after induction, mean heart rate was 54 bpm and mean cardiac Index 2.5 l/min/m2. Intra-operative echocardiographic monitoring showed SAM (fig.1) with peak gradient of 40mmHg (fig.2) and VCI diameter of 10 mm. Subsequent fluid therapy with 500 ml of crystalloid bolus was effective to reduce gradient. Surgery lasted 120 minutes without significant complications. Patient was admitted to intensive care unit for 24 hours, maintaining a good hemodynamic assessment. She was discharged from hospital after 7 days. Follow up at 6 months showed a NYHA class II and an acceptable quality of life.

Conclusion

Anesthesia management in Fabry’s disease is a clinical challenge and decision workout should be individualized according to echocardiographic findings and patient symptoms. When cardiac involvement is prevalent with SAM and dynamic obstruction, maintaining adequate cardiac pre-load is mandatory. An adequate post-operative intensive care unit monitoring is advisable.

Ethical Compliance

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A6).

Systolic anterior motion of mitral valve showed during intra-operative evaluation

Fig. 2 (abstract A6).

Intra-operative left ventricular outflow tract with peak gradient of 40mmHh

A7 Diffuse alveolar hemorrhage induced by sevoflurane: a possible case

F. Russo, N. Grossi, A. Vitiello, V. De Vivo, S. Sorrentino, A. Milone, C. Candurro

PO Villa Malta - ASL Salerno, Sarno, Italy

Correspondence: N. Grossi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A7

Diffuse alveolar hemorrhage (DAH) is a syndrome characterized by hemoptysis, anemia, diffuse pulmonary infiltrates on imaging and hypoxemic respiratory failure. It is frequently due to capillaritis associated with systemic autoimmune diseases, but can also result from coagulopathies, infections, drugs, toxins or barotrauma. The underlying mechanism involves injury to the alveolar microcirculation with diffuse bleeding.

We report a suspected case of DAH following varicocele surgery in a 16-year-old patient (70 kg, healthy, non-smoker/drug user, athletic, ASA I).

Balanced general anesthesia was performed with premedication using midazolam and fentanyl, induction with propofol and rocuronium, and maintenance with sevoflurane at 3%.

Mechanical ventilation was conducted with normal peak and plateau pressures. The patient experienced a complete and prompt awakening on the operating table (Aldrete score 10).

Approximately one hour after awakening, the patient developed worsening hemoptysis, dyspnea and desaturation. Chest examination was unremarkable. ABG showed severe normocapnic respiratory failure with a P/F ratio of 120. Oxygen therapy was initiated using a Venturi mask (FiO2 50%).

Nasal fiberoptic endoscopy showed no bleeding from the upper airways. High-resolution chest CT (HRCT) revealed “multiple ground-glass opacities with a tendency toward consolidation diffusely distributed throughout both lungs”.

The patient was transferred to the ICU, where treatment with intravenous methylprednisolone 500 mg (4/die) N-acetylcysteine 600 mg (3/die), and tranexamic acid 1 g (3/die) was initiated.

The introduction of HFNC oxygen therapy at 50 L/min (FiO2 50%) resulted in an improved P/F ratio.

Leukocyte count, D-dimer and procalcitonin levels were normal, with no hemoglobinuria or proteinuria. Respiratory tract cultures were negative. COVID-19, autoimmune and toxicology panels were also negative.

Hemoptysis progressively decreased and resolved by the second day. After 48 hours, HRCT showed a reduction in the number and density of ground-glass opacities, with no lymphadenopathy.

On the third day, neutrophilic leukocytosis and mild hypofibrinogenemia were observed, leading to the initiation of broad-spectrum antibiotic therapy and prophylactic low molecular weight heparin.

Improved ABGs eventually led to transitioning back to a Venturi mask with FiO2 50% and starting cautious respiratory physiotherapy. High-dose steroids were tapered to methylprednisolone 20 mg (2/die).

By day five ABG showed normal acid-base balance and gas exchange on room air, with a P/F ratio of 433, allowing discontinuation of oxygen therapy.

After seven days HRCT showed normal pleuroparenchymal findings. The patient was discharged at home in good clinical condition.

Our patient developed DAH without clinical or laboratory evidence of an underlying systemic disease. Given the close temporal relationship with balanced general anesthesia and the limited number of administered drugs, we hypothesize—based on the scant literature available—that the triggering factor may have been inhaled sevoflurane.

The authors obtained informed consent for the publication of the patient's data in an anonymized form.

References

1. Kim CA et Al. “Diffuse alveolar hemorrhage induced by sevoflurane”. AnnAmThoracSoc 2014

2. Mersh R et Al. “Postoperative diffuse alveolar haemorrhage: insidious negative pressure or sevoflurane induced?” BMJCaseRep. Jul 10;2018.

3. Austin A et Al. “Sevoflurane Induced Diffuse Alveolar Hemorrhage in a young patient” RespirMedCaseRep 2017

Informed consent was obtained for the publication of this scientific article.

A8 Case report: severe bronchospasm following induction with propofol in a patient with previously unknown soy sensitisation

I. Rigoli¹, A. Finocchio¹, E. Montrasio², E. Saccavino², A. Mossini², L. Guatteri²

¹Università Milano Bicocca, Milano, Italy; ²ASST Brianza - Ospedale Pio XI, Desio, Italy

Correspondence: I. Rigoli

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A8

Background

Propofol is the most commonly used hypnotic drug worldwide for induction and maintenance of general anaesthesia, as well as for sedation in intensive care and during diagnostic procedures. Due to its lipophilic nature, it is administered as a lipid emulsion containing refined soybean oil and egg lecithin. Since its introduction in the 1980 s, various formulations have aimed to reduce the risk of adverse reactions, particularly severe allergic ones. This goal has been pursued by purifying traces of soy in the drug to reduce its allergenic protein content. Despite this, it is known that there is a potential risk of cross-reactivity between soy and propofol. Marketed formulations differ in terms of excipients: the most widely used products, such as Fresenius Kabi, B. Braun (Propofol-Lipuro), and Rapiva, contain approximately 50 mg of refined soybean oil per mL. However, other formulations like Unifol, Ripol, and Diprivan contain up to 100 mg of soybean oil per mL, doubling the potential allergenic load. Some experimental preparations use alternative lipid vehicles, though these are not widely available.

Case Report

We present the case of a 26-year-old woman with a history of prior general anesthesia without complications, who developed a severe allergic reaction following induction of general anesthesia with propofol (Fresenius Kabi 10 mg/ml) for a laparoscopic cholecystectomy. Prior to induction she had been administered midazolam, fentanyl and cefazolin; but shortly after propofol administration, the patient developed severe bronchospasm and significant desaturation, requiring emergency pharmacological intervention. Subsequent allergy testing revealed negative skin tests for propofol, but positive specific IgE to soy (0.65 kUA/L, cutoff <0.10). Skin prick tests for the other anesthetic agents (rocuronium, midazolam, fentanyl, penicillin, and ceftriaxone) were all negative. Based on these findings, the allergist contraindicated further use of propofol in this patient, concluding that two possible triggering mechanisms could be involved: either a mechanism other than IgE-mediated, or possible cross-reactivity between soy and propofol. A second anesthetic induction using the same agents—except with thiopental replacing propofol—was completed without incident.

Conclusions

Given the large population exposed to propofol, we believe this sentinel case is worth reporting, as it highlights the potential risk of severe allergic reactions in patients with soy sensitisation, even in the absence of prior clinical symptoms. While the majority of current literature supports the safety of propofol in soy- or egg-allergic patients, available studies have several important methodological limitations (small sample sizes, predominantly observational and retrospective designs, lack of standardization in allergy testing protocols, low event rates). In this case report, it emerges that a negative skin prick test to propofol, even in apparently non-allergic subjects, is not a guarantee of the absence of anaphylactic or anaphylactoid reactions. This case reinforces the importance of clinical vigilance, especially given the likelihood that adverse reactions are underreported, and supports the consideration of allergen-free formulations in at-risk populations.

Written informed consent was obtained from the patient for the publication of this case report

A9 Selection of peep guided by the recruitment-to-inflation ratio during laparoscopic surgery in obese patients

F. Polzoni¹, M. Varisco¹, F. Verdina², D. Rosalba², G. Furlan², R. Simonte³, D. Azzolina¹, G. Scaramuzzo¹, S. Spadaro¹, G. Cammarota²

¹Università degli Studi di Ferrara, Italy; ²Università del Piemonte Orientale, Alessandria, Italy; ³Università degli Studi di Perugia, Italy

Correspondence: F. Polzoni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A9

Background

Growing awareness of ventilator-induced lung injury has led to the adoption of strategies aimed at customizing ventilatory settings to ensure lung-protective ventilation. One area of ongoing debate is the optimal level of positive end-expiratory pressure (PEEP), particularly in obese patients who often present with varying degrees of intraoperative alveolar collapse and restrictive lung mechanics. (1) The recruitment-to-inflation (R/I) ratio is a simple bedside tool that estimates alveolar recruitment resulting from PEEP through a single expiratory maneuver. (2) However, its use has been largely restricted to intensive care settings, particularly in patients with acute respiratory distress syndrome (ARDS).(3)

This study aimed to explore the applicability of the R/I ratio in obese patients undergoing laparoscopic surgery after the induction of pneumoperitoneum and Trendelenburg positioning. Specifically, it sought to evaluate the extent of alveolar recruitability and guide individualized PEEP titration in this population.

Methods

The study included adult patients (>=18 years) with a body mass index (BMI) over 30 kg/m² scheduled for laparoscopic or robotic surgery. Written informed consent was obtained from all participants in accordance with current ethical guidelines.

Following pneumoperitoneum induction and placement in the Trendelenburg position, airway opening pressure (AOP) was determined using a slow-flow maneuver. PEEP was then set either at 15 cmH2O or at 10 cmH2O plus AOP. Respiratory and hemodynamic parameters were recorded at four time points: before (T1) and after (T2) pneumoperitoneum and Trendelenburg positioning, and at 5 minutes (T3) and 30 minutes (T4) after T2. At T3 and T4, the R/I ratio was calculated by abruptly reducing PEEP and measuring the corresponding exhaled volume.

Mechanical respiratory data were expressed as medians with interquartile ranges, and their temporal changes were analyzed using a mixed-effects model to account for intra-subject variability across repeated measures.

Informed consent was obtained for the publication of this scientific article.

Results

A total of 29 obese patients undergoing laparoscopic surgery were enrolled. (Table 1) Median R/I ratio values were 0.31 [−0.02 to 0.53] at T3 and 0.39 [0.02 to 0.55] at T4. A significant increase in driving pressure was observed at T2 compared to T1 (p < 0.01). (Figure 1) Although a reduction in driving pressure was noted at T3, it did not reach statistical significance (p = 0.06). By T4, values had stabilized, with no significant further changes (p > 0.05). A similar trend was observed for respiratory system compliance, with a significant decrease at T2 compared to T1, followed by stabilization (Figure 1).

Conclusions

The recruitment-to-inflation (R/I) ratio is a practical bedside tool for evaluating alveolar recruitability in obese patients during laparoscopic surgery. Its use following pneumoperitoneum and Trendelenburg positioning offers valuable guidance for tailoring PEEP settings, contributing to more individualized and protective ventilatory strategies and protective ventilatory strategies in this patient population.

Fig. 1 (abstract A9).

Driving pressure & compliance

Table 1 (abstract A9).

Demographic data

Variables	N = 29
Age (years)	62 [52–69]
BMI (Kg/m2)	32.3 [31–36]
PBW (Kg)	57 [54.2–65.8]
Males	12 (41)
ASA class, n (%)
ASA 1	0 (0)
ASA 2	13 (44.8)
ASA 3	16 (55.2)
Number of comorbidities, n (%)
0	4 (13.7)
1	5 (17.2)
2	11 (37.9)
3	8 (27.5)
4	1 (3.4)
Types of comorbidities, n (%)
Cardiovascular disease	21 (72.4)
Thyroid disease	11 (37.9)
Dyslipidemia	10 (34.4)
Diabets type 2	7 (24.1)
Liver disease	4 (13.7)
Kidney disease	3 (10.3)
Types of surgery, n (%)
Colecistectomy	13 (44.8)
Histerectomy	6 (20.6)
Colic resection	4 (13.7)
Exploratory laparoscopy	2 (6.8)
Nefrectomy + colecistectomy	1 (3.4)
Distal esofagectomy	1 (3.4)
Sigmoidectomy + adnessiectomy	1 (3.4)

A10 Anesthesiologic management of inferior vena cava thrombectomy with robotic surgery: a case report

F. Pizzi¹, M. Covotta², V. Ceccarelli¹, S. Orlando¹, G. Gazzè¹, S. Pricone³, C. Claroni², G. Torregiani²

¹Department of Anesthesia, Intensive Care and Pain Therapy, Policlinico Umberto I, Sapienza University of Rome, Roma, Italy; ²Department of Anesthesia, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Roma, Italy; ³Intensive Care Unit, Tor Vergata University of Rome, Roma, Italy

Correspondence: F. Pizzi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A10

Background

Inferior vena cava (IVC) thrombectomy for renal cell carcinoma is the most challenging urologic oncologic surgeries. IVC neoplastic thrombosis is associated with 2-10% of patients with renal carcinoma. The robotic technique, used to minimise major bleeding, is a challenge for anaesthetists and perioperative management has not been widely described.

Case Report

A 57 years-old-man, 80 kg (BMI28.7 Kg/m2), ASA3, presented left kidney cancer and neoplastic thrombosis of IVC shown at CT-scan(Fig.1). The thrombus occupied the entire circumference of the venous lumen. He presented with arterial hypertension in follow-up. The day before surgery had angiographic embolization of the left renal artery, in order to reduce the risk of intraoperative bleeding. At surgery procedure 4 units of packed red blood cells and 4 units of fresh frozen plasma were available. Surgery was performed under general anesthesia. Two peripheral venous catheters, one central venous catheters and one arterial line were placed. Hemodynamic management was guided by continuous monitoring of electrocardiogram, Heart Rate (HR), Invasive Blood Pressure, Mean Arterial Pressure (MAP), Cardiac Index (CI), Stroke Volume Variation, pulse oximetry and temperature by esophageal probe. At the beginning of the surgical procedure a volume filling with 2000 ml of crystalloids was performed. (MAP 76mmHg; HR 80bpm; C.I. 1.1 L/min/m2). During surgery, homeostatic balance was monitored by serial blood gas analysis. In the early stages, mild respiratory alkalosis emerged, which was corrected by increasing the respiratory rate (pH 7.54vs7.37; RR 14vs20) (pCO2 32mmHg; HCO3- 29mEq/L). First the caval stage was performed with the patient in the left lateral decubitus position and then the renal stage was performed in the right lateral decubitus position. A valveless trocar was used for pneumoperitoneum. Total duration of surgery was 6 h and 30min. The critical phase of the clamping of infrarenal vena cava, left renal vein, suprarenal vena cava, subepathic vena cava lasted 33 minutes. However, all the hemodynamic parameters remained constant without needing vasopressor support. (C.I. 2.2 L/min/m2 vs 2.3 L/min/m2; PAM 89mmHg vs 95mmHg; HR 78bpm vs 89 bpm). At the end of surgery the patient was transferred to the intensive care unit awake. Two days later the patient shows a worsening of respiratory exchanges in blood gas with a pulmonary inflammatory disease. This condition resolved after five days with antibiotic therapy and high-nasal- flow alternating with Venturi-mask, so the patient was safely admitted in urology unit with great general conditions and he was discharged from the hospital three days later.

No surgical complications occurred. Haemodynamic parameters always remained stable without any pharmacological support.

None unit of hemocomponents were used and the hemoglobin remained stable during the postoperative period (Fig.2).

Conclusions

Robotic-assisted IVC thrombectomy is a rare and extremely delicate surgical procedure that requires close coordination between surgeons and anaesthetists. However, especially when the thrombus occupies the entire circumference of the venous lumen, the risk of haemodynamic instability during the clamping procedure is reduced.

Thanks to the continuous multi-parametric monitoring, there was no need to make excessive corrections.

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A10).

VCI thrombosis

Fig. 2 (abstract A10).

Hemoglobin trend

A11 Impact of a multimodal prehabilitation program on the cardiovascular risk profile of high-risk oncologic and non-oncologic patients undergoing major colorectal surgery

P. Perrone¹, G. Senesi¹, M. Vannini², G.D. Testa³, S. Romagnoli¹, S. Caciolli², G. Baldini¹

¹Azienda Ospedaliero Universitaria Careggi, Dipartimento di Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Firenze, Italy; ²Azienda Ospedaliero Universitaria Careggi, Dipartimento di Cardiologia generale, Firenze, Italy; ³Azienda Ospedaliero Universitaria Careggi, Centro di Preabilitazione Multimodale, Firenze, Italy

Correspondence: P. Perrone

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A11

Background

Multimodal prehabilitation (MPrehab) is an emerging strategy to optimize patient fitness before surgery. Preoperative NT-pro-BNP concentrations independently predict cardiovascular risk and are recommended by the European Society of Cardiology guidelines. It is well known from other non-surgical settings that physical exercise enhances functional capacity, reduces NT-pro-BNP levels, and thus leading to better cardiovascular outcomes.

Objective: investigate the impact of MPrehab on NT-pro-BNP preoperative concentrations.

Methods

Prospectively collected data from patients scheduled for elective major colorectal surgery were evaluated before and after MPrehab. High-risk patients were referred to the Multimodal Prehabilitation Centre for a baseline evaluation and MPrehab prescription. The MPrehab was personalized, and it included aerobic and resistance exercise, nutritional, psychological and medical optimization. Paired t-test or Wilcoxon signed-rank test were used when appropriated.

Informed consent was obtained for the publication of this scientific article.

Results

Forty-six high-risk consecutive patients were evaluated and treated with a MPrehab program. Baseline patients demographic and clinical features, and the characteristic of the MPrhab program received are presented in Table 1.

After MPrehab (median duration 44 days, interquartile range, IQR 29-84), functional capacity significantly increased (mean 6-minutes walking distance ± standard deviation: 428.3±136.4 m vs 472±142.4 m, + 44 m, p=0.0028) while NT-pro-BNP plasma concentrations significantly decreased (median 244 pg/ml, IQR 88-889.5 vs median 180 pg/ml, IQR 65-143, p=0.025) (Figure 1).

Conclusions

MPrehab increased functional capacity and reduced NT-pro-BNP levels of high cardiovascular risk surgical patients. Future studies are necessary to confirm these benefits, and to establish whether these clinical improvements are also associated with better postoperative cardiovascular outcomes.

Fig. 1 (abstract A11).

6-min walking distance and NT-pro-BNP change after Multimodal Prehabilitation

Table 1 (abstract A11).

See text for description

	n = 46
Age, year	75.5 (62–80)
Sex, (M/F), n(%)	33/13 (71.7/28.3)
Diagnosis, n(%)
Colorectal adenocarcinoma	30 (65.2)
Inflammatory bowel disease	16 (34.8)
Hypertension, n(%)	25 (56.9)
Coronary artery disease, n(%)	7 (15.9)
Diabetes Mellitus, n(%)	12 (27.3)
Heart Failure	4 (9.1)
Dyslipidemia	15 (34.1)
Arrythmia, n(%)	6 (13.4)
Chronic Obstructive Pulmonary Disease (COPD), n(%)	10 (22.7)
Chronic Kidney Dysfunction	7 (15.9)
Cerebrovascular disease, n(%)	3 (6.8)
Peripheral Artery disease, n(%)	3 (6.8)
Hyperuricemia, n(%)	4 (9.1)
Duke Activity Status Index (DASI)	32.6 (15.6)
Revised Cardiac Risk Index, (RCRI 1/2/3/4), n	33/9/1/2
6-min walking distance (m), n(%)	427.6 (134.3)
PG-SGA
B/C, n(%)	22/15 (47.83/32.61)
Symptoms	7.5 (4.1)
Hang Grip Strength (Kg)
M	31.3 (8.7)
F	17.4 (6.8)
Sarcopenia*, n(%)	6 (13)
Frail** (Fried ≥ 3)/Pre-frail (Fried 1–2)	12 (35.3)/14 (41.2)
Anemia	15 (34.1)
NT-pro-BNP, pg/ml	244 (88–889.5)
HbA1c, mmol/mol	38.7 (8.2)
CRP, mg/dl	6 (1–13)
Characteristics of the MPrehab Program received
Duration of MPrehab, days	44 (29–84)
Aerobic Exercise
High Intensity Interval Training (HITT)	31 (68.9)
Moderate Continuous Training (MCT)	13 (28.9)
Resistance Exercise, n (%)	44 (97.8)
Oral nutritional supplements, n (%)	29 (63)
Whey Proteins, n (%)	46 (100)
Supervised, n (%)	26 (57.8)
N sessions/N total session planned, (%)	67 (45–86)
Aerobic exercise intensity reached, (%)	94 (90–98)
Home-based, n (%)	19 (42.2)
IV-iron, n (%)	23 (50)
Smoking cessation, n (%)	4 (9.76)
Psychological support, n (%)	5 (10.9)

A12 Perioperative management of feasibility for one day surgery in single-port robot-assisted radical prostatectomy: a case series

S. Orlando¹, M. Covotta², V. Ceccarelli¹, F. Pizzi¹, G. Gazzè¹, C. Claroni², G. Torregiani²

¹Università di Roma La Sapienza, Roma, Italy; ²IRCCS Regina Elena National Cancer Institute, Roma, Italy

Correspondence: S. Orlando

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A12

Background

Prostate cancer is the most common non-cutaneous malignancy in men. Radical prostatectomy remains the gold standard for curative treatment of localized prostate cancer. Compared to the widely adopted multi-port robotic radical prostatectomy (RRP), the Single Port (SP) approach has been associated with significantly improved perioperative outcomes, including reduced postoperative pain, decreased postoperative morphine use, shorter hospital stays, and earlier removal of urinary catheters (1). On January 2024, da Vinci Single Port (SP) Robotic Surgical System received CE mark approval for use in Europe. We want to study the feasibility of a perioperative protocol for discharge on the same operating day.

Material and Method

Starting in March 2025, a prospective study was conducted on patients ASA 1-2 undergoing SP-RRP. Ethical committee approval and patient’s informed consent were obtained. Surgery is planned as first on the operating list. Upon arrival in the operating theatre, we performed ultrasound Transversus Abdominis Plane block using Ropivacaine 0.375mg/ml. Following induction of general anesthesia (using fentanyl 1.25-2.5 mcg/kg, propofol 1.5-2 mg/kg, and rocuronium 0.6mg/kg), we administered ketorolac 30 mg and paracetamol 1 g for intraoperative analgesia. Anesthesia was maintained with desflurane, and the depth of anesthesia was monitored. The operation was performed with the same surgical equipe, in moderate Trendelenburg position (20°) and with pneumoperitoneum using valveless trocar. Upon awakening, sugammadex was administered under neuromuscular monitoring. During the first 6 postoperative hours, the following parameters were recorded: need for additional analgesia, ability to drink fluids, return of bowel function (e.g., passage of flatus), and early mobilization. Based on a study for one-day discharge from robotic surgery in endometrial cancer (2), we hypothesized discharge at home upon reaching the criteria reported in Table 1.

Informed consent was obtained for the publication of this scientific article.

Results

We enrolled 10 cases. Only one patient required opioid administration shortly after awakening from anesthesia, and non-opiod postoperative analgesia was needed in just one case. The mean duration of anesthesia was 165 minutes. No postoperative delirium was observed. All patients were transferred to the urology ward. Within the first 6 postoperative hours, all patients were able to sit up in bed. 5 out of 10 patients were able to stand with only one experiencing orthostatic hypotension. Five patients had return of bowel function, and 8 were able to drink fluids.

Conclusions

In our series, although preliminary, these results suggest that SP technology with standardised perioperative management may support same-day discharge. Further investigation into the relevant criteria may help establish a structured perioperative management pathway for these patients.

References

1. Soputro NA, Kaouk J. Single-port robot-assisted radical prostatectomy. World J Urol. 2024 Apr 20;42(1):245. 10.1007/s00345-024-04914-5. PMID: 38643347; PMCID: PMC11032265.

2. Zhang N, Same-day discharge after robotic surgery for endometrial cancer. J Robot Surg. 2022 Jun;16(3):543-548. 10.1007/s11701-021-01253-0. Epub 2021 Jul 8. PMID: 34236587.

Table 1 (abstract A12).

Criteria for same-day discharge

1	Adequate pain control
2	Patient must be ambulatory
3	Voiding spontaneously
4	Tolerating oral intake
5	Negative orthostatic vital signs (< 20 mmHg BP drop or < 20/min HR rise from sitting to standing)
6	Motivated to leave

A13 Continuous vital signs monitoring with wearable device in perioperative setting: a pilot study

F. Marconi, V. Bellini, D. Donelli, E. Cerdelli, M. Panizzi, E.G. Bignami

¹Anesthesiology, Intensive Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Italy

Correspondence: F. Marconi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A13

Background

The cosinuss° health technology holds significant promise for enhancing diagnostic care in hospitals, optimizing and personalizing postoperative therapy through mobile continuous in-ear monitoring of vital signs [1]. Monitoring vital sign trends, rather than evaluating isolated alarms from wearable devices based on clinician established thresholds, can enhance decision-making efficiency by fostering a proactive rather than reactive approach [2].

Materials and Methods

The cosinuss° c-med° alpha is an advanced in-ear wearable device (Class IIa MDR) that generates continuous data streams on important vital parameters: core body temperature, heart rate and blood oxygen saturation. The device does not require consumable accessories, but is completely disinfectable. In the data transmitted by the device it is possible to directly detect the quality index (QI) and the perfusion index (PI). The QI shows the quality of the photoplethysmogram signal (PPG) relating to the calculation of heart rate values. It should always be above 30 to ensure valuable calculated data. The PI can be used to assess the quality of the PPG signal relating to the calculation of SpO2 values. The main objective of the study was to investigate the signal quality of the device in different perioperative settings. The subjects who took part in the pilot study simulations were physicians and medical residents in anaesthesia and intensive care, who expressed consent to the use of clinical data. In our pilot study vital signs were continuously recorded using wearable sensors (Figure 1) across intrahospital transport with stretcher (T), overnight patient monitoring (N) and operating room settings during work (OR).

Informed consent was obtained for the publication of this scientific article.

Results

The boxplot analysis (Figure 2) shows that the Quality Index (QI) was generally above the reliability threshold (QI > 30) across most recording conditions. Two recordings in the operating room showed significantly lower signal quality values, but this is compatible with an incorrect sensor size choice or movements by the user during work. In the remaining 13 sessions the QI remained above the value of 50 (good quality) for 75% of the entire recording time, with median values above 60. The median was above 70, 60 and 55, for N, T and OR sessions, respectively. The Perfusion Index (PI) showed greater variability, with more consistent and reliable values (>0.2) observed during continuous monitoring at night (N).

Conclusions

Cosinuss° c-med° alpha signal quality was satisfactory in perioperative settings in hospital. Night sessions showed the highest and most stable QI values, likely due to the absence of movement artifacts during sleep. Nevertheless, it also performed well in the other settings in which it was used. Further studies are needed to confirm our data.

References

1. Zellhuber et al. Transforming in-clinic post-operative and intermediate care with cosinuss°. Computational and Structural Biotechnology Journal (2024) Volume 24, 630–638

2. Bignami EG et al. Wearable devices as part of postoperative early warning score systems: a scoping review. Journal of Clinical Monitoring and Computing (2025) 39:233–244

Fig. 1 (abstract A13).

Device positioning and data transmission to the smartphone via application

Fig. 2 (abstract A13).

Boxplot Analysis of Quality Index and Perfusion Index

A14 Impact of guideline-based preoperative testing in low-risk elective surgery patients: an observational study at san giuseppe hospital, empoli

M. Viggiano, M. Luchini, R. Spina

Azienda USL Toscana Centro - Ospedale San Giuseppe, Empoli (FI), Italy

Correspondence: M. Viggiano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A14

Objectives

To evaluate the impact of guideline-based prescribing of preoperative laboratory and instrumental tests in low–anesthesia-risk patients scheduled for elective surgery at San Giuseppe Hospital, Empoli (FI).

Introduction

Preoperative assessments aim to supplement a patient’s clinical history with diagnostic and prognostic information to confirm their suitability for elective surgery. Ideally, such investigations identify undiagnosed conditions so that anesthesiologists and surgeons can optimize perioperative management, select the most appropriate techniques, and minimize patient risk. In practice, however, routine testing of apparently healthy individuals or those with well-controlled chronic diseases often yields findings that do not alter clinical management. False positives may lead to unnecessary delays or cancellations, additional invasive procedures, unneeded treatments, and increased healthcare costs. Our study investigates whether adherence to evidence-based guidelines for test ordering reduces unnecessary examinations without compromising patient safety.

Methods

We conducted a retrospective observational analysis of all elective surgical patients aged 3–60 years, enrolled between May 2023 and December 2024. Data from 554 consecutive cases were extracted from the hospital’s anesthesia database. For each patient, we recorded.

Informed consent to data acquisition and analysis.

American Society of Anesthesiologists (ASA) physical status classification.

Presence of major comorbidities (renal, respiratory, cardiovascular).

Surgical complexity (minor, intermediate, major).

Indications for preoperative laboratory tests and electrocardiography (ECG) based on institutional guidelines.

Patients with ASA I–II status and no significant comorbidities were classified as low anesthesia risk. We compared the number and type of tests ordered against guideline-recommended indications and monitored perioperative outcomes, including any test-related complications or delays.

Informed consent was obtained for the publication of this scientific article.

Results:

Of 554 patients (306 females, 248 males; mean age 42.5 ± 12.3 years), 51 (9.2 %) were under 10 years, 27 (4.9 %) aged 11–20, 145 (26.2 %) aged 21–40, and 331 (59.7 %) aged 41–60. Surgical specialties included general surgery (30.2 %), otolaryngology (23.1 %), gynecology (18.6 %), senology (13.7 %), urology (11.6 %), vascular (2.4 %), and orthopedics (0.5 %). Anesthetic techniques comprised general anesthesia (50.5 %), local anesthesia (19.7 %), spinal anesthesia (18.2 %), and sedation (11.6 %).

Guideline-concordant test ordering reduced the mean number of laboratory panels per patient by 37 % compared to the previous year, without increasing perioperative risk. No patient experienced complications attributable to omitted or performed tests or to preoperative ECG. All postoperative courses were uneventful, and discharge timelines remained unchanged.

Conclusions

Appropriate, guideline-based preoperative testing confers dual benefits: clinically, it preserves patient safety by focusing on high-yield investigations; economically, it curtails unnecessary expenditure on routine, nonselective testing. Ordering should be guided by a rational algorithm incorporating patient history, proposed surgical procedure, and potential intraoperative bleeding risk. Adoption of such protocols can streamline perioperative workflows, prevent avoidable delays, and optimize resource utilization without compromising outcomes.

A15 Atypical presentation of wernicke’s encephalopathy after thoracic surgery

P.C. Kouroupis, G. Sciacca, V. Basso, M. Cinicola, C.A. Ajmone, L. Tritapepe

Anesthesia and Resuscitation Unit, San Camillo-Forlanini Hospital, Rome, Italy

Correspondence: G. Sciacca

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A1

Background

Wernicke’s encephalopathy (WE) is a life-threatening neurological disorder caused by thiamine (vitamin B1) deficiency. In surgical patients, especially in the postoperative setting, WE may present atypically, often mimicking acute cerebrovascular events. Early diagnosis remains challenging due to the variable clinical manifestations and low sensitivity of classical criteria[1]. The typical MRI findings, including symmetrical signal alterations in the thalami, mammillary bodies, and periaqueductal gray matter, provide critical diagnostic support when clinical signs are ambiguous [2].

Case Report

We report the case of a 74-year-old male with a history of acute coronary syndrome and COPD who underwent video-assisted thoracoscopic surgery (VATS) for the resection of a pulmonary adenocarcinoma. Postoperative recovery was initially stable, but the patient experienced a sudden neurological deterioration in the ICU approximately 30 minutes after admission, presenting with tonic seizures and a Glasgow Coma Scale (GCS) score of 4. After emergency sedation, intubation, and a negative brain CT, further evaluations including EEG and lumbar puncture excluded epileptic activity and infectious causes. Subsequent neurological evaluation revealed right-sided hemiparesis. Notably, a brain MRI revealed bilateral symmetrical hyperintensities in the medial thalamus on T2/FLAIR sequences (Figure 1), raising suspicion for a metabolic encephalopathy.

Following a multidisciplinary consultation and revaluation of the patient’s history—which included previously undocumented alcohol use—a presumptive diagnosis of WE was made. High-dose intravenous thiamine (500 mg twice daily) and magnesium supplementation were initiated. Clinical improvement was rapid, with full neurological recovery within 72 hours. A follow-up MRI performed three weeks later demonstrated near-complete resolution of thalamic signal alterations (Figure 2), confirming the diagnosis.

Conclusion

This case underscores the importance of considering WE in the differential diagnosis of acute postoperative neurological deterioration, even when predisposing factors are not suspected and in the absence of classical signs such as ocular abnormalities or ataxia. The unusually rapid onset of hemiparesis post-anesthesia mimicked an ischemic stroke, emphasizing the risk of misdiagnosis and potential overtreatment (e.g., unnecessary thrombolysis) in similar scenarios. As highlighted in previous literature, stroke mimics account for up to 24.8% of presumed ischemic strokes, with metabolic causes being the second most common [3]. Prompt MRI evaluation and a high index of clinical suspicion are critical for early diagnosis and effective treatment. Clinicians must remain vigilant in assessing nutritional status, especially thiamine reserves, in surgical patients—even when no obvious risk factors are documented. Prophylactic thiamine administration should be considered in high-risk populations to prevent irreversible complications.

Consent

Written informed consent was obtained for the publication of this case report and any accompanying images.

References

1. Sechi G, Serra A. Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007;6(5):442–55.

2. Galvin R, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol. 2010;17(12):1408–18.

3. Pohl M, et al. Ischemic stroke mimics: A comprehensive review. J Clin Neurosci. 2021;93:174–82.

Fig. 1 (abstract A15).

T2/FLAIR sequences, arrows indicating signal alterations in the medial thalamus bilaterally

Fig. 2 (abstract A15).

T2/FLAIR sequences, arrows indicating resolution of the pathological findings at thalamic area

A16 Blood pressure monitoring in thyroid surgery patients: a comparison between sphygmomanometer and vitawave finger cuff

M. Guarnieri, V. Bellini, L.J. Darhour, N. Razzoli, M. Panizzi, E.G. Bignami

Anesthesiology, Intensive Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy

Correspondence: M. Guarnieri

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A16

Backgrounds

Variations from baseline blood pressure (BP) during general anesthesia have been associated with multiple negative outcomes and mortality [1].

Intraoperative stimulation can cause significant changes in heart rate and BP, with hypotensive, tachycardic, and hypertensive episodes frequently observed [2]. The intermittent oscillometric method, used as the standard for BP monitoring, may fail to promptly detect events between readings, limiting its effectiveness. Factors like the patient's position and the surgical team's movements may also interfere with the instrument, leading to inaccurate measurements.

The VitaWave Finger Cuff by Edwards Lifesciences is a non-invasive device for continuous hemodynamic monitoring, used with the HemoSphere Vita system. Based on the volume-clamp method, it measures arterial pressure in real time via an inflatable cuff placed on a finger. It offers rapid setup and a user-friendly alternative to traditional arterial line monitoring.

We compared the quality of BP monitoring periods using the VitaWave to the reference pressure obtained through sphygmomanometer-based monitoring.

Materials and Methods

A pilot study was performed at the University of Parma between March and April 2025. Informed consent was obtained from all patients. Measurements were recorded during general anesthesia in thyroid surgery. Patients were not excluded due to other medical conditions.

Hemodynamic variables were measured from VitaWave for the entire procedure. The mean arterial pressure (MAP), systolic and diastolic blood pressures were continuously collected from the sphygmomanometer every 3 minutes and from VitaWave from entry into the operating room through the entire surgery.

Hypotensive events were defined as all recordings with MAP <60 mmHg lasting at least one minute; hypertensive events as MAP >100 mmHg lasting at least one minute.

Informed consent was obtained for the publication of this scientific article.

Results

Data from 4 adult patients requiring hemodynamic monitoring during tyhroid surgery were analyzed in this study. No hypotensive events were recorded during the monitoring period; however, 75% of the patients showed at least one hypertensive event.

The VitaWave device was easy to set up and install, provided continuous and reliable blood pressure monitoring, and demonstrated greater accuracy compared to standard cuff-based monitoring. It enabled the pressure monitoring also when the standard monitoring failed to detect the BP (Figure 1).

Conclusion

Our findings showed that the VitaWave device was able to provide continuous blood pressure monitoring throughout the entire procedure, detecting hypertensive peaks with virtually no delay - events that would likely have gone unnoticed using the standard cuff-based method.

References

1. Wijnberge M, Van Der Ster B, Vlaar APJ et al. The effect of intermittent versus continuous Non-Invasive Blood Pressure monitoring on the detection of intraoperative hypotension, a sub-study. JCM. 2022; 11(14): 4083.

2. Khanna AK, O'Connell NS, Ahuja S et aI. Incidence, severity and detection of blood pressure and heart rate perturbations in postoperative ward patients after noncardiac surgery. J Clin Anesth. 2023; 89: 111159.

Fig. 1 (abstract A16).

Blood pressure measurements with sphygmomanometer and VitaWave®

A17 Brain-targeted goal-directed therapy in high-risk patients undergoing major elective surgery: the brain-promise randomized control trial

M. Greco^1,2, M. Cavallo¹, G. Calgaro^1,2, A. Pradella², F. Piccirillo², M. Mascari², F. Piccioni², M. Cecconi^1,2

¹Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; ²Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Italy

Correspondence: M. Cavallo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A17

Background

With an aging surgical population, the surgical risk increases, and the need for patient-centered, goal-directed strategies in anesthesia is growing. Targeted hemodynamic management can reduce complications, particularly in elderly and frail patients at risk of neurological disfunction, such as delirium or Postoperative Cognitive Disfunction (POCD). Near-infrared spectroscopy (NIRS) is a non-invasive tool for monitoring regional brain oxygenation, which could enable early detection of cerebral hypoperfusion. Though widely used in cardiac surgery, its application in high-risk surgical populations remains underexplored. This prospective randomized controlled trial aimed to evaluate whether NIRS-guided goal-directed therapy can reduce rSO2 desaturation and improve postoperative outcomes, including neurocognitive ones, in high-risk elderly patients undergoing major surgery in general anesthesia.

Methods

The Brain Promise trial enrolled hypertensive patients aged >/= 65 or patients with a clinical frailty score >/= 5, undergoing moderate- to high-risk surgery under general anesthesia. Participants were randomized 1:1 to NIRS-guided management or standard care. NIRS monitoring was applied to both groups but used to guide treatment only in the experimental arm, while anesthesiologists were blinded to NIRS values in the control group. The primary outcome was the incidence of perioperative complications at 30 days. Secondary outcomes included POCD, delirium, length of stay, and mortality at 90 days.

Informed consent was obtained for the publication of this scientific article.

Results

We included 206 patients, 104 cases and 102 controls. There was no significant difference in the total number of postoperative complications or in the EPCO composite score (p = 0.51 and p = 0.52). Ninety-day mortality was 0% in the treatment group and 1% in the control group (p = 0.9). Readmission rates were similar (4.8% vs 7.1%, p = 0.7). A statistically significant decline in MMSE score was observed on postoperative day 1 in the control group (p = 0.034).

Conclusions

This study explored the effectiveness of NIRS-guided goal-directed therapy in high-risk elderly patients undergoing general anesthesia. No differences in complication rates were found between patients treated with NIRS-based goal directed therapy and controls.

Trial registration: ClinicalTrials.gov Identifier: NCT04266574

Keywords: NIRS; Hemodynamic monitoring; Complications; Surgery; Frailty; POCD

A18 The effects of smoking in obese surgical patients ventilated with low vs. high positive end-expiratory pressure and lung recruitment maneuvers

L.G. Giaccari, F. Coppolino, M.B. Passavanti, M.C. Pace, V. Pota, P. Sansone

Università della Campania Luigi Vanvitelli - Dipart. della Donna del Bambino e di Chirurgia Generale e Specialistic, Napoli, Italy

Correspondence: L.G. Giaccari

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A18

Background and Goal of Study

Obesity and smoking are associated with an increased morbility and mortality. The management of these patients during surgery is becoming challenging. These conditions significantly increase the risk of preoperative, intraoperative and postoperative surgical complications [1][2]. We evaluated the incidence of postoperative pulmonary complications (PPCs) in obese and smoking patients compared to obese and non-smoking patients undergoing elective surgery under general anesthesia.

Protocol Ethics Committee approval number: 003208/2016.

Informed consent was obtained for the publication of this scientific article.

Materials and Methods

95 obese surgical patients (45 in the lower PEEP group – 11 smokers; 50 in the higher PEEP group – 17 smokers) underwent volume-controlled mechanical ventilation with a tidal volume of 7 mL/kg of predicted body weight and two ventilatory strategies: 1) PEEP of 4 cmH2O without alveolar recruitment maneuvers; 2) PEEP of 12 cmH2O and alveolar recruitment maneuvers. Main measurements were pulmonary complications incidence, their distribution among the groups and postoperative admission rate to ICU.

Results and Discussion

We found that smoking was associated with poor postoperative outcomes in obese patients undergoing elective surgery. Among obese, smokers are at significantly higher risk than non-smokers for PPCs (see Figure 1). The incidence of PPCs was 8.9% in the low PEEP group and 8% in the high PEEP group (p > 0.05). The incidence of pulmonary complications was higher in smokers. When the ventilation strategy with a higher PEEP was used, complications occurred in 11.8% (n = 2) of smoking patients compared to 6.06% (n = 2) of non-smoking patients (p > 0.05). Intraoperative mechanical ventilation with a PEEP of 12 cmH2O and alveolar recruitment maneuvers did not reduce PPCs compared with a PEEP of 4 cmH2O. 18.2% of patients in low PEEP group reported PPCs compared to 11.8% of those in high PEEP group.

The use of a moderate tidal volume (6–8 ml/kg) is appropriate. Selecting appropriate PEEP could be complex, especially due to the risk of hyperinflation in smokers. The degree of hyperinflation must be closely monitored with the aim of obtaining Pplat <28 cmH2O and setting PEEP, that is enough to keep airways open and to keep transpulmonary pressure positive at end-expiration.

Conclusions

Active smoking obeses have a comparatively poor postoperative respiratory outcome after elective surgery. An intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce PPCs.

References:

1. Bamgbade OA, Rutter TW, Nafiu OO, Dorje P. Postoperative Complications in Obese and Nonobese Patients. World J Surg. 2007;31(3):556–60.

2. Yoshikawa R, Katada J. Effects of active smoking on postoperative outcomes in hospitalised patients undergoing elective surgery: a retrospective analysis of an administrative claims database in Japan. BMJ Open. 2019;9(10):e029913.

Fig. 1 (abstract A18).

Distribution of pulmonary complications

A19 Use of the assisted fluid management (AFM) software in intraoperative volume optimization of high risk patients undergoing major non-cardiac surgery: a case series

R. Fogacci¹, N. Tavlahidis¹, G. Monaco¹, A. Rescigno¹, J. Toni², E. Bernardi², S. Buda², S. Tigano², A. Siniscalchi²

¹Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Università di Bologna, Italy; ²Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy

Correspondence: R. Fogacci

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A19

Background

The intraoperative fluid therapy strategy during major abdominal surgery impacts post-operative outcomes in terms of recovery and complications. Goal-Directed Fluid Therapy (GFDT) proved to be effective in reducing postoperative complications rate and hospital length of stay [1]. Although this approach has been shown to be effective in optimizing cardiac output, there is considerable variability in its application based on patient comorbidities, surgical context, monitoring tools and hemodynamic targets set [2]. To assist clinicians in optimizing intraoperative patient volume status, the Assisted Fluid Management (AFM) system (Edwards Lifesciences) was implemented. Using a Machine Learning Algorithm (MLA) [3], AFM can suggest when a fluid bolus is most likely to optimize stroke volume (SV) according to hemodynamic individual responses to previous bolus tests.

Materials and Methods

In this Case Series, we present 6 high risk patients who underwent major abdominal surgery. In each case we previously obtained consent for the use of the AFM system during the surgical procedure. Boluses of approximately 200 ml with crystalloids or 5% Albumin were administered at the discretion of the clinician, and their effectiveness in terms of increasing SV by 10%, 15%, or 20% was assessed. Both test and recommended boluses by the AFM system were evaluated. Additionally, the effectiveness of boluses administered that were not recommended by the AFM system was also assessed.

Informed consent was obtained for the publication of this scientific article.

Results

A total of 6 patients were monitored (2 females and 4 males) for an average duration of 6 hours. Patients characteristics and surgery procedures are resumed in Table 1 and Results of our analysis is presented in Figure 1. In 83% of the cases, at least one hypotensive event (MAP < 65 mmHg) was recorded, with an average duration of 5.9 ± 7.1 minutes per event and a total average of 34 minutes per patient. A total of 45 boluses were analysed, including 16 test boluses and 29 recommended boluses. In 60% of the total cases, the boluses administered were effective in increasing SV. Specifically, 50% of the test boluses and the 66% of the recommended boluses were effective. Additionally, 3 non-recommended boluses were analysed, which were effective in 75% of the cases.

Conclusions

Although the effectiveness of the recommended boluses was limited and considering the necessary learning curve for the effective use of the system, AFM allows for better traceability of the volume of fluid boluses administered and their benefit in terms of SV augmentation and time-in-target for SVV within the context of precision medicine.

References

1. Benes J, Giglio M, Brienza N, Michard F. The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. Crit Care. 28 ottobre 2014;18(5):584.

2. Bennett-Guerrero E. Hemodynamic Goal-Directed Therapy in High-Risk Surgical Patients. JAMA. 4 giugno 2014;311(21):2177.

3. Joosten A, Alexander B, Delaporte A, Lilot M, Rinehart J, Cannesson M. Perioperative goal directed therapy using automated closed-loop fluid management: the future? Anestezjol Intensywna Ter. 4 dicembre 2015;47(5):517–23

Fig. 1 (abstract A19).

Summary of descriptive statistics of cases analysed

Table 1 (abstract A19).

General and surgical characteristics of patients included

ID (Gender, Age)	ASA	Surgery	Surgical indication	Comorbidities	Discharge from ICU
1 (66,M)	III	Right hepatectomy and biliodigestive anastomosis	Cholangiocarcinoma complicated by cholangiosepsis, and pancreatitis	Hypertensive cardiomyopathy, Chronic Obstructive Pulmonary Disease	Postoperative day 3
2 (63,M)	III	Videolaparoscopic wedge hepatectomy of the VI segment	Hepatocellular carcinoma	Hypertensive cardiomyopathy, cirrhosis	Postoperative day 1
3 (43,F)	III	Pre-emptive Kidney Transplant	Autosomal Dominant Polycystic Kidney Disease (ADPKD)	CKD III stage, Hypertensive cardiomyopathy	Postoperative day 1
4 (74, M)	IV	Whipple procedure	Pancreatic adenocarcinoma complicated by gastroduodenal fistula, and peritoneal abscesses	Sepsis, pneumonia, pleural and pericardial effusion, chronic anemia, supraventricular tachycardia	Postoperative day 3
5 (77,M)	III	Right nephroureterectomy and lymphadenectomy	Renal cell carcinoma	Chronic Kidney Disease III stage, Hypertensive Cardiomyopathy, Type 2 Diabetes Mellitus	Postoperative day 3
6 (50,F)	III	Evacuation of hemoperitoneum	Haemorrhagic shock following robotic anterior rectal resection	Adrenal adenoma, hypertension	Postoperative day 3

A20 Removal of epidural catheter in a patient with postoperative acute coronary syndrome under dual antiplatelet therapy: a case report

D. Ferraccioli¹, D. Fiume¹, C. Cacace², E. De Carolis¹, G. Liciani¹, L. Di Lallo¹, M. Arciuolo¹, S. Coppa¹, S. Carlini³, S. Parrino¹, L. Befani¹, A.M. Martini¹, M. Arduini⁴, M. Peverini¹, M. Galletti¹

¹UOC Anestesia e Rianimazione - Ospedale Sant'Eugenio, Roma, Italy; ²UOC Anestesia e Rianimazione - Università di Roma Tor Vergata, Roma, Italy; ³UOC Anestesia Operatoria - Azienda Ospedaliera San Giovanni Addolorata, Roma, Italy; ⁴UOC Ortopedia e Traumatologia - Ospedale Sant'Eugenio, Roma, Italy

Correspondence: C. Cacace

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A20

Background

The incidence of spinal hematoma after epidural anesthesia is estimated to be 1 in 150,000. This incidence increases to 1 in 3000 in some specific types of patients. A review suggests that catheter removal has a risk almost overlapping with the execution of epidural (1-2). And the incidence increases even more in patients receiving antiplatelet drugs, anticoagulants and/or thrombolytics. The American Society of Regional Anesthesia and Pain Management (ASRA) recommends 5-7 days of suspension of clopidogrel before catheter removal (3). In the case of multidrug therapy antithrombotic a precise and safe time for catheter removal is not defined.

Case report

78-year-old patient, hypertensive, diabetic, previous PTCA + Stent, accessed in the Emergency Department for multiple trauma with pulmonary contusions, underwent to reduction and synthesis of pelvic fracture, in elective regimen. Combined spinal anesthesia + epidural catheter implantation is performed. On the first postoperative day (POD) he presents cardiogenic shock with depressed EF (45%->25%) and request for norepinephrine at 0.5 y/kg/min, elevated ST, asymptomatic. Subjected to ballooning for subocclusive restenosis on DA. Subsequently double antiaggregant therapy (aspirin + clopidogrel) at full dosage. Removal of the epidural catheter was performed on 6 PODs after suspension of clopidogrel for 3 days, infusion of cangrelor 4 y/kg/min for 24 hours, suspension for 1 hour, removal, and initiation of clopidogrel the following day. He underwent continuous neurologic and cardiac evaluation and did not develop acute deficits.

Conclusion

This is a case report showing for the first time a successful management in the safe handling and removal of a peridural catheter in a patient with acute coronary syndrome in the postoperative period.

Consent to publish

Written informed consent for the publication is obtained from the patient.

References

1. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994;79:1165-77.

2. Vandermeulen E. Regional anaesthesia and anticoagulation. Best Pract Res Clin Anaesthesiol 2010;24:121-31.

3. Horlocker TT, Vandermeulen E, Kopp SL, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: american society of regional anesthesia and pain medicine evidence-based guidelines (Fourth Edition). Regional Anesth Pain Med. 2018;43:263—309.

A21 Reliability of nociception level index monitoring in general anesthesia: a systematic review

S. Ferraioli¹, V. Donatiello², M.C. Pace¹, M.B. Passavanti¹, P. Sansone¹

¹Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy; ²Department of Elective Surgery, Postoperative Intensive Care Unit and Hyperbaric Oxygen Therapy, A.O.R.N. A. Cardarelli, Naples, Italy

Correspondence: S. Ferraioli

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A21

Nociception monitoring during anesthesia aims to optimize analgesic administration, potentially reducing opioid consumption and improving patient outcomes. This systematic review evaluates the impact of nociception-guided anesthesia on opioid use and related outcomes.

Materials and Methods

Ten studies were selected: three randomized controlled trials (RCTs), two prospective observational studies, two retrospective analyses, and three systematic reviews/meta-analyses. These studies compared standard anesthesia care with nociception-guided approaches using monitors like the Nociception Level (NOL), Analgesia Nociception Index (ANI), Surgical Pleth Index (SPI), and pupillometry. Participants were adults aged >17 with ASA scores I–III and no significant comorbidities.

Informed consent was obtained for the publication of this scientific article.

Results

One RCT demonstrated a 30% reduction in remifentanil consumption in the NOL-guided group compared to standard care. Additionally, fewer hypotensive events and a reduced need for vasoactive medications were observed in the NOL group. A retrospective analysis in intracerebral surgery patients found that NOL monitoring was feasible and correlated with nociceptive events, suggesting potential for targeted analgesic interventions. A systematic review found that nociception monitoring could reduce intraoperative opioid consumption, though results varied across studies. A network meta-analysis indicated that pupillometry significantly decreased intraoperative opioid use compared to standard care, while NOL showed no significant difference.¹ ²

Conclusions

Nociception-guided anesthesia may reduce opioid consumption and improve perioperative outcomes. However, the effectiveness varies among different monitoring technologies. Further large-scale, multicenter RCTs are needed to establish definitive guidelines for integrating nociception monitoring into standard anesthesia practice. This review highlights the potential benefits of nociception monitoring in anesthesia, emphasizing the need for further research to optimize its application in clinical settings.

References

1. Snoek MAJ, van den Berg VJ, Dahan A, Boon M. Comparison of different monitors for measurement of nociception during general anaesthesia: a network meta-analysis of randomised controlled trials. Br J Anaesth. 2025;134(1):180–191. 10.1016/j.bja.2024.09.020.

2. Meijer FS, Martini CH, Broens S, et al. Nociception-guided versus standard care during remifentanil-propofol anesthesia: A randomized controlled trial. Anesthesiology. 2019;130(5):745–755. 10.1097/ALN.0000000000002634.

3. Ruemmler R, Moravenova V, Al-Butmeh S, et al. A novel non-invasive nociceptive monitoring approach fit for intracerebral surgery: a retrospective analysis. PeerJ. 2024;12:e16787. 10.7717/peerj.16787.

4. Meijer FS, Niesters M, van Velzen M, et al. Does nociception monitor-guided anesthesia affect opioid consumption? A systematic review of randomized controlled trials. J Clin Monit Comput. 2020;34(4):629–641. 10.1007/s10877-019-00362-4.

Table 1 (abstract A21).

Studies on General Anesthesia and Nociception Monitoring

Table 2 (abstract A21).

Studies on General Anesthesia and Nociception Monitoring (continued)

A22 The role of Frank’s sign as predictive marker for cardiovascular diseases

A. Federici¹, M. Ciuffreda², E. Pisello², L. Brugiaferri¹, S. Sorrenti¹, C. Piangatelli², D. Galante³

¹UNIVPM - Department of Anesthesia, Resuscitation, Intensive Care and Pain Managment, Ancona, Italy; ²Ospedale E. Profili - AST Ancona, Department of Anesthesia, Resuscitation, Intensive Care and Pain Managment, Fabriano, Italy; ³Ospedale Tatarella - ASL Foggia, Department of Anesthesia, Resuscitation, Intensive Care and Pain Managment, Foggia, Italy

Correspondence: A. Federici

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A22

Background

Frank’s sign is a characteristic diagonal earlobe crease. This retrospective observational study aimed to establish the relationship between Frank's sign and the prevalence of cardiovascular diseases. The Results were stratified among patients of various ages and the practical applications of the Results were also examined to understand the possible implications on diagnosis and prevention.

Material and Methods. The study was conducted on 200 patients at Engles Profili Hospital in Fabriano, Italy, between February 2023 and February 2024. Informed consent was obtained before data collection and drafting of the paper. Participants were categorized into three age groups: 0-19 years, 20-49 years, and over 50 years, to analyze the occurrence of Frank's sign and its correlation with heart disease. Each group was then compared to a composition-adjusted group to determine whether there was a statistically significant difference between young and older individuals, as cardiovascular risk increases with age. The analysis utilized univariate and multivariate statistical methods, as we can see with table number 1 and 2, to explore the relationship between Frank's sign and cardiovascular health indicators.

Results. The findings of this study revealed a significant association between Frank's sign and an increased likelihood of heart disease (OR 21.07), with a fourfold higher risk of developing cardiovascular disease in older populations compared to younger ones, particularly after the age of fifty. The strongest correlation between Frank's sign and heart disease was observed among the elderly (p < 0.001). Moreover, after adjusting for all factors, individuals with Frank's sign had a significantly higher risk of developing CVD (p = 5.62e-14). These results suggest that Frank's sign is not only a dermatological anomaly but also a symptom of vascular disease. It could serve as a valuable non- invasive marker in clinical settings for identifying cardiovascular disease risk, especially in older adults. The graphical representations in this study, as table 3 can demonstrate, showed the prevalence of Frank’s sign in obesity, smocking and metabolic syndrome, as well as its overall prevalence, which is consistent with overall cardiovascular risk. Frank’s sign could become a biomarker visible outwards to identified patients who need a quick and accurate diagnosis and could be an alternative in situations where traditional approaches are not timely or reliably accessible.

Conclusion

These findings underscore the importance of dermatological markers in predicting cardiovascular diseases and advocate for their potential inclusion in routine clinical assessments to enhance prediction and preventive strategies for managing CVD, particularly in resource-limited settings. This study, therefore, underlines how Frank’s sing is a useful tool for early diagnosis and supports a health model focused on prevention.

Table 1 (abstract A22).

Univariate Analysis for Cardiopathy Risk

Variable	Coefficient B	Standard Error	z	p	Odds Ratio	95% CI
Male Sex	−0.8	0.29	2.74	0.006	0.45	0.25—0.79
Age > 50	3.05	0.46	6.60	<.001	21.07	8.52—52.08
Presence of Frank’s sign	5.10	0.54	9.40	<.001	4.99	4.48—42.524
Monolateral Frank’s sign	0.67	1.24	1.24	0.21	1.95	0.68—5.61
Bilateral Frank’s sign	1.24	0.67	1.85	0.07	3.45	1.95—6.54
Preoperatives ECG abnormalities	3.95	1.03	3.84	<.001	4.94	2.48—394.86
ASA class 3–4	2.34	1.01	2.33	0.02	3.89	1.25—12.12
METs 0–2	0.35	1.33	1.02	0.3	1.42	0.25—7.98
Family history of ischemic heart disease	2.52	0.35	3.35	0.001	5.26	2.45—11.22
Obesity	1.67	0.38	4.38	<.001	5.29	2.5—11.22
Hypertension	3.27	0.45	7.26	<.001	26.36	9.65—73.75
Diabetes	2.58	0.64	4.03	<.001	13.19	3.76—46.27
Dyslipidemia	2.65	0.51	5.18	<.001	14.05	5.21—38.17
Smoking	2.00	0.84	7.34	<.001	7.36	2.82—19.19
Osas	2.52	0.77	3.25	0.001	12.42	2.72—56.65
Metabolic Syndrome	1.86	0.49	3.77	<.001	6.44	2.45—16.94

Table 2 (abstract A22).

Multivariate Analysis for Cardiopathy Risk

Variable	Coefficient B	Standard Error	z	p	Odds Ratio	95% Conf. Interval
Age > 50	1.63	0.78	2.08	0.037	5.09	1.1—23.52
Presence of Frank’s sign	3.13	0.91	3.42	<.001	22.78	7.19—136.78
Bilateral Frank’s sign	2.00	0.83	2.41	0.016	7.39	1.7—32.1
Preoperatives ECG abnormalities	3.24	1.81	1.79	0.073	25.63	0.74—889.45
ASA class 3–4	1.42	1.42	1.01	0.031	7.33	1.13—51.09
Hypertension	1.67	0.77	2.17	0.03	5.30	1.04—27.19
Dyslipidemia	−0.50	0.72	−0.69	0.49	0.61	0.15—2.49

Table 3 (abstract A22).

Comparison of Variables between Frank's Sign and No Frank's Sign

Variable	Total Population (n = 200)	Frank's Sign (+) (n = 140)	Frank's Sign (-) (n = 60)	p-value
Hypertension	140 (70%)	90 (64.3%)	30 (50%)	5.62e-14
Diabetes	100 (50%)	80 (57.1%)	20 (33.3%)	1.91e-11
Genetic predisposition	125 (62.5%)	90 (64.3%)	35 (58.3%)	6.45e-10
Metabolic Syndrome	138 (69%)	100 (71.4%)	38 (63.3%)	1.23e-14
Obstructive Sleep Apnea Syndrome	140 (70%)	100 (71.4%)	40 (66.7%)	3.45e-13
Smoking	121 (60.5%)	80 (57.1%)	41 (68.3%)	5.32e-05
Obesity	130 (65%)	95 (67.9%)	35 (58.3%)	2.14e-11

A23 National survey of current management of the use of neuromuscolar blocking agents and its reversal in adult, pediatric and pregnant patients

A. Federici¹, M. Ciuffreda², E. Pisello², L. Brugiaferri¹, S. Sorrenti¹, C. Piangatelli², D. Galante³

¹UNIVPM - Department of Anesthesia, Resuscitation, Intensive Care and Pain Management, Ancona, Italy; ²Ospedale E. Profili - AST Ancona, Department of Anesthesia, Resuscitation, Intensive Care and Pain Management, Fabriano, Italy; ³Ospedale Tatarella - ASL Foggia, Department of Anesthesia, Resuscitation, Intensive Care and Pain Management, Cerignola, Italy

Correspondence: A. Federici

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A23

Background

Despite the existence of national and international guidelines in management of myoresolution, there is a persistent heterogeneity in the use of neuromuscolar blocking agents by Italian anesthesiologists. The aim of this article is to show the Results of an Italian survey conducted to obtain information on the current management of myresolution in Italy.

Materials and Methods

A digital questionnaire was created and spread in different ways (as link via social networks or by word of mouth) to obtain data among specialists and residents in Anesthesia and Resuscitation, Intensive Care and Pain during a period between February 2023 and February 2024. The questions were about the type of patient, neuromuscular blocking agents used, frequency of use and type of neuromuscular monitoring, TOF ratio value considered safe to assess recovery from myoresolution, use of reversals with side effects related, incidence of postoperative residual curarization (PORC). All the information obtained has been stratified by age, geographical location and type of workplace (public or private centre). Moreover, after obtain informed consent, data were collected anonymously and were analysed considering the values in percentages.

Informed consent was obtained for the publication of this scientific article.

Results

Results. The questionnaire was completed by 287 anesthesiologists (2% of anesthesiologists active in Italy in 2023) and all the results obtained, stratified according to the type of patient, are well represented in tables 1, 2 and 3. Rocuronium is the most widely used neuromuscular blocking agent in adult, pediatric and pregnant patients (>90%). Neuromuscular monitoring is used most frequently in relation to the type of patient (ASA > 2) and the type of procedure (major surgery) in both adults (46%) and children (41%). In pregnant women, anesthesiologists who never use it predominate (39%). Sugammadex is the most widely used reversal in both adults (85%), pregnant women (81%) and children (94%). Neuromuscular monitoring systems are little used while the clinical manifestations would seem to guide the possible additional doses of neuromuscular blocking agents or to evaluate recovery from neuromuscular blockade. This is one of the aspects that can explain why the incidence of PORC is not so low. The data show that, in the adult patient, the incidence of PORC is 16%, 6% in the pregnant woman and 9% in the child..

Conclusion

This survey highlights what is the current Italian experience regarding the myoresolution. The data obtained show that clinical practice is still not standardized so the risk of incomplete neuromuscular recovery is a real consequence. A routine use of neuromuscular monitoring systems should be pursued to manage both neuromuscular blocking agents and their reversals in a more rational and conscious way.

Table 1 (abstract A23).

Results: Adult Patient

VARIABLE	VALUE	N°(%)
Neuromuscolar blocker	Rocuronium, Cisatracurium	248 (97%), 9 (3%)
Neuromuscolar monitoring usage	No never, Yes always, Sometimes	84 (33%), 55 (21%), 118 (46%)
Most frequently used neuromuscolar monitoring	Acceleromyography, No use, Pressure peaks detection, Kinesiomyography	158 (62%), 81 (31%), 14 (6%), 4 (1%)
Use of PTC as a guide in deep muscle relaxation	No never, Yes always, Sometimes	132 (51%), 26 (10%), 99 (39%)
Guideline for administering NMBA booster doses	Clinical signs, Monitoring, Time since last dose, Surgeon request, No boosters	145 (56%), 58 (23%), 47 (18%), 5 (2%), 2 (1%)
Reversal	Summagades, None, Reversal mix	219 (85%), 26 (10%), 12 (5%)
Sugammadex dosage selection based on	Time since last NMBA dose, Monitoring values, Both, Don't use Sugammadex	91 (35%), 30 (12%), 109 (42%), 27 (11%)
Most common Sugammadex side effects	Never observed, Don't use Sugammadex, Bradycardia, Cough, Allergic reactions, Hypotension	185 (72%), 32 (13%), 29 (11%), 6 (2%), 3 (1%), 2 (1%)
Minimum TOF value for extubation	No TOF ratio usa, 0.9, 1, 0.8, 0.7	75 (29%), 155 (60%), 18 (7%), 5 (2%), 4 (2%)
Completion of anesthetic record with neuromuscolar monitorig data	No never, Yes always, Occasionally	118 (46%), 60 (23%), 79 (31%)
PORC experience	Yes, No	40 (16%), 217 (84%)
Sugammadex in PORC cases	PORC yes, PORC no	37 (17%), 182 (83%)
Reversal mix or spontaneous recovery in PORC	PORC yes, PORC no	3 (8%), 35 (92%)
PORC neuromuscolar monitoring	Always, Sometimes, Never	20 (50%), 15 (37.5%), 5 (12.5%)

Table 2 (abstract A23).

Results: Pregnant Patient

VARIABLE	VALUE	N°(%)
Neuromuscolar blocker	Rocuronium, Cisatracurium, Other	80 (94%), 2 (2%), 3 (4%)
Neuromuscolar monitoring usage	No never, Yes always, Sometimes	33 (39%), 17 (20%), 35 (41%)
Most frequently used neuromuscolar monitoring	Acceleromyography, No use, Pressure peaks detection, Kinesiomyography	46 (54%), 33 (39%), 2 (2%), 4 (5%)
Use of PTC as a guide in deep muscle relaxation	No never, Yes always, Sometimes	55 (65%), 8 (9%), 22 (26%)
Guideline for administering NMBA booster doses	Clinical signs, Monitoring, Time since last dose, Surgeon request, No boosters	35 (41%), 25 (29%), 16 (19%), 1 (2%), 8 (9%)
Reversal	Summagades, None, Reversal mix	69 (81%), 14 (17%), 2 (2%)
Sugammadex dosage selection based on	Time since last NMBA dose, Monitoring values, Both, Don't use Sugammadex	34 (40%), 18 (21%), 21 (25%), 12 (14%)
Most common Sugammadex side effects	Never observed, Don't use Sugammadex, Bradycardia, Cough, Allergic reactions, Hypotension	60 (71%), 12 (14%), 9 (11%), 1 (1%), 2 (2%), 1 (1%)
Minimum TOF value for extubation	No TOF ratio usa, 0.9, 1, 0.8, 0.7	28 (33%), 46 (54%), 6 (7%), 3 (4%), 2 (2%)
Completion of anesthetic record with neuromuscolar monitorig data	No never, Yes always, Occasionally	38 (45%), 25 (29%), 22 (26%)
PORC experience	Yes, No	5 (6%), 80 (94%)
Sugammadex in PORC cases	PORC yes, PORC no	5 (8%), 64 (92%)
Reversal mix or spontaneous recovery in PORC	PORC yes, PORC no	0 (0%), 16 (100%)
PORC neuromuscolar monitoring	Always, Sometimes, Never	2 (40%), 2 (40%), 1 (20%)

Table 3 (abstract A23).

Results: Pediatric Patient

VARIABLE	VALUE	N°(%)
Neuromuscolar blocker	Rocuronium, Cisatracurium	104 (99%), 1 (1%)
Neuromuscolar monitoring usage	No never, Yes always, Sometimes	27 (26%), 35 (33%), 43 (41%)
Most frequently used neuromuscolar monitoring	Acceleromyography, No use, Pressure peaks detection, Kinesiomyography	73 (70%), 27 (26%), 3 (3%), 2 (2%)
Use of PTC as a guide in deep muscle relaxation	No never, Yes always, Sometimes	69 (66%), 8 (8%), 28 (26%)
Guideline for administering NMBA booster doses	Clinical signs, Monitoring, Time since last dose, Surgeon request, No boosters	45 (43%), 34 (32%), 20 (19%), 1 (1%), 5 (5%)
Reversal	Summagades, None, Reversal mix	99 (94%), 4 (4%), 2 (2%)
Sugammadex dosage selection based on	Time since last NMBA dose, Monitoring values, Both, Don't use Sugammadex	27 (26%), 20 (19%), 56 (53%), 2 (2%)
Most common Sugammadex side effects	Never observed, Don't use Sugammadex, Bradycardia, Cough, Bronchospasm	87 (83%), 3 (3%), 13 (12%), 1 (1%), 1 (1%)
Minimum TOF value for extubation	No TOF ratio usa, 0.9, 1, 0.8, 0.7	24 (23%), 59 (56%), 18 (17%), 3 (3%), 1 (1%)
Completion of anesthetic record with neuromuscolar monitorig data	No never, Yes always, Occasionally	30 (29%), 40 (38%), 35 (33%)
PORC experience	Yes, No	9 (9%), 96 (91%)
Sugammadex in PORC cases	PORC yes, PORC no	9 (9%), 96 (91%)
Reversal mix or spontaneous recovery in PORC	PORC yes, PORC no	0 (0%), 6 (100%)

A24 Efficacy of maltodextrin intake before cesarean section, a randomised control trial: pilot data

T. Palladino¹, A. Discenza², A. Basta², S. Tamburrano², F. Cardinale², G. Ferrara², P. Vaira¹, A. Cotoia²

¹Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy; ²Dipartimento di Medicina e Scienze della Salute, Università degli Studi di Foggia, Italy

Correspondence: A. Basta

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A1

Background

Administration of carbohydrate rich fluids before major surgery have been proven to enhance patient comfort prior to surgery and to reduce insulin resistance, catabolism, with a positive impact on perioperative glucose control and muscle preservation 1,2, lower blood glucose level up to 24 h postoperative and fewer insulin administration needed3.

Few data are available about the beneficial effects of maltodextrins administration on pregnant woman undergoing to cesarean section (CS)

The aim of this randomized controlled study was to compare preoperative administration of maltodextrin with untreated patients in patients undergoing elective CS.

Materials and Methods

This pilot study included 20 patients undergoing elective CS aged from18 to 40 years. Inclusion and exclusion criteria are resumed in Table 1. Patients were randomly assigned in two groups: group M treated with oral intake of maltodextrins 200 mL, group C with clear liquid.

After obtaining informed consent, anthropometric data, maternal blood glucose level (BGL) before and after CS, monitoring time per patient (in minutes), was collected in all the patients. Spinal anaesthesia was performed with levobupivacaine (between 2-3 mL) and fentanyl (20 mcg) according to internal anaesthesiologic protocol between L2-L3 or L3-L4 interspace. All intrathecal drugs were preservative free. After birth, blood gas analysis was performed on the foetus, then Apgar at 1 and 5 minutes, blood gas analysis pO2, pCO2, lactate (LAC), base excess (BE) were collected.

Informed consent was obtained for the publication of this scientific article.

Results

Comparing the variation of BGL intragroup, a significant difference appears to be present in the C group between preoperative (80.5±8.36mg/dL) and postoperative(91.0±12.51 mg/dL) blood glucose levels (p = 0.004), whereas no statistically significant difference was observed in the M group (preoperative 85.5±13.06mg/d, postoperative 83.1±7.90, p = 0.644) (Fig. 1). Preoperative BGL in group M was similar compared to group C (Fig 1) (p 0.321), likewise postoperative comparison between M group and C group (p 0.109). Moreover, there were no significant differences between the two groups in terms of anthropometric characteristics and duration of monitoring, APGAR and foetal blood gas analysis (Table 2).

Conclusions

The data collected in this pilot study suggest that patients who received oral maltodextrins exhibited better glycemic control compared to the control group, without adverse effects on the fetus. This outcome may be attributed to improved glycemic regulation, and we hope that continuation of the study will confirm these preliminary findings.

Reference

1. Pogatschnik C, Steiger E. Review of Preoperative Carbohydrate Loading. Vol. 30, Nutrition in Clinical Practice. SAGE Publications Inc.; 2015. p. 660–4.

2. Qin H, Ji J, Miao Y, Liu T, Zhao D, Jia Z, et al. Efficacy of the Oral Administration of Maltodextrin Fructose Before Major Abdominal Surgery: A Prospective, Multicenter Clinical Study. World J Surg. 2022 Sep 1;46(9):2132–40.

3. Kumar L, Ashok A, Sudhakar A, Sreekumar G. Preoperative maltodextrin in minimally invasive colorectal surgery: Is it safe for diabetics? A randomised controlled trial. Indian J Anaesth. 2023 Dec 1;67(12):1084–9.

Registration code at ClinicalTrials.gov: ID NCT05553756

Ethics committee approval: Dr. Michele Giuliani, protocol no. 1169/09-DG, on 13/02/2020

Fig. 1 (abstract A24).

Blood glucose levels (BGL), preoperative and postoperative values between C group and M group

Table 1 (abstract A24).

Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Elective caesarean section	Any contraindication to single shot spinal anaesthesia
Singleton pregnancy	Presence of known cardiovascular disease
American Society of Anaesthesiologist score (ASA score) ranging from I grade to II grade	Refusal to participate to the study
Body mass index (BMI) between 18 and 35 (18 < BMI < 35)

Table 2 (abstract A24).

Outcomes; Not applicable (NA): p-value not computed due to lack of variability in the data

	Mean C Group	Mean M group	p
Age (years)	33.3 ± 3.43	34.3 ± 5.66	0,639
Height (cm)	160.0 ± 8.39	159.6 ± 6.17	0,905
Monitoring time per patient (min)	28.167 ± 4.34	34.78 ± 8.34	0,039
APGAR 1 min	8.70 ± 0.48	8.80 ± 0.44	0,153
APGAR 5 min	9.00 ± 0.00	9.00 ± 0.00	NA
pO2 (mmHg)	17.99 ± 7.63	14.95 ± 6.63	0,354
pCO2 (mmHg)	52.22 ± 13.71	48.5 ± 8.72	0,48
Lac (mmo/l)	2.41 ± 1.76	2.05 ± 0.88	0,57
BE (mmol/L)	−3.19 ± 2.22	−2.65 ± 1.39	0,523

A25 Opioid Free Anesthesia (OFA) Vs Opioid Inclusive Anesthesia (OIA) In Otorhinolaryngology (ENT)/Head And Neck Surgery

M. Cusenza, D. Rampulla

A.O.O.R. Villa Sofia Cervello - P.O. Villa Sofia, Palermo, Italy

Correspondence: M. Cusenza

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A25

Background

Although OFA protocols have found maximum use in abdominal surgery, their application has expanded to other specialties.

We present the OFA protocol used for the surgical treatment of neck diseases employed at our Anesthesia Department at Ospedali Riuniti VillaSofia Cervello of Palermo – VillaSofia Hospital.

Materials and Methods

We compared data from 107 adult patients undergoing scheduled general anesthesia for the surgical treatment of neck diseases from 1 st January to 30th October 2024: 52 patients treated with OFA protocol; 55 adult patients treated with OIA protocol.

OFA patients have been premedicated with i.m. 75 mcg clonidine and i.v. 0,05 mg/kg midazolam; they received ultrasound-guided Superficial Cervical Plexus Block (SCPB), with Ropivacaine 0,5%, unilateral (8ml) or bilateral (16 ml) according to the surgical site. Before the induction, they received i.v. 30 mg/kg of magnesium sulphate in 100 ml of NaCl 0,9%, and an i.v. infusion of 8 mg/kg/h of magnesium sulphate 5%. After 1 hour from the surgical incision, continuous i.v. infusion 90 mg Ketorolac in 48 ml NaCl 0,9% has been administrated. Five minutes before the end, infusion of magnesium sulphate has been stopped and replaced with i.v. 1 g paracetamol bolus. Control group received general anesthesia based on opioids administration for the intra- and post-operative analgesia.

We recorded post-operative pain evaluation according to the Numeric Rating Scale (NRS) at five time point (T0: End of surgery; T1: 6 post-operative hours; T2: 12 post-operative hours; T3: 18 post-operative hours; T4: 24 post-operative hours) and the occurance of adverse effects, such as paralytic ileus, hypoxemia, PONV, itching, delayed awakening,

Informed consent was obtained for the publication of this scientific article.

Results

A lower NRS has been recorded in the OFA group than control one at each time point (T0-T1-T2-T3 p<0.0001; T4 p=0.004), as shown in Figure 1. Considering the adverse effects, no episodes of intestinal paralysis or hypoxemia were observed in either group. The difference in the incidence of itching (p=0.165) and delayed awakening episodes (p=0.190), was not statistically significant between the two observed groups. The real advantage of using the OFA protocol, highlighted by data analysis, appears to be the reduced incidence of postoperative PONV (p=0.011); although manipulation of the surgical site may influence the onset of such disorders, the data we obtained suggest that the main determinant for their development remains the intraoperative use of opioids.

Conclusion

From this retrospective monocentric observational study, it can be concluded that, although opioid-inclusive anesthesia is the technique chosen by most healthcare providers in perioperative medicine, the OFA protocol used in our Department ensures an adequate anesthetic plan as well as optimal postoperative pain control, significantly reducing the incidence of PONV compared to an opioid-inclusive anesthesiology protocol (OIA).

Our data, referring to the experience of a single center, require further confirmatory studies. Ultimately, the

Results obtained, considering the advantages of opioid-free anesthesia, the easy applicability of the presented OFA protocol, and the reduced incidence of adverse effects related to its use, encourage further studies.

Fig. 1 (abstract A25).

Post-operative pain assessment by NRS score

A26 Hypoglossal nerve palsy following endotracheal intubation with videolaryngoscopy

D. Cucina¹, E. Ioppolo¹, G. Cavenaghi², V. Torrano²

¹School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; ²Department of Anesthesia, Critical Care and Pain Medicine, Asst Grande Ospedale Metropolitano Niguarda, Milan, Italy

Correspondence: D. Cucina

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A26

Background

Nerve injuries are rare complications of airway management during general anesthesia [1]. Hypoglossal nerve palsy (HNP) typically presents with tongue deviation, dysarthria and dysphagia. HNP has been reported after the use of endotracheal tubes, laryngeal mask airways and direct laryngoscopy [1,2]. To date, no case of unilateral HNP following videolaryngoscope-assisted intubation has been reported. The hypoglossal nerve’s extracranial course makes it susceptible to compression or stretch, especially near the hyoid bone or cervical vertebrae during neck hyperextension, elevated cuff pressures, or prolonged intubation [2,3]. Anatomical variants [Figure 1], such as a low-looping hypoglossal nerve or ossification of the stylohyoid ligament, may further increase vulnerability to injury during airway manipulation [2,4]. We report the first known case of isolated, unilateral HNP following videolaryngoscopy.

Case report

A 58-year-old man with benign prostatic hyperplasia and history of mitral valve plasty was scheduled for elective transurethral resection of the prostate and bladder stone lithotripsy. Due to refusal of spinal anesthesia, total intravenous anesthesia was performed. Endotracheal intubation was successfully achieved at the first attempt using a videolaryngoscope, with no immediate complications. No oropharyngeal airway was employed. After intubation, cuff pressure was checked and confirmed to be between 20 and 30 cmH2O. Surgery and extubation were uneventful. Upon returning to the ward, the patient reported speech impairment. Central causes of neurological injury were excluded. Tapia's syndrome—i.e., concurrent unilateral paralysis of the hypoglossal nerve and recurrent laryngeal nerve—was first hypothesized. However, otolaryngological evaluation excluded damage to the latter as vocal cord mobility was preserved. Electromyography showed active denervation of the left genioglossus muscle, consistent with partial axonal injury of the left hypoglossal nerve. Despite corticosteroid and neurotrophic therapy, complete clinical recovery was not achieved.

Conclusion

This is the first reported case of isolated, unilateral hypoglossal nerve palsy following videolaryngoscopic intubation. An underlying anatomical nerve variant cannot be excluded as a contributing factor. Further investigation is needed to clarify the mechanism and guide prevention strategies. Proper head positioning, endotracheal tube cuff pressure monitoring and visual confirmation of cuff position may help prevent nerve injury, since videolaryngoscopy alone does not eliminate this risk.

Written informed consent was obtained from the patient for publication of this case report.

References

1. Ulusoy H, Besir A, Cekic B, Kosucu M, Geze S. Transient unilateral combined paresis of the hypoglossal nerve and lingual nerve following intubation anesthesia. Rev Bras Anestesiol. 2014;64(2):124–7.

2. Shah AC, Barnes C, Spiekerman CF, Bollag LA. Hypoglossal nerve palsy after airway management for general anesthesia: an analysis of 69 patients. Anesth Analg. 2015;120(1):105–20.

3. Al-Benna S. Right hypoglossal nerve paralysis after tracheal intubation for aesthetic breast surgery. Saudi J Anaesth. 2013;7(3):341–3.

4. Brattou P, Iliakopoulos K, Anagnostou E, et al. Bilateral palsy of the hypoglossal nerve following general anesthesia for emergency surgery: a case report. Int J Surg Case Rep. 2022;96:107387.

Fig. 1 (abstract A26).

Reconstructed surgical view of a neck dissection. Anatomical variants of the hypoglossal nerve may descend more caudally, increasing the risk of proximity to the larynx

A27 Critical illness polineuropathy can occur even after a short period of septic shock: a case report

S. Canciello, G. Lauro, S. Cotena, M. Mariani, V. Schettini, M.E. Porcelli, P. Rinaldi, R. Villani

AORN Antonio Cardarelli, Napoli, Italy

Correspondence: S. Canciello

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A27

Background

Critical illness polyneuropathy (CIP) is a common complication in critically ill patients, (1) particularly those who experience prolonged immobilization and systemic inflammatory responses (2). CIP is associeted with prolonged mechanical ventilation and overall fuctional recovery, potentially leading to long term neuromuscolar deficts (3). In patients with sepsis, multi-organ failure, or requiring protracted mechanical ventilation, the combined prevalence of CIP and critical illness myopathy (CIM) is estimated to be as high as 50% (4).

Case Report

This report presents a 47-year-old male with a history of gastrointestinal stromal tumor (GIST) already treated surgically, who developed an intestinal perforation due to tumor recurrence, resulting in septic shock. The patient underwent an abdominal laparotomy with intestinal resection, Abthera device placement, and a second-stage surgery for ileostomy creation within 36 hours. Postoperatively, the patient was admitted to the ICU and required mechanical ventilation for seven days due to respiratory failure secondary to his critical condition. The septic shock was characterized by a brief duration, lasting only four days, during which serum levels of procalcitonin, white blood cells and lactates were markedly elevated. (e.g. Figure 1). The patient required high-dose vasoactive medication therapy, a cycle of dialysis treatment with a Toramixin filter, and exhibited difficult weaning from mechanical ventilation, with a 72-hour interval between sedation withdrawal and extubation, during which he remained unresponsive despite being unsedated, showing only minimal eye opening to verbal stimuli. Difficulty in weaning from mechanical ventilation is a common and characteristic feature of critical illness polyneuropathy (5) and is associated with dysfunction of the phrenic nerves, diaphragm, intercostal, and other accessory respiratory muscles (6). Despite the brief duration of septic shock and its rapid resolution, the patient developed clinical and electrophysiological signs of CIP. Electromyography revealed asymmetric peripheral nerve damage, more prominent in motor fibers of both upper and lower limbs, with clear signs of denervation in distal muscles, such as the anterior tibialis. These findings are consistent with the long-term complications of CIP (7). This development raises important considerations regarding the timing and recognition of CIP, especially in patients who experience cirtic short-lived septic episodes.

Conclusion

The interesting aspect of this case lies in the rapidity of the patient’s recovery from septic shock, combined with the subsequent development of CIP, underscoring that even relatevely short episodes of critical illness and ICU recovery can lead to significant neuromuscolar complications. Clinicians must maintain a high index of suspicion for CIP in critically ill patients, regardless of the duration or severity of their septic episodes. Further research is needed to elucidate the pathophysiology of CIP in short-lived septic episodes and to develop protocols for early diagnosis and management.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Tankisi H, de Carvalho M, Z'Graggen WJ. Critical Illness Neuropathy. J Clin Neurophysiol. 2020 May;37(3):205-207. 10.1097/WNP.0000000000000658. PMID: 32358246.

2. Tennilä A, Salmi T, Pettilä V, Roine RO, Varpula T, Takkunen O. Early signs of critical illness polyneuropathy in ICU patients with systemic inflammatory response syndrome or sepsis. Intensive Care Med. 2000 Sep;26(9):1360-3. 10.1007/s001340000586. PMID: 11089765.

3. Zifko UA. Long-term outcome of critical illness polyneuropathy. Muscle Nerve Suppl. 2000;9:S49-52. https://doi.org/10.1002/1097-4598(2000)999:9<::aid-mus9>3.0.co;2-9. PMID: 11135284.

4. Zhou C, Wu L, Ni F, Ji W, Wu J, Zhang H. Critical illness polyneuropathy and myopathy: a systematic review. Neural Regen Res. 2014 Jan 1;9(1):101-10. 10.4103/1673-5374.125337. PMID: 25206749; PMCID: PMC4146320.

5. Koch S, Spuler S, Deja M, Bierbrauer J, Dimroth A, Behse F, Spies CD, Wernecke KD, Weber-Carstens S. Critical illness myopathy is frequent: accompanying neuropathy protracts ICU discharge. J Neurol Neurosurg Psychiatry. 2011 Mar;82(3):287-93. 10.1136/jnnp.2009.192997. Epub 2010 Aug 27. PMID: 20802220.

6. Garnacho-Montero J, Madrazo-Osuna J, García-Garmendia JL, Ortiz-Leyba C, Jiménez-Jiménez FJ, Barrero-Almodóvar A, Garnacho-Montero MC, Moyano-Del-Estad MR. Critical illness polyneuropathy: risk factors and clinical consequences. A cohort study in septic patients. Intensive Care Med. 2001 Aug;27(8):1288-96. 10.1007/s001340101009. PMID: 11511941.

7. Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G. Clinical review: Critical illness polyneuropathy and myopathy. Crit Care. 2008;12(6):238. 10.1186/cc7100. Epub 2008 Nov 25. PMID: 19040777; PMCID: PMC2646339.

Fig. 1 (abstract A27).

Legend: Timeline and Septic markers

A28 Dynamic phenotypes of expiratory flow limitation in patients undergoing laparoscopic surgery: determinants and clinical impact

M. Bonanni¹, F. Montanaro¹, M. Ciniero¹, M. Orsinger¹, F. Cinquegrana¹, M. Bertoni², F. Bongiovanni³, M. Verri¹, C.A. Volta¹, S. Spadaro¹, G. Scaramuzzo¹

¹Department of Anesthesia and Intensive Care, University Hospital of Ferrara, Italy; ²Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy; ³Department of Emergency, ASST Spedali Civili University Hospital, Brescia, Italy

Correspondence: M. Bonanni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A28

Background

Expiratory flow limitation (EFL) has been linked to a higher risk of postoperative pulmonary complications (PPCs) [1], extubation failure and regional dynamic hyperinflation. Pneumoperitoneum and patient positioning might increase the tendency for EFL, but the factors associated with this phenomenon remain poorly explored.

Materials and Methods

We enrolled patients undergoing elective laparoscopic surgery under general anesthesia, all ventilated with a PEEP (positive end-expiratory pressure) of 4 cmH2O. EFL was assessed using the PEEP test, based on the sudden subtraction of PEEP during expiration and on the real-time visual inspection of the flow-volume. The test was performed at two predefined time points (T): T1 (10 minutes post-induction) and T2 (10 minutes after positioning and pneumoperitoneum). Patients were therefore classified at each time point as flow limited or not flow limited based on the results of the PEEP test. Afterwards, considering the trajectory of EFL, patients were stratified as: 1) never-flow limited (NFL: never developed EFL), 2) acquired EFL (aEFL; EFL only in T2), and 3) persistent flow limited (pEFL, EFL both in T1 and T2). Additional respiratory and hemodynamic parameters were recorded. Differences among the three groups were analyzed using ANOVA and Turkey`s Post-Hoc Test. Informed consent was obtained from all participants.

Informed consent was obtained for the publication of this scientific article.

Results

A total of 375 patients (111 male) with a median age of 66 years [22–89], BMI of 27 kg/m² [13–65], and SpO2 of 97% [90–100] were included in the study. More than half of the patients (52.5%) were classified as NFL, while 24.3% were classified as aEFL and 17.1% as pEFL (Figure 1). When considering demographic parameters, NFL patients had significantly lower BMI, ASA score and higher SpO2 (Table 1), while no significant differences were observed between aEFL and pEFL. After anesthesia induction, NFL patients had consistently higher PaO2/FiO2 ratio and SpO2 levels, along with lower plateau pressure and peak pressure values, compared to both aEFL and pEFL. When comparing pEFL and aEFL, pEFL patients showed significantly higher peak pressure and plateau pressure values compared to aEFL patients. After positioning and pneumoperitoneum, NFL patients confirmed their significantly higher PaO2/FiO2 ratio and SpO2 levels and lower plateau pressure and peak pressure values compared to both aEFL and pEFL. No significant differences were found between aEFL and pEFL at T2, nor were any significant variations found in hemodynamic parameters (all p > 0.05).

Conclusions

EFL during major laparoscopic surgery is a dynamic phenomenon with distinct phenotypes. Patients initially classified as NFL at T1, may develop EFL at T2. This highlights the importance of reassessing EFL after pneumoperitoneum. The aEFL group shows distinct respiratory characteristics even before developing EFL, suggesting a preexisting predisposition. Identifying these patients may allow for tailored ventilation strategies to reduce the risk of complications.

Trial registration: NCT06215001

Reference

1. Spadaro S, et al. EFL as a Risk Factor for Pulmonary Complications After Major Abdominal Surgery. AnesthAnalg.febbraio2017;124(2):524–30.

Fig. 1 (abstract A28).

Graphical representation of dynamic EFL phenotypes during major laparoscopic surgery

Table 1 (abstract A28).

Comparison of parameters among groups. * post-hoc analysis: significantly different from NFL. # post-hoc analysis: significantly different from aEFL

Parameter	NFL (n = 197)	aEFL (n = 91)	pEFL (n = 64)	ANOVA (p-value)
BMI (kg/m2)	25.2 ± 4.7	28.6 ± 5.9*	29.0 ± 7.0*	< 0.001
SpO₂ (T0) (%)	97.7 ± 1.5	97.1 ± 1.9*	96.8 ± 2.1*	0.001
ASA Score	2.5 ± 0.6	2.7 ± 0.5*	2.7 ± 0.5	0.004
SpO₂ (T1) (%)	98.7 ± 1.3	98.1 ± 1.8*	98.3 ± 1.8	0.008
PaO₂/FiO₂ (T1)	403.8 ± 118.6	316.0 ± 133.0*	298.5 ± 122.5*	< 0.001
Peak Pressure (T1) (cmH2O)	16.0 ± 4.1	17.7 ± 4.2*	20.9 ± 5.5*#	< 0.001
Plateau Pressure (T1) (cmH2O)	13.5 ± 3.4	15.0 ± 4.1*	16.8 ± 3.6*#	< 0.001
SpO₂ (T2) (%)	98.5 ± 1.5	97.6 ± 1.9*	98.1 ± 1.9	< 0.001
PaO₂/FiO₂ (T2)	361.3 ± 110.2	264.7 ± 102.3*	284.3 ± 89.8*	< 0.001
Peak Pressure (T2) (cmH2O)	23.5 ± 4.3	27.6 ± 4.3*	28.8 ± 6.0*	< 0.001
Plateau Pressure (T2) (cmH2O)	20.7 ± 3.8	24.6 ± 4.3*	24.9 ± 6.2*	< 0.001

A29 Impact of minimal flow ventilation on intraoperative hemodynamic performance

G. Bonadio, F. Bonadio, M. Caruso, A. Monardo

Presidio Ospedaliero Giovanni Paolo II di Lamezia Terme, Azienda Sanitaria Provinciale di Catanzaro, Lamezia Terme, Italy

Correspondence: G. Bonadio

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A29

Background

Low-flow anesthesia is a well-established technique offering numerous advantages in terms of anesthetic gas economy, potential reduction of environmental impact, as well as improving body temperature maintenance, without compromising gas exchange or patient safety [2]. In this retrospective case series, a minimal flow anesthesia protocol based on Sevoflurane and Oxygen/Air mixture is applied in line with the principles illustrated in Dräger's minimal flow anesthesia management scheme [1] on 18 patients (ASA physical status I-II, without significant respiratory or cardiac comorbidities) undergoing abdominal and gynecological surgery.

Case Series

18 patients (ASA I–II) undergoing abdominal and gynecological surgery (cholecystectomy, hysterectomy, hemicolectomy, appendectomy, removal of renal and ovarian cysts) were observed. Anesthesia induction was performed with Fentanyl (2 mcg/kg), Propofol (2 mg/kg), and Rocuronium (0.8 mg/kg), while maintenance used Sevoflurane and Air/Oxygen mixture at low flows, guided by continuous and non-invasive hemodynamic monitoring via the Hemosphere system (Edwards Lifesciences).

The observed results suggest hemodynamic stability throughout the entire duration of the procedures, with minimal variations in monitored parameters. Heart rate (HR): average variations <5% compared to baseline. Mean arterial pressure (MAP): average variations <3% compared to baseline. Cardiac output (CO): non-significant variations compared to baseline (Figure1).

Conclusions

The use of minimal flow ventilation in general anesthesia with Sevoflurane ensures adequate ventilatory safety in ASA I–II patients without significant lung or heart diseases, without increasing the risk of cardiovascular instability. Additional benefits include reduced anesthetic gas consumption, economic savings of volatile anesthetic up to 25% [3], better heat preservation, and lower environmental impact [2,4].

References

1. White paper: Low- and minimal-flow anesthesia, Drägerwerk AG & Co. KGaA. (n.d.). Low-and minimal-flow-anesthesia. https://www.draeger.com/Content/Documents/Content/low-and-minimalflow-210x260-whitepaper-9104624-it.pdf.

2. Metha Brattwall, Margareta Warrén-Stomberg, Fredrik Hesselvik, Jan Jakobsson. Brief review: theory and practice of minimal fresh gas flow anesthesia. Can J Anaesth. 2012 Aug;59(8):785-97. PMID: 22653840. https://pubmed.ncbi.nlm.nih.gov/22653840/.

3. A D Baxter. Low and minimal flow inhalational anaesthesia. Can J Anaesth. 1997 Jun;44(6):643-52; quiz 652-3. PMID: 9187785. https://pubmed.ncbi.nlm.nih.gov/9187785/

4. J Baum, H G Stanke. Low-flow and minimal-flow anesthesia with sevoflurane. Anaesthesist. 1998;47 Suppl 1:S70-6. PMID: 9893885. https://pubmed.ncbi.nlm.nih.gov/9893885/

Ethical statement

This study describes a retrospective case series. All data analyzed were fully anonymized prior to analysis and do not contain any information that could directly or indirectly identify the patients. Informed consent for data publication was not obtained, as the data used are not attributable to specific individuals. Patient privacy and confidentiality were fully protected throughout the study.

Furthermore, clinically validated procedures were applied in this study, which are duly cited in the article’s reference list.

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A29).

Variation of Intra-operative Hemodynamic Parameters

A30 Systematic review on gender anesthesia

L. Baccari¹, C. Grandis², A. Calabrese², M. Sarnataro², P. Russo¹, A. Fruncillo¹, C. Chiumiento², L. Spinelli¹, F. Chiumiento¹

¹Asl Salerno Dea I Livello Battipaglia-Eboli-Roccadaspide, Eboli, Italy; ²Università Degli Studi Di Salerno - Scuola Di Specializzazione In Anestesia E Rianimazione, Salerno, Italy

Correspondence: L. Baccari

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A30

Anesthesiology research and medical practice must take into account the biological differences between the two sexes, guaranteeing personalized treatment that is sensitive to the needs of each individual. Educating doctors about gender anesthesia is essential. Today, there remains a lack of correct and balanced enrollment of women, men and/or transgender people in experimental clinical trials on drugs, because this makes these studies much more complex and expensive. All this leads to a lack of equity in care.

Materials and Methods

This systematic literature review aims to identify relevant publications from 2006 to 2022 and summarize differential acute and chronic pain treatment strategies in both sexes. Gender pharmacology studies different responses between males and females, as well as the physiological variations of women that occur as function of the cyclical nature of reproductive life. Gender differences in drug response are based on pharmacokinetic and pharmacodynamic variations. The main gender-related variables include: weight and body surface area, adipose tissue, plasma volume, gastric emptying, plasma proteins, Cytochrome P450 system activity, function of membrane transporters.

Informed consent was obtained for the publication of this scientific article.

Results

Women are heavy consumers of drugs and natural remedies, herbal products, supplements. Increase in state of personal poly-pharmacy implies increase for adverse reactions and drug interactions.

Several studies have shown that men are more sensitive to the action of propofol, therefore the expected dose should be reduced by 30-40% compared to the dosage used in females.

Women tend to wake up from anesthesia faster than men: on average, women take 7 minutes compared to 11 for men.

Many women of childbearing age use estrogen-progestin-based contraceptives and prolonged use of oral contraceptives can lead to the modulation of the effect of numerous drugs.

Women who undergo the process of medically assisted procreation undergo a significant hormonal bombardment, which should be taken into account in the perioperative period.

Women experience more postoperative nausea and vomiting.

In studies on post-operative pain in patients with the patient-controlled delivery system (PCA), males consumed approximately 2.4 times more opioids than females. It has been shown that males require at least 60% more morphine than females to achieve the same pain relief. This means that women are more sensitive to morphine than men. The onset and end of the effects of morphine are slower in women.

Differences in response to analgesic therapy have also been documented for FANS drugs, such as ibuprofen. Study of effect of ibuprofen, demonstrated that analgesic effect was present in healthy male subjects but less so in females. Result is not unexpected since a strong individual variability in response to nonsteroidal antiinflammatories had already been noted, however gender had not yet been studied.

Conclusions

Gender differences in drug response are based on pharmacokinetic and pharmacodynamic variations. Pain is a complex experience, which derives from integration of physical, psychological and socio-cultural components. Nociceptive stimuli are integrated differently in the two sexes and chronic pain affects the female sex in a significantly higher percentage. In a world where diversity is our strength, it is crucial to address issues such as gender anesthesia.

A31 Hemodynamic parameters and pulse rate variability during oncological, head and neck demolitive-reconstructive surgery: an observational study

C. Adembri, A. Ungar, T. Lazar, G. Spinelli, S.M. Romano

University of Florence, Florence, Italy

Correspondence: C. Adembri

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A31

Background:

Oncological demolitive-reconstructive surgery in the head and neck region causes significant stress on patients'bioumoral, cardiac, and vascular systems, leading to disturbances in macrocirculatory parameters. In response to cardiovascular stress, the integrated response between the sympathic and parasympathic systems is of crucial importance.

The aim of our study was to describe the main haemodynamic parameters and the balance between the sympathetic and parasympathetic systems during this type of surgery.

Methods

We conducted a pilot, observational, prospective study in patients undergoing demolitive surgery for oral cancers and requiring free flap reconstruction. During the study, standard mini-invasive, hemodynamic monitoring was used and, in addition to the standard hemodynamic parameters (Stroke volume (SV), Cardiac output (CO), Indexed Systemic Vascular Resistance (SVRI), dp/dt max, and Cardiac cycle efficiency (CCE), all recorded by using the Pressure Recording Analytical Method (PRAM) technique), pulse rate variability (PRV, expressed as LF/HF ratio) was evaluated. PRV is the fluctuation in time intervals between adjacent heartbeats generated by the interaction between the heart and the brain through the autonomic nervous system (sympathetic and parasympathetic), which acts dynamically and non-linearly. PRV was calculated by analyzing beat-to-beat variations in arterial pressure wave forms obtained at a frequency of 1000 Hz from a standard cannula inserted into an artery (MostCare-UP®, Vygon, Ecouen, France).

Informed consent was obtained for the publication of this scientific article.

Results

We enrolled 10 patiens, 7 men and 3 women. Surgery lasted mean 590 +/- 95 min. Reconstruction was always obtained with fibula flaps. Hemodynamic results are reported in Table1 as mean +/- SD. Data were analyzed for all patients together and stratified by sex. No significant difference in the intra-operative macro-hemodynamic parameters occurred between women and men, but a significant difference was observed for PRV, assessed as LF/HF ratio (p=0.048, see Table 1)

Conclusions

The analysis of macro-haemodynamics during oncologic head and neck demolition-reconstructive surgery - a very complex and time-consuming operation - can help to understand how to rationally treat the alterations that are common during it. The role of an imbalance between the sympathetic and parasympathetic systems (and the factors associated with this imbalance) is of interest because of its possible association with post-operative complications.

Table 1 (abstract A31).

Main hemodynamic parameters, reported as mean ± SD

	SV	CO	SVRI	dp/dt max	CCE	LF/HF ratio
ALL	59.8 ± 13.9	5.0 ± 0.9	31.1 ± 7.2	0.89 ± 0.31	0.89 ± 0.31	1,01 ± 0.41
Women	61.623 ±	4.2 ± 1.1	38.2 ± 15.3	0.73 ± 0.18	0.73 ± 0.18	0,41 ± 0,18
	27.652
Men	55.28 ±	4.5 ± 0.4	28.8 ± 11.5	0.78 ± 0.22	0.78 ± 0.22	0,99 ± 0,41
	14.9
P	NS	NS	NS	NS	NS	0.048

A32 Autonomic dysfunction occuring at the moment of brain death

E. Abdalla¹, V.F. Tripodi¹, P. Capua², E. La Monaca², A.F. Neri², A. Bartolotta², D.C. Risitano², N. Stagni¹, M.D. Randazzo¹, I. Piper³, L. Mascia⁴, A.T. Mazzeo¹

¹University of Messina, Department of Human Pathology, Anesthesia Unit, Messina, Italy; ²University of Messina, Intensive Care Unit, Messina, Italy; ³University of Edinburgh, Usher Informatics Institute, Edinburgh, United Kingdom; ⁴University of Salento, Dipartimento Di Medicina Sperimentale, Lecce, Italy

Correspondence: E. Abdalla

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A32

Background

Brain death (BD) is a catastrophic physiological event associated with a profound physiological disturbances characterized by hemodynamic instability and endocrine dysfunction. Neuroendocrine failure or autonomic nervous system disorders, including Cushing's response (bradycardia and hypertension), autonomic storm (hypertension and tachycardia), and subsequent hypotension refractory to treatment, can be typically observed. Active management of these changes is important if optimal preservation of organs for transplantation is to be provided. As a part of a pilot study, we aimed to analyse autonomic dysfunctions occurring in patients with acute severe brain injury at the moment of brain death.

Methods

We analysed data collected from consecutive adult patients admitted to ICU from the University Hospital of Messina, Italy for severe acute brain damage and with Glasgow coma score (GCS) less than/equal 5. This was done after minute by minute capturing of hemodynamic and respiratory parameters including BPs, BPd, BPm, heart rate and SpO2 from a central station connected to patient’s bedside over 6 Months. Plots of mean and confidence level of 388.572 BPm datapoints from 21 patients who have met the inclusion criteria of this pilot study were done. The variance of arterial systolic BP 3 hours before and during the 6 hours’ time interval of brain death certification in patients evolved to brain death (BD) were plotted against non-brain death patients (NBD). The changes of BPs and HR in during three hours before BD in a single patient was also represented.

Informed consent was obtained for the publication of this scientific article.

Results

We analysed data of eight out of 21 patients (38%) evolved to BD. A significant decrease of mean systolic BP was predominant in BD patients and this was associated also with a significant variance (p=0.0085) of arterial systolic blood pressure 3 hours before BD vs NBD (Figure 1). Figure 2 shows high spikes of BPs followed by a sudden fall in BPs associated with bradycardia which suggests the occurrence of Cushing syndrome.

Conclusion

The finding of the present study demonstrated the occurrence sever hemodynamic impairment 3 hours before BD associated with marked changes at the onset of brain death. All the changes found are likely to reflect the rostrocaudal progression of brain stem dysfunction at the moment of BD.

References

1. Gunst, J., Souter, M.J. Management of the brain-dead donor in the intensive care unit. Intensive Care Med 50, 964–967 (2024).

2. Hayashi Kenichiro et al., Autonomic and endocrine response in the process of brain death in a child with hypoxic-ischemic brain injury. Front. Pediatr., 22 July (2022).

Funding: PRIN20223TWA55_001

Fig. 1 (abstract A32).

Variance of arterial systolic blood pressure 3 h before BD vs NBD

Fig. 2 (abstract A32).

Systolic arterial BP and HR 3 h before BD in single patient

A33 The incidence of secondary insults in patients with acute brain injury impending to brain death. an observational prospective study

E. Abdalla¹, V.F. Tripodi¹, P. Capua², E. La Monaca², A.F. Neri², A. Bartolotta², D.C. Risitano², N. Stagni¹, D.C. Randazzo¹, I. Piper³, L. Mascia⁴, A.T. Mazzeo¹

¹University of Messina, Department of Human Pathology, Anesthesia Unit, Messina, Italy; ²University of Messina, Intensive Care Unit, Messina, Italy; ³University of Edinburgh, Usher Informatics Institute, Edinburgh, United Kingdom; ⁴University of Salento, Dipartimento Di Medicina Sperimentale, Lecce, Italy

Correspondence: E. Abdalla

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A33

Background

Maintainance of systemic homeostasis is the cornerstone of treatment in critical care and may affect outcome. In patients with catastrophic acute neurological injury evolving to brain death (BD), timely diagnosis of BD is critical in the organ donation and transplantation process. Early identification of the potential organ donor and the application of early bundles of ICU care would improve maintenance of systemic homeostasis and eventually improve neurological outcome in those who survive and increase the number of harvested organs in the patients that evolve to BD and donate. The aim of this study is to measure the occurence of secondary insults during ICU stay of severe acute brain injury patients evolving or not to BD.

Methods

Adult patients admitted to ICU for catastrophic acute brain injury with a Glasgow coma score (GCS) <= 5 were enrolled as part of an ethically approved study. Minute by minute physiological data were collected from the central station connected to bedside monitors. Data including BPs, BPd, BPm, heart rate and SpO2 were collected using ICU PC/sever “Mirth” HL7 Praser engine. Hypotension was defined as 5 sequential minutes of data below a mean arterial pressure (mmHg) of 70 (Grade 1), 60 (Grade 2) or 50 (Grade 3) severities. Hypoxemia was defined as SpO2 below 94% (EUSIG classification). Short-acting (<5 minute) insults were discarded as potentially artefactual with an algorithm used to estimate the percentage of ‘Valid Monitoring Time’(VMT) so that the proportion of time spent at the insult level of VMT could be calculated.

Informed consent was obtained for the publication of this scientific article.

Results

To date, twenty- one patients have been recruited prospectively from the University Hospital of Messina, Italy as a part of this pilot study. Patient monitoring data was 8-3000 hours (range 0.3-125 days). Admission diagnoses of these patients were intracerebral haemorrhage n=12 (58%), TBI n=3 (14%), SAH n=3 (14%) and Ischaemic Stroke n=3 (14%). Mean age was 70 (range 47-88) years, and mean GCS was 4 (range 3-5). Mean ICU LOS was 22 (range 1-136) days. Five patients were alive at discharge. Eight out of 21 patients (38%) evolved to brain death (BD) while thirteen patients (62%) did not (NBD). In figure 1 and 2, the proportion of VMT for hypotension and hypoxemia insults, in BD (N=8) vs NBD patients (N=13) are presented, respectively.

Conclusion

The incidence of hypotension remains the most significant among secondary insults in patients evolved to BD. Day 3 and 4 post ICU admission demonstrated the largest amount of secondary insults.

References

1. Jones PA et al. Measuring the Burden of Secondary Insults in Head Injured Patients During Intensive Care. J Neurosurg. Anaesth.6(1) 4-14, 1994.

2. Patel MS et al: The impact of meeting donor management goals on the number of organs transplanted per expanded criteria donors. JAMA Surg 2014;149:969-75

Funding: PRIN20223TWA55_001

Fig. 1 (abstract A33).

Proportion of VMT of hypotension insult in BD vs NBD according to grades

Fig. 2 (abstract A33).

Proportion of VMT of Hypoxemia insults in BD vs NBD

Loco-regional anaesthesia

A34 Low-dose prilocaine in spinal anesthesia for urological surgery

A. Ragone¹, P. Raimondo², G. Montenero¹, G. Sfregola¹, M. Ciuffreda³, C. Piangatelli³, D. Galante¹

¹Dipartimento di Anestesia e Terapia Intensiva, Ospedale G. Tatarella, ASL Foggia, Cerignola, Italy; ²Anestesia e Unità di Terapia Intensiva, Dipartimento di Precisione e Medicina Rigenerativa, Policlinico di Bari, Bari, Italy; ³Dipartimento di Anestesia e Terapia Intensiva, AST Ancona, Fabriano, Italy

Correspondence: G. Sfregola

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A34

Background

In urology, the rapid turnover associated with day surgery procedures necessitates the passage of an increasing number of patients through the operating room. This demands relatively quick recovery times, while still ensuring adequate attention to patient comfort during the intraoperative and immediate postoperative phases. In order to determine which anesthetic provides better anesthetic management in this setting, we conducted a randomized comparison of the clinical effects of spinal anesthesia using Prilocaine (at different dosages) and Bupivacaine, evaluating their efficacy, safety, recovery times, and any adverse effects.

Materials And Methods

Between October 2024 and December 2024, at the Tatarella Hospital in Cerignola (Fg), we analyzed – after informed consent - the spinal anesthesia outcomes of 30 patients undergoing TURP. Patients were divided into three groups: Group A, treated with a standard dose (50 mg) of hyperbaric Prilocaine; Group B, treated with a low dose (30 mg) of hyperbaric Prilocaine; and Group C, treated with 10 mg of hyperbaric Bupivacaine. Outcome evaluation considered key indicators such as systolic, diastolic, and mean blood pressure, heart rate, and oxygen saturation at various time intervals after injection. Recovery parameters included sensory block test, duration of surgery, intraoperative pain assessment, Bromage score at the end of the procedure, patient comfort score, and overall patient satisfaction score. Monitored complications included PONV (postoperative nausea and vomiting) and the potential need for conversion to general anesthesia or deep sedation.

Informed consent was obtained for the publication of this scientific article.

Results And Discussion

Analysis of the mean arterial pressure trend revealed that patients in Group B showed better hemodynamic profiles, with more effective perfusion regulation during surgery, lower risk of hypo- or hypertension, and a better autonomic response under anesthesia. The heart rate trend showed a significantly decrease in bpm in the group treated with Bupivacaine compared to the Prilocaine groups. The oxygen saturation trend indicated that all three groups maintained relatively stable saturation levels during the first 10 minutes of anesthesia. Data analysis showed comparable onset times of sensory block across the three groups, deeper levels of anesthesia in patients treated with Bupivacaine, greater hemodynamic stability in patients treated with low-dose Prilocaine, immediate recovery times in the low-dose Prilocaine group, and significantly longer recovery times in the Bupivacaine group. Only one patient from Group B required deep sedation due to intraoperative pain. Adverse events such as postoperative nausea and vomiting were evenly distributed among the Prilocaine groups and were more frequent in the Bupivacaine group.

Conclusions

Rapid discharge times, adequate intra- and postoperative pain control, and a low incidence of complications demonstrate that low-dose Prilocaine is particularly suitable for day surgery, and specifically for urological procedures.

References

1. Manassero A et al. Prilocaine hydrochloride 2% hyperbaric solution for intrathecal injection: a clinical review. Local Reg Anesth. 2017 Mar 31; 10:15-24.

2. Ambrosoli AL et al. Safety and effectiveness of prilocaine for spinal anesthesia in day surgery setting: a retrospective study on a sample of 3291 patients. J Anesth Analg Crit Care. 2023 Oct 20;3(1):40.

A35 Triblock (femoral, obturator, sciatic) in right ventricular restrictive cardiomyopathy with Glenn shunt, nyha class IV

D. Morgante, D. Antonio, C. Francesca, D.T. Marina, F.M. Romito

UOC Anestesia E Rianimazione - ASM Basilicata, Matera, Italy

Correspondence: D. Morgante

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A35

Case Description

A 59-year-old female presented to the Emergency Department of Matera Hospital following an accidental fall. She was diagnosed with a non-concussive head trauma and a right pertrochanteric femoral fracture. Her medical history included severe right-sided restrictive cardiomyopathy, previously treated with a Glenn shunt procedure, and she was currently classified as NYHA Class IV. She was awaiting right heart catheterization for potential heart transplant listing.

She was urgently admitted for surgical repair of the femoral fracture.

Home Medication

• Zaroxolyn

• Furosemide

• Rosuvastatin (Crestor)

• Pantoprazole (Pantorc)

• Warfarin (Coumadin)

• Inhaled medications: Fluispiral, Spiriva

Glenn Procedure Overview

The Glenn shunt involves dividing the superior vena cava at its junction with the right atrium, followed by an end-to-side anastomosis with the right pulmonary artery, which is previously separated from the main pulmonary artery. This procedure Results in a passive systemic-to-pulmonary arterial shunt.

Preoperative Findings

• • Hyponatremia: Na 118 mmol/L

• • Anemia

• • Coagulopathy due to warfarin:

• ◦ INR: 3.2

• ◦ aPTT ratio: 2.10

• ◦ On the day of surgery (after LMWH bridging): INR 2.62

Arterial blood gas analysis:

• pH: 7.51

• PaCO₂: 27 mmHg

• PaO₂: 62 mmHg

• HCO₃⁻: 21.5

• BE: −1.5

• Lactate: 1.2

• Na⁺: 117

• K⁺: 3.3

• Cl⁻: 89

• Ca²⁺: 0.95

• Hb: 10 g/dL

• SpO₂: 93%

Multidisciplinary Evaluation & Anesthesia Plan

After a multidisciplinary evaluation (anesthesiology, cardiology, orthopedic surgery), the patient was scheduled for open reduction and internal fixation (ORIF) of the femoral fracture.

The preoperative anesthesiology assessment classified her as ASA Physical Status Class V.

Given the coagulopathy, central neuraxial blocks and paravertebral or sacral plexus blocks were contraindicated. Similarly, general anesthesia was avoided due to its potential hemodynamic and respiratory depressant effects, with expected challenges in weaning from mechanical ventilation.

Therefore, a combination of three peripheral nerve blocks was chosen:

• "Right femoral nerve block

• "Right obturator nerve block (anterior and posterior branches)

• "Right sciatic nerve block

Procedure Details

The procedure was conducted under strict aseptic conditions, using ultrasound guidance and nerve stimulation.

Premedication (~50 minutes pre-incision):

• "Midazolam 1 mg

• "Sufentanil 5 mcg

to reduce discomfort during patient positioning.

Nerve blocks administered:

• "Femoral nerve:

• ◦ 15 mL of 0.5% levobupivacaine

• ◦ 5 mL of 2% mepivacaine

• "Obturator nerve (anterior and posterior branches):

• ◦ 10 mL of 0.5% levobupivacaine

• "Sciatic nerve:

• ◦ 5 mL of 2% mepivacaine

• ◦ 15 mL of 0.5% levobupivacaine

Surgery duration: 60 minutes.

Intraoperatively, a continuous infusion of propofol (0.05-0.1 mg/kg/min) was administered for 20 minutes for anxiolysis (total dose: 40 mg).

Oxygen was delivered via Venturi mask at FiO? 0.5.

Vital signs remained stable throughout the procedure.

Postoperative Course

At the time of discharge from the operating room:

• "GCS: 15

• "NRS pain scale: 0

• "SpO₂: 93%

• "Heart rate: 74 bpm, irregular (atrial fibrillation)

• "BP: 100/60 mmHg

• "Bromage score (right lower limb): 3 (complete motor block)

Complete resolution of the nerve blocks occurred within 24 hours.

No procedural complications were reported.

During her stay in the Intensive Care Unit, she received one unit of packed red blood cells.

She was subsequently transferred to the Cardiology ward, where she continued care, and was discharged home after 5 days.

Consent

Informed consent was obtained for the publication of this scientific article.

A36 Frail patient candidate for reconstructive flap surgery: a retrospective observational analysis for the development of an Eras protocol

M. Ricci, J. Poloni, F. Costa, G. Pascarella, L.M. Remore, M. Carassiti, R. Cataldo, F.E. Agrò

Fondazione Policlinico Campus Bio-Medico di Roma, Italy

Correspondence: M. Ricci

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A36

Background

In Lazio, there are more than 37,000 new cases of skin cancer each year, particularly among individuals over the age of 75. Around 10% of these tumours are aggressive and require complex surgery. Historically, the use of microsurgical flaps such as the latissimus dorsi (LD) or anterolateral thigh (ALT) flap has entailed the use of general anaesthesia (GA), which is associated with a higher incidence of systemic complications and frequent recourse to postoperative intensive therapy (TIPO). The ERAS (Enhanced Recovery After Surgery) guidelines set out strategies for optimising perioperative management and improving clinical outcomes. Loco-regional anaesthesia, in particular, has been shown to effectively reduce opioid use, improve pain control, and shorten hospital stays. We therefore conducted a retrospective observational study to compare different anaesthesiological methods used in reconstructive surgery involving free or pedicled flaps.

Materials and Methods

A total of 60 patients over the age of 75 undergoing resection of cutaneous neoplasms with subsequent microsurgical reconstruction using a LD or ALT flap were enrolled in the study. The patients were divided into three groups. The first group of 20 patients underwent the operation with AG alone; the second group of 20 patients underwent the operation with AG and loco-regional anaesthesia (ALR); and the third group of 20 patients underwent the operation with ALR alone accompanied by mild sedation. The analysed outcomes included hospital admission, QoR-15 value, opioid consumption, incidence of systemic complications, length of hospital stay, time to recanalisation, resumption of feeding, and duration of mechanical ventilation.

Informed consent was obtained for the publication of this scientific article.

Results

Data analysis showed that patients managed with ALR + sedation experienced a significant reduction in ICU admissions, lower opioid consumption, a decreased incidence of systemic complications, and faster functional recovery compared to the other two groups, even in operations on body sites distant from the donor site that are traditionally considered difficult to manage without AG.

Conclusions

The results obtained support the efficacy and safety of ALR as the preferred strategy for managing frail patients undergoing complex reconstructive surgery. This evidence will inform the development of a dedicated Enhanced Recovery After Surgery (ERAS) protocol, which aims to reduce postoperative complications and optimise postoperative recovery.

A37 Surgical block in proximal humerus surgery: superior trunk block versus interscalene block

D. Ricci, D. De Lauri, S. De Pascalis, M.P. Armillotta, M. Cavaliere, P. Di Marco

Università la Sapienza, Roma, Italy

Correspondence: D. Ricci

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A37

Background

Interscalene brachial plexus block (ISB) is the current gold standard for regional anesthesia in shoulder surgery, providing anesthetic coverage during the procedure and prolonged postoperative analgesia; however, it is often associated with phrenic nerve involvement and resulting hemidiaphragmatic paresis, which can be critical in patients with pre-existing respiratory conditions, such as COPD and asthma. The superior trunk block (STB) has emerged as a promising “phrenic-sparing” alternative, as the phrenic nerve courses on the anterior surface of the anterior scalene muscle and is located closer to the brachial plexus in the ISB, making phrenic nerve involvement in the STB less common. (1)

Objective: The primary objective of this study is to compare the superior trunk block (STB) and the interscalene block (ISB), both employed as surgical regional anesthesia technics, in terms of the incidence of complete hemidiaphragmatic paresis (HDP) and diaphragmatic dysfunction (DD). Secondary objectives include assessing the anesthetic efficacy, postoperative analgesia, and the extent of motor and sensory blockade achieved with each technique. In particular, the study aims to determine whether STB can provide a comparable level of surgical anesthesia, characterized by complete loss of motor strength and sensory perception in the targeted region, while minimizing respiratory complications.

Materials and Methods

This was a single-blind, monocentric, randomized controlled trial involving 33 adult patients undergoing proximal humerus surgery. Patients were assigned to receive either ISB + supraclavicular nerve block (n=15) or STB + supraclavicular nerve block (n=18). Written informed consent was obtained from all participants prior to their inclusion in the study Diaphragmatic excursion was measured using M-mode ultrasound before and after the block. HDP was defined as >75% reduction and DD as 25–75% reduction in diaphragmatic excursion from baseline. Both blocks were executed using a mixture of Ropivacaine 0,5%+Dexmedetomidine 1 mcg/ml, injecting a total volume of 10 ML in both ISB and STB and 5 ML in supraclavicular nerve block. Patients were sedated using Midazolam 0,03 mg/kg as premedication after the measurement of diaphragmatic excursion and using Dexmedetomidine 0,4-0,7 mcg/kg/h during surgery.

Informed consent was obtained for the publication of this scientific article.

Results

Median diaphragmatic excursion reduction was 67% (IQR 59–71) in the ISB group versus 2% (IQR −1–5) in the STB group (p < 0.001) (Table 1). Both groups achieved similar anesthetic efficacy, with complete absence of strength and sensitivity. No significant differences were observed in postoperative pain, opioid use, or patient satisfaction (Figure 1).

Conclusions

Superior trunk block provides equivalent anesthetic efficacy compared to the interscalene block while significantly reducing the risk of hemidiaphragmatic paresis. It may represent a safer alternative for regional anesthesia in shoulder surgery, particularly in patients with compromised respiratory function.

1. Selzer A, Sarkiss M. Preoperative Pulmonary Evaluation. Vol. 103, Medical Clinics of North America. W.B. Saunders; 2019. p. 585–99.

Fig. 1 (abstract A37).

SpO2 change, pain at 8 h, complications and patient satisfacion: a comparison made among control and experimental group

Table 1 (abstract A37).

Diaphragmatic excursion reduction: a comparison made among control and experimental group

Characteristic	Control Group (N = 151)	Experimental Group (N = 181)	p-value
Diaphragmatic Excursion Reduction (%)	67 (59, 71)	2 (−1, 5)	< 0.001

A38 Ultrasound guided periarticular vasoconstrictor infiltration (PVI) versus proximal adductor canal block (p-acb) with local infiltration analgesia (LIA) for pain management in total knee arthroplasty

G. Ranieri¹, F. Rucci¹, P. Ciocchetti¹, F. Tamburi², A. Coviello³, F. Fattorini⁴, P. Fusco⁵, D. Cirillo³

¹Ospedale Isola Tiberina - Gemelli Isola, Roma, Italy; ²Policlinico Universitario Agostino Gemelli, Roma, Italy; ³Università Federico II, Napoli, Italy; ⁴Università La Sapienza, Policlinico Umberto I, Roma, Italy⁵Ospedale Ss. Filippo E Nicola, Avezzano, Italy

Correspondence: D. Cirillo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A38

Background Perioperative pain control is crucial in TKA to ensure an optimal perioperative course and early patient mobilization, according to ERAS and Fast-Track Surgery protocols (1,2,3). An important component of perioperative pain in TKA surgery is likely due to the placement of a thigh tourniquet whose utility is increasingly debated (4,5).

PVI combines local anesthetics and vasoconstrictors injected periarticularly to reduce bleeding and provide effective analgesia (6,7).

In this study, we aim to evaluate the effectiveness of PVI in managing perioperative pain in primary TKA performed without a tourniquet, compared to the ACB with LIA in primary TKA performed with a tourniquet, ensuring adequate control of perioperative blood loss.

Materials And Methods

We included patients scheduled for primary TKA after obtaining informed consent. Exclusion criteria were coagulopathy, allergy to study drugs, BMI>34.9, eGFR<60mL/min, and ischemic heart disease. The intervention group received PVI: under sterile conditions, 140 mL of a solution, containing Ropivacaine 0.1%, Adrenaline 1:200,000, and Dexmedetomidine 0.375 mcg/mL, is used to perform the Interspace between the Popliteal Artery and Capsule of the Knee (IPACK) Block and to infiltrate around the genicular nerves, except the inferolateral one, and the suprapatellar bursa (fig.1). The control group received p-ACB (Ropivacaine 0.5%, 20 mL, and Dexmedetomidine 0.3 mcg/kg, fig.2) plus LIA performed by the surgeon (40 mL of a solution with Ketorolac 0.015%, Clonidine 0.075%, Ropivacaine 0.125%, and Adrenaline 0.5:200,000). In both groups, spinal anesthesia was administered with Bupivacaine 0.5% (0.15 mg/kg, max 12.5 mg) and Sufentanil 2,5 mcg. Postoperative analgesic therapy was administered using an elastomeric pump (containing ketoprofen 640 mg for 48 hours), along with scheduled paracetamol (1 g three times daily), oxycodone/paracetamol 20 mg + 325 mg (at 10:00 p.m.), and celecoxib 200 mg (at 2:00 p.m. for 4 days). In case of breakthrough pain, the rescue dose consisted of tramadol 100 mg.

Informed consent was obtained for the publication of this scientific article.

Results

Data about 52 subjects were observed, 27 in ACB and 25 in PVI group. Preliminary analysis showed that the sample was homogeneous in terms of anthropometric characteristics and comorbidities.

Overall, between the two groups there was not a significant difference in pain assessment (group effect p=0.585) and no significant difference in VAS from 12–24 hours postoperatively (hours x group interaction effect, p=0.840).

Among the secondary endpoints we evaluated pain progression over 24 hours groups measured by VAS, which was significant over hours in both groups (time effect p<0.001) and no difference between the two groups was observed (group effect p=0.387; fig 3). Moreover, no significant differences were observed in blood loss, calculated with Ward and Meunier formulas (8) (fig.4) (p=0.746) and the surgery time was not different between the two groups (p=0.825).

Conclusions

Based on preliminary data from an initial patient cohort, the PVI technique appears to be a promising, safe, and effective alternative to ACB for perioperative pain management in primary TKA procedures.

Fig. 1 (abstract A38).

PVI (supero-medial genicular artery)

Fig. 2 (abstract A38).

p-ACB

Fig. 3 (abstract A38).

Visual Analogue Scale (VAS)

Fig. 4 (abstract A38).

Surgical field without tourniquet after performing PVI

A39 Hemodynamical effects during segmental spinal anesthesia in noncardiac surgery: an effective strategy to prevent it

L. Mori, B. Basta, D. Vailati, T. Fusco, G. Marino

Anesthesia and Intensive Care, Melegnano Hospital-ASST Melegnano e Martesan, Vizzolo Predabissi (Milan), Italy

Correspondence: L. Mori

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A39

Background

Thoracic Segmental Spinal Anesthesia (TSSA) for non-cardiac surgery is a well-established technique to ensure adequate intraoperative anesthesia. However, TSSA can cause hemodynamic changes, especially hypotension, due to extensive sympathetic nervous system blockade. We evaluated patients undergoing laparoscopic surgery in whom a strategic approach known as Neuraxial Awareness Surgery [1] was employed: a combination of TSSA and GABA-sparing intravenous sedation while maintaining spontaneous breathing. Our endpoints were the duration and severity of hypotension and the dose of vasoconstrictors administered in high-risk patients treated with a proactive approach.

Materials and Methods

The study included 17 patients who underwent videolaparoscopic right or left hemicolectomy and anterior rectal resection for colorectal cancer. The average age was 77 years; 66% of patients were classified as ASA III, and 34% as ASA IV. The prevalence of comorbidities was as follows: coronary artery disease in 19.2%, arterial hypertension in 77.8%, and cardiac arrhythmias in 26.4%. All patients had an ARISCAT score < 44. Dexmedetomidine intravenous infusion was initiated at a rate of 0.5 mcg/kg/h, 15 minutes before TSSA, while norepinephrine infusion was started at 0.2 mcg/kg/min, 5 minutes prior to TSSA. Standard monitoring, including invasive arterial blood pressure measurement, was applied. All patients received TSSA at the T7–T10 levels using a minimalist anesthetic mixture of levobupivacaine 0.5% (10 mg) and dexmedetomidine (8 mcg) in a total volume of 4 ml. A thoracic epidural catheter was also placed. Hypotension was defined as a mean arterial pressure (MAP) < 65 mmHg or a >25% reduction from baseline and was managed with norepinephrine infusion.

Results

A reduction in MAP occurred immediately after the intrathecal injection in 64.7% of cases, with MAP values dropping below 65 mmHg in 35.3% of cases (mean duration: 17 minutes). Norepinephrine infusion was discontinued if no MAP reduction occurred or was increased promptly in response to hypotension. It was administered in 53% of patients, with a mean dosage of 0.042 mcg/kg/min for an average duration of 64 minutes. Norepinephrine was never administered postoperatively.

Conclusion

The early use of low-dose norepinephrine is an effective and safe strategy for preventing hypotension following TSSA. This strategy counteracts neuraxial block-induced sympathetic vasodilation before the onset of clinically significant hypotension, thereby enhancing intraoperative hemodynamic stability. Prophylactic low-dose vasopressor administration appears to be particularly advantageous in the context of TSSA. Additionally, this strategy has been shown to reduce the need for fluid loading. Finally, during TSSA, the anesthesiologist must maintain heightened vigilance in detecting and preventing hypotension in order to avoid patient discomfort—such as dizziness, nausea, or vomiting—which may occur if hypotension develops while the patient remains conscious.

Consent

Consent to data collection and publication was obtained from the patient.

References

1. Magistro, C., Ferrari, C., Vailati, D., Basta, B., Colasuonno, M., Tresoldi, M., Barbaro, S., Crippa. Awareness surgery: laparoscopic right colectomy in a heart transplant patient—a case report. Journal of Visualized Surgery - JOVS. 2024 Nov; 10. 11.

A40 Radical mastectomy under ultrasound-guided regional anesthesia in a patient with severe heart disease: a case report

F. Demelas¹, G. Olianas¹, G. Fancello², A. Demurtas³, F.M. Loddo³

¹Dipartimento Chirurgico-Oncologico - Ospedale A Businco - SC Anestesia e Rianimazione - ARNAS Brotzu, Cagliari, Italy; ²Dipartimento Chirurgico-Oncologico - Ospedale A Businco - SC Chirurgia Oncologica e Senologica - ARNAS Brotzu, Cagliari, Italy; ³Dipartimento Attività Cliniche - Ospedale NS della Mercede - SC Anestesia e Rianimazione - ASL Ogliastra, Lanusei, Italy

Correspondence: F. Demelas

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A40

Background

Performing non-cardiac surgery in patients with severe heart disease presents significant challenges, requiring adequate anesthesia, effective pain control and hemodynamic stability. We report a successful radical mastectomy and axillary dissection performed under ultrasound-guided regional anesthesia and sedation in a patient with severe cardiovascular disease.

Case report

A 58-year-old woman (height 165 cm, weight 58 kg) with an ASA physical status IV, an history of hypokinetic-dilated cardiomyopathy due to desmoplakin gene mutation, an implantable cardiac defibrillator (ICD) and severely reduced systolic function (EF 15-20%), was diagnosed with infiltrating lobular carcinoma of left breast and proposed for radical mastectomy and axillary lymphadenectomy. Considering her severe cardiac disease and the high risk associated with general anesthesia, a regional anesthesia technique was suggested to minimize perioperative risk, and she was scheduled for admission to postoperative intensive care.

Thirty minutes before surgical incision, after premedication with midazolam 1 mg and sufentanyl 5 mcg, a left-side pectoserratus and parasternal plane block were performed under ultrasound guidance with an in-plane approach [1].

The pectoserratus plane block was performed over the 3rd and 4th rib at the level of serratus anterior muscle with 20 ml of 0.75% ropivacaine. An ipsilateral parasternal injection was performed at the 2nd and 4th intercostal space with 10 ml of 0.75% ropivacaine. An 8 mg intravenous dose of dexamethasone was administered to prolong the analgesic effect of fascial plane block [2]. Skin infiltration performed by the surgeon helped to achieve complete surgical anesthesia.

Standard monitoring (ECG, SpO2), invasive arterial pressure and BIS were applied (target > 70). A magnet was used to suspend anti-tachyarrhythmia functions of ICD and defibrillator pads were placed. Sedation was achieved by dexmedetomidine infusion (0.5-0.8 mcg/kg/h) combined with boluses of midazolam (totaling 3 mg) and ketamine (totaling 40 mg). Ketorolac 30 mg intravenously was administered 30 minutes before the end of surgery.

Spontaneous ventilation with supplementary oxygen via nasal cannula was maintained throughout the procedure, and no significant hemodynamic changes were reported. Neither the patient nor the surgeon experienced any discomfort. As a result, there was no need for admission to intensive care. Postoperative pain was reported 24 hours after surgery, but no rescue analgesia was required.

Conclusion

Radical mastectomy is commonly performed under general anesthesia, due to the complex innervation of the breast and chest wall. Regional anesthesia with sedation proved to be a safe and effective alternative to general anesthesia for breast surgery in patients with major cardiovascular disease, offering appropriate pain control and fewer side effects.

Consent

Consent to publication was obtained from the patient.

References

1. Garreffa, E., Cantagalli, F., Mastrantuono, A., Cammarota, E., Torresini, G., Sozio, A., Minora, S. and Brucchi, M. (2020), Pectoral nerves blocks (PECS) and sedation: A way to avoid general anesthesia in breast surgery – A single institution early experience. Breast J, 26: 303-305. 10.1111/tbj.13587.

2. Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev. 2017 Nov 9;11(11):CD011770. 10.1002/14651858.CD011770.pub2. PMID: 29121400; PMCID: PMC6486015.

A41 Trauma pain and regional anesthesia in the ed: what are we really doing and what do we think? a national survey among italian physicians

M. Leo¹, C. Cicerone¹, B. Savarese¹, M. Bellan², F. Gavelli², R. Boverio¹, M. Peruzzo¹, G. Cammarota¹

¹Azienda Ospedaliero-Universitaria SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; ²Azienda Ospedaliero-Universitaria Maggiore della Carità, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy

Correspondence: M. Leo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A41

Background

Acute traumatic pain is common in emergency departments (EDs), yet frequently undertreated. This phenomenon, known as oligoanalgesia, may contribute to increased patient discomfort, delayed recovery, chronic pain development, and other avoidable complications. Regional anesthesia (RA) provides effective, opioid-sparing analgesia and is well suited for emergency settings. However, little is known about how RA is perceived and implemented in real-life ED practice.

Materials and Methods

A national cross-sectional survey was conducted among physicians working in or collaborating with Italian EDs. A 43-item online questionnaire was used to collect data on demographics, departmental organization, and pharmacological strategies based on pain severity. The questionnaire explored both clinical approaches to pain treatment and physicians’ perceptions of regional anesthesia in the emergency setting. Responses were collected using 5-point Likert scales ranging from “strongly disagree” to “strongly agree”.

Informed consent was obtained for the publication of this scientific article.

Results

A total of 245 complete responses are collected. Among respondents, 36.7% are aged 31–35 years and 19.3% are aged 36–40 years. Emergency physicians account for 59.6% of participants, anesthesiologists 26.1%, and others 12.4%. Only 19.9% report having a standardized protocol for initial pain assessment. Over half of respondents (53.5%) have completed a specific training course in regional anesthesia, while 42.2% have not. Among those without formal training, 33.3% report performing RA nonetheless. While 55.9% of physicians state they currently perform RA in the ED, RA is used in 3.2% of mild, 21.1% of moderate, and 46.5% of cases of severe pain. RA is also used in 36.7% of orthopedic reductions, while 24.5% of respondents report using no analgesia at all for these procedures. The most frequently reported barriers to RA implementation are the lack of dedicated protocols (76.6%) and ED overcrowding (73.3%). Other limiting factors include insufficient time (64%) and staff shortages (64%), particularly in urgent orthopedic scenarios. 80.8% believe RA should become a standard tool in emergency pain management.

Conclusions

Despite its limited current use, regional anesthesia is viewed by the majority of respondents as an important tool for the future of emergency pain management. Investments in training, protocols, and cultural change may support its safe and progressive integration into routine clinical practice.

References

1. Zanza C, Romenskaya T, Zuliani M, Piccolella F, Bottinelli M, Caputo G, Rocca E, Maconi A, Savioli G, Longhitano Y. Acute traumatic pain in the emergency department. Diseases. 2023 Mar 3;11(1):45. 10.3390/diseases11010045. PMID: 36975594; PMCID: PMC10046963.

2. Sampson FC, Johnson M. Why is pain management so difficult in the emergency department? A systematic mixed studies review and thematic synthesis of staff perceptions of enablers and barriers to pain management within the emergency department. Emerg Med J. 2023 Aug;40(8):606-613. 10.1136/emermed-2022-212759. Epub 2023 Jun 6. PMID: 37280046.

3. Fabbri A, Voza A, Riccardi A, Serra S, Iaco F for the Study and Research Center of the Italian Society of Emergency Medicine (SIMEU). The pain management of trauma patients in the emergency department. J Clin Med. 2023 May 5;12(9):3289. 10.3390/jcm12093289. PMID: 37176729; PMCID: PMC10179230.

4. Wolmarans M, Albrecht E. Regional anesthesia in the emergency department outside the operating theatre. Curr Opin Anaesthesiol. 2023 Aug 1;36(4):447-451. 10.1097/ACO.0000000000001281. Epub 2023 Jun 14. PMID: 37314169; PMCID: PMC10328532.

A42 Failed axillary brachial plexus block: technical issue or true resistance to local anesthetics?

E. Ioppolo¹, D. Cucina¹, D. Menghin¹, V. Torrano²

¹School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy²Department of Anesthesia, Critical Care and Pain Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

Correspondence: E. Ioppolo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A42

Background

Resistance to local anesthetics (LAs) is a rare but clinically significant phenomenon that can lead to unsuccessful local and regional anesthesia. Failure may result from errors in LA dosage, preparation, and injection, operator inexperience, tissue inflammation, or excessive patient preoperative anxiety. Although limited in number, cases of true resistance to LAs have been documented. Several factors have been identified as potential contributors, including voltage-gated sodium channel mutations, a history of scorpion stings, red-haired phenotype, Ehlers-Danlos Syndrome, and chronic opioid use, all of which may alter nerve sensitivity and pharmacokinetics or pharmacodynamics of LAs [1,2] (Figure 1).

Case Report

We report the case of a 59-year-old male patient with left median nerve neuropathy following compartment syndrome of the wrist, scheduled for median nerve neurolysis. We performed an axillary brachial plexus block with 20 mL of Mepivacaine 1.5%. We employed combined ultrasound and electrical nerve stimulation guidance to accurately identify nerve structures and verify LA injection. However, the patient experienced intense pain at the beginning of the procedure, requiring conversion to general anesthesia.

In light of this, a thorough clinical workup was performed. During the preoperative assessment, the patient had reported a previous episode of failure of an interscalene nerve block for shoulder arthroscopy. Nevertheless, in the past he had received local anesthesia for dental procedures without complications. He had no history of opioid use or prior scorpion envenomation, and both his personal and family histories were negative for Ehlers-Danlos Syndrome or connective tissue disorders. A physical examination revealed no distinguishing features, such as red hair. We thus performed genetic testing for the SCN5A gene (variant c.1715C>A – p.Ala572Asp) – commonly associated with LA resistance – but no pathogenic mutations were identified.

Conclusion

This case highlights an instance of unexplained resistance to local anesthetics in a patient without known risk factors. Negative findings in SCN5A suggest alternative genetic or molecular mechanisms may be responsible. Further research, including broader genetic screening and functional testing, is warranted to improve understating of this rare phenomenon.

Consent to publish

Written informed consent was obtained from the patient for publication of this case report.

References

1. Marti F, Lindner G, Ravioli S. Resistance to local anaesthetics: a literature review. Br J Anaesth. 2022 Aug;129(2):e43-e45.

2. Clendenen N, Cannon AD, Porter S, Robards CB, Parker AS, Clendenen SR. Whole-exome sequencing of a family with local anesthetic resistance. Minerva Anestesiol. 2016 Oct;82(10):1089-1097.

Fig. 1 (abstract A42).

Resistance to Local Anesthetics. [Abbreviations: LA = Local Anesthetic; GA = General Anesthesia]

A43 Virtually augmented self-hypnosis in breast surgery

G. Galasso¹, I. Esposito¹, T. Pagano¹, A. Persico¹, A. Cicalese², D. Carbone¹

¹Anesthesia and Intensive Care Unit - Umberto I, Nocera Inferiore, Italy; ²Breast Unit - ASL Salerno, Italy

Correspondence: G. Galasso

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A43

Introduction

Hypnosis is useful for diminishing distress during medical procedures. This study investigated the efficacy of virtually augmented self-hypnosis as an adjunctive non-pharmacological method for procedural pain and anxiety relief during total mastectomy for breast cancer. The main aim of this retrospective nonrandomized study was to evaluate if mastectomy performed with perioperative hypnosedation led to a lower use of drugs and opioid and a lower incidence of post-operative pain compared with mastectomy without hypnosedation.

Matherials and Methods

The study was performed at Umberto I Hospital in Nocera Inferiore (SA). Twenty-four women underwent total mastectomy, twelve (group 1) had locoregional anesthesia and sedation with ketamine 0.6 mg/kg/h in spontaneous breathing, while twelve (group 2) has locoregional anesthesia featuring virtual reality (VR) using a head-mounted display with a setting chosen by the patient in spontaneous breathing. Interpectoral, pectoserratus and parasternal plane block were performed for both groups with ropivacaine 0.25%, total volume 35 ml. The surgery started 30 minutes after plane block. All women signed an informed consent to the procedure.

Informed consent was obtained for the publication of this scientific article.

Results

The characteristics of the two groups were similar for diagnosis, age and BMI, all women underwent total mastectomy for malignant mammal tumor.

Women included in the group 1 needed to increase the dose of ketamine from 0.6 to 1 mg/kg/h and to add a dose of 50 mcg of fentanyl during the surgery to control intra-operative pain, no women in the group 2 needed adjunctive dose of ketamine or fentanyl (p<0,01). Post-operative pain was evaluated with VAS and NGS after 3 and 12 and 24 hours post-surgery and there was no difference in post- operative pain in the two groups (p>0,05).

Conclusion

This study shows that hypnosedation using virtual reality during breast surgery is useful in reducing the dosage of intra-operative drugs without increasing post-operative pain. Despite the limitations of this study (nonrandomized, small sample), preliminary Results merit further study of hypnosedation.

References

1. Berryman DR. Augmented reality: a review. Med Ref Serv Q. 2012;31(2):212–8

2. Privorotskiy, A., Garcia, V.A., Babbitt, L.E. et al. Augmented reality in anesthesia, pain medicine and critical care: a narrative review. J Clin Monit Comput 36, 33–39 (2022). 10.1007/s10877-021-00705-0

A44 Sacral ESP block as part of a combined regional anesthesia strategy for hip fracture surgery in a high-risk elderly patient: a case report

D. Gaetano¹, G. Landi², G. Borrelli², D. De Divitiis², A. Testa¹, P. Prisco¹, C. Ferrigno², R. Naimoli², P. Masturzo², M.L. De Prisco², P. Sansone¹, L. Pandolfo²

¹University of Campania Luigi Vanvitelli, Naples, Italy; ²San Francesco d’Assisi Hospital, ASL Salerno, Oliveto Citra (SA), Italy

Correspondence: D. Gaetano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A44

Background

Hip fractures in elderly patients with significant cardiovascular and respiratory comorbidities represent a major anesthetic challenge. Regional anesthesia techniques, especially when combined, may offer superior hemodynamic stability, reduce pulmonary complications, and avoid the risks of general anesthesia. Using a multimodal regional strategy, we describe the anesthesia management of a medically complex frail patient undergoing hip endoprosthesis.

Case Report

A 76-year-old male presented to the emergency department following an accidental fall. Imaging revealed a pertrochanteric fracture of the right femur. His past medical history included: ascending aortic ectasia (4 cm), infrarenal abdominal aortic aneurysm (2.7 cm), right common iliac artery aneurysm (3 cm), chronic obstructive pulmonary disease (COPD) with emphysema, active smoking habit, and recent hospitalization for community-acquired pneumonia. His left ventricular ejection fraction was estimated at 50%. Given the high cardiovascular and pulmonary risk, a regional anesthesia-based approach was selected. On the day of surgery, the patient received premedication with intravenous (IV) midazolam 0,03 mg/kg. A femoral nerve block was performed under ultrasound guidance with 10 mL of a local anesthetic mixture: ropivacaine 0.375% and mepivacaine 2%. A lateral femoral cutaneous nerve block was added using 3 mL of a local anesthetic mixture: ropivacaine 0.375% and mepivacaine 2%. With the patient in lateral decubitus (fractured side down), a sacral erector spinae plane (ESP) block was administered at the S2 level under ultrasound guidance using 20 mL of ropivacaine 0.2%. Subsequently, a selective spinal anesthesia was performed under sterile conditions, injecting 5 mg of hyperbaric bupivacaine. The patient was maintained in the lateral position for 7 minutes to achieve targeted distribution. Preemptive intravenous analgesia was provided with paracetamol 1 g and ketorolac 30 mg. The surgical procedure, right hip endoprosthesis, lasted 100 minutes. The intraoperative numeric rating scale (NRS) pain score remained at 0, no sedation was required, and no rescue opioid administration was necessary. No episodes of perioperative hypotension were recorded. Postoperatively, pain management included paracetamol 1 g IV every 8 hours and ketorolac 30 mg IV every 12 hours. Pain assessments at 24 and 48 hours revealed an NRS score of 0. No complications related to anesthesia or surgery were recorded.

Conclusion

This case illustrates the safety and effectiveness of a multimodal regional anesthesia strategy combining selective spinal anesthesia with peripheral nerve and sacral ESP blocks in a high-risk geriatric patient undergoing hip surgery. The technique provided optimal analgesia, hemodynamic stability, and obviated the need for systemic sedation or opioids. In frail patients with significant cardiovascular and respiratory comorbidities, such an approach may offer a valuable alternative to traditional general or neuraxial anesthesia alone. Informed consent to publication was obtained.

Consent

Informed consent was obtained for the publication of this scientific article.

A45 Ultrasound-guided interpectoral plane block and superficial serratus anterior plane block for subcutaneous implantable cardioverter-defibrillator implantation: a preliminar study

C. D'Errico, F. Giordano, G. Coppola, M. Pellegrino, S. Savino, V. Chierchia, M. Martone, C. Cilento, R. Miccio

Nuovo Ospedale Della Costiera, Sorrento (Napoli), Italy

Correspondence: F. Giordano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A45

Interpectoral plane block (IPP) and superficial serratus anterior plane block (S-SAP) was established to reduce the risk of general anesthesia or too excessive doses of local anesthetic for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation in patients with high operative risk. This study compared outcomes from ultrasound-guided PSP and S-SAP in 10 patients requiring a subcutaneous implantable cardioverter-defibrillator (S-ICD).

Material and Methods

16 patients were so divided A group of 8 patients (group A) ASA III - IV qualified for S-ICD implantation was included, they received echoguided IPP + superficial SAP block with Ropivacaine 7.5 mg/ml (Figure 1). We also enrolled 5 patients in group B (ASA III- IV), that received echoguided IPP only with Ropivacaine 7.5 mg/ml, finally 3 patients in group C whom local anesthesia (Mepivacina 2%) was performmed by cardiologist. The pain assessment using numerical rating scale (NRS), patient’s comfort using Quality of Recovery-15 (QoR-15), the operator’s satisfaction using Operator’s Comfort Scale, adverse event occurrence, and the parameters’ stability were evaluated. All patients were premedicated by Midazolam 0.03 mg/kg. In case of discomfort a bolus of 0.1- 0-5 mg/kg of Propofol was administered. Informed consent was obtained for the publication of this scientific article.

Results

The mean volume of the local anesthetics mixture of IPP block was 9.4 mL, in S-SAP was 28.7 mL (mean total volume, 38.1 mL). The mean duration for the execution of the block was 11.3 min; the mean time of the S-ICD implantation was 108.4 min. Neither circulatory nor respiratory instability was observed. In11 patients (51%), non-opioid analgesics were administered intraoperatively; in 8 patients (36%), fentanyl bolus up to 200 mcg was administered (6 of group B). The intraoperative NRS score was low (max 2 points); NRS 24 h after the procedure was low (max 4 points). The mean value of QoR-15 was 133.9 points.

Conclusions

S-SAP combined with IPP is feasible and safe in providing anesthesia analgesia during S-ICD implantation and showed good effects in a group of patients with high operative risk (ASA III or IV).

Fig. 1 (abstract A45).

A serratus plane block performed prior to PMK implantation

A46 Effectiveness of tap block versus intravenous analgesia in postoperative pain management following gynecologic laparoscopic surgery

V. Cognetti, G. Petruzzelli, L. Montrano, M. Rauseo, L. Mirabella

Department of Anesthesia and Intensive Care Medicine, Policlinico of Foggia Italy, University of Foggia, Italy

Correspondence: G. Petruzzelli

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A46

Introduction

Optimal postoperative pain control is crucial in laparoscopic gynecologic surgery, particularly within Enhanced Recovery After Surgery (ERAS) protocols. The transversus abdominis plane (TAP) block is a regional anesthesia technique that may reduce opioid consumption and enhance recovery. However, data comparing TAP block directly with standard intravenous analgesia in this surgical context are limited.

Methods

This prospective, randomized controlled trial included patients undergoing laparoscopic gynecologic procedures (e.g., myomectomy, ovarian cystectomy, endometriosis surgery). Patients were randomized into two groups:

- TAP Block Group: Bilateral ultrasound-guided TAP block with 0.25% levobupivacaine and 75 mcg clonidine per side, plus standard intraoperative intravenous analgesia (ketorolac, tramadol, ondansetron).

- Intravenous Analgesia Group: Standard intraoperative intravenous analgesia as above, followed by a postoperative elastomeric pump delivering tramadol 500 mg and ondansetron in 100 ml saline at 2 ml/h for 48 hours.

Primary outcome: Postoperative pain intensity (NRS) at 1, 6, and 24 hours. Secondary outcomes included additional analgesic use, side effects, and patient satisfaction.

Results

Preliminary analysis showed significantly lower postoperative pain scores in the TAP-block group. Mean NRS scores (± SD) at 1, 6, and 24 hours were 2.17 ± 1.17, 2.83 ± 0.98, and 1.67 ± 0.52, respectively, compared to 4.86 ± 0.90, 4.71 ± 1.70, and 3.29 ± 0.76 in the IV analgesia group (p = 0.001, 0.033, and 0.001, Fig.1).No patients in the TAP-block group required additional analgesics, whereas 43% of patients in the IV group received paracetamol. Adverse events were only observed in the IV group, including nausea (14%), sedation (14%), and vomiting (14%). No side effects occurred in the TAP group.

Conclusion

These findings support the use of TAP block for improved postoperative analgesia in laparoscopic gynecologic surgery. TAP block significantly reduces pain scores, opioid consumption, and improves patient comfort, in line with ERAS principles.

References

1. Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery. Cochrane Database Syst Rev. 2010;(12):CD007705. Published 2010 Dec 8. 10.1002/14651858.CD007705.pub2;

2. Dai C, Zhang K, Huang J. The Efficacy of Transversus Abdominis Plane Block for Abdominal Hysterectomy Post-operative Analgesia. Cureus. 2018;10(8):e3131. Published 2018 Aug 10. 10.7759/cureus.3131;

3. Jemal B, Mohammed F, Tesema HG, et al. Analgesic Efficacy of Spinal Morphine in Comparison With Transversus Abdominis Plane Block for Postoperative Pain Management in Patients Undergoing Cesarean Section Under Spinal Anesthesia: A Randomized Controlled Trial. Front Med (Lausanne). 2022;9:814538. Published 2022 Feb 9. 10.3389/fmed.2022.814538;

4. Qin C, Liu Y, Xiong J, et al. The analgesic efficacy compared ultrasound-guided continuous transverse abdominis plane block with epidural analgesia following abdominal surgery: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol. 2020;20(1):52. Published 2020 Feb 28. 10.1186/s12871-020-00969-0

Clinicaltrial.gov identifier: NCT07051499

Consent: Informed consent was obtained from all participants included in the study.

Fig. 1 (abstract A46).

Postoperative Pain Score Distribution by Group and Time

A47 A randomized controlled trial on the effects of continuous sciatic and femoral blocks in a fast track protocol after total knee replacement

S. Liguori¹, A. Arena¹, D. Ghisi², G. Cappelleri²

¹Università degli studi di Milano Bicocca, Milano, Italy; ²Istituto alta specialità Policlinico di Monza, Monza, Italy

Correspondence: S. Liguori

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A47

Background

Fast track methodology in total knee arthroplasty (TKA) is spreading steadily. We performed a randomized controlled trial to assess the effect of regional anesthesia techniques on long-term outcome. In this setting we have directly compared both continuous sciatic-femoral nerve block to continuous adductor canal block + IPACK in length of hospital stay after TKA.

Methods

After ethical committee approval 139 ASA I-III patients scheduled for TKA in spinal anesthesia were randomly allocated to receive both continuous sciatic-femoral nerve block (group 0, N = 79) or continuous adductor canal block + IPACK (group 1, N = 60). All patients received a multimodal analgesia including IV Paracetamol, Oral Colecoxib, IV dexamethasone, and a patient controlled analgesia with morphine (PCA). Primary outcome was the length of hospital stay. The criteria for home discharge were: being able to perform a complete both up & go and the six-minute walking test, climbing upstairs, an active range of motion > 90° and a NRS <4 with only oral analgesics. Functional tests at baseline, 72 h, and at discharge, as well as the 72 h PCA morphine requirement were also evaluated. A P<0.05 was considered significant.

Results

Patients characteristics and morphine requirement are showed in Table 1. The length of hospital stay (figure 1) required a median of 5 (IQR 4-6) days in group 1 and 5 (IQR 4-7) in group 2 (P=0.222). The functional tests at 72 h have been completed by 22/79 (27%) Pts in group 1 and 39/60 (65%) Pts in group 2 (P <0.001), while the ratio between the baseline and functional tests at discharge are showed in table 1.

Conclusion

This preliminary study showed that, although a higher number of patients with the adductor canal infusion + iPACK were able to receive an early active rehabilitation in the first 72 h, that was not effective in decreasing the length of hospital stay compared with patients receiving both sciatic and femoral continuous LA infusion after TKA. Moreover, patients belonged to this latter group have request significantly less morphine showing a better analgesic profile compared with the adductor canal + IPack block.

Registration code: clinical trials.gov ID: NCT06182059.

Consent: Informed consent was obtained for the publication of this scientific article.

Table 1 (abstract A47).

Patients characteristics, morphine requirement and Functional tests baseline and at discharge. Data are presented as number or mean ± SD

	Group 0	Group 1	p value
N° of patients	79	60
Age	70,9 ± 9	71,8
Sex	F = 47 M = 32	F = 47 M = 13
BMI	28,52 ± 3,32	28,27 ± 3,25	0,7
Morphine recieved 72 h (mg)	11 ± 13	20 ± 17	0,005
Morphine requested 72 h (mg)	16 ± 20	35 ± 44	0,003
Baseline Up-Go (sec)	18 ± 10	17 ± 7	0,54
Baseline 6mwt (mt)	304 ± 118	304 ± 110	0.99
At discharge Up-Go (sec)	37 ± 19	31 ± 14	0,05
At discharge 6mwt (mt)	151 ± 57	172 ± 68	0,09

Fig. 1 (abstract A47).

Length of hospital stay (days)

A48 Ultrasound-guided modified blocking the branches of intercostal nerves in the middle axillary line (Brilma) for open hepato-biliary surgery: a case series

A. Balducci¹, S. Tigano², A. Bianchini², C. Laici², S. Romano², L. Ramahi², S. Patti², A. Siniscalchi²

¹Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Università di Bologna, Italy²Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy

Correspondence: A. Balducci

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A48

Background

Effective pain control in open hepatobiliary surgery (HBS) is crucial to minimize postoperative complications (Table 1). The modified continuous blocking the branches of intercostal nerves in the middle axillary line (BRILMA) is a novel thoracic block that consists of injection of local anesthetic between the serratus anterior (SAM) and external intercostal (EIM) muscles, providing analgesia for T6–T11 dermatomes [1] [2].

This block can be done at the end of surgery under general anesthesia, avoiding interference with surgical equipment, while offering an opioid-sparing effect [3], making it an interesting alternative choice to traditional loco-regional blocks for HBS pain management (Table 2).

Materials and Methods

Two females, aged 58 and 64, underwent different HBS open procedures and received postoperative analgesia using a continuous modified BRILMA block. The block was performed at the end of surgery, using a sterile technique and ultrasound guidance with a 6-15 MHz linear probe. The puncture was performed with an in-plane approach at the 7th intercostal space (Figure 1 A). After hydrodissection of the fascial planes between SAM and EIM using 5-10 ml of saline, a bolus of local anesthetic was administered, followed by placement of a catheter inserted approximately 2-3 cm from the skin (Figure 1B). Catheter placement was confirmed by ultrasound and secured. Informed consent was obtained from both patients prior to the procedure.

Informed consent was obtained for the publication of this scientific article.

Results

Postoperative outcomes were encouraging in terms of both length of hospital stay and pain control (Table 3). In the first patient, pain control was optimal with only the continuous infusion of local anesthetic via the catheter, without requiring any opioids.

The second patient required a single dose of tramadol on postoperative day 1 as rescue analgesia.

Conclusions

The modified continuous BRILMA block appears to be a promising component of multimodal analgesia for managing pain following supraumbilical incisions in open HBS.

However, more robust evidence from randomized controlled trials or prospective observational studies is needed to validate these preliminary findings.

References

1. Tiwari AK, Mar AA, Fairley MA. Serratus anterior plane block for upper abdominal incisions. Anaesth Intensive Care 2019;47:197–9. 10.1177/0310057X19842461.

2. Fernández Martín MT, López Álvarez S, Mozo Herrera G, Platero Burgos JJ. Bloqueo fascial ecoguiado de las ramas cutáneas de los nervios intercostales: una buena alternativa analgésica para la cirugía abierta de vesícula biliar. Rev Esp Anestesiol Reanim 2015;62:580–4. 10.1016/j.redar.2015.02.011.

3. Fernandez MT, Lopez S, Ortigosa E. Reply to Dr Wang et al: serratus-intercostal block as opioids-saving strategy in supraumbilical surgery. Reg Anesth Pain Med 2019;44:535.1-535. 10.1136/rapm-2019-100384.

Fig. 1 (abstract A48).

1A—Ultrasound view of a BRILMA block. 1) Skin; 2) Subcutaneous Tissue; 3) Serratus Anterior Muscle; 4) External Intercostal Muscle; 5) Pleural line; 6) VII rib; 7) Hydrodissection; 8) Needle (in-plane). Figure 1B—Local anesthetic injection after catheter placement

Table 1 (abstract A48).

Potential benefits of loco-regional analgesia in abdominal surgery

Complication Type	How Effective Pain Control Helps
Pulmonary (e.g., pneumonia, atelectasis)	Improves ventilation, cough, and secretion clearance
Thromboembolic (DVT, PE)	Enables early mobilization
Gastrointestinal (ileus)	Reduces opioid use, stress response
Cardiovascular	Limits sympathetic overactivity
Chronic pain	Reduces risk of persistent pain
Wound healing/infection	Supports immune function, healing

Abbreviations: DVT, Deep Venous Thrombosis; PE, Pulmonary Embolism

Table 2 (abstract A48).

Pros and cons of different analgesia techniques for hepatobiliary surgery (HBS)

Technique	Pros	Cons
	Bilateral analgesia	-Relative contraindications are common (i.e. severe coagulophaty, anticoagulation therapy, sepsis, severe cardiomiopathyes, etc.)
Thoracic Epidural Analgesia (TEA)	Optimal visceral and somatic analgesia	-Technically challenging and need for patient collaboration (pre-operative only)
	Long history of use	- Difficult ultrasound guidance and assistance
Paravertebral (PV) Block	Good visceral and somatic analgesia	-Same contraindication of TEA
	Ultrasound guidance	-Technically challenging and need for patient collaboration (pre-operative only)
		-Potential risk of accidental pleural or vascular puncture
		- Potential risk of hypotension
Erector Spinae Plane (ESP) Block	Easier and safer than TEA and PVB	-Technically challenging and need for patient collaboration (pre-operative only)
	Ultrasound guidance	-Potential risk of pleural puncture
	Some visceral analgesia for paravertebral local anaesthetic spread
Oblique Subcostal Abdominis Transversus Plane (OSTAP) Block	Easier and safer than dorsal loco-regional analgesia techniques (i.e.TEA, PVB and ESPB)	-Potential risk of accidental liver puncture
	-Ultrasound guidance	-The procedure can conflict with surgical dressings and drains
	- Superficial block	-Potential risk of postoperative wound infections
	-Feasible in anesthetized, supine patient after end of surgery
	-Proven somatic analgesia efficacy in HBS
Modified Continuous blocking the branches of intercostal nerves in the middle axillary line (BRILMA) Block	-Easier and safer than TEA, PVB and ESPB	-Somatic analgesia only
	-Ultrasound guidance	- Relatively new technique
	- Superficial block	-Limited data for upper abdominal surgery
	-Feasible in anesthetized, supine patient after end of surgery
	-No conflict with surgical dressings or drains

Abbreviations: TEA, Thoracic Epidural Analgesia; PV, Paravertebral; ESP, Erector Spinae Plane; OSTAP, Oblique Subcostal Abdominis Transversus Plane; DVT, Deep Venous Thrombosis; PE, Pulmonary Embolism

Table 3 (abstract A48).

Patient Characteristics, Analgesia Protocol, and Postoperative Outcomes Following Modified BRILMA Block for hepatobiliary surgery (HBS)

ID (Gender, Age)	Surgery, disease	ASA	Surgery duration (min)	LA	NRS	Cumulative LA dosage	Cumulative morphine equivalents (mg)	Rescue analgesia	Timing of catheter removal	LOS
				(type, %, ml, continuous vs pop-up)	(T0, T6, T12, T24)	(Type and mg)				(ICU and Ward)
1 (58, F)	Cholecystectomy for cholelithiasis	III	175'	OR: Ropivacaine 0.375% 20 ml single-shot;	1;1;1;1	Ropivacaine 95 mg	None	ICU: none; Ward: none	POD1	ICU: 26 h;
				ICU: Ropivacaine 0.2% single bolus 10 ml;						Ward: 2 days;
				Ward: none;
2 (64, F)	Wedge resection (VII liver segment) for metastatic ovarian cancer	III	210'	OR: Ropivacaine 0.2% 20 ml single-shot;	1;2;2;3	Ropivacaine 680 mg	10 mg	ICU: tramadol 100 mg; Ward: none	POD3	ICU: 24 h;
				ICU: Ropivacaine 0.2%: 2 boluses 10 ml + 100 ml continuous infusion;						Ward: 9 days;
				Ward: Ropivacaine 0.2% 200 ml continuous infusion

Abbreviations: LA, Local Anesthetic; NRS, Numerical Rating Scale (at timepoints T0 = baseline, T6 = 6 h, T12 = 12 h, T24 = 24 h); OR, Operating Room; ICU, Intensive Care Unit; POD, Post Operative Day; LOS, Length of Stay

Anaesthesia in the frail patient

A49 Case report: cesarean section in a patient with type 1a von willebrand disease and previous postpartum hemorrhage

O.P. Volino, M. Loreto, S. Perna, F. Salvato, P. Vasta, E. Va Fai Rad, F. Russo, M. Mainini, M. Brita, A. De Simone, C. Sala, R. Villani

UOSC TIGU - CAV - AORN Antonio Cardarelli, Napoli, Italy

Correspondence: O.P. Volino

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A49

Anesthetic management in obstetric patients with coagulopathies remains a critical challenge. We report the case of a 37-year-old woman in her second pregnancy at 36 weeks of gestation, affected by type 1 A von Willebrand disease (vWD), with a past medical history of thyroid carcinoma treated with total thyroidectomy, and a previous cesarean section complicated by severe postpartum hemorrhage (PPH). The patient was scheduled for an elective cesarean delivery at our institution, with multidisciplinary planning involving obstetrics, anesthesiology, hematology, and neonatology.

During the preoperative assessment, the patient exhibited no active symptoms. Her medical history included a diagnosis of type 1 A von Willebrand disease (vWD). No significant bleeding episodes had been reported since the previous cesarean section; however, due to the history of severe postpartum hemorrhage, a comprehensive hemostatic plan was implemented. Preoperative laboratory evaluations revealed stable hemoglobin and platelet counts, with mildly decreased vWF levels consistent with her baseline profile.

Given the underlying coagulopathy and surgical history, the anesthetic plan prioritized regional anesthesia, in accordance with guidelines for cesarean sections. Furthermore, the management of the case under general anesthesia would have posed significantly higher risks. Following a hematology consultation, it was decided not to administer prophylactic factor replacement or desmopressin, as the vWF levels were adequate and there were no signs of bleeding. The patient was closely monitored for any signs of bleeding or hematologic instability.

In the operating room, standard monitoring was applied, and spinal anesthesia was performed at the L2-L3 intervertebral space using a 27G Whitacre pencil-point needle. Hyperbaric bupivacaine 11 mg and morphine 100 mcg were administered intrathecally. The sensory block reached the T4 level within 5 minutes. Hemodynamic parameters remained stable throughout the procedure, with no episodes of hypotension or bradycardia observed.

The cesarean delivery proceeded without complications, and a healthy female neonate was delivered with Apgar scores of 9 and 10 at 1 and 5 minutes, respectively. The estimated blood loss was 850 mL, and no excessive bleeding occurred during the procedure. Given the high risk of hemorrhage, a Bakri balloon was prophylactically placed at the level of the cervix in combination with uterotonic therapy.

Postoperatively, the patient was transferred to the obstetric ward for close monitoring. Vital signs remained stable, and no signs of delayed bleeding were observed. Hemoglobin levels and coagulation parameters were rechecked at 12 and 24 hours post-surgery, showing no significant deviations from baseline. Pain was effectively managed with a multimodal analgesic regimen, including scheduled acetaminophen and non-opioid adjuncts.

The patient was discharged on the third postoperative day in stable condition. A follow-up was scheduled in collaboration with the hematology department. She reported no complications during the postpartum period.

This case highlights the importance of an individualized and multidisciplinary approach in managing pregnant patients with coagulation disorders. Spinal anesthesia can be safely performed in selected patients with von Willebrand disease when coagulation parameters are within acceptable ranges and the clinical bleeding history is favorable. Peripartum vigilance remains essential to reduce the risk of hemorrhagic complications and ensure maternal and neonatal safety.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Castaman G, Tosetto A, Federici AB, et al. *Pregnancy and delivery in women with von Willebrand disease*. Eur J Haematol. 2019;103(1):73–83. 10.1111/ejh.13250. [1]

2. American Society of Hematology (ASH), International Society on Thrombosis and Haemostasis (ISTH), National Hemophilia Foundation (NHF), World Federation of Hemophilia (WFH). *ASH ISTH NHF WFH 2021 guidelines on the management of von Willebrand disease*. Blood Adv. 2021;5(1):301–325. 10.1182/bloodadvances.2020003261.

3. Centers for Disease Control and Prevention (CDC). *Von Willebrand Disease and Pregnancy*. Updated May 15, 2024. Available at: https://www.cdc.gov/von-willebrand/female/index.html.

4. Hara K, Kishi N, Sata T. *Considerations for epidural anesthesia in a patient with type 1 von Willebrand disease*. J Anesth. 2009;23(4):597–600. 10.1007/s00540-009-0782-z.

5. Butwick AJ, Carvalho B. *Spinal anesthesia for a cesarean delivery in a woman with type-2M von Willebrand disease: case report and mini-review*. J Clin Anesth. 2009;21(5):372–375. 10.1016/j.jclinane.2008.10.013.

6. American College of Obstetricians and Gynecologists (ACOG). *Von Willebrand Disease in Women*. Committee Opinion No. 580. Obstet Gynecol. 2013;122(6):1368–1373.

7. James AH, Jamison MG. *Bleeding events and other complications during pregnancy and childbirth in women with von Willebrand disease*. J Thromb Haemost. 2007;5(6):1165–1169. 10.1111/j.1538-7836.2007.02556.x.

8. Arakaki T, Kanagawa T, Okada Y, et al. Prophylactic use of Bakri balloon tamponade during cesarean section for placenta previa. Journal of Obstetrics and Gynaecology Research. 2013;39(1):67–72. 10.1111/j.1447-0756.2012.01938.x.

A50 Anesthetic decision-making in the gray zone: a case of spinal anesthesia with severe aortic stenosis

E. Trimarchi, F. Sorrenti, V. Marando, M. La Motta, V. Tripodi, A.T. Mazzeo

Anesthesia and intensive Care Section, Human Pathology Department Gaetano Barresi, G. Martino University Hospital, Messina, Italy

Correspondence: F. Sorrenti

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A50

Background

A 96-year-old female patient, BMI 33.2, presented to the emergency department with a left pertrochanteric femoral fracture and associated lesser trochanter displacement. She was alert but only partially cooperative and intermittently disoriented (RASS 2), breathing spontaneously with eupnea in oxygen-enriched room air via nasal cannula. Vital signs were stable: HR 88 bpm, non-invasive blood pressure within normal limits, and SpO2 approximately 93%. Her medical history included chronic respiratory failure requiring continuous home oxygen therapy, a dual-chamber pacemaker due to third-degree AV block, and a prior episode of aspiration pneumonia requiring ICU admission for one week. She had a history of severe heart failure with markedly reduced ejection fraction (~20%), leading to previous surgical denial at another institution. Urgent cardiology evaluation revealed concentric left ventricular hypertrophy, interventricular septal dyskinesia, and moderately reduced systolic function (~45% EF), with left atrial enlargement. Associated findings included moderate mitral regurgitation and a severely stenotic, sclerocalcific aortic root (mean gradient 75 mmHg, peak gradient 120 mmHg). Anesthesiology consultation advised against neuraxial anesthesia due to the severity of aortic stenosis, suggesting peripheral nerve block with sedation or general anesthesia. The patient was functionally dependent (MET ~4) and classified as ASA IV E.

Case Report

In the operating room, the patient was alert and intermittently cooperative, breathing spontaneously with nasal cannula oxygen at 3 L/min. Vitals: HR 86 bpm, SpO2 ~92%, NIBP within acceptable range, pain VAS during movement 6, RASS 1. The patient has been informed of the risks and has signed consent for both subarachnoid anesthesia and data publication. Monitoring included 2-lead ECG (leads II and V), peripheral SpO2, NIBP, and nasal cannula delivering O2 at 4 L/min with concurrent end-tidal CO2 measurement. A femoral nerve block was performed under triple guidance (ultrasound, nerve stimulator, and injection pressure monitoring), administering 10 mL of 0.375% ropivacaine, which provided immediate analgesia. The patient was then positioned in right lateral decubitus, and after sterile field preparation, subarachnoid anesthesia was administered using a 25G Sprotte needle (103 mm). A minimal dose of 6 mg levobupivacaine was injected, and the lateral position was maintained for 5 minutes to limit anesthetic spread. The patient was then placed supine, and a closed reduction with internal fixation of the femoral fracture was performed. She remained alert and intermittently cooperative throughout the procedure (RASS 1).

Conclusion

Severe aortic stenosis with high transvalvular gradient is generally considered an absolute contraindication to spinal anesthesia due to the risk of profound hypotension from sympathetic blockade. However, general anesthesia was also contraindicated due to the patient’s chronic respiratory insufficiency. While a combined femoral and sciatic nerve block could have provided adequate anesthesia, it would have required procedural sedation, which was deemed unsafe given the patient’s comorbidities. In this context, a carefully titrated low-dose spinal anesthesia performed in the lateral position allowed for effective analgesia while minimizing hemodynamic instability. The patient remained hemodynamically stable and was returned to the ward two hours postoperatively, awake and intermittently cooperative, without significant complications.

Consent

Informed consent was obtained for the publication of this scientific article.

A51 Impact of frailty on outcome in emergency surgery: a preliminary prospective study

L.A. Sorrentino, C. Grillandini, A. Valletta, S. di Valvasone, C. Guetti, F. Pelagatti, A. Ottaviano, C. Fabiani, F. Socci, S. Batacchi, M. Bonizzoli

SODc Cure Intensive Emergenza e Trauma e centro di riferimento ECMO Dipartimento Emergenza e Accettazione AOU Careggi, Firenze, Italy

Correspondence: L.A. Sorrentino

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A51

Background

An increasing number of elderly individuals and pluripathological patients undergo emergency surgery. For predicting perioperative outcomes, frailty has proven to be more accurate than chronological age. The factors contributing to the development of frailty are numerous and diverse; therefore, in the absence of clear evidence, the predominant hypothesis suggests a syndrome influenced by the patient's environment and social sphere, which also affects multiple pathologies (1). The perioperative management of frailty is complex, as these patients often experience pharmacokinetic and pharmacodynamic alterations due to physiological decline caused by various deficits, particularly in the presence of polypharmacotherapy, comorbidities, and organ dysfunctions that frequently characterize frail patients. However, according to the survey guided by SIAARTI, frailty scoring is routinely performed only in 51.8% of care settings (2). The emergency setting typically does not allow for the optimization of a patient’s functional state, since the underlying condition can often be addressed only through surgery. However, certain clinical situations warrant greater attention, always considering the risk-benefit ratio without excessively delaying surgery (3).

There is insufficient consensus on a gold standard for assessing frailty, with over 70 assessment scores identified in the literature, few of which have been explicitly validated for emergency surgery patients.

Materials and Methods

We conducted a prospective study from June to August 2024 involving patients who underwent emergency surgery for abdominal disorders, excluding those of traumatic origin. The included patients were divided into three groups (frail, non-frail, and pre-frail) according to the Frail Scale (4,5). Figure 1.

The primary outcomes included detecting postoperative complications, the length of hospital stay, and the discharge outcome related to the level of frailty.

Results

Our study involved 146 patients: 13 in the frail group, 56 in the pre-frail group, and 77 in the non-frail group (Table 1). In our cohort, frail patients had higher age and Charlson Comorbidity Index (CCI) scores than pre-frail patients, who, in turn, had higher age and CCI scores than non-frail patients. Applying the ERAS protocol in emergency surgery was more common among non-frail patients. In contrast, frail patients more frequently required the maintenance of a nasogastric tube, bladder catheter, and surgical drains. The incidence of complications during the primary surgery was significantly higher in frail patients and in the postoperative period. However, there was no difference in the number of subjects needing reoperation. Postoperative hospitalization in intensive care was significantly more frequent in frail patients, as was the length of the hospital stay.

Conclusions

The preoperative frailty assessment in emergency surgery, utilizing a score beyond the patient's subjective evaluation, could enhance the clinical approach to the patient. It may also assist in identifying appropriate indications for surgery, fostering the relationship with the patient. Optimizing the management of the perioperative period for frail patients, whose numbers are expected to rise in the coming decades, will therefore represent a commitment for both doctors and the health system.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Chan SP, Ip KY, Irwin MG. Peri-operative optimisation of elderly and frail patients: a narrative review. Anaesthesia. 2019 Jan;74 Suppl 1:80–9.

2. Greco M, Luca E, Chiumiento F, Behr AU, Bettelli G, Bignami E, et al. Perioperative assessment and management of frailty in elderly patients: a national survey of Italian anesthesiologists. Journal of Anesthesia, Analgesia and Critical Care. 2025 Feb 22;5(1):11.

3. Tan HL, Chia STX, Nadkarni NV, Ang SY, Seow DCC, Wong TH. Frailty and functional decline after emergency abdominal surgery in the elderly: a prospective cohort study. World J Emerg Surg. 2019;14:62.

4. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016 Aug 31;16(1):157.

5. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012 Jul;16(7):601–8.

Fig. 1 (abstract A51).

Frail Scale

Table 1 (abstract A51).

Patients’ characteristics and outcomes

	All	Non-Frail group	Frail group	Pre-Frail group	p value
Age	61 (42–73)	46 (27–67)	71 (69–85)	65 (55–75)	.0014
Charlson Comorbidity Index	2 (0–4)	0 (0–2)	6 (3–7)	4 (2–5)	.0003
ERAS	67 (45.89%)	47 (61.04%)	7 (53.85%)	13 (23.21%)	<.0001
Intra-operative complications	10 (6.85%)	2 (2.60%)	0 (0.00%)	8 (14.29%)	.018
Post-operative complications	25 (17.36%)	7 (9.09%)	6 (54.55%)	12 (21.43%)	.001
ICU post-operative hospitalization	5 (3.42%)	2 (2.60%)	2 (15.38%)	1 (1.79%)	<.0001
Reoperation rate	9 (6.25%)	4 (5.26%)	1 (8.33%)	4 (7.14%)	0.864

A52 Preoperative pupillometry evaluation and post-operative delirium during total intravenous anaesthesia with target controlled infusion: a prospective observational study

F. Linassi¹, P. Zanatta², L. Polesello², M. Carron³

¹Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Italy; ²Department of Anesthesia and Intensive Care, Ca'Foncello Treviso Regional Hospital, Treviso, Italy; ³Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Italy

Correspondence: F. Linassi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A52

Post-operative delirium (POD) is a frequent and serious complication in frail patients undergoing surgery, associated with increased morbidity and long-term cognitive decline [1]. Pupillometry, the quantitative assessment of pupillary light reflexes, has emerged as a non-invasive tool to evaluate cognitive vulnerability. Alterations in pupil diameter (PD), constriction latency (PL), and maximum constriction velocity (MCV) have been associated with neurodegenerative conditions such as Alzheimer's disease [2]. A previous study also suggested that the hypnotic requirement during total intravenous anesthesia (TIVA) is influenced more by cognitive impairment than by age or gender [3]. However, no data are currently available on the potential role of preoperative pupillometry in predicting the risk of POD in surgical patients, particularly in the setting of TIVA with target-controlled infusion (TCI).

Methods

We conducted a prospective observational study in 111 adult female patients undergoing elective breast cancer surgery under TIVA-TCI. Preoperative bilateral pupillometry was performed to measure PD, PL, and MCV. POD was assessed in the post-anesthesia care unit (PACU) using the Confusion Assessment Method (CAM). Estimated Propofol concentrations (CeP) at Loss of responsiveness (LoR), Burst Suppression occurrence (BSupp), during Anesthesia Maintenance (MA) and at Reutrn of Responsiveness (RoR) were also considered. Statistical analysis included comparisons between POD and non-POD patients and logistic regression to identify independent predictors.

Results

POD was observed in 10 patients (9%). Compared to non-POD patients, those who developed POD had significantly smaller left pupil diameter (PD-L: 2.74 vs 3.08 mm, p<0.05), a trend toward longer left pupillary light reflex latency (PL-L: 0.27 vs 0.23 s, p=0.08), and lower CeP at RoR (1.51 mcg.ml-1 vs 1.94 mcg.ml-1, p<0.05), Table 1. Logistic regression confirmed PD-L (p<0.05; area under the curve [AUC]: 0.73, 95% confidence interval [CI]: 0.54–0.89) and PL-L (p<0.05; AUC: 0.68, 95% CI: 0.42–0.91) as independent predictors of POD

Conclusion

Preoperative pupillometric evaluation, particularly reduced PD-L and prolonged PL-L, may serve as a simple, non-invasive tool to identify patients at increased risk of postoperative delirium. These findings support the role of pupillometry as a potential screening method for cognitive frailty in the perioperative setting [3].

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56. 10.1093/gerona/56.3.m146.

2. Prettyman R, Bitsios P, Szabadi E. Altered pupillary size and darkness and light reflexes in Alzheimer's disease. J Neurol Neurosurg Psychiatry. 1997;62(6):665–8. 10.1136/jnnp.62.6.665

3. Linassi F, Kreuzer M, Kratzer S, et al. Unwanted spontaneous responsiveness and burst suppression in patients undergoing entropy-guided total intravenous anesthesia with target-controlled infusion: An observational prospective trial. J Clin Anesth. 2023;86:111045. 10.1016/j.jclinane.2022.111045

Table 1 (abstract A52).

General characteristics of patients presenting PostoperativeDelirium (POD) and not

Variables	Total POD patients (n = 10)	Total Not POD patients (n = 101)	P-value	Effect size
Preoperative, demographic and LoR variables
Age, yrs	63.50 [24–68]	63.00 [59,83—64,63]	0,77	−0,07
Weight, kg	66.00 [23–72]	67.00 [10, 33–72]	0,5	−0,23
Height, cm	160.00 [166, 81 - 169, 19]	165.00 [163,02—165,42]	0,33	−0,19
BMI, kg m-2	25.40 [24,52—27,78]	25.75 [24,57—27,56]	0,97	−0,12
P- R (mm)	3.07 [2, 45 - 3, 30]	3.17 [3,08—3,39]	0,18	−0,48
PL-R (s)	0.23 [0,21—0,26]	0.23 [0,24—0,25]	0,57	−0,21
MCV-R (mm s-1)	2.89 [2.03–3.71]	3.03 [1.3—4.7]	1.27	#####################
PD-L (mm)	2.74 [2,20—3,02]	3.07 [3,00—3,26]	0,03	−0,83
PL-L (s)	0.27 [0,22—0,29]	0.23 [0,23—0,24]	0,08	0,73
MCV-L (mm s-1)	2.13 [1.88–2.31]	2.95 [1.6–4.36]	0.34	#####################
CeP variables
CeP LOR, μg ml-1	1.18 [0.95—1.77]	1.48 [1,40—1,63]	0,38	−0,26
CeP BSupp arousal, μg ml-1	5.85 [2.48—7,17]	5.25 [4,74—5,56]	0,44	0,64
CeP MA, μg ml-1	3.00 [2, 67 - 3, 22]	3.10 [3,03—3,26]	0,32	−0,34
CeP ROR, μg ml-1	1.51 [1,24—1,98]	1.94 [1,87—2,08]	0,04	−0,66

BMI: Body Mass Index; PD-R: Pupil diameter Right; PL-R: Pupil Latency Right; PD-L: Pupil diameter Left; PL-L: Pupil Latency Left; MCV-R: Maximum Contraction Velocity Right; MCV-L: Maximum Contraction Velocity Left; CeP: Concentration of propofol; LoR: Loss of Responsiveness; BSupp: Burst Suppression; MA: maintenance of Anesthesia; RoR: Return of Responsiveness

A53 Experience with continuous remimazolam infusion in patients undergoing radiofrequency treatment for hepatocellular carcinoma

M. Barberio, C. Minucci, S. Virno, D. Abbenante, R. Giurazza, R. De Rosa

A.O.R.N. Dei Colli Monaldi-Cotugno-C.T.O. P.O. Domenico Cotugno, Naples, Italy

Correspondence: M. Barberio

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A53

We present our clinical experience with continuous remimazolam infusion in patients with hepatocellular carcinoma undergoing radiofrequency ablation of hepatic lesions. Our study included five patients (4M, 1 F), with a mean age of 65±5, classified as ASA III. They exhibited stable liver function without cardiovascular or renal abnormalities. The study was approved by the ethics committee. The patients gave written informed consent.

Sedation Protocol: -Premedication: sufentanil (10µg) and remimazolam (5mg) intravenously -Continuous Infusion: remimazolam 0.15–0.2 mg/kg/h -Pain Management: additional intravenous boluses of sufentanil (5µg) and remimazolam (5mg) during peak pain moments.

Monitoring and Respiratory Support: -standard monitoring -NOL nociception monitoring -BIS sedation monitoring -spontaneous respiration with nasal oxygen 3 L/min.

Adjustments for Complex Cases: in one instance, due to the lesion's depth and procedural complexity, deeper sedation was required. This included: -increased remimazolam dosing (initial and additional 10 mg boluses) -higher continuous infusion rate (0.25 mg/kg/h) -placement of a laryngeal mask, maintaining spontaneous respiration.

Outcomes: -all patients maintained adequate sedation/analgesia (BIS: 40–50, NOL: 20-25) -no involuntary movements or reflexes interfered with the procedure -hemodynamic stability was consistently observed, without hypotensive events or rhythm disturbances -patients regained full alertness within 2-3 minutes post-infusion, with BIS levels normalizing (~90) -no memory of the procedure was reported by any patient -no event of postoperative delirium was reported by any patient -no antidote was administered for either sufentanil or remimazolam.

The field of anesthesiology has continuously evolved as new pharmacological agents have emerged, offering potential improvements in safety. One such advancement is remimazolam, a novel ultra-short-acting benzodiazepine that has garnered attention owing to its rapid onset, predictable metabolism, and presumed hemodynamic stability [1]. Remimazolam exhibits pharmacokinetic properties that are distinct from those of other benzodiazepines; it is rapidly degraded by nonspecific esterases in the liver, resulting in a faster recovery and reduced accumulation in patients with impaired organ function. Among its various advantages, hemodynamic stability is particularly notable. Compared with propofol, remimazolam has been associated with a significantly lower incidence of hypotension, making it a valuable option in condition of cardiovascular instability. This characteristic may be especially beneficial for elderly or critically ill patients in whom maintaining stable blood pressure is crucial [2-3]. Additionally, its anesthetic effects are rapidly reversed by flumazenil, providing an added safety margin.

Our protocol demonstrates that continuous remimazolam infusion provides, in fragile liver patients, an effective and controlled sedation with always stable hemodynamic parameters, and a swift recovery without the need for the antidote. The pharmacological profile of remimazolam—rapid onset, predictable metabolism, and minimal cardiovascular impact—makes it a valuable alternative to conventional agents, particularly for patients with comorbidities. Its ability to maintain spontaneous respiration while offering reliable sedation adds to its clinical appeal, reducing the risks associated with deeper anesthesia. The approach proved safe and well-tolerated, without reported adverse events, postoperative delirium. Future studies with larger sample sizes are necessary to establish remimazolam’s role in broader anesthetic applications.

References

1. Anesthesiology and Perioperative Science (2023) 1:25.

2. Korean J Anesthesiol. 2025;78(2):89-90

3. Korean J Anesthesiol. 2025;78(2):118-128

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Informed consent was obtained for the publication of this scientific article.

A54 A multicenter retrospective analysis of risk factors and outcomes of blood transfusion in hip fracture patients

L. Al-Husinat¹, S. Al Sharie², M. Alisi³, N. Obeidat⁴, H. Aljarrah⁴, F. Haddad⁵, A. Del Piano⁶, D. Battaglini⁷

¹Faculty Of Medicine, Yarmouk University, Irbid, Jordan; ²Office Of Scientific Affairs And Research, Amman, Jordan; ³Faculty Of Medicine, Islamic University Of Gaza, Gaza, Palestine; ⁴Jordanian Ministry Of Health, Amman, Jordan⁵Michigan Kidney Center, Michigan, Usa; ⁶University Hospital Of Naples Federico II, Naples, Italy; ⁷Department Of Surgical Sciences And Integrated Diagnostics (Disc), University Of Genova, Genova, Italy

Correspondence: L. Al-Husinat

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A54

Background

Anemia is prevalent among elderly patients undergoing hip fracture surgery and is frequently managed with postoperative blood transfusion. However, the risk factors necessitating transfusion and its impact on clinical outcomes remain controversial. This study aims to identify risk factors associated with postoperative blood transfusion and assess its relationship with clinical outcomes, including mortality, in elderly patients undergoing hip fracture surgery.

Methods: A retrospective multicenter study was conducted on 1,040 patients aged 65 and older who underwent hip fracture repair between 2019 and 2021 across three centers in Jordan. Patients were categorized into transfusion (n=373) and non-transfusion (n=667) groups. Clinical and demographic variables were compared using appropriate statistical tests. Logistic and Cox regression analyses were performed to identify predictors of transfusion and to evaluate the association between transfusion and postoperative outcomes.

Results

Patients in the transfusion group were significantly older (median age 79 vs. 77 years, p=0.0015), more likely to be female (60.59% vs. 52.5%, p=0.012), and had lower preoperative hemoglobin levels (10.85 vs. 12.62 g/dL, p<0.001). Clopidogrel use (10.99% vs. 6%, p=0.004) and unstable intertrochanteric fractures (53.08% vs. 42.13%, p=0.001) were more common among transfused patients. Transfusion was associated with higher ICU admission rates (19.03% vs. 6.45%, p<0.001), longer hospital stays (median 7 vs. 6 days, p<0.001), and increased in-hospital (4.02% vs. 1.65%, p=0.019), 30-day (7.51% vs. 3.3%, p=0.002), and overall mortality (18.23% vs. 11.24%, p=0.002). Multivariate analysis showed that clopidogrel use (OR=1.797, p=0.044), lower hemoglobin (OR=0.520, p<0.001), and fracture type were independent predictors of transfusion. Blood transfusion independently predicted ICU admission (OR=2.168, p=0.004) and longer hospital stay (OR=1.053, p=0.005), but not overall mortality (HR=1.148, p=0.465).

Conclusion

Postoperative blood transfusion in elderly patients undergoing hip fracture repair is significantly associated with specific risk factors including advanced age, female sex, low preoperative hemoglobin, clopidogrel use, and fracture instability. While transfusion increases ICU admission and hospital stay, it is not an independent predictor of mortality. These findings support the adoption of individualized and restrictive transfusion strategies to optimize surgical outcomes.

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Informed consent was obtained for the publication of this scientific article.

Cardio-Thoraco-Vascular

A55 Refractory mixed shock after cardiac surgery: don’t forget the mitral valve!

R. Traversi¹, M. Giunta², R. Lara^1,2, M. Francesca², P. Tommaso², T. Anna Chiara², L. Brazzi^1,2

¹Dipartimento di Scienze Chirurgiche, Università degli Studi di Torino, Italy; ²Anestesia e Rianimazione 1U, AOU Città della Salute e della Scienza, Torino, Italy

Correspondence: R. Traversi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A55

Background

Systolic anterior motion (SAM) of the mitral valve (MV) is a life-threatening condition1. SAM can result in severe left ventricular outflow tract obstruction (LVOTO) and/or mitral regurgitation. The mechanisms of SAM are complex and depend on the functional status of the ventricle but is now recognized to arise in any setting that alters the dynamic anatomy of left ventricle. Although early reports identified LVOTO to occur in all cases of SAM, its presentation can vary from clinically silent disease to severe LVOTO with associated haemodynamic compromise

Case Report

Here we present the case of a 79-year-old female admitted to our cardiac Intensive Care Unit (ICU) at Città della Salute e della Scienza University Hospital in Turin after ascending aorta and aortic hemiarch replacement for acute type I aortic dissection. Relevant past medical history included the known ascending aorta aneurism in regular follow-up and Horton’s arteritis for which she was treated with anti-IL6 monoclonal antibody (tocilizumab) infusion every 3 weeks.Surgical procedure was performed without complications and Cardio-Pulmonary Bypass (CBP) was successfully weaned with low-dose norepinephrine.Early post-operative course was characterized by development of acute kidney injury (AKI) and hypoxic respiratory failure. In POD 3 patient developed refractory shock with severe hypotension. Lung CT-scan showed consolidation in the right inferior lobe (Fig.1)

A diagnosis of septic shock superimposed to cardiogenic shock was made.

Norepinephrine was started to achieve a mean arterial pressure (MAP) of 65 mmHg, and after few hours low dose epinephrine was added due to failure to maintain an adequate MAP only with high dose norepinephrine (up to 1 mcg/kg/min). After infectious disease consult for antimicrobial stewardship broad spectrum therapy with Ceftazidime/Avibactam and anti-MRSA (Daptomicine) was started. In POD 4 haemodynamic furtherly worsened after developed of rapid atrial fibrillation. Electric cardioversion failed rhythm control, and adequate rate control was obtained with continuous infusion of amiodarone.

In POD 5 an echocardiography was made that showed SAM with LVOTO. Epinephrine was therefore suspended and continuous infusion of a rapid onset beta-blocker (Esmolol) was started. This change of management lead to reduction of vasopressive support, that was suspended in POD 6, 8 hours later that the diagnosis of SAM.

Conclusion

In a recent multicentre observational study by Vignon2, diastolic dysfunction during septic shock showed high prevalence but no impact on mortality. In our experience, the identification of high-grade diastolic dysfunction, especially when associated with specifical dynamic physiopathological alteration of the heart such as SAM, which may severely worse the clinical manifestation of the syndrome, should be taken into account to properly target the vasopressor and inotropic management.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Ibrahim et. al Modern management of systolic anterior motion of the mitral valve. European Journal of Cardio-Thoracic Surgery (2012), 41 :1260–1270

2. Vignon P et al. Left Ventricular diastolic dysfunction is prevalent but not associated with mortality in patients with septic shock. Intensive Care Medicine (2025) 51 :94-105

Fig. 1 (abstract A55).

Lung CT scan

A56 Successful treatment of a 15 centimetres ecmella-related aortic thrombus in a D-LVAD patient using inari flowtriever system

B. Silano¹, M. Giunta², S. Pourshayestheh¹, A. Loforte³, A. Spitaleri³, F. Canavosio², G. Gallone⁴, A. Di Scalzi⁵, A.C. Trompeo², M. Rinaldi³, L. Brazzi^1,2

¹Dipartimento di scienze chirurgiche, Università degli Studi di Torino, Italy; ²Dipartimento di Anestesia, Terapia Intensiva e Emergenze, Città della salute e della scienza, Torino, Italy; ³Dipartimento di CardioToracoVascolare, Cardiochirurgia, città della salute e della scienza, Torino, Italy; ⁴Dipartimento di Scienze Mediche, Cardiologia, Città della salute e della scienza, Torino, Italy; ⁵Dipartimento di Scienze Mediche, Radiologia, Città della salute e della scienza, Torino, Italy

Correspondence: B. Silano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A56

ECMELLA is a hybrid mechanical circulatory support strategy that combines VA-ECMO and Impella. Its purpose is to provide full cardiopulmonary support while unloading the left ventricle especially in patients with cardiogenic shock as a bridge to recovery, durable LVAD (d-LVAD) or transplantation.

Nonetheless, in the ECMELLA set up the dual circulation is responsible for very turbulent blood flow inside the “mixing cloud” (it occurs where the retrograde ECMO flow and the antegrade Impella flow converge), which is reported to be associated with thrombotic risk and spinal cord ischemia.

We describe the case of a 55-year-old man with acute myocardial infarction-related cardiogenic shock (AMI-CS) who was bridged from ECMELLA to d-LVAD.

After LVAD implantation, the patient developed early right heart failure and required a temporary right ventricular assist device (t-RVAD). Four days later, during the evaluation for RV function recovering by TEE, an incidental 15 cm long floating thrombus was found in the descending aorta. The intravascular clot happened despite full anticoagulation and fibrinolysis was not a suitable option due to high bleeding risk of pre-existing cerebral lesions. On the other hand, the thrombus size and shape were considered at too high risk of mesenteric or renal embolism for a “watch-and-see” approach.

Therefore, after a multidisciplinary team discussion (anesthesiologists, cardiac surgeons, interventional radiologists), we decided for mechanical thrombectomy using the FlowTriever System (Inari Medical, Irvine, CA). The procedure was conducted under radioscopic and TEE guidance and showed no embolic or bleeding complication (Fig.1)

The RVAD was weaned off on post-operative day 8 and the patient was discharged safely from the ICU and, later, at home without residual organ failure.

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Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A56).

The thrombus found in the descending aorta

A57 Continuous non-invasive hemodynamic monitoring with clearsight™ in minimally invasive thoracic surgery: a goal-directed therapy approach in asa II patients

G. Sciacca, P. Kouroupis, L. Tritapepe

A.O. San Camillo - Forlanini, Roma, Italy

Correspondence: G. Sciacca

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A57

Background

Continuous hemodynamic monitoring is crucial in thoracic surgery to optimize perioperative outcomes(1) and to avoid hypotensive periods(2)(3). In ASA II patients undergoing minimally invasive thoracic surgery, the use of an arterial line may represent overtreatment. This study investigates the utility of non-invasive continuous hemodynamic monitoring using the ClearSight™ system(4), guided by goal-directed therapy (GDT) based on stroke volume index (SVI) (5).

Methods

We conducted a retrospective observational study involving 56 ASA II patients undergoing video-assisted thoracoscopic surgery (VATS). Hemodynamics were managed intraoperatively using a GDT protocol guided by SVI via ClearSight™ or by standard intermittent noninvasive blood pressure measurement (iNIBP). Primary outcome assessed intraoperative time of hypotension. Secondary outcomes assessed amount of intraoperative fluid administration, postoperative complications, hospital length of stay.

Results

Patients monitored with ClearSight™ and managed with SVI-guided GDT showed a significantly lower cumulative duration of intraoperative hypotension compared to the iNIBP group (median 4 min [IQR 2–7] vs 11 min [IQR 6–18], p < 0.01). The ClearSight™ group received a more tailored fluid management, with a lower total volume of intraoperative crystalloids administered (mean 850 ± 200 mL vs 1050 ± 250 mL, p = 0.03). Postoperative complication rates were comparable between groups, but a trend toward reduced hospital length of stay was observed in the ClearSight™ group (median 3.2 vs 4.1 days, p = 0.08).

Conclusion

Continuous non-invasive monitoring with ClearSight™ offers a reliable alternative to arterial cannulation in ASA II patients undergoing minimally invasive thoracic surgery. When combined with GDT guided by SVI, it allows effective hemodynamic management while reducing invasiveness and potential complications.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. 1Piccioni F, et al. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond). 2020 Oct 23;9:31. 10.1186/s13741-020-00159-z. PMID: 33106758; PMCID: PMC7582032

2. 2Continuous intra-arterial versus intermittent oscillometric arterial pressure monitoring and hypotension during induction of anaesthesia: the AWAKE randomised trial Kouz, Karim et al. British Journal of Anaesthesia, Volume 129, Issue 4, 478 - 486

3. 3Sessler DI, Bloomstone JA, Aronson S, Berry C, Gan TJ, Kellum JA, et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth. 2019;122:563–574. https://doi.org/10.1016/j.bja.2019.01.013

4. 4Lee SW, Lee S, Kim H, Kim YJ, Kim M, Choi JH. Accuracy of noninvasive continuous arterial pressure monitoring using ClearSight during one-lung ventilation. Medicine (Baltimore). 2021 Mar 19;100(11):e25152. 10.1097/MD.0000000000025152. PMID: 33726000; PMCID: PMC7982160.

5. 5Li, X., Zhang, Q., Zhu, Y. et al. Effect of perioperative goal-directed fluid therapy on postoperative complications after thoracic surgery with one-lung ventilation: a systematic review and meta-analysis. World J Surg Onc 21, 297 (2023). https://doi.org/10.1186/s12957-023-03169-5

A58 Effective use of a laryngeal mask airway for post-rigid bronchoscopy ventilatory management in a patient with hypercapnia and hypoxia: a case report

G.M. Rizzi, F. Coppolino, A. Izzo, F. Russo, M. Fiore, M.B. Passavanti, P. Sansone, M.C. Pace

Università degli Studi della Campania Luigi Vanvitelli, Napoli, Italy

Correspondence: G.M. Rizzi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A58

Background

Rigid bronchoscopy is a fundamental tool for managing tracheobronchial obstructions, particularly in cases of endoluminal tumors. [1] However, it can lead to significant postoperative respiratory complications, especially in patients with pre-existing chronic pulmonary diseases such as chronic obstructive pulmonary disease (COPD). Selecting the most appropriate ventilatory strategy in the immediate post-procedural phase is crucial, especially in the presence of both hypercapnia and hypoxia. In this context, the laryngeal mask airway (LMA) may represent an effective alternative to invasive endotracheal intubation. [2]

Case report

We report the case of a 72-year-old male with severe COPD (GOLD stage III, FEV1 38%), on long-acting bronchodilator and inhaled corticosteroid therapy, and nocturnal home oxygen. The patient presented with worsening dyspnea, dry cough, and wheezing. Chest CT revealed a tracheal mass causing approximately 70% luminal obstruction. The patient underwent rigid bronchoscopy with mechanical debulking of the mass under general anesthesia using TIVA-TCI and neuromuscular blockade. Although the procedure was technically successful, the patient developed postoperative respiratory failure characterized by tachypnea (34 breaths/min), desaturation (SpO2 84% on FiO2 0.6), and somnolence, while maintaining intact airway protective reflexes. Arterial blood gas analysis revealed severe hypercapnia (PaCO2 76 mmHg), hypoxemia (PaO2 58 mmHg), and respiratory acidosis (pH 7.23). High-concentration oxygen delivered via non-rebreather mask proved ineffective. Given the patient’s preserved consciousness and airway reflexes, an appropriately sized LMA was inserted, thereby avoiding endotracheal intubation. Pressure support ventilation was initiated (PSV 12 cmH2O, PEEP 5 cmH2O, FiO2 0.8). After approximately one hour of assisted ventilation, gas exchange improved (PaCO2 66 mmHg, PaO2 82 mmHg, pH 7.30); the patient was alert, breathing spontaneously and effectively. The LMA was successfully removed, and the patient maintained stable respiratory function with low-flow nasal oxygen. This case highlights the utility of the LMA as an intermediate ventilatory strategy for post-bronchoscopy respiratory failure in selected COPD patients. The LMA ensured airway patency and effective ventilation, allowing gradual correction of hypercapnia without requiring endotracheal intubation. Pressure support ventilation provided synchrony with the patient’s respiratory effort, reduced sedation requirements, and facilitated early weaning.[3]

Conclusion

In selected patients with reversible hypercapnic respiratory failure following rigid bronchoscopy, the laryngeal mask airway can serve as a safe and effective intermediate solution. It offers a balance between non-invasive ventilatory support and airway control, particularly in conscious patients with preserved protective reflexes. This approach may reduce the need for endotracheal intubation and its associated complications, especially in patients with COPD and complex airway anatomy.

Consent

Informed consent was obtained for the publication of this scientific article.

References

• 1. Fadaizadeh L, Hoseini MS, Bagheri M. Anaesthesia Management During Interventional Bronchoscopic Procedures: Laryngeal Mask Airway or Rigid Bronchoscope. Turk J Anaesthesiol Reanim. 2014 Dec;42(6):302-7. 10.5152/TJAR.2014.85579. Epub 2014 Dec 1. PMID: 27366442; PMCID: PMC4894128.

• 2. Brimacombe J. The advantages of the LMA over the tracheal tube or facemask: a meta-analysis. Can J Anaesth. 1995;42(11):1017-1023. 10.1007/BF03011075

• 3. Perrin G, Colt HG, Martin C, Mak MA, Dumon JF, Gouin F. Safety of interventional rigid bronchoscopy using intravenous anesthesia and spontaneous assisted ventilation. A prospective study. Chest. 1992;102(5):1526-1530. 10.1378/chest.102.5.1526

A59 Hemadsorption therapy for myoglobin removal in patient with post-cardiotomy cardiogenic shock with tmcs and crrt. When one filter is not enough

S. Pourshayesteh^1,2, M. Giunta¹, B. Silano², A. Costamagna^1,2, A. Orsello¹, A.C. Trompeo¹, M. Rinaldi³, L. Brazzi^1,2

¹Dipartimento Scienze Chirurgiche, Università degli Studi di Torino, Torino, Italy; ²Dipartimento Anestesia e Rianimazione, Città della Salute e della Scienza, Torino, Italy; ³Dipartimento Chirurgia Cardiovascolare e Toracica, Città della Salute e della Scienza, Torino, Italy

Correspondence: M. Giunta

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A59

Myoglobin is a small protein located into muscle fiber cells whose function is reversibly binding oxygen. In case of rhabdomyolysis, muscle fiber cells release myoglobin in the blood flow to kidneys to be eliminated. High levels of myoglobinemia can cause acute tubular damage and lead to acute kidney injury (AKI).

Mechanical circulatory supports (MCS) are essential to guarantee a correct systemic perfusion, avoiding multiorgan failure, while high cut-off filters and sorbent filters, such as Cytosorbâ, are useful to remove the excess of medium sized molecules as this toxin, preventing permanent renal injuries1,2.

We report a case of a 77-year-old female, undergone a cardiac surgery for mitral valve replacement, complicated by intraoperative acute myocardial infarction leading to a biventricular disfunction with necessity of a tMCS support.

Upon admission to the Intensive Care Unit, the Cytosorb filter was directly integrated into the ECMO circuit.

On day 1, due to upcoming oligo-anuria, Continuous Veno-Venous Haemodialysis (CVVHD) was initiated continuing to use the Cytosorb and integrating EMIC 2 filter to facilitate the removal of toxic metabolic products such as myoglobin. Every 24 h, cartridges were changed to cope with sorbent saturation. Myoglobin plasma levels were monitored once a day and after 96 hours, considering the dosage consistently below 5000 mcg/l, as recommend by the literature2, the Cytosorb filter was removed, while keeping the EMIC-2. Myoglobin levels increased immediately and in 48 h reached dosages above 7000 mcg/l. The Cytosorb filter was again mounted on CRRT machine and myoglobin was successfully removed. After 36 hours, a new peak in myoglobinemia was observed despite the simultaneous use of both filters, likely due to cartridge saturation, which was resolved by replacing it. Following this episode, myoglobinemia levels steadily decreased, and after one week, both filters were removed. The myoglobin plasmatic levels were monitored and were constantly lower than 1000 mcg/l (fig.1)

Despite the early removal of metabolic toxins and cardiocirculatory support, a state of kidney failure requiring RRT was maintained for several days, but with signs of partial renal recovery on day 28.

In conclusion, myoglobin may contribute to the development of AKI, especially when multifactorial damages hit the kidney during extracorporeal circulatory support. Hemadsorption filters and high cut-off filters are useful to eliminate these molecules and prevent renal damage, but attention should be taken to the functioning of these devices, rapidly replacing a saturated cartridge to maintain efficiency.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Blood purification with cytokine adsorber for the elimination of myoglobin in critical ill patients with severe rhabdomyolysis. Scharf, Crit Care, 2021

2. Hemadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the hemadsorption in rhabdomyolysis task force. Forni, BMC Nephrol, 2024

Fig. 1 (abstract A59).

Trend of myoglobinemia

A60 The role of near-infrared spectroscopy in spinal-cord hypoperfusion during open thoraco-abdominal aortic repair

R. Piscopo¹, G. Lionetti^1,3, F. Nisi^1,3, D. Barillà^2,3, M. Tamburrini^2,3, F. Piccioni¹, E. Civilini^2,3, E. Giustiniano¹

¹IRCCS Humanitas Research Hospital, Unit of Anesthesia and Perioperative Medicine, Rozzano, Italy; ²IRCCS Humanitas Research Hospital, Unit of Vascular Surgery, Rozzano, Italy; ³Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy

Correspondence: R. Piscopo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A60

Background

Open thoraco-abdominal aortic repair (OTAAR) is a very challenging surgery both for the surgical impact and for the high risk of post-operative complications. One of the most distressing outcomes is the spinal-cord injury (SCI) which has a significant incidence (5-11%), [1,2]. In our hospital, we carry out around ten OTAAR/year and we adopt a close semi-invasive hemodynamic monitoring along with trans-esophageal echocardiography (TEE) associate to cerebro-spinal fluid (CSF) drainage and pressure monitoring. During the last decade, we included the near-infrared spectroscopy (NIRS) over the skin region of paraspinous muscles, according to the principle of the collateral network described by Etz and coll., [3,4].

Methods. From 2021 on, patients submitted to OTAAR received the standard intraoperative monitoring plus the CSF pressure (PCSF) that permitted to evaluate the SC perfusion pressure (SC-PP = MAP - PCSF) and measure the CSF concentration of lactate (CSFLac). Furthermore, we applied the NIRS sensors to the skin over the paraspinous muscles bilaterally at the thoraco-lumbar transition. A left atrium-left femoral artery by-pass (L-ByP) has been used during the aortic clamping. When, MAP reduced <70mmHg and SC-PP <60 mmHg, Norepinephrine with or without Dobutamine (according to Cardiac index <2.5 L/min/m2 and TEE-Ejection fraction reduced in comparison with preoperative value) was administered. Informed consent was obtained from all individual participants included in the study. Patients have agreed to the use of their blinded medical images and other data for research and publication.

Results

Twenty-eight subjects were submitted to OTAAR due to aneurysm (Crawford I=9; II=8; III=7; IV=3; V=1); ASA 2-4, age 68+12 yrs. Out of the sample, three patients experienced SCI confirmed by MRI exam post-operatively. After L-ByP starting and aortic clamping these patients experienced significant hypotension and concomitant reduced oxygenation of paraspinous muscles (−19% right; −34% left). Despite the hemodynamics quickly recovered, the NIRS values did not, mainly on the left side. The duration of the aortic clamping was 91+35 min vs 122+58 min in patients without and with SCI, respectively (p=0.201). The Results are summarized below (figure 1).

Conclusions

According to the collateral network concept, in our patients we observed coherence between the hemodynamics and NIRS trends and consequently with the SCI evidence. NIRS application over the paraspinous muscles may be tool for SC blood supply monitoring during OTAAR, but more studies are desirable to confirm such a promising system.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Conrad MF, Cambria RP. Contemporary management of descending thoracic and thoracoabdominal aortic aneurysms: endovascular versus open. Circulation. 2008 Feb 12;117(6):841-52. 10.1161/CIRCULATIONAHA.107.690958. PMID: 18268161.

2. Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008 Aug 19;118(8):808-17. 10.1161/CIRCULATIONAHA.108.769695. Epub 2008 Aug 4. PMID: 18678769.

3. Etz CD, Kari FA, Mueller CS, et al. The collateral network concept: a reassessment of the anatomy of spinal cord perfusion. J Thorac Cardiovasc Surg. 2011 Apr;141(4):1020-8. 10.1016/j.jtcvs.2010.06.023. PMID: 21419903; PMCID: PMC3062787.

4. Etz CD, von Aspern K, Gudehus S, et al. Near-infrared spectroscopy monitoring of the collateral network prior to, during, and after thoracoabdominal aortic repair: a pilot study. Eur J Vasc Endovasc Surg. 2013 Dec;46(6):651-6. 10.1016/j.ejvs.2013.08.018. Epub 2013 Sep 5. PMID: 24099957.

Fig. 1 (abstract A60).

Mean values of MAP, Spinal cord perfusion pressure, NIRS, Lactate in serum and CSF, Cardiac Index in patients with SCI (dashed line) and without SCI (solid line). Basal: after induction of general anesthesia; L-Byp: Left Atrium-Left femoral artery by-pass pump; 15 min: time after L-ByP started; 30 min: time after L-ByP started; End: wound closure

A61 Curare-free approach for a myasthenia gravis patient undergoing videothoracoscopic thymectomy: a case report

M. Fabris^1,2, D. Orso², F. Poldini², T. Bove^1,2

¹Department of Medicine (DME), University of Udine, Udine, Italy²Department of Emergency Santa Maria della Misericordia, University Hospital of Udine, ASUFC, Udine, Italy

Correspondence: M. Fabris

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A61

Background

Myasthenia gravis is a neuromuscular disease given by the destruction of nicotinic post-synaptic receptors for acetylcholine (AchR) primarily due to anti-AchR antibodies, thus affecting the transmission of the plaque potential throughout the neuromuscular plaque [1].

Therapy is based on: optimization of neuromuscular conduction with acetylcholinesterase inhibitors, immunomodulation with corticosteroid drugs, immunosuppression, plasmapheresis and thymectomy; video-assisted thoracoscopic technique (VATS) was shown to guarantee decreased surgical stress and intraoperative bleeding [2].

Case report

A 68-years-old woman underwent VATS thymectomy with subxifoid access for myasthenia gravis treatment.

Clinical presentation referred to dysphagia, palpebral ptosis, rhinolalia and neck muscles weakness. Diagnosis was confirmed by anti-AchR antibodies detection.

Preoperative CT scan showed no malignant lesions involving thorax or mediastinum. Pulmonary function tests were unremarkable.

In-room monitoring consisted in: 5-derivations electrocardiography, saturimetry, capnometry, invasive blood pressure, bispectral index (BIS) and neuromuscular transmission monitoring, obtained by train-of-four (TOF) with accelerometer.

After pre-oxygenation, fentanyl 4ug/Kg intravenous boluses were injected to obtain a sedation level (BIS = 70-72) suitable to start TOF monitoring and determining the basal contraction level intensity. 7% Sevoflurane was then administered by facial mask for 180 seconds, detecting a minimal alveolar concentration (MAC) 1.6, BIS 40-45, TOF-R 72% and loss of ciliary reflex. Orotracheal intubation with a 37Fr bilumen Robertsaw ® tube was thus performed. According to Viby-Mogensen classification, “good” intubation conditions were identified (Tab. 1).

Intraoperative maintenance of anesthesia was fulfilled by remifentanil 0.08-0.13 ug/Kg/min intravenous continuous infusion and sevoflurane MAC 0.7-0.8; BIS levels remained in the range 45-58 whereas TOF-R showed maximum at 78% and nadir at 67%.

Operation was uneventful, with surgical time of 105 minutes and surgical equipe satisfied due to the lack of any complications depending on the residual muscular activity.

Eight minutes after sevoflurane suspension, TOF-R was 94%. Estubation was performed during remifentanil 0.02ug/Kg/min continuous intravenous infusion still on course to guarantee patient’s compliance to endotracheal tube while performing clinical evaluation of muscular strength: complete mouth opening and tongue protrusion on request, head lift > 5 s, Bromage 0, no upper limbs muscular weakness.

After estubation, there was no evidence of respiratory muscles impairment nor desaturation. Arterial blood gas analysis was unremarkable (Tab 2).

Conclusion

Specific feature of myasthenia gravis is the unpredictable response to neuromuscular blocking drugs (NMBDs). Cholinesterase inhibitors therapy increases the activity of suxamethonium whereas the exiguous number of active Ach receptors induces an augmented response for non-depolarizing NMBDs [1].

In this report no NMBDs were used during anesthesia induction neither maintenance. This suggests how, in MG patients, inhalant anesthesia with sevoflurane could represent a feasible technique to obtain good intubation conditions, safe intraoperative muscle relaxation for VATS thymectomy and optimal estubation criteria, whenever a curare-free approach is chosen.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Sieb JP. Myasthenia gravis: an update for the clinician. Clin Exp Immunol. 2014 Mar;175(3):408-18.

2. Aljaafari D, Ishaque N. Thymectomy in Myasthenia Gravis: A Narrative Review. Saudi J Med Med Sci. 2022 May-Aug;10(2):97-104.

The editable version of the table2 cannot be included here. It has been sent as attachment A61.

Table 1 (abstract A61).

Viby-Mogensen intubation classification. Highlighted: intubation conditions found in our report

	Intubation conditions
	Excellent	Good	Poor
Laryngoscopy	Easy	Fair	Difficult
Vocal cords
Position	Abducted	Intermediate	Closed
Movement	None	Moving	Closing
Reactions to insertion of tracheal tube
Movement of the limbs	None	Slight	Vigorous
Coughing	None	Diaphragm	Sustained (> 10 s)
Intubation conditions: • Excellent: all qualities are “excellent”; • Good: all qualities are either “excellent” or “good”; • Poor: presence of at least a single quality listed under “poor”		Laryngoscopy: • Easy: jaw relaxed, no resistance to blade during laryngoscopy; • Fair: jaw not fully relaxed, slight resistance to blade insertion; • Difficult: poor jaw relaxation, active resistance of the patient to laryngoscopy

Table 2 (abstract A61).

Operative room records

A62 Use of intracavitary ECG for accurate tip localization during percutaneous superior vena cava cannulation

M. Calabrese, G. Arlotta, M.E. Antoniucci, T. Taccheri, D. D'Errico, F. Bevilacqua, J. Vargas, M. Grandinetti, N. Pavone, S. De Paulis, M. Corrado, F. Corsi, A. Scapigliati

Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

Correspondence: M. Calabrese

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A62

Background

Percutaneous insertion of a venous cannula into the superior vena cava (SVC), for extracorporeal circulation is a well-established technique in cardiac surgery, particularly during ministernotomy or reoperations [1]. Accurate tip localization is crucial for effective venous drainage and optimal cardiopulmonary bypass. Although transesophageal echocardiography (TEE) is the standard for catheter positioning, intracavitary electrocardiography (IC-ECG)—widely validated for central venous catheter (CVC) tip localization [2]—is a simple, faster, and feasible alternative. Recent studies have expanded IC-ECG application to other venous access devices [3] This study evaluates the accuracy of IC-ECG in identifying the tip of a percutaneously inserted cannula in the SCV, differing in size and material from conventional catheters.

Materials and Methods

Twenty consecutive cardiac surgery patients requiring percutaneous SCV cannulation for extracorporeal circulation were included. Participants provided informed consent. Cannula was inserted percutaneously into the SCV via the right internal jugular vein using Seldinger technique.

Concordance between IC-ECG and TEE was assessed at three positions: 3 cm above the cavoatrial junction (CAJ), at the level of CAJ, and 2 cm below the CAJ. Cannula positioning was adjusted according to surgical needs.

Result

Data are expressed as mean ± standard deviation. ANOVA with Bonferroni correction was used to compare P wave amplitudes at three anatomical positions. ROC curve analysis assessed the accuracy of P wave patterns in discriminating the correct tip position at the CAJ versus the right atrium (RA) and SVC. A two-sided p-value < 0.05 was considered statistically significant. ANOVA showed significant differences in P-wave amplitudes across three sites (Table 1). ROC analysis demonstrated that IC-ECG had high discriminative ability in identifying tip position (Table 2).

Conclusion

This study extends the clinical application of IC-ECG to cannulas used for extracorporeal circulation, differing from traditional CVCs in caliber, rigidity, and purpose. ROC analysis showed high AUC values, notably in differentiating the CAJ from SCV (AUC = 0.99), confirming the method’s accuracy. These findings support IC-ECG as a reliable, reproducible and broadly applicable technique for real-time tip localization, even with cannulas structurally and functionally distinct from conventional CVCs.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Luciani N, Anselmi A, De Geest R. Extracorporeal circulation by peripheral cannulation before redo sternotomy: Indication and Results J Thoracic Cardiovasc Surg 2008; 136:572-7

2. Pittiruti M, Bertollo D, Briglia E. The intracavitary ECG method for positioning the tip of central venous catheters: Results of an Italian multicenter study J Vasc Access 2012; 13(3): 357-365

3. Capasso A, Mastroianni R, Passariello A. The intracavitary electrocardiography method for positioning the tip of epicutaneous cava catheter in neonates: Pilot study J Vasc Access 2018; 19(6): 542-547

Table 1 (abstract A62).

ANOVA of the P-wave measurements according to anatomical site

Anatomical site	Mean ± SD (mm)	Pairwise comparison	p-value (*)
SCV	2.6 ± 0.86	SCV vs CAJ	0.02
CAJ	7.4 ± 1.7	CAJ vs RA	0.02
RA	5.2 ± 1.5	RA vs SCV	0.02

Legend: SD = standard deviation; (*) Bonferroni’s correction

Table 2 (abstract A62).

ROC analysis of the P-wave measurement at different site

Anatomical site	AUC ± SE (95%CI)	Cut-off value (mm)	p-value
CAJ vs RA	0.83 ± 0.07 (0.65–0.94)	> 6.8	< 0.001
CAJ vs SVC	0.99 ± 0.01 (0.78–1)	≤ 4	< 0.001

Legend: SE = standard error; CI = confidence interval

A63 Multidisciplinary management of infective endocarditis through clinical pathways and the central role of the cardiac anesthesiologist

M. Calabrese, N. Pavone, G. Scoppettuolo, T. Taccheri, G. Arlotta, M.E. Antoniucci, F. Corsi, M. Guerrera, A. Stronali, F. Cammertoni, S. Guarneri, A. Scapigliati

Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy

Correspondence: M. Calabrese

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A63

Background

Infective Endocarditis (IE) is a severe and increasing condition affecting native and prosthetic heart valves, as well as intracardiac devices. An aging population drives its rising incidence together with higher rates of chronic illness, and the growing use of invasive procedures and cardiac devices. Despite advances in diagnosis and therapy, IE remains associated with high morbidity, mortality, and healthcare costs. [1].Heart Valve Centers are encouraged to implement two strategies to address these challenges: standardized Clinical Pathways (CPs) to ensure evidence-based care across all treatment phases, and dedicated Endocarditis Teams (ETs) to coordinate multidisciplinary management.

Materials and Methods

In 2023, our institution developed and implemented CP for IE, organized in three-phases:1) Evidence Review and Clinical Standards Definition; 2) Operational Development with formation and Endocarditis Team setup with definition of patient inclusion criteria, and development of clinical algorithms for emergency and elective settings; 3) Monitoring and Evaluation, involving the assessment of process and outcome indicators, with targeted quality improvement actions (Fig. 1). Over 18-months, 177 patients were evaluated by the ET and stratified by valve involvement: native valve (n = 102), prosthetic/repaired valve (n = 65), and device-related endocarditis (PM/ICD, n = 10).

Results

Median age was highest in the PM/ICD group (78 years), followed by the prosthetic/repair (70 years) and native valve (68 years) (P = 0.024. A surgical indication was present in 130 patients (73.4%) distributed as follows: elective (n = 41; 31.5%), urgent (n = 81; 62.3%), and emergent (n = 8; 6.1%). The remaining 47 patients (26.5%) were managed medically, either due to clinical stability or high surgical risk. Of those with surgical indication, 84 patients (64.6%) underwent surgery. Among the 46 (35.4%) who did not, most (n = 43; 93.5%) were deemed at high risk, a few (n = 3; 6.5%) refused surgery.

Conclusion

The implementation of a multidisciplinary CP for IE facilitated systematic evaluation and improved clinical decision-making. The ET served as the operational core of the pathway, ensuring early diagnosis, tailored treatment, and comprehensive care. While other models focus on cardiologists, infectious disease specialists and cardiac surgeons [2], our approach highlights the central role of the cardiac anesthesiologist. This specialist provides continuous perioperative care from preoperative assessments to intraoperative management, postoperative stabilization, and coordination of discharge and rehabilitation. Their continuous involvement ensures personalized continuity of care, positioning them as a key figure within the Endocarditis Team.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Delgado V, Marsan NA, de Waha S.2023 ESC Guidelines for the management of endocarditis: Developed by the task force on the management of endocarditis of the European Society of Cardiology (ESC). Eur Heart J. 2023; 39: 3948-4042

2. Lau L, Baddour L, Hidalgo NF. Infective endocarditis: it tales a team Eur Heart J. 2025; 00: 1-14

Fig. 1 (abstract A63).

Algorithm for the diagnostic and therapeutic management of IE based on the multidisciplinary Endocarditis Team approach. CT computed tomography, MRI: magnetic resonance imaging, PET: positon tomography tomography, WBC SPECT: white blood cell single-photon emission computed tomography, PCR polymerase chain reaction; PVE: prosthetic valve endocarditis; OPAT: outpatient parenteral antibiotic therapy

A64 Neuromonitoring during intraoperative aortic dissection

E. Bertoni¹, P. Severgnini², G. Inzigneri¹, M. Vavassori¹, L. Frattini¹, A.M. Musazzi², S. Ferrarese², M. Matteucci¹

¹Dipartimento di Anestesia e Rianimazione Cardiologica, Ospedale di Circolo - ASST Settelaghi, Varese, Italy ²Università degli Studi Insubria, Varese, Italy

Correspondence: E. Bertoni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A64

Intraoperative aortic dissection during cardiac surgery is a rare event (incidence 0.1-0.3%). It is more frequent in case of emergent or REDO surgery and difficult cannulation. The symptoms are changes in pressure, systemic hypoperfusion and alterations in aorta’s morphology. The diagnosis is obtained using transesophageal echocardiography (TEE). (1)

Cerebral protection is achieved with systemic hypothermia, circulatory arrest and antegrade cerebral perfusion. Cerebral perfusion can be monitored with different techniques, the most used is cerebral oximetry, which however analyses only the frontal lobes.(2)

Transcranial color Doppler (TCD) supplies continuous information about changes in cerebral hemodynamic and the development of microembolism. A recent publication showed it can reduce complications and increase the outcome, adjusting the cardiopulmonary bypass (CBP) flow and vasoactive drugs preventing both cerebral hypoperfusion and hyperemia. (3)

Case Report

A 70 years old woman, with systemic hypertension, came to the cardiac surgeons because of a moderate mitral insufficiency (IM). She underwent a first cardiac surgery of mitral valve repair with right minithoracotomy, but she had a persistent moderate- severe IM associated with a moderate mitral stenosis, so she underwent a second cardiac surgery, with a classical median sternotomy, after a month.

At the start of the CPB the surgeons found an aortic dissection, confirmed with TEE. They stopped the CPB, isolated femoral vessels and restart CPB with peripheral cannulation.The patient underwent, at 26° (central temperature), with a cardiac arrest of 48 minutes and an antegrade cerebral perfusion with Kazui technique of 43’, an intervention of replacement of the aortic arch, replacement of mitral valve with a biological prosthesis, a biological Bentall surgery and a coronary bypass to the right coronary, because of the involvement of the aortic valve and right coronary ostium. The CPB lasted 480 minutes with an aortic cross clamp of 284 minutes.

During surgery we monitored BIS, cerebral oximetry with INVOS and TCD (not continuously but in the most critical moments).During the entire lenght of the hypothermic cardiac arrest BIS was 0, and INVOS showed a significant reduction of the values. They slowly went back up to basal score after the cardiac arrest. TCD, showed constant values during the whole period of the cardiac arrest with values superimposable to the other we measured after the weaning from the CPB. We also didn’t detect any embolus in the moments we performed the TDC. [Figure 1]

After the surgery the patient was transferred to ICU and we obtained complete weaning from all the supports after 4 days. She didn’t show any neurological complications. Informed consensus was obtained from the patient.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Iatrogenic Aortic Dissection Associated With Cardiac Surgery: A Narrative Review. H. Ram, S. Dwarakanath, A. Green. 2021, Vol. Journal of Cardiothoracic and Vascular Anesthesia.

2. Cerebral Oxygenation Monitoring for Total Arch Replacement Using Selective Cerebral Perfusion. s.l. : K. Yamashita, T. Kazui, H. Terada, 2001, Vol. Ann Thorac Surg.

3. Transcranial Doppler monitoring for Stanford type A aortic dissection surgery. J. Yang, J. Gu and Y. Song. 2023, Vol. Asian Journal of Surgery.

Fig. 1 (abstract A64).

Neuro-monitor values

A65 Transcranial color doppler monitoring in cardiac surgery patient and during cardiopulmonary bypass

E. Bertoni¹, P. Severgnini², G. Inzigneri¹, M. Vavassori¹, L. Frattini¹, A.M. Musazzi², S. Ferrarese², M. Matteucci¹

¹Dipartimento di Anestesia e Rianimazione Cardiologica, Ospedale di Circolo - ASST Settelaghi, Varese, Italy; ²Università degli Studi Insubria, Varese, Italy

Correspondence: E. Bertoni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A65

Cardiac surgery is at risk of developing neurological complications also related to the increase of age and the greater number of comorbidities. During surgery, the cardiopulmonary bypass (CBP) changes the physiology because of a non-pulsatile flow, hemodilution and development of SIRS. (1)These changes are reflected on cerebral blood flow (CBF). Autoregulation tries to maintain a constant CBF despite all these hemodynamic alterations. (1) There is no consensus about a specific fixed value of median systemic pressure we need to maintain during the CPB to reduce the neurological complications and guarantee autoregulation. (1)

Transcranial color Doppler (TCD) is a technique that allows to study changes in cerebral hemodynamic. It isn’t listed in the guidelines of neuromonitoring during cardiac surgery, because of its intrinsic characteristics: adequate temporal window to value cerebral vessels and a continuous maintenance of the probe during the whole duration of the surgery. Despite these limitations TCD seems the best technique to monitor CBF through the valuation of the median velocity (vACM) of the flow in the median cerebral artery (ACM), and the valuation of the cerebral perfusion pressure (CPP). The formulas used to study these parameters are (2):

$$\text{vACM = [PSV + (EDV}\times 2)]/3$$ 1

$$\text{CPP = [PAM x (EDV/vACM)] + 14}$$ 2

In our study we evaluated the trend of the cerebral hemodynamic changes during CPB with TCD. We studied 30 patients (Figure 1) underwent cardiac surgery, performing TCD bilaterally, with a sectorial probe (Informed consensus obtained). The analysis wasn’t performed continuously, because of the presence of a single ultrasound machine shared with the transesophageal probe. We performed TCD in 6 different moments: basal (T0), after general anesthesia (T1), during

CPB (T2), after CPB (T3), at the end of surgery (T4) and after the extubation (T5).

We found that there was a significant reduction of vACM, so indirectly of CBF, only during the CPB. (Figure 2)

We also analyzed the trend of values in our and in healthy population, and we found that, in our sample, vACM was lower than in healthy people before the surgery, but it was superimposable after the correction of cardiac disease. (Figure 3 - 4)

From our study we found that the use of TCD allows to evaluate the CBF changes during cardiac surgery, making possible to adequate the management of the CPB, the moment at higher risk of hemodynamic changes, and the vasoactive drugs to reduce as more as possible the alterations of CBF in order to minimize the development of neurological complications.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Optimal Blood Pressure During Cardiopulmonary Bypass Defined By Cerebral Autoregulation Monitoring. D. Hori, Y. Nomura. 2017. J Thorac Cardiovasc Surg.

2. Transcranial Doppler ultrasound in neurocritical care. P. Blanco, A. Abdo Cuza. 2018, Vol. Journal of Ultrasound

3. Transcranial Doppler Ultrasound: Technique and Application. S. Purkayastha, F. Sorond. 2012, Semin. Neurology.

Fig. 1 (abstract A65).

characteristics of our population

Fig. 2 (abstract A65).

trend of vACM during surgery

Fig. 3 (abstract A65).

trend of vACM in our population

Fig. 4 (abstract A65).

vACM in healty people (3). Mean cerebral blood flow velocity (cm/s) related to age. MCA = Middle cerebral artery, PCA = Posterior cerebral artery

A66 Could renal artery blood flow changes during cardiopulmonary bypass predict acute kidney injury in cardiac surgery?

G. Arlotta, T. Taccheri, M. Calabrese, M.E. Antoniucci, S. Palma, F. Bevilacqua, S. Guarneri, A. Scapigliati

Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy

Correspondence: S. Palma

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A66

Background

The pathophysiology of acute kidney injury (AKI) in cardiac surgery is multifactorial [1]. Among the main contributing factors, renal hypoperfusion and hypoxia, particularly in the medullary region are believed to play a main role. These conditions lead to vasoconstriction of the afferent arterioles to the glomeruli and a subsequent reduction in glomerular filtration rate (GFR) [2].This study aims to assess if there is a variation in the mean blood flow velocity (MBFV) in the right renal artery (RRA) during cardiopulmonary bypass (CPB) compared to pre-CPB surgical phases and if this variation could be associated with postoperative AKI.

Methods

In this prospective, observational, single-center study adult patients undergoing cardiac surgery with CPB were enrolled after signing an informed consent. Exclusion criteria included age <18 years, contraindications to transesophageal echocardiography (TEE), atrial fibrillation, and serum creatinine >1.2 mg/dL. Using a TEE probe in a deep transgastric view, MBFV in the RRA was measured at the following time points: before CPB (after induction of anesthesia and after sternotomy) and during CPB (5,30,60 minutes after the first dose of cardioplegia). The average RRA MBFV during CPB with continuous flow was compared with MBFV measured before CPB and was correlated with urinary Neutrophil –Gelathinase-Associated-Lipocalin (NGAL) and Cystatin C levels measured 4 and 24 hours after the end of CPB as well as with the development of AKI according to KDIGO criteria (https://kdigo.org/guidelines) in postoperative period.

Results

We enrolled 33 patients: age 63.9 ± 8.3 years, 29 males and 4 females, creatinine of 0.78 ± 0.1 mg/dl. Patients underwent various procedures: coronary artery bypass grafting (27 patients), Bentall procedure (2 patients), aortic valve replacement (2 patients), mitral valve replacement (1 patient), and mitral valvuloplasty (1 patient). The CPB duration was 111.9 ± 45.02 minutes. The MBFV in the renal artery was significantly increased during CPB (39,7 ±15,53 cm/sec pre-CPB vs 59,88 ± 24,85 cm/sec during CPB; p<0,05); no patients developed acute kidney injury (AKI) during postoperative period. NGAL (17,09 ±39 ng/ml pre-CPB vs 11,98 ± 21,05 ng/ml 4 h and 23,87 ± 37,86 ng/ml 24 hours post CPB, p=0,57) and Cystatin C levels (0,94 ± 0,33 vs 0,93 ± 0,39 mg/L 24 hours post CPB; p = 0,86) didn’t increase significantly after CPB and no significant correlation of their values with the blood flow velocity in the RRA was observed.

Conclusion

The MBFV in the RRA increases significantly during CPB in absence of postoperative renal failure. A greater sample size and inclusion of patients with preoperative renal failure are needed to investigate potential differences in this population of patient.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Wittlinger T, Maus M, Kutschka I, Baraki H, Martin GF. Identification of risk factors for renal failure after cardiac surgery by RFILE classification. Am J Cardiovasc Dis. 2021; 11(1): 155–16

2. Evans RG, Lankadeva YR, Cochrane AD, Marino B, Iguchi N, et al. Renal haemodynamics and oxygenation during and after cardiac surgery and cardiopulmonary bypass. Acta Physiol 2018. 222: 1-15.

Acute pain

A67 Synergistic effect of ultrasound-guided regional analgesia on persistent acute pain managed with systemic therapy: a case report

E. Trimarchi¹, V. Marando¹, D. Villarmonte², M. La Motta¹, S. Di Stefano², L. Cardia¹

¹Anesthesia and intensive Care Section, Human Pathology Department Gaetano Barresi, G. Martino University Hospital, Messina, Italy; ²School of Anesthesia, Intensive Care, and Pain Management UNIME, Messina, Italy

Correspondence: D. Villarmonte

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A67

Background

A 54-year-old female with a complex medical history — including end-stage renal disease on peritoneal dialysis, systemic lupus erythematosus (SLE), antiphospholipid syndrome, Hashimoto’s thyroiditis, chronic ischemic heart disease and history of substances of abuse, in treatment with dual antiplatelet therapy and Low Molecular Weight Heparin (LMWH) — presented to the emergency department with a large traumatic hematoma on the lateral mid-third of the left leg, confirmed by CT angiography and treated with a compressive bandage.

Case Description:

The patient was alert but in severe pain (Numerical Rating Scale 9/10), tachypnoeic (RR ~22/min), hypertensive (BP ~150/90 mmHg). For the surgical bandage application, the systemic analgesia with IV morphine (10 mg) was ineffective, and propofol (50 mg) was necessary for sedation. Despite escalation to Tapentadol 100 mg twice daily, the pain level remained uncontrolled (NRS 8–9/10), and the patient exhibited hypertensive, tachycardic, and agitated.

Considering the unresponsiveness to systemic analgesia, and the comorbidities, an ultrasound-guided sensory block of the saphenous and sciatic nerves at the popliteal fossa was performed using 20 mL of ropivacaine 0.375% (10 mL per nerve), without adjuvants. The patient gives her consent to the procedure and to the publication of the case. An echogenic 50 mm needle connected to a nerve stimulator and pressure modulator was used under strict sterile conditions. The procedure resulted in immediate and complete pain relief (NRS 0/10) without complications.

Post-procedural systemic analgesia was optimized with paracetamol 15 mg/kg three times daily, pregabalin 25 mg daily, and Tapentadol 50 mg twice daily. A perineural catheter was planned for potential chronic pain management.

Eighteen hours after the nerve block, the analgesic effect faded, however, systemic therapy remained effective in controlling pain without the need for catheter placement. The hematoma was evacuated five days later. No further nerve blocks or interventions were required.

Conclusion:

Ultrasound-guided peripheral nerve blocks can serve as a valuable adjunct to systemic analgesia in complex patients with persistent acute pain, refractory to IV standard medications. In the present case, a dual nerve block provided rapid relief and enabled better response to systemic medications, avoiding invasive catheter placement. This synergistic approach may be beneficial in similar high-risk, multimorbid patients. The regional nerve block not only provided immediate relief but also enhanced the efficacy of subsequent systemic analgesics.

Consent

Informed consent was obtained for the publication of this scientific article.

A68 Immersive virtual reality to reduce acute procedural pain in pediatric patients: a systematic review and meta-analysis

M. Piattoli¹, C. Bertinotti¹, A. Mirasola², E. Renzi³, G. Misseri⁴, C. Gregoretti¹

¹Saint Camillus International University of Health and Medical Sciences UniCamillus, Rome, Italy; ²Section of Anesthesia, San Giovanni di Dio Hospital, Agrigento, Italy; ³Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy; ⁴Anaesthesiology and Intensive Care Unit, Fondazione Istituto G. Giglio, Cefalù, Italy

Correspondence: M. Piattoli

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A68

Background

Effective pain management is essential to optimize success of medical procedures in children. Emerging evidence suggests that immersive virtual reality (VR) could be an effective, non-invasive, non-pharmacological intervention to distract patients and mitigate pain. This study aimed to evaluate the effectiveness of immersive VR in reducing acute procedural pain among children undergoing medical procedures.

Materials and Methods

A systematic literature search was conducted on PubMed, PsycINFO, Scopus, and Web of Science up to September 2024, encompassing all experimental studies evaluating immersive VR interventions in children undergoing medical procedures. A random effects meta-analysis was performed to quantify the effect of VR interventions on procedural pain reduction, using standardized mean differences (SMD) with corresponding 95% confidence intervals (CI). Heterogeneity was assessed using the I² statistic. Quality was assessed with the Cochrane Risk of Bias 2.0 (RoB 2.0) tool for randomized controlled trials and the ROBINS-I tool for non-randomized studies.

Results

Out of 4,825 records identified, 21 studies met inclusion criteria (20 randomized controlled trials, one non-randomized study), comprising a total sample of 2,171 pediatric patients aged 6 months to 17 years. Most interventions concerned needle-related procedures (n = 18; 85.7%), while a minority addressed burn wound care and debridement (n = 3; 14.3%). Among these, 19 (90.5%) demonstrated a statistically significant reduction in pain with VR interventions, relative to both alternative digital distraction modalities (e.g., tablet-based content) and standard strategies (e.g., topical anesthetic). The meta-analysis synthesized evidence from seven studies specifically investigating venipunctures and identified a statistically significant reduction in procedural pain with VR interventions (n = 7; SMD = –1.50; 95% CI: –2.38 to –0.19; p < 0.01) (Figure 1). However, heterogeneity was considerable (I² = 97%). Furthermore, secondary outcomes consistently demonstrated favorable effects associated with VR interventions, with improvements in patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs), including lower anxiety and fear, enhanced compliance, and increased parent-reported satisfaction.

Conclusions

Immersive virtual reality appears to be an effective non-pharmacological tool for reducing procedural pain in children, particularly during needle-related procedures. Secondary benefits include lower anxiety, improved compliance, and high caregiver satisfaction. Despite substantial heterogeneity, the overall findings consistently favored VR over standard and digital distraction methods. Further research is warranted to standardize interventions and assess long-term impact.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A68).

Meta-analysis of the effectiveness of VR intervention for pain management compared with standard care and/or alternative procedures in venipunctures

A69 Exploring the efficacy of intra-articular stem cell therapy for osteoarthritis: preliminary results

E. Cianciola¹, F. Saturno¹, G. Monaco¹, A. Salerno², A. Cianciola³, S. Paladino¹, G. Tripari¹, F. Marino¹

¹ASL Salerno, Sapri, Italy; ²Dipartimento di medicina di precisione, università della Campania Vanvitelli, Napoli, Italy; ³Saint Camillus International University of Health Sciences, Roma, Italy

Correspondence: E. Cianciola

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A69

Introduction

Osteoarthritis (OA) is the leading joint disease, significantly impacting disability, especially in the elderly. It affects approximately 4 million people and is the primary cause of temporary disability and the third leading cause of hospitalization. The estimated annual incidence is about 100,000 new cases, with the probability of developing OA progressively increasing after the age of 45. OA is no longer viewed solely as a degenerative process related to aging, but as a multifactorial condition involving inflammation and immune imbalance. All patients signed explicit consents to participate in the study

Case Series

We retrospectively analyzed 46 patients treated at our pain therapy clinic between January 10, 2023, and January 3, 2024. The average age was 50 years (range 42-75), with 30 males and 16 females. Patients selected had mild to moderate OA and were excluded if they had advanced OA or were eligible for joint replacement surgery.

Procedure

Patients were treated with three weekly intra-articular injections of local anesthetic and triamcinolone (40 mg) to reduce joint inflammation. Subsequently, mononuclear bone marrow cells were harvested from the iliac crest under local anesthesia and sterile conditions. All patients gave explicit consent to participate in the study. The cells were processed using the Sepax Cell Separator, which allows for the selective isolation of mononuclear cells, removing erythrocytes and plasma. The concentrated cells were then injected into the affected joint.

Results

No patients experienced severe postoperative complications, such as intense pain, edema, infections, or bruising. However, some patients reported a sensation of'heaviness'in the joint for approximately 15 days. At the 9-month follow-up, 11 patients (24%) showed a 50% reduction in pain, measured using the I.K.D.C. questionnaire and the V.A.S. scale. MRI revealed instrumental improvement of the joint lesions. The procedure of bone marrow aspiration from the iliac crest is illustrated in Figure 1.

Conclusions

Intra-articular injection of autologous mesenchymal stem cells represents a valid alternative to traditional treatments, such as high-molecular-weight hyaluronic acid and PRP, in managing osteoarthritis. The observed reduction in inflammation and cartilage regeneration is consistent with the existing literature. Despite the limited follow-up, preliminary results suggest that this procedure, although technologically advanced, is safe and free from significant side effects.

Looking ahead, our future goals include evaluating the long-term clinical outcomes of this procedure, as well as investigating the potential use of PRP at 3, 6, and 9 months post-treatment to prolong the benefits of the procedure.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A69).

Images of bone marrow sampling from iliac crest

A70 Exploring the efficacy of peng block and pulsed radiofrequency for hip osteoarthritis: a clinical case study

E. Cianciola¹, F. Saturno¹, G. Monaco¹, A. Salerno², A. Cianciola³, S. Paladino¹, G. Tripari¹, F. Marino¹

¹Asl Salerno, Sapri, Italy; ²Dipartimento di medicina di precisione, Università Vanvitelli di Napoli, Italy; ³Unicamillus, Roma, Italy

Correspondence: E. Cianciola

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A70

Premise

The Pericapsular Nerve Group PENG block targets sensory branches of the hip joint, particularly the accessory obturator and obturator nerves. First described in 2018 for postoperative analgesia after total hip arthroplasty, it showed motor-sparing effects and significant pain relief. This ultrasound-guided technique may represent a valid alternative to fluoroscopy-guided radiofrequency (RF) for hip interventions.

Objective

To evaluate the feasibility and clinical effects of using PENG-guided pulsed radiofrequency (PRF) in an outpatient setting for three patients with moderate to severe hip osteoarthritis, all non-candidates for surgery and unresponsive to intra-articular injections.

Technique

With the patient supine, the ultrasound probe is placed transversely on the anterior superior iliac spine, then aligned with the pubic ramus and rotated ~45° to follow the inguinal fold. The transducer is moved medially to visualize the anterior inferior iliac spine, iliopubic eminence, and iliopsoas tendon. A 20–22G, 100 mm needle is inserted in-plane from lateral to medial, between the iliopsoas tendon and pubic ramus.

The procedure takes 15 minutes. Though less precise than fluoroscopic guidance, it offers good tolerability and cost-efficiency. All patients gave informed consent. FIG:1-2

Case Reports

Case 1: A 60-year-old male with diabetes and hypertension reported right hip pain (NRS 8/10). MRI showed advanced osteoarthritis. A prior injection gave brief relief. PRF was performed (impedance 230, 70 V, 42 °C). Tingling was evoked in the inguinal and medial knee regions without motor response. At 15 days, NRS dropped to 2/10, with sustained benefit at 3 and 5 months.

Case 2: A 72-year-old obese female (ASA 3) with bilateral hip osteoarthritis declined surgery. Baseline NRS was 7/10. An intra-articular injection gave modest, short-lived benefit. PRF was performed bilaterally. At 15 days, NRS was 3/10 (right) and 4/10 (left), with improved quality of life. At 7 months, values were 6/10 and 5/10, respectively. She later achieved weight loss via bariatric care.

Case 3: A 24-year-old female with achondroplasia and a history of femoral surgeries presented with disabling bilateral hip pain. Prior injections failed. PRF was performed preoperatively. At 7 days, NRS dropped to 3/10 (right) and 4/10 (left), increasing slightly to 5/10 bilaterally at 30 days. Use of rescue medication decreased. Surgery followed as planned.

Discussion

Though originally not considered suitable for RF due to its fascial plane mechanism, the PENG block may succeed because of its proximity to the obturator nerve. Initial literature (e.g., Feigin et al.) supports its use in ultrasound-guided RF.

Advantages include reduced costs, no radiation exposure, and shorter procedural time. However, precision is lower than fluoroscopy-guided techniques.

Conclusion

PENG-guided PRF may be a viable, outpatient alternative to conventional RF for hip osteoarthritis, especially in patients unfit for surgery. Preliminary results are promising, but larger studies are needed to confirm efficacy and reproducibility.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A70).

Peng block ultrasound-guided approach. PENG block with high frequency linear probe. The needle is outlined by yellow dotted line. FA femoral artery; L, Lateral side; LA local anesthetic; M, medial side; PE pectinous muscle; *poses tendon

Fig. 2 (abstract A70).

Pulsed RF with fluoroscopic technique

A71 Prevalence and severity of pain in hospitalised adults in an Italian teaching hospital: a cross-sectional study

M. Bussa¹, F. Ambrogi², P. Rebora¹, M.T. Cuppone³, A. D'acquisto³

¹School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; ²Department of Clinical Sciences and Community Health, University Milan, La Statale, Milan, Italy; ³IRCCS Policlinico San Donato, San Donato Milanese, Italy

Correspondence: M. Bussa

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A71

Background

Pain remains a frequent challenging issue among hospitalized patients, with reported prevalence rates ranging from 38% to 84% [1] in hospital settings, despite clinical advancements in pain and organizational guidelines. In Italy, pain management is regulated by Law 38/2010, but few studies have assessed the prevalence and severity of pain among hospitalised patients since its implementation [2]. This study aimed to estimate the prevalence and severity of pain in an Italian teaching hospital and to identify factors associated with moderate-to-severe pain and patients'preferences for pain relief.

Material and methods

We conducted a cross-sectional study at IRCCS Policlinico San Donato in May 2023. Adult inpatients who had been hospitalised for at least 24 hours completed an anonymous self-report questionnaire. The NRS was used to assess the pain intensity. Descriptive statistics were performed, followed by multivariable logistic regression to identify factors associated with pain severity and patient satisfaction with pain management.

Results

Among the 229 patients surveyed, 84% reported experiencing pain at the time of the interview, with 52.4% reporting moderate pain and 9.6% severe pain. Additionally, 52% had experienced pain in the previous 24 hours. No significant associations were found between pain severity and age, gender, ethnicity, education level, area of residence, or hospital ward (Table 1). However, reporting pain in the previous 24 hours was significantly associated with a moderate-to-severe pain (OR_c: 2.0, p = 0.02). A hospital stay of 4-6 days was also significantly associated with increased pain severity (OR_c = 2.52, p = 0.02), whereas a stays of ≥7 days was not (OR_c = 1.04, p = 0.90). The overall association between length of hospital stay and pain severity was statistically significant (p = 0.03). Regarding awareness of Law 38/2010, 68% of respondents reported being unaware of it. Patients who were aware of the law were less likely to report moderate to severe pain (OR_a: 0.45, p = 0.01), and were twice as likely to report high satisfaction with pain management (OR_a = 2.10, p = 0.02). Figure 1 illustrates patients’ preferences for relief.

Conclusion

Pain remains highly prevalent among hospitalized adults. Notably, our findings indicate that patient awareness of their rights under Law 38/2010 is associated with both reduced pain severity and greater satisfaction, suggesting that enhancing legal awareness may improve patients’ experience of pain care, regardless of their formal educational attainment.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Sawyer J, Haslam L, Daines P, Stilos K. Pain prevalence study in a large Canadian teaching hospital. Round 2: lessons learned? Pain Manag Nurs. 2010;11(1):45-55.

2. Damico V, Murano L, Cazzaniga F, Dal Molin A. Pain prevalence, severity, assessment and management in hospitalized adult patients: a result of a multicenter cross-sectional study. Ann Ist Super Sanita. 2018;54(3):194-200.

Fig. 1 (abstract A71).

illustrates patients’ references for relief

Table 1 (abstract A71).

Factors associated with pain during hospitalization, comparing moderate-to-severe pain (N = 142) versus mild or no pain (N = 87)

Chronic pain

A72 Laser-assisted percutaneous disc decompression: a viable alternative for low back pain management?

F. Saturno¹, E. Cianciola¹, G. Monaco¹, A. Cianciola², A. Salerno³, S. Paladino¹, G. Tripari¹, F. Marino¹

¹ASL Salerno, Sapri, Italy; ²Università Unicamillus, Roma, Italy; ³Dipartimento di medicina di precisione, Università della Campania Luigi Vanvitelli, Napoli, Italy

Correspondence: F. Saturno

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A72

Introduction

The standard surgical treatment for refractory sciatica remains open surgery; however, a series of percutaneous procedures under local anesthesia are increasingly becoming established worldwide. One of these treatments is Percutaneous Laser Disc Decompression (PLDD). This procedure can be performed on an outpatient basis, with rapid recovery and return to daily activities expected. Some studies in the literature demonstrate its efficacy and safety compared to standard surgical procedures. Among the various medical products used in PLDD, those that allow disc decompression with Radiofrequency Ablation and Coblation should theoretically offer advantages in terms of efficacy and safety.

For refractory cases, disc decompression surgery remains the gold standard. This treatment targets the removal of the herniated disc fragment that compresses the nerve root. The absorption of the applied laser energy leads to the vaporization of the water content in the nucleus pulposus, combined with a modification of its protein structure. The subsequent volume reduction causes a disproportionate decrease in intradiscal pressure, alleviating the nerve root. The first clinical percutaneous laser disc decompression was performed in Europe by Choy and Ascher in 1986. The U.S. Food and Drug Administration (FDA) approved PLDD for use in the United States in 1991. In this study, patients will be evaluated for primary endpoints at 15 days, 6 months, and 1 year of follow-up. All patients have signed explicit consent to data processing

Execution Technique

A Thuoi Needle is inserted under fluoroscopic guidance in the anterior-posterior view. Correct placement is confirmed in lateral view. Three Coblation treatments are performed at three distinct points in the treatment area. (Fig. 1)

Case Series

We evaluated our case series for 2023-2024, consisting of 30 percutaneous laser discectomies. Patients were reassessed at 15 days, 3 months, and 1 year.

•After 15 days, 100% of patients reported benefits from the procedure.

•After 3 months, 28 out of 30 patients reported a VAS score <3.

•After 6 months, 25 out of 30 patients reported a VAS score <3.

•After 1 year, 23 out of 30 patients reported a VAS score <3.

Of the 7 patients who did not report benefits, 4 underwent Pulsed RF of the GRP, and 3 were candidates for endoscopic discectomy.

Conclusion

PLDD is an interesting treatment due to its minimally invasive nature, thus likely reducing the risk of structural damage to muscles, bones, ligaments, and nerves. Additionally, it is expected that patients will have a shorter hospital stay and rapid functional recovery. However, the literature lacks sufficient data on the long-term efficacy and safety of this technique.

We plan to conduct a subsequent study to evaluate postoperative MRIs at 6 months for all treated patients and assess pain levels at 6 months and 1 year.

Consent

The following scientific work received approval from the Ethics Committee after obtaining the patient's informed consent for the procedure. The Ethics Committee considered the signing of the informed consent form alone to be sufficient for the approval of the scientific work. It is also specified that the above-mentioned works are solely intended to describe the patient's diagnostic and therapeutic pathway.

Fig. 1 (abstract A72).

Intraoperative images: the image shows the percutaneous approach to the disc and the Seldinger insertion

Fig. 2 (abstract A72).

The image shows the caliper of the kit which offers both the possibility of extracting debris from the disc and performing laser cutting. (Fig. 2)

A73 Safety and efficacy of medical-grade silicone VK100 in vertebroplasty: a two-year case series

F. Saturno¹, E. Cianciola¹, G. Monaco¹, A. Cianciola², A. Salerno³, S. Paladino¹, G. Tripari¹, F. Marino¹

¹ASL salerno, Sapri, Italy ²Università Unicamillus, Roma, Italy³Dipartimento di medicina di precisione, Università della Campania Luigi Vanvitelli, Napoli, Italy

Correspondence: F. Saturno

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A73

Introduction

Percutaneous vertebroplasty and kyphoplasty are widely recognized as treatments of choice for vertebral compression fractures involving collapse of the vertebral endplates without posterior wall compromise. These fractures are commonly secondary to osteoporosis and, in selected cases, to primary (e.g., plasmacytoma) or metastatic vertebral tumors in patients over 55 years of age.

Traditionally, these procedures utilize polymethyl methacrylate (PMMA) bone cement. Although PMMA has demonstrated favorable outcomes in terms of pain relief and patient satisfaction, it carries notable risks, including increased incidence of adjacent vertebral fractures, release of toxic monomers due to exothermic polymerization, cement leakage, and pulmonary embolism.

Technique

After establishing peripheral venous access, the patient is positioned prone on a radiolucent surgical table. Following sterile field preparation and radiographic localization, local anesthesia is administered to the subcutaneous tissue, soft tissue, and periosteum at the needle entry site.

Under fluoroscopic guidance, a percutaneous transpedicular approach—either unilateral or bilateral—is used to access the target vertebral body. The needle is advanced to reach the anterior third of the vertebral body. In cases of severe osteoporosis, manual pressure is sufficient; otherwise, a mallet may be used. Cement is delivered through 11G or 13G vertebroplasty needles. Fig.1

Case Series

We retrospectively analyzed patients treated between January 1, 2023, and January 1, 2025. A total of 50 vertebroplasty procedures were performed using VK100 medical-grade silicone. All patients gave explicit informed consent.

At the two-year follow-up, no major complications—such as neurological injury or embolic events—were reported. Eight patients experienced transient musculoskeletal pain during the early postoperative period, which fully resolved with physical therapy (FSK), without the need for further intervention.

Advantages of VK100 Silicone

VK100 has proven to be a safe and effective alternative to PMMA. Its main advantages include:

Absence of exothermic reaction, minimizing the risk of neural injury;

Tenfold greater elasticity compared to PMMA, resulting in biomechanical behavior closer to natural bone;

Two-stage augmentation capability, allowing for delayed revisions even years after the initial procedure;

Reduced risk of screw pull-out in future transpedicular instrumentation.

Limitations and Future Perspectives

The primary limitation encountered was the lower radiopacity of VK100 compared to PMMA. However, this can be mitigated by waiting at least 15 minutes after mixing before injection, thereby improving fluoroscopic visibility.

Based on our preliminary experience, VK100 medical-grade silicone represents a promising advancement in minimally invasive spinal procedures. Further multicenter studies with larger patient cohorts are necessary to confirm these encouraging results.

Consent

The following scientific work received approval from the Ethics Committee after obtaining the patient's informed consent for the procedure. The Ethics Committee considered the signing of the informed consent form alone to be sufficient for the approval of the scientific work. It is also specified that the above-mentioned works are solely intended to describe the patient's diagnostic and therapeutic pathway.

Fig. 1 (abstract A73).

Intraoperative images: vertebroplasty surgery images

A74 Psychiatric comorbidity in chronic pain: an old but underestimated issue

L. Pelizza¹, S. Pupo², G. Musetti², M. Menchetti¹

¹Dipartimento di Scienze Biomediche e Neuromotorie - Università di Bologna, Bologna, Italy²Dipartimento di Medicina e Chirurgia - Azienda Ospedaliero-Universitaria, Parma, Italy

Correspondence: L. Pelizza; S. Pupo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A74

Background

Prevalence of mental disorders in chronic pain varies widely across studies and can be overestimated using screening tools. Mental illness has also been considered a negative prognostic factor in chronic pain treatment, inducing poorer outcomes. The aims of this investigation were: (a) to estimate baseline prevalence of previous clinically assessed psychiatric comorbidity in a chronic pain population during their first contact within an Italian specialist pain clinic, and (b) to examine differences in socio-demographic, clinical, and pain features between patients with and without such comorbidity. Additional aim was to explore prevalence of current psychopathology in the subgroup without psychiatric comorbidity.

Methods - One-hundred-seventy-two participants were recruited within the Pain Therapy Service at the Parma University Hospital. At presentation, they completed the Brief Pain Inventory (BPI) and the Millon Clinical Multiaxial Inventory-III edition (MCMI-III) for measuring current psychopathology. Inter-group comparisons were analyzed using the Chi-Square or the Mann-Whitney U test.

Results

Thirty-one (18%) participants had a previous clinically assessed psychiatric comorbidity, especially depressive disorder (9.9%). Comorbid patients were more likely to be unemployed and to have longer pain duration, higher BPI severity and interference scores, and fixed-dose analgesic therapy. Moreover, they had a greater prevalence of current major depression. Notably, 51.8% (n=73) of individuals without psychiatric comorbidity showed MCMI-III scores indicative of the current presence of clinically relevant psychiatric syndromes, especially anxiety and somatoform disorders.

Conclusions

Although psychiatric illness was noted to be more frequently among patients with chronic pain than in the general population, a large proportion of them remain undiagnosed and potentially undertreated. A stable presence of mental health professionals within the multidisciplinary teams for chronic pain treatment is therefore recommended.

Consent

Informed consent was obtained for the publication of this scientific article.

A75 Cannabinoids in post-herpetic neuralgia: preliminary data

A. Genovese¹, G.T. Giuffrè², F. Iannelli¹, D. Iannelli¹

¹Centri Iannelli Diagnosi, Barcellona Pozzo di Gotto, Italy; ²ASP Messina, Patti, Italy

Correspondence: A. Genovese

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A75

Background and Goal of Study

The objective of this study is to demonstrate the efficacy of the use of cannabinoids in a group of patients suffering from post-herpetic neuralgia refractory to other medical and physical therapies.

Materials and Methods:

We examined 30 patients aged from 59 to 73 years, 18 male, 12 female. They were treated with tricyl antidepressants (duloxetine up to 60 mg twice daily), antiepileptics (pregabalin up to 150 mg twice daily) and opioids (tramadol up to 200 mg twice daily and tapendatol up to 200 mg twice daily). All patients selected in the study were forced to discontinue drug therapy due to side effects or lack of pain reduction. They were then subjected to analgesic blocks of the dorsal or lumbar ganglia under ultrasound guidance with local anesthetic. This therapy was also not effective poor pain relief (NRS 8). Onthis basis, the patient underwent Cannabinoid's therapy (19% THC; <1% CBD). He started with 5 sublingual drops twice a day, up to 10 sublingual drops 3 times a day. Patients were evaluated at 15, 30, 60, and 90 days

Results and Discussion:

There is a wide range of studies in the literature on the benefits derived from the use of cannabinoids for the treatment of neuralgia. Cannabinoid-based drugs act on the human endocannabinoid system, a network of CB1, CB2, and other receptors distributed throughout the body.

In our observational study 20 patients achieved a 50% reduction in pain (NRS 4-5), 7 patients a 40% reduction in pain (NRS 6), 3 patients unfortunately did not obtain any benefit. 7 patients needed an increase in cannabis dosage (15 drops 3 times a day) to achieve a 50% reduction in pain Only 3 patients had no benefit in treating pain and in 4 patients we observed increased sleepiness.

Conclusion(s):

The present case series demonstrates that cannabinoid therapy has been effective in treating the painful symptoms of post-herpetic neuralgia.

Consent

Informed consent was obtained for the publication of this scientific article.

References:

1. Velio Alvaro Bocci. Scientific and medical aspects of ozone therapy. State of the art - Arch Med Res.2006 May;37(4):425-35..- 10.1016/j.arcmed.2005.08.006.

2. Peggy Arthur et al. Applications of Cannabinoids in Neuropathic Pain: An Updated Review. - Crit Rev Ther Drug Carrier Syst. 2024;41(1):1-33.

3. Jakub Mlost et al Cannabidiol for Pain Treatment: Focus on Pharmacology and Mechanism of Action - Int J Mol Sci. 2020 Nov 23;21(22):8870. 10.3390/ijms21228870.

4. S Grossman, H Tan, Y Gadiwalla. Cannabis and orofacial pain: a systematic review. - Br J Oral Maxillofac Surg. 2022 Jun;60(5):e677-e690. 10.1016/j.bjoms.2021.06.005. Epub 2021 Jun 23.

A76 Pulsed radiofrequency treatment of the pericapsular nerve group (Peng) for chronic postoperative hip pain: a case report

V. Donatiello¹, P. Buonavolontà¹, M. Alfieri¹, A. Scalvenzi¹, V. Maffei¹, V. Fabbricante², F. Coppolino², M.C. Pace², P. Sansone², M.B. Passavanti²

¹Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli, Napoli, Italy; ²Azienda Ospedaliera Universitaria Luigi Vanvitelli, Napoli, Italy

Correspondence:

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A1

Background

Chronic postoperative pain (CPSP) following total hip arthroplasty (THA) remains a significant clinical challenge, especially in older adults. It is estimated that up to 28% of patients may develop persistent pain after THA, often impacting mobility, autonomy, and overall quality of life (1). Although neuropathic components are frequently considered, a subset of patients continues to experience nociceptive pain without overt nerve injury. The pericapsular nerve group (PENG) block, first described by Girón-Arango et al. (2018), has demonstrated utility in perioperative analgesia for hip procedures. Pulsed radiofrequency (PRF), a minimally neuromodulatory technique, has shown efficacy in the treatment of various chronic pain conditions by modulating nociceptive pathways (3). This report describes the successful application of ultrasound-guided PRF targeting the PENG in a patient with refractory chronic nociceptive pain following right hip replacement.

Case Report

A 64-year-old male presented with chronic right hip pain persisting for more than three months following total hip arthroplasty. The pain was present both at rest and during active/passive motion, without clinical signs of neuropathy. Initial pharmacological treatment included gabapentin 100 mg twice daily and a fixed-dose combination of tramadol 75 mg/paracetamol 650 mg twice daily, which yielded suboptimal analgesia and poor tolerability at higher doses.

An ultrasound-guided PENG block was administered using 20 ml of 0.375% ropivacaine and 8 mg dexamethasone. The patient experienced immediate and substantial pain relief, discontinuing tramadol/paracetamol for approximately two weeks. Upon symptom recurrence, a more sustained intervention was pursued.

Pulsed radiofrequency treatment was performed under ultrasound guidance with a 21G RF cannula placed adjacent to the iliopubic eminence. Sensory stimulation at 0.6 mA confirmed accurate placement. PRF was applied at 42 °C for 300 seconds. Subsequently, 20 ml of 0.25% ropivacaine and 20 mg triamcinolone were injected.

At six-month follow-up, the patient reported significant improvement, with an average Numeric Rating Scale (NRS) score of 0/10 at rest and 3/10 during movement. He discontinued all opioid and adjuvant therapy within one month post-procedure, reporting improved mobility and quality of life. Informed consent was obtained from the patient for publication.

Conclusion

This case supports the potential role of PRF targeting the PENG as a safe, minimally invasive strategy for managing chronic nociceptive pain following THA. Given its favorable risk profile and sustained analgesic effects, PENG-focused PRF may serve as a valuable therapeutic option for selected patients with CPSP refractory to conservative measures.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2(1):e000435.

2. Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) block for hip fracture. Reg Anesth Pain Med. 2018;43(8):859–863.

3. Van Zundert J, de Louw AJ, Joosten EA, Kessels AG, Honig W, Dederen PJ, Vles JS, van Kleef M. Pulsed and continuous radiofrequency current adjacent to the cervical dorsal root ganglion in a neuropathic pain model: Efficacy and safety. Anesthesiology. 2005;102(1):125-131.

A77 Microvibration for chronic pain management

A.U. de Siena, P. Buonanno, G. Giugliano, S. Nappi, G. Servillo

Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy

Correspondence: G. Giugliano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A77

Background

Chronic pain significantly affects patients’ quality of life and has a substantial socioeconomic impact. Pharmacological treatments are often limited by adverse effects and comorbidities. Focal microvibration (FMV) delivered through the wearable devices, which transforms body heat into high-frequency vibration, has shown efficacy in neurological conditions but has not yet been explored for pain relief [1,2].

Materials and Methods

This randomized controlled trial enrolled 60 adults (30 per group) with chronic nociceptive or neuropathic pain lasting over six months. Participants were randomly assigned to an experimental group (FMV plus standard therapy) or a control group (pharmacological therapy alone). In the FMV group, a trained physician performed pain mapping to identify application sites for three/four devices for 2 hours in the morning and evening. The control group received conventional pharmacological treatment based on pain characteristics. Rescue therapy with paracetamol or tramadol was allowed in both groups. The primary outcome was pain intensity change over time, measured using the Brief Pain Inventory BPI at baseline and on days 7, 15, 30, 60, and 90.

Results

Table 1 presents the evolution of BPI scores. In the FMV group (Group E), there was a notable reduction in the worst pain reported over the previous 24 hours, with a statistically significant decrease already evident by day 15 (median 5.5 [3.25–6.75]) compared to baseline (8 [7–10], p < 0.05, sustained across subsequent assessments at days 30, 60, and 90 (all p < 0.001). Similarly, the median intensity of average pain within the last 24 hours showed a consistent decline at these timepoints, dropping from a baseline value of 6 (5–7) to 5 (3–5), 4.5 (3–5.75), 4 (2.75–5.25), and 4 (2.5–5.5), all reaching statistical significance (p < 0.05). Although there was a downward trend in current pain scores from 6 (4–7.5) at baseline to 3 (2–5) at day 90, this change did not achieve statistical significance. Additional benefits were observed in various dimensions of pain interference, with improvements noted in general activity, emotional well-being, mobility, occupational functioning, interpersonal relationships, sleep quality, and overall life satisfaction among patients in Group E. In contrast, no significant alterations were found in any of these areas in the control group (Group C) during the follow-up period.

Conclusions

FMV may represent a safe, non-invasive, and effective tool for the management of chronic pain, potentially reducing reliance on analgesic medications and improving quality of life. Further studies are needed to clarify its mechanism of action and to standardize application protocols.

Trial registration

Registered at University of Naples “Federico II” Ethics Committee.

Consent to publish

Written informed consent for participation and publication was obtained from all study participants.

References

1. Niv D, Kreitler S. Pain and quality of life. Pain Pract. 2001;1:150–61. 10.1046/j.1533- 2500.2001.01016.x.

2. Becker N, Thomsen AB, Olsen AK, Sjøgren P, Bech P, Eriksen J. Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center. Pain. 1997;73:393–400. https://doi.org/10. 1016/S0304-3959(97)00126-7.

Table 1 (abstract A77).

Brief Pain Inventory scores (median; IQR) recorded during the follow up

		T0	T7	T15	T30	T60	T90	p value
Q3. Worst pain last 24 h	Group E Group C	8 (7–10) 7.5 (6–9.5)	6 (6–8) 8 (6–9)	5.5 (3.25–6.75)* 7 (4.5–9)	5 (3.25–6) † 7 (4.5–9)	5 (3–6) † 7 (6–8)	4 (3–5) † 6. (5–8)	p < 0.001 p = 0.198
		0.303	0.125	0.128	< 0.001	0.003	0.004
Q4. Least pain last 24 h	Group E Group C	4 (2.5–5.5) 5 (3–6.5)	3 (2–4) 4.5 (3–5.5)	3 (2–5) 4 (2–6)	2.5 (2–4) 4 (3–5)	2.5 (1.75–4) 4 (3–5)	2 (1.5–4.5) 4 (2–5)	p = 0.225 p = 0.345
		0.278	0.032	0.429	0.003	0.032	0.106
Q5. Average pain last 24 h	Group E Group C	6 (5–7) 6 (4–7.5)	5 (4–6) 6 (4–7)	5 (3–5)* 5 (3–7.5)	4.5 (3–5.75)* 5 (3–6)	4 (2.75–5.25)* 5 (3–6.5)	4 (2.5–5.5)* 5 (4–6.5)	p < 0.001 p = 0.077
		0.437	0.254	0.323	0.418	0.27	0.216
Q6. Current pain	Group E Group C	6 (4–7.5) 6 (4.5–7)	4 (3–5) 7 (5–8)	3 (2–5.75) 6 (4–7)	3.5 (2.25–6) 6.5 (5–8)	3.5 (2–5) 6 (4–8)	3 (2–5) 5.5 (2.5–7)	p = 0.09 p = 0.717
		0.981	0.974	0.001	0.002	0.014	0.079
Q8. Pain relief from drugs or interventions	Group E Group C	40% (25–60) 42.5% (30–60)	50% (35–75) 42.5% (30–55)	50% (30–60) 40% (30–55)	50% (32.5–60) 50% (30–65)	50% (32.5–62.5) 50% (30–70)	50% (25–50) 50% (30–77.5)	p = 0.846 p = 0.240
		0.647	0.344	0.684	0.973	0.702	0.358
Q9. Pain interference last 24 h
a. general activity	Group E Group C	7 (6–7) 6.5 (5–8)	5 (4–6) 7 (6–9)	4 (3–6)* 6 (3–7.5)	5 (3–5)* 6 (4–7.5)	3.5 (3–6)* 6.5 (5–8)	3 (3–5.5)* 6 (4.5–8)	p = 0.002 p = 0.102
		0.924	< 0.001	0.213	0.027	< 0.001	< 0.001
b. mood	Group E Group C	7.5 (5–8.75) 5.5 (3–8)	5 (4–6) 6.5 (3–8)	4.5 (2–6.75) 6 (5–8)	4.5 (2.25–6)* 6 (4–8)	3 (1–5)* 5 (3.5–7.5)	2 (1–3.5)* † 7 (4.5–8.5)	p < 0.001 p = 0.168
		0.052	0.324	0.011	0.027	0.007	0.042
c. walking ability	Group E Group C	7 (3.25–8) 6.5 (4–8.5)	5 (3–8) 6 (4–8)	4 (1–5.75)* 6.5 (3–8)	4 (1–5)* 5.5 (2–6.5)	3 (1–5)* 6 (4.5–9)	2 (1–4.5)* 6 (2.5–7)	p < 0.001 p = 0.096
		0.900	0.552	0.054	0.038	0.008	< 0.001
d. normal work	Group E Group C	7.5 (5–8.75) 6 (5–9)	5 (2–6) 7 (6–8)	5 (2–5)* 6 (5–8)	4 (2–5)* 6.5 (4–8)	4.5 (2–5.5) 6 (5–7.5)	3 (2–5)* 6.5 (5–8)	p < 0.001 P = 0.152
		0.968	0.168	0.038	0.029	< 0.012	< 0.001
e. relations	Group E Group C	6 (2–7) 6.5 (3–8)	4.5 (1–6)* 6.5 (3–8)	2 (1–4)* 5.5 (2–6.5)	2.5 (1–4.75)* 5.5 (2.5–6.5)	2 (1–4.25)* 5.5 (2.5–7)	2 (1–4)* 6 (3–7.5)	p < 0.001 p = 0.612
		0.632	0.067	< 0.001	< 0.001	0.005	< 0.001
f. sleep	Group E Group C	6.5 (2.25–8) 5 (3.5–7)	4.5 (1.75–7) 6 (3–8)	2.5 (1–6.25) 5 (2.5–7)	3 (1–6.5) 5.5 (2.5–6.5)	2.5 (0.75–4)* 5 (3–6.5)	1 (0–3.5)* 4.5 (2–7)	p < 0.001 p = 0.368
		0.604	0.155	0.104	0.104	0.013	< 0.001
g. enjoyment of life	Group E Group C	6.5 (4–8.75) 7 (5–8.5)	4.5 (1.75–6.25) 6 (4.5–8)	3 (2–5.75)* 5.5 (3–8)	4 (2–6)* 4.5 (2–7)	2 (1–4)* 7 (4.5–8)	2 (1–3.5)* † 6 (2.5–8)	p < 0.001 p = 0.431
		0.505	0.062	0.213	0.047	< 0.001	< 0.001

A78 Dorsal root ganglion stimulation for painful peripheral neuropathy in diabetic patients

M. De Luca, G. Liguori, R. Ragone, C. Criscuolo, M. Sucre

UOC Anestesia, Rianimazione,Terapia del dolore, Castellammare di Stabia, Italy

Correspondence: M. De Luca

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A78

Background

Diabetic peripheral neuropathy (DPN) is one of the most frequent chronic complications of diabetes.

DPN affects more than 50% of diabetic patients, approximately 15-25% experience neuropathic pain.

Painful diabetic neuropathy is defined as a symmetric sensorimotor polyneuropathy, attributable to metabolic and microvascular alterations due to chronic exposure to hyperglycemia and other cardiovascular risk factors.

Only a third of patients achieve relief with conventional therapies.

Appropriate treatment of painful DPN is important because this pain determines a poor quality of life causing sleep disturbances, anxiety and depression.

The basic principle for managing DPN is to control hyperglycemia and other modifiable risk factors, but these treatments are often insufficient to prevent or improve symptoms of neuropathy.

Because there is no disease-modifying drug, it is important to treat pain.

Drugs used for DPN are gabapentinoids, serotonin-noreepinefin reuptake inhibitors, tricyclic antidepressants, alpha lipoic acid, topical capseiscin.

Spinal cord stimulation has been approved by the FDA for the treatment of painful diabetic neuropathy.

We thought that DRG stimulation could be an alternative or prior treatment to SCS (neuromedullary stimulation) to reduce pain and use and medications.

The dorsal root ganglion contains a collection of cell bodies of primary sensory neurons. DRG neurons are involved in the translation of pain to the CNS by acting as a filter for the propagation of afferent signals to the dorsal horn. DRG stimulation is a selective neuromodulation that can be used in numerous chronic neuropathic pain conditions and has been approved by the FDA (food and drug administration) for the treatment of CRPS complex regional syndrome.

The DRG-S allows precise targeting of nerve fibers innervating targeted painful regions without nonspecifically recruiting uninvolved dermatomes.

Materials and Methods

We treated 15 diabetic patients with DPN with DRG-S who also simultaneously presented low back pain in the lumbosacral region

Both low back and neuropathic lower extremity pain were not controlled by conventional medications: gabapentinoids and high-dose tapentalol. The NRS ranges between 7/9

We performed neuromodulation with an electrocatheter inserted at sacral level and treated the L4 L5 S1 ganglion bilaterally.

The procedure was performed under fluoroscopic guidance and after suitable sensory and motor stimulation

Results

All patients had a reduction in NRS of 7 to 1 for lumbar pain and from 9 to 2 for foot pain, as well as an improvement in the quality of life due to an improvement in walking, lumbar pain, paraesthesia of the lower limbs.

Conclusion

Given the results obtained, stimulation of the GRD represents a useful alternative and initial strategy for patients suffering from painful peripheral neuropathy associated with diabetes. This neuropathy determines alteration of proprioception with alteration of posture and walking, is often associated with lumbar pain which can be treated at the same time when associated with neuropathic pain.

Consent

Informed consent was obtained for the publication of this scientific article.

A79 REPORT OF A CLINICAL CASE OF CRPS TYPE II WITH AN ABNORMAL PRESENTATION

L. D Auria¹, G. Topi², G. Conversa³, C. Bonezzi³, L. Demartini³, S. Natoli^1,2

¹IRCCS Policlinico San Matteo di Pavia, Pavia, Italy; ²Dipartimento di scienze cliniche, chirurgiche, diagnostiche e pediatriche, Università di Pavia, Pavia, Italy; ³IRCCS Maugeri di Pavia, Pavia, Italy

Correspondence: L. D Auria

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A79

Introduction

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition characterized by hyperalgesia, allodynia, and vasomotor, sudomotor, and trophic disturbances, primarily affecting the limbs. It is classified into CRPS type I (in the absence of documented nerve injury) and type II (when a confirmed nerve lesion is present).

Although the pathophysiology remains partially unclear, recent evidence suggests a pivotal role of neuropathic inflammation — particularly the activation of C-fiber nociceptors — and the autonomic nervous system in the onset and maintenance of symptoms.

Case Report

A 49 year old woman was referred to our Pain Unit for severe pain and significant dysfunction of the left upper limb. The patient reported an injury to the left arm two years before our evaluation: she suffered a wrist fracture, reduced and treated with K-wire fixation right away, as well as radial head fracture, which was initially undiagnosed so that the arm was casted without reduction. Upon physical examination, the arm appeared adducted to the torso, with fixed forearm flexion and severe functional limitation due to intense pain (NRS 9/10). Other findings were: involuntary muscle spasms; marked hypothermia compared to the contralateral limb; intense allodynia and the absence of cutaneous annexes.

The patient also showed a pronounced reddish-brown, reticular, nontender, nonblanching skin discolorations and large lesions resembling bullae on the forearm, while denying itching, scratching or thermal injuries.

Magnetic resonance imaging revealed bone marrow oedema of the radial head. Electromyography Results were within normal ranges.

Pharmacological therapy was set with duloxetine 60 mg/day and tapentadol, titrated up to 150 mg

In light of the poor response to conservative treatment and the persistence of debilitating symptoms, the patient was selected for neuromodulation with spinal cord stimulation (SCS). A cervical lead was positioned (tip at C4) for the trial phase using a FAST Therapy stimulation by Boston Scientific. Within minutes, the patient reported a clear and substantial reduction in pain intensity (NRS 2/10). Given the sustained pain relief after 45 days (NRS 3/10), an implantable pulse generator (IPG Boston Scientific, WaveWriter Alpha) was permanently implanted.

Follow-up

Three months later, the upper limb function is gradually improving, with progressive reduction of vasomotor and trophic alterations. Therapy is progressively tapered in parallel with functional improvement. Rehabilitation process remains challenging, despite substantial pain relief due to residual functional limitations.

Discussion and Conclusions

When dealing with CRPS, early recognition is crucial to avoid the condition to become chronic. This case was further complicated by the presence of localized, reticular, nontender, discolorations and water blisters, requiring differential diagnosis with erythema ab igne and livedo reticularis. The patient denied any prolonged exposure to heat sources, making a vascular etiology more plausible. We hypothesized that the significant diagnostic delay regarding the radial head fracture may have caused structural alterations in the arm vascularization, contributing to impaired blood flow and the observed cutaneous findings.

A multimodal approach enabled substantial functional recovery and reduced analgesic burden. This case supports the role of spinal cord stimulation in refractory cases of CRPS.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A79).

Pre/post SCS

A80 Pain control and opioid reduction in patients with aromatase inhibitor arthropathy

V. Ceccarelli¹, C. Claroni², S. Orlando¹, G. Gazzè¹, F. Pizzi¹, C. Stigliano², M. Covotta², G. Torregiani²

¹Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Roma, Rome, Italy; ²Unit of Anesthesiology and Intensive Care, IRCCS Regina Elena National Cancer Institute, Rome, Italy

Correspondence: V. Ceccarelli

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A80

Background

Aromatase inhibitors (AIs) represent a standard treatment for hormone-sensitive early-stage breast cancer. However, they are frequently associated with Aromatase Inhibitor-Associated Musculoskeletal Syndrome (AIMSS), characterized by arthralgia, myalgia, and joint or muscle stiffness [1–3].

Case Report

A 48-year-old female patient (ASA I) underwent quadrantectomy and sentinel lymph node excision for breast cancer in 2020, followed by adjuvant AI therapy. She was referred to the Cancer Pain Therapy Service at the IRCCS Regina Elena National Cancer Institute in Rome for chronic burning pain affecting the spine, left hemithorax, pelvis, shoulders, knees, and occipital region (NRS 9). The pain severely impaired daily functioning and emotional well-being, despite high-dose opioids (fentanyl), NSAIDs, and neuroleptics. Written informed consent for publication was obtained.

An ultrasound-guided intercostal nerve block at the D5-D6 and D6-D7 levels was performed using 10 mL of 1% ropivacaine and 4 mg of dexamethasone per level, as a preparatory step for radiofrequency treatment. Additionally, bilateral occipital nerve blocks were performed with 2 mL of 1% ropivacaine and 1 mg of dexamethasone per side. The diagnostic blocks yielded complete pain relief, leading to the scheduling of radiofrequency ablation.

Under ultrasound guidance, a radiofrequency needle was placed at D5-D6 and D6-D7, and neurolysis was performed at 80 °C for 60 seconds per site. At follow-up 30 days later, the patient reported general improvement with a reduced NRS score of 5, allowing for a significant reduction in opioid use. The pharmacological regimen was grdually adjusted to include paracetamol, weak opioids (codeine), pregabalin, duloxetine, and cannabis (Bediol). At present, pain control is maintained through pharmacotherapy and alternating bilateral occipital nerve blocks with epidural analgesia at the L3-L4 level. Epidural analgesia consists of 13 mL of 1% ropivacaine and 8 mg of dexamethasone.

Conclusion

Despite recent advancements, the management of therapy-related cancer pain remains suboptimal and continues to pose a significant clinical challenge. Effective pain control requires the integration of multiple strategies, both pharmacological and non-pharmacological. Interventional procedures have emerged as a crucial component of multimodal analgesia.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Zhu Y, Loggia ML, Edwards RR, et al. Increased Clinical Pain Locations and Pain Sensitivity in Women After Breast Cancer Surgery: Influence of Aromatase Inhibitor Therapy. Clin J Pain. 2022;38:721–729.

2. Zhu Y, Cohen SM, Rosenzweig MQ, et al. Symptom Map of Endocrine Therapy for Breast Cancer: A Scoping Review. Cancer Nurs. 2019;42:E19–E30.

3. Lombard JM, Zdenkowski N, Wells K, et al. Aromatase Inhibitor-Induced Musculoskeletal Syndrome: A Significant Problem with Limited Treatment Options. Support Care Cancer. 2016;24:2139–2146.

Multi-organ donors and Anaesthesia and Intensive Care in organ transplantation

A81 USE OF A CONTINUOUS INFUSION OF LANDIOLOL IN AN ORGAN DONOR BRAIN-DEAD PATIENT: A CASE REPORT STUDY

G. Giugliano, I. Iacovazzo, M. Massaro, G. Servillo, P. Buonanno, A. Coviello, M. Vargas

Unit of Anesthesia and Intensive Care, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy

Correspondence: G. Giugliano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A81

Introduction

Brain-dead patients often exhibit multiple physiological dysfunctions, such as tachyarrhythmias triggered by the sympathetic storm. These cardiovascular events can compromise the viability of organs intended for donation, making their management crucial. However, treating such events is particularly challenging due to the hemodynamic instability commonly present in these patients. Among these adverse hemodynamic events, the most challenging to manage is undoubtedly hypotension. Landiolol hydrochloride is an ultra-short-acting, highly selective <beta>1 adrenoceptor antagonist, characterized by rapid onset and offset, high cardiac selectivity, and the lack of intrinsic sympathomimetic activity. We present the case of a brain-dead patient with concurrent tachyarrhythmias and hypotension successfully managed with landiolol.

Case presentation

On October 21, 2024, a 76-year-old man presented to the emergency department with a Glasgow Coma Scale (GCS) score of 3 and a right-to-left anisocoria. He was intubated and underwent an immediate brain CT scan, which revealed diffuse subarachnoid hemorrhage with involvement of the cisternal system. Subsequent cerebral angiography identified a vertebrobasilar dissecting aneurysm. Following neuroradiologic intervention, the patient was admitted to the intensive care unit (ICU) under sedation with continuous propofol and nimodipine infusions. Neurologically, he exhibited a Richmond Agitation-Sedation Scale (RASS) score of −5, persistent right-to-left anisocoria, and preserved brainstem reflexes. Cardiovascular assessment showed atrial fibrillation (AF) at 110 bpm and blood pressure (BP) of 120/80 mmHg.

On October 22, the patient experienced bradycardia (HR 40 bpm) and hypertension (BP 160/70 mmHg). A repeated CT scan indicated increased intracranial pressure (ICP), prompting the neurosurgical team to place an external ventricular drain. Postoperatively, the patient remained intubated and sedated. He kept on demonstrating a RASS score of −5, anisocoria, and intact brainstem reflexes. Cardiovascular parameters showed AF at 110 bpm and hypotension (BP 80/50 mmHg), necessitating the start of norepinephrine infusion.

On October 24, sedation was stopped. Neurological examination revealed persistent GCS of 3, right-to-left anisocoria, and preserved brainstem reflexes. Cardiovascular findings included AF at 160 bpm and BP of 110/60 mmHg. To manage the tachyarrhythmia, we started a continuous infusion of landiolol while maintaining norepinephrine. After three hours, based on clinical evaluation, we increased the landiolol infusion rate and reduced the norepinephrine dose. At five hours, norepinephrine was stopped, and landiolol was further increased. Six hours after the landiolol drip start, the patient's heart rate normalized to 96 bpm without significant changes in arterial pressure (BP 120/80 mmHg). Later that day, successful organ donation was carried out without complications.

Conclusion

Landiolol may represent a valuable therapeutic option for managing tachyarrhythmias in brain-dead patients who are potential organ donors, particularly when aiming to minimize vasopressor use and preserve organ viability. Further studies involving larger patient populations are warranted to better describe the safety profile and clinical impact of landiolol in this unique context.

Consent

Informed consent was obtained for the publication of this scientific article.

A82 Use of iga- and igm-enriched immunoglobulins in liver transplantation recipients with hypogammaglobulinemia: a case report

M. Esposito, G. Azan, R. Romano, A. De Felice, V. Amatucci, R. Montesano, N. Lisco, C. Chierego, G. De Simone

AO A. Cardarelli Terapia Intensiva Trapianti di Fegato, Naples, Italy

Correspondence: M. Esposito

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A82

Hypogammaglobulinemia (HGG), with a serum immunoglobulin G (IgG) level < 700 mg/dl is a well- known complication of solid organ transplantation (SOT). Within the first-year post-transplantation the overall rate of HGG is 45% with high prevalence following heart, lung and kidney transplantation. In liver transplantation (OLT), the incidence of HGG is lower, ranging from 16 to 26%. Severe HGG (<400 mg/dl) within 1-year post-transplantation significantly increases the risk of CMV, fungal and respiratory infections, and it is associated with higher 1-year all-cause mortality.

We report the case of a 30-year-old man, who underwent Kasai surgery in childhood for biliary atresia. Informed consent was obtained, when he was admitted to our centre for fever and acute on chronic liver failure (ACLF II) with ascites, jaundice (total bilirubin 22.8 mg/dl), and renal failure with preserved diuresis (creatinine 3.01 mg/dl). He also exhibited leukopenia (WBC 2930 mm³), with CRP 22.8 mg/l and PCT2.2 ng/ml, and normal IgG levels. Empirical antibiotic therapy with IV cefotaxime 1 g twice a day was started. Broncho-aspirates, blood, urine, and ascitic fluid cultures resulted negative. Legionella antigen in urine, molecular swab for Covid 19 and multiplex NAAT panels performed on respiratory specimens were also negative. Due to the worsening of the encephalopathy (Grade IV West-Haven), emergency OLT was performed. Immunosuppressive therapy was started with prednisone 25 mg once a day, mycophenolate 500 mg twice a day, tacrolimus 0.5 mg twice a day. The post-operative course was regular for the first 6 days. A CMV prophylaxis was established because of multiple risk factors with IV ganciclovir 5 mg/kg twice a day. Empirical antibiotic therapy with IV cefotaxime 1 g twice a day was continued.

On the 7th postoperative day, our patient showed fever (TC 38.5 °C), leukopenia, increased PCR (167.9 mg/l), PCT (2.1 ng/ml), IL6 (80pg/ml). Empiric ATB was started with meropenem, zyvoxid and fluconazole, and immunosuppression was reduced.

Blood culture resulted positive for Klebsiella Pneumoniae and the patient was treated with IV ceftazidime-avibactam 2.5 g thrice a day and IV phosphomycin 4.5 g four times a day. On the 14th day, CMV-DNA increase to 84947 copies/ml. Despite therapy, 3 weeks into his OLT surgery our patient conditions further deteriorated exhibiting the signs of a septic shock and CMV viremia continued to increase.

Protein panel showed a reduction in gamma-globulins to 5.6% (vs. 23% soon after OLT), with IgG values <400mg/dl. Therefore, a treatment with IgM- and IgA-enriched immunoglobulin (250 mg/kg/die infusion 20 mg/kg/h) was started and carried out for 5 days.

After seven days from the start of treatment, we observed the resolution of septic shock, with improvement of hemodynamic parameters and interruption of any vasopressor support. During the observation period, CMV eradication was not achieved, but the patient became asymptomatic.

The use of intravenous immunoglobulin (IVIG) in sepsis patients is still debatable. In our case the treatment with IgM- and IgA-enriched immunoglobulin induced a stable improvement in hemodynamic parameters. IVIG represents a promising treatment for specific patients with sepsis such as OLT patients developing severe post-operative hypogammaglobulinemia

Consent

Informed consent was obtained for the publication of this scientific article.

Underwater and Hyperbaric Emergencies

A83 Severe carbon monoxide poisoning with unilateral cortical lesions: complete neurological recovery following hyperbaric oxygen therapy and intensive rehabilitation

D. Gemmi¹, C. Ferraro², L. Cantadori¹, L. Martani¹

¹Department of Surgery, Anesthesiology, Critical Care and Hyperbaric Medicine Unit, Parma, Italy; ²Department of Medicine and Surgery, Anesthesiology, Critical Care and Pain Medicine Division, University of Parma, Italy

Correspondence: D. Gemmi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A83

Background

Carbon monoxide (CO) poisoning is a serious medical emergency associated with significant neurological morbidity. Clinical presentations range from mild symptoms to coma, often with persistent cognitive or motor deficits. Ischemic brain damage due to CO-related hypoxia typically affects the basal ganglia, although atypical patterns have also been reported. Early treatment with hyperbaric oxygen therapy (HBOT) may improve clinical outcomes.[1,2]

Case report

A 24-year-old man with a history of anxiety-depressive disorder and chronic tobacco use was found comatose at home approximately 18 hours after last contact. A wood-burning stove was present in the room; environmental detectors confirmed CO exposure. Upon arrival of emergency medical services, his Glasgow Coma Scale score was 9 with rightward gaze deviation. Diazepam was administered intravenously for seizures and the patient was airlifted to the hospital. At emergency department admission, carboxyhemoglobin (COHb) level was 17.6%. The brain CT revealed multiple cortico-subcortical hypodensities in the left hemisphere, suggestive of acute ischemia (Figure 1a).

The patient was intubated and transferred to our ICU, where he underwent five HBOT sessions. Brain MRI confirmed ischemic cortical and juxtacortical lesions confined to the left hemisphere (Figure 1b), with a suspected M1 segment stenosis of the left middle cerebral artery, which was ruled out by angiographic CT. Autoimmune and embolic work-up was negative. Progressive improvement in cerebral electrical activity without signs of paroxysms. No ischemic causes other than CO intoxication were identified.

In the early phase, neurological assessment revealed severe impairment: the patient was unresponsive, with flexion of all four limbs and eye opening only in response to painful stimuli. He began to regain consciousness after 18 days, with progressive improvement and was subsequently transferred to Neurology for intensive rehabilitation. At 50-day follow-up, the patient showed full recovery of all neurological functions.

Conclusion

This case represents a rare presentation of unilateral cortical lesions following CO intoxication, with MRI features of selective cortical ischemia[2,3]. Despite the initial severity, prompt HBOT, intensive care management and early rehabilitation led to complete neurological recovery. The case highlights the importance of a multimodal approach and dynamic prognostic reassessment, even in patients presenting with severely impaired neurological status.

Consent to publish

Written informed consent for publication of clinical data in anonymous form was obtained from the patient.

References

1. Weaver LK. Carbon monoxide poisoning. N Engl J Med. 2009;360(12):1217–1225.

2. Prockop LD, Chichkova RI. Carbon monoxide intoxication: an updated review. J Neurol Sci. 2007;262(1-2):122–130.

3. Lo CP et all. Brain injury after acute carbon monoxide poisoning: early and late

Fig. 1 (abstract A83).

Brain CT (1a) and Brain MRI (1b)

A84 Safe treatment with hyperbaric oxygen therapy in a carbon monoxide intoxicated pediatric patient mechanically ventilated and hemodynamically unstable

G.E. Fulceri¹, A. Franci¹, E. Cipriani¹, F. Socci¹, M. Orlandi¹, A. Valletta¹, C. Grillandini¹, A. Marabotti¹, Z. Ricci², M. Bonizzoli¹

¹Azienda Ospedaliero Universitaria Careggi, Firenze, Italy; ²Azienda Ospedaliero Universitaria Meyer, Firenze, Italy

Correspondence: M. Orlandi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A84

Carbon monoxide (CO) develops in incomplete combustion processes of substances containing carbon, the clinical symptoms of acute carbon monoxide intoxication range from headache and dizziness to loss of orientation, symptoms of cardiac angina, loss of consciousness, and death [1]. Most deaths are due cardiac insult arising from hypoxic stress mediated by carboxyhemoglobin (COHb) and mitochondrial dysfunction, morbidity is related to neurological injuries; cognitive, vestibular and motor impairments occur in ~25–50% of survivors from severe poisoning, neurological sequelae appear up to 21 days after poisoning. Hyperbaric oxygen therapy (HBOT) was first introduced with the notion that COHb is the principal basis for injuries and HBOT will hasten COHb dissociation, this action may be responsible for reductions in mortality and myocardial infarction, furthermore patients treated with HBOT had a lower incidence of neurocognitive sequalae [2].

A six-year-old female on 19/12/2024 was found unconsciousness at home due to CO intoxication, her parents and her brother were found death. On the scene she was in GCS 3 with low SpO2 (70%), transferred to open air and initiated with high flow oxygen she recovered to GCS 7 and SpO2 was 99%. The patient at 15:30 arrived in the emergency department of AOU-Meyer where she still unconscious and hemodynamically unstable. Intubation was performed, at blood gas analysis COHB was 9.7%, lactate 9.6 mmol/l, echocardiography demonstrates widespread hypokinesis with ejection fraction of 30% and TAPSE 10 mm; hemodynamic support was initiated whit dobutamine 5 mcg/Kg/min and adrenaline 0.25 mcg/Kg/min. Computed tomography demonstrated cerebral edema. The baby-girl was transferred in intensive care where she still hemodynamically unstable with lactate increase to 11.3 mmol/l.

The patient at 18:00 was referred to hyperbaric center of Careggi university hospital, she was presented sedated, mechanically ventilated, hemodynamically unstable and anuric, adrenaline and dobutamine infusion where on course; due to critical condition HBOT was delayed, the hyperbaric chamber is a hostile environment with few resources for resuscitation, in few hours dobutamine was stopped and diuresis start; at that point we decide to commence HBOT. The baby-girl at 23:00 was accompanied in hyperbaric chamber by the pediatric intensivist, who was temporarily authorized by the hospital director to participate exceptionally in the hyperbaric treatment with the Careggi hyperbaric physician in charge; patient was monitored (NIBP, ECG,SPO2) and ventilated via SERVO-I HBO, infusion of sedative and vasopressors were maintained whit HBO certified pumps, treatment was made for 1h30min at 2.4 ATA, as soon the treatment begun we saw an hemodynamic improvement and vasopressors dosage decrease, we repeat treatment the 20-21/12/24.

The patient underwent 3 HBO cycle whit hemodynamic improvement, at the beginning of the third cycle EF was 40% and TAPSE normalized. At Hospital discharge she had no cardiological sequelae and CPC scale was 1.

Our case demonstrates the safeness and feasibility of HBOT in mechanically ventilated pediatric patients even under unstable hemodynamic conditions; moreover, HBOT may result in improvement of hemodynamic because of the role of myocardial hypoxia on cardiac impairment. It appears of great importance close collaboration between pediatric intensivist and hyperbaric doctors.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Eichhorn L, Thudium M, Jüttner B. The Diagnosis and Treatment of Carbon Monoxide Poisoning. Dtsch Arztebl Int 2018; 115: 863–70.

2. Sethuraman K, Thom SR. Hyperbaric oxygen should be used for carbon monoxide poisoning. Br J Clin Pharmacol. 2023; 89(3): 939–941.

Follow-up/outcomes

A85 Post-intensive care syndrome (Pics) and delirium: an observational study at the san Giuseppe hospital

L. Venturi, E. Gorrila, M. Luchini, R. Spina

Azienda USL Toscana Centro- Ospedale S. Giuseppe, Empoli(FI), Italy

Correspondence: L. Venturi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A85

Background

Delirium is an acute neuropsychiatric syndrome characterized by disturbances in attention, awareness, and cognition that develop over a short period of time and fluctuate throughout the day. It is a common yet underdiagnosed condition among patients in Intensive Care Units (ICUs), particularly in those who are mechanically ventilated or critically ill. Delirium can present in hyperactive, hypoactive, or mixed forms, and is associated with increased morbidity, prolonged hospital stays, long-term cognitive impairment, and higher mortality rates. In the post-ICU context, delirium is recognized as a major component of Post-Intensive Care Syndrome (PICS), which encompasses persistent cognitive, physical, and psychological impairments that affect patients after critical illness and ICU discharge.

Objective

This study aims to investigate the factors associated with the development of delirium in ICU patients, with a particular focus on identifying correlations with mechanical ventilation and ICU length of stay, within the framework of a structured post-ICU follow-up program.

Methods

This prospective, observational cohort study was conducted at the San Giuseppe Hospital in Empoli, Italy, between 2020 and 2024. A total of 513 ICU survivors were initially considered. After applying exclusion criteria—including ICU stay of less than 5 days, death within 6 months, or loss to follow-up—the final sample consisted of 426 patients.

Inclusion criteria:

ICU stay longer than 5 days

Signed informed consent for clinical and telephone follow-up

Completion of follow-up at 3 and 6 months (with 12-month follow-up in selected cases)

Patients were divided into two groups:

Those who developed delirium during their ICU stay (n = 200)

Those who did not develop delirium (n = 226)

Variables analyzed included age, sex, ICU admission diagnosis, pre-existing cognitive impairment, comorbidities, use of non-invasive/invasive mechanical ventilation, ICU stay duration, and duration of mechanical ventilation.

Results:

No statistically significant differences were found between the two groups in terms of age, gender, diagnosis on admission, pre-existing cognitive conditions, or comorbidities. COVID-19 pneumonia was the most frequent cause of ICU admission (30%), followed by sepsis, trauma, COPD exacerbations, and post-surgical complications.

While the use of non-invasive ventilation did not appear to correlate with the onset of delirium, a strong association was observed between delirium and both longer ICU stays (image 1) and the use of invasive mechanical ventilation (image 2). Among delirium patients, 77% required invasive mechanical ventilation, compared to 38% in the non-delirium group.

Conclusions:

Delirium remains a highly prevalent and clinically significant complication in critically ill patients, affecting nearly half (47%) of the ICU population studied. This study emphasizes that although baseline demographic and clinical characteristics may not predict delirium onset, prolonged ICU admission and invasive ventilation are significant risk factors. The findings reinforce the need for early prevention strategies and structured post-ICU follow-up to monitor and address PICS-related complications. Implementing multidisciplinary approaches—including cognitive rehabilitation, early mobilization, and delirium screening—may reduce long-term impacts and improve patient outcomes.

Consent

Informed consent was obtained for the publication of this scientific article.

Infections and sepsis

A86 Implementation of targeted diagnostic algorithms enhances early management of bloodstream infections in critically ill patients: a pre-post evaluation in a tertiary care ICU

V. Vago^1,3, M. Petrone^1,3, M. Tomasello^2,3, C. Abbruzzese³, D. Mangioni², V. Scaravilli^3,4, A. Bandera^1,2, G. Grasselli^1,3, M. Panigada³

¹Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; ²Infectious Diseases Unit, IRCCS Ca'Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy; ³Department of Anaesthesiology, Critical Care and Emergency, Intensive Care and Emergency, Fondazione IRCCS Ca'Granda, Milan, Italy; ⁴Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy

Correspondence: V. Vago

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A86

Background

Timely identification of pathogens and appropriate antimicrobial therapy are critical in the management of bloodstream infections (BSIs), particularly in intensive care settings. In 2024, a multidisciplinary team at Fondazione IRCCS Ca’ Granda Policlinico Hospital (Milan) designed and introduced diagnostic pathways tailored for BSIs (fig.1 e fig.2), based on the review of local epidemiology (hospital cumulative antibiograms) and availability of fast-microbiology diagnostic strategies.

Methods

BSI episodes managed before (2023) and after (2024) algorithms implementation were retrospectively compared.

Outcomes included microbiological turnaround time - from sample collection to first microbiological data (pathogen identification and/or resistance pattern) and the proportion of patients receiving antibiotic optimization within 72 hours from blood culture collection (i.e., how often and how rapidly treatments were de-escalated or changed once microbiological data became available). All patients signed BSI-STUDY consent.

Results

A total of 73 BSI episodes were analyzed, 32 from the pre-implementation period and 41 post-implementation period (Tab.1).

Most cases originated in the emergency department 38 (52%) or the ICU 19 (26%), with sepsis or septic shock present in 78% of cases at onset. The most frequently isolated pathogens included Escherichia coli 13/73 (17.8%), Klebsiella pneumoniae 10/73 (13.6%), and Staphylococcus aureus 9/73 (10.9%). Multidrug-resistant organisms accounted for 28/73 (38.3%) of isolates, with similar proportions across Gram-positive and Gram-negative infections. (Tab. 2).

The use of BCID2 rose from 12% in the pre-intervention group to 60% post-intervention (p<0.0001). Following implementation, median microbiological turnaround time decreased significantly (30 [IQR 22–70] vs 77 [IQR 42–129] hours; p=0.003), and early antibiotic therapy optimization became more frequent (43.9% vs 16%; p=0.008). No significant difference was observed in the overall duration of antibiotic treatment between groups.

Conclusions

The adoption of structured, pathogen-specific diagnostic algorithms - supported by fast molecular microbiology - was associated with faster microbiological reporting and a significant improvement in early antibiotic adjustments. Ongoing evaluation will assess their long-term influence on antimicrobial consumpion and resistance patterns over time.

Consent

Informed consent was obtained for the publication of this scientific article.

References

Peri A, Ling W et al. Performance of BioFire Blood Culture Identifcation 2 Panel (BCID2) for the detection of bloodstream pathogens and their associated resistance markers: a systematic review and meta-analysis of diagnostic test accuracy studies. BMC Infectious Diseases (2022).

Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med. 2020 Feb;46(2):266-284.

Chang CM, Hsieh MS, Yang CJ, How CK, Chen PC, Meng YH. Effects of empiric antibiotic treatment based on hospital cumulative antibiograms in patients with bacteraemic sepsis: a retrospective cohort study. Clin Microbiol Infect. 2023 Jun;29(6):765-771.

Fig. 1 (abstract A86).

Empiric therapy algorithm for BSI caused by Gram +

Fig. 2 (abstract A86).

Empiric therapy algorithm for BSI caused by Gram -

Table 1 (abstract A86).

Epidemiological data. Continuous variables are expressed as median (Q1-Q3), categorical are expressed as n (%)

EPIDEMIOLOGY	OVERALL	2023	2024
N° patients	67	30	37
N° events	73	32	41
Age	65(52–75)	63,5 (46,5–74,25)	66 (57–75,5)
Male	45 (67,1%)	20 (67%)	25 (68%)

Table 2 (abstract A86).

Clinical and microbiological data. Continuous variables are expressed as median (Q1-Q3), categorical are expressed as n (%). *Genitourinary, intestinal traslocation, CNS; **S. epidermidis; ***Enterobacter hormaechei, Klebsiella spp; ****Neisseria meningitidis, Salmonella spp, Bacteroides spp, Citrobacter spp

	OVERALL	2023	2024
	N = 73	N = 32	N = 41
SETTING OF BCx COLLECTION
Medical wards	10 (13,6%)	3 (9,3%)	7 (17%)
Surgical wards	6 (8,2%)	2 (6,2%)	4 (9,7%)
ED	38 (52%)	17 (53,1%)	21 (51,2%)
ICU	19 (26%)	10 (31,2%)	9 (21,9%)
CLINICAL SEVERITY
No sepsis	16 (21,9%)	7 (21,8%)	9 (21,9%)
Sepsis	14 (19,1%)	6 (18,7%)	8 (19,5%)
Septic shock	43 (58,9%)	19 (59,3%)	24 (58,5%)
BACTERAEMIC FOCUS
Skin and soft tissue	12 (16,4%)	9 (28,1%)	3 (7,3%)
Secondary to intra-abdominal infection	15 (20,5%)	7 (21,8%)	8 (19,5%)
Secondary to HAP/VAP	7 (9,5%)	2 (6,2%)	5 (12,1%)
Urinary tract	13 (17,8%)	3 (9,3%)	10 (24,3%)
CR-BSI	6 (8,2%)	2 (6,2%)	4 (9,7%)
Other/Unknown*	20 (29.8%)	9(28.1%)	11 (26,8%)
CLINICAL OUTCOME
Discharged alive	55 (82%)	2 (%)	3 (84%)
Dead	12 (18%)	6 (20%)	6 (16%)
Length of stay, days	5 (2–27,2)	8,5 (2–22,25)	5 (2–11)
GRAM +
Staphylococcus aureus	8 (25,8%)	4 (21%)	4 (33,3%)
CoNS **	6 (19%)	4 (21%)	2 (16,6%)
Enterococcus faecium	6 (19%)	3 (15,7%)	3 (25%)
Streptococcus spp	5 (16,1%)	4 (21%)	1 (8,3%)
Streptococcus pneumoniae	6 (19%)	3 (15,7%)	3 (25%)
Other***	1 (3,2%)	1 (5,3%)	-
Total	31	19	13
GRAM -
Escherichia coli	13 (31,7%)	4 (30,7%)	9 (32,1%)
Enterobacterales (other)***	8 (19,5%)	3 (23%)	5 (17,8%)
Klebsiella pneumoniae	10 (24%)	2 (15,3%)	7 (25%)
Pseudomonas aeruginosa	6 (14,6%)	1 (7,6%)	5 (17,8%)
Proteus spp	1 (2,4%)	1 (7,6%)	-
Other****	3 (7,3%)	2 (15,3%)	1 (3,5%)
Total	41	13	28
MULTIDRUG RESISTENCE
Gram +	12 (37.5%)	6 (31.5%)	6 (46.1%)
Gram -	16 (40%)	7 (53.8%)	9 (33.3%)
Total	28 (38,3%)	13 (40,3%)	15 (36.6%)

A87 Use of pentaglobin in a patient affected by neisseria meningitidis serogroup B

M. Toma, D. Puscio, G. Paiano, D. Mastria, L. Giaccari, R. De Maglio, R. Barbieri, F. Madaro, G. Pulito, L. Mascia

UOC Anestesia E Rianimazione - P.O. Vito Fazzi, Lecce, Italy

Correspondence: M. Toma

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A87

Meningitis caused by Neisseria Meningitidis, a serious infectious disease caused by Gram-negative diplococcus, despite having an incidence in Italy of 0.14 cases per 100,000 inhabitants (ISS 2024 data), continues to have a high rate of hospitalization in intensive care, permanent sequelae and mortality despite timely treatment. Adjuvant therapy with IgM seems to be a promising solution for the control of severe infection by N. meningitidis because it neutralizes bacteriotoxins, exotoxins and improves opsonization and phagocytosis of pathogens. The only available polyclonal drug preparation enriched with IgM immunoglobulins is Pentaglobin (Biotest-AG, Dreieich, Germany); This contains 76% IgG, 12% IgA and 12% IgM and has shown greater efficacy in vitro against gram-negative bacteria through the improvement of the phagocytosis process. In a study conducted in Tuscany in 2017, it was seen how the group treated with Pentaglobin had a lower mortality rate than the control group.

Case report (Informed consent to the processing of personal data required): 35-year-old male patient went to the emergency room for hyperpyrexia (for about 2 days), vomiting and appearance of diffuse blood extravasations all over the body and confusion (Fig. 1). He arrived disoriented and uncooperative with initial signs of nuchal rigidity. Given the neurological picture and the presence of a septic picture (Lat: 3.8; PCT 58.8) the patient was transferred to intensive care. He performed a negative total body CT scan and a lumbar puncture which was positive for Neisseria Meningitidis. During hospitalization in intensive care the patient maintained spontaneous breathing, neurologically intact with stable hemodynamics. Upon admission the patient was treated with Ceftriaxone 2 g x 2/day, replaced with Meropenem 2 g x 3/day and Linezolid 600 mg x 2/day. Pentaglobin 50mg/ml at 36 ml/h was then started. The clinical picture began to improve the day after admission with progressive improvement of laboratory tests and reduction of hemorrhagic petechiae (Fig 2). After a week of hospitalization, the patient was discharged.

The case report we described highlights the efficacy of IgM immunoglobulins in Neisseria-mediated meningitis and shows a rapid improvement of the patient's clinical and laboratory picture, confirming Pentaglobin as a key player in fighting meningeal infections.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A87).

DIFFUSE BLOOD EXTRAVASATIONS ALL OVER THE BODY

Fig. 2 (abstract A87).

WHITE BLOOD CELL COUNT AND PCT TREND DURING THE DAYS OF HOSPITALISATION

A88 Point-of-care evaluation of fibrinolysis in Sepsis: the pocefis study

I. Silvestri^1,3, C. Bonetti¹, A. Caccioppola², A. Meli², G. Corica¹, E. Bellavia¹, A.G. Motta¹, A. Rosati¹, G. Zimei¹, F. Cappelli¹, G. Grasselli^1,2, M. Panigada²

¹Department of pathophysiology and transplantation, University of Mila, Milano, Italy; ²Intensive care unit, IRCCS Ca'Granda Fondazione, Milano, Italy; ³Policlinico di Milano Ospedale Maggiore | Fondazione IRCCS Ca'Granda, Milano, Italy

Correspondence: I. Silvestri

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A88

Background

Fibrinolytic shutdown is a recognized phenomenon observed in septic patients and is associated with worsened prognosis. However, a standardized, bedside diagnostic approach still lacks. The ClotPro® viscoelastic assay, specifically its TPA-test, offers a point-of-care method to quantify fibrinolysis impairment by measuring lysis time (LT) and maximum lysis (ML). The POCEFIS study aims to assess the prevalence and clinical relevance of impaired fibrinolysis in sepsis.

Methods

This single-center, prospective cohort study enrolled adult ICU patients with a diagnosis of sepsis or septic shock, admitted to the adult ICU of Policinico Hospital of Milan, Italy.. Exclusion criteria included ECMO, history of known coagulopathies and oral anticoagulation therapy.. Patients were enrolled within 12 hours from the diagnosis of sepsis or septic shock. The primary endpoint was the prevalence of fibrinolysis impairment based on prolonged LT on the ClotPro® TPA-test. Secondary outcomes included associations with standard coagulation tests, inflammatory biomarkers, organ dysfunction (SOFA score), ICU mortality, and ICU length of stay.

Standard laboratory tests, ClotPro® (including TPA, EX, IN, FIB, and AP-tests), and VCM were performed at enrollment, and on day 1, 2, 3, and 7 after enrollment. Biomarkers such as PAI-1, plasminogen, IL-6, and TNF were measured at enrollment and on day 2 and 7.

Results

From January 2024 to April 2025, 57 patients were enrolled in the study.. Fibrinolysis response was categorized based on TPA lysis time, with a cut-off of 411 seconds. 23 patients (40.4%) had normal response, and 34 (59.6%) showed altered fibrinolysis. No significant differences in age, sex, BMI, comorbidities, or site of infection were observed between groups. ICU mortality was similar in the two groups (13.0% vs. 14.7%, p=1.00).

While SOFA scores at enrollment did not differ significantly, patients with altered fibrinolysis showed higher SOFA scores on day 2 (11.1 ± 2.3 vs. 8.9 ± 3.0, p=0.029), suggesting a transient association with organ dysfunction. Trends over the first 72 hours revealed that persistent fibrinolysis impairment was associated with higher inflammatory markers (e.g., IL-6, TNF), elevated fibrinogen and PAI-1, and reduced plasminogen levels. A subgroup of 13 patients (22.8%) exhibited severe fibrinolysis resistance persisting across all time points, with biochemical markers suggestive of consumptive coagulopathy.VCM analysis confirmed lower maximum lysis (ML%) in the resistant group, particularly on days 1 and 2, supporting the ClotPro® findings.

Conclusions

The ClotPro® TPA-test effectively identifies fibrinolysis impairment in septic ICU patients. Nearly 60% of cases exhibited altered fibrinolysis at enrollment, with variable recovery trajectories. Persistent resistance was associated with elevated inflammatory and antifibrinolytic markers, but not conclusively with worse clinical outcomes in this preliminary analysis. VCM Results paralleled ClotPro® findings, further validating the presence of a hypofibrinolytic phenotype. These insights support the use of bedside viscoelastic testing for early phenotyping of septic patients and potential guidance of individualized therapeutic strategies in sepsis induced coagulopathy.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Iba T, Umemura Wada Levy JH. Roles of Coagulation Abnormalities and Microthrombosis in Sepsis: Pathophysiology, Diagnosis, and Treatment. Arch Med 2021;52(8):788-797.10.1016/j.arcmed.2021.07.003

2. M. Panigada et al., ‘Assessment of Fibrinolysis in Sepsis Patients with Urokinase Modified Thromboelastography’,2015,10.1371/journal.pone.0136463.

A89 Two cases of acinetobacter baumannii-related ventriculitis following external ventricular drain placement

D. Scarano, C. Bussemi, A. Piedepalumbo, A. Lucarelli, F. Scarpato, D. Carbone

Presidio Ospedaliero Umberto I, Nocera Inferiore, Italy

Correspondence: A. Piedepalumbo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A89

Background

Ventriculitis is an infection of cerebral ventricles that may result from meningitis, open head trauma, neurosurgical procedures, or the placement of devices such as an external ventricular drain (EVD). The clinical presentation includes fever, altered level of consciousness, and, in advanced cases, nuchal rigidity and signs of intracranial hypertension. Diagnosis is based on cerebrospinal fluid (CSF) analysis—typically showing leukocytosis, hypoglycorrhachia, and elevated protein levels—CSF cultures for pathogen identification, and neuroimaging (CT or MRI) that may reveal ependymal enhancement and thickening, periventricular edema, and hydrocephalus. Certain conditions, such as EVD placement, prolonged ICU stay, and immunosuppression, are risk factors for ventriculitis due to multidrug resistant bacteria such as Acinetobacter baumannii. Treatment includes removal or replacement of the infected catheter and targeted antibiotic therapy, either intravenous and/or intrathecal, according to antimicrobial susceptibility testing.

Case Report

We report two cases of ventriculitis caused by extensively drug-resistant (XDR) Acinetobacter baumannii, arising after EVD placement in patients admitted to the intensive care unit for acute cerebral hemorrhagic events. The first patient, a 62-year-old man, was admitted for hypertensive intracerebral hemorrhage. The second case involved a 77-year-old woman with subarachnoid hemorrhage caused by the rupture of an aneurysm of the right middle cerebral artery. Both patients developed complications from their condition which required placement of an EVD. After 7 days from placement in the first case and after 5 days in the second, both patients showed rapid neurological deterioration with sudden decrease in the GCS score, fever and elevated inflammatory markers. Blood cultures were negative in both cases. MRI was suggestive of ventriculitis (Figure 1,2,3), which was subsequently confirmed by CSF analysis and culture isolation of XDR A. baumannii. Treatment included a combined antimicrobial approach with 0.125 MU/day of intrathecal colistin and intravenous cefiderocol (6 g/day), fosfomycin (16g/day) and colistin (4.5 MU/bid). The EVDs were removed and replaced with new ventricular catheters dedicated to intrathecal colistin administration. In both cases, microbiological sterilization of the CSF was achieved within approximately 10 days, along with clinical and radiological improvement. Antibiotic therapy continued for 14 days. No adverse events related to intrathecal colistin administration were observed. The ventricular catheters were later removed without complications, and both patients were discharged from the ICU with preserved cognitive and motor functions.

Conclusion

This case series highlights the effectiveness and safety of intravenous cefiderocol, fosfomycin and colistin in combination with intrathecal colistin. The combined approach, in addition to demonstrating a good safety profile, led to resolution of the infection, suggesting a potential benefit in case of MDR pathogens. These preliminary results are promising; however, further confirmation is needed through prospective, randomized studies to establish the role of this antibiotic regime and to develop shared therapeutic guidelines, particularly given the limited number of Acinetobacter-related ventriculitis cases reported in the scientific literature.

Written informed consent was obtained from the patients for publication of this case report and any accompanying images or clinical data.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Ulloque-Caamaño L, Mo-Carrascal J, Maraby J, Narvaez-Rojas A, Quintana-Pajaro L, Ramos-Villegas Y, Moscote-Salazar LR. Ventriculitis associated with extraventricular drainage: etiology, diagnosis and treatment focused on neurocritic care units. Cir Cir. 2019;87(2):230-240. English. 10.24875/CIRU.18000052. PMID: 30768063.

2. Hasbun R. Healthcare-associated ventriculitis: current and emerging diagnostic and treatment strategies. Expert Rev Anti Infect Ther. 2021 Aug;19(8):993-999. 10.1080/14787210.2021.1866544. Epub 2020 Dec 24. PMID: 33334204.

3. Karaiskos I, Galani L, Baziaka F, Giamarellou H. Colistina intraventricolare e intratecale come ultima risorsa terapeutica per il trattamento della ventricolite e meningite da Acinetobacter baumannii multifarmaco-resistente ed estesamente farmaco-resistente: una revisione della letteratura. Int J Antimicrob Agents. Giugno 2013;41(6):499-508. 10.1016/j.ijantimicag.2013.02.006. Epub 16 marzo 2013. PMID: 23507414.

4. Karaiskos I, Galani L, Baziaka F, Giamarellou H. Colistina intraventricolare e intratecale come ultima risorsa terapeutica per il trattamento della ventricolite e meningite da Acinetobacter baumannii multifarmaco-resistente ed estesamente farmaco-resistente: una revisione della letteratura. Int J Antimicrob Agents. Giugno 2013;41(6):499-508. 10.1016/j.ijantimicag.2013.02.006. Epub 16 marzo 2013. PMID: 23507414.

Fig. 1 (abstract A89).

Rm patient n°1

Fig. 2 (abstract A89).

Rm patient n°1

Fig. 3 (abstract A89).

Rm patient n°2

A90 Impact of extracorporeal membrane oxygenation on incidence rates of bacterial bloodstream infections and ventilator-associated pneumonia

M. Petrone¹, V. Vago¹, T. Mara², A. Chiara³, B. Alessandra^4,5, G. Amedeo³, M. Davide⁴, M. Andrea³, P. Mauro³, G. Giacomo^3,5, S. Vittorio^3,6

¹School of Specialization in Anesthesia Intensive Care, and Pain Management, University of Milan, Italy; ²School of Specialization in Infectious Diseases, University of Milan, Italy; ³Department of Anesthesia, Critical Care and Emergency, Intensive Care and Emergency, Foundation IRCCS Ca'Granda Hospital, Milan, Italy; ⁴Infectious Diseases Unit, Foundation IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy; ⁵Department of Pathophysiology and Transplantation, University of Milan, Italy; ⁶Department of Biomedical, Surgical and Dental Sciences, University of Milan, Italy

Correspondence: M. Petrone

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A90

Background

Extracorporeal membrane oxygenation (ECMO) is a life-saving support for patients with refractory cardiac or respiratory failure. Its potential role in promoting nosocomial infections, such as ventilator-associated pneumonia (VAP) and bloodstream infections (BSI), remains unclear. This study investigates the association between ECMO and BSI/VAP.

Methods

This retrospective observational study includes all consecutive adult patients admitted to the ICU of Ospedale Policlinico in Milan for >48h. Patients mechanically ventilated for <48h were not considered for VAPs.

Only the first microbiologically-confirmed bacterial infection leading to the initiation/modification of an antimicrobial therapy was considered.

We defined infection time at risk: a) for BSI from 48 hours after ICU admission until discharge, infection, or death; b) for VAP from 48 hours after intubation until extubation, infection, or death.

Crude incidence and incidence rate (IR) were calculated for BSI/VAP in ECMO and non-ECMO patients. A univariate Fine and Gray competing risk analysis was performed, considering death as a competing event. ECMO was considered a time-varying variable, with an ECMO-related infection timeframe starting and ending 48 hours after ECMO initiation and decannulation.

Results

From January 1, 2023, to December 31, 2024, 404 patients were admitted to ICU. 204 stayed in the ICU for >2 days and were included in the analysis. Median age was 60 [IQR 49–68], 144 (71%) were male; 133 (66%) patients were intubated for 7 [3–17] days.

Forty-two (21%) patients received extracorporeal support, mainly for respiratory failure (34 VV-ECMO, 6 ECCO2R, 2 VA-ECMO) for 6.5 [4–10] days. Six were not intubated during ECMO, one was intubated for <2 days.

BSI occurred in 18 (9%) patients (12 (7%) non-ECMO vs. 6 (14%) ECMO patients, p=0.098). VAP occurred in 16 (12%) intubated patients (13 (13%) non-ECMO vs. 3 (9%) ECMO patients, p=0.464). Two (11%) BSIs and 9 (56%) VAPs were polymicrobial. 17/48 (35%) isolates were multidrug-resistant (10/28 (36%) of Gram-negative vs. 7/20 (35%) of Gram-positive bacteria). Table 1 shows details of the microbiological isolates.

BSI and VAP IRs were 8.6 (5.4–13.6) and 16.2 (9.9–26.5) infections/1000 days-at-risk, respectively. Figures 1 and 2 show the cumulative incidence of BSI and VAP.

The risk factors analysis detected no difference in BSI hazard (IR (95%CI) 8.1 (4.8–13.7) vs. 10.7 (4.0–28.5) infections/1000 days-at-risk, sHR (95%CI) 1.02 (0.94–1.10), p=0.654) and VAP hazard (IR 18.5 (10.7–31.8) vs. 10.6 (3.4–32.8) infections/1000 days-at-risk, sHR 0.62 (0.18–2.08), p=0.435) between non-ECMO and ECMO patients, respectively.

Conclusions

In our population, ECMO did not seem to increase the risk of bacterial BSI and VAP.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Grasselli G, Scaravilli V, Di Bella S, Biffi S, Bombino M, Patroniti N, et al. Nosocomial infections during extracorporeal membrane oxygenation: Incidence, etiology, and impact on patients’outcome. Crit Care Med.2017;45(10).

2. Abrams D, Grasselli G, Schmidt M, Mueller T, Brodie D. ECLS-associated infections in adults: what we know and what we don’t yet know. Intensive Care Med.2020;46(2).

3. Peña-López Y, Machado MC, Rello J. Infection in ECMO patients: Changes in epidemiology, diagnosis and prevention. Anaesth Crit Care Pain Med.2024;43(1).

Fig. 1 (abstract A90).

CI of VAP/BSI

Table 1 (abstract A90).

Microbiological isolates

	BSI			VAP
	Overall (n = 20)	ECMO (n = 6)	No ECMO (n = 14)	Overall (n = 28)	ECMO (n = 6)	No ECMO (n = 22)
Gram +	13 (65%)	3 (50%)	10 (71%)	7 (25%)	2 (33%)	5 (23%)
S. aureus	3 (15%)	-	3 (21%)	6 (21%)	1 (16%)	5 (23%)
CoNs	4 (20%)	1 (17%)	3 (21%)	-	-	-
Enterococcus spp	4 (20%)	1 (17%)	3 (21%)	-	-	-
Others	2 (10%)	2 (33%)	1 (7%)	1 (4%)	1 (16%)	-
Gram -	7 (35%)	3 (50%)	4 (29%)	21 (75%)	4 (66%)	17 (77%)
P. Aeruginosa	1 (5%)	1 (17%)	-	5 (18%)	1 (16%)	4 (18%)
E.Coli	3 (15%)	1 (17%)	2 (14%)	5 (18%)	-	5 (23%)
K. pneumoniae	1 (5%)	-	1 (7%)	2 (7%)	1 (16%)	1 (5%)
Enterobacterales (other)	2 (10%)	1 (17%)	1 (7%)	9 (32%)	2 (32%)	7 (32%)

A91 Cerebrospinal fluid (CSF) lactate measurement as a diagnostic and prognostic tool in suspected cns infections in emergency department

E. Petrillo¹, M.A. Zingaropoli², G. Imbimbo³, R. Renna¹, P. Pasculli², A. Falcou⁴, M.R. Ciardi², G. Galardo¹

¹Dipartimento Emergenza Accettazione, Area Critica e Trauma Policlinico Umberto 1, Roma, Italy; ²Dipartimento di Malattie Infettive, Sapienza Università di Roma, Roma, Italy; ³Dipartimento di Medicina Traslazionale e di Precisione, Sapienza Università di Roma, Roma, Italy; ⁴Dipartimento Emergenza Accettazione, Area Critica e Trauma- UTN, Policlinico Umberto 1, Roma, Italy

Correspondence: E. Petrillo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A91

Background

Infectious meningitis and encephalitis are major causes of morbidity and mortality worldwide, posing a severe threat to life if not promptly diagnosed and treated. Early diagnosis and appropriate management, facilitated by accurate etiological identification, significantly improve patient outcomes. However, achieving a precise diagnosis can be challenging due to the non-specific initial clinical presentations of many Central Nervous System (CNS) infections. Moreover, distinguishing between meningitis and encephalitis can be difficult, as their clinical presentations often overlap. Lactate levels in cerebrospinal fluid (CSF) are increase, due to the oxidative stress of neuroinflammation and CSF levels are independent from blood lactate levels. In previous studies, blood gas analyser was used as a rapid assay to assess CSF lactate levels at the patient’s bedside.

By this study we aimed at investigating the association between CSF lactate levels with i) the presence of meningitis and encephalitis and ii) its association with clinical outcomes.

Materials and Methods

This is a observational single center study conducted at the Emergency Department (ED) of Sapienza University of Rome, Policlinico Umberto I University Hospital in collaboration with the Department of Public Health and Infectious Diseases, Sapienza University of Rome. We enrolled patients with suspected meningitis or encephalitis, requiring lumbar puncture for diagnosis. The CSF lactate levels were measured immediately on a point-of-care analyser (Abbott i-STAT analyser, Abbott Park, IL, USA) available in the ED. The study was approved by the Local Ethical Committee and performed in accordance the Declaration of Helsinki. All the patients signed the informed consent. Receiver operating characteristic (ROC) analysis and multivariate logistic regression were employed to evaluate the diagnostic performance of CSF lactate levels and identify factors associated with ICU admission, respectively.

Results

We enrolled 100 patients (50% male) with a mean age of 57.2 ± 21.8 years. Among them, 18 were diagnosed with meningitis, 21 with encephalitis, and 61 with non-CNS infectious diseases. CSF lactate levels were available for 80 participants. Patients with meningitis showed significantly higher mean CSF lactate levels (9.8 ± 6.4 mg/dL) compared to those with non-CNS infections (2.0 ± 0.7 mg/dL, p < 0.001), and a non-significant trend toward higher levels compared to patients with encephalitis (2.4 ± 0.9 mg/dL, p = 0.054). ROC analysis demonstrated good diagnostic performance of CSF lactate in identifying meningitis, with an AUC of 0.820 (p < 0.001). No significant differences were observed between the AUCs of CSF lactate, glucose (0.760), and protein (0.851). In a multivariate logistic regression analysis including age, sex, CRP, CSF glucose, CSF protein, and diagnosis (meningitis or encephalitis), only CSF lactate levels were significantly associated with increased risk of ICU admission (OR = 1.567, 95% CI: 1.045–2.350, p = 0.030).

Conclusion

CSF lactate levels measured at the bedside in the Emergency Department demonstrated strong diagnostic performance for identifying meningitis and were independently associated with ICU admission. These findings support the potential utility of CSF lactate as a rapid, reliable biomarker to guide early clinical decision-making in suspected CNS infections.

Consent

Informed consent was obtained for the publication of this scientific article.

A92 The control of bacterial infections of the oral cavity in intensive care patients

C.M. Petrangeli¹, A.K. Vergou², M. Ciotti³, F.M. Petrangeli⁴, F. Semenzato⁵, C. Sicignano³, F. Claro¹, M. Martucci¹, V. De Angelis¹, F. Frisardi¹, S. Verrengia¹, I. Brandolini¹, D.J. Brunetti¹, D. Cipollone¹, M. Silvi¹, T. Galli¹, C. Manni¹, S. Di Florio¹, F. Leonardis¹

¹UOSD Terapia Intensiva Policlinico Tor Vergata, Roma, Italy; ²UOSD Microbiologia e Virologia Policlinico Tor Vergata, Roma, Italy; ³UOSD Odontoiatria Policlinico Tor Vergata, Roma, Italy; ⁴Dipartimento di Matematica Università Sapienza, Roma, Italy; ⁵Facoltà di Medicina e Chirurgia Università Tor Vergata, Roma, Italy

Correspondence: C.M. Petrangeli

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A92

Background

Daily hygiene of the oral cavity of patients admitted to intensive care, reducing the presence of bacteria in the oral cavity, is a practice that increases the chances of improving the clinical status of patients with bacterial pneumonia.

Materials and Methods

We carried out our study to search for the presence of pathogenic microorganisms of the oral cavity in patients admitted to intensive care and verify a percentage difference in their presence in discharged patients compared to that in deceased patients. We enrolled 40 patients admitted to the ICU suffering from bacterial pneumonia, all on mechanical ventilation via orotracheal tube or tracheostomy cannula. Of the 40 patients (22 males and 18 females), 25 were discharged (13 males and 12 females) while 15 died (9 males and 6 females). The micro-IDent plus 11 kit we used allowed us to search for the following microorganisms: Aggregatibacter actinomicetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia, Troponema denticola, Parvimonas micra, Fusobacter nucleatum, Campylobacter rectus, Eubacterium nodatum, Eikenella nodatum, Capnocytophaga spp. Each patient underwent oral hygiene two hours before the sampling carried out by the dentist specialist in the periodontal sac of four different teeth, two of the upper arch and two of the lower arch. Oral hygiene was performed according to ward protocol with a cleaning brush and aspirator using 0.12% chlorhexidine associated with dental gel for 5 minutes. The samples taken were analyzed to our microbiology laboratory using the technique of bacterial DNA extraction and amplification according to the GenoLyse protocol (Bruker, Germany).

Results

The results obtained showed that in patients who arrived at discharge, the overall percentage of the 11 bacterial species sought was 45% while in deceased patients the percentage rose to 64%. The data collected therefore confirm that the presence of these bacterial species in the oral cavity in ventilated patients with bacterial pneumonia is significantly higher in deceased patients than in discharged patients.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Rabello F, A. V. Effectiveness of oral chlorhexidine for the prevention of nosocomial pneumonia and ventilator-associated pneumonia in intensive care units: Overview of systematic reviews. Int. J. Dent Hyg. 2018 Nov; 16(4): 441-449.

2. Vidal CF, Vidal AK, Monteiro JG Jr Cavalcanti A, and others. Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: a randomized study. BMC Infect Dis. 2017 Jan; 17(1): 112.

A93 Healthcare-associated infections in ecmo patients: a retrospective single-center study on incidence and outcomes

M. Orlandi, A. De Felice, A. Cardoni, G. Cianchi, M. Bonizzoli

AOU Careggi, Firenze, Italy

Correspondence: M. Orlandi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A93

In recent years, the use of Extracorporeal Membrane Oxygenation (ECMO) therapy has seen significant growth, especially following the COVID-19 pandemic, which highlighted its usefulness in managing the most severe cases of respiratory failure. However, patients undergoing ECMO are extremely vulnerable to healthcare-associated infections (HAIs), complications that negatively impact clinical outcomes and significantly increase mortality. This abstract, based on the retrospective single-center observational study'ECMOin'conducted at the Careggi University Hospital in Florence, analyzed data from 67 patients treated with veno-venous ECMO between 2021 and 2024. The study aimed to describe the clinical, microbiological, and epidemiological characteristics of ECMO-related infections, identify associated risk factors, and assess their prognostic impact. Informed consent was obtained from the patient and/or family members.

The analysis revealed an overall HAI incidence of 35.9 episodes per 1,000 ECMO days. The most frequent infections were ventilator-associated pneumonia (HAP/VAP), followed by primary bloodstream infections and central line-associated bloodstream infections (CR-BSI). A clear correlation emerged between prolonged ECMO support (>21 days) and increased infection risk, confirming the need for early weaning strategies. Moreover, there was a high prevalence of multidrug-resistant (MDR) pathogens, particularly Klebsiella pneumoniae KPC and vancomycin-resistant Enterococcus (VRE), with increased colonization observed during intensive care stays.

Overall mortality was 44.8%, with 66.7% of deaths partially attributed to nosocomial infections. Mortality was especially high among patients with respiratory infections and bloodstream infections. Further analysis showed significantly higher mortality among patients over 50 years of age. A comparison between COVID-19 and non-COVID-19 patients revealed a higher incidence of infections and greater absolute mortality in the SARS-CoV-2 group, likely due to complications from viral pneumonia (Table 1).

In terms of management, empirical antibiotic therapy was initiated in most cases, followed by targeted therapy based on microbiological results. In the most complex MDR infection cases (28.9%), infectious disease consultations were requested, fostering a multidisciplinary approach. The implementation of antimicrobial stewardship programs and the use of biomarkers such as procalcitonin proved potentially useful tools to optimize diagnosis and therapy.

The study confirmed the impact of HAIs on the outcomes of ECMO patients and emphasized the importance of preventive strategies, such as the adoption of strict management protocols and early identification of infections. Among the limitations were the retrospective design and the small sample size. Future prospective multicenter studies will be essential to further validate the findings and improve the management of these critically ill patients.

Consent

Informed consent was obtained for the publication of this scientific article.

Table 1 (abstract A93).

ECMO outcomes

Death n (%) (N = 67)
Yes	30 (44,8)
No	37 (55,2)
Outcome of infectious episodes, n (%) (N = 76)
Resolution	56 (73,7)
Death	20 (26,3)
Mortality by age, n (%) (N = 67)
< 50 years (N = 22)	4 (18,2)	p value = 0,002
≥ 50 yearsN = 45)	26 (57,8)
Infection-related deaths n (%) (N = 67)
Yes (N = 47)	28 (59,6)	p value < 0,001
No (N = 20)	2 (10,0)
Mortality stratified by ECMO therapy duration, n (%) (N = 67)
> 21 days (N = 35)	20 (57,1)	p value < 0,001
≤ 21 days(N = 32)	10 (31,3)

A94 Providencia stuartii infection in a critically ill patient: a case report

I. Maruzzella, P.F. Marsilia, F. Cirillo, G. Liguori, F. Imparato, M. Grazia, F. Di Biase, F. Imperatore

UOC Rianimazione DEA - AORN Cardarelli, Napoli, Italy

Correspondence: I. Maruzzella

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A94

Background

Providencia stuartii is a Gram-negative bacillus of the Enterobacterales order, often associated with healthcare-related infections, particularly in immunocompromised or critically ill patients [1]. It shows intrinsic resistance to several <beta>-lactam antibiotics and frequently acquires extended-spectrum <beta>-lactamases (ESBL) or carbapenemases, significantly narrowing therapeutic options. Strains resistant to all commonly used antibiotics, including carbapenems, have been reported, posing a serious clinical challenge [1]. In this context, the combination of aztreonam and ceftazidime/avibactam has shown promising

Results against MDR Gram-negative bacteria [2,3].

Case Report

A 32-year-old woman was admitted to the ICU with suspected autoimmune encephalitis, later confirmed by the presence of anti-NMDAR antibodies and linked to an ovarian dermoid cyst, which required surgical removal due to its unresponsivenesss to immunotherapy. During her ICU stay, the patient developed several infectious complications, including ventilator-associated pneumonia (VAP) from MDR Pseudomonas aeruginosa and C. Parapsilosis candidemia. The clinical course was further complicated by pulmonary embolism and right-sided infarction, followed by the development of empyema in the middle and lower right lobes, requiring bilobectomy. Due to a post-surgical bronchopleural fistula and recurrent empyema, she underwent open window thoracostomy with resection of the sixth and seventh ribs and later required a complete pneumonectomy.

Given the onset of septic shock, rapid and coordinated intervention was critical. Targeted antibiotic therapy and source control were implemented to stabilize her condition.

Serial microbiological cultures of the pleural cavity revealed persistent P. stuartii resistant to all tested antibiotics, including carbapenems, aminoglycosides, and fluoroquinolones. A 14-day course of cefiderocol had previously failed to achieve microbiological eradication and was discontinued in accordance with national regulatory guidelines (AIFA).

With no remaining active options, combination therapy with aztreonam and ceftazidime/avibactam was initiated [2,3]. Clinical status progressively improved, with resolution of septic shock, reduction in inflammatory markers, and progressive healing of the surgical site. Serial cultures confirmed complete sterilization of the pleural cavity within 20 days of starting combination therapy. No relapse or recurrence was observed. (Fig. 1)

Conclusions

This case highlights the life-saving potential of the aztreonam-ceftazidime/avibactam combination therapy for the treatment of pan-resistant P. stuartii infections. In an era of growing antimicrobial resistance, this combination may represent a key option against MDR Gram-negative pathogens [2,3]. Early identification and antimicrobial susceptibility testing remain essential for guiding therapy. Furthermore, the timely initiation of appropriate antibiotic therapy, alongside adequate surgical source control, played a pivotal role in stabilizing the patient's condition, optimizing the timing and conditions for surgical intervention, and ultimately overcoming septic shock.

Consent for Publication

Written informed consent was obtained from the patient for publication of this case report.

References

1. Emeraud C et al. Providencia stuartii infection in critically ill patients: case series and literature review. Infect Dis Now. 2021;51(1):37–42. 10.1016/j.idnow.2020.08.006

2. Rossolini GM et al. In vitro activity of aztreonam-avibactam vs MBL-producing Enterobacterales: ATLAS 2016–2020. J Glob Antimicrob Resist. 2024;36:123–31. 10.1016/j.jgar.2023.12.027

3. Castanheira M et al. Aztreonam-avibactam vs resistant Enterobacterales from Europe, Latin America, Asia- Pacific (2020–2022). Int J Antimicrob Agents. 2024;63(1):106803. 10.1016/j.ijantimicag.2023.106803

Fig. 1 (abstract A94).

Antimicrobial susceptibility profile of the isolated pan-resistant Providencia stuartii

A95 Extracorporeal blood purification therapies in pediatric septic shock: a case report on sequential therapies with ha60 and toraymyxin 05r in combination with CRRT and ECMO

M.M. Paoletti¹, M. Luciani², M. Marano³, F. Stoppa³, M. Di Nardo³, S. Perdichizzi³, G. Bottari³, C. Cecchetti³

¹Università di Pisa, Italy; ²Università di Bologna, Italy; ³Ospedale pediatrico Bambino Gesù, Roma, Italy

Correspondence: M.M. Paoletti

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A95

Septic shock and multiple organ failure remain a leading cause of pediatric mortality worldwide. Pediatric patients affected by severe septic shock, in particular those who received extracorporeal therapies such as extracorporeal membrane oxygenation (ECMO) and renal replacement therapy (RRT), still present a high mortality rate.

Extracorporeal Blood Purification (EBP) strategies may be considered in sequence or as separate entities according to the pathophysiological status. Haemoadsorption systems can be added for the treatment of patients with early-stage sepsis and can be coupled with organ support provided by haemofiltration, ECMO, CRRT or other techniques. At present the availability of blood purification devices customized for newborn and small children is limited.

Among devices adapted for pediatric use, the HA60 Jafron cartridge incorporates a highly adsorptive resin composed of double cross-linked styrene-divinylbenzene copolymers, with a priming volume of 65±20 ml. Its relatively low volume renders it advantageous for integration into pediatric extracorporeal circuits.

Another device utilized in children is Toraymyxin cartridge, which employs polystyrene fibers covalently immobilized with polymyxin B. It is specifically designed for the selective removal of circulating endotoxins in the context of gram-negative sepsis and septic shock.

We describe for the first time to the best of our knowledge a clinical experience in using HA60 and Toraymyxin 05R in combination with CRRT and ECMO in a Gram negative fulminant septic shock.

Materials and Methods

The patient was a 3-month-old male infant with a diagnosis of posterior urethral valves and anorectal malformation. He had two previous hospitalizations for urosepsis episodes after birth. Following endoscopic laser ablation of the urethral valves, he was transferred to our center overnight in septic shock due to Gram-negative infection, presenting with refractory hypotension, hyperlactatemia, and anuria. The patient was treated with a combination of ceftazidime-avibactam and cefiderocol, along with intravenous immunoglobulin therapy and hydrocortisone. Despite aggressive management—including high-dose vasopressor support, continuous renal replacement therapy (CRRT), and extracorporeal membrane oxygenation (ECMO)—the patient exhibited a clinical deterioration marked by an increase in serum lactate, worsening metabolic acidosis, persistence of elevated inflammatory markers, and progressive increase of hepatic enzyme levels. Sequential Hemoadsorption therapy was performed using HA60 cartridges and two cycles of Toraymyxin (Fig 1).

Baseline concentrations of Presepsin, C-Reactive Protein, and Procalcitonin were 2299 pg/ml, 17.46 mg/ml, and 116 ng/ml, respectively. Following EBP treatment, these levels changed to 2944 pg/ml, 12.82 mg/ml, and 12.4 ng/ml, respectively.

Over the course of three days, the patient’s condition continued to decline, and despite maximal supportive care, the patient died.

Discussion and Conclusions:

Even though the outcome was fatal, this case report aims to demonstrate the feasibility of using multiple hemoadsorbent cartridges in combination with CRRT and ECMO. While the patient ultimately succumbed to multiorgan failure, the therapeutic approach—featuring sequential hemoperfusion with HA60 cartridges and Toraymyxin highlights the potential role of advanced extracorporeal therapies in the management of severe septic shock.

Importantly, this case also emphasizes the critical role of timing, particularly in the initiation of hemoadsorption therapy. Early intervention may be a key factor in maximizing the potential benefits.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A95).

Timeline

A96 Antimicrobial resistance and the challenges of antibiotic prescription: an antimicrobial stewardship-based approach

A. Usai¹, F. Utzeri², F. Vacca², S. Paba¹, E. Lai¹, A. Orrù¹, A. Busia¹, F.M. Loddo¹

¹Dipartimento Attività Cliniche - Ospedale NS della Mercede - SC Anestesia e Rianimazione - ASL Ogliastra, Lanusei, Italy; ²Dipartimento Area Servizi - Ospedale NS della Mercede - SSD Farmacia Ospedaliera - ASL Ogliastra, Lanusei, Italy

Correspondence: A. Usai

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A96

Background

In the European Union, healthcare-associated infections (HAIs) account for approximately 71% of infections caused by antibiotic-resistant bacteria, including carbapenem-resistant Enterobacterales. The implementation of robust infection prevention and control (IPC) measures is essential, particularly in intensive care units (ICUs), where patients are at increased risk of acquiring multidrug-resistant infections [1]. Antimicrobial stewardship (AMS) encompasses coordinated strategies aimed at optimizing antimicrobial use to mitigate the development and spread of antimicrobial resistance (AMR) [2]. Effective AMS programs are founded on continuous surveillance of antimicrobial consumption and resistance patterns, supported by interdisciplinary collaboration among clinicians, microbiologists, pharmacists, and infection control specialists [3].

Materials and Methods

A retrospective analysis was conducted on AMR patterns and antimicrobial consumption in an ICU from January 2018 to December 2023. Data was retrieved from dedicated surveillance software. The analysis focused on infections including lower respiratory tract infections (LRTIs), catheter-related bloodstream infections (CR-BSIs), and catheter-associated urinary tract infections (CA-UTIs). Antimicrobial usage over the same period was also assessed.

Results

During the study period, susceptibility trends in LRTIs demonstrated a notable decline in response to cefepime, piperacillin-tazobactam, fluoroquinolones, and meropenem. Conversely, the susceptibility to linezolid and vancomycin remained stable at 75% and 80%, respectively. CR-BSI data revealed a significant reduction in vancomycin susceptibility (33%). In CA-UTIs, susceptibility rates were consistently low for piperacillin-tazobactam, meropenem, linezolid, and vancomycin, whereas ciprofloxacin susceptibility significantly improved, reaching 60%. Antimicrobial consumption analysis indicated a reduction in ceftriaxone and ciprofloxacin use, paralleled by an increase in the administration of levofloxacin, meropenem, vancomycin, and linezolid.

Conclusions

Antimicrobial consumption in the ICU increased over the 2018–2023 period, likely reflecting the frequent use of empiric therapy in critically ill patients due to delays in microbiological diagnostics. This study highlights the ongoing challenge of AMR in ICU settings and the vital role of AMS programs in promoting appropriate antibiotic prescribing practices. Furthermore, the findings underscore how increasing use of penicillins, cephalosporins, and carbapenems—driven by clinical necessity—has contributed to diminished susceptibility to these antibiotic classes. A comprehensive AMS program is essential to enhance prescribing appropriateness, relying on key tools such as local antibiograms, surveillance of antibiotic usage, and the implementation of rapid diagnostic tests that facilitate early pathogen identification and susceptibility profiling. These tools aim to align empiric therapy as closely as possible with targeted treatment. Despite the current limitations, particularly the lack of rapid diagnostic technologies capable of promptly identifying resistant pathogens, antimicrobial therapy in our setting is increasingly informed by stewardship principles.

References

1. European Centre for Disease Prevention and Control (ECDC). Healthcare-associated infections.

2. Dyar OJ, Huttner B, Schouten J, Pulcini C. What is antimicrobial stewardship? Clin Microbiol Infect. 2017;23(11):793–798.

3. European Centre for Disease Prevention and Control (ECDC). Antimicrobial Stewardship: E-learning course.

4. Machowska A, Stålsby Lundborg C. Drivers of irrational use of antibiotics in Europe. Int J Environ Res Public Health. 2019;16(1):27.

A97 Fusobacterium necrophorum complicated infection without evidence of lemierre’s syndrome in a previously healthy adult male

S. Pilloni, M. Deplano, A. Demurtas, F.M. Loddo

Dipartimento Attività Cliniche - Ospedale NS della Mercede - SC Anestesia e Rianimazione - ASL Ogliastra, Lanusei, Italy

Correspondence: S. Pilloni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A97

Background

Fusobacterium Necrophorum is an anaerobic Gram-negative bacillus classically associated with Lemierre’s syndrome—a rare, life-threatening condition characterized by septic thrombophlebitis of the internal jugular vein, typically following oropharyngeal infections in healthy young adults [1]. Its occurrence in older adults without Lemierre’s syndrome is rare [2]. We report a case of F. Necrophorum bacteremia in a 65-year-old man with no significant comorbidities, complicated by hepatic and spinal epidural abscesses, in the absence of Lemierre’s syndrome signs.

Case report

The patient presented a 5-day history of fever, back pain, and progressive lower limb weakness. He was febrile (38°C), hypotensive (90/50 mmHg), and tachycardic (HR 110 bpm). He complained of severe lumbar pain radiating to the legs, without sensory loss or sphincter dysfunction. Bloodwork showed leukocytosis (8,200/mcL, 90% neutrophils), elevated CRP (214.11 mg/L), PCT (29.88 ng/mL), and thrombocytopenia (47,000/mcL).

Initial management included intravenous fluids, blood cultures, and full-body CT, which revealed multiple hepatic abscesses, bilateral pleural effusion, and intravertebral air at L4. MRI identified a 9 × 22 × 7 mm posterior epidural abscess at L4, dural enhancement up to L1, and edema of paravertebral and iliopsoas muscles, consistent with spondylodiscitis and liver abscesses. Empiric antibiotics (piperacillin-tazobactam, levofloxacin) were started. Cardiology and neurosurgical evaluations found no need for surgery; echocardiography excluded endocarditis.

The patient’s condition deteriorated, requiring norepinephrine (0.15 mcg/kg/min), mechanical ventilation, and ICU transfer. Chest CT showed bilateral lung consolidations and worsening effusions. Despite treatment, fever and inflammation persisted and the MRI took one week after admission showed enlargement of the epidural abscess (Figure). Antibiotic therapy was then escalated to meropenem and vancomycin. Transesophageal echocardiogram was performed and identified a 1 cm filamentous structure on the aortic valve, without regurgitation or stenosis.

As soon as initial blood cultures showed signs of growth, molecular testing was promptly performed and identified Fusobacterium Necrophorum, which was later confirmed by conventional microbiology. The isolate demonstrated broad antibiotic susceptibility. Metronidazole was added, and CT angiography of the head and neck ruled out Lemierre’s syndrome or oral/dental infection.

After one day of mechanical ventilation, the patient was extubated and continued on non-invasive ventilation for two days. He remained on meropenem, vancomycin, and metronidazole for six weeks. Following clinical stabilization, he was discharged on intravenous meropenem for an additional two months. Imaging showed reduction of hepatic and spinal abscesses, and oral flucloxacillin 1 g was prescribed for a final six-week course.

Conclusion

Although typically responsive to antibiotics, F. Necrophorum can cause severe, disseminated infections even in patients without classic risk factors or Lemierre’s syndrome. This case emphasizes the importance of early identification, comprehensive imaging, and prolonged targeted antimicrobial therapy for successful outcomes.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Karkos PD, Asrani S, Karkos CD, Leong SC, Theochari EG, Alexopoulou TD, et al. Lemierre’s syndrome: A systematic review. The Laryngoscope. agosto 2009;119(8):1552–9.

2. Guerrero IC, Slap GB, MacGregor RR, Lawner P, Ruggeri S, Gennarelli T. Anaerobic spinal epidural abscess: Case report. Journal of Neurosurgery. marzo 1978;48(3):465–9.

Fig. 1 (abstract A97).

Epidural abscess

A98 Severe infections and sepsis network for identification of clinical and diagnostic markers, immunological monitoring, and therapies for patients admitted to intensive care units: a case series

G. Lo Scrudato¹, M. Ippolito¹, G. Catalisano², T. Fasciana³, G.M. Giammanco³, M. Damiano¹, M. Campione¹, M. Velardo¹, C. Palmeri di Villalba¹, S.M. Raineri¹, A. Cortegiani¹, A. Giarratano¹

¹Department of Precision Medicine in Medical, Surgical and Critical Care Area (Me.Pre.C.C.), Palermo, Italy; ²University Hospital Policlinico Paolo Giaccone, Anaesthesia and Intensive Care, Palermo, Italy; ³University Hospital Policlinico Paolo Giaccone, Microbiology and Virology Unit, Palermo, Italy

Correspondence: G. Lo Scrudato

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A98

Background

Etiology of community-acquired pneumonia (CAP) is heterogenous, encompassing multidrug resistant bacteria, emerging and re-emerging virus and fungi and associated with different host response and outcomes [1]. Multicenter studies are essential to provide epidemiological surveillance data, define the characteristics of these infections, identify predictors of clinical outcomes, and guide therapeutic choices for both adults and pediatrics hospitalized in intensive care units (ICUs) and infectious disease wards. The SIS-NET ICU study [2] focuses on CAP in adults admitted to ICUs in Italy. Here we present a case series from our center.

Materials and Methods

The SIS-NET ICU is an observational, non-interventional, prospective, multicenter, national, non-profit, and ongoing study. The preliminary data presented here were collected at University Hospital of Palermo from January 27 to April 18, 2025. Prior patients’ consent, adults admitted to the ICU with a documented CAP, developed within 48 hours of hospital admission, were included. The primary outcomes are the proportion of patients with CAP admitted to the ICU and their mortality. Among the study secondary outcomes, we evaluated the duration of ICU stay and overall hospitalization and the ventilator-free days at 28 days. Continuous variables were expressed as means +/- Standard Deviation (SD) when normally distributed, as median and interquartile range [IQR] when non-normally distributed. Categorical data were reported as frequencies and proportions.

Results

Preliminary data regarding the first 7 patients included in the study were collected. Patients’ characteristics are summarized in (Table 1). All subjects presented bilateral pulmonary infiltrates on radiological imaging. To describe clinical severity and mortality risk the Charlson Comorbidity Index, the Sequential Organ Failure Assessment (SOFA) and the Acute Physiology and Chronic Health Evaluation II (APACHE II) were used (Table 1). Clinical presentation was heterogeneous. All patients were on invasive mechanical ventilation at ICU admission. Samples for rapid microbiology testing were collected and Results in (Figure 1) suggest the presence of polymicrobial infections mostly by Gram-negative bacteria and viruses. The Results of the standard culture analyses show the presence of Gram-negative bacteria (Figure 2). ICU mortality was 14%. Results regarding some of the study secondary outcomes are shown in (Table 1).

Conclusions

Preliminary data of this case series suggest that patients admitted to ICU due to CAP often have pre-existing comorbidities and severe clinical conditions with moderate to severe respiratory dysfunction. Polymicrobial infections by Gram negative bacteria and viruses are commonly isolated. ICU mortality occurred in 1 out of 7 cases, with hospital discharge in all other cases. Data regarding wider cohorts are needed to draw more definitive Conclusions.

Funding

This work was supported by “European Union funding within the Next Generation EU-MUR M4C2.I.1.3 PNRR Extended Partnership initiative on Emerging Infectious Diseases (PE00000007, INF-ACT) through the INF-ACT Cascade Open Call 2023 (COC-1-2023-ISS-01) – CUP I83C22001810007”. SIS-NET, ID S4-01.P0001

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med. 2014 Oct 23;371(17):1619-28. 10.1056/NEJMra1312885. PMID: 25337751.

2. [https://www.inf-act.it/index.php?l=IT#top%20https://www.siaarti.it/page/sis-net]

Fig. 1 (abstract A98).

See text for description

Fig. 2 (abstract A98).

Isolated microorganisms with standard microbiological investigations

Table 1 (abstract A98).

Patients characteristics and study outcomes

Overall		N	7
Sex	Female	N (%)	3 (43)
Age	year	Mean (SD)	52 (18)
BMI	kg/m^2	Mean (SD)	23 (12,5)
Pulmonary infiltrates		N (%)	7 (100)
Infiltrates distribution	Bilateral	N (%)	7 (100)
Symptoms at Onset	Fever	N (%)	5 (71)
	Cough	N (%)	5 (71)
	Dyspnea	N (%)	4 (57)
Mechanical Ventilation	Oxygen therapy	N (%)	0 (0)
	NIV (Non-Invasive Ventilation)	N (%)	0 (0)
	Invasive Ventilation	N (%)	7 (100)
PaO2/FiO2	Oxygen therapy	Mean (SD)	0 (0)
	NIV (Non-Invasive Ventilation)	Mean (SD)	0 (0)
	Invasive Ventilation	Mean (SD)	188 (114)
CCI score		Median [IQR]	4 [3–5]
SOFA score		Median [IQR]	7 [7, 8]
APACHE II score		Median [IQR]	29 [25–32]
Primary Outcome
ICU mortality		N (%)	1 (14)
Secondary Outcome
Length of stay in ICU	Days	Median [IQR]	19 [10–30]
Length of hospitalization	Days	Median [IQR]	23 [10–34]
Ventilation	Free days at 28 from baseline	Median [IQR]	4 [3–5]

A99 Effects of continuous veno-venous hemodiafiltration on biomarkers and outcomes in acute liver injury induced by abdominal sepsis using cytosorb®: a case report

G.R. Risalvato¹, G. Scimonello¹, M. Lo Magno², I. Fidone¹, R. Trombadore¹

¹U.O.C. Anestesia e Rianimazione Ospedale Maggiore Modica, Italy; ²U.O.C. Anestesia e Rianimazione Ospedale Guzzardi Vittoria, Italy

Correspondence: G.R. Risalvato

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A99

Background

Acute hepatocolangitis is an infection of the biliary tract that can rapidly progress to abdominal sepsis and subsequent acute liver injury if not promptly treated (figure 1). The standard management involves broad-spectrum antibiotics, supportive medical therapy, and surgical intervention when needed. However, in cases of septic shock, conventional treatment may not be sufficient. CytoSorb® hemoadsorption therapy has been developed to remove excessive cytokines and other inflammatory mediators from the bloodstream, aiming to modulate the hyperinflammatory state and stabilize hemodynamics1;2

Methods

We report the case of a 56-year-old Caucasian woman, admitted for surgical revision due to anastomotic stenosis. Postoperatively, she developed acute hepatocolangitis. Upon ICU admission, she presented a qSOFA score of 2 and lactates at 9.3 mmol/L. Despite broad-spectrum antibiotics and vasopressor support, her condition deteriorated with a progressive rise in lactate levels (14.5 mmol/L). Continuous Veno-Venous hemodiafiltration (CVVHD) was initiated, resulting in a modest lactate reduction (12 mmol/L). Due to persistent Hyperbilirubinemia and abnormal liver function parameters, CytoSorb® was integrated into the extracorporeal circuit. At the time of CytoSorb® initiation, lactate was measured at 9.8 mmol/L.

Results

Following the combination of CytoSorb®, a rapid decrease in lactate levels was observed: 1.9 mmol/L within three hours (figure 2). Hemodynamic stabilization enabled the cessation of norepinephrine infusion. Renal function improved with spontaneous diuresis recovery, while hepatic and inflammatory markers normalized. By the third day, CVVHD was discontinued, and the patient was transferred back to the surgical unit in stable condition.

Conclusions

This case highlights the critical role of extracorporeal blood purification in septic patient resuscitation. The early integration of CytoSorb® into standard CVVHD significantly enhanced lactate clearance and inflammatory biomarker reduction, promoting rapid clinical stabilization. Our findings suggest that hemoadsorption may serve as a valuable adjunctive therapy in abdominal sepsis complicated by acute liver dysfunction, with potential benefits in improving clinical outcomes.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Jansen A, Waalders NJB, van Lier DPT, Kox M, Pickkers P. CytoSorb hemoperfusion markedly attenuates circulating cytokine concentrations during systemic inflammation in humans in vivo. Crit Care. 2023 Mar 21;27(1):117. 10.1186/s13054-023-04391-z. PMID: 36945034; PMCID: PMC10029173.

2. Berlot G, Carocci P, Votrico V, Iacoviello B, Taverna N, Gerini U, di Maso V, Tomasini A. Real-World Outcomes of Hemoadsorption with CytoSorb® in Patients with Septic Shock: Insights from a Single-Center Study. J Intensive Care Med. 2025 Apr 1:8850666251331905. 10.1177/08850666251331905. Epub ahead of print. PMID: 40170437.

3. Friesecke S, Stecher SS, Gross S, Felix SB, Nierhaus A. Extracorporeal cytokine elimination as rescue therapy in refractory septic shock: a prospective single-center study. J Artif Organs. 2017 Sep;20(3):252-259. 10.1007/s10047-017-0967-4. Epub 2017 Jun 6. PMID: 285892

Fig. 1 (abstract A99).

diagnostic imaging

Fig. 2 (abstract A99).

lactates trend

A100 The crucial role of filmarray molecular testing in diagnosing legionella pneumophila pneumonia

R. Giurazza, F. Falso, G. Viola, C. Minucci, D. Abbenante, R.C. De Rosa

AORN Ospedali dei Colli - Department of Anesthesia and Intensive Care - D. Cotugno Hospital, Napoli, Italy

Correspondence: R. Giurazza

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A100

A 62-year-old man was admitted to our Emergency Department with fever and dyspnea. His medical history was unremarkable, and he worked as a chef on cruise ships.

Laboratory tests were conducted, including sputum culture and Legionella and pneumococcus urinary antigen tests, all of which resulted negative. A chest CT scan revealed massive consolidation in the right upper lobe with an air bronchogram, surrounded by ground-glass opacity (Halo sign), as well as smaller contralateral consolidations (Figure 1).

Initially, the patient was transferred to a sub-intensive care unit with a diagnosis of community-acquired pneumonia (CAP). He was started on non-invasive ventilation (NIV) and antibiotic therapy with ceftobiprole (500 mg every 8 hours) and azithromycin (500 mg daily).

Due to NIV failure and severe acute respiratory distress syndrome (ARDS), the patient was transferred to the Intensive Care Unit the following day. He was intubated and received lung-protective ventilation with sedation and neuromuscular blockade. Upon admission, Legionella and pneumococcus urinary antigen tests, bronchoalveolar lavage culture, and a BioFire™ FilmArray Pneumonia (FAPN) test were performed. The antibiotic regimen was upgraded with the addition of levofloxacin (750 mg daily) due to high suspicion for Legionella infection (history and CT scan). All tests resulted negative, except for the FAPN test, which detected “Legionella pneumophila”, prompting ceftobiprole discontinuation.

Over the following days, the patient showed significant clinical improvement, with gradual weaning from mechanical ventilation. A follow-up CT scan, performed 10 days after admission, revealed complete resolution of the previous consolidations, with only mild residual ground-glass opacities (Figure 1).

L. pneumophila is an intracellular atypical bacterium, sensitive to macrolides and quinolones. It’s a rare cause of CAP, known as Legionnaires’ disease [1]. The clinical and radiological features of Legionella pneumonia are similar to other forms of pneumonia. The Halo sign (pulmonary consolidation surrounded by ground-glass opacity) can be observed in lung cancer, metastases, and Legionella pneumonia.

According to the Infectious Diseases Society of America, Legionella testing is recommended for all patients with moderate to severe CAP and for any patient with CAP potentially exposed to Legionella [2]. Since the urinary antigen test only detects L. pneumophila serogroup 1, it’s advisable to perform polymerase chain reaction (PCR) testing or culture on lower respiratory tract samples, when urinary antigens return negative Results and suspicion for Legionella remains high [3].

Clinical suspicion is crucial: factors such as occupational exposure or contact with Legionella reservoirs (e.g., water pipes, air conditioning systems, thermal facilities) must be considered for timely diagnosis and appropriate treatment.

In our case, despite negative results from the urinary antigen test and sputum culture, the BioFire™ FAPN test was the only one to detect L. pneumophila, prompting intensification of antibiotic therapy. Patient gave written informed consent for publication of this report.

Consent

Informed consent was obtained for the publication of this scientific article.

References:

1. N Engl J Med. 1977 Dec 1;297(22):1189-97

2. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67

3. J Clin Microbiol. 2015 Nov;53(11):3474-7.

Fig. 1 (abstract A100).

Chest CT scan on day 0 and Chest CT scan on day 10

A101 Impact of inhaled nitric oxide on the incidence of secondary bacterial pneumonia in covid-19 ICU patients

A. Genovese¹, L. Dall'ara², S. Busani², M. Girardis²

¹Scuola di specializzazione in anestesia, rianimazione, terapia intensiva e del dolore, UNIMORE, Modena, Italy²Struttura complessa di anestesia e terapia intensiva 1, Policlinico di Modena, Modena, Italy

Correspondence: A. Genovese

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A101

Background

Critically ill COVID-19 patients are at high risk of developing secondary bacterial and fungal infections [1], due to factors such as immunological dysregulation, high-dose vasopressor support, and renal replacement therapy. The lungs, already compromised by SARS-CoV-2-induced damage, are particularly susceptible, often resulting in severe acute respiratory distress syndrome (ARDS). Inhaled nitric oxide (iNO), commonly employed as a rescue therapy in refractory ARDS, both in COVID-19 and non-COVID-19 settings [2], has shown potential not only for improving oxygenation but also for exerting antimicrobial effects, possibly via modulation of surfactant production [3][4]. This study investigates the potential role of iNO in preventing secondary pulmonary infections in patients with COVID-19-associated ARDS.

Methods:

This retrospective observational study included 141 adult ICU patients with confirmed COVID-19 and ARDS, 50 of them received iNO as part of standard care (Table 1), median value of iNO dose was 36,54 ±3,01 ppm. Patients were stratified according to Berlin criteria based on PaO₂/FiO₂ (P/F) ratio to assess disease severity (table 2). Clinical outcomes were analysed using multivariate regression models, adjusting for covariates including sex, age, BMI > 30, SOFA score, P/F ratio, and presence of comorbidities (Table 3). To mitigate confounding bias, 1:1 propensity score matching was performed, resulting in 42 matched patients per group (iNO vs. No iNO). Primary outcome was the incidence of secondary bacterial pulmonary infections. Secondary outcomes were ventilator-free days at 30 days, 30-day mortality, ICU length of stay (ICULOS), and hospital length of stay (HLOS). Subgroup analyses were also performed based on ARDS severity.

Results:

In the unmatched cohort, multivariate logistic regression showed a significant association between iNO treatment and reduced 30-day mortality (OR = 0.29, p = 0.018), independent of other clinical variables. Age also emerged as a significant predictor of mortality (OR = 0.93, p < 0.001). No significant associations were observed between iNO and secondary pulmonary infections (p = 0.808), ventilator-free days (p = 0.385), ICU stay duration (p = 0.105), or hospital stay duration (p = 0.929). After propensity score matching, the association between iNO and 30-day mortality was no longer significant (OR = 0.91, p = 0.826), and no significant differences were observed across any other clinical endpoints (table 3). Subgroup analyses by ARDS severity (severe: P/F ≤ 100; moderate: 100 < P/F ≤ 200) revealed no statistically significant impact of iNO on outcomes in either group. No matched patients were available in the mild ARDS category (P/F > 200) (Figure 1).

Table 1 (abstract A101).

Characteristics and treatments of COVID – 19 ICU patients

Variable	iNO Group. n; (%)	No iNO Group. n; (%)
Male Patients	42 (84)	67 (73.6)
Female Patients	8 (16)	24 (26.4)
BMI > 30	26 (52)	34 (37.4)
Comorbidity	38 (76)	65 (71.4)
Steroid	48 (96)	85 (93.4)
Immunotherapy	46 (92)	80 (87.9)
Antiviral	17 (34)	40 (44)
Antibiotic Prophylaxis	13 (26)	35 (38.5)
Amine	25 (50)	45 (49.5)
Tracheostomy	18 (36)	30 (33)
Pronation	46 (92)	70 (76.9)

Table 2 (abstract A101).

Stratification according to Berlin definition

ARDS Severity	iNO Group. (n)	No iNO Group. (n)
Severe (P/F ≤ 100)	32	50
Moderate (P/F 101–200)	17	40
Mild (PF 201–300)	1	1

Table 3 (abstract A101).

Summary of the findings in unmatched and matched cohort

O2utcome	Unmatched Cohort	Matched Cohort
30-day Mortality	OR = 0.29, p = 0.018	OR = 0.91, p = 0.826
Age as Predictor of Mortality	OR = 0.93, p < 0.001	—
Secondary Pulmonary Infections	p = 0.808	OR = 0.61, p-value = 0.265
Ventilator-Free Days	p = 0.385	p-value = 0.48
ICU Length of Stay (ICULOS)	p = 0.105	p-value = 0.222
Hospital Length of Stay (HLOS)	p = 0.929	p-value = 0.929
Subgroup Analysis (ARDS severity)	No differential impact of iNO	No differential impact of iNO

A102 Ecco2r and prone positioning for ards in aids: a case of successful multimodal ICU management

D. Gaetano, A. Picazio, A. Piedepalumbo, C. Iavarone, G. Vocca, M. Vargas, F. De Vita, R. Fiorito, L. Attianese, M. Ciaravola, F. Ferraro

Università degli Studi della Campania Luigi Vanvitelli, Napoli, Italy

Correspondence: D. Gaetano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A102

Background

Acquired immune-deficiency syndrome (AIDS) patients developing acute respiratory distress syndrome (ARDS) represent a unique clinical challenge due to their profound immunosuppression, high risk of opportunistic infections, and increased susceptibility to ventilator-associated complications. In this setting, management often requires balancing lung-protective ventilation strategies[1], infection control, and complex decision-making regarding therapeutic escalation. We present the case of a patient with AIDS complicated by Pneumocystis jirovecii pneumonia (PCP) and cytomegalovirus (CMV) pneumonitis, who developed severe ARDS[2], spontaneous bilateral pneumothorax, and multidrug-resistant infections, managed in the intensive care unit (ICU) with prone positioning and extracorporeal CO2 removal (ECCO2R)[3].

Case Report

A 27-year-old man with newly diagnosed AIDS was admitted to the ICU with respiratory failure due to ARDS secondary to PCP and CMV pneumonitis, ongoing treatment with trimethoprim-sulfamethoxazole and ganciclovir, complicated by a right spontaneous pneumothorax requiring thoracic tube placement. Prior serology raised systemic syphilitic infection treated with sigmacillin. Antiretroviral therapy (bictegravir/emtricitabine/tenofovir alafenamide) continued. Non-invasive ventilation (NIV) trial was interrupted early due to worsening symptoms. The patient was intubated with volume-controlled ventilation (VCV) mode: tidal volume (Vt) 410 mL, positive end-expiratory pressure (PEEP) 6 cmH2O. Due to severe hypercapnia (PaCO2 120 mmHg, PaO2/FiO2 65), ECCO2R therapy was initiated and combined with 16 hours of prone positioning cycles. Blood flow started at 200 mL/min, increased to 400 mL/min; automatic sweep gas was used. Vt was reduced to 250 mL; PEEP was optimized to 10 cmH2O (driving pressure 18 cmH2O).

During ECCO2R-proning therapy, PaCO2 decreased to 55.4 mmHg, PaO2/FiO2 improved to 283. Noradrenaline supported hemodynamics for 48 hours. ECCO2R was stopped on day 6 (VCV: Vt 400 mL, PEEP 8 cmH2O). On day 7, percutaneous tracheostomy (PaO2/FiO2 207) was performed. Sedation (propofol, remifentanil) was stopped on day 10; weaning began with pressure support ventilation PSV trials (Inspiratory Pressure 14 cmH2O, PEEP 6 cmH2O), PaO2/FiO2 370. During hospitalization, he developed vancomycin-resistant Enterococcus faecium and Candida parapsilosis bloodstream infections, treated with daptomycin and caspofungin; Klebsiella oxytoca from BAL/tracheal aspirate was treated with ampicillin/sulbactam. No hemodynamic instability or tracheostomy infection occurred. Progressive ventilatory improvement allowed right thoracic tube removal. On day 25, a left pneumothorax developed, requiring a thoracic tube and 48 hours of mechanical ventilation with PSV mode. On day 27, in stable clinic conditions, weaning resumed with spontaneous breathing trials (PaO2/FiO2 458); the left thoracic tube was removed on day 31, and on day 36, tracheostomy decannulation was possible. He was transferred to the infectious disease ward, breathing spontaneously.

Conclusion

This case highlights the feasibility and potential benefit of combining ECCO2R with prone positioning in managing severe ARDS in an AIDS patient with multiple infectious and mechanical complications. A multidisciplinary, stepwise approach—including thoracic surgical input and tailored antimicrobial, antiviral, and antiretroviral therapy—enabled ventilatory weaning and recovery despite profound immunosuppression, superimposed multidrug-resistant infections, and multiple pneumothoraces. Intensive care management of critically ill AIDS patients may warrant individualized escalation strategies, including extracorporeal support, even in the presence of adverse prognostic factors. Informed consent was obtained.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. G. Grasselli et al., «ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies», Intensive Care Med, vol. 49, fasc. 7, pp. 727–759, lug. 2023, 10.1007/s00134-023-07050-7.

2. A. Demoule et al., «Respiratory Mechanics and Outcomes in Immunocompromised Patients With ARDS: A Secondary Analysis of the EFRAIM Study», Chest, vol. 158, fasc. 5, pp. 1947–1957, nov. 2020, 10.1016/j.chest.2020.05.602.

3. A. Morelli, L. Del Sorbo, A. Pesenti, V. M. Ranieri, e E. Fan, «Extracorporeal carbon dioxide removal (ECCO2R) in patients with acute respiratory failure», Intensive Care Med, vol. 43, fasc. 4, pp. 519–530, apr. 2017, 10.1007/s00134-016-4673-0.

A103 Severe respiratory failure in a pediatric patient associated with human bocavirus infection: a case report

L. Floridi¹, M. Bellucci², R. Simonte¹, D.R. Edoardo¹

¹University of Perugia, Department of Medicine and Surgery, Perugia, Italy²Azienda Ospedaliera di Perugia, Anesthesia and Intensive Care, Perugia, Italy

Correspondence: L. Floridi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A103

Background

Human Bocavirus (HBoV), a parvovirus increasingly detected in pediatric respiratory tract infections, [1-2] it is frequently identified as a co-infecting agent, yet its independent pathogenic role in severe respiratory disease remains controversial [3-4]. This report describes a case of severe respiratory failure attributable to HBoV monoinfection in a previously healthy child requiring admission to Intensive Care unit (ICU).

Case Report

A 4-year-old, unvaccinated male with no prior medical history presented to a peripheral hospital with fever, cough, and asthenia. Following clinical deterioration, the patient was transferred to a tertiary care center, where high-flow nasal cannula oxygen therapy (HFNC), corticosteroids, aerosol treatments, and empiric antibiotic were initiated. Due to progressive hypoxemia and acute respiratory failure, he was transferred to the ICU for endotracheal intubation and mechanical ventilation.

Comprehensive microbiological testing was performed during hospitalization. The only pathogen identified was HBoV, via nasopharyngeal swab. Blood cultures, bacterial antigen tests, and multiplex PCR panels for other respiratory viruses were all negative. Chest radiography revealed a right basal parenchymal consolidation. No underlying immunodeficiencies or chronic conditions were identified. Management remained supportive, with no antiviral therapies administered.

Mechanical ventilation was interrupt after 72 hours, followed by stepwise transitions to full-face non-invasive ventilation (NIV), HFNC, and finally low-flow nasal cannula oxygen therapy upon transfer to the Pediatric ward. The patient was discharged in stable conditions without residual oxygen requirements six days post hospital admission.

Conclusion

This case challenges the prevailing perception of HBoV as an incidental co-infection by demonstrating its capacity to independently drive severe respiratory failure in immunocompetent children. HBoV is often regarded as an incidental or clinically insignificant finding. Although in this case, the absence of co-infections, the severity of respiratory symptoms, and the clinical recovery pattern strongly support its pathogenicity.

These findings advocate for the inclusion of HBoV in differential diagnoses of pediatric respiratory failure and highlight the need for further studies to delineate its pathogenic mechanisms, optimize diagnostic frameworks, and guide therapeutic strategies.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Trapani S, Caporizzi A, Ricci S, Indolfi G. Human Bocavirus in Childhood: A True Respiratory Pathogen or a'Passenger'Virus? A Comprehensive Review. Microorganisms. 2023;11(5):1243.

2. Mohanty M, Mishra B, Satapathy AK, et al. Human Bocavirus infection in childhood acute respiratory infection: Is it an innocent bystander?. Indian J Med Microbiol. 2023;46:100436.

3. Zhou L, Zheng S, Xiao Q, et al. Single detection of human bocavirus 1 with a high viral load in severe respiratory tract infections in previously healthy children. BMC Infect Dis. 2014;14:424.

4. Petrarca L, Nenna R, Frassanito A, et al. Human bocavirus in children hospitalized for acute respiratory tract infection in Rome. World J Pediatr. 2020;16(3):293-298.

A104 Hemoadsorption therapy for malaria-induced liver damage: evaluating cytosorb® as an adjunctive treatment– a case report

F. Falso, G. Viola, R. Giurazza, S. Virno, M. Barberio, R.C. De Rosa

AORN Ospedali dei Colli - Department of Anesthesia and Intensive Care - D. Cotugno Hospital, Napoli, Italy

Correspondence: F. Falso

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A104

This clinical case highlights the crucial role of integrating advanced medical technologies with conventional therapeutic approaches in the management of severe malaria. Severe malaria, particularly caused by Plasmodium falciparum, presents a significant clinical challenge due to its potential for multi-organ dysfunction, high parasitemia levels, and associated systemic complications. While standard antimalarial therapy remains the backbone of treatment, complementary interventions aimed at controlling systemic inflammation and metabolic derangements can substantially improve patient outcomes. This report discusses the multidisciplinary management of a critically ill patient with severe malaria, emphasizing the role of extracorporeal hemoperfusion adsorption EHA as an adjunctive therapy. The patient gave written informed consent.

A 53-year-old male presented to our ICU with hyperpyrexia, dyspnea, profound asthenia, mental confusion, anemia, and hyperbilirubinemia following recent travel to Africa. Initial diagnostic evaluation included polymerase chain reaction (PCR) testing, which confirmed the presence of Plasmodium falciparum with a 30% parasitemia level. Laboratory investigations revealed markedly elevated procalcitonin (PCT>100 ng/ml), C-reactive protein (CRP 20 mg/dL), hemoglobin (Hb) 8.0 g/dL, total bilirubin 32 mg/dL (direct bilirubin 20 mg/dL), pancreatic amylase 241 IU/L, lipase 253 IU/L, and serum creatinine 1.6 mg/dL. CT scan demonstrated moderate bilateral pleural effusion and perihepatic fluid accumulation.

Despite these concerning findings, the patient’s hemodynamic and respiratory parameters remained stable. He was initially supported with high-flow oxygen therapy, which was sufficient to maintain adequate oxygenation. Importantly, diuresis remained preserved throughout the illness. The primary antimalarial intervention consisted of intravenous artesunate, administered at 240 mg at time intervals T0, T12, T24, T48, with close monitoring of the QT interval to mitigate potential cardiac risks. Concurrently, supportive therapy was instituted to manage the systemic impact of malaria.

Given persistently elevated bilirubin levels and inflammatory markers, EHA using a CytoSorb® filter was initiated on the third day. The procedure lasted 24 hours under continuous heparin infusion. EHA led to significant laboratory improvements, notably reductions in bilirubin and inflammatory markers (PCT/CRP). Concurrently, anemia was managed through blood transfusion. A second EHA cycle was performed on the fourth day, resulting in additional biochemical and clinical improvements (Figure 1). On the fifth day, the patient commenced a three-day oral antimalarial regimen consisting of Atovaquone/Proguanil (250mg/100mg/day). By the eighth day, his clinical status had markedly improved, allowing transfer to the infectious diseases ward. The patient exhibited continued recovery and was eventually discharged home on the fourteenth day.

This case underscores the potential benefit of EHA with CytoSorb® in disrupting the albumin-bilirubin complex, effectively adsorbing bilirubin, and managing systemic cytokine overload. By mitigating the inflammatory and metabolic disturbances associated with severe malaria, EHA provided a critical bridge that facilitated the optimal efficacy of antimalarial pharmacotherapy. The rapid clinical improvement observed—reflected in decreasing bilirubin levels, enhanced neurological status, and complete resolution of jaundice—highlights the promise of hemoperfusion as an adjunctive intervention in challenging malaria cases. Further studies are recommended.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. J Vector Borne Dis. 2023, 60:432-4

2. Cells. 2022, 11:10.3390

3. Artif Organs. 2019, 43:189-94

Fig. 1 (abstract A104).

C-reactive protein, total bilirubin, direct bilirubin and creatinine values before and after treatment with CytoSorb®

A105 Fulminant suspected myocarditis due to methicillin-sensitive staphylococcus aureus (MSSA): a case report

L. Facciotto, F. Bresadola, S. Roda, A. Luppi, M. Menghini, C.A. Compagnone

AUSL Bologna, Anestesia e Terapia Intensiva Nord Bentivoglio, Bologna, Italy

Correspondence: L. Facciotto

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A105

Background

Myocarditis caused by Staphylococcus aureus (SA) is a rare but potentially fatal condition, although SA is the most frequent bacterial etiology. Clinical presentation may mimic acute coronary syndrome or septic cardiomyopathy, often delaying diagnosis and treatment. In literature we found very few cases of SA related myocarditis, most of which were fatal.

Case Presentation.

A 60-year-old male presented to the emergency department with fever, malaise, and progressive dyspnea. In his medical history: systemic hypertension, moderate chronic kidney disease, chronic obstructive pulmonary disease with prescription of CPAP during night time, previous lung cancer (wedge resection two years ago with negative follow-up). Laboratory tests revealed neutrophilia, elevated C-reactive protein and procalcitonin, as well as impaired liver and kidney function. Chest X-ray showed signs of acute heart failure. Cardiac evaluation revealed elevated troponin I (4100 ng/L) and BNP and electrocardiogram (ECG) showed diffuse ST-segment depression associated with ST-segment elevation in aVR and diffuse T-wave inversion. Despite these findings, coronary angiography was deferred by cardiology due to low suspicion for acute coronary syndrome. The patient rapidly deteriorated, developing respiratory failure requiring intubation. CT scan revealed bilateral ground-glass opacities and a suspected splenic abscess. He was then admitted to intensive care unit, where he developed mixed septic and cardiogenic shock requiring escalating vasopressor support (norepinephrine and vasopressin) and ultimately associated epinephrine, guided by PiCCO hemodynamic monitoring. Continuous renal replacement therapy was initiated due to anuria and worsening metabolic acidosis. MSSA was isolated from blood, urine and bronchoalveolar lavage cultures. Ceftriaxone was initiated in the emergency department. We escalated antibiotic therapy to piperacillin/tazobactam plus daptomicin and then ceftobiprole plus daptomicin while waiting for the antibiogram. Troponin dosage increased up to 35.000 ng/L in the following two days without any change in the ECG. We proposed transferring the patient to an ECMO center, but our colleagues form cardiologic intensive care unit did not support ECMO initiation due to significant vasoplegia. Despite early initiation of appropriate antibiotic therapy in the emergency department and maximal organ support, the patient died 72 hours after admission due to refractory multiorgan failure. Autopsy was not performed, therefore we did not find any certain cause of his cardiac failure, although myocarditis is one of the possible etiology.

Conclusion.

This case underscores the fulminant course that MSSA-associated myocarditis can take, even in the absence of pre-existing cardiac disease. Early recognition, aggressive hemodynamic support and appropriate antimicrobial therapy are critical, but prognosis remains poor in rapidly progressive cases. Diagnosis of myocarditis is typically confirmed through cardiac magnetic resonance imaging or endomyocardial biopsy. In selected cases of autoimmune or inflammatory myocarditis, high-dose immunosuppressive therapy and intravenous immunoglobulins may offer clinical benefit, although current evidence remains limited. Further awareness and research into early diagnostic markers are needed to improve outcomes in such presentations.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Lampejo T, Durkin SM, Bhatt N, Guttmann O. Acute myocarditis: aetiology, diagnosis and management. Clin Med (Lond). 2021 Sep;21(5):e505-e510. 10.7861/clinmed.2021-0121. PMID: 34507935; PMCID: PMC8439515.

2. Trpkov C, Chiu M, Kang EY, Box A, Grant A. Fulminant Bacterial Myocarditis Presenting as Myocardial Infarction. JACC Case Rep. 2020 May 20;2(5):830-831. doi: 10.1016/j.jaccas.2020.03.023. PMID: 34317358; PMCID: PMC8302025.

3. McGee M, Shiel E, Brienesse S, Murch S, Pickles R, Leitch J. Staphylococcus aureus Myocarditis with Associated Left Ventricular Apical Thrombus. Case Rep Cardiol. 2018 May 23;2018:7017286. 10.1155/2018/7017286. PMID: 29951322; PMCID: PMC5989289.

4. LeLeiko RM, Bower DJ, Larsen CP. MRSA-associated bacterial myocarditis causing ruptured ventricle and tamponade. Cardiology. 2008;111(3):188-90. 10.1159/000121602. Epub 2008 Apr 25. PMID: 18434723.

A106 Foodborne botulism: a case report

V. Drago, S.T. Saglimbene, M.L. Granata, S. De Luca, G. Leonardi, G. Magro, C. Nicocia, F. Messina, M.T. Montalto, V. Carnemolla, L.C. Cavallo, G. Cammarrata, M. Quercio, G. Rapisarda

Department of Anesthesia and Intensive Care, Santa Marta and Santa Venera Hospital, ASPCT, Acireale, Italy

Correspondence: V. Drago

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A106

Background

Foodborne botulism is a rare but potentially fatal neurotoxin-mediated disease, characterized by an acute symmetric descending flaccid paralysis. The severity of paralysis is proportional to the ingested toxin dose [1].

Case Report

A 59-year-old male, with a history of bronchial asthma and chronic vascular disease, presented to the emergency department with diplopia, dysarthria, palpebral ptosis, right greater than left anisocoria and headache. 24 h after the first admission, the patient entered a comatose state (despite negative brain CT scan), going into respiratory failure and needed intubation, sedation and admission to ICU. Our team started a mechanical ventilation, hemodynamic support with norepinephrine, stimulation of diuresis, blood tests, surveillance swabs and empirical antibiotic therapy. Another brain CT scan, cardiology consult and echocardiogram, arterial and venous doppler of lower limbs, brain and cervical spine MRI were performed (with negative Results for acute injuries). 72 h after the ICU admission, the patient’s daughter was admitted to another hospital with similar but milder symptoms, raising suspicion of foodborne botulinum toxin intoxication, later confirmed by testing a contaminated jam. The Poison Control Center in Pavia was contacted and, after authorization from the ISS, botulinum antitoxin serum was administered. Within 24 hours, an interruption of sedation was performed (patient was aware and able to move only his feet, with which he communicated) and vasopressor support was discontinued; a physiatric consultation was performed and rehabilitation started promptly. On day 10, a percutaneous tracheostomy (percutwist technique) was performed. On day 12, due to hemodynamic instability, vasopressor support with norepinephrine and vasopressin was resumed; anemia and thrombocytopenia required transfusions and after a total-body CT scan w and w/o contrast, the patient underwent emergency splenectomy (a traumatic fall about one month prior was reported by family). Post-operative intestinal atony resolved after 14 days with prokinetics, followed by enteral nutrition. On day 19, electromyography showed acute motor axonal polyneuropathy with denervation signs in the deltoid and tibialis anterior (bilateral), right biceps brachii and right EDC. IV IgG was administered over five consecutive days. Slight improvement was seen in the electromyography on day 39. Between day 42 and 54 AKI occurred; SCUF, CVVHD and SLED were performed with excellent recovery of diuresis and renal function. On day 55, vasopressor support was permanently discontinued. Antibiotic de-escalation was performed according to microbiological culture

Results during hospitalization. On day 57, the patient was discharged to a rehabilitation center: successfully adapted to home ventilator support 24h/day through trachestomy, alert, cooperative, able to follow with gaze and to communicate using an eye pointer, to smile, nod, move both feet and hands. Consent for data publication was obtained from the patient’s brother.

Conclusion

Foodborne botulism diagnosis depends on a high level of clinical suspicion and thorough neurological examination. Timely diagnosis is crucial for effective treatment, as botulinum antitoxin, the only specific therapy, must be administered as soon as possible [1].

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Agam K. Rao, Jeremy Sobel, Kevin Chatham-Stephens, Carolina Luquez. Clinical Guidelines for Diagnosis and Treatment of Botulism, 2021. MMWR/May 7, 2021/Vol.70/No.2

A107 Fulminant sepsis due to capnocytophaga canimorsus complicated by secondary atypical hemolytic uremic syndrome in an asplenic young woman: a case report

C. De Domenico¹, G. Chiarini², R. Marino², C. Cattaneo³, S. Liana⁴, S. Lorenzotti⁴, C. Manenti⁵, R. Baraziol⁶, A. Casiraghi⁷, S. Cattaneo⁷, C. Galante⁷, N. Latronico^1,2, S. Piva^1,2

¹Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Università di Brescia, Italy; ²Department of Emergency, Spedali Civili University Hospital, Brescia, Italy; ³Hematology, Spedali Civili University Hospital, Brescia, Italy; ⁴Unit of Infectious and Tropical Diseases, Spedali Civili University Hospital, Brescia, Italy; ⁵Nephrology Unit, Spedali Civili University Hospital, Brescia, Italy; ⁶Department of Plastic Surgery, Spedali Civili University Hospital, Brescia, Italy; ⁷Department of Bone and Joint Surgery, Spedali Civili University Hospital, Brescia, Italy

Correspondence: C. De Domenico

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A107

Background

Capnocytophaga canimorsus is a Gram-negative commensal bacterium found in the oral flora of dogs. Although typically harmless in immunocompetent hosts, it can cause fulminant sepsis following dog bites, particularly in asplenic individuals or those with cirrhosis or alcohol abuse.The infection carries a high mortality even with appropriate treatment.[1]

Case report

We report the case of a 32-year-old woman with a history of total splenectomy for a benign cyst, followed by prophylactic vaccination against Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b.She had also undergone a cesarean section six months earlier.

She was admitted to our emergency department with fever and abdominal pain, two days after a superficial bite from her family dog. On admission, she was alert and hemodynamically stable (blood pressure 130/85mmHg, heart rate 130bpm).Abdominal examination revealed tenderness in the right hypochondrium, without signs of peritonitis.

Initial laboratory findings were consistent with sepsis, multiorgan failure and metabolic acidosis (pH 7.16, bicarbonate 16.5mmol/L, lactate 13.7mmol/L): leukopenia(WBC 2,180/µL), elevated procalcitonin (28.8ng/mL), disseminated intravascular coagulation (platelets 40,000/µL, INR 3.2, aPTT 132.7s), hypoglycemia and elevated levels of creatinine, bilirubin and transaminases.

Contrast-enhanced computed tomography of the chest and abdomen showed non-specific findings, including bibasilar lung atelectasis, hepatomegaly, free fluid in multiple abdominal compartments and non-perfusion of the renal cortices.

Empiric broad-spectrum antibiotics with piperacillin–tazobactam and amikacin were initiated and the patient was transferred to the Intensive Care Unit (ICU).

Upon ICU admission, her condition worsened with development of refractory shock. Despite extensive supportive therapy including mechanical ventilation, antibiotic escalation with clindamycin and daptomycin, stress-dose hydrocortisone, high-dose vasopressor support (norepinephrine, vasopressin, epinephrine), angiotensin II, IgM-enriched immunoglobulins, continuous renal replacement therapy and multiple transfusions, no clinical improvement was observed. Blood cultures later tested positive for Capnocytophaga canimorsus.

The course was further complicated by acral necrosis and critical ischemia involving all four extremities and nose, requiring digital amputations and lower limb debridement.Brain involvement was also evident with delirium, coma and microhemorrhages on brainCT.

Peripheral blood smear revealed numerous schistocytes and laboratory tests confirmed microangiopathic hemolytic anemia and thrombocytopenia (undetectable haptoglobin, increased reticulocyte count, elevated LDH). Direct Coombs test returned positive, likely due to multiple transfusions.

On day 8,a diagnosis of secondary atypical hemolytic uremic syndrome (saHUS) was suspected and treatment with Eculizumab, a C5-inhibiting monoclonal antibody, was initiated. A pneumococcal vaccine booster was administered concurrently, and antibiotics were continued.

The diagnosis of aHUS was confirmed by normal ADAMTS13 activity (44%). Subsequently, the patient showed rapid improvement: platelet counts normalized, hemolysis resolved, herapid improvementy was restored and renal function gradually recovered. After 30 days in ICU, she was transferred to a general ward and ultimately discharged home after 121 days of hospitalization.

Conclusion

This case highlights the rare and life-threatening presentation of C.canimorsus infection in an asplenic patient, leading to fulminant sepsis and saHUS. Complement activation in saHUS is transitory and there aren't genetic abnormalities that may increase relapse risk: a short course of Eculizumab can be life-saving.

Informed consent for publication was obtained.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. J.Zajkowska:Capnocytophaga canimorsus-an underestimated danger after dog or cat bite-review of literature.PRZeglEpidemiol.2016;70(2):289-295

A108 Weil’s syndrome: a case report

V. D'Amicis¹, E.G. Porcile², D. Bianchi², S. Pizzasegale², M. Centanaro²

¹Università degli Studi di Genova, Genova, Italy; ²IRCCS Policlinico San Martino, Genova, Italy

Correspondence: V. D'Amicis

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A108

Background

Leptospirosis is a zoonosis that is widespread in the world and potentially underestimated in Italy. The natural reservoir of leptospires consists of infected animals (rats, wild rodents, domestic animals), in which leptospires persist in the renal tubules without causing disease, and transmit indirectly the infection to humans through water or soil contaminated by infected urine, or through direct contact. Tipically the disease follow a seasonal pattern with a peak in the summer-autumn period. The most affected groups typically include farmers and livestock breeders, veterinarians and animal husbandry workers, sewage and water system workers. The severe form of the disease is known as Weil’s Syndrome, characterized by severe jaundice, acute kidney failure, and respiratory failure. Mortality can reach up to 50%.

Case report

The patient, a 52-year-old male farmer, presented to the Emergency Department of Villa Scassi Hospital with abdominal pain, fever, jaundice, and altered mental status (agitation, flapping tremor, hallucinations). He also reported the onset of gastrointestinal symptoms, such as nausea and diarrhea, as well as diffuse arthralgia in the previous week. He was evaluated by the Infectious Diseases Consultant and empirical antibiotic therapy with Ceftriaxone 2 g/day was initiated on clinical suspicion of Weil’s syndrome. The patient was transferred to our facility due to respiratory failure (Figure 1), marked hyperbilirubinemia, and acute renal failure (bilirubin 32.93 mg/dL, creatinine 4.97 mg/dL). Continuous renal replacement therapy (CRRT) was initiated (CVVHDF with regional calcium-citrate anticoagulation), using CytoSorb hemoadsorption filters starting promptly with CytoSorb in association with usual ST150. We used 3 cartridges of CytoSorb, for 24 hrs each, in a 3 days period. After that we switched to another 3 CRRT sessions with ST150. On day 5 of hospitalization, the diagnosis of leptospirosis was confirmed by PCR for Leptospira DNA on serum and urine samples sent to the San Matteo Hospital in Pavia. After the initiation of targeted antibiotic therapy with ceftriaxone, the patient developed a widespread, non-pruritic skin rash consistent with a Jarisch-Herxheimer reaction due to massive spirochete lysis following antibiotic administration. Following dialysis and antibiotic therapy, we observed a rapid improvement in respiratory function, bilirubin levels (Figure 2), and neurological status. Renal replacement therapy was continued intermittently due to residual renal failure. On day 19, the patient was transferred to the inpatient unit of the Infectious Diseases Department and was discharged home on day 29.

The patient provided written informed consent for the publication of this case report.

Conclusions

Leptospirosis remains an infection with a wide spectrum of clinical presentations and varying degrees of severity. In our case, the patient presented with severe multiorgan failure involving the central nervous system, respiratory, and hepatorenal systems, with residual renal insufficiency requiring renal replacement therapy. However, both the pulmonary manifestations and jaundice responded promptly to the combined antibiotic and purification therapies. The literature highlights the importance of early diagnosis to guide immediate and targeted therapy, ultimately improving patient outcomes.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A108).

See text for description

Fig. 2 (abstract A108).

See text for description

A109 Angiotensin II in an immunocompromised patient with primary CNS Lymphoma with refractory septic shock: a case report

R. Busatto¹, E. Trenti¹, M. Zanzotti¹, K. Donadello², E. Polati²

¹AOUI of Verona, Anesthesia and Intensive Care B, Verona, Italy²University of Verona, Department of Surgery, Dentistry, Gynecology and Pediatrics, Anesthesia and Intensive Care B, AOUI, Verona, Italy

Correspondence: R. Busatto

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A109

We report the case of a patient with primary central nervous system lymphoma and chemotherapy-induced bone marrow aplasia who presented with refractory septic shock.

Despite high-dose conventional vasopressors, severe hypotension with hypoperfusion persisted until the initiation of angiotensin II, which led to a rapid restoration of perfusion and enabled limitation of adrenergic overload. This case highlights the potential efficacy and adjunctive role of angiotensin II in refractory septic shock.

Introduction

Refractory septic shock is a life-threatening condition characterized by extreme vasoplegia and resistance to catecholamines. Angiotensin II, recently introduced into clinical practice, acts on AT1 receptors to induce systemic vasoconstriction and restore arterial pressure. Its efficacy has been demonstrated in complex clinical scenarios resistant to conventional treatment [1,2].

Case Presentation

A 55-year-old male with a diagnosis of primary CNS and chemotherapy-induced bone marrow aplasia was transferred to neurosurgery for hydrocephalus to be submitted to external ventricular drainage. After 18 days from surgery, he was admitted to our general ICU for Carbapenemase-producing Klebsiella Pneumoniae sepsis, which progressed to refractory septic shock.

On admission, he was conscious (GCS 15), febrile, blood pressure was 80/40 mmHg, heart rate and SpO2 were110 bpm and 96%, respectively. Arterial blood gas showed lactate 8.5 mmol/L, hemoglobin 8.6 g/dL, and procalcitonin >70 ng/mL. He needed prompting intubation and, despite broad-spectrum antibiotic therapy, he was unresponsive to fluid resuscitation with crystalloids and albumin, and to high dose vasopressor infusion [norepinephrine (0.5 mcg/kg/min), vasopressin (0.03 U/min), and epinephrine (0.2

mcg/kg/min)]. Due to significant endotoxemia, continuous renal replacement therapy (CRRT) and hemoadsorbtion with Toraymyxin were initiated. Advanced hemodynamic monitoring with Transpulmonary Thermodilution (TPTD, EV1000, Edwards) revealed a cardiac index of 4 L/min/m² and systemic vascular resistance index (SVRI) dropping below 900 dyn x s/cm5, consistent with severe vasodilatatory shock, also confirmed by bedside echocardiography.

Given the extreme vasoplegia unresponsive to catecholamines, angiotensin II infusion was started, resulting in rapid and sustained hemodynamic improvement, de-escalation of adrenergic support and lactate clearance (Figure 1). No adverse events were recorded. The infusion was maintained for 48 hours, allowing for complete vasopressors weaning.

Discussion

Angiotensin II proved to be safe and effective for refractory septic shock management. Its non-adrenergic mechanism of action allows bypassing the receptor desensitization typically seen in advanced shock states [3]. Advanced hemodynamic monitoring enabled a targeted approach.

Conclusion

In this immunocompromised patient the use of angiotensin II was effective in management of refractory septic shock. Early administration in cases of severe vasoplegia may be lifesaving, particularly when conventional vasopressors fail.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Khanna A, et al. Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med. 2017;377(5):419–430.

2. Tumlin JA, et al. Effect of angiotensin II on blood pressure in patients with vasodilatory shock: a systematic review. Crit Care. 2018;22(1):324.

3. Bellomo R, et al. Angiotensin II in septic shock: when physiology meets pharmacology. Am J Respir Crit Care Med. 2019;199(9):1129–1131.

Table 1 (abstract A109).

Drug infusion and changes in hemodynamic parameters. TPTD reported was measured every 8h

A110 Pulmonary aspergillosis in immunocompromised critically ill patients: prevalence, diagnosis and clinical characteristics. a monocentric retrospective analysis

M.G. Bocci¹, C. Fontana¹, S. Leone¹, G. Capecchi¹, A. Lesci², V. Sabatini¹, D. Rubino¹, F. Evangelista¹, E. Agostini¹, G.v. Stazi¹, R. Di Lorenzo¹, A. Capone¹, S. Cicalini¹

¹INMI L. Spallanzani, Roma, Italy; ²Università Cattolica del Sacro Cuore, Roma, Italy

Correspondence: V. Sabatini

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A110

Introduction:

Aspergillosis is the most common invasive fungal infection in immunocompromised patients (Fig. 1), especially those with hematologic malignancies, solid organ transplants, or receiving corticosteroids or chemotherapy (1,2).

In the ICU, diagnosis is difficult due to non-specific signs and the limited utility of classical EORTC/MSG criteria. Alternative algorithms such as AspICU and its modifications address these gaps (3)(Fig. 2).

Objectives and Methods

This monocentric retrospective study assessed the prevalence, clinical features, and outcomes of pulmonary aspergillosis in immunocompromised ICU patients at the Lazzaro Spallanzani National Institute (Jan 2021–Dec 2024). We analyzed patients who underwent PCR for Aspergillus spp. on lower respiratory tract samples due to suspected IPA (defined as respiratory failure without an alternative cause in the setting of immunosuppression). PCR-positive patients were included, and a matched PCR-negative control group with similar clinical profiles was selected. Early diagnosis was PCR positivity within 7 days of ICU admission; late diagnosis was from day 8 onward. The primary outcome was 28-day mortality; secondary outcomes included infection onset and concordance with galactomannan (serum/BAL) and cultures.

Population:

Eligible patients were adults (more than 18 years) with PCR-confirmed Aspergillus infection or suspicion based on immunosuppressive risk factors: neutropenia, corticosteroids, HSCT, SOT, CAR-T, hematologic/solid malignancies, HIV, or congenital immunodeficiencies. Exclusion criteria: age lower than 18 years, ICU stay no longer that 48 h, no risk factors, and PCR negativity.

This study was conducted according to the Declaration of Helsinki. Approval was obtained from the local Ethics Committee CET Lazio-Area4; informed consent was waived due to the retrospective design.

Results

We included 118 PCR-positive and 193 PCR-negative patients. The PCR-positive group (mean age 66) included 81 males; PCR-negative (mean age 59) included 128 males. Among PCR-positives, 41 were immunocompromised (14 HIV, 8 SOT, 19 oncology). Sixty-four PCR-positive patients died, including 21 immunocompromised individuals. Mortality was lower in PCR-negative patients with similar risk factors (<50%).

Infection prevalence was 23.7% based on PCR testing, and 11.3% relative to ICU admissions. Galactomannan was positive in 37 PCR-positive cases, including 4 serum samples.

Conclusions

Pulmonary aspergillosis is a relevant complication in immunocompromised ICU patients. PCR testing enabled early identification and stratification. Mortality was higher among PCR-positive patients, especially the immunocompromised. Routine fungal screening should be considered in critically ill patients with unexplained respiratory failure. Combining PCR with galactomannan and clinical criteria may improve diagnosis. Molecular tools should be integrated into standard ICU protocols for suspected invasive fungal infections.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A110).

Spectrum of disease due to the interaction between Aspergillus and the human host

Fig. 2 (abstract A110).

Criteria for probable aspergillosis diagnosis in patients admitted in ICU

A111 Implementation of the astar system for rapid antimicrobial susceptibility testing in bloodstream infections in intensive care unit: single centre preliminary results from the lifetimes study

A. Antoniucci¹, R. Accattoli¹, M. Cocca¹, F. Allegrucci², A. Mencacci^2-3, E. De Robertis^1-4, A. Giacomucci⁴

¹University of Perugia, Department of medicine and surgery, anaesthesia and intensive care section, Perugia, Italy; ²Azienda Ospedaliera di Perugia, Microbiology, Perugia, Italy; ³University of Perugia, Department of medicine and surgery, Microbiology section, Perugia, Italy; ⁴Azienda Ospedaliera di Perugia, Anaesthesia and Intensive care, Perugia, Italy

Correspondence: M. Cocca

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A111

Background

Bloodstream infections (BSI) in critically ill patients are associated with high morbidity and mortality, necessitating rapid pathogen identification and antimicrobial susceptibility testing (AST) to optimize therapeutic management. Conventional methods such as broth microdilution (BMD) are time-consuming, often delaying the initiation of targeted therapy. The LIFETIMES is a multicentre prospective study aimed to assess the clinical and economic impact of integrating the ASTar system, a rapid phenotypic AST technology, in the diagnostic and therapeutic workflow for BSI.

Materials and Methods

This was a prospective, multicentre, case-control interventional study, of which we analyse the cases from University Hospital of Perugia. All patients provided written informed consent, when patients were unconscious, the declaration of enrolment was signed by an independent physician. Patients admitted to the intensive care unit (ICU) with documented Gram-negative BSI were included according to predefined criteria. Pathogen identification was performed using MALDI-TOF and FilmArray® panels. Antimicrobial susceptibility was assessed with both the ASTar system and conventional BMD methods. The primary endpoint was the time to initiation of optimal antimicrobial therapy. Secondary endpoints included clinical outcomes, length of stay (LOS) in ICU and hospital, and therapy modification rates.

Results

A total of 26 patient cases and 30 historical controls were analyzed. The mean time to optimal therapy using ASTar was approximately 9.05 hours (standard deviation ±1.55 hours), significantly shorter than the 40 hours (±13.28 hours) observed with standard BMD (p < 0.000001). Therapy modifications induced by ASTar occurred in 21.05% of patients, with 60% of these showing positive clinical outcomes. In contrast, standard BMD led to therapy modifications in only 5.4% of patients (1 out of 26). The majority of empirical therapies were confirmed as appropriate (78.94%), suggesting effective initial management. However, in cases where therapy was modified based on ASTar results, the ICU stay tended to be longer, potentially reflecting greater initial clinical severity.

Conclusion

The integration of the ASTar system into the ICU diagnostic workflow significantly reduces the time to appropriate antimicrobial therapy, demonstrating a statistically and clinically relevant benefit compared to standard methods. The system rapid turnaround time and high concordance with BMD results position it as a valuable tool for optimizing antimicrobial stewardship, improving early clinical outcomes, and potentially reducing healthcare-associated costs. These are preliminary results from a single centre participating to a multicentre study. We expect that data from the other centres will consolidate our findings. To overcome the limitations of the study particularly related to pathogen coverage, further multicentre studies are warranted.

Consent

Informed consent was obtained for the publication of this scientific article.

Critical care and out-of-hospital emergency medicine

A112 Recognition, management, and transport times of suspected stroke in the prehospital setting: a retrospective observational pilot study conducted by the South Sardinia co118 emergency medical service

C. Marini, A. Pinna, L. Guddelmoni, F. Cadoni, C. Casula, L. Frau, D. Barillari

AREUS, C.O. 118 Cagliari, Sardinia, Italy, Cagliari, Italy

Correspondence: L. Guddelmoni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A112

Background

Stroke is one of the most common neurological emergencies, currently representing the second leading cause of death worldwide. Recent studies suggest that in high-income countries, one in five individuals will suffer a stroke, while in low- and middle-income countries, the incidence may reach one in two. Stroke demands rapid diagnosis and treatment (“time is brain”), yet accurate diagnosis in the prehospital setting remains limited.[1]

This retrospective observational study aimed to assess the performance of suspected ischemic and hemorrhagic stroke management within the jurisdiction of the Emergency Medical Service Dispatch Center (CO118) of South Sardinia.

Materials Methods

Data were retrospectively collected for suspected stroke cases transported to designated HUB centers after appropriate consultation with the Stroke Unit. All data were entered into a single Excel file by extracting relevant information from intervention records of patients who had undergone the Cincinnati Prehospital Stroke Scale (CPSS) assessment, during the period from May 1 to December 31, 2024. Temporal variables such as time to target, on-scene time, and time to door were also recorded.

Results

During the 8-month study period, 294 patients with a positive CPSS were evaluated by advanced life support teams, with the highest incidence observed in May, October, and December. After teleconsultation with the Stroke Unit, 70% of symptomatic patients were deemed eligible for acute treatment and were consequently directed to the appropriate HUB center.

Average time intervals were as follows: Time to target: 16 minutes and 28 seconds; On-scene time: 26 minutes; Time to door: 147 minutes.

Conclusions

Time-dependent pathologies present a significant challenge for the territorial emergency network, involving all professionals from the moment the emergency call is received. At this stage, the operator must determine the most appropriate vehicle to dispatch and may administer a prehospital stroke scale via phone. The findings, though preliminary, reflect the current operational context and serve as a valuable starting point for identifying improvement strategies. Among these are educational initiatives and awareness-raising among rescue personnel, with a focus on stroke-specific knowledge, accurate administration of the CPSS, increasing the proportion of patients proposed for thrombolysis during neurologic consultations, and reducing response and transport times. Performance analysis focused on the recognition of eligibility criteria, percentage of teleconsultations performed, and management times will allow timely adaptation of current protocols to any critical issues encountered, thereby enhancing both the efficiency and effectiveness of care delivery while ensuring patient safety.From a prevention standpoint, the continued development of a comprehensive database containing demographic data and clinical variables—such as comorbidities—will enable prospective evaluations to identify high-risk populations. This information will guide public awareness campaigns and the strengthening of community-based health services, with a central role played by primary care providers in optimizing therapeutic targets for hypertension, hyperlipidemia, and diabetes. Informed consent was obtained.

Consent

Informed consent was obtained for the publication of this scientific article.

Reference

1. eske SK. Ischemic Stroke. Am J Med. 2021 Dec;134(12):1457-1464. 10.1016/j.amjmed.2021.07.027. Epub 2021 Aug 27. PMID: 34454905.

A113 Red code, pain ignored: rethinking analgesia in emergency care

M. Frau¹, L. Guddelmoni², C. Marini², A. Pinna², L. Frau², C. Casula², D. Barillari²

¹School of Anesthesia and Intensive Care, Unica University of Cagliari, Sardinia, Italy, Cagliari, Italy²AREUS, C.O. 118 Cagliari, Sardinia, Italy, Cagliari, Italy

Correspondence:

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A113

Background The clinical context of emergency and urgent care is characterized by the phenomenon of oligoanalgesia, defined as inadequate pain management. Factors contributing to this phenomenon include the lack of pain assessment, the absence of guidelines for its management, inadequate documentation investigating pain properly, and the failure to evaluate treatment adequacy. [1]

Oligoanalgesia is a significant issue in Italy. A study conducted on 629 patients in an emergency department in Emilia-Romagna revealed that pain was documented in 75.5% of cases, but 79.7% of patients did not receive any pharmacological treatment. When treatment was administered, pain intensity significantly decreased, but reassessment was performed in only 24.3% of patients. [2]

This issue is also reflected in Europe, with variations in pain management across different countries. Currently, there is no single standard for pain treatment in emergency settings, and practices vary based on local protocols, as highlighted by the European Society for Emergency Medicine (EUSEM).[3]

Materials and Methods

An ongoing retrospective study conducted on a sample of 181 adults treated by nurses and physicians of the Regional Emergency and Urgency Agency of Sardinia (AREUS) from October 1, 2024, to March 31, 2025. All individuals over the age of 18 with GCS > 8, GCSm > 6, and without neurocognitive disorders incompatible with pain assessment were included. Numeric Rating Scale (NRS) scores, administered drugs, and their effectiveness were recorded. Data analysis is being conducted using an Electronic Case Report Form compiled on the REDCap platform.

Results Preliminary data show that only 33 cases (18.2%) include a pain assessment, while in 148 cases (81.8%), pain was not assessed. Despite the initial evaluation, only six cases (3.3%) included a second assessment, and only in 50 cases (27.5%) was pharmacological treatment administered, primarily consisting of opioids, followed by ketamine and paracetamol.

Conclusions The presence and quantification of pain remain poorly considered parameters by healthcare personnel working in the field, who do not prioritize them or consider them as important as other vital signs. The lack of pain assessment makes its management impractical, both in terms of selecting the right analgesic and evaluating its effectiveness. Oligoanalgesia in emergency and urgent care represents a serious problem, directly affecting the quality of assistance, patient well-being, and even clinical outcomes. Inadequate pain management is not just a matter of immediate discomfort but can lead to far-reaching consequences, such as worsening prognosis and increased physiological and psychological stress. Addressing this issue requires a cultural and structural change in how pain is considered within emergency protocols. Healthcare professional training, the implementation of clear guidelines, and the use of easily accessible pain assessment tools can significantly help reduce oligoanalgesia. Informed consent was obtained.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Albrecht E, Taffe P, Yersin B, Schoettker P, Decosterd I, Hugli O. Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10-year retrospective study. British Journal of Anaesthesia. 2013;110(1):96–106. 10.1093/bja/aes355

2. Hachimi-Idrissi S, Dobias V, Hautz WE, Leach R, Sauter TC, Sforzi I, Coffey F. Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines—part 2: management and recommendations. Internal and Emergency Medicine. 2020;15:1141–1155. 10.1007/s11739-020-02411-2

3. Ferri P, Gambaretto C, Alberti S, Parogni P, Rovesti S, Di Lorenzo R, Sollami A, Bargellini A. Pain Management in a Prehospital Emergency Setting: A Retrospective Observational Study. Journal of Pain Research. 2022;15:3433–3445. 10.2147/JPR.S376586

A114 Outdated stemi network criteria? Is there a need to revise the current ones?

P. Uccheddu¹, R. Marini¹, L. Guddelmoni², M. Frau², C. Marini², A. Pinna², L. Frau², C. Casula², D. Barillari²

¹School of Anesthesia and Intensive Care, Unica University of Cagliari, Italy; ²AREUS, C.O. 118 Cagliari, Italy

Correspondence: L. Guddelmoni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A114

Background

Based on current STEMI criteria, some ECG patterns that still require urgent reperfusion therapy in the cardiac catheterization laboratory do not meet the recognized criteria for direct access. This limitation stems primarily from the need to identify ST-segment elevation, which is not always indicative of an acute coronary occlusion. Conversely, not all acute coronary occlusions present with ST-segment elevation. In fact, three-quarters of initially unrecognized myocardial infarctions can be identified by subtle ST-segment changes that suggest dynamic or evolving ST-segment elevation. [1] (Figure 1). Our focus, therefore, should be on identifying signs of acute coronary occlusion rather than simply relying on the presence of ST-segment elevation.[2]

Case report

A 56-year-old patient reported angina-like chest pain triggered by progressively milder exertion, accompanied by autonomic symptoms including nausea, vomiting, and cold sweating. Cardiovascular risk factors: arterial hypertension. During an exercise stress test, widespread ST-segment depression was noted, prompting early termination of the examination. We were contacted by the outpatient cardiologist, and upon our arrival, the patient was lying supine with resolution of symptoms. The hemodynamic and respiratory parameters were as follows: Blood pressure: 156/83 mmHg, Heart rate: 76 bpm, Oxygen saturation: 98%, Respiratory rate: 15 breaths per minute. A 12-lead electrocardiogram (Figure 2) was performed, and our interpretation took into account the Precordial Swirl or Northern OMI patterns, as outlined in the previously referenced table. The ECG was forwarded to the cardiologist on duty in the Coronary Care Unit (CCU), who concluded that the standard STEMI criteria were not fulfilled to justify immediate access to the catheterization laboratory. Consequently, the patient was transported to the emergency department for further clinical evaluation. Following communication with hospital colleagues 24 hours after admission to the emergency department, coronary angiography revealed a 70% occlusion of the left main coronary artery. Consequently, the patient was transferred to another facility equipped with cardiac surgery capabilities.

Consent

Informed consent was obtained for the publication of this scientific article.

Conclusion

There are several clinical scenarios in which the absence of clear-cut STEMI criteria on the ECG may delay intervention, despite the underlying presence of an acute coronary occlusion. Early recognition and treatment in such cases remain essential to improving patient outcomes. Therefore, the current evaluation criteria for patients with myocardial infarction may benefit from refinement—potentially through the development of a'STEMI-plus'network, or more appropriately, an'OMI'(Occlusion Myocardial Infarction) network. Informed consent was obtained.

Reference

1. Ricci F, Martini C, Scordo DM, Rossi D, Gallina S, Fedorowski A, Sciarra L, Chahal CAA, Meyers HP, Herman R, Smith SW. ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review. Ann Emerg Med. 2025 Apr;85(4):330-340. 10.1016/j.annemergmed.2024.11.019. Epub 2025 Jan 17. PMID: 39818676.

2. de Alencar Neto JN, Scheffer MK, Correia BP, Franchini KG, Felicioni SP, De Marchi MFN. Systematic review and meta-analysis of diagnostic test accuracy of ST-segment elevation for acute coronary occlusion. Int J Cardiol. 2024 May 1;402:131889. 10.1016/j.ijcard.2024.131889. Epub 2024 Feb 20. PMID: 38382857.

Fig. 1 (abstract A114).

Omi patterns in ECG

Fig. 2 (abstract A114).

ECG during out of hospital valutation

A115 Simsuem: simulation-based training to improve competence in pre-hospital emergency care

A. Graziano¹, M. Zagagnoni¹, C. Piagnani², M. Arrigoni¹, P. Antonello¹, A. Borziello¹, V. Guidotto¹, M. Dei Tos¹, A. Piovesan¹, M. Nardelli³, G. Zilio¹, A. Chies¹, M. Ferramosca¹

¹UOC Emergency Medical Service (SUEM 118), Treviso, Italy; ²UOC Anesthesia and Intensive Care, Montebelluna, Italy; ³Department of Medicine, University of Padua, Italy

Correspondence: M. Zagagnoni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A115

Background

Simulation in healthcare is a well-established method for training both technical and non-technical skills in a fully safe environment. However, research on non-technical skills remains limited, as their direct impact on clinical outcomes is difficult to measure.

This study aims to evaluate the effectiveness of a high-fidelity simulation-based training program for both the acquisition and retention of technical and non-technical skills.

Materials and Methods

This prospective observational study was based on the SimSUEM training program, which focused on high-fidelity simulations covering key topics in pre-hospital emergency care (medical, traumatic, and pediatric emergencies). The program ran from September to December 2024 at the U.O.C. SUEM 118 in Treviso.

Participating healthcare professionals (physicians and nurses involved in pre-hospital emergency response) were divided into groups and took part in clinical scenarios either as team leaders or team members.

After each simulation session, three questionnaires were administered to assess learning at three points: before the course, immediately after, and three months later.

Data analysis was conducted using SPSS and Microsoft Excel.

The study was approved by the Local Ethics Committee.

Results

This abstract reports data from simulations focusing on medical emergencies.

A total of 48 pre-course questionnaires were collected. Of these, 26 participants (54%) reported that their main learning goal was to improve their ability to manage an evolving clinical scenario; 14 (29%) aimed to improve technical skills; 7 sought to enhance teamwork capabilities; and only 1 participant wished to improve theoretical knowledge.

The post-simulation questionnaire received 52 responses. Most participants found the activities extremely or very relevant and expressed interest in attending future editions of the course.

All participants found the debriefing sessions and theoretical explanations at the end of each scenario to be very (36.5%) or extremely (63.5%) useful.

The majority rated their performance in both technical and non-technical skills positively. Only one participant (1.9%) rated their technical performance as “poor,” and two participants (3.8%) rated their non-technical skills similarly.

A total of 37 responses were collected from the follow-up questionnaire administered three months after the medical emergency simulation. Most participants reported increased self-confidence in the months following the course.

Overall, technical skills improved after the simulation. However, no correlation was found between this improvement and years of work experience in the pre-hospital setting (p = 0.176).

In contrast, improvement in non-technical skills was significantly greater among participants with more than 10 years of experience (p = 0.032).

Consent

Informed consent was obtained for the publication of this scientific article.

Conclusions

SimSUEM proved to be an effective program for enhancing both the technical and non-technical skills of professionals working in out-of-hospital emergency care.

References

1. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13 Suppl 1(Suppl 1):i2-i10.

2. Rosen MA, Diaz Granados D, Dietz AS, et al. Teamwork in healthcare: Key discoveries enabling safer, high-quality care. Am Psychol. 2018;73(4):433-450.

3. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med. 2003;78(8):783-788.

A116 Thermal dispersion in trauma patients transported by helicopter: a retrospective observational analysis of hypothermia risk and mitigation strategies

C. Bulfone¹, A. Cossettini¹, A. Tullio¹, C. Pegani³, S. Tomasino¹, A. Spasiano¹, T. Bove²

¹Medical Doctor and Dentist Association, Udine, Italy; ²Medical Doctor and Dentist Association, Milan, Italy; ³Nursing Professionals Association, Trieste, Italy

Correspondence: S. Tomasino

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A116

Background

Polytrauma patients are at high risk of hypothermia during prehospital transport, especially in cold environments. This study aims to evaluate the extent of thermal dispersion (>0.5°C) and the effectiveness of warming measures used in our Regional Helicopter Emergency Medical Service (HEMS FVG).

Methods

This is a retrospective observational study conducted on 43 trauma patients managed by the regional HEMS. Tympanic temperature was recorded at three timepoints: arrival (T1), during transport (T2), and emergency department admission (T3) (Table 1). Environmental conditions, trauma mechanism, clinical data and warming devices used (Table 2) were collected. Statistical analysis included binomial logistic regression models for continuous and dichotomized variables, Friedman and Wilcoxon paired tests, and a mixed effects linear model estimated with REML. For variables such as age, ambient temperature and on-scene time, cutoffs that maximized statistical significance were identified, applying the LOESS smoothing function (locally weighted scatterplot smoothing technique). The study was approved by the Department of Medicine Institutional Review Board (I.R.B.) on 10.03.2025 (ref Prot. IRB 072/2025). It was granted a waiver of informed consent due to the retrospective nature of the study. The management of sensitive data respected the European Privacy Regulation 2016/679 on General Data Protection Regulation (GDPR)

Results

Mean age: 47.5 +- 20.1 years; 72.1% male. Median ambient temperature: 8°C. A drop >0.5°C occurred in 9.3% of patients. The greatest decrease was between T1 and T2 (−0.775 +- 0.798°C, p<0.05). Patients with >0.5°C loss from T1 to T3 were older (64.8 vs 43.6 years, p=0.01). LOESS analysis (Figure 1) and logistic regression with a 55-year age cutoff confirmed the association (p<0.05). On-scene time >25 minutes was associated with increased thermal dispersion and application of multiple warming devices (p<0.05). A moderately significant association was found between penetrating trauma and thermal dispersion (p=0.08). No single warming device was superior, but cabin heating (46.5%) appeared promising.

Conclusions

Thermal dispersion is clinically relevant in older patients, those in critical clinical condition and under adverse environmental conditions. Early intervention with combined strategies and active temperature control is recommended. Our findings are consistent with literature recommendations [1–3]. This pilot analysis shows a trend without statistical significance regarding the type and number of warming devices, underlining the need to expand the sample.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A116).

Association between age and thermal dispersion (LOESS regression)

Table 1 (abstract A116).

Core body temperatures at the three measurement points (T1: arrival, T2: transport, T3: ED)

Time	Mean ± SD (°C)	Median (°C)	IQR (°C)
T1	35.8 ± 1.29	36.1	[1;30]
T2	36.0 ± 1.17	36.2	[1;50]
T3	36.1 ± 0.89	36.3	[0;95]

Table 2 (abstract A116).

Warming devices used and their frequency

Device	Applied (n, %)	Not applied (n, %)
Thermal blanket	39 (90.7%)	4 (9.3%)
Heated blanket	4 (9.3%)	39 (90.7%)
Cap	2 (4.7%)	41 (95.3%)
Cabin heating	20 (46.5%)	23 (53.5%)
Ambulance heating	8 (18.6%)	35 (81.4%)
Not necessary	1 (2.3%)	42 (97.7%)

Critical care and intra-hospital emergency medicine

A117 Relationship of D-dimer, carboxyhemoglobin and haptoglobin levels during oxygenator exchange in VV-ecmo patients

V. Brizzi¹, A. Marabotti¹, G. Cianchi¹, V. Tabolli², S. Romagnoli², M. Bonizzoli¹

¹Intensive Care Unit and ECMO Center, Careggi Teaching Hospital, Florence, Italy; ²Anesthesiology and Intensive Care, Department of Health Science, University of Florence, Italy

Correspondence: V. Brizzi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A117

Backround

During ECMO treatment D-dimer is considered as a reliable estimate of clotting inside the oxygenator [1] and a sharp rise in D-dimer prompts the need of oxygenator substitution [2].

Carboxyhemoglobin (COHb) seems to be correlated to Plasma Free Hemoglobin levels and has been proposed as a marker of subclinical hemolysis in ECMO [3]. Hemolysis can be associated with coagulopathy and clots within ECMO circuits. We have investigated whether COHb, D-dimer and haptoglobin levels are affected by oxygenator change.

Materials and Methods

52 subsequent patients on VV-ECMO support admitted to the ICU and ECMO center of Careggi Teaching Hospital from April 2021 to April 2024 were enrolled. Data were collected retrospectively and anonymized. Patients or next of kin provided consent to collect clinical data. Oxygenator was exchanged by substituting the whole ECMO circuit. The decision to change the oxygenator was made when a sharp rise in D-dimer was observed with or without a decrease in platelet count below 80.000 n/mL, onset of bleeding or loss of oxygenation efficiency, according to local protocol. D-dimer, COHb and haptoglobin levels were analyzed before and after oxygenator change.

Results

100 oxygenator changes were performed. D-Dimer values are presented in figure1. COHb significantly decreased after circuit change: from 2.5% to 2.3% (p < 0.001) (figure 2). Haptoglobin levels did not show any significant difference after oxygenator substitution (figure 3).

Conclusions

In our series of oxygenator changes, D-dimer levels drop after replacement, confirming that D-dimer production is associated with oxygenator obsolescence and clotting and can be used to monitor such events. COHb increase is also associated with oxygenator clotting and obsolescence. Being a marker of hemolysis, it is likely that this process can be promoted by oxygenator clotting. Haptoglobin is a poor marker of oxygenator performance.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Dornia C, Philipp A, Bauer S, Stroszczynski C, Schreyer AG, Müller T, Koehl GE, Lehle K. D- dimers Are a Predictor of Clot Volume Inside Membrane Oxygenators During Extracorporeal Membrane Oxygenation: Coagulation Activity During Venovenous ECMO Therapy. Artif Organs. September 2015; 39(9):782–7.

2. Lubnow M, Philipp A, Dornia C, Schroll S, Bein T, Creutzenberg M, Diez C, Schmid C, Pfeifer M, Riegger G, Müller T, Lehle K. D-dimers as an early marker for oxygenator exchange in extracorporeal membrane oxygenation. J Crit Care. 2014 Jun; 29(3):473.e1-5.

3. Rodgers IL, Yip DS, Patel PC, Keller CA. Carboxyhemoglobin and methemoglobin levels to diagnose hemolysis in patients supported with mechanical circulatory support devices. JHLT Open. November 2023; 3:100025

Fig. 1 (abstract A117).

D-dimer (ng/mL) (mean) variation according to circuit change (CC)

Fig. 2 (abstract A117).

COHb (%) (mean) variation before and after circuit change

Fig. 3 (abstract A117).

Haptoglobin (g/L) (mean) variation before and after circuit change

A118 The role of carboxyhemoglobin (COHB) in hemolysis in relation to intra-hospital mortality of patients undergoing veno-venous extracorporeal membrane oxygenation

V. Tabolli¹, G. Cianchi², A. Marabotti², V. Brizzi², S. Romagnoli¹, M. Bonizzoli²

¹Anesthesiology and Intensive Care, Department of Health Science, University of Florence, Italy; ²Intensive Care Unit and ECMO Center, Careggi Teaching Hospital, Florence, Italy

Correspondence: V. Tabolli

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A118

Background

Hemolytic phenomena have an incidence of forty percent in Extracorporeal Membrane Oxygenation (ECMO) treatments. Hemolysis arises when red blood cells undergo mechanical stress during their passage through the circuit, particularly in the blood pump and in high-resistance areas like the oxygenator. [1] [2] It is usually diagnosed and quantified through a combination of laboratory tests, as haptoglobin.

In recent years, Carboxyhemoglobin (COHb) has been proposed as a new potential hemolysis marker. It is produced by the binding of carbon monoxide to hemoglobin and its endogenous levels increase through the action of heme oxygenase, which catabolizes heme into biliverdin, iron, and CO. [3]

The aim of the study was to investigate the role of COHb in hemolysis in relation to intra-hospital mortality among patients treated with veno-venous ECMO.

Materials and Methods

The monocentric retrospective observational clinical study was conducted at the Careggi Hospital University of Florence, Italy, from April 2021 to April 2024. The study included adults suffering from acute respiratory failure on veno-venous ECMO support for more than forty-eight hours.

Written informed consent was previously obtained by all patients recruited.

COHb values were measured through arterial blood gas analysis.

The correlation between COHb and haptoglobin levels was evaluated, allowing the identification of a COHb cut-off value indicative of hemolysis. The relationship between the identified COHb cut-off value and intra-hospital mortality was subsequently analyzed.

Statistical analysis was performed using Receiver Operator Characteristic (ROC) curve, Youden’s index and Chi-squared test.

Results

Fifty-two patients were enrolled, with an average age of 53.48 (±10.43) and an average Sequential Organ Failure Assessment score of 7.10 (± 2.70).

Using haptoglobin serum levels <0.3 g/dL as a marker of hemolysis, the ROC curve with COHb levels showed an association with an area under the curve (AUC) of 0.685 (IC 95% 0.659-0.712) (Figure 1).

Youden’s index identified a COHb cut-off of 3.13% indicative of hemolysis.

64% of patients with COHb > 3.13% vs 33% of patients with COHb < 3.13% died, revealing a significant difference in outcome terms for patients who exhibited mean COHb levels > 3.13% for at least one day (Table 1).

Chi-square test returned a p-value of 0.027.

Conclusions

COHb may be a valid predictor of in-hospital mortality in patients with hemolysis receiving veno-venous ECMO support. Nevertheless, further studies with a larger patient population are needed to confirm these findings.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Lehle K, Philipp A, Zeman F, Lunz D, Lubnow M, Wendel HP, et al. Technical-Induced Hemolysis in Patients with Respiratory Failure Supported with Veno-Venous ECMO – Prevalence and Risk Factors. PLOS. 2015; 10(11):e0143527.

2. Yen JH, Chen SF, Chern MK, Lu PC. The effect of turbulent viscous shear stress on red blood cell hemolysis. J Artif Organs. June 2014; 17(2):178–85.

3. Osborne J, Sobh M, Trudel G. Carbon monoxide as a clinical marker of hemolysis.J Hematol. July 2023; 98(7):1127–5

Fig. 1 (abstract A118).

ROC curve

Table 1 (abstract A118).

Chi-square test

	COHb > 3.13%	COHb < 3.13%	Marginal Row Totals
Survived	9 (12.98) [1.22]	18 (14.02) [1.13]	27
Deceased	16 (12.02) [1.32]	9 (12.98) [1.22]	25
Marginal column totals	25	27	52 (Grand Total)

A119 Role of mitral annular plane systolic excursion (MAPSE) for the assessment of septic cardiomyopathy in ICU: a prospective observational analysis from a single-center case series

S. Sfondrini, F. Torresani, D. Testa, M. D'Astuto, A. Lombardo

ASST Lariana - Nuovo Ospedale Sant'Anna, Como, Italy

Correspondence: S. Sfondrini

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A119

Introduction

Septic cardiomyopathy (SCM) is a common complication in critically ill patients with sepsis or septic shock. Its true incidence remains unknown due to the lack of a universally accepted diagnostic parameter. Hemodynamic monitoring with a Swan-Ganz catheter is unreliable in this context due to significant afterload alterations. [1]

Transthoracic echocardiography (TTE) is now the reference tool [3] for non-invasive and repeatable cardiac assessment in the ICU. Left ventricular ejection fraction (LVEF), although commonly used, has limitations in septic shock as it is influenced by preload and afterload changes and often compromised by poor acoustic windows in ventilated patients.

Mitral Annular Plane Systolic Excursion (MAPSE) [2], instead, is a simple and reproducible parameter obtainable even with suboptimal images and has shown good correlation with myocardial contractility. It may thus represent a valid alternative in assessing left ventricular dysfunction in sepsis.

Objectives

The study aimed to evaluate the reliability of MAPSE in diagnosing and stratifying septic cardiomyopathy. We specifically analyzed the correlation between MAPSE values at ICU admission and ICU length of stay (LOS) to explore its prognostic value.

Materials and Methods

This prospective observational study included patients consecutively admitted to the ICU of Sant'Anna Hospital in Como with a diagnosis of sepsis or septic shock (SEPSIS-3 criteria) [FIG.1]. All underwent TTE within 24 hours of diagnosis. Each patient was enrolled after providing informed consent [FIG.2]. The study consisted of two phases: a case-control comparison between septic and non-septic patients, and an analysis of the septic group to evaluate the correlation between MAPSE values and ICU LOS. Forty-two patients were included: 20 with sepsis/septic shock and 22 non-septic controls.

Results

Septic patients showed significantly lower MAPSE compared to controls (p = 0.001) [FIG.3] [FIG.4]. A statistically significant inverse correlation was observed between MAPSE values and ICU LOS (Spearman’s ρ = −0.500; p = 0.012) [FIG.5]. Lower MAPSE values were associated with longer ICU stays, supporting its role as a prognostic marker in septic patients.

Discussion

MAPSE emerged as a sensitive indicator of myocardial dysfunction in sepsis, with practical advantages over LVEF. Its ease of use and reliability even with limited acoustic access make it a valuable bedside tool. The correlation between reduced MAPSE and prolonged ICU stay highlights its potential in early risk stratification. Its value may be attributed to the fact that the subendocardial longitudinal myocardial fibers are the most vulnerable in conditions of energetic failure.

Conclusions

MAPSE is a reliable and accessible echocardiographic parameter for identifying and stratifying septic cardiomyopathy. Its integration into routine ICU assessment could improve early diagnosis and help identify patients at risk for prolonged ICU stays.

References

Singer et al. “The third international consensus definitions for sepsis and septic shock” JAMA, 2016

Bergenzaun et al “Mitral annular plane systolic excursion (MAPSE) in shock: A valuable echocardiographic parameter in intensive care patients,” Cardiovasc Ultrasound, 2013

Via et al., “International evidence-based recommendations for focused cardiac ultrasound,” Journal of the American Society of Echocardiography, 2014

1.Case group-enrollment criteria

INCLUSION CRITERIA

Age > 18 years

Diagnosis of sepsis or septic shock according to SEPSIS-3, within 24 hours prior to enrollment (either present at ICU admission or developed subsequently)

EXCLUSION CRITERIA

Mitral valve disease previously treated with surgical or transcatheter correction

Known hypokinetic cardiomyopathy

Known segmental wall motion abnormalities

Inadequate acoustic window

Lack of informed consent

2.Demographic characteristics

3.TTE Parameters

4.Case-control analysis

5.Regression

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A119).

Demographic and Clinical Characteristics

Fig. 2 (abstract A119).

Septic group - TTE Parameters

Fig. 3 (abstract A119).

See text for description

Fig. 4 (abstract A119).

See text for description

A120 Contrast-induced encephalopathy: a rare complication following contrast administration in a high-risk patient

F. Russo, G. Messalli, A. Vitiello, V. De Vivo, A. Milone, A. Torino, C. Candurro

P.O. Villa Malta - ASL SALERNO, Sarno, Italy

Correspondence: V. De Vivo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A120

Contrast-induced encephalopathy (CIE) is a rare complication associated with diagnostic procedures utilizing intravenous or intra-arterial iodinated contrast agents. We report the case of a 60-year-old male patient with a known diagnosis of progressive neurodegenerative disease, who was mechanically ventilated. The patient was urgently evaluated for suspected hemothorax and initially underwent contrast-enhanced CT of the chest and abdomen, followed by selective arteriography of the terminal intercostal branches and splenic arterial branches via femoral access. A water-soluble iodinated contrast agent was used in both istances. The procedure was technically uneventful and free of immediate complications; the patient was returned to the intensive care unit in relatively stable condition. Pre-procedural renal function parameters were within normal limits. Approximately 24–36 hours post-procedure, the patient developed mild lethargy, decreased responsiveness, and a transient reduction in urine output, which responded positively to intravenous hydration and medication with loop diuretics. At 48 hours, a follow-up contrast-enhanced chest CT was performed using the same water-soluble iodinated contrast agent. Despite cautious fluid administration and treatment with intravenous N-acetylcysteine, renal function further deteriorated, with elevated serum creatinine and urea levels, progressing to oligoanuria. Continuous high-dose intravenous furosemide infusion was initiated. Within 60 hours of intra-arterial contrast administration, the patient developed fever, facial and truncal flushing, and overt neurological symptoms, including altered mental status and right upper limb weakness progressing to hemiplegia. This was followed by generalized tonic-clonic seizures, necessitating sedation with benzodiazepines and initiation of intravenous valproic acid therapy. An urgent non-contrast brain CT revealed no ischemic or hemorrhagic lesions but demonstrated persistent contrast enhancement within cerebral tissues. In the following days, progressive improvement in renal excretory function was achieved through pharmacological therapy and continuous fluid resuscitation, with subsequent resolution of fever and flushing, full recovery of consciousness, and complete restoration of right upper limb strength. No further seizure episodes occurred. A follow-up brain CT confirmed complete contrast washout and absence of acute or subacute lesions. CIE can mimic severe neurological disorders and should be considered in the differential diagnosis when neurological symptoms arise after iodinated contrast administration, particularly in high-risk patients and following intra-arterial injection.

The authors obtained informed consent for the anonymous publication of the patient's clinical data.

References

1. Chen K et al. Iodinated Contrast Encephalopathy. Can J Neurol Sci. 2017

2. Kawatharani S et AlContrast Induced Encephalopathy: Case Report and Review of The Literature. Journal of Neurology and Neuromedicine 8.1 February 2024

3. Babalova L et Al Contrast-induced Encephalopathy. Bratisl Lek Listy. 2021

A121 Lung and diaphragm ultrasonography in patients with covid-19: a pilot study of correlation with albumin assessment

M.A. Chitani¹, P. Raimondo¹, P. dell'Aquila², L. Dell'Olio³, S. Lagroia⁴, N. Susca⁵, S. Grasso¹, L. Vetrugno⁶, V. Racanelli⁷

¹Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area Policlinico Bari, Italy; ²Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy; ³Physical Medicine and Rehabilitation Unit - USU Policlinico di Bari, Italy; ⁴Department of Anesthesia and Intensive Care P.O. Vittorio Emanuele II, Bisceglie, Italy; ⁵Internal Medicine Division, Santa Chiara Hospital, Provincial Health Care Agency (APSS), Trento, Italy; ⁶Anesthesia and Intensive Care Unit, P.O. San Antonio Abate, University of Friuli Centrale (ASUFC), Tolmezzo, Italy; ⁷Centre for Medical Sciences, University of Trento and Internal Medicine Division, Santa Chiara Hospital, Trento, Italy

Correspondence: M.A. Chitani

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A121

Introduction

The revolution represented by COVID 19 showed how fundamental can be the role of lung and diaphragm ultrasound (US) as diagnostic tool within intensive and sub-intensive care units.

The aim of the study is to investigate the role of ultrasound evaluating lung and diaphragm and possible clinical role of albumin in the evaluation of COVID-19 patients.

Ultrasound findings and albumin levels can reflect the state of inflammation and organ damage associated with SARS-Cov-2 infection: ultrasound can detect pulmonary alteration which are often associated whit significant inflammation; concurrently, levels of serum proteins, such albumin, may be elevated in response to inflammation.

Besides albuminemia correlates with the nutritional status, that significantly influences patient outcomes.

Methods

After informed consent, we enrolled patients who were: COVID-19-positive (molecular test of nasopharyngeal swab), age> 18 years, P/F 150-250, without sedation and neuromuscular disease. At the admission to our sub-intensive department, an experienced resident physician conducted bedside ultrasound exams following World Federation for Ultrasound in Medicine and Biology (WFUMB) guidelines. The Lung Ultrasound Score, diaphragm ultrasound excursion (in spontaneous breathing with or without oxygen therapy) and serum albuminemia, were reported in a case for report (CFR).

Results

From September to December 2021, we enrolled 42 patients. Our dataset included demographics, LUS, diaphragm ultrasound, and laboratory results. The outcome was favorable in 31 who were discharged, while 11 patients died after ICU admission. LUS scores significantly differed between survival and non-survival patients (p-value = 0.0002): patients with high LUS had a worse outcome. Diaphragm excursion correlates with LUS (0.01 < p-value < 0.05; rho: – 0.33), but there was no statistical difference between survival and non-survival patients. Albumin’s concentration in the survival group was greater than non-survival one with a statistical difference (Wilcoxon test, p-value = 0.01565). An increased LUS correlates with a decreased Albumin (0.01 < p-value < 0.05; rho: −0.44), while there was an initial but not significant correlation between diaphragm excursion and Albumin’s concentration (p-value 0.05 - 0.10; rho: 0.29), probably because nutritional status at the admission was not compromised among COVID patients (Fig 1; Fig 2).

Conclusion

Despite the low sample size, this pilot study suggests a multifactorial approach can represent a fundamental element for diagnosis and treatment for clinical status of the COVID-19 patients. The important predictive role of LUS was confirmed by the correlation with outcome of COVID positive patients and their diaphragm function studied using echography. The relationship between the outcome and LUS confirmed the importance of albuminemia level but not diaphragm echography. It is possible that this result was clarified by the nutritional status at the patient’s admission.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A121).

Bar graph for lus, diaphragm excursion, albumin’s concentration and outcome

Fig. 2 (abstract A121).

Scatter matrix (spearman correlation)

A122 Lactate gap” as a diagnostic clue in ethylene glycol intoxication

E. Raddi¹, S. Spadaro^1,2, G. Scaramuzzo^1,2, T. Tassinati², D. Osti², E. Marangoni², C.A. Volta¹

¹Università di Ferrara, Italy; ²Azienda ospedaliero universitaria di Ferrara, Italy

Correspondence: E. Raddi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A122

Background

Ethylene glycol (EG) is a widely used industrial alcohol, commonly found in household products, particularly as an automotive antifreeze. It is a colorless, odorless, and sweet-tasting liquid - characteristics that contribute to the risk of both accidental and intentional ingestion. In 2023, 7,454 cases of EG exposure were reported in the United States alone [1]. Toxicity typically Results from oral ingestion, with a lethal dose estimated at approximately 100 mL or 1-1.5 mL/kg [2,3], and mortality rates ranging from 1% to 22% [2]. The toxic effects of EG are primarily mediated by its metabolites, glycolic acid and oxalic acid, which induce severe high anion gap metabolic acidosis and calcium oxalate crystal deposition - particularly in the kidneys - leading to acute kidney injury. Point-of-care blood gas analyzers commonly utilize lactate oxidase to measure lactate levels: glycolic acid is structurally similar to lactic acid and can cross-react with this enzyme, resulting in falsely elevated lactate readings [4]. This phenomenon is called “lactate gap” and correlates linearly with serum glycolic acid concentrations [5].

Case report

A 27-year-old man with no previous relevant medical history was found unresponsive at home and transported to the Emergency Department. On arrival, he was comatose with a Glasgow Coma Scale score of 9 (E2 V2 M5). Pupils were normal and reactive. He was tachypneic and had experienced multiple episodes of vomiting. Vital signs were within normal limits (SpO2 96% on room air, BP 130/90 mmHg, HR 85 bpm). A point-of-care arterial blood gas (ABG) analysis (Radiometer ABL90) revealed a severe high anion gap metabolic acidosis (pH 7.018, pCO2 10.1 mmHg, HCO3- 2.6 mmol/L, anion gap 25.4 mmol/L). Notably, the lactate level was reported as non-measurable (>31 mmol/L), indicating it was beyond the device’s detection range. Initial blood tests showed hemoconcentration and mild-to-moderate creatinine elevation. A toxicology screen was negative. Imaging including brain CT, ECG, and chest X-ray were unremarkable. Point-of-care ultrasound revealed a collapsing inferior vena cava, suggesting hypovolemia. Fluid resuscitation with Ringer’s lactate and sodium bicarbonate was initiated. Due to progressive CNS depression, the patient was admitted to the ICU and intubated. A repeat ABG showed persistently severe acidosis and again a lactate level above the measurable range. Consequently, an arterial blood sample was sent to the central laboratory for confirmatory lactate measurement, which returned as 2.6 mmol/L. The marked discrepancy between the point-of-care and laboratory lactate levels raised suspicion for ethylene glycol poisoning. Following consultation with the Poison Control Center, treatment with intravenous fomepizole and high-efficiency intermittent hemodialysis was initiated. A few hours later, serum ethylene glycol levels confirmed the diagnosis.

Conclusion

Recognition of ethylene glycol poisoning can be challenging due to its nonspecific clinical presentation and misleading point-of-care lactate results. However, the presence of a “lactate gap” may serve as an important indirect marker of EG intoxication, with falsely elevated lactate levels potentially reflecting serum glycolic acid concentrations.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Rivers LJ, Feldman R, et al. 2023 Annual Report of the National Poison Data System® (NPDS) from America’s poison centers®: 41 st Annual Report. Clin Toxicol (Phila) [Internet]. 2024;62(12):793–1027. Available from: 10.1080/15563650.2024.2412423

2. Kraut JA, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management: Clinical features, diagnosis, and management. Clin J Am Soc Nephrol [Internet]. 2008;3(1):208–25. Available from: 10.2215/CJN.03220807

3. Kruse JA. Methanol and ethylene glycol intoxication. Crit Care Clin [Internet]. 2012;28(4):661–711. Available from: 10.1016/j.ccc.2012.07.002

4. Tintu A, Rouwet E, Russcher H. Interference of ethylene glycol with (L)-lactate measurement is assay-dependent. Ann Clin Biochem [Internet]. 2013;50(Pt 1):70–2. Available from: 10.1258/acb.2012.012052

5. Manini AF, Hoffman RS, McMartin KE, Nelson LS. Relationship between serum glycolate and falsely elevated lactate in severe ethylene glycol poisoning. J Anal Toxicol [Internet]. 2009;33(3):174–6. Available from: 10.1093/jat/33.3.174

A123 Impact of the trauma team on the management of polytrauma: experience from a level II trauma center

L. Neitzert¹, C. Druetto², D. Forno³, P. Molino³, M. Grio²

¹Università degli Studi di Torino, Torino, Italy; ²S.C. Anestesia e Rianimazione, Rivoli, Italy; ³S.C. Medicina e Chirurgia di Accettazione e di Urgenza, Rivoli, Italy

Correspondence: L. Neitzert

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A123

Background

Trauma Team (TT) Activation is crucial for the prompt care to trauma patients resulting in improved patient outcomes and reduced hospital stay and costs.

Objective

A prospective observational study was carried out to assess the outcomes of trauma patients before and after the implementation of a dedicated Trauma team at a Level II trauma center.

Methods

This prospective observational study includes all trauma patients during the observation period (2024-2025) who met the criteria for Trauma Team activation. The collected data were compared with a retrospective dataset (2023-2024) from the period prior to the implementation of the Trauma Team. Descriptive and inferential statistical analyses were performed. A multivariate regression model was applied to identify risk factors associated with 30-day mortality. The study was approved by the Local Ethics Committee (n.00483/2024).

Results

A total of 264 patients were prospectively enrolled in the study. Our study showed a non-statistically signifant reduction in overall 72h- (1.3% vs 2.3%; p: 0.635) and 30-day mortality (3.75% vs 5.88%; p:0.393). Age>65 years (OR 14.8; 95%CI:2.9-76.6; p<.001), ISS>15 (OR 90,9; 95%CI 5.1- 1605.8; p<.001), GCS<9 (OR 20,1; 95%CI 1.8- 73.6; p<.001), hemorrhagic shock (OR 13,1; 95%CI 2.1- 81.9; p=.006), unstable pelvic fracture (OR 60; 95%CI 8.1- 442.1; p<.001) were associated with higher 30- day mortality. Besides, after the activation of TT, we observed a statistically significant reduction of the Door-to-imaging (40 vs 54 minutes; p<.001), Door-to-OR (172 vs 252 minutes; p:0.02), Door to transfer (157 vs 337 minutes; p<.001) and Door-to-ICU (158 vs 226 minutes; p:0.03) time (Figure 1, 2 and 3).

Consent

Informed consent was obtained for the publication of this scientific article.

Conclusions

The implementation of a dedicated Trauma Team protocol is associated with an improved overall timeliness of care for trauma patients. Although a positive trend was observed, the reduction in overall mortality did not reach statistical significance.

Fig. 1 (abstract A123).

Characteristics of the patients included in the study, comparing the pre- and post-intervention periods related to the activation of the Trauma Team

Fig. 2 (abstract A123).

Multivariate analysis of risk factors associated with increased 30-day mortality

Fig. 3 (abstract A123).

Analysis of in-hospital management times for polytrauma patients

A124 Multimodal analgesia with dexdor, ketamine, lidocaine and magnesium in emergency laparotomy, a monocentric, retrospective study

S. Cotena¹, R. Annunziata¹, A. De Simone¹, A. Longobardi¹, R. Pirolli¹, M. Nugnes¹, M.E. Porcelli¹, G. Ragosta², E. Santoriello¹, M. Mariani¹

¹Emergency Anesthesia and Burn Intensive Care Unit, AORN A. Cardarelli, Naples, Italy; ²Anesthesia and Intensive Care Unit, PO Ospedale dei Pellegrini, ASL NA1, Naples, Italy

Correspondence:

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A124

Background

Epidural analgesia is considered the gold standard for postoperative pain control in major abdominal surgery. However, patients undergoing Emergency surgery may often present absolute and/or relative contraindications to the aforementioned anesthesiological technique, such as hemodynamic instability, coagulopathies or failure to suspend antiplatelet/anticoagulant therapies. The general conditions of the patient must also be considered, as they are often suffering and weakened and unable to maintain an adequate position for the execution of the technique. Multimodal analgesia (using combinations of systemic drugs and peripheral nerve blocks) has emerged as a potentially equivalent alternative, with fewer technical and logistical complications. This study aims at proving that multimodal analgesia is as effective as thoracic epidural analgesia in terms of postoperative pain control (assessed by the mean NRS/VAS score at T0 (basal), T1 (End of surgery/Recovery from anesthesia), T12.

Materials and Methods

This was a single-center observational retrospective study. We conducted this study between June 2024 and October 2024 at the department of Trauma and Emergency Surgery of Hospital Antonio Cardarelli. This study was approved by the local institutional review board (Ethics Committee). All patients >18 years of age undergoing emergency laparotomy for intestinal obstruction, intestinal perforation, intestinal ischemia/infarction were enrolled in the study.

The protocol for the Multimodal Analgesia involved the association of the TAP (Transversus Abdominis Plane) Block with Ropivacaine 0.375% + desametasone 2 mg, for a total of 20 ml, combined with the administration of i.v. drugs that act at different levels and with different mechanisms on the pain transmission pathways:

1. MAGNESIUM SULFATE: 2 g in 2 hours

2. DEXDOR: 0.2–0.7 mcg/kg/h

3. KETAMINE: 0.08–0.25 mg/kg/h

4. LIDOCAINE: 0.5–1.25 mg/Kg/h

Paracetamol 1 g + Tramadol 100 mg + Toradol 30 mg (if not contraindicated) would be administered. Post-operative analgesia was guaranteed with a 24-hours long infusion pump set at 2 ml/h, with Toradol 90 mg + Clonidine 150 mcg/. Paracetamol 1 g was also given every 8 hours. Each rescue dose of 2 mg IV of Morphine was recorded.

Results

In our analysis, we included 42 patients who fulfilled inclusion criteria. NRS values at T0, T1 and T12 were 6 (5-8), 1 (0-2), 2 (0-3), respectively.

Pairwise comparisons using paired Wilcoxon signed-rank test with p-values adjusted using the Bonferroni multiple testing correction method revealed statistically significant differences in NRS score between NRS T0, T1 and T12, as shown in Figure 1.

Consent

Informed consent was obtained for the publication of this scientific article.

Conclusions

Patients undergoing emergency surgery of the abdomen often present hemodynamic instability, are frequently affected by coagulopathies and the urgency of the procedure prevents the suspension of antiplatelet/anticoagulant therapies. In these cases, the conventional anesthesia used for elective surgery involving thoracic epidural analgesia is off the table.

Multimodal anesthesia has proven to be a viable option for open major abdominal surgery, securing a pain-free post operative course. In fact, we argue that the post-op pain was efficently managed (NRS max 3) with an opiod-free combination of drugs

Fig. 1 (abstract A124).

NRS score was statistically and significantly different using Friedman test, X2(2) = 64.06, p < 0.0001

A125 Severe systemic complications following pregnancy termination in a patient with sickle cell disease: a case report

G. Belmonte¹, S. Landini¹, D. Nodari², S. Cattaneo³

¹Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy; ²Department of Intensive Care Medicine, ASST Spedali Civili University Hospital of Brescia, Italy; ³Department of Anaesthesia and Cardiothoracic Intensive Care, ASST Spedali Civili University of Brescia, Italy

Correspondence: G. Belmonte

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A125

This report presents a complex case of a young woman with sickle cell disease (SCD) who developed life-threatening, multisystem complications following second-trimester pregnancy termination. The clinical course was characterized by vaso-occlusive crisis, severe thromboembolic events, and neurological impairment.

A young woman affected by known SCD underwent a medically indicated termination of pregnancy following premature rupture of membranes at approximately 19 weeks of gestation. After induction of abortion and uterine revision, she rapidly deteriorated, presenting with lower limb vaso-occlusive pain crises, febrile episodes, and worsening anemia with HbS fraction >50%. Following hematology consultation, erythrocytapheresis was initiated, with the goal of reducing HbS below 30%.

Subsequently, the patient developed acute respiratory distress. Given clinical suspicion for acute pulmonary embolism, an urgent chest CT was performed. The imaging confirmed bilateral pulmonary embolism involving segmental and subsegmental arteries. An emergent echocardiogram revealed severe right ventricular dysfunction.

Due to worsening respiratory and hemodynamic status, she was promptly transferred to the ICU, intubated, and mechanically ventilated with high oxygen requirements. Systemic thrombolysis with alteplase was administered after multidisciplinary consultation.

Despite timely intervention, the patient’s clinical status continued to deteriorate, prompting transfer to the Cardiac ICU for ECMO evaluation. ECMO was eventually avoided due to stabilization achieved with inhaled nitric oxide therapy.

After sedation discontinuation, the patient exhibited persistent unresponsiveness. Initial brain

CT was negative, while MRI later revealed findings consistent with cerebral fat embolism, showing characteristic lesions involving the corpus callosum and cerebellar peduncles, associated with cytotoxic edema and microhemorrhages.

Simultaneously, the patient experienced a hyperhemolytic crisis, managed successfully with eculizumab. Although off-label in this context, eculizumab was administered due to suspected complement-mediated mechanism contributing to the severity and refractoriness of the episode. Transfusions were complicated by atypical antibodies, significantly restricting compatible units and necessitating conservative targets around 7.5 g/dL.

The clinical course was further complicated by difficulty weaning from mechanical ventilation, necessitating tracheostomy and PEG placement.

After over 30 days of hospitalization, the patient remains in a minimally conscious state. However, she has shown early signs of neurological improvement, including visual tracking and occasional smiling in response to familiar voices.

Ongoing treatment includes anticoagulant therapy, along with careful hematological and neurological monitoring. Transfer to a neurorehabilitation center is planned to support further recovery.

This case highlights the challenges of managing multiorgan complications in SCD, following pregnancy termination. The concurrence of embolic syndromes, alloimmunization, and neurological impairment necessitated complex multidisciplinary management. Prompt recognition and targeted interventions are vital to improving outcomes in this high-risk population.

Consent

Informed consent was obtained for the publication of this scientific article.

A126 Pulmonary embolism and cardiac arrest in early post operative setting

S. Tantillo¹, M. Guarnera¹, E. Panigas², F. Matteo³, L. Giuntoli¹, F. Talarico¹, A.G. Franchini¹, C. Barbalace¹, D. Fecarotti¹, C.N. Tartivita¹, E. Morettini¹, R. Petracca¹, I. Farinelli¹, A. Tugnoli¹, I. Ottaviani¹, N. Cilloni¹

¹AUSL di Bologna, Ospedale Maggiore, UOC Terapia Intensiva e HUB Maxi Emergenze, Bologna, Italy; ²Ausl di Imola, Ospedale di Imola, UOC Anestesia e Rianimazione, Bologna, Italy; ³AUSL di Bologna, Ospedale Maggiore, UO Governo dei blocchi operatori e Anestesia Sud, Bologna, Italy

Correspondence: M. Guarnera

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A126

Background. Acute pulmonary embolism (PE) is a serious complication of oncology surgery, major liver surgery is often associated with postoperative derangements in coagulation balance. The incidence of PE after surgery is 3%, and the recognized associated risks post hepatectomy include: age greater than or equal 75 years old, male gender, BMI greater than 25, operative time greater than 240 minutes, extent of hepatectomy and occurrence of postoperative major complications.1 We present the clinical case of a patient who underwent liver resection complicated by cardiac arrest. Informed consent was obtained from the patient for the processing of data for scientific purposes.

Case Report. A 67-year-old patient was admitted to the ward following hepatic resection for colon cancer metastasis. She was mobilized 18 hours after surgery. During the transfer from chair to bed in the ward, the patient experienced cardiac arrest. Basic life support (BLS) was immediately initiated by the nursing staff, and the emergency team was called to proceed with advanced cardiovascular life support (ACLS). The initial rhythm presented as pulseless electrical activity (PEA). A cardiologist was consulted to help identify the underlying causes, specifically focusing on the “4 Ts.” An echocardiogram revealed a severely dilated right ventricle, consistent with a diagnosis of PE. Consequently, after approximately 50 minutes of chest compression with the LUCAS device and five doses of epinephrine, it was decided to administer 50 mg of alteplase. After 50 minutes from the administration of the drug, return of spontaneous circulation was observed. An epinephrine infusion was started, and the patient was transferred to a CT scan, which confirmed extensive PE. The patient was transferred to the intensive care unit, where progressive anemia was observed due to blood loss from the surgical site. Interventional radiologists subsequently performed embolization at the surgical site.

The patient was not given anticoagulant therapy for the first 48 hours due to the high risk of bleeding. A repeat CT scan of the brain at 24 hours showed no abnormalities, and CT scans of the chest and abdomen at 48 hours also showed no acute events. Following a marked overall improvement, the patient was discharged from the intensive care unit one month after admission. She was discharged with a Glasgow Coma Scale (GCS) score of 15, breathing spontaneously without oxygen, with stable hemodynamics, and capable of mobilizing independently.

Discussion. Despite having undergone hepatic surgery less than 24 hours prior, the patient was successfully treated with alteplase without unmanageable complications. We believe that the use of alteplase in suspected cases of cardiac arrest following recent non-cranial surgery in a hub hospital should be viewed as standard clinical practice. Furthermore, we advocate that the LUCAS device should be mandatory in hospital settings, as it ensures stable and adequate perfusion to the central nervous system and the entire body during prolonged resuscitations.

References

1. Lancellotti F, Coletta D, de'Liguori Carino N et al. Venous thromboembolism (VTE) after open hepatectomy compared to minimally invasive liver resection: a systematic review and meta-analysis. HPB (Oxford). 2023 Aug;25(8):872-880. 10.1016/j.hpb.2023.04.012.

Consent

Informed consent was obtained for the publication of this scientific article.

A127 Stellate ganglion block as treatment or prevention of arrhythmias in the septic patient: a case report

S. Tantillo¹, M. Guarnera¹, E. Cencigh², F. Mazzanti¹, L. Farabegoli¹, L. Alcamisi¹, C. Adiletta¹, I. Ottaviani¹, N. Cilloni¹

¹AUSL of Bologna, Ospedale Maggiore, Intensive Care Unit and Major Emergencies HUB, Bologna, Italy; ²University of Bologna, Department of Medicine and Surgery, Bologna, Italy

Correspondence: E. Cencigh

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A127

Introduction: Stellate ganglion blockade is recommended in the treatment of ventricular arrhythmic storms1, recently also used as a treatment for atrial fibrillation (AF)2 and introduced in the perioperative context, as a preventive treatment in the onset of AF, for its regulatory role in neurotransmitter secretion.3 Septic patients are subjected to high catecholaminergic stress, which is the reason for a compromise of myocardial function at different degrees of severity, a possible cause of patient mortality.4 We present the clinical case of a patient affected by septic shock, causing hemodynamic and arrhythmic instability, treated with continuous stellate ganglion block. Informed consent was obtained from the patient for the treatment of data for scientific purposes.

Clinical case. A 70-year-old patient admitted to intensive care unit after intestinal resection for ischemic necrosis of the right colon due to strangulated incisional hernia, with the packaging of a Bogotà bag, and subsequent recanalization after 48 hours. In anamnesis: obesity, previous bladder and breast cancer, the latter in follow-up. From a hemodynamic point of view, the patient presented a mixed shock, hypovolemic and septic, with the need for aggressive fluid resuscitation and circulatory support with norepinephrine (up to 0.2 mcg/kg/min), methylene blue and hydrocortisone. On the first and second postoperative day, AF with a high hemodynamic response appeared, for which therapy with landiolol in continuous infusion was started without efficacy. Given the lack of pharmacological response to the treatments administered, a stellate ganglion block was performed with the positioning of a perineural catheter and infusion of local anesthetic (ropivacaine 0.2% at 3 ml/h) for 48 hours. Norepinephrine and landiolol were withheld within the first 24 hours of blockade.On the 7th postoperative day, a new episode of supraventricular tachyarrhythmia up to 160 bpm without hemodynamic disturbance resolved with amiodarone bolus. The patient was discharged on the 15th postoperative day without further cardiovascular complications.

Discussion and Conclusions. Clinical studies are needed to demonstrate the efficacy of stellate ganglion blockade as a bridge treatment or prevention in arrhythmias in septic patients. The procedure should be considered as a therapeutic option in cases of arrhythmias refractory to poly-pharmacological treatments in a patient population, such as septic patients, with severe hemodynamic instability.

References

1. Baldi E, Dusi V, Rordorf R et al. Efficacy of early use of percutaneous stellate ganglion block for electrical storms. Eur Heart J Acute Cardiovasc Care. 2024 Dec 3;13(11):757-765.10.1093/ehjacc/zuae109.

2. Leftheriotis D, Flevari P, Kossyvakis C et al. Acute effects of unilateral temporary stellate ganglion block on human atrial electrophysiological properties and atrial fibrillation inducibility. Heart Rhythm. 2016 Nov;13(11):2111-2117. 10.1016/j.hrthm.2016.06.025.

3. Cai-Neng Wu 1, Xin-Hai Wu, Dong-Nan Yu, Wu-Hua Ma, Chun-Hui Shen, Ying Cao. A single-dose of stellate ganglion block for the prevention of postoperative dysrhythmias in patients undergoing thoracoscopic surgery for cancer: A randomised controlled double-blind trial. Eur J Anaesthesiol. 2020 Apr;37(4):323-331.10.1097/EJA.0000000000001137.

4. SchwartzA,Brotfain E, KoyfmanL,KleinM. Cardiac arrhythmias in a septic ICU population: a review. J Crit Care Med(TarguMures).2015;1(4): 140-146. 10.1515/jccm-2015-0027

Consent

Informed consent was obtained for the publication of this scientific article.

A128 Albumin versus crystalloids: fluid distribution and albumin kinetics in pigs ventilated at different mechanical power

G. Gazzè, E. Rollo, B. Donati, M. Caronna, I. Grava, L.M. Titherington, C. Chiumiento, Z. Li, W. Gallese, F. Collino, M. Busana, M. Quintel, O. Moerer, S. Gattarello

Department of Anesthesiology and Intensive Care, University Medical Centre Göttingen, Germany

Correspondence: G. Gazzè

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A128

Background

The rationale for using albumin in fluid resuscitation lies in its ability to increase plasma oncotic pressure and optimize hemodynamics and tissue perfusion. However, randomized trials in sepsis have not demonstrated a survival benefit, and the effects of albumin infusion on fluid distribution remain unclear. This study investigates, in healthy pigs, whether albumin infusion modifies intravascular fluid volume (IFV) distribution, compared to crystalloids, and explores albumin kinetics.

Methods

Thirty-nine healthy female pigs ventilated for 48 hours were categorized into four groups based on mechanical power (MP) (High ~18 J/min vs. Low ~6 J/min) and fluid type (5% albumin vs. balanced crystalloid) to achieve a set fluid balance: MPLOW-Crystalloid; MPLOW-Albumin; MPHIGH-Crystalloid; and MPHIGH-Albumin. Measurements were taken at baseline and six-hourly thereafter. Outcome variables included IFV and albumin kinetics and other physiological variables.

Results

No significant differences in IFV were observed over time across groups (Figure), and at 48 hours: MPLOW-Crystalloid.92 (±0.38) L; MPLOW-Albumin.86 (±0.37) L; MPHIGH-Crystalloid.72 (±0.40) L; MPHIGH-Albumin 2.10 (±0.58) L; p=0.389.

As expected, the theoretical and the actual quantities of albumin in the IFV were higher in the albumin groups compared to the crystalloid groups. Wasted albumin, defined as the difference between theoretical and actual albumin is shown in Figure 2. At 48 h, albumin-treated groups demonstrated significantly greater albumin waste, as high as: 62 (±13) % in the MPLOW-Albumin group and 58 (±24) % in the MPHIGH-Albumin group (p<0.001).

Groups receiving albumin had a higher volume of ascites: MPLOW-Crystalloids= 261 (±380)mL, MPLOW-Albumin = 710 (±664) mL, MPHIGH-Crystalloids =44 (±148) mL, and MPHIGH-Albumin = 685 (±651) mL (p=0.034) (Figure 3, Panel A). Additionally, the amount of infused albumin was linearly related to the volume of ascites (p<0.001; R2=0.750) (Figure 3, Panel B).

Conclusions

The 48h-long administration of albumin was associated with higher quantities of wasted albumin and greater volume of ascites.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A128).

Time course of intravascular fluid volume in the four experimental groups

Fig. 2 (abstract A128).

Time course of the percentage of wasted albumin in the four experimental groups

Fig. 3 (abstract A128).

Panel A – End-of-experiment ascites volume in the four experimental groups. Panel B – Association between the end-of-experiment infused albumin amount and ascites volume

A129 Driving pressure calculation during chest wall excision

D. Fiume, J. Fiore², G. Iafrate², C. Cacace², L. Coen Tirelli², G. Brignone², E. Lepore², B. Bartolozzi², C. Muolo³, D. Gaudio⁴, G. Massai⁴, A. Monticelli², A. Tiberi², F. Marchetti², S. Rezk⁵, S. Carlini⁶, P. Picerno², G. Spaltro⁷, M. Peverini, M. Galletti

¹UOC Anesthesia and Intensive Care – Sant’Eugenio Hospital, Rome, Italy; ²UOC Anesthesia and Intensive Care – University of Rome ‘Tor Vergata’, Rome, Italy; ³UOC Anesthesia and Intensive Care – University of Rome ‘La Sapienza’, Rome, Italy; ⁴UOC Anesthesia and Intensive Care – ‘Campus Bio-Medico’ University, Rome, Italy; ⁵‘UniCamillus’ – Saint Camillus International University of Health and Medical Sciences, Rome, Italy; ⁶UOC Surgical Anesthesia – San Giovanni Addolorata Hospital, Rome, Italy; ⁷UOC Plastic and Reconstructive Surgery – Sant’Eugenio Hospital, Rome, Italy

Correspondence: J. Fiore

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A129

Background

The management of the severely burned patient is complex. In severe and circumferential, or almost circumferential, burns of the trunk there is a concrete risk of compromise of thoracic-pulmonary function, with a decrease in the elasticity of the rib cage, and a consequent increase in pulmonary strain under mechanical ventilation (delta L/L0).

Materials and Methods

From January to December 2024, 8 patients with severe burns (TBSI >30%) involving the chest wall were observed, and during mechanical ventilation we calculated the driving pressure (kVT/FRC). The patients were divided into two groups of 4 patients each: the first group had a driving pressure higher than 5; the second group included patients with driving pressure below 5.

Results

Patients with a driving pressure higher than 5 were those who benefited most from surgical excision. In fact, in this group of patients, a substantial decrease in driving pressure (−48%) was observed compared to the other group (−15%) (8; 6-12) after the surgical procedure.

Conclusions

Fast and reliable calculation of driving pressure could help in the choice of performing thoracic excision in patients with circumferential or semicircumferential lesions of the rib cage.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Neto AS, Hemmes SN, Barbas CS, Beiderlinden M, Fernandez-Bustamante A, Futier E, Gajic O, El-Tahan MR, Ghamdi AA, Günay E, Jaber S, Kokulu S, Kozian A, Licker M, Lin WQ, Maslow AD, Memtsoudis SG, Reis Miranda D, Moine P, Ng T, Paparella D, Ranieri VM, Scavonetto F, Schilling T, Selmo G, Severgnini P, Sprung J, Sundar S, Talmor D, Treschan T, Unzueta C, Weingarten TN, Wolthuis EK, Wrigge H, Amato MB, Costa EL, de Abreu MG, Pelosi P, Schultz MJ; PROVE Network Investigators. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data. Lancet Respir Med. 2016 Apr;4(4):272-80. doi:0.1016/S2213-2600(16)00057-6. Epub 2016 Mar 4. Erratum in: Lancet Respir Med. 2016 Jun;4(6):e34. doi:0.1016/S2213-2600(16)30026-1. PMID: 26947624.

A130 Management of extensive third-degree burns in a young adult: a multidisciplinary approach

D. Fiume, G. Iafrate², J. Fiore², L. Befani, M. Arciuolo, G. Liciani, D. Ferraccioli, E. De Carolis, S. De Chiara, S. Parrino, S. Coppa, F. Spinelli, S. Carlini³, O. Bellucci, M. Casali, V. Mazzeo, L. Ceccherini, G. Spaltro⁴, M. Peverini, M. Galletti

¹UOC Anesthesia and Intensive Care – Sant’Eugenio Hospital, Rome, Italy; ²UOC Anesthesia and Intensive Care – University of Rome ‘Tor Vergata’, Rome, Italy; ³UOC Surgical Anesthesia – San Giovanni Addolorata Hospital, Rome, Italy; ⁴UOC Plastic and Reconstructive Surgery – Sant’Eugenio Hospital, Rome, Italy

Correspondence: G. Iafrate

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A130

Background

This case report details the complex management of a 23-year-old man upon arrival at the emergency department with severe third-degree burns involving 76.5% of his body surface area. The patient was immediately admitted to the Burns Center of the Sant'Eugenio Hospital in Rome. The affected areas extended to the anterior trunk, upper limbs and lower limbs.

Case report

On admission, the patient's vital signs were unstable, with tachycardia, hypotension, and altered mental status consistent with hypovolemic shock. The patient was immediately stabilized with sedation, followed by orotracheal intubation, and protective mechanical ventilation was initiated. A central venous catheter and an arterial catheter for invasive blood pressure monitoring were quickly placed, and fluid therapy according to the Parkland formula was started. Early percutaneous tracheostomy was performed. He was then subjected to two escharotomies with homologous skin grafts at two weeks intervals, and subsequently three surgical procedures of debridement and autologous skin grafts. During hospitalization, five septic shocks from pathogens of different nature occurred. These events were diagnosed and treated early. Early rehabilitation therapy was imposed, first passive and then active, and nutritional support adequate to the patient's needs. After56 days of hospitalization, our patient was discharged to a functional recovery facility, where he stayed for a few days before returning home.

Conclusion

This case report demonstrates the successful management of a young adult with third-degree external burns using a multidisciplinary approach. Early and aggressive resuscitation, meticulous surgical intervention, and vigilant infection control are essential to improve outcomes in these complex patients.

Consent to publish

Written informed consent for the publication is obtained from the patient.

A131 Pris, infectious complications and multi-organ failure in a pediatric patient with severe s. aureus and influenza B pneumonia: a case report

V. Fincati ¹, D. Saggioro², F. Filippone², F. Papaccio²

¹Department of Medicine, University of Padua, Italy; ²Department of Anesthesia ad Critical Care of Mestre, Mestre, Italy

Correspondence: V. Fincati

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A131

Background

Propofol Infusion Syndrome (PRIS) is a rare but potentially fatal complication of prolonged or high-dose propofol administration, characterized by metabolic acidosis, rhabdomyolysis, myocardial failure, and acute renal dysfunction. Pediatric patients with severe infections requiring sedation are particularly vulnerable. Moreover, viral-bacterial coinfections such as Influenza B and methicillin-sensitive Staphylococcus aureus (MSSA) have been increasingly associated with fulminant pneumonia and multi-organ failure. This case highlights the intersection of these two high-risk conditions in a critically ill adolescent.

Case Report

A7-year-old previously healthy female was admitted to the emergency department for high fever, cough, and pleuritic chest pain. She rapidly progressed to acute respiratory failure requiring ICU admission, tracheal intubation and prone ventilation. Bronchoalveolar lavage revealed Influenza B and MSSA. Targeted antibiotical therapy with on oxacillin and clindamycin was started. Prior to transfer to a second ICU, she received continuous propofol infusion for sedation. She subsequently developed profound metabolic acidosis, rhabdomyolysis (CPK > 90000 U/L), and acute kidney injury with anuria —clinical features consistent with early PRIS.

Upon arrival at tertiary care ICU, continuous renal replacement therapy (CRRT) was initiated. Despite multi-organ dysfunction including hepatic injury, coagulopathy (INR >.5), leukocytosis (WBC > 32 x10^9/L), and reactive thrombocytosis, the patient showed progressive improvement under advanced supportive therapy. Surveillance rectal swab revealed colonization by multidrug-resistant Pseudomonas aeruginosa without systemic infection. She underwent tracheostomy, successful ventilatory weaning, and neurological recovery.

Conclusion

This case illustrates the critical impact of dual viral-bacterial pneumonia compounded by PRIS in an adolescent patient. Early recognition of PRIS—especially in the setting of unexplained metabolic derangement during propofol sedation—is essential for prognosis. The clinical evolution reinforces the need for tight biochemical monitoring and a high index of suspicion when propofol is used, particularly in pediatric patients with severe infections.

Written informed consent for publication was obtained from the patient’s parent.

References

1. Larsen SAH, Kyhl K, Baig S, et al. Life-Threatening Necrotizing Pneumonia with Panton-Valentine Leukocidin-Producing, Methicillin-Sensitive Staphylococcus aureus in a Healthy Male Co-Infected with Influenza B. Infect Dis Rep. 2021;14(1):12-19. 10.3390/idr14010002

2. Randolph AG, Vaughn F, Sullivan R, et al. Critically Ill Children During the 2009–2010 Influenza Pandemic in the United States. Pediatrics. 2011;128(6):e1450–e1458. 10.1542/peds.2011-0774

3. Laquay N, Prieur S, Greff B, et al. Le syndrome de perfusion du propofol. Ann Fr Anesth Reanim. 2010;29(5):377–386. 10.1016/j.annfar.2010.02.030

A132 Impact of the introduction of critical care outreach on icu activity and clinical outcomes at spedali civili of brescia university hospital (Brescia, Italy)

M. Filippini, A. Francione², A. Capone², E. Roberti², A. Cirelli², P.F. De Michele², J. De Valiere², D. Fiumanò², L. Maruca², M. Stefanini², L. Spinuzza², R. Zangari², E. Zendra², M. Parzani, L. Grillo⁴, N. Latronico³, F.A. Rasulo³

¹Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Brescia, Italy; ²Specialization School in Anesthesiology and Intensive Care, University of Brescia, Italy; ³Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy; ⁴School of Medicine and Surgery, University of Brescia, Italy

Correspondence: A. Francione

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A132

Background

The Critical Care Outreach (CCO) service, introduced in February 2023 at Spedali Civili University Hospital (Brescia, Italy), represents a proactive, systematic, and structured model of intensive care consultation aimed at the early identification and prompt management of clinical deterioration in hospitalised patients. This study stems from the hypothesis that the CCO may improve both the organisation of work within Intensive Care Units (ICUs) and the clinical outcomes of patients transferred from other hospital wards. [1]

Objectives

1.To analyse the impact of CCO on the number of emergency intra-hospital intervention requests.

2.To evaluate changes in the number and timing of ICU admissions from general wards.

3.To examine the clinical characteristics and outcomes of patients transferred to the ICU before and after the introduction of the CCO.

Materials and Methods

A retrospective observational study analysing data from 2019 (pre-CCO starting) and 2024 (post-CCO starting). ICU patients were categorised as “Internal” (admitted to the ICU from hospital wards after intensive care consultation) and “External” (admitted to the ICU from the Emergency Department, other hospitals, or other ICUs). Data were extracted from internal databases and the digital emergency call log of the Anaesthesia and Intensive Care Unit. Variables analysed included: Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA), mortality, intubation, Ventilation-Free Days (VFDs), use of vasoactive drugs, and Vasoactive Drug-Free Days (VDFDs). Statistical analysis was performed using Student’s t-test, Mann-Whitney U test, and Chi-square test, with significance set at p < 0.05.

Informed consent was obtained according to the law

Results

The introduction of the CCO was associated with a significant reduction in emergency intervention requests (from 3 to/week, −66%, p<0.01). In 2024, “Internal” patients were younger and had lower SAPS II scores compared to 2019. ICU mortality for “Internal” patients decreased from 29.6% to 21.1% (p<0.05), while it increased for “External” patients (Table). The intubation rate among “Internal” patients decreased (from 62.9% to 53.6%) and VFDs increased (from 2 to 3 days).

Patients directly managed by the CCO in 2024 showed better clinical outcomes (Figure).

A change was also observed in the hourly distribution of ICU admissions for “Internal” patients, with fewer transfers during 00:00–08:00 and 08:00–16:00, and an increase during6:00–24:00.

The median admission time shifted from4:00 (2019) to5:00 (2024), indicating a more structured and planned transfer process.

Conclusions

The introduction of the CCO at Spedali Civili of Brescia was associated with significant organisational and clinical improvements, particularly for patients transferred from general wards. The data suggest that CCO is an effective model for optimising the management of critically ill patients and improving ICU outcomes. Further prospective studies are warranted to confirm these findings, along with an assessment of the associated economic implications.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Trenchard-Turner, N., Desai, N., & Metaxa, V. (2023). Critical care outreach teams: a service without walls. Intensive Care Medicine,49(5),572-574.

Fig. 1 (abstract A132).

Clinical outcomes in ICU patients: impact of CCO

Table 1 (abstract A132).

ICU mortality in analysed patients

ICU mortality (%)	Year 2019	Year 2024	p
"Internal"patients	29,6	21,1	< 0,05
"External"patients	14,3	17,1	< 0,05

A133 Comparative analysis of performance levels in floor-based CPR versus hospital bed-based CPR using QCPR technology. Preliminary data from a prospective observational study

V. Di Nardo¹, M. Scimmi¹, F.A. Ferilli²

¹Azienda Ospedaliera S. Maria, Terni, Italy; ²Italian Academy of Rescue and Resuscitation, Castelfranco di Sotto (PI), Italy

Correspondence: V. Di Nardo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A133

Background

The quality of chest compressions is a determining factor in the success of CPR. Numerous studies have shown that the depth, frequency and continuity of compressions affect the chances of survival and neurological recovery after arrest.

However, in in-hospital clinical practice patients in ACC are placed on soft surfaces, such as beds with standard mattresses.

The hypothesis that soft surfaces can compromise the effectiveness of CPR is supported by several empirical observations, but there is still a lack of scientific evidence.

The aim of this study is to evaluate to what extent the surface on which CPR is performed influences its effectiveness.

Materials and Methods

Prospective observational study. Involved 16 participants, nursing students and nurses with a valid BLSD certification and no physical limitations. CPR maneuvers were performed on two different surfaces: floor, and hospital bed with a height of 65 cm, of which 16 cm of polyurethane foam mattress, with a rigid CPR board 55 cm long and 40 cm wide placed under the manikin.

The experiment was carried out with the aid of QCPR technology (figure 1), developed by Laerdal Medical. The following parameters were monitored:

• Average CPR performance in bed (%)

• Compression performance (%)

• Ventilation performance (%)

• Percentage of time in which compressions are delivered

• Average depth (mm)

• Average insufflated volume

• Average time between compression series

Each participant performed two-minute practice sessions for each of the two conditions, in a random order to avoid the learning effect.

Results

The results show how the average depth of compressions varies in favor of CPR performed on the floor 49.1 mm, compared to 46.1 mm of CPR performed on the bed.

The performance related to the frequency of chest compressions shows a value of 66.3% in CPR on the floor, compared to 60.7% of CPR performed on the bed. The average ventilatory volume was similar between the two conditions (table 1).

From the analysis of the data it emerges that the quality of CPR is generally better when the patient is on the floor.

An additional aspect that emerged during the study concerns the height of the operator in relation to the height of the bed.

For operators (7) with a height of less than 165 cm, it was necessary to use a riser to ensure an ergonomically correct position and optimize the quality of compressions.

Conclusions

In relation to the results that emerged, the depth of compressions was confirmed as the parameter most influenced.

The results of this study will provide concrete data on how the surface on which CPR is performed can affect CPR, contributing to a deeper understanding of the practical challenges that healthcare workers face during emergencies in hospital settings.

The relatively small sample size (16 participants) and the short duration of the experimental sessions (2 minutes) may not have captured the effect of muscle fatigue.

The height and physical strength of the workers may have affected the ability to generate adequate compressions.

Table 1 (abstract A133).

Results

	FLOOR	BED
Average CPR performance in bed (%)	70,5	61,3
Compression performance (%)	66,3	60,7
Ventilation performance (%)	95,3	92,6
Percentage of time in which compressions are delivered (%)	65,1	65,0
Average depth (mm)	49,1	46,1
Average insufflated volume (ml)	460,2	450,4
Average time between compression series (seconds)	10,0	10,1

Fig. 1 (abstract A133).

QCPR2

Table 2 (abstract A133).

Results

	FLOOR	BED
Average CPR performance in bed (%)	70,5	61,3
Compression performance (%)	66,3	60,7
Ventilation performance (%)	95,3	92,6
Percentage of time in which compressions are delivered (%)	65,1	65
Average depth (mm)	49,1	46,1
Average insufflated volume (ml)	460,2	450,4
Average time between compression series (seconds)	10	10,1

A134 Evaluation of cardiac compression efficacy: manual cpr versus lucas device using transesophageal echocardiography

L. Curcio, A. Credendino, C. Visani, M. Vargas

Department of Neuriosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy

Correspondence: L. Curcio

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A134

Introduction

Manual chest compressions are the cornerstone of cardiopulmonary resuscitation (CPR), particularly in the early stages of cardiac arrest. Their effectiveness depends on factors such as depth, rate, full chest recoil, and interruptions.[1]

According to the 2020 AHA and 2021 ERC guidelines, chest compressions should be performed at a depth of 5–6 cm, at a rate of00–120 compressions/minute, with complete chest recoil between compressions. Proper technique ensures optimal coronary and cerebral perfusion during cardiac arrest.[2-3] The quality of manual compressions is influenced by the rescuer’s strength and fatigue level. Studies have shown that compression quality begins to deteriorate within the first two minutes of continuous effort.[4] High-quality manual CPR has been associated with increased rates of return of spontaneous circulation (ROSC), survival and better neurological outcomes. Conversely, inadequate compressions impair perfusion and decrease the probability of survival.[5] The LUCAS device (Lund University Cardiopulmonary Assist System) is a mechanical system designed to deliver automatic chest compressions during CPR. It aims to standardize compression quality and overcome the limitations of manual CPR. The LUCAS device delivers chest compressions at preset depth and rate (approximately 5 cm at00–120/min), ensuring consistent perfusion and minimizing interruptions. It can operate in continuous mode or synchronized with ventilation, enhancing hemodynamic effectiveness.[6] LUCAS has proven especially valuable during patient transport and in scenarios requiring prolonged resuscitation. Additionally, it allows healthcare providers to focus on other critical interventions, such as defibrillation or airway management.[7]

AIM. The aim of our study is to investigate the association between the use of the LUCAS device during CPR and the enhanced left ventricular compressions compared to manual chest compressions.

Materials And Methods

After obtaining informed consent, echocardiographic acquisitions, lasting 5 minutes, were performed using a transesophageal cardiac probe in the four-chamber mid-esophageal view (Fig.1) on patients experiencing cardiac arrest, admitted to the intensive care unit of AOU Federico II, Naples, Italy. During these acquisitions, CPR was administered with both manual chest compressions and the LUCAS device.

DISCUSSION. We assessed the left ventricular area at the point of maximal compression during CPR, comparing chest compressions by the LUCAS (Figure 2) with those delivered by manual compression (Figure 3). The analysis demonstrated a left ventricular area of approximately 4 cm² during maximal compression with LUCAS-assisted compressions, compared to approximately 20 cm² during manual compressions.

Conclusions

Our results suggest that the maximal left ventricular compression achieved with the LUCAS device is nearly five times greater and more consistent than that obtained with manual compressions. This mechanical consistency may translate into more effective forward blood flow and improved hemodynamic stability during resuscitation efforts. Moreover, compressions delivered by the LUCAS device exhibited consistent depth across the entire resuscitation sequence. Instead, manual compressions showed greater variability, likely influenced by operator fatigue and turnover. These results support the potential hemodynamic advantages of automated CPR systems in maintaining high-quality chest compressions.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Ochoa, F. J., Ramalle-Gomara, E., Lisa, V., & Saralegui, I. (1998). The effect of rescuer fatigue on the quality of chest compression. Resuscitation, 37(3), 149–152. https://doi.org/10.1016/S0300-9572(98)00099-4

2. Ashton, A., McCluskey, A., Gwinnutt, C. L., & Keenan, A. M. (2002). Effect of rescuer fatigue on performance of continuous external chest compressions over 3 min. Resuscitation, 55(2), 151–155. 10.1016/S0300-9572(02)00174-5

3. Christenson, J., Andrusiek, D., Everson-Stewart, S., et al. (2009). Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation, 120(13), 1241–1247. 10.1161/CIRCULATIONAHA.109.852202

4. Meaney, P. A., Bobrow, B. J., Mancini, M. E., et al. (2013). Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation, 128(4), 417–435. 10.1161/CIR.0b013e31829d8654

5. Panchal, A. R., Bartos, J. A., Cabañas, J. G., et al. (2020). Guide line AHA 2020 per RCP ed ECC. Circulation, 142(16_suppl_2), S366–S468. 10.1161/CIR.0000000000000916

6. Rubertsson, S., Lindgren, E., Smekal, D., et al. (2014). Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. *JAMA*, 311(1), 53–61. 10.1001/jama.2013.282538

7. Gates, S., Quinn, T., Deakin, C. D., et al. (2015). Mechanical chest compression for out-of-hospital cardiac arrest: Systematic review and meta-analysis. *Resuscitation*, 94, 91–97. 10.1016/j.resuscitation.2015.06.016

Fig. 1 (abstract A134).

Echocardiographic acquisitions using a transesophageal cardiac probe in the four-chamber mid-esophageal view

Fig. 2 (abstract A134).

Echocardiographic acquisitions during LUCAS compressions

Fig. 3 (abstract A134).

Echocardiographic acquisitions during manual compressions

Paediatric and neonatal perioperative medicine

A135 New psychoactive substances and anaesthesia: a systematic appraisal of literature

C. Lazzari², M. Vason², R. Zoppellari, B. Palazzi², G. Dallocchio², A. Marra³, B. Quarta³, C.A. Locatelli⁴

¹Medical and Surgical Society of Ferrara, Ferrara, Italy; ²Deparetment of Anesthesia and Intensive Care, S. Anna Hospital, Ferrara, Italy; ³Pharmacy, S. Anna Hospital, Ferrara, Italy; ⁴Toxicology Unit, Pavia Poison Centre and National Toxicology Information Centre IRCCS, Pavia, Italy

Correspondence: C. Lazzari

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A135

Objective

A shocking augmentation in the use of new psychoactive substances (NPS) increases the likelihood of anesthesiologic procedures for patients using these kinds of substances of abuse (SoA). Signs and symptoms of NPS – i.e. arilcicloexilamines, phenethylamines, piperazines, synthetic cannabinoids, synthetic cathinones, tryptamines [1] (Fig. 1)- can be variable and unpredictable. A systematic appraisal of literature regarding the pharmacological and clinical interactions between NPS with anaesthetic drugs is proposed.

Methods

We performed a literature search limited to articles published in English using PubMed, Cochrane and Medline from 2000 to september 30, 2024. The following keywords were used: NPS, synthetic cannabinoids, synthetic cathinones, anaesthesia and perioperative. After a systematic search, a preliminary assessment considered 15 articles presenting in the abstract the keywords NPS, and/or synthetic cannabinoids, synthetic cathinones, combined with anaesthesia and/or perioperative. A second screening limited in our review 8 articles for their relevance.

Results

The choice of optimal timing of surgery may be challenging, due to the occurrence of acute coronary syndrome in patients using cathinones and amphetamine-type stimulants. General anaesthesia could reduce metabolic demands, decrease body temperature and give better control of cardiovascular alterations. Nevertheless, regional anaesthesia is not contraindicated, but requires adequate cooperation of the patient. Hyperkalaemia due to rhabdomyolysis, caused by muscle activity, contraindicates succinylcholine administration. NPS induce sympathetic excitation resulting in tachycardia and peripheral depletion of catecholamines: prudence in administering ketamine for induction, due to its depressive effects on cardiac performance, is suggested. Sympathetic excitation also increases risk of myocardial infarction and non-cardiogenic pulmonary oedema. Propranolol, and particularly labetalol, are generally contraindicated to treat hypertension due to their effect on unopposed alpha-receptor activation; calcium channels blockers, nitroprussiade and phentolamine may be beneficial. The treatment of intraoperative hypotension requires cautionary administration of direct-acting vasopressors, such as epinephrine, norepinephrine and phenylephrine, whereas ephedrine administration is not indicated, due its powerful sympathetic stimulation. To manage severe postoperative agitation due to withdrawal or cardiovascular alterations, monitoring in intensive care unit or other monitored setting, has been suggested.

Conclusion

This review is a noteworthy concern that is on the rise, because adequate data regarding chemistry, pharmacology and toxicology of NPS are limited compared to traditional SoA. To date, thorough consensus guidelines about optimal anaesthesiologic strategies for NPS users are insufficient.

References

• Locatelli CA, Lonati D, Petrolini VM. New drugs of abuse and cardiovascular function. In: Govoni S, Politi P, Vanoli E, eds. Brain and heart dynamics. Springer: Cham; 2020.−27.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A135).

See text for description

A136 Anesthetic approaches during enzymatic debridement with nexobrid™ in pediatric burn care

E. La Rosa¹, E. Paoli², D. Grifoni¹, F. Facchini¹, Z. Ricci¹

¹Department of Anesthesia and Critical Care, Meyer Children's Hospital IRCCS, Florence, Italy; ²Pediatric Plastic Surgery and Burn Centre Division, Meyer Children's Hospital IRCCS, Florence, Italy

Correpondence: E. La Rosa

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A136

Background

Enzymatic debridement with bromelain represents an established treatment option for deep partial-thickness and full-thickness burns, offering a selective and less invasive alternative to surgical excision.1 However, the procedure is associated with significant procedural pain.There is limited evidence regarding the optimal anesthetic strategy in the pediatric population, where pain management represents the main challenge. 2 This study aims to describe the anesthetic approaches in a tertiary-level pediatric burn center for children undergoing bromelain-based enzymatic debridement.

Materials and Methods

We conducted a single-center retrospective study including pediatric patients (age <6 years) with scalds burns, resulting in deep dermal or full-thickness burns, for which they underwent enzymatic debridement with NexoBrid™. Eligible patients have been treated between July 2024 and May 2025 at our tertiary-level Pediatric Burn Center at Meyer Children’s Hospital, Florence, Italy. The surgical treatments have been performed either in the operating room or at bedside, combined with different anesthesiology techniques. The primary outcome was to describe the anesthesiology management during both phases of enzymatic debridement, consisting in application and removal of Nexobrid™, respectively. The secondary outcome was the assessment of pain treatment during product application.

Results

A total of 22 pediatric patients were included in the study,0 females and2 males, with a mean age of 5.3 years (range: to4 years). Burn injuries were extended with a mean Total Body Surface Area (TBSA) of1.7% (range: 2%–30%), mostly on arms and legs (73%), but with rare extension to the head (22%) and genitalia (18%). In one case, the application procedure has been performed at the bedside with moderate sedation in spontaneous breathing. All the remaining procedures have been performed in the operating room under general anesthesia. Dosages and different kind of anesthetic drugs are described in table. Only one procedure was performed with combined regional anesthesia and moderate sedation. Laringeal respiratory mask (LMA) was used in all general anesthesia, except for burns extended to head and neck which required laryngotracheal intubation. For removal procedures, anesthetic drug use was significantly reduced, with an increasing number of moderate sedation over general anesthesia, requiring minimal or null oxygen supply. The procedures were mostly performed in the operating room; one was performed bedside and two in ICU: for all patients, setting of choice was used for both applying and removal. For the secondary outcome, opioid analgesia, with fentanyl and/or morphine, was administered in all cases to achieve effective pain control.

Conclusion

In our experience, general anesthesia combined with opioid-based analgesia provided effective pain control in a variety of clinical settings, including the operating room and ICU.

Consent

Informed consent was obtained for the publication of this scientific article.

References

Hirche C. Eschar removal by bromelain based enzymatic debridement (Nexobrid®) in burns: European consensus guidelines update. Burns. 2020 Jun;46(4):782-796.

Claes K. Pain management during a bromelain-based selective enzymatic debridement in paediatric and adult burn patients. Burns. 2022 May;48(3):555-567.

Table 1 (abstract A136).

Anesthetic approaches in both applying and removal of Nexobrid™

	Nexobrid apppliance								Nexobrid removal
	Anesthesia	S	P	K	M	OT	WO	SO	Anestesia	S	P	K	M	OT	WO	SO
1	s								S		X	X
2	G	x	x					x	S			X	X
3	G	x						x	S		X	X
4								x	S		X
5	S			x			x	x	S			x		protossido
6	G		x		x			x	S		x		x		X
7	G		x		x			x	G	X	X					X
8	G	x	x				x	x	S		x				X	X
9								x	S					dex		X
10	G	x	x		x			x	S		x					X
11	G		x		x		x	x	G	X			X			X
12	G	x	x		x			x	S						X	X
13	G	x	x					x	G	x	x		x		X	X
14	G	x	x		x			x	S			x	x		X	X
15	G		x	x	x			x	G		x	x		dex		X
16	G	x	x	x	x	dex	x	x	G			x	x	dex		X
17	G	x	x		x		x	x	G	x	x				X	X
18								x	G
19	G	x	x	x				x	S		x			dex	X
20	G		x		x			x	G	x	x					X
21	G	x	x	x	x			x	S	x	x	x				X
22	ALR	x	x	x	x	ALR		x	ALR + S	x	x	x	x

S. sedation; G: general anesthesia; ALR: loco-region anesthesia; P: propofol; S: Sevoflurane; K: ketamine; M: midazolam; OT:others; WO: weak opioids; SO: strong opioids

A137 Pediatric obstructive sleep apnea: anesthesiologic implications in patients undergoing otolaryngological surgery

C. Di Fabio¹, R. Petronca¹, A. Piroli³, F. Marinangeli³, E. Iacomino³, C. Ansevini²

¹Scuola Di Specializzazione Anestesia Rianimazione E Terapia Del Dolore, L'aquila, Italy; ²Università Degli Studi Dell’Aquila, L'aquila, Italy; ³Ospedale San Salvatore, L'aquila, Italy

Correspondence: C. Di Fabio

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A137

Introduction: Pediatric obstructive sleep apnea syndrome (OSAS) represents a high anesthetic risk condition, particularly in children undergoing ENT procedures [1]. This study aims to assess the impact of OSAS on perioperative management under general anesthesia.

Materials and Methods

A single-center, prospective, observational study was conducted at the Department of Anesthesia and Intensive Care, in collaboration with the Department of Otolaryngology, at San Salvatore Civil Hospital in L’Aquila, between July 4, 2024, and December3, 2024. Pediatric patients (aged 3–16 years), classified as ASA I–II, undergoing adenoidectomy, tonsillectomy, or adenotonsillectomy were enrolled. Patients were divided into two groups: Group A with OSAS, Group B without OSAS. Anesthetic, intraoperative, and postoperative variables were analyzed using non-parametric statistical methods.

Results: A total of 40 patients were included: 21 with OSAS (52.5%) and9 without OSAS (47.5%). The presence of OSAS was associated with significantly longer surgical duration (51.7 ±6.2 min vs 40.2 ±7.1 min; p=0.0248) (Table), lower oxygen saturation at T0 (97.5% vs 98.8%; p<0.001) and T1 (99.0% vs 99.9%; p<0.0001) (Tables 2 and 3), and a higher number of intubation attempts (66.67% vs 5.26%; p<0.0001) (Table 4). Additionally, OSAS patients showed prolonged awakening times (18.2 ± 4.2 min vs1.2 ±.9 min; p<0.0001) and longer stays in the post-anesthesia care unit (9.9 ± 2.4 min vs 7.6 ± 2.8 min; p=0.0103) (Table 5).

Conclusions

The results highlight that pediatric patients with OSAS are at higher anesthetic risk, requiring careful preoperative planning and tailored perioperative protocols. A multidisciplinary approach and extended postoperative monitoring are essential to minimize the risk of complications and ensure perioperative safety [2].

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Lucero A, Dalesio NM. Pediatric Obstructive Sleep Apnea. Open Anesthesia, 2023.

2. SIAARTI. La gestione perioperatoria del paziente con Sindrome delle Apnee Ostruttive del Sonno (OSA) - versione 01, 28.02.2019

Table 1 (abstract A137).

Surgical duration (minutes)

DURATION	MEAN	SD	MEDIAN	MIN	MAX
GROUP A	51.7	16.2	55	20	75
GROUP B	40.2	17.1	43	20	75

Table 2 (abstract A137).

Oxygen saturation (SaO2) at T0 (start of intubation)

SaO2T0(%)	MEDIA	DEV. STD	MEDIANA	VALORE MINIMO	VALORE MASSIMO
GRUPPO A	97.5	0.9	97	94	99
GRUPPO B	98.8	0.9	99	97	100

Table 3 (abstract A137).

Oxygen saturation (SaO2) a T1 (end of intubation)

SaO2T1(%)	MEAN	SD	MEDIAN	MIN	MAX
GROUP A	99	0.6	99	98	100
GROUP B	99.9	0.3	100	99	100

Table 4 (abstract A137).

Number of orotracheal intubation attempts(IOT)

N°. ATTEMPTS IOT	1	> 1	TOTAL
GROUP A	7 33.33%	14 66.67%	21 52.5%
GROUP B	18 94.74%	1 5.62%	19 47.5%
TOTAL	25 62.5%	15 37.5%	40 100%

Table 5 (abstract A137).

Awakening time

AWAKENING TIME (minutes)	MEAN	SD	MEDIAN	MIN	MAX
GROUP A	18.2	4.2	17.0	12.0	25
GROUP B	11.2	1.9	10.0	10.0	15.0

A138 Volume-controlled ventilation provides an additional lung protection in healthy anesthetized children: an electrical impedance tomography study

A. Camporesi¹, P. Cruces^2,3, V. De Giorgis¹, S. Cereghini¹, E. Zoia¹

¹Ospedale dei Bambini Vittore Buzzi, Milano, Italy²Unidad de Paciente Crítico Pediátrico, Hospital El Carmen Dr. Luis Valentín Ferrada, Santiago, CHILE³Laboratory of Translational Research in Critical Care, Faculty of Life Sciences, Universidad Andres Bello, Santiago, CHILE

Correspondence: A. Camporesi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A138

Background

There are no definitive data on choice of best intraoperative ventilation mode between Volume-Controlled, constant flow mode (VCV) and Pressure Regulated Volume Controlled (PRVC) with decelerating flow in healthy pediatric patients during surgery. We aimed to study differences in respiratory mechanics, regional ventilation distribution, intra-lung compliance, global Inhomogeneity, and energy dissipation related to changes in flow morphology in healthy anesthetized children.

Methods

Prospective, observational, cross-over study. Healthy children scheduled for general anesthesia were enrolled after parental consent. Exclusion criteria included chronic or acute pulmonary and heart disease, chest wall deformity. After anesthesia induction and muscle relaxation, patients were ventilated first in VCV then in PRVC with same settings: VT 8 to0 mL/kg, Positive End Expiratory Pressure 5 cmH2O, fraction of inspired oxygen (FiO2) 0.3, respiratory rate (RR) adjusted to achieve an end-tidal carbon dioxide (ETCO2) 40 (plus or minus 5) mmHg. RR was kept constant across modes. Intra-lung compliance and global inhomogeneity Index were assessed though Electric Impedance Tomography (EIT) (PulmoVista 500, Draeger Medical, Germany), allowing at least five minutes after change of mode to let adequate time for gas distribution. At the same time, respiratory mechanics measures were obtained in quasi-static conditions after an inspiratory hold manoeuver, ensuring stability of plateau pressure (PPLAT). We assessed resistive (PIP-PPLAT) and elastic components (DP and quasi-static compliance) of working pressure, and mechanical power as a marker of energy dissipation. Data was expressed as median (IQR). Respiratory mechanics and EIT data were compared with Wilcoxon matched-pairs sign rank test.

Results

23 patients were enrolled (71 males). Age was 6 (4-7) years-old, weight was 21 (17-25) kg, and BMI5.5 (14.3-17.3) kg/m2. During transition from VCV to PRVC, the resistive component decreased (8 (7-9.5) vs 4 (3-5) cmH2O; p<0.001), without changes in DP and quasi-static compliance.

Regarding EIT assessments, patients showed higher net Compliance Loss 8 (3.5-10) % and Global Inhomogeneity Index (38 (36-41) vs 38 (35-40); p<0.001). Mechanical power increased (0.33 (0.28-0.39 vs 0.4 (0.33-046)) J/min*kg; p<0.001). Figure and Figure 2.

Discussion

Despite VT and inspiratory time being constant, the decelerating flow worsen regional mechanics, declining intra-lung compliance and homogeneity, and increasing energy dissipation than squared-shaped flow. All these changes are closely related to higher risk of ventilation-induced lung injury, at a global and regional levels. It may be related to increased stress on lung tissue due to rapid insufflation. Therefore, controlling inspiratory airflow through VCV may provide additional lung protection.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A138).

Intralung Compliance according to EIT, Global Inhomogeneity Index, PIP-PPLAT and Mechanical Power across ventilation modes

Fig. 2 (abstract A138).

Compliance win and Compliance loss in the shift from VCV to PRVC

Metabolism, nutrition and renal therapies

A139 Impact of the eras protocol on clinical outcomes in colorectal surgery: correlation between adherence and postoperative length of stay

P. Maiolino¹, M.R. Sarno², M. Casale³, A. Nitrato Izzo⁴, N. Frizzante⁵, R. Nisco⁶, F. Ratti⁷, F. Cavallaro⁸, V. Oliva⁹, R. Guarino⁰, L. Perna¹, M. D'Amico², F. Moccia³, M. Di Marzo⁴, P. Delrio⁵

¹Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ²Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ³Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ⁴Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ⁵Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ⁶Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ⁷Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ⁸Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ⁹Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ¹⁰Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ¹¹Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ¹²Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ¹³Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ¹⁴Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy; ¹⁵Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy

Correspondence: P. Maiolino

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A139

Background

The ERAS (Enhanced Recovery After Surgery) approach is a multidisciplinary protocol aimed to improve clinical outcomes in surgical patients by reducing postoperative complications and hospital length of stay [1]. The protocol includes a preoperative phase (prehabilitation and correction of nutritional deficiencies), an intraoperative phase and a postoperative phase (in-hospital recovery) [1]. This study aims to assess the level of patient adherence to the ERAS protocol and the length of hospital stay in patients undergoing colorectal surgery, with particular focus on the preoperative nutritional management carried out by the Hospital Pharmacy Unit.

Materials and Methods

A retrospective analysis was conducted on patients who underwent colorectal surgery during the period 2023-2024. The analysis included a total of07 patients. Patients with missing data regarding length of hospital stay were excluded in order to reduce the risk of bias in the Results. Data were extracted from a clinical database containing information on surgical patients. For each patient, the following variables were considered:

-type of surgical procedure (colon resection ± stoma; rectal resection ± stoma; other abdominal procedures related to neoplastic disease);

-date of surgery;

-length of hospital stay (in days);

-percentage adherence to the ERAS protocol;

-preoperative nutritional support.

Adherence to the ERAS protocol was calculated based on 25 standardized targets for each patient. Patients were divided into two groups according to their level of adherence to the protocol: group A (adherence less than 70%) and group B (adherence equal to or greater than 70%). For each patient, the number of postoperative hospital days was recorded, and the mean length of stay was compared between Groups A and B. To supplement the clinical database, the management database of the Hospital Pharmacy was consulted to review the type of Food for Special Medical Purposes administered during the preoperative and to assess the appropriate procurement of nutritional supplement. Informed consent and data processing authorization were obtained.

Results

Group A recorded an average hospital stay of 6.7 days while group B showed a mean hospital stay of 5.7 days. The patients with adherence equal to or greater than 70% to the ERAS protocol experienced an average reduction of4.9% in postoperative length of stay (Figure, Figure 2 and Figure 3). The supply of the liquid nutritional supplement for surgical patients in the preoperative phase was verified by Hospital Pharmacy's information system. This supplement was selected based on its specific nutritional characteristics, in accordance with the requirements of the ERAS protocol.

Conclusions

The analysis confirms that higher adherence to the ERAS protocol is associated with a significant reduction in hospital stay among patients undergoing colorectal surgery. It is important to highlight that all patients included in the study had undergone preoperative nutritional screening, underscoring the central role of nutritional assessment as an integrated and essential component of the ERAS pathway. This was made possible through the synergistic collaboration of the multidisciplinary team.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr. 2017 Jun; 36(3):623-650.

Fig. 1 (abstract A139).

Correlation between the ERAS protocol adherence and length of hospital stay

Fig. 2 (abstract A139).

Correlation between length hospital stay and number of patients with adherence equal to or greater than 70% to the ERAS protocol

Fig. 3 (abstract A139).

Correlation between length hospital stay and number of patients with adherence less than 70% to the ERAS protocol

A140 Hemoperfusion with cytosorb® in a complex case of hemorrhagic shock and rhabdomyolysis: impact on renal recovery

I. Maruzzella, C. Pellegrini, C. Sassone, A.R. Iodice, C. Cafora, F. Gritti, E. Rossella, P.F. Marsilia, F. Imperatore

UOC Rianimazione DEA - AORN Cardarelli, Napoli, Italy

Correspondence: I. Maruzzella

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A140

Background

Rhabdomyolysis is a known cause of acute kidney injury (AKI) in critically ill patients, often related to trauma, surgery, sepsis, or prolonged ischemia. The release of myoglobin into the bloodstream can directly contribute to tubular damage and renal vasoconstriction through several mechanisms. Conventional CRRT fails to effectively remove myoglobin due to its molecular size and hydrophobicity. Hemoperfusion with CytoSorb® has emerged as an adjunct strategy to early remove circulating myoglobin and prevent renal damage¹-³.

Case report

A 17-year-old polytrauma patient was admitted in red code due to a severe road accident. Initial vital signs were indicative of hemorrhagic shock (BP 95/55 mmHg, HR 116 bpm). Laboratory tests showed metabolic acidosis, lactate 4.4 mmol/L, and serum potassium 6.75 mmol/L. Imaging confirmed multiple fractures, including an unstable open-book pelvic fracture and a displaced distal left femur fracture, along with soft tissue injuries in the perineal region, without signs of active bleeding. The patient underwent surgical packing, orthopedic intervention, gynecologic revision, and was admitted to the ICU under mechanical ventilation, fluid resuscitation, and vasopressor support.

Within 24 hours, urine output dropped to <30 mL/h and myoglobin levels exceeded 10,000 ng/mL. Creatinine levels doubled in the same timeframe, and the patient was classified as AKI stage III according to KDIGO criteria. CRRT was initiated along with CytoSorb® hemoperfusion, with cartridge replacement every 24 hours for the first 4 days.

CytoSorb® enabled efficient myoglobin removal. In combination with CRRT and supportive therapy, the patient achieved hemodynamic and metabolic stabilization.

During the first 48 hours of hemoperfusion, a marked reduction in serum myoglobin was observed. Urine output improved progressively and renal replacement therapy was discontinued on day 12, with a complete renal function recovery by day 30, in line with literature data.

No further need for dialysis was recorded during hospitalization. (Table 1)

This case highlights the clinical utility of CytoSorb® in managing rhabdomyolysis-related AKI. While supportive therapy remains the first-line treatment, hemoadsorption may accelerate myoglobin clearance and mitigate tubular injury. Current recommendations suggest early initiation (within 24 h of diagnosis) of CytoSorb® hemoperfusion in cases with serum myoglobin >10,000 ng/mL¹. This case aligns with those expert opinions, emphasizing its relevance in post-trauma AKI settings.

Conclusion

Early and adjunctive use of CytoSorb® hemoperfusion contributed to the complete renal recovery in a patient with severe rhabdomyolysis and AKI. Future prospective studies are needed to define optimal timing and patient selection to deliver more tailored therapy.

Consent to publish

Written informed consent was obtained for publication.

References

1. Forni L, et al. Hemoadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the Hemoadsorption in Rhabdomyolysis Task Force. BMC Nephrol. 2024;25(1):247. 10.1186/s12882-024-03679-8

2. Scharf C, et al. Blood purification with a cytokine adsorber for the elimination of myoglobin in critically ill patients with severe rhabdomyolysis. Crit Care. 2021;25(1):41. 10.1186/s13054-021-03468-x

3. Gräfe C, et al. The effect of CytoSorb® application on kidney recovery in critically ill patients with severe rhabdomyolysis: a propensity score matching analysis. Ren Fail. 2023;45(2):2259231. 10.1080/0886022X.2023.2259231

Table 1 (abstract A140).

Trend of serum myoglobin and CPK levels and renal function during CytoSorb treatment

Neuroanesthesia and neuroreanimation

A141 Impact of ventilator settings on outcomes - a comparison between neurocritical and non–neurocritical ICU patients

S.C. Serafini, R. Cinotti², K. Asehnoune², D. Battaglini, C. Robba, A.S. Neto³, L. Pisani⁴, G. Mazzinari⁵, E.M. Tschernko⁶, M.J. Schultz⁷

¹University of Genoa, Italy; ²CHU Nantes, Nantes, France; ³School of Public Health And Preventive Medicine, Melburne, Australia; ⁴Giovanni XXIII Policlinic Hospital, Bari, Italy; ⁵Hospital Universitario La Fe, Valencia, Spain; ⁶Medical University Wien, Vienna, Austria; ⁷Amsterdam UMC, Amsterdam, The Netherlands

Correspondence: S.C. Serafini

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A141

Introduction

We compared ventilatory management strategies and examined ventilation–related factors independently associated with outcomes between neurocritical and non–neurocritical care patients receiving invasive ventilation.

Methods

We used harmonized individual patient data from three large observational studies of ventilatory management, pooled into the ‘PRIME’ database, to describe ventilatory parameters. Using a multivariable model incorporating demographic, clinical and respiratory variables, we identified modifiable and non–modifiable factors associated with intensive care unit (ICU)–mortality, the primary endpoint of this analysis. ICU– and hospital length of stay (LOS) were secondary endpoints.

Results

The final analysis included702 neurocritical care patients and920 non–neurocritical care patients (Table). Neurocritical care patients had a lower ICU–mortality rate (14.3% vs. 22.8%, P < 0.001), and a longer ICU– and hospital LOS. Neurocritical care patients were ventilated with lower median tidal volume, positive end expiratory pressure, fraction of inspired oxygen (FiO2), plateau pressure, driving pressure and mechanical power (Figure and Table 2). Respiratory rate was not different between the two groups. Neurocritical care patients had a higher respiratory system compliance. In neurocritical care patients, age, sex, body mass index, diabetes, FiO2 and Glasgow coma scale minor or equal to 6 had an independent association with ICU–mortality; in non–neurocritical care patients, only body mass index and Simplified Acute Physiology Score III were independently associated with this outcome (Table 3).

Conclusion

In this cohort of invasively ventilated patients, showing a lower ICU–mortality in neurocritical care patients compared to non–neurocritical care patients, only FiO2 was independently associated ICU–mortality, and only in neurocritical care patients. These findings highlight the importance of proper oxygen management in neurocritical care patients.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A141).

Distribution graphs of ventilatory parameters; vertical dotted lines indicate the median of the overall population; horizontal dotted lines always represent the proportion of 0.5

Table 1 (abstract A141).

Patient Demographics, Baseline Characteristics and Outcomes

	neurocritical care patients (N = 1702)	non–neurocritical care patients (N = 1920)	P
demographics
age, year	54 [36–66]	61 [47–71]	< 0.001
sex, male	1145 (67)	1143 (60)	< 0.001
height, cm	170 [165–176]	165 [160–172]	< 0.001
weight, kg	75 [65–85]	70 [59–80]	< 0.001
PBW, kg	66 [57–71]	61 [52–68]	< 0.001
BMI, kg/m2	25 [23–28]	25 [22–28]	< 0.001
admission type, n (%)			< 0.001
trauma	809 (47.6)	32 (1.7)
surgical urgency	686 (40.3)	274 (14.5)
medical	198 (11.6)	1032 (54.7)
surgical elective	8 (0.5)	549 (29.1)
admission reason, n (%)			< 0.001
traumatic brain injury	808 (47.5)	0 (0.0)
intracranial bleeding	566 (33.3)	0 (0.0)
SAH	293 (17.2)	0 (0.0)
stroke	201 (11.8)	0 (0.0)
CNS infection	116 (6.8)	0 (0.0)
intoxication	0 (0.0)	44 (2.4)
pneumonia	7 (2.8)	120 (6.5)
metabolic	0 (0.0)	94 (5.1)
sepsis	0 (0.0)	91 (4.9)
heart failure	1 (0.4)	87 (4.7)
nosocomial pneumonia	3 (1.2)	66 (3.6)
exacerbation COPD	1 (0.4)	56 (3.0)
postsurgical	5 (2.0)	45 (2.4)
other	37 (2.2)	142 (7.4)
comorbidities			< 0.001
diabetes	226 (13.3)	480 (25.5)
neoplasia	66 (3.9)	328 (17.4)
COPD	59 (3.5)	170 (9.1)
chronic heart failure	56 (3.3)	241 (12.8)
outcomes
ARDS*, n (%)	147 (8.7)	75 (3.9)	< 0.001
ICU mortality, n (%)	230 (14.3)	397 (22.8)	< 0.001
ICU LOS, days	13 [7–23]	4 [2–8]	< 0.001
hospital LOS, days	20 [7–36]	16 [9–34]	0.986

Data are expressed as median with [IQR] or numbers (proportions %) where appropriate

Abbreviations: BMI, body mass index; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; PBW, predicted body weight; SAH, subarachnoid hemorrhage; ARDS, acute respiratory distress syndrome; ICU, intensive care unit; LOS, length of stay

Table 2 (abstract A141).

Ventilatory Settings, Variables, and Parameters

	neurocritical care patients (N = 1702)	non–neurocritical care patients (N = 1920)	P
ventilation mode, n (%)			< 0.001
VCV	1052 (63)	498 (27)
PCV	469 (28)	476 (26)
PSV	30 (2)	109 (6)
other	122 (7)	760 (41)
VT, mL	460 [420–500]	474 [402–530]	0.004
VT, mL/kg PBW	7.2 [6.5–8.0]	7.9 [6.8–9.2]	< 0.001
PEEP, cmH2O	5 [5, 6]	5 [5–8]	< 0.001
Pmax, cmH2O	18 [15–20]	18 [15–23]	0.056
Pplat, cmH2O	16 [14–19]	17 [14–21]	< 0.001
ΔP, cmH2O	10 [8–13]	12 [9–16]	< 0.001
set RR, bpm	14 [14–16]	14 [14–16]	0.616
total RR, bpm	16 [14–20]	16 [14–19]	0.281
ventilatory ratio	1.17 [0.97–1.42]	1.29 [1.02–1.72]	< 0.001
CRS, mL/cmH2O	43 [34–53]	39 [28–50]	< 0.001
MP, J/min	7.9 [6.5–10.0]	8.4 [6.6–11.8]	< 0.001
PaO2, mmHg	115 [90–158]	127 [90–178]	0.001
FiO2	0.40 [0.30–0.50]	0.50 [0.40–0.60]	< 0.001
PaO2/FiO2	300 [224–413]	278 [180–390]	< 0.001
PaCO2, mmHg	37 [33–41]	38 [32–45]	0.023
pHa	7.40 [7.34–7.43]	7.35 [7.29–7.41]	< 0.001

Data are expressed medians with [IQR] or numbers (proportions %) where appropriate

Abbreviations: C_RS, compliance respiratory system; FiO₂, fraction of inspired oxygen; MP, mechanical power; PaCO₂, partial pressure of carbon dioxide; PaO₂, partial pressure of oxygen; PBW, predicted body weight; PCV, pressure control ventilation; PEEP, positive end-expiratory pressure; Pmax, maximum airway pressure; Pplat, plateau pressure; PSV, pressure support ventilation; RR, respiratory rate; VCV, volume control ventilation; V_T, tidal volume; ΔP, driving pressure

Table 3 (abstract A141).

Factors associated with ICU Mortality

	neurocritical care patients		non–neurocritical care patients
	odds ratio	P	odds ratio	P
age	1.55 (1.17–2.06)	0.002
sex	1.88 (1.09–3.25)	0.024	1.57 (0.75–3.32)	0.233
BMI	0.62 (0.47–0.83)	0.001	0.67 (0.44–1.01)	0.053
admission type
medical	1 (reference)
elective surgery	–	–
urgent surgery	1.50 (0.53–4.23)	0.440
trauma	0.70 (0.24–2.03)	0.515
comorbidities
diabetes	2.45 (1.30–4.63)	0.006
chronic heart failure	2.62 (0.95–7.21)	0.062
COPD	0.25 (0.03–1.95)	0.186
neoplasm	0.79 (0.22–2.76)	0.705
VT, mL/kg PBW	1.27 (0.94–1.70)	0.119	1.17 (0.74–1.83)	0.503
ΔP, cmH2O	1.06 (0.81–1.39)	0.651	1.26 (0.87–1.84)	0.224
total RR, bpm	0.87 (0.65–1.16)	0.336	0.78 (0.51–1.19)	0.245
FiO2	1.28 (1.00–1.62)	0.046	1.12 (0.76–1.67)	0.563
pHa	1.08 (0.81–1.44)	0.610	0.70 (0.45–1.08)	0.109
PaO2, mmHg	1.22 (0.96–1.56)	0.102	0.79 (0.52–1.21)	0.278
PaCO2, mmHg	0.69 (0.41–1.18)	0.174	1.26 (0.82–1.93)	0.302
disease severity score
GCS > 9	1 (reference)
GCS > 6 and ≤ 9	1.21 (0.67–2.18)	0.533
GCS ≤ 6	1.83 (1.02–3.27)	0.043
SAPS III			1.03 (1.02–1.05)	< 0.001

Results from the logistic regression models, with results presented as odds with 95%–confidence intervals

Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; GCS, Glasgow coma scale; PaCO₂, partial pressure of carbon dioxide; PaO₂, partial pressure of oxygen; PBW, predicted body weight; PEEP, positive end–expiratory pressure; RR, respiratory rate; SAPS III, simplified acute physiology score 3; V_T, tidal volume; ΔP, driving pressure

A142 Sporadic creutzfeldt-jakob disease (SCJD) a case report

E. Scapini, S. Barbaro, A. Cavuoto, F. Corvasce, V. De Palo, M. Gaglio, G. Garribba, A. Spinelli, M. Stuppiello, A. Zagaria, M. Vurchio, M.L. Debitonto

Ospedale Mons R. Dimiccoli, Barletta, Italy

Correspondence: S. Barbaro

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A142

Creutzfeldt-Jakob disease (CJD) is a rare condition that causes brain damage and is always fatal within two years. CJD can be classified into sporadic (80%), genetic (10–15%) and acquired. This disease is characterized by abnormal prion protein accumulation in the brain, spongiform alteration, neuronal loss and gliosis. Brain imaging may show high signal intensity in caudate, putamen, and/or cortical regions, a typical EEG pattern consisting of generalized periodic sharp wave complexes is observed in many cases. [1] Clinically it is marked by quickly cognitive impairment and neurologic signs and symptoms. Consent to this publication has been obtained.

We present a case of a 63-year-old woman who was referred to hospital for rapidly progressive symptoms of balance disorders, depressed mood, asthenia and visual impairment which started two months before the first visit. Over the past two weeks, her cognitive issues have significantly gotten worse, according to her family. Upon admission to intensive care, the patient was clinically in a coma with myoclonus in all four limbs, pyramidal or extrapyramidal dysfunction. She died after approximately two months of hospitalization in intensive care.

Most of the biological samples were transported and analyzed in Rome at the ISS - Istituto Superiore di Sanità. Cerebrospinal fluid (CSF) studies were performed. CSF tests showed elevated TAU protein values (2000 pg/mL), pathognomonic of degenerative disease. Laboratory tests for inflammatory and infectious diseases were negative. Further tests were sent to exclude paraneoplastic pathologies and demyelinating diseases of the CNS. The new technique RT-QuIC (real-time quaking-induced conversion) was performed on a liquor sample with a positive result, further confirmation of the CJD. Genetic testing showed no pathogenic mutations for prion disease. Magnetic Resonance Imaging (MRI) of the brain performed in baseline conditions and after contrast, was significant for global parenchymal loss. The supratentorial bihemispheric cortex and striatum of both sides were included by a subtle restriction of free water diffusivity and subtle hyperintensity in FLAIR. There were no recent ischemic brain lesions or signs of intracranial hemorrhage. An electroencephalogram (EEG) showed pattern characterized by periodic recurrence of generalized bi-triphasic sharp waves at frequency-3 Hz, on a globally slowed background. This pattern appears in most patients with CJD, according to the ISS epidemiological surveillance card.

There is wide differential diagnosis for CJD, including vascular disorders, neurodegenerative, autoimmune, infectious, malignant metastatic, iatrogenic, toxic or metabolic conditions that can result in rapid progressive dementia or progressive cognitive impairment.

WHO has defined the diagnostic criteria of sporadic CJD comprising progressive dementia, with at least two out of the four clinical signs (myoclonus, visual or cerebellar impairment, pyramidal or extrapyramidal dysfunction, and atypical mutism) along with atypical EEG pattern in the course of the disease and identification of protein4-3-3 in cerebrospinal fluid or the most recent RT-QuIC positive test. [2]

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Jurcau, M.C. et Al. A Systematic Review of Sporadic Creutzfeldt-Jakob Disease: Pathogenesis, Diagnosis, and Therapeutic Attempts. Neurol.Int.2024,6,039-1065. 10.3390/neurolint16050079

2. Al-Ansari A, Robertson NP. Creutzfeldt-Jacob disease: new directions in diagnosis and therapeutics. J Neurol. 2017;264:1029–31. doi:0.1007/s00415-017-8473-4.

A143 Acute brain injury: the impact of hub and spoke network centralization

A. Demurtas¹, S. Pilloni¹, M. Deplano¹, F. Demelas², F.M. Loddo¹

¹Dipartimento Attività Cliniche - Ospedale NS della Mercede - SC Anestesia e Rianimazione - ASL Ogliastra, Lanusei, Italy; ²Dipartimento Chirurgico-Oncologico - Ospedale A Businco - SC Anestesia e Rianimazione - ARNAS Brotzu, Cagliari, Italy

Correspondence: A. Demurtas

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A143

Background

Healthcare systems have increasingly resorted to rapidly transfer patients admitted in a Spoke Center with time dependent illnesses (such as acute brain injury) to a Hub center, using a telemedicine service for image transfer, to ensure the best possible treatment. This work aims to analyse the effectiveness of centralization in the management of patients with acute brain injury admitted to the Hospital in Lanusei who required neurointensive care evaluation, analysing treatment times, 3-month outcome and final outcome.

Methods

Retrospective observational study of cases from January 2022 to September 2024. 49 patients were included, with a diagnosis of ischemic stroke (21 cases) and cerebral haemorrhage (28 cases, of which5 were traumatic and3 spontaneous). Demographic, clinical, imaging, treatment and outcome data were collected. The 3-month outcome was assessed using the modified Rankin Scale (mRS) defining between favourable (mRS <=3) and unfavourable (mRS >3) outcomes.

Results

The main age was 80 years, with a prevalence of men (59%). 59% of patients were under antithrombotic therapy,7% of them underwent reversal of anticoagulation treatment. In patients with ischemic stroke, 42% were transferred for fibrinolytic/endovascular treatment, with good outcomes (35% mRS 0-1 at 3 months). In patients with haemorrhage, 57% were centralized, after hemodynamic and respiratory stabilization, with3 undergoing decompressive craniectomy and endovascular therapy with moderate functional outcome (mRS =3). The timing from the patient’s arrival in the Emergency Department to reaching the Hub center had a median value of80 minutes. 78% of them were transferred by ambulance to the Hospital in Nuoro, 22% by air ambulance to the Hub center in Nuoro, Sassari, Cagliari. In non-transferred patients outcome was influenced by a more severe initial presentation with low GCS, high NIHSS and comorbidities (>2 risk factors). Furthermore, in transferred patients an association was observed between unfavourable outcome and INR >2,5 values (in anticoagulated patients) and/or radiological signs of intraventricular haemorrhage, midline shift >10 mm, hematoma expansion. Age did not show an association with outcome in both groups.

Conclusions

In patients with acute brain injury, proper management of the acute phase, with rapid stabilization and centralization of patients, is crucial. However, the outcome was not conditioned by centralization itself, although this fate involved about half of the observed cases, and the timing of the transfer was in line with the main international guidelines. The intrinsic challenges in the management of acute brain injuries are well known, but in a decentralized healthcare context a factor that can certainly be addressed is the stabilization of the patient, in a context of standards of care that begins in the Spoke Center to continue in the means used for transfer until arrival at the Hub center, where the patient will receive advanced treatments.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Greenberg M S, Ziai W C, et al. Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 Jul;53(7):e282-e361.

A144 TBI patients admitted to neuro-icu in low/middle income countries don’t have worse neurological outcomes compared to patients in high income: a secondary analysis of the train study

F. Gloria¹, C. Bittencourt Rynkows³, I. Sbaraini Zernini¹, M. Giglio², S. Grasso², F. Puntillo², F.S. Taccone¹, E. Gouvêa Bogossian¹

¹Department of Intensive Care Erasme hospital, University hospital of Brussels Belgium; ²Intensive Care Unit, Policlinico di Bari, Italy; ³Department of neuro-intensive care Cristo Redentor Hospital Porto Alegre, Brazil

Correspondence: F. Gloria

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A144

Introduction

Traumatic brain injury is an important public health issue that affects 55-70 million people annually1 and is associated with high mortality rates and long-term disability2.Low- and middle-income countries (LMICs) bear a disproportionate burden of TBI, accounting for over 90% of all trauma-related fatalities3. Previous studies reported that patients in LMICs have higher risk of dying from severe TBI compared to those in high-income countries (HICs)4. However, whether the neurological outcome and mortality rates of patients TBI in low-middle income countries admitted to high volume centers is higher than in high income centers has not been explored.

Objectives

The main objective of this study is to assess the rate of poor neurological outcomes of TBI patients admitted to high volume centers in low-middled compared to high income countries.

Methods

This is a secondary analysis of TBI patients enrolled in the TRAIN study5, a multicenter, randomized, pragmatic clinical trial that assessed the impact on outcome of two transfusion strategies. The primary outcome is the incidence of poor neurological outcome at 6 months defined as a GCS-extended of-5 in patients admitted to centers in LMIC and in HIC. Secondary outcome is the ICU mortality rate in patients admitted to centers located in LMIC and in HIC.

Results

A total of 486 patients with TBI were analyzed:36 (27.98%) were admitted to centers in LMIC and 350 (72.02%) to centers in HIC. In the LMIC centers the media age was 42.6 years, 71.4% were male, the median APACHE II score at admission was7 (14-20) and the median GCS at the ictus was 7 (5-10) which was statistically similar to patients admitted to centers in HIC. 92 (67.6%) patients from LMIC had unfavorable neurological outcome at 6 months compared to 218 (62.3%) patients in HIC (p=0.27). The ICU mortality rate was 29.1% (n=39) in patients admitted to centers in LMIC compared to7.1% (n=60) in patients admitted to centers in HIC (p=0.004). In a multivariate logistic regression patients admitted to centers in LMIC compared to patients in HIC did not a higher chance of unfavorable outcome (odds ratio 0.85 95% CI 0.85-0.94) when adjusted to age; GCS, pupillary reactivity, hypoxemia on admission, hypotension on admission, cerebral ischemia, organ failure, ICP crisis requiring second TIER therapy.

Consent

Informed consent was obtained for the publication of this scientific article.

Conclusions

In this secondary analysis of the TRAIN study patients be admitted to high volume centers in LMIC and HIC had similar rates of unfavorable outcome.

Reference

1. Dewan MC et al Estimating the global incidence of traumatic brain injury. JNeurosurg. 2019;30:080–1097(2019)

2. Iverson GL Outcome from mild traumatic brain injury. Curr Opin Psychiatry8,301–317(2005)

3. Guan, Bin et al Global, regional and national burden of traumatic brain injury and spinal cord injury,990-2019: a systematic analysis for the Global Burden of Disease Study 2019(2023)

4. MRC CRASHTrialCollaborators et al.'Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients.” (2008): 425-9

5. Taccone FS et al Restrictive vs Liberal Transfusion Strategy in Patients with Acute Brain Injury: The TRAIN Randomized Clinical Trial

A145 Cerebral fat embolism: a rare case report

R. De Maglio¹, L.G. Giaccari^,2, E. Epifani¹, R. Barbieri¹, F. Madaro¹, G. Paiano¹, D. Mastria¹, G. Pulito¹, L. Mascia³

¹Vito Fazzi Hospital - Dipartimento di Anestesia e Rianimazione, Lecce, Italy;²University of Campania Luigi Vanvitelli - Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Napoli, Italy; ³University of Salento - Dipartimento di Medicina Sperimentale, Lecce, Italy

Correspondence: R. De Maglio

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A145

Background

Cerebral fat embolism (CFE) is a rare but potentially fatal complication that usually occurs within 2-72 hours of trauma with long bone fractures [1]. CFE has an incidence of 0.9%–2.2%. It is usually self-limiting with a mortality rate of0%. This type of fat embolism syndrome is characterized by purely cerebral involvement. The main manifestations are headache, confusion, convulsions, focal deficit, altered state of consciousness and coma. Neuroimaging, mainly brain MRI, can speed up the diagnosis, avoiding other unnecessary investigations and treatments [2]. No specific treatment is recommended other than symptomatic and supportive treatment.

Case report

A 20-year-old man was admitted to our Emergency Department (ED) with comminuted fractures of both the lower limbs secondary to a motorcycle accident without head trauma. He presented normal vital signs and initial brain CT was negative for intracranial hemorrhage. He was treated with skeletal traction and extramedullary nailing of femur. After8 hours, the patient was unresponsive. Emergency brain CT was negative. The patient was admitted to our Intensive Care Unit (ICU) due to the altered state of consciousness and to the acute respiratory failure. He was initially intubated and mechanically ventilated. EEG showed findings of generalized periodic discharges (GPD) and a brain MRI showed multiple bilateral foci of restricted diffusion in the cerebrum indicative of acute infarcts.

Low molecular weight heparin (LMWH), antiepileptic drugs, antibiotics and dexamethasone were started following the patient clinical course. The patient slowly and steadily improved and he was discharged and transferred to a rehabilitation center.

Discussion

Due to the presence of variable and nonspecific neurological signs and symptoms, in the absence of simultaneous pulmonary and dermatological manifestations, it represents a diagnostic challenge.

To date, there are no specific guidelines for the treatment of this pathological condition. Prophylactic measures, such as early stabilization of fractures and an adequate diagnostic and therapeutic management may help to reduce both mortality and severe disability [3]. Treatment is based on the administration of corticosteroids (dexamethasone or methylprednisolone) and heparin. It is important to support vital functions and prevent cerebral edema. Finally, the early use of hyperbaric therapy seems to be promising.

Conclusions

CFE is a rare syndrome. The diagnosis is based on clinical and imaging findings, but requires a high index of suspicion. Treatment is mainly supportive and prophylactic strategies may help decrease the incidence of CFE.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Vetrugno et al. Cerebral fat embolism after traumatic bone fractures:a structured literature review and analysis of published case reports. Scand J Trauma Resus 2021;29:47

2. Godoy et al. Cerebral Fat Embolism: Recognition, Complications and Prognosys. NCC 2018;29:358-65

3. Nattaphol et al. Fat embolism Syndrome: A Case Report and Review Literature. Hindawi Case Rep. Med.Vol8

A146 Off-label combined treatment with an ampa receptor antagonist and plasmapheresis in a case of ndd-related encephalitis and subsequent immune-mediated epilepsy

I.G. Bonanno¹, D.E. Di Stefano¹, A. Pecora¹, S. Cefalù¹, G. Bufalino¹, L. Andrea¹, T. Francesco¹, Z. Gabriele¹, M. Liliana Serena Agata¹, F. Monica¹, R. Nicoletti¹, A. Salice¹, C. Geraci¹, S.L. Orlando¹, G. Restuccia¹, G. Di Giovanni¹, T. Locicero¹, L. Sicurella¹, M. Panebianco¹, L. La via²

¹Arnas Garibaldi, Catania, Italy; ²Policlinico G. Rodolico, Catania, Italy

Correspondence: A. Pecora

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A146

Background

Immune-mediated epilepsy is caused by a dysfunction of the immune system that impairs the central nervous system (CNS). The immune system may produce antibodies against Glutamate or GABA receptors, disrupting their function.

Plasmapheresis (PF) is an extracorporeal therapy that enables the removal of high molecular weight pathogenic elements from the plasma, such as immunoglobulins, immune complexes, or inflammatory mediators. Therapeutic PF has been applied to treat autoimmune diseases and conditions that require rapid toxin removal from plasma. Its effects include immunomodulation via activation of the reticuloendothelial system and stimulation of lymphocyte clones following the elimination of circulating pathogenic solutes.

In this case report, we demonstrate how the off-label use of plasmapheresis in a case of NDD-related encephalitis proved effective in ensuring full neurological and motor recovery.

Case Report

A 32-year-old woman with an unremarkable medical history presented with recent-onset headache and fever, managed at home with cefixoral and bentelan. She was admitted to the emergency department for recurrent tonic-clonic seizures, initially treated with benzodiazepines and brivaracetam. She underwent lumbar puncture, Biofire meningitis panel, blood tests, cultures, brain MRI, and total body CT, all of which were negative. She started combined therapy with antibiotics, antivirals, and anti-seizure medication (levetiracetam). Due to persistent seizures, she was intubated and transferred to our ICU. EEG was compatible with convulsive status epilepticus, and valproate therapy was initiated. Due to elevated liver enzymes and poor seizure control, valproate was discontinued and perampanel started.

Following initial neurological improvement, the patient was extubated but required re-intubation due to diffuse weakness and cognitive decline. A repeat EEG showed disorganized and slowed brain activity. In the following neurological assessment, the patient was minimally responsive, with spontaneous eye opening, tetraplegia, and a GCS of 6/15 (E4, M1, V1). After unsuccessful weaning attempts, she underwent tracheostomy.

During hospitalization, she developed septic shock due to MDR bacteria with thrombocytosis, managed with targeted antibiotics. She underwent another brain MRI, CSF analysis, ENG, EMG, and screening for onconeural antigens—all negative. In agreement with the Neurology team, off-label plasmapheresis was initiated, followed by a course of intravenous immunoglobulins (IVIG). Due to recurrence of clonic seizures with positive EEG, perampanel was increased to the maximum dose. Following the sixth plasmapheresis session and IVIG administration, the patient showed progressive neurological improvement, both cognitively and motorically, with optimal seizure control.

She was transferred with a tracheostomy and home ventilator support to a rehabilitation center with a GCS of1/15 (E4, M6, V1). Her clinical course was regular, without complications; the tracheostomy was closed, spontaneous breathing resumed, strength recovered, and interaction was excellent. At50 days from admission, the patient returned home and resumed her daily activities without neurological or motor deficits.

Conclusion

Perampanel appears to be a valid and well-tolerated therapeutic option for patients with drug-resistant recurrent seizures.

Off-label plasmapheresis followed by IVIG proved effective in treating a CNS inflammatory condition likely of autoimmune origin, in the absence of an identifiable etiology.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Abril Jaramillo J, et al. Effectiveness and safety of perampanel as early add-on treatment in patients with epilepsy and focal seizures in the routine clinical practice: Spain prospective study (PERADON). Epilepsy Behav. 2020 Jan;102:106655.

2. Laurenza A, et al. Absence of Liver Toxicity in Perampanel-Treated Subjects: Pooled results from partial seizure phase III perampanel clinical studies. Epilepsy Res. 2015 Jul;113:76-85.

3. Ryuichiro Hirano, et al. Pleiotropic effects of double filtration plasmapheresis. 2024 Sep;101111/1744-9987.14194

4. Philippe R Bauer, et al. Plasma exchange in the intensive care unit: a narrative review. 2022 Oct; 10.1007/s00134-022-06793-z.

5. Holzer FJ, Seeck M, Korff C. Autoimmunity and inflammation in status epilepticus: From concepts to therapies. Expert Rev Neurother. 2014;14:1-22. 10.1586/14737175.2014.956457.

6. Steriade C, Bauer J, Bien CG. Autoimmune encephalitis-associated epilepsy. Nat Rev Neurol. 2025 May 2. 10.1038/s41582-025-01089-4.

7. Nieto-Aristizábal I, et al. Therapeutic Plasma Exchange as a Treatment for Autoimmune Neurological Disease. Autoimmune Dis. 2020 Jul 31;2020:3484659. 10.1155/2020/3484659.

8. Cheng L, Jia B, Wang C, et al. Immunotherapy for autoimmune encephalitis. Cell Death Discov. 11, 207 (2025). 10.1038/s41420-025-02459-z

A147 Transcranial Doppler and perfusion imaging in meningoencephalitis: a functional prognostic approach in critically ill patients

M.G. Bocc¹i, G. Capecchi¹, D. Rubino¹, I. Caravella¹, G. Taloni¹, F. Albarello¹, G. Anello¹, P. Campioni¹, S. Ianniello¹, T. Ascoli¹, A. Lesci², G. Maffongelli¹, D.G. Biasucci³, E. Nicastri¹

¹INMI L. Spallanzani, Roma, Italy; ²Università Cattolica del Sacro Cuore, Roma, Italy; ³Università degli studi di Roma Tor Vergata, Roma, Italy

Correspondence: G. Taloni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A147

Background

Meningoencephalitis in critically ill patients poses significant diagnostic and prognostic challenges. While MRI and CT provide structural insights, Transcranial Doppler ultrasonography (TCD), especially in its duplex modality (TCCD), offers a bedside, non-invasive method for real-time evaluation of cerebral blood flow (CBF). Its prognostic value in neuroinfectious diseases remains underexplored.

Methods:

We retrospectively analyzed0 ICU patients with meningoencephalitis. All underwent early TCCD and brain MRI with FLAIR and DWI sequences In 5 cases, no additional tests were performed; the remaining 5 patients underwent CASL (Continuous Arterial Spin Labeling) perfusion MRI. CBF alterations in the M1 segment of the middle cerebral artery were assessed within 72 hours of a documented Glasgow Coma Scale (GCS) decline. The pulsatility index (PI) was the primary hemodynamic parameter and was correlated with ICU mortality and the 28-day Glasgow Outcome Scale (GOS) (Figure 1). This study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the local Ethics Committee of CET (Comitato Etico Locale) Lazio-Area4, and the requirement for informed consent was waived due to the retrospective nature of the analysis.

Results

Patients with normal PI values (<1.2) demonstrated no significant MRI abnormalities and recovered fully. Conversely, patients with elevated PI (>1.2) showed perfusion deficits on CASL-MRI and had worse neurological outcomes. In two cases, PI values exceeded 3, and MRI revealed severe, lateralized perfusion deficits; both patients died. CASL-MRI findings confirmed the topography and magnitude of flow disturbances detected via TCCD, underscoring the latter’s reliability as a dynamic, functional monitoring tool (Figure 2).

Discussion

Hemodynamic complications in bacterial meningitis, including vasospasm and hyperemia, typically occur between days 3 and 5, driven by inflammatory cytokines. These changes may lead to ischemia or secondary injuries. TCCD captured these vascular alterations through elevated PI values, offering early signs of clinical deterioration. While TCD has assessed cerebral perfusion in other conditions, its role in encephalitis is still limited. Weber et al. (1995) emphasized its potential in CNS infections, but targeted studies are lacking.

Conclusion:

This case series suggests that elevated PI detected through early TCCD is associated with poor prognosis in meningoencephalitis. TCCD offers a complementary, functional perspective to conventional imaging, enhancing diagnostic precision and supporting individualized management. The integration of TCCD and perfusion MRI, particularly in severe or atypical presentations, may refine prognostic evaluation and therapeutic planning. Although the sample size is limited, our results provide preliminary support for incorporating TCCD into standard ICU neuromonitoring protocols for neuroinfectious diseases. Future multicenter prospective studies are needed to validate these findings and develop standardized algorithms combining clinical, immunoinflammatory, and multimodal imaging data.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Weber M et al., J Neurol Sci.995.

2. Pierrakos C et al., BMC Anesthesiol. 2014.

3. Kumar VS, Brain Circ. 2023.

4. Batino LKJ et al., J Clin Ultrasound. 2024.

Fig. 1 (abstract A147).

Integrated diagnostic data of the patients of the case series

Fig. 2 (abstract A147).

Neuroimaging of patient 2 from case series, A) MRI with FLAIR, B) MRI with DWI sequence, C) CASL perfusion MRI

New technologies for diagnosis and treatment

A148 Renal function composite score: a global index of renal function? Investigation in renal transplant patients

L.M. Titherington¹, G. Lascialfari¹, L. Ricci¹, I. Mattei¹, V. Giglioni¹, V. Ghidoni¹, I. Gianassi², F. Peyronel², L. Malatesta², G. Baldini¹, G. Villa¹, Z. Ricci³, F. Barbani¹, L. Foti¹, G. Manzoni⁴, S. Romagnoli¹

¹Department of Anesthesia and Critical Care Azienda Ospedaliero-Universitaria Careggi, University of Florence, Italy; ²Nephrology, Dialysis and Transplantation Department, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Italy; ³Anesthesia and Critical Care Meyer Children Hospital IRCCS, University of Florence, Italy; ⁴Kures S.r.l, Milan, Italy

Correspondence: L.M. Titherington

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A148

Background

Renal function is generally evaluated by measuring creatinine to derive an eGFR. However there are many known limitations in using creatinine but mostly important it only gives information about glomerular function, tubular function is rarely investigated[1]. Acid-base and water balance, and electrolyte homeostasis are amongst the primary roles of the renal tubules. Urinary Na+ and Cl- reflect the state of water balance, urinary NH4+ reflects the acid-base compensation activation, and urinary K+ reflects it plasma homeostasis and effect of aldosterone[2]. In post-renal transplant patients, common complications include hyperkalaemia and metabolic acidosis[3]. Furthermore, low urinary Na+ has been associated with increased risk of acute rejection[4]. In order to identify an indicator of global renal function (tubular + glomerular) in these patients, we hypothesised to use urinary electrolytes as indicators of tubular function and serum creatinine as a marker of glomerular function. An increase in urinary electrolytes, after graft implantation, might suggest an adequate renal function.

Methods

To evaluate a parameter globally reflecting the recovery of a transplanted renal graft we used a point-of-care analyser, the Kidney INstant monitorinG® (Kures, Milan, Italy), to directly measure urinary electrolyte concentration (NH4+, Na+, K+ and Cl-) in a 24-h urine collection on post-transplant days G0-to-G1, G3-to-G4 and G9-to-G10. Enrolled patients were then divided into two groups: group) those without complications; and group 2) those with complications (table). We took the sum of the urinary electrolytes and divided them by the serum creatinine to test the Renal Function Composite Score (RFCS) and plotted the trend over the 3 time points (figure).

Results

Seventeen patients were enrolled:2 belonged to group and 5 to group 2 respectively. Figure shows that RFCS in group 2 changes over time but the slope is 0.06 units per time point lower than group. The group-time interaction is significant (p = 0.043), whereas the baseline RFCS difference was not statistically significant. Whilst the baseline values at G0-G1 did not differ significantly, patients that developed complications showed a flattened recovery curve, consistent with impaired glomerular-tubular recovery.

Consent

Informed consent was obtained for the publication of this scientific article.

Conclusions

Having a global parameter that reflects both glomerular and tubular function could provide more information than a single evaluation of glomerular function. Our results suggest that RFCS could be a useful dynamic biomarker for global renal recovery after transplantation as it demonstrates whether the transplanted kidney is adequately compensating for the underlying disarrangements associated with renal transplantation.

Fig. 1 (abstract A148).

Renal Functional Composite Score (RFCS) by outcome

Table 1 (abstract A148).

Groups of patients classified according to the occurrence of complications

Patient ID	Complications
1	None
2	None
3	None
4	Renal artery thrombosis
5	None
6	Reduced renal perfusion
7	None
8	None
9	None
10	Delated graft function
11	Obstruction
12	Delayed graft function
13	None
14	None
15	None
16	None
17	None

A149 Effectiveness of high-frequency chest wall oscillation (HFCWO) in copd patients

S. Notaro¹, P. Smaldone³, A. Notaro¹, A. Riccio¹, M. Tamborrino¹, G. La Cerra², E. Piscitelli¹, A.M. Esquinas⁵

¹Intensive Care Unit and ECMO, Monaldi Hospital, AORN Colli, Naples, Italy; ²Bronchology Operating Unit, Monaldi Hospital, AORN Colli, Naples, Italy; ³Intensive care Unit, Vanvitelli University, Naples, Italy; ⁴Respiratory Physiopathology, Monaldi Hospital, AORN Colli, Naples, Italy; ⁵Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain

Correspondence: P. Smaldone

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A149

Background

Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory condition characterized by airflow limitation and mucus hypersecretion. Traditional airway clearance techniques (ACT) show variable efficacy, whereas High-Frequency Chest Wall Oscillation (HFCWO) has been proposed as an effective alternative to improve mucociliary clearance and respiratory function (Fig.1, Fig.2, Fig.3). This retrospective observational study aims to evaluate the impact of HFCWO in COPD.

Study Objective

The primary objective is to compare the effectiveness of HFCWO with conventional respiratory physiotherapy in terms of: Improvement in respiratory function (FEV1, FVC), Reduction in exacerbations and hospital admissions, Increase in mucus expectoration, Improvement in patient quality of life.

Methods

Retrospective observational study conducted on COPD patients admitted to Monaldi Hospital between January 2020 and December 2023. Inclusion Criteria: Patients >= 50 years old with a documented diagnosis of COPD according to GOLD criteria Presence of mucus hypersecretion confirmed by clinical assessment and bronchoscopy. Complete data on respiratory function and hospitalizations. Exclusion Criteria:Patients with interstitial lung diseases, patients with severe heart failure (EF < 30%), patients undergoing invasive mechanical ventilation during the study period. Total patients analyzed: 300, HFCWO Group:50 patients treated with HFCWO. Control Group (Conventional Physiotherapy):50 patients treated with standard ACT. Pulmonary function tests (FEV1, FVC) at baseline and after 6 months. ABG analysis (PaO2 PaCO2) before and after treatment. Number of exacerbations and hospital admissions over the following2 months. Mucus expectoration. Quality of life, assessed with the COPD Assessment Test (CAT). Informed consent was collected for each patient.

Statistical Analysis Report

This statistical analysis compares the effectiveness of HFCWO and Conventional Respiratory Physiotherapy. The study was designed to assess the improvements in respiratory function, reduction in exacerbations, and changes in the quality of life over a 6-month treatment period.

Descriptive Statistics

Descriptive statistics (Tab.1) for the key variables were calculated for both groups. For the HFCWO group, the t-statistic indicated a significant improvement in FEV1. Similarly, for FVC, the t-statistic suggested a significant improvement in FVC. For the Conventional Physiotherapy group, the t-statistic for FEV1 change and for FVC change, indicated significant improvements in both FEV1 and FVC. Independent t-tests were performed too: For FEV1, the t-statistic indicated no significant difference between the groups. For FVC, the t-statistic also showed the same result. A Poisson regression was conducted to analyze the number of exacerbations over2 months : The regression model revealed that patients in the HFCWO group had significantly fewer exacerbation. The Quality of Life scores (COPD Assessment Test - CAT) were compared: No significant difference was found between the groups.

Conclusions

This retrospective observational study will provide concrete data on the effectiveness of HFCWO in managing COPD with mucus hypersecretion. The results may support the implementation of this technique in clinical practice and guide large-scale prospective studies to optimize therapeutic protocols.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A149).

HFWCO, wereable vest attached to a vibrating machine

Fig. 2 (abstract A149).

Parameters to be set

Fig. 3 (abstract A149).

Vest on the chest wall

Table 1 (abstract A149).

Descriptive statistics

Group	Baseline FEV1 Mean	Post FEV1 Mean	Baseline FVC Mean	Post FVC Mean	Exacerbations Mean	CAT Mean
HFCWO	48.77 ± 14.14	53.93 ± 14.32	71.42 ± 20.43	77.93 ± 20.84	2.01 ± 1.45	19.97 ± 5.96
Conventional Physiotherapy	49.47 ± 15.49	52.85 ± 15.83	73.99 ± 18.96	79.34 ± 19.50	3.89 ± 1.97	20.01 ± 5.58
Physiotherapy	15.49	15.83	18.96	19.50		5.58

A150 Procedural compliance in children’s vein cannulation with digital sedation to support green anesthesia tecnique

M.L. Lasorella¹, P. Raimondo², F. Maranzano¹, D. Merlicco³, S. Grasso²

¹Pediatric Department of Anesthesia and Intensive, Giovanni XXIII Pediatric Hospital - Policlinico of Bari, Italy; ²Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area Policlinico of Bari, Italy; ³Vascular Access, Department of General Surgery, Policlinico Riuniti di Foggia, Italy

Correspondence: M.L. Lasorella

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A150

Background

Digital Sedation in a non-pharmacological tool that use virtual reality to capture attention and redirect neural activity away from pain pathways.

The technique is introduced by anesthetist during preoperative evaluation as an alternative to inhalation induction technique useful to vein cannulation in pediatric patients aged 4 years and over.

Sevoflurane is inhalation induction agent used in our standard of care for vein cannulation in patient younger of 8 years of age. Aims of this pilot study are understand if digital sedation enhances patients'experiences associated with preoperative vascular access in term of procedure’s compliance, satisfaction compared with our standard preoperative procedure and if there was an impact on time procedure.

Materials and Methods

Children scheduled for elective pediatric surgery to pediatric hospital of Policlinico of Bari (Italy) were included in the study with parental signed informed consent. Since December 2023, all children fitted inclusion criteria received digital sedation (HypnoVR, helmet Oculus Rift, Oculus VR) were randomized to utilization of DS during vascular access or standard of care: IV placement after mask induction with sevoflurane.

The children undergoing the same procedure without DS support were included in the control group.

Modified Induction Compliance Checklist (mICC), and satisfaction surveys, and respectively the time from the access in operating department to IV placement were measured.

Results

The analysis included0 patients in the VR group and0 in the control. Groups were quite similar with respect to demographic characteristics: 2 males and 8 females with a median age of 8.9 years (SD 3.2 years) with a min 4 and max6 years

The compliance Children in the virtual reality group were satisfied with the intervention and the patient, family and operators’ satisfaction was better than in the control group. In time procedure there is a statistical difference between two groups (p-value = 0.0001): IV placement was inserted faster in patient of VR group, (Figure-1-2).

Conclusions

VR distraction help to improve compliance and satisfaction of patient and family minimizing use of Sevoflurane inhalation when vascular access is attempted prior to surgery. Digital sedation is a complementary and relevant anesthetic tool which gets a good adhesion of patients. Sevoflurane is the most frequently used gases, persist in the atmosphere for.1 year, multiple analyses suggest that use of total intravenous anesthesia (TIVA) has a reduced carbon footprint compared with inhalation anesthesia but vein cannulation in mandatory and in pediatric anesthesia this require use of inhalation agent.

Digital sedation could be a valid alternative tool and these findings of this pilot study are encouraging. Future larger randomized controlled trials are necessary to confirm our findings.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A150).

Bar graph of Time Procedure (VR vs Control)

Fig. 2 (abstract A150).

Bar graph of Compliance MiCC)

A151 Role of mir-9 in the regulation of nf-kb signaling pathway and cytokines expression in covid-19 intensive care patients

C.M. Petrangeli¹, M. Ciotti², F. Semenzato³, F.M. Petrangeli⁴, F. Claro¹, M. Martucci, V. De Angelis¹, F. Frisardi¹, S. Verrengia¹, I. Brandolini¹, D.J. Brunetti¹, M. Silvi¹, D. Cipollone¹, C. Del Giudice¹, R. Polidoro¹, S. Mottola¹, C. Cacace¹, R. Franzoni¹, F. Leonardis¹

¹UOSD Terapia Intensiva Policlinico Tor Vergata, Roma, Italy; ²UOSD Microbiologia e Virologia Policlinico Tor Vergata, Roma, Italy; ³Facoltà di Medicina e Chirurgia Università Tor Vergata, Roma, Italy; ⁴Dipartimento di Matematica Università Sapienza, Roma, Italy

Correspondence: F.M. Petrangeli

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A151

Background

The recent coronavirus disease 2019 (COVID-19) pandemic caused by the novel coronavirus SARS-CoV-2 has caused millions of deaths worldwide. A common feature of patients presenting with severe acute respiratory distress was the rapid fatal evolution characterized by multiple organs failure and cytokine storm. It has been reported that the NF-kB signaling pathway, modulated by microRNAs, might have an important role in the inflammatory response.

Materials and Methods

Thus, this study investigated the possible role of miR-9 in modulating NF-kB signaling pathway and cytokines expression in COVID-19 patients admitted to the Intensive Care Unit of the University Hospital Tor Vergata (Rome, Italy) during the second pandemic wave: March - June 2021.The study included 41 COVID-19 patients and 20 healthy controls. Serum samples were analyzed for the expression level of miR-9, NF-kB, IkBalfa, IL-6, IL-1 beta and TNF-alfa by RT-PCR; while the production of the pro-inflammatory cytokines IL-6, IL-1beta, and TNF-alfa was measured by ELISA. Statistical analyses were performed to investigate the relationship between these variables. COVID-19 patients, especially non-survivors, showed significantly higher levels of miR-9 and NF-kB compared to controls. miR-9 and NF-kB expression showed a strong positive correlation (r = 0.813, p < 0.001). The levels of NF-kB were significantly correlated with IL-6 (r = 0.971, p < 0.001), IL-1beta (r = 0.968, p < 0.001), and TNF-alfa (r = 0.968, p < 0.001). The findings indicate that miR-9 modulates NF-kB signaling and inflammation in COVID-19 patients. Furthermore, the detected high levels of miR-9 in non-survivors suggest its potential use as severity biomarker.

Conclusions

Finally, miR-9 and NF-kbeta could be valuable targets in others inflammatory conditions such as autoimmune diseases underlining the importance of continuing the research in this area.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Prezioso G, Marcocci ME, Palamara AT, De Chiara G, Pietropaolo V. The Three Italy of the Covid-19 epidemic and the possible involvement of SARS-CoV-2 in triggering complications other than pneumonia. J. Neurovir. 2020; 6: 311-323.

2. Freigeh GE, Michniacki TF, NF-kB and related autoimmune and autoinflammatory diseases. Rheum. Dis. Clin. N. Am. 2023; 49: 805-823.

3. Hassan NE, Moselhy WA, Eldomany EB, Kholef EFM. Correction to: Evaluation of miRNA-16-2-3P, miRNA-618 levels and their diagnostics and prognostic value in the regulation of immune response during SARSCov-2 infection. Immunogenetics. 2023; 75: 411.

A152 Automating the gruen zone detection with a convolutional deep neural network model

M. Panizzi, T. Domenichetti, M. Berdini, M. Guarnieri, V. Bellini, E. Bignami

Anesthesiology and Critical Care, Department of Medicine and Surgery, University of Parma, Parma, Italy

Correspondence: M. Panizzi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A152

Background

Periprosthetic fractures (PF), which occur around prosthetic implants, are challenging to diagnose and manage due to the diversity of fracture types, their location and biomechanical interactions with the implant. The Gruen zones are essential for accurately localizing and classifying these fractures [1]. However, the Vancouver classification does not address fracture patterns. To address this, González-Martín et al. proposed an updated Unified Classification System (UCS) with a subclassification for B2 fractures, incorporating fracture patterns [2]. In cases of B2-B3 fractures treated with osteosynthesis, stem mobilization occurs when the fracture line extended to more than three Gruen zones [3]. We developed an Artificial Intelligence (AI) model that enables the automatic classification of PF in Gruen zones.

Methods

Hip or pelvic radiographs from the Department of Medicine and Surgery at the University of Parma, collected during 2023-2024, were used after obtaining the informed consent. We trained an object detection deep convolutional neural network implemented in Python, supported by the Segment Anything Model and a Hough filter, to build the model architecture. The framework consists in prosthesis detection, image rotation and cropping, fracture detection and Gruen zone classification [Fig.1]. To obtain ordinal variables, the type of intervention was clustered in revision, plate and screws and cerclage. Then we tested the correlation between the number of Gruen zone detected by the model and the type of intervention and other relevant clinical variables.

Results

A total of20 patients were included. All phases of the model’s framework achieved remarkable accuracy, sensitivity, and specificity. The final classification of fractures into Gruen zones attained an accuracy of 96.721%. Traditional statistics showed a significant correlation between the type of intervention, intraoperative transfusion (IT), admission and Length of Stay (LOS) in ICU. ICU LOS and total LOS were correlated with total blood unit transfused and IT. No correlation was found with the number of Gruen zones [Tab.1].

Conclusion

The combination of high accuracy, sensitivity and specificity across all phases underscores the system’s reliability and potential for clinical integration. A wider sample it’s needed to further train the model and obtain more insights on the correlation between the characteristics of fractures and perioperative management. The automation of fracture pattern detection would allow the automation of the perioperative risk stratification by predicting the type of surgery and the appropriate postoperative setting.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Duncan CP, Haddad FS. The Unified Classification System (UCS): improving our understanding of periprosthetic fractures. Bone Joint J. 2014 Jun;96-B(6):713-6. doi:0.1302/0301-620X.96B6.34040. PMID: 24891568.

2. González-Martín D, Pais-Brito JL, González-Casamayor S, Guerra-Ferraz A, Ojeda-Jiménez J, Herrera-Pérez M. New Sub-Classification of Vancouver B2 Periprosthetic Hip Fractures According to Fracture Pattern. Injury. 2022 Mar;53(3):1218-1224. doi:0.1016/j.injury.2021.10.026. Epub 2021 Oct 31. PMID: 34749906

3. Schiavi P, Vaienti E, Ferrari A, Ceccarelli F, Maniscalco P, Pogliacomi F. Treatment of periprosthetic fracture Vancouver B2-B3 in cementless total hip athroplasty: are we able to predict stem mobilization?. Minerva Orthopedics 2024 June; 75 (3):183-90. DOI:0.23736/S278469.24.04438-9

Fig. 1 (abstract A152).

Model framework

Table 1 (abstract A152).

Results Table

T-test ICU LOS
	Test	p
Number of Gruen zones	U di Mann–Whitney	0.429
Type of intervention	U di Mann–Whitney	0.031
Nota. Hₐ μ0 ≠ μ1
Contingency table
	ICU admission	Total
Type of intervention	0
1	28	39
2	39	43
3	26	29
Total	93	111
Test χ2
	Value	p
χ2	6.37	0.041
N	111
		Type of intervention
Intraoperative Unit of blood	Spearman's Rho	−0.236*
gdl		114
p-value		0.011
		Cardiac complications
HB POST-OP	Spearman's Rho	−0.191*
gdl		106
p-value		0.048
ICU length of stay	Spearman's Rho	0.443***
gdl		110
valore p		<.001
Intraoperative Unit of blood	Spearman's Rho	0.202*
gdl		113
p-value		0.031
Total Unit of blood	Spearman's Rho	0.253**
gdl		113
p-value		0.006
		Respiratory complications
Total length of stay	Spearman's Rho	0.356***
gdl		113
p-value		<.001
ICU length of stay	Spearman's Rho	0.277**
gdl		110
p-value		0.003
		Surgical Complication
Total Unit of blood	Spearman's Rho	0.230*
gdl		113
p-value		0.013
		Total lenght of stay
ICU length of stay	Spearman's Rho	0.241*
gdl		111
p-value		0.010
Intraoperative Unit of blood	Spearman's Rho	0.221*
gdl		116
p-value		0.016
		HB POST-OP
ICU length of stay	Spearman's Rho	−0.231*
gdl		104
p-value		0.017
		ICU length of stay
Intraoperative Unit of blood	Spearman's Rho	0.379***
gdl		111
p-value		<.001
Total Unit of blood	Spearman's Rho	0.307***
gdl		111
p-value		<.001

A153 Strategic priorities for artificial intelligence integration in emergency, critical and perioperative medicine in Italy

B. Loriga¹, F. Baglivo^2,1, V. Bellini³, C. Adembri⁴, J. Montomoli^5,6, M. Cascella^7,10, G. Diedenhofen^8,11, L. De Angelis^2,11, N. Gentili^9,2, M. Altini², A. Pastori², R. Gaggeri², E.G. Bignami^3,0

¹Unit of Anesthesia, Intensive Care and Pain Medicine, Department of Emergency and Urgent Care, Tuscany South East Local, Montepulciano, Italy; ²Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy; ³Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Italy; ⁴Department of Health Sciences, University of Florence, Careggi University Hospital, Florence, Italy; ⁵Department of Anesthesia and Intensive Care, Infermi Hospital, Romagna Local Health Authority, Rimini, Italy; ⁶Health Services Research, Evaluation and Policy Unit, Romagna Local Health Authority, Rimini, Italy; ⁷Department of Medicine, University of Salerno, Salerno, Italy, Salerno, Italy; ⁸Postgraduate School of Health Statistics and Biometry, Department of Public Health and Infectious Diseases, Sapienza University, Roma, Italy; ⁹IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Italy; ¹⁰Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI), Roma, Italy; ¹¹Italian Society of Artificial Intelligence in Medicine (SIIAM), Roma, Italy; ¹²Italian Society of Leadership and Management in Medicine (SIMM), Meldola, Italy

Correspondence: B. Loriga

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A153

Background

Artificial Intelligence (AI) offers transformative potential for emergency, critical, and perioperative medicine by enhancing clinical decision-making, predicting adverse events, optimizing resource allocation, and improving patient outcomes [1]. However, its implementation remains limited and uneven, particularly in public healthcare systems like Italy’s. Structural fragmentation across the 21 regional health services, variability in digital maturity [2], and the absence of coordinated national strategies hinder effective and ethical integration. Addressing these challenges is essential to unlock AI’s full potential in high-stakes clinical environments. Promoted by three national societies (SIAARTI, SIIAM, and SIMM) we aimed to identify practical and strategic recommendations to guide the safe and effective adoption of AI in Italian emergency, critical, and perioperative care.

Materials and Methods

A structured consensus process using the nominal group technique was conducted with experts from the three societies. Participants included clinicians, researchers, healthcare managers, and digital health specialists with experience in AI applications. Discussions were guided by a focused question: “What are the most urgent priorities for integrating AI safely and effectively into emergency, critical, and perioperative care in Italy?” Recommendations were consolidated through iterative rounds of feedback, informed by literature review and real-world case examples.

Results

Three interdependent strategic priorities emerged:

Digitalization of the patient journey: Implement healthcare data lake architectures that accommodate diverse data formats (structured, semi-structured, and unstructured) to enable both real-time clinical applications and comprehensive historical analysis. This hybrid approach facilitates immediate utilization of available structured data while establishing pathways for progressive standardization through shared protocols (e.g., HL7 FHIR) and secure data governance frameworks [3].

Clinical validation of AI models: Initial integration of AI tools requires robust validation through methodologically rigorous approaches such as prospective cohort studies or randomized trials. However, recognition of AI systems as transformative agents necessitates implementation of structured, periodic validation infrastructures to monitor performance longitudinally, identify domain shifts, and adapt to evolving clinical practice patterns. This dynamic validation paradigm ensures sustained clinical utility despite progressive modifications to the healthcare ecosystem precipitated by AI implementation itself [3].

AI education and leadership development: AI training must be tailored to roles and embedded in medical education at all levels. Leadership 4.0 skills—including digital literacy, strategic vision, adaptability, and collaboration—are key to successful implementation and sustained cultural change. The group also stressed the need for regulatory clarity, stakeholder engagement, and a supportive digital culture to overcome resistance and enable long-term adoption.

Conclusions

AI integration in emergency, critical, and perioperative care requires more than technical readiness. Coordinated action across infrastructure, governance, and education is essential. Despite regional variability, Italy’s public healthcare system can lead in ethical, human-centered AI by investing in interoperability, validated tools, and clinician empowerment. These priorities provide a roadmap for transitioning from fragmented experimentation to system-wide transformation.

References

1. Topol EJ. High-performance medicine: the convergence of human and artificial intelligence. Nat Med. 2019;25(1):44–56.

2. Addeo F, D'Auria V, Delli Paoli A, Punziano G, Ragnedda M, Ruiu ML. Measuring digital capital in Italy. Front Sociol. 2023 May 19;8:1144657. 10.3389/fsoc.2023.1144657. PMID: 37274604; PMCID: PMC10235697.

3. Montomoli J, Bitondo MM, Cascella M, Rezoagli E, Romeo L, Bellini V, Semeraro F, Gamberini E, Frontoni E, Agnoletti V, Altini M, Benanti P, Bignami EG. Algor-ethics: charting the ethical path for AI in critical care. J Clin Monit Comput. 2024 Aug;38(4):931-939. 10.1007/s10877-024-01157-y. Epub 2024 Apr 4. PMID: 38573370; PMCID: PMC11297831.

A154 Urinary electrolyte profiling during short-term liquid fasting in healthy adults using the K.I.N.G. monitoring system

V. Ghidoni¹, L.M. Titherington¹, G. Lascialfari¹, L. Ricci¹, I. Mattei¹, V. Giglioni¹, I. Gianassi¹, F. Peyronel¹, L. Malatesta¹, G. Baldini¹, G. Villa¹, Z. Ricci¹, F. Barbani¹, L. Foti¹, G. Manzoni², S. Romagnoli¹

¹Department of Anesthesia and Critical Care, University Hospital of Careggi. School of Anesthesia and Critical Care, Florence, Italy; ²Kures S.r.l., Milan, Italy

Correspondence: V. Ghidoni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A154

Background

Urinary electrolyte values are typically reported in nephrology as mmol/day, based on 24-hour collections. However, such data are not directly applicable in acute settings, where anesthesiologists and intensivists require rapid, time-resolved information. In perioperative or critical care, decision-making often occurs over hours—not days—yet reference values for urinary electrolytes over shorter timeframes are scarce.

The Kidney INstant monitorinG® (K.I.N.G.; Kures, Milan, Italy)¹ system allows semi-continuous real-time analysis of urinary electrolytes and output, offering a new tool to assess renal function dynamically. Among urinary markers, ammonium plays a key role in acid-base homeostasis but is rarely reported outside of 24-hour collections². Moreover, interpretation of concentrations alone may be misleading, as they are influenced by hydration and urine flow.

This study aims to define reference values for ammonium and other urinary electrolytes during short-term liquid fasting, and to propose total excretion (concentration × volume) as a more physiologically robust parameter.

Methods

We conducted a prospective descriptive study (11/2024-01/2025) at the Careggi University Hospital of Florence, Italy, enrolling healthy adult (>18 years, no kidney disease, signed informed consent). Participants underwent 8–10 hours of fluid fasting, simulating perioperative conditions.

Urinary concentrations of ammonium was measured in real time using the K.I.N.G. system. Both omnivorous and vegetarian participants were included. Quantitative variables were expressed as means (±SD) or medians (IQR). The primary outcome was the measurement of urinary ammonium concentration and total excretion (calculated as ammonium concentration×urine volume).

To assess concordance with nephrological References, total excretion values were extrapolated to a standard 24-hour diuresis of.5 L.

Results

Twenty-six healthy adults were enrolled. The mean fasting time was 9.96 ±.65 hours (see table).

Median urine volumes and urinary ammonium are presented in Table 2. No statistically significant differences were observed in ammonium excretion between vegetarians (N= 6) and omnivores (N=20), nor between participants who had or had not consumed meat at their last meal (see Table 3).

All values remained within expected physiological ranges. Notably, total ammonium excretion—when extrapolated to.5 L/24h—was consistent with existing nephrology literature, supporting the internal validity of both the calculation method and the real-time K.I.N.G. system.

Conclusions

This study provides time-resolved reference values for ammonium excretion during short-term fasting in healthy adults. Calculating total excretion provides a more physiologically accurate estimate than concentration alone.

The K.I.N.G. system proved effective in detecting subtle changes in urinary composition over a short timescale and offers a practical, bedside alternative to traditional 24-hour collections. These findings support its application in perioperative and critical care settings, where conventional nephrological data may be insufficiently time-sensitive.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Caironi P, Langer T, Taccone P, Bruzzone P, De Chiara S, Vagginelli F, et al. Kidney instant monitoring (K.I.N.G.): a new analyzer to monitor kidney function. Minerva Anestesiol. 2010;76(5):316-324.

2. Uribarri J et al. Am J Kidney Dis. 2022Nov; 80(5);667-676

Table 1 (abstract A154).

Demographics characteristics of study population

Variable	Value
Subjects, n	26
Age range, years	26—61
Mean weight, kg	68.8
Gender: Female, %	61.54
Mean liquid fasting (hours), men (SD)	9.96 (1.65)

Table 2 (abstract A154).

Median, interquartile range (IQR), and quartiles for: NH4, urine volume, urinary NH4 during fasting and estimated 24-h ammonium excretion

	Median	Q1.25%	Q3.75%	IQR
NH4, mEq/L	23.16	14.87	27.85	12.98
Urine volume, L	0.50	0.41	0.88	0.46
NH4, mEq	12.62	9.56	16.55	6.99
NH4 (24 h), mEq	34.7	22.30	41.77	19.46

Table 3 (abstract A154).

NH4 excretion in different populations

	Median	IQR	p value
NH4 vegeterian	8.61	5.06	p > 0.05
NH4 omnivorous	12.95	5.40
NH4 meat last meal	11.80	5.12	p > 0.05
NH4 no meat last meal	12.95	8.54

A155 Gender-specific alterations in exosomal mir-27a-5p: unveiling hypoxemia risk in obese males undergoing sleeve gastrectomy

N. Curlo¹, A. Sgalippa², M. Cabiati², V. Casieri³, A. Basta¹, M. Rauseo¹, L. Mirabella¹, A. Cotoia¹, G. Cinnella¹, S. Del Ry², V. Lionetti³

¹Departement of Anesthesia and Intensive Care Medicine, Policlinico di Foggia, University of Foggia, Italy; ²Laboratory of Biochemistry and Molecular Biology, Institute of Clinical Physiology, CNR, Pisa, Italy; ³Unit of Translational Critical Care Medicine, Laboratory of Basic and Applied Medical Sciences, Interdisciplinary Research, Scuola Superiore Sant’Anna, Pisa, Italy

Correspondence: N. Curlo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A155

Background

Obesity increases the risk of perioperative hypoxemia, posing challenges for enhanced recovery after Sleeve Gastrectomy (SG). The lack of reliable biomarkers limits the ability to personalize perioperative respiratory strategies and to effectively mitigate hypoxemic events. Exosomal microRNAs (miRs), small non-coding RNAs encapsulated within plasma exosomes (pEXOs), may regulate respiratory function and inflammation, offering potential for precision preoxygenation protocols. We focused on exosomal miR-27a-3p and miR-27a-5p due to their distinct roles in maintaining alveolar-capillary membrane integrity: miR-27a-3p elevation can disrupt oxygen exchange, while miR-27a-5p increase supports alveolar stability and reduces inflammation, especially under hypoxic conditions. Identifying gender-specific miRs profiles could clarify their role and guide tailored preoxygenation protocols in obese patients undergoing SG.

Aim of the study

To detect gender differences in the expression of the exosomal miR-27a isoforms in obese patients undergoing SG compared to healthy controls.

Methods:

Exosomal RNA was extracted from pEXOs of two groups: eight non-diabetic, non-dyslipidemic patients with severe obesity (age8-45 years, male/female = 4/4) undergoing SG (January-April 2025) and eight age- and gender-matched healthy lean volunteers as Control group. Exosomal RNA reverse transcription was carried out for the detection of selected miRs, followed by Real-Time PCR analysis, with snRNA U6 used for data normalization. For the obese patients, exosomal miR-27a-3p and miR-27a-5p levels were measured at baseline (T0, before anesthesia induction) and early after emergence (T1).

Results

Exosomal miR-27a-5p levels were significantly higher in control males compared to obese males (p = 0.02)(Fig 1). In contrast, no significant differences were observed between control and obese females. Regarding exosomal miR-27a-3p levels, no significant differences were detected between control and obese patients of either gender(Fig 1). A significant correlation between miR-27a-3p and miR-27a-5p levels was identified in both control subjects (p = 0.01) and obese patients (p = 0.05)(Fig 1). Furthermore, no significant changes were observed between T0 and T1 in the levels of both exosomal miR-27a-5p and miR-27a-3p in either gender.

Conclusion

Our preliminary findings indicate a gender-specific alteration in exosomal miR-27a-5p levels related to obesity, with obese males potentially more susceptible to perioperative hypoxemia. This highlights the need for tailored preoxygenation strategies in obese male patients undergoing SG to reduce the risk of hypoxemic events.

Consent statement

Informed consent was obtained from all participants prior to enrollment.

References:

1. Smith, J., & Brown, L. (2020). Perioperative management in obese patients: tailoring anesthesia to reduce complications. Journal of Anesthesia, 34(2), 123-135.

2. Rossi, A., et al. (2019). Obesity and surgical stress: implications for anesthetic strategies. Anesthesiology Review, 45(4), 245-259.

3. Garcia, M., & Lee, S. (2021). Sex-specific differences in perioperative responses: a review. Gender Medicine, 18(3), 210-220.

4. Patel, R., et al. (2018). Gender disparities in surgical outcomes and stress responses. Surgical Endocrinology, 32(7), 312-321.

5. Valadi, H., et al. (2007). Exosome-mediated transfer of mRNAs and microRNAs as a novel mechanism of genetic exchange between cells. Nature Cell Biology, 9(6), 654-659.

6. Théry, C., et al. (2018). Minimal information for studies of extracellular vesicles 2018 (MISEV2018): a position statement. Journal of Extracellular Vesicles, 7(1), 1535750.

7. Kulyte, A., et al. (2019). Exosomal Perilipin-1 as a biomarker of lipid metabolism and inflammation. Lipids in Health and Disease, 18, 123.

8. Zhang, Y., et al. (2020). Molecular changes in exosomal cargo following bariatric surgery. Obesity Surgery, 30(4), 1234-1242.

9. Liu, X., et al. (2022). Postoperative exosomal biomarkers in obese patients: gender differences and clinical implications. Journal of Clinical Endocrinology & Metabolism, 107(5), e2004-e2015.

Fig. 1 (abstract A155).

Workflow of the gender-based observational study evaluating plasma exosomal miR-27a-3p and miR-27a-5p expression. Blood samples were collected from obese and healthy subjects at two time points (T0: post-preoxygenation; T1: emergence). Exosomes were isolated from plasma and analyzed via RNA extraction and RT-PCR for miRNA quantification

A156 Exosomal perilipin-1 as a novel early marker of surgical stress after sleeve gastrectomy in severely obese patients with gender-specific baseline exosome signatures

N. Curlo¹, V. Casieri², M. Rauseo¹, L. Mirabella¹, A. Cotoia¹, A. Basta¹, G. Cinnella¹, V. Lionetti²

¹Departement of Anesthesia and Intensive Care Medicine, Policlinico di Foggia, University of Foggia, Italy; ²Unit of Translational Critical Care Medicine, Laboratory of Basic and Applied Medical Sciences, Interdisciplinary Research, Scuola Superiore Sant’Anna, Pisa, Italy

Correspondence: N. Curlo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A156

Background

The complex systemic response to surgical stress in severely obese patients requires tailored anesthetic strategies to minimize complications and hospital stay. Sex-specific differences in this response are increasingly recognized. Circulating exosomes—nano-sized extracellular vesicles—have emerged as non-invasive biomarkers and mediators of perioperative homeostasis. This pilot study aimed to explore the early molecular impact of sleeve gastrectomy and anesthesia by measuring plasma exosome (pEXO) concentrations and a specific exosomal cargo protein, Perilipin-1 (Plp-1), a regulator of lipid metabolism with potential anti-inflammatory effects. The study examined early postoperative changes in pEXO and Plp-1 levels in obese patients, considering gender differences and comparing findings with healthy lean controls.

Methods

pEXOs were analyzed in two groups: eight non-diabetic, non-dyslipidemic obese patients (18–45 years, 4 males and 4 females) undergoing sleeve gastrectomy (January–April 2025), and eight age- and sex-matched healthy lean volunteers. In the obese group, blood samples were collected at T0 (pre-anesthesia) and T1 (early postoperative period). pEXOs were isolated by serial centrifugation/ultracentrifugation and quantified using Nanoparticle Tracking Analysis (NTA), assessing three size ranges: 40–75 nm, 76–100 nm, and01–160 nm. Western blot was performed to assess exosomal markers (CD9, TSG101) and Plp-1 expression.

Results

At baseline (T0), obese males had significantly higher total pEXO concentrations than obese females (p = 0.03); no sex differences were observed in the control group. Obese females had significantly lower levels of large pEXOs (101–160 nm) than healthy females (p = 0.005), despite similar total pEXO counts. Obese males had more small pEXOs (40–75 nm) compared to control males (p = 0.04). A significant postoperative increase in exosomal Plp-1 concentration was observed at T1 in obese patients, compared to both T0 and controls.

Conclusion

Severely obese patients exhibit sex-related baseline differences in plasma exosome profiles, which may serve as personalized perioperative biomarkers. The early postoperative rise in exosomal Plp-1 suggests its role as a potential marker of surgical stress. These findings underscore the relevance of exosome-based monitoring in bariatric surgery and warrant further studies to explore diagnostic and therapeutic applications.

Consent statement: Informed consent was obtained from all participants prior to enrollment.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Varela JE, Wilson SE, Nguyen NT. Laparoscopic surgery significantly reduces surgical-site infections compared with open surgery in obese patients. Surg Endosc. 2010;24(2):404-409. 10.1007/s00464-009-0598-8

2. Houlden RL, Moore MJ. Obesity and perioperative risk: General principles. Can J Anaesth. 2021;68(4):520-533. 10.1007/s12630-020-01872-3

3. Kim HJ, Park JH, Choi YJ, et al. Sex differences in stress responses after surgery: Focus on hormonal and inflammatory mechanisms. Front Endocrinol (Lausanne). 2022;13:835855. 10.3389/fendo.2022.835855

4. Angele MK, Pratschke S, Hubbard WJ, Chaudry IH. Gender differences in sepsis: Cardiovascular and immunological aspects. Virulence. 2014;5(1):12-19. 10.4161/viru.26472

5. Zhang Y, Liu Y, Liu H, Tang WH. Exosomes: biogenesis, biologic function and clinical potential. Cell Biosci. 2019;9:19. 10.1186/s13578-019-0282-2

6. Liu C, Su C. Design strategies and application progress of therapeutic exosomes. Theranostics. 2019;9(4):1015-1028. 10.7150/thno.30853

7. Arman GA, Çetinkaya Z, Ercan S, et al. Early changes in adipokines and inflammatory markers after sleeve gastrectomy in morbidly obese patients. Obes Surg. 2021;31(4):1560-1567. 10.1007/s11695-020-05146-2

8. Peterli R, Wolnerhanssen BK, Peters T, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: The SM-BOSS randomized clinical trial. JAMA. 2018;319(3):255-265. 10.1001/jama.2017.20897

9. Brasaemle DL. The perilipin family of structural lipid droplet proteins: Stabilization of lipid droplets and control of lipolysis. J Lipid Res. 2007;48(12):2547-2559. 10.1194/jlr.R700014-JLR200

10. Chen X, Li R, Jiang Y, Sun Z, Wang Y, Deng Y. Exosome-encapsulated perilipin 1 regulates lipid metabolism and inflammation in macrophages. J Cell Mol Med. 2021;25(8):3766-3778. 10.1111/jcmm.16400

11. Di Stefano L, Salerno G, Casella C, Viggiano D, D’Alessandro A, et al. Late plasma exosome microRNA-21-5p depicts magnitude of reverse ventricular remodeling after early surgical repair of primary mitral valve regurgitation. JACC Basic Transl Sci. 2023;8(5):518-532. 10.1016/j.jacbts.2023.01.008

Fig. 1 (abstract A156).

Schematic representation of exosome and Plp-1 analysis in obese patients undergoing sleeve gastrectomy with different preoxygenation strategies

A157 Augmentative and alternative communication (AAC) systems in intensive care: our initial experience in Tolmezzo hospital

S. Cotrozzi, S. Bellanti, A. Ercolini, C. Gonano, N. Fasano, E. Zompicchiatti, A. Dibenedetto, P. Pillinini, L. Vetrugno

Azienda Sanitaria Universitaria Friuli Centrale, Tolmezzo, Italy

Correspondence: S. Cotrozzi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A157

Introduction: Effective communication with patients in the intensive care unit (ICU) setting remains a crucial and demanding challenge and have the potential to improve their outcomes [1]. Patients who are intubated, paralyzed, or suffering from severe neurological impairments often lose the ability to speak or express themselves, which significantly compromises their autonomy, emotional well-being, and engagement in the care process. Augmentative and Alternative Communication (AAC) systems offer promising solutions by providing nonverbal communication tools that bridge this gap. [2] This study presents the preliminary experience of Tolmezzo Hospital’s ICU in implementing two innovative AAC systems: the Tobii Dynavox I-16 Expert™ (TOBII DYNAVOX, Tobii Dynavox I-16 Expert, Danderyd Sweden), an advanced eye-tracking communication device, and the DICo1000™(DICo TECHNOLOGIES SRL, DICo1000,Milan Italy), a wearable Bluetooth-based kinetic interface.

Methods: A prospective observational case-series was conducted involving three patients with distinct clinical profiles. The focus was placed on evaluating the usability, effectiveness, and impact of the two AAC devices across several dimensions: the quality of communication exchanges, therapeutic adherence, perceived patient well-being, interaction with healthcare professionals and the care process.

Results

The Tobii Dynavox I-16™ proved to be a highly sophisticated and versatile tool: its strengths included extensive functionality and adaptability to multiple clinical situations. It also presented significant drawbacks: a high cost, complex installation procedures, and the need for accurate calibration of eye-tracking systems to ensure optimal performance. The DICo1000™ demonstrated an excellent easy use, an immediate and simple communication, an intuitive design and flexibility across different cultural and physical contexts. However, it turns out to be less suitable for long-term or more complex communication needs. Both AAC systems brought notable benefits: their led to increased therapeutic compliance, faster clinical responses, and enhanced emotional well-being among patients. Our experience highlighted the crucial role of proper staff training and the need for dedicated time and resources.

Conclusion: This initial experience underscores the powerfull role of AAC technologies in the ICU. By enhancing communication for voiceless patients, these tools contribute not only to improved clinical outcomes but also to more inclusive and humane healthcare practices. [3] The study emphasizes the importance of tailoring AAC tools to patient-specific needs and hospitalization stages, while also advocating for further scientific validation and the creation of standardized implementation protocols.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Duffy EI, Garry J, Talbot L, Pasternak D, Flinn A, Minardi C, Dookram M, Grant K, Fitzgerald D, Rubano J, Vosswinkel J, Jawa RS. A pilot study assessing the spiritual, emotional, physical/environmental, and physiological needs of mechanically ventilated surgical intensive care unit patients via eye tracking devices, head nodding, and communication boards. Trauma Surg Acute Care Open. 2018 Sep9;3(1):e000180.

2. Ten Hoorn S, Elbers PW, Girbes AR, Tuinman PR. Communicating with conscious and mechanically ventilated critically ill patients: a systematic review. Crit Care. 2016 Oct9;20(1):333.

3. Zaga CJ, Berney S, Vogel AP. The Feasibility, Utility, and Safety of Communication Interventions With Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review. Am J Speech Lang Pathol. 2019 Aug 9;28(3):1335-1355.

A158 Evaluating the practical impact of rapid microbiology on antimicrobial choices: a small-scale observational analysis

M.G. Bocci¹, C. Fontana¹, S. Leone¹, G. Capecchi¹, A. Lesci², G. Mogavero¹, V. Sabatini¹, D. Rubino¹, G. Taloni¹, I. Caravella¹, G.V. Stazi¹, A. Capone¹, S. Cicalini¹

¹INMI L. Spallanzani, Rome, Italy; ²Università Cattolica del Sacro Cuore, Rome, Italy

Correspondence: D. Rubino

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A158

Introduction

Bloodstream infections are a leading cause of morbidity and mortality, often progressing rapidly to sepsis or septic shock. Timely pathogen identification and appropriate antimicrobial therapy are critical for improving outcomes and combating antimicrobial resistance (1). While rapid microbiological diagnostics (RMDs) offer promising benefits, their impact on outcomes remains debated due to methodological limitations and real-world variability (2). Integrating RMDs into antimicrobial stewardship (AMS) and diagnostic stewardship programs may reduce inappropriate antibiotic use and enhance patient care, but further evidence is needed from diverse clinical settings (3).

Objectives

To assess the impact of implementing rapid microbiological diagnostic tools on antimicrobial decision-making and outcomes in sepsis patients at a specialized infectious disease hospital.

Methods:

This retrospective quasi-experimental pre-post observational study was conducted over 24 months at INMI L. Spallanzani Hospital in Rome. Two cohorts of adult patients (>18 years) with sepsis were compared: a pre-intervention group (conventional blood culture diagnostics) and a post-intervention group (rapid diagnostic tests using MBT Sepsityper® and/or BioFire® FilmArray® BCID). Patients were admitted to either the ICU or the Unit of Systemic Infections in Immunocompromised Patients (USIIP).

Microbiological workflows, turnaround times, time to therapeutic intervention, and modifications to antimicrobial therapy were evaluated. Monthly meetings with clinicians were held to analyze trends and integrate microbiological data with clinical decision-making. This study was conducted according to the Declaration of Helsinki. Approval was obtained from the local Ethics Committee CET Lazio-Area4; informed consent was waived due to the retrospective design.

Expected Outcomes

We hypothesize that rapid diagnostics, integrated with AMS strategies, will lead to earlier appropriate antimicrobial adjustments, reduced empirical therapy duration, and improved clinical outcomes. Key indicators include time from blood culture positivity to organism identification, clinician response time, and 28-day mortality. Diagnostic accuracy and agreement between rapid and conventional methods will also be assessed.

Results

In the pre-intervention phase, in the USIIP, 26 patients were enrolled (15 women,1 men; mean age 72 years), 4 of whom were immunocompromised. In the pre-intervention phase ICU, 71 patients were enrolled (30 women, 41 men; mean age 72.4 years), including0 immunocompromised patients. In the post-intervention phase, in the USIIP, 28 patients were enrolled (8 women, 20 men; mean age 65 years),1 of whom were immunocompromised. In the post-intervention phase in the ICU, 67 patients were enrolled (27 women, 40 men; mean age 65 years), including4 immunocompromised patients.

In both clinical settings, a reduction in the time to initiation of appropriate antibiotic therapy was observed (p < 0.05). Overall, no positive impact on in-hospital mortality was observed among ICU patients, whereas a positive impact was seen in the other ward.

Conclusions

This study aims to provide real-world evidence of the effectiveness of rapid microbiology in sepsis management, emphasizing the need for a contextualized, multidisciplinary approach. Insights gained could inform future strategies for implementing diagnostic tools in antimicrobial stewardship frameworks.

Consent

Informed consent was obtained for the publication of this scientific article.

References:

1. Salam MA et al. Healthcare. 2023.

2. Tiseo G et al. Int J Antimicrob Agents. 2022.

3. Zakhour J et al. Int J Antimicrob Agents. 2023.

A159 Quantitative lung ultrasound in children with acute respiratory symptoms and association with oxygenation – preliminary findings from a prospective study in a low-resource setting

l. Barresi¹, Z. Chowdhury², A.M. Dondorp^3,4,5, C. Fanello^3,6, L. Vetrugno⁷, A. Goffi⁸, L. Pisani³

¹DiMePRe-J, Section of Anaesthesiology and Intensive Care Medicine, University of Bari Aldo Moro, Italy; ²Department of Paediatrics, Chittagong Medical College Hospital, Chattogram, Bangladesh; ³Mahidol Oxford Tropical Medicine Research Unit Moru, Bangkok, Thailand; ⁴Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, United Kingdom; ⁵Institute of Global Health, Academic Medical Center, Amsterdam, The Netherlands; ⁶Kinshasa-MORU research Unit (KIMORU), Kinshasa School of Public Health, School of Medicine, University of Kinshasa, Democratic Republic of the Congo, Congo (KINSHASA); ⁷Department of Anesthesia and Intensive Care, Tolmezzo Hospital,Italy; ⁸Critical Care and Medicine Departments, Unity Health Toronto, St. Michael s Hospital, Toronto, Canada

Correspondence: l. Barresi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A159

Introduction

Acute respiratory distress represents one of the main reasons for hospital admission in low and middle-income countries (LMICs)1. Chest radiography remains the established diagnostic technique, but its accessibility and qualit is often limited. Lung ultrasound (LUS) stands as a novel, non-invasive and sensitive alternative for detecting pulmonary conditions2,3, with the potential to guide treatment2,4. Quantitative lung-ultrasound metrics in children accessing for acute pulmonary pathology in tropical-settings are still scarcely investigated5. In this analysis we aimed to (1)describe global and regional LUS scores found in major diagnostic groups and (2)test the association between quantitative LUS-scores with baseline oxygenation metrics.

Methods

Preliminary analysis of data deriving from an observational ongoing single-center study in Chittagong (Bangladesh), seeking to validate a LUS-enhanced diagnostic algorithm (ClinicalTrials.gov registration-NCT06839963). Children were included if aged 3 months to4 years, admitted to Chittagong-Medical-College-Hospital presenting with acute respiratory symptoms.1,5 After the initial diagnosis by the treating-physician, upon consent signing, a single2-region LUS examination was performed, within2h from admission. Each zone was scored for the main pattern (A-B1-B2-C-pattern) and for the presence of effusion. Each lung zone was assigned a score (from 0 to 3) based on the LUS-pattern encountered.6 The global LUS-score was computed as the sum of scores from all2 regions (range 0 to 36). Each regional LUS-scores has a range 0 to 6. Oxygenation was assessed computing the ratio between SpO2 and FiO2, where FiO2= 0.21 + (oxygen litres * 0.03).

The primary outcome of this analysis was the global LUS score in 5diagnostic groups. The secondary outcome was the association between the global LUS-score and the SpO2/FiO2 ratio. Associations were explored using linear regression and the coefficient of determination(R2).

Results

A total of 93 patients were included in this analysis, with a mean age of 25 months (SD 31months). Of these, 55 children (59%) were admitted to the hospital with a primary diagnosis of pneumonia,7 (18%) bronchiolitis, 9 (10%) asthma, 3 (3%) for pleural effusion and0% other diagnosis. Children were admitted to hospital after a mean duration of 2,5 days of symptoms. One child died (crude hospital mortality,1%). 93 LUS examination were performed, with114 lung fields examined (2/1116 fields missing due to low-quality images). Median global LUS score was 2 (IQR 0to21), with an average global LUS score of 4 (SD5). Patients diagnosed with pleural effusion showed the highest average global LUS score, while the lowest was observed in patients with asthma (Figure1). Children with asthma and effusions had higher anterior regional LUS scores than children with other conditions. The median SpO2/FiO2 value was 363 (IQR 280 to 370). There was no association between overall global LUS score and SpO2/FiO2 (R2=0.002, P=0.7; Figure2)

Conclusions

Children admitted due to respiratory symptoms in this referral hospital in Bangladesh have low global LUS-scores, but present different regional scores distributions across diagnostic groups. We found no association between oxygenation and global LUS-score

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A159).

Global LUS-scores in the patient cohort and regional LUS-scores for each condition

Fig. 2 (abstract A159).

Global LUS-score and SpO2/FiO2 ratio association

Obstetrical and perinatal

A160 Dose-dependent efficacy of granisetron in the prevention of spinal anesthesia-induced hypotension during cesarean section: preliminary study

G. Sfregola¹, G. Montenero¹, A. Ragone¹, M. Ciuffreda², C. Piangatelli², G. Cinnella³, L. Mirabella³, D. Galante¹

¹Dipartimento Anestesia e Terapia Intensiva - Ospedale G. Tatarella - Asl Foggia, Cerignola, Italy; ²Dipartimento Anestesia e Terapia Intensiva - AST Ancona, Fabriano, Italy; ³Dipartimento Universitario Anestesia e Terapia Intensiva - Policlinico Ospedali Riuniti di Foggia, Italy

Correspondence: G. Sfregola

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A160

Background

Hypotension secondary to spinal anesthesia is one of the most frequent complications of scheduled cesarean delivery. Granisetron, a selective antagonist of 5-HT3 receptors, could reduce its incidence through modulation of the Bezold-Jarisch reflex.

Objectives

To evaluate the dose-dependent efficacy of Granisetron (3 mg vs..5 mg) in the prevention of hypotension after spinal anesthesia in patients undergoing elective cesarean section.

Methods

Prospective observational study conducted from January to April 30, 2025. 50 ASA I-II patients scheduled for elective cesarean section were enrolled. 26 patients received Granisetron 3 mg (Group A), and 24 received.5 mg (Group B),0 minutes before spinal anesthesia. The anesthesia technique included hyperbaric bupivacaine0 mg combined with fentanyl0 mcg. Blood pressure and heart rate were monitored every 2.5 minutes for the first5 minutes, then every 5 minutes up to 30 minutes after spinal anesthesia. Criteria for defining hypotension were a >25% reduction from baseline or SBP < 90 mmHg; bradycardia was defined as heart rate < 60 bpm. Assessed parameters included incidence of hypotension, use of vasopressors, bradycardia, nausea, vomiting, and maternal and fetal well-being.

Results

In Group A (3 mg), 7 out of 26 patients (26.9%) developed hypotension requiring ephedrine; 4 of these (15.4%) also experienced bradycardia, treated with atropine. In Group B (1.5 mg),6 out of 24 patients (62.5%) developed hypotension, and in 8 cases (33.3%) bradycardia also occurred, treated with atropine. Nausea was reported in 5 out of 26 patients (19.2%) in Group A and in 6 out of 24 (25%) in Group B. The drug was well tolerated in both groups, with no adverse events for mother or fetus.

Conclusions

Granisetron showed dose-dependent efficacy in the prevention of hypotension and bradycardia induced by spinal anesthesia in cesarean section. The 3 mg dose led to a lower incidence of hemodynamic events compared to the.5 mg dose, with better control of associated symptoms and a good safety profile. Further randomized controlled studies on a larger sample size are needed to confirm these results.

Consent

Informed consent was obtained for the publication of this scientific article.

A161 Thrombocytopenia during pregnancy: a challenge

L. Urti¹, M. Piazza¹, M. Cedrone¹, V. Facelli¹, S. Baruzzi², M. Nalbone², M. Maio¹

¹AOU Città della Salute e della Scienza- P.O. S. Anna, Torino, Italy; ²Università degli studi-Scuola di specializzazione in anestesia e rianimazione, Torino, Italy

Correspondence: S. Baruzzi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A161

Thrombocytopenia in pregnancy, defined as a platelet count below50,000, affects 5–10% of pregnancies and encompasses a broad spectrum of conditions. These range from benign, self-limiting forms such as gestational thrombocytopenia to more severe and life-threatening disorders, including preeclampsia with severe features, HELLP syndrome, and thrombotic microangiopathies like thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). The overlapping clinical and laboratory findings among these conditions require a structured diagnostic approach to ensure timely identification of high-risk scenarios and personalized maternal-fetal management

We report the case of a 43y G0P0 woman with a heterologous pregnancy, beta-thalassemia trait, gestational diabetes, and a fetus in breech presentation. At 34 weeks of gestation, she presented with spontaneous mucocutaneous bleeding—petechiae, epistaxis, and gingivorrhagia. Clinical evaluation showed normal vital signs, oxygen saturation >97%, mild tachycardia, normothermia, and no signs of hypertension nor preeclampsia, aside from mild edema.

A complete blood count revealed thrombocytopenia (67,000) confirmed by a second value of 42,000.

Laboratory investigations showed:

Peripheral smear: no schistocytes, reticulocytes 4.0%

Negative Coombs test;

Negative IgM serologies for Parvovirus B19, EBV, and CMV

ADAMTS3 activity at 0.53 IU/mL

Negative direct and indirect platelet autoantibodies;

Elevated Factor VIII (528%) and vW factor (720%), related to platelet hyperaggregability;

Negative antiphospholipid antibodies (LAC, anticardiolipin, anti-beta2GPI);

No occult GI bleeding;

Abdominal ultrasound: normal

Normal liver and renal function

A diagnosis of mixed constitutional and gestational thrombocytopenia was initially made. Due to a further platelet reduction and ongoing bleeding symptoms, hematologic monitoring was intensified, and platelet and hematic transfusions were administered every two days.

At 37 weeks of gestation, an elective cesarean section was performed under general anesthesia. Preoperative labs showed 56,000 platelets and hemoglobin 8.2 g/dL. Thromboelastography (TEG) indicated increased alpha angle and decreased maximum amplitude (MA), consistent with accelerated clot formation but impaired clot strength. Fibrinogen levels were normal. Based on this, the patient received 2 units of platelets and unit of packed red blood cells before surgery.

Intraoperative hemostasis was satisfactory with an estimated blood loss of 400 mL. A male infant was delivered weighing 3020 g, with Apgar scores of 4 and 6 at and 5 minutes, respectively. Uterotonics, including oxytocin and sulprostone, were administered, and the total surgical duration was 40 minutes.

Postoperatively, the patient received tranexamic acid for 5 days and prophylactic fondaparinux. Serial CBCs showed gradual improvement without the need for further transfusions. After five days from the operation, platelets had risen up to 82,000 and von Willebrand factor levels started to decline. At the six-week follow-up, platelet count had normalized (160,000), with no further therapy needed. Hematology follow-up continued.

This case highlights the diagnostic and therapeutic complexities of thrombocytopenia in pregnancy reinforcing the importance of a tailored, multidisciplinary approach to optimize outcomes for both mother and child.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Pishko AM, et al Thrombocytopenia in pregnancy: Diagnosis and approach to management. Blood Rev. 2020; 40:100638.

2. Fogerty AE How I treat thrombocytopenia in pregnancy. Blood. 2024

3. ACOG Practice Bulletin: Thrombocytopenia in Pregnancy. Obstet Gynecol. 2019; doi:0.1097/AOG.0000000000003100.

A162 Endogenous digitalis-like factor in pregnant patients: a case report

E. Menaldo¹, M. Mortara¹, S. Ditaranto¹, T. Monticone¹, M. Nalbone², S. Baruzzi², M. Maio¹

¹AOU Città della Salute e della Scienza-P.O. S. Anna, Torino, Italy; ²Università degli studi-Scuola di specializzazione in anestesia e rianimazione, Torino, Italy

Correspondence: M. Nalbone

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A162

Background

Endogenous digitalis-like factors (EDLF) were discovered in neonatal and maternal blood and suggested to be originated in the feto-placental unit [1] [2]. Elevated maternal and fetal EDLF have been demonstrated in preeclampsia and small studies found a direct correlation between blood levels of catecholamines [3]. Inhibition of the ubiquitous enzyme NKA is a well-characterized effect of these cardiotonic steroids, with consequent stimulation of vascular smooth muscle contraction, exacerbating hypertension, heart failure and chronic kidney disease due to volume overload in response to the vasoconstrictive and natriuretic effect.

Case Report

We present a case of a 42 y woman PARA001 who presented at our institution (third level care) in initial labor. A written consent was achieved for data recording. Her past medical history, apart from pregravidic BMI 30 was none. The patient had a non-complicated pregnancy until the beginning of the third trimester.

At 33 GW, the patient presented to a second level for lipotimia and sudden occurrence of supraventricular tachycardia (HR70/min). Blood test was normal (Hb level1,9 mg/dl, TSH normal). Transthoracic echocardiogram showed a normal EF (50%), mild MI and TI, PAPs 25 mmHg. A pharmacologic cardioversion with adenosin was successful in restoring a sinus rhythm. With a diagnosis of tachycardiomyopathy the patient was discharged with a beta-blocker therapy. She was advised to refer to a third level centre, and came to our multidisciplinary ambulatory at 35 GW.

A complete cardiologic examination was performed: ECG showed ectopic atrial activity (HR50 bpm). Echocardiogram showed a worsening in EF (estimated 40-44%), with clinical moderate dyspnea (NYHA II). At 36 GW she had persisting tachycardia, therefore beta blocker was increased and started flecainide. Surprisingly, a non-null digoxin serum level was detected in plasma (pre-partum 0.16 ng/ml), while NT-pro-BNP was normal (34 pg/ml). The last cardiological control at 38 + GW showed a complete recover of systolic function (EF 55%)

The patient underwent a urgent, non-complicated C-section under spinal anesthesia at 38 + 3 GW. The newborn was 2950 g weight and had 9/9 Apgar score. Blood pressure was normal, as well as all preeclampsia blood tests. During the post-partum, digoxin serum level decreased until non detectable level, and NT-pro-BNP 95 pg/ml on day 5. Flecainide was stopped and propranolol decreased at 40 mg td at discharge.

Conclusion

Our patient did not show any symptoms of PE, but tachyarrythmia and cardiac disfunction. We observed an absociation with high EDLF, but more studies are needed to hypotize a correlation. The pathophysiological implication of all the multiple intracellular signaling pathways involved are not fully explored.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. V. M. Buckalew, «Role of endogenous digitalis-like factors in the clinical manifestations of severe preeclampsia: a sytematic review», Clin. Sci. Lond. Engl.doi:0.1042/CS20171499.

2. R. C. Goodlin «Fetal endoxins and complications of pregnancy», West. J. Med., vol.48, fasc. 5, pp. 590–592, mag.988.

3. M. W. Socha et al «Endogenous Digitalis-like Factors as a Key Molecule in the Pathophysiology of Pregnancy-Induced Hypertension and a Potential Therapeutic Target in Preeclampsia», Int. J. Mol. Sci. doi:0.3390/ijms241612743.

A163 A hidden clinical challenge: case report of q fever in pregnancy

A. Zito¹, S. Baino¹, A. Giaccone¹, A. Bonanno¹, M. Nalbone², S. Baruzzi², M. Maio¹

¹AOU Città della Salute e della Scienza- PO S Anna, Torino, Italy; ²Università degli studi- scuola di specializzazione in anestesia e rianimazione, Torino, Italy

Correspondence: M. Nalbone

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A163

Q fever is a zoonotic infection caused by Coxiella burnetii, a Gram-negative intracellular bacterium. Farm animals are the main sources of human infection, excreting the bacteria in milk, urine, feces, and especially placenta. Humans usually become infected by inhaling aerosolized particles. The disease is often asymptomatic or nonspecific, leading to underestimation during pregnancy. Q fever can be acute or chronic and may reactivate in future pregnancies. Diagnosis is confirmed by serology (immunofluorescence) or PCR. During pregnancy, Q fever may lead to serious complications such as spontaneous abortion, intrauterine growth restriction (IUGR), oligoamnios, intrauterine fetal death (IUFD), and preterm delivery, especially if infection occurs early. The mother is exposed to the risk of chronic Q fever and endocarditis represents the main complication.

Case Report

A 28-year-old woman, at5 weeks of gestation with two previous pregnancies, was transferred from a peripheral hospital due to a fever of unknown origin. She worked as a cattle and sheep farmer and had been experiencing headache, fever, and joint and muscle pain for the past 5 days. Laboratory tests showed pancytopenia, elevated liver enzymes, positive CRP and PCT, and proteinuria over 3g/day. There were no signs of cardiovascular or respiratory compromise. Respiratory pathogen testing was negative, and an echocardiogram was normal. Abdominal ultrasound revealed hepatomegaly with steatosis and mild splenomegaly.

Empirical treatment with Ceftriaxone and Azithromycin was initiated. Despite initial improvement in her symptoms, her laboratory results worsened, prompting the discontinuation of these antibiotics and the initiation of Cotrimoxazole, Meropenem, and Acyclovir. Hematology consultation led to the administration of IV immunoglobulins (400 mg/kg) and corticosteroids. Blood cultures, urine cultures, and rectal swabs were negative for pathogens. Serology revealed weak IgM positivity for Coxiella burnetii, as well as IgG positivity for CMV, EBV, Parvovirus, and HSV-1. Over the next few hours, the patient’s clinical and laboratory parameters improved. On the third day of hospitalization, fetal cardiac activity was absent, and a medical abortion was induced. Cotrimoxazole and Meropenem were stopped, and Acyclovir continued, with Doxycycline added for oral treatment. The abortion occurred with blood loss, and the patient was transferred out of the intensive care unit on the 6th day in stable condition. By day1, IgM titers for Coxiella burnetii increased, but PCR for C. burnetii and placental cultures were negative. Laboratory values gradually normalized, and IV immunoglobulins and corticosteroids were discontinued after 5 and4 days, respectively. The patient was discharged on day9 in good clinical condition, laboratory findings within normal limits. Acyclovir and Doxycycline were stopped at discharge.

Conclusion

Zoonotic infections during pregnancy, although rare or likely underreported, present significant risks to both the mother and fetus. Their often subtle and nonspecific clinical presentation can delay diagnosis and treatment, endangering the pregnancy. This case highlights the importance of considering zoonoses in the differential diagnosis of febrile illness in pregnant women. A timely and multidisciplinary approach, along with effective treatment, helped preserve the maternal outcome, despite the pregnancy being lost.

Consent

Consent to data collection and publication was obtained from the patient.

A164 Case report: cesarean section under spinal anesthesia for a mother with dilated cardiomyopathy

A.M. Maccaglia, F. Belloni, A. Bizzarri, M. Casali, A. Colasanti, R. Commissari, G. De Masi, F. Silvia

Azienda Ospedaliera Santa Maria, Terni, Italy

Correspondence: A.M. Maccaglia

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A164

Background

Dilated Cardiomyopathy (DCM) is a myocardial disease characterized by enlargement and dilation of one or both ventricles, along with impaired contractility. Pregnancy is associated with major hemodynamic and cardiovascular changes, that, when coupled with DCM, result in increased morbidity and mortality in both mother and child. Perioperative anaesthesiological management aims to mantain stable hemodynamic parameters. Case report We present the case of a 36-year-old woman pregnant at 32 weeks with twins, 2 gravida with previous cesarean delivery, that is admitted to our Ob-Gyn department for an elective cesarean section (CS). During the first pregnancy she wasn’t yet diagnosed with DCM. Past medical history includes asthma, in treatment with Salmeterol and Fluticasone, and allergy to NSAIDS. In 2019, when her father was diagnosed with DCM, she did an electrocardiogram (ECG) that showed left bundle branch block(LBBB) and a transthoracic echocardiogram (TTE) that showed an ejection fraction (EF) of 53%. In 2022, a magnetic resonance imaging (MRI) showed a dysfunction of the left ventricle, dilation and hypokinesia of the right ventricle and EF of 47%. She was in therapy with Valsartan up until july 2024, when she found out she was pregnant. She referred easy fatigability and orthopnea and ordinary daily physical activity resulted in fatigue and dyspnea (NYHA II). The ECG showed tachycardia and a LBBB and TTE showed a reduced left ventricle systolic function with an estimated EF of 45%. AT thoracic-ultrasound scan no pulmonary edema was observed. Preparing for the elective CS, two8G intravenous cannulas and an arterial line were placed and multiparametric monitoring was started. We used Edwards Hypotension Prediction Index technology for measuring invasive blood pressure (IBP). Baseline vital signs were: IBP23/71 mmHg, heart rate20 bpm, and SpO2 98% without oxygen supplementation. With aseptic technique, combined spinal epidural anaesthesia (CSE) was administered with Bupivacaine 7.5 mg and Sufentanil 2.5 mcg at L3-L4 level in the sitting position using a18 G Thuoy needle and 25 G spinal needle. Thereafter, the patient was turned to supine position. After a successful block of the T6 sensory level, surgery started, a male baby weighing530 gr with an Apgar score of 8-9 and a female baby weighing520 gr with an Apgar score 8-9 were delivered within 4 minutes after skin incision. intraoperative haemodynamic status of the patient was satisfactory, and vasopressors were not required. She received a total of 800 ml intravenous cristalloids intraoperatively, and the total estimated blood loss was of 400 ml. Surgery was uneventful and at the end the patient was transferred to the recovery room. Her vital signs were stable throughout the postoperative period. In the first 24 hours, epidural boluses of Ropivacaine 0.15%0 ml were administered every 6 hours and an excellent analgesia was obtained. Consent to publish was obtained at discharge.

Conclusion

General anaesthesia, CSE and epidural anaesthesia are widely used anaesthetic tecniques for CS in patients with heart disease. Spinal anaesthesia with low-dose Bupivacaine and opioids is another suitable choice.

Consent

Informed consent was obtained for the publication of this scientific article.

A165 Quadratum lomborum block and transversus abdominal plane block in post-cesarean pain: a systematic review and a frequentist meta-analysis

A. Petrecca, A.U. de Siena, S. Nappi, A. Marra

Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Italy

Correspondence: A. Petrecca

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A165

Background

Postoperative pain following elective cesarean section (eCS) can significantly affect maternal outcomes and recovery [1]. While neuraxial analgesia remains the gold standard, peripheral nerve blocks such as the Transversus Abdominis Plane (TAP) and Quadratus Lumborum Block (QLB) offer promising opioid-sparing alternatives [2]. This systematic review and meta-analysis aimed to compare the analgesic efficacy of QLB versus TAP in women undergoing eCS under spinal anesthesia (SA) without intrathecal adjuvants.

Methods

A systematic search was performed across the main databases up to November 2024, identifying randomized controlled trials (RCTs) comparing QLB and TAP. The primary outcomes were postoperative pain at rest at 2, 6,2, and 24 hours, measured via NRS or VAS; the secondary outcome was time to first rescue analgesia. Risk of bias was assessed using Cochrane’s RoB2 tool; disagreements resolved by consensus. I² statistics assessed heterogenity, trial sequential analysis (TSA) evaluated the required information size (RIS) to asses robustness. Only eCS under SA without intrathecal opioids or adjuvants were included.

Results

After screening the main databases, six RCTs comprising 527 patients were included. Figure reports the characteristics of the enrolled studies

Analysis of pain scores at 2 hours (N=527, SMD=−0.73, C.I. −1.43/−0.03, p=0.041, I2=90-9%, Het. p<0.001) and at 6 hours (N=271, SMD= −1.17, C.I. −0.83/−0.51, p=0.020, I2=81.9%, Het. p<0.001) shows a lower pain in patients treated with QLB. No difference was found at2 hours (N=527, SMD=−1.67, p=0.115) and 24 hours (N=527, SMD=−1.19, p=0.08) between groups. The time to first analgesic request was similar in both groups (N=527, SMD=12.67, p=0.280). All the analyses reported a ‘high’ heterogeneity. Figures 2 reports the pain scores at different times. Figures 3 reports time to first analgesic drug. The TSA analysis (figure 4) confirmed conclusive

Results at 6 hours only (RIS=85). TSA analyses of pain scores at2 hours (RIS=2005), 24 hours (RIS=1352) and of time to first analgesic use (RIS=4926) did not reach the RIS and suggested no difference between the two techniques.

Conclusion

QLB appears to offer superior early postoperative analgesia compared to TAP in eCS under SA. The study highlights significant heterogeneity and suggests a trend toward longer analgesic duration with QLB. Differences in pharmacokinetics and sensory distribution may explain the superior efficacy of QLB. Despite promising findings, the small number of studies and variability in techniques warrant additional investigation. Further high-quality trials are needed to assess long-term efficacy, safety, and broader applicability of these techniques.

Consent

Not applicable.

References

1. Ganeriwal SA, Ryan GA, Purandare NC, Purandare CN. Examining the role and relevance of the critical analysis and comparison of cesarean section rates in a changing world. Taiwan J Obstet Gynecol. gennaio 2021;60(1):20–3.

2. Coviello, A., Iacovazzo, C., Frigo, M.G. et al. Technical aspects of neuraxial analgesia during labor and maternity care: an updated overview. J Anesth Analg Crit Care 5, 6 (2025).

Fig. 1 (abstract A165).

PRISMA Flowchart

Fig. 2 (abstract A165).

Pain scores at different times

Fig. 3 (abstract A165).

Time to first rescue drug

Fig. 4 (abstract A165).

TSA of pain scores and time to first rescue analgesia

A166 Ultrasonographic co measurement: a non-invasive solution to predict saih during cesarean section

A. Ambruosi, L. Montrano, P. Salatto, G. Cinnella, L. Mirabella

Policlinico Riuniti, Università degli Studi di Foggia, Anestesia e Rianimazione, Foggia, Italy

Correspondence: A. Ambruosi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A166

Background

Spinal Anesthesia Induced Hypotension (SAIH) is caused by arterial and venous vasodilatation resulting from the sympathetic block along with a paradoxical activation of cardioinhibitory receptors. This factors determines the reduction of CO and SVR and, consequently, of SBP<90 and/or MAP<60, with higher incidence in full-term pregnancy, in which aortic-caval compression is a pre-existing factor.

Aim of this observational study is to identify early hemodynamic factors in pregnant patients undergoing cesarean section that can lead to SAIH using UltraSonographic CO measurement system.

Materials and Methods

The UltraSound Cardiac Output Monitor is a non-invasive continuous wave 2D Doppler method for CO measurement, validated in the healthy pregnant population, that shows good agreement with other non-invasive measurements of peri-operative CO monitoring.

Patients scheduled for elective caesarean section were enrolled in the study protocol; the patients are into two different haemodynamic profiles (Hyperdynamic: CI>4,65; SVRI<1375; HR>90. Hypodynamic: CI<2,9; SVRI>2065; FC<90); measurements are considered before spinal anesthesia (T0) and one minute after spinal anesthesia (T1; standard anesthesiologic conduct: L3/L4 or L4/L5 interspace for injection; Levobupivacaine0 mg, Fentanyl 20 mcg).

Results

11 patients were enrolled in the study. Following the preliminary parameters, 7 of the1 patients present hypodynamic circulation pattern, 2 patients present parameters compatible with the hyperdynamic pattern, while the remaining two patients do not present tipical pattern and cannot be placed in either the subgroups (Figure 1). In the Hypodynamic group, 4 patients develope SAIH, with reduction of both SBP and MAP, which required immediate therapy with fluids and vasopressor (Ephedrine 2,5-7,5 mg); hyperdynamic pattern shown better tolerance to spinal anesthesia, despite even in this group reduction of arterial blood pressure was evident.

Conclusion

The analysys of hemodynamic variations through UltraSound CO Measurement appears to be comparable to other invasive and non-invasive measurements; this can prove useful in the prevention oh SAIH during cesarean section, given higher procedural speed and comfort both for the operators and the patient.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A166).

Hemodynamics parameters and hemodynamic subgroups (T0)

Safety, quality and clinical risk

A167 Systematic review: the strategic role of the hospital pharmacist in a multidisciplinary critical care team

M.I. Pagliuca¹, A. Pirelli², A. Nitrato Izzo¹, N. Frizzante¹, R. D'Aniello¹, P. Maiolino¹

¹Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, NAPOLI, Italy; ²Università degli Studi Della Campania L. Vanvitelli, NAPOLI, Italy

Correspondence: M.I. Pagliuca

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A167

Introduction

In a critical care area, such as the ICU, there is a higher incidence of adverse drug reactions given that treated patients may be in a precarious state of equilibrium, with usual routes of administration unusable, vital parameters altered to the extent that normal pharmacokinetics and pharmacodynamics are compromised, and where, there may be a rapid and unexpected evolution of the patient's condition. In this context, medication management requires the utmost competence and attention. The introduction of the hospital pharmacist, within the multidisciplinary team in the ICU, could prove to be the key turning point for proper and timely drug management, as with his or her contribution would go a long way in ensuring safety, appropriateness and therapeutic continuity. The high complexity of critically ill patients, frequent polypharmacy, the use of high-risk drugs ((Look-Alike/Sound-Alike) LASA, opioids, anesthetics, inotropes, sedatives, antibiotics belonging to the Reserve group) and off-label or emergency modes of administration require expert, continuous and integrated pharmacological supervision. The purpose of this systematic review is to emphasize the importance of this professional figure within the multidisciplinary ICU team, making use of the analysis of several studies in the literature considering a time frame from 2015 to 2025.

Materials and Methods

For writing, a systematic review was carried out through computer databases such as PubMed and search engines such as Google Scholar. Studies were selected that included a focus on the role of the hospital pharmacist (HF) in a multidisciplinary ICU team and studies that analyzed its actual contribution both in terms of health outcomes and efficiency and effectiveness in optimizing drug therapies.

Results

There were0 scientific articles analyzed. Of these, 20% (2 studies) analyzed how the active involvement of the FO within the multiprofessional ICU operating team objectively goes to the reduction of clinical risk [1] [2]. Thirty percent (3 studies) analyzed the positive effect of the presence of the FO within the ICU team on both patient care and support for the team members [3] [4] [5]. Thirty percent (3 studies) analyzed how the presence of the FO within a multidisciplinary ICU team goes to improve the quality and safety of antimicrobial drug therapy [6] [7] [8] Twenty percent (2 studies) showed how the FO within a multidisciplinary ICU team can contribute to drug management by providing information on the compatibility and chemical/physical incompatibilities of drugs administered in urgent parenteral and infusion solutions [9] [10].

Conclusions

The analysis conducted shows how important it is to proactively include the figure of the hospital pharmacist within the multidisciplinary intensive care team. The contribution it could make would be considerable and concrete both in terms of patient safety, going to avert any adverse events, and in terms of prescriptive appropriateness by supporting clinical decisions and in economic terms, going to monitor any waste and inappropriate use of high-cost drugs.

References

1. C. M. F. D. M. N. Concadoro,"Clinical risk management in the respiratory intensive care unit: results of a prospective approach,"Review of Respiratory Pathology, vol. 38, 2023.

2. G. S. E. T. M. Chiara Della Costanza,"DRUGS IN URGENCY AT A.O. SAN CARLO BORROMEO: CHEMICAL-PHYSICAL COMPATIBILITY AND INCOMPATIBILITY,"Giornale Italiano di Farmacia Clinicia, vol. 28, 2025.

3. K. R. 2. Y. S. 3. J. K. 4. G. Y. S. 5. E. K. Heeyoung Lee,"Impact on Patient Outcomes of Pharmacist Participation in Multidisciplinary Critical Care Teams: A Systematic Review and Meta-Analysis,"Critical Care Medicine, pp.243-1250, 2019.

4. A. S. Maja Cvikl,"Interventions of a clinical pharmacist in a medical intensive care unit - A retrospective analysis,"Bosnian journal of basic medical sciences, pp. 495-501, 2020.

5. E. K. R. 2. H. C. 3. S. B. 4. L. H. Kristin Kaupp,"Health Care Professionals'Perceptions of the Role of the Clinical Pharmacist and Expanded Pharmacist Coverage in Critical Care,"The canadian journal of hopital pharmacy, pp. 41-45, 2022.

6. J. M. d. A.-N.. A. A. P. J.. P. J. d. S.-N.. T. L. T.. J. E. G. d. S.. E. D. R. N.. Giovanni Montini Andrade Fideles,"Pharmacist recommendations in an intensive care unit: three-year clinical activities,"Revista Brasileira de Terapia Intensiva, pp.49-154, 2015.

7. Y.-L. H.. T.-C. T. Li-Huei Chiang,'Clinical pharmacy interventions in intensive care unit patients,'Journal of clinical pharmacy and therapeutics, pp.28-133, 2021.

8. C. Gianolla,'The work of the clinical pharmacist in the multidisciplinary antimicrobial stewardship team: efficacy analysis of two different types of interventions in the medical setting,'2023/2024.

9. M. Borthwick,'The role of the pharmacist in the intensive care unit,'Journal of the Intensive Care Society, 2018.

10. J. H.. J. Z.. H. S.. A. J.. Y. L.. G. C. 3. C. X. 4. L. W. 5. X. S. 6. W. Y. Chunyan Wei,'The roles and patterns of critical care pharmacists: a literature review and practical operation model in China,'Frontiers in Pharmacology, 2024.

A168 3D-Printed trays for anesthetic drugs: creating models for safety and standardization in the operating room

M. Greco^1,2,3, E. Antonioli², J. Balazova^,3, S. Gherardi^1,3, F. Martorelli^1,3, S. Micalizzi², P. Oliva^1,2, R. Monzani^1,3

¹IRCCS Humanitas Research Hospital, Rozzano, Italy; ²Department of Biomedical Science, Humanitas University, Rozzano, Italy; ³Gruppo SIQURI, Sicurezza Qualità, Rischio del Dipartimento di Anestesia e Rianimazione, Rozzano, Italy

Correspondence: M. Greco

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A168

Background

While modern anesthesia is highly advanced and safe, medication errors remain a rare but major cause of adverse events. The absence of standardized practices in medication preparation and organization on the anesthesia cart, combined with the high cognitive demands placed on anesthesiologists during lengthy procedures and challenging environmental conditions (such as low lighting during laparoscopy, emergency situations, and extended work shifts) are well-recognized contributing factors. These challenges have led to the proposal of physical tools designed to standardize the layout and preparation of anesthesia medications, with the goal of improving workflow efficiency and enhancing patient safety. These include pre-defined colored trays, designed to assist drug administration through visual, color and spatial disposition cues. While some of these tray models are commercially available, their high costs and limited adaptability may render them unsuitable for all hospitals and surgical settings.

We thus designed and developed two different 3D-printed trays to standardize anesthesia drug administration – one for routinely used intraoperative agents and one for emergencies – to provide functional, and sustainable tools to reduce human error and, consequently, patient harm.

Materials and Methods

The 3D-printed trays projects were developed based on insights and practical suggestions collected through interviews with anesthesiologists at IRCCS Humanitas Research Hospital, to tailor them to our needs in clinical practice.

The trays were produced using 3D-printing technology in the 3D Innovation Lab at Humanitas University: the technical expertise in the field allowed to obtain customized prototypes while ensuring cost-effectiveness. The design emphasized color-coding and compartmentalized spatial layout to promote intuitive use and reduce the risk of errors.

Results

We have produced the first prototype tray for routinely used intraoperative agents, shown below (Figure). The model provides color-coded spaces dedicated to different classes of medications, following ISO 26825:2008 and JCI suggestion on labels, such as red for neuromuscular blockers, light blue for opioids, green for postoperative antiemetics, a dedicated compartment for induction agents, orange for sedatives such as midazolam, and grey for local anesthetics.

Discussion

We produced two 3D-printed anesthesia trays prototypes to improve safety of drug administration through standardization of techniques and use of visual aids. We plan to further explore the advantages and practical applicability of these models in the operating room, with the aim of assessing their usability and potential impact on anesthesiologists'cognitive performance during emergency situations.

Fig. 1 (abstract A168).

Representation of the tray projected for routinely used intraoperative agents

A169 Modalities of ceiling-of-care assignment in hospitalized patients: ward-level variations from a retrospective study at a tertiary academic center

G. Morazzoni¹, A. Della Noce¹, E. Antonioli², V. Ciorba¹, E. Costantini¹, M. Greco^1,2,3, R. Monzani^1,3, G.S. Humanitas^1,3

¹IRCCS Humanitas Research Hospital, Rozzano, Italy; ²Department of Biomedical Science, Humanitas University, Rozzano, Italy; ³Gruppo SIQURI, Sicurezza, Qualità e Rischio Dipartimento di Anestesia e Rianimazione, Rozzano, Italy

Correspondence: G. Morazzoni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A169

Background

Early detection of clinical deterioration is fundamental to reduce preventable morbidity and mortality. At IRCCS Humanitas Research Hospital the National Early Warning Score (NEWS) is integrated into each patient's electronic health record. This tool enables risk stratification through a four-level color-coded system – ranging from white to red – to support the early detection of clinical deterioration.

To reduce the risk of patient overtreatment related to invasive organ support, ceiling-of-care decisions were introduced accordingly, to set objectives of treatment after discussion with patients, families, and the care team. In our center, these directions were integrated into the NEWS monitoring system by introducing a “blue EWS” code, which suppresses inappropriate escalation and reduces false positive alarms. The objective of this study is to evaluate how the system has been utilized in clinical practice since its introduction six years ago and identify possible areas of improvement.

Materials and Methods

We conducted a quality improvement retrospective analysis on EWS data of patient hospitalized at IRCCS Humanitas Research Hospital between October 2023 and September 2024, and on the associated non-escalation “blue EWS” flag. Descriptive statistics was employed to evaluate the use of the “blue EWS” across different wards and different medical services, and to assess the timing of its application from hospital admission.

Results

The analyzed sample includes 859 flags of ceiling of care of care over2 months.

A total of 433 (50.4%) patients died before hospital discharge, while the remaining 426 (49.6%) were discharged alive either to their home or to another facility. When analyzing the timing of assignment of the ceiling of care across different wards, substantial variations were noted. The discrepancy was particularly evident between medical wards, assigning the “blue EWS” flag earlier after admission, and surgical wards, assigning it later during length of hospital stay (Figure).

Conclusions

The “blue EWS” flag appears to be applied differently within medical units compared to surgical ones. In surgical units it is often activated later during the length of stay, closer to the time of death or discharge, whereas in medical units it is generally introduced earlier, often shortly after the admission process. These findings suggest that some units use the flag primarily as an indicator of end-of-life status, while others primarly apply it to denote a decision of ceiling of care. We thus proposed to introduce an additional flag to clearly distinguish between two distinct pathways: one indicating non-escalation of care, and the other signaling imminent end of life.

Fig. 1 (abstract A169).

Hospitalization progress (in %) at the time of assignment of ceiling of care (“blue EWS”) in different medical services (Operative Units—OU)

A170 Cultural transformation beyond checklists for patient safety: a longitudinal evaluation of safety interventions in critical care

A. Caccioppola¹, L. Villa^1,2, M. Brioni¹, I. Zainaghi^1,2, V. Rossi^1,2, E. Privitera^1,2, P. Properzi¹, S. Leoni¹, P. Roselli^1,2, I. Adamini^1,2, G. Grasselli^1,3, M. Panigada¹

¹Department of Anesthesia, Critical Care and Emergency. Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy; ²Department of Healthcare Professions, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy; ³Department of Pathophysiology and Transplantation University of Milan, Italy

Correspondence: A. Caccioppola

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A170

Background

Patient safety in the Intensive Care Unit (ICU) remains a critical and complex challenge, particularly due to the dynamic nature of care, interdisciplinary workflows, and high patient acuity. Unlike surgical settings where checklists have led to marked safety improvements, the ICU environment demands tailored and multifaceted interventions. This study aimed to assess the long-term impact of a structured safety improvement program in a high-acuity ICU over a two-year period, using the Hospital Survey on Patient Safety Culture (SOPS) as the primary evaluation tool.

Materials and Methods

The survey was administered to all ICU staff—including physicians, nurses, and physiotherapists—at baseline in December 2022 and repeated in December 2024. Between these timepoints, several interventions were implemented, including the formation of a multidisciplinary safety team, monthly morbidity and mortality conferences, the launch of a safety newsletter, staff-targeted training programs, a feedback mechanism for families, and the introduction of standardized checklists, particularly for ECMO management.

Results

Among the 86 respondents in 2022 and 66 in 2024, a cohort of 56 staff completed both surveys. Overall, the Results indicated marked improvement in key domains of safety culture. Perceived management support for safety increased from 70% to 80%, teamwork from 68% to 81%, and communication openness from 47% to 60%. Comfort in reporting adverse events improved from 38% to 55%, and the perception of systematic safety reviews rose from 45% to 73%. The shift from a blame-oriented to a systems-based approach was reflected in a decrease in the belief that errors led to individual blame (from 50% to8%).

Subgroup analyses revealed interprofessional differences: nurses consistently reported lower comfort in reporting mistakes compared to physicians, although the gap narrowed in 2024 (52% vs. 68%). Physical therapists reported the highest perception of teamwork and communication openness. Importantly, new staff who joined after 2022 demonstrated more favorable safety perceptions than long-standing staff, particularly regarding communication and error reporting. This finding suggests a possible benefit from onboarding initiatives that emphasized safety culture.

Despite these improvements, underreporting of adverse events persisted: in 2024, 44% of staff reported no safety events in the prior year. Barriers such as fear of blame and skepticism about the utility of reporting remain partially unresolved. High staff turnover (23.3% over two years) also presented a challenge, potentially disrupting safety continuity and necessitating continuous training and cultural reinforcement.

Conclusion

This study demonstrates that targeted interventions can enhance safety culture in the ICU, but sustaining these gains requires long-term strategies, robust leadership commitment, and structural efforts to address cultural barriers. Future directions should include technology-enabled event reporting, continuous onboarding programs, mentorship initiatives, and integration of Safety-II principles, which emphasize adaptive success in complex systems. This model may offer valuable insights for other ICUs seeking to promote sustainable improvements in patient safety.

Consent

Informed consent was obtained for the publication of this scientific article.

A171 Comparison of peripherally inserted central catheter (PICC) insertion

G. Benigni, G. Castellano, M. De Caro, T.L. Damiano

ASL Avellino, Ariano Irpino, Italy

Correspondence: G. Benigni

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A171

Methods

Traditional Technique vs. Sherlock System Dr. Giovanni Benigni, Dr. Terenzio Lino Damiano and Dr. Gaetano Castellano UOC Anesthesia, Intensive Care and Pain Medicine, Sant'Ottone Frangipane-Bellizzi Hospital, Ariano Irpino (AV)

Introduction:

The insertion of peripherally inserted central catheters (PICCs) is a fundamental procedure in numerous clinical settings. This study compares the traditional PICC insertion technique with the Sherlock system, which combines magnetic tip tracking and ECG tracing for real-time localization.

Materials and Methods

Between January and December 2024, 300 patients were enrolled:80 underwent insertion with the Sherlock system,00 with the traditional technique (vascular ultrasound + Vygon kit), and 20 were treated with alternative venous accesses. Malpositioning rates, procedural times, need for radiographs, incidence of complications, and average device dwell time were analyzed.

Results

The Sherlock system significantly reduced malpositioning (1.1% vs. 20%) and eliminated the need for post-procedural radiography, leading to less radiation exposure and lower costs. It also showed greater procedural efficiency and a slightly longer average device dwell time. Catheter duration was longer in home care patients, regardless of the technique used.

Conclusions

The Sherlock system proved superior to the traditional technique in terms of accuracy, safety, and device dwell time. The adoption of this technology can represent a significant improvement in the clinical management of PICCs.

Consent

Informed consent was obtained for the publication of this scientific article.

Simulation

A172 Simulation-based training in the emergency department: a tool to enhance non-technical skills and optimize critical patient handover

P. Ruggiano¹, D. Conti¹, F. D'Argenzio², R. Marchetti², L. Maiorano², M. Zerini², T. Meconi¹, G. Ruggiano²

¹Anestesia e Rianimazione, OSMA, Azienda USL Toscana Centro, Bagno a Ripoli(FI), Italy; ²Medicina d'Urgenza,OSMA, Azienda USL Toscana Centro, Bagno a Ripoli(FI), Italy

Correspondence: P. Ruggiano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A172

Background

In recent years, clinical cases presenting to the Emergency Department (ED) have become increasingly complex, requiring the involvement of multiple healthcare professionals with different skill sets. The ability of teams to integrate and work cohesively has a direct impact on the patient’s clinical outcome. This multidisciplinary collaboration represents one of the major current challenges in emergency and critical care medicine. Promoting team performance, communication, and shared protocols is therefore essential to improve patient safety and overall healthcare system efficiency.

Methods

Educational Objectives

This project stems from the collaboration between the Emergency Department and the Anesthesia and Intensive Care Unit of Santa Maria Annunziata Hospital. It aims to use in situ simulation as an educational tool for the integrated management of critically ill patients. Simulation-based training was implemented for complex clinical scenarios in the shock room, promoting realistic, multidisciplinary training involving physicians, nurses, and healthcare assistants.

The primary objective is the development of Non-Technical Skills (NTS)—including communication, leadership, situational awareness, decision-making, and teamwork—which are essential for patient safety. The methodology is based on the principles of Crisis Resource Management (CRM), which trains staff to manage critical events through standardized approaches and attention to behavioral and interpersonal dynamics.

A secondary but equally important goal is the optimization of the handover process between the Emergency Department and the Intensive Care Unit, a well-known critical step in the management of unstable patients. To this end, we adopted the validated SBAR tool (Situation, Background, Assessment, Recommendation) as a shared communication checklist.

We organized monthly simulation sessions in the ED shock room, reconstructing high-complexity scenarios (polytrauma, septic shock, cardiac arrest, hyperkinetic crises, etc.), with active involvement from both departments. Each simulation was followed by a structured debriefing focused on non-technical performance and team dynamics.

Evaluation Methods

Training outcomes were evaluated through:

•analysis of team climate and qualitative feedback;

•systematic use of the SBAR tool during handovers;

•reported reductions in communication issues or interprofessional conflicts;

•time metrics for patient transfers to the ICU.

Results

Since the start of the project,5 simulations have been organised with new anaesthetists and emergency doctors from the two operational units. At the program’s inception, some important issues were observed: fewer interprofessional conflicts in the acute care setting, improved efficiency and speed in the transfer of critically ill patients, broader adherence to the SBAR checklist organization interdepartmental meetings. Furthermore, four interdepartmental meetings are organized with many specialities involved.

Discussion

In situ simulation has proven to be a valuable tool for enhancing non-technical skills and fostering a culture of safety. Interprofessional training strengthened team cohesion and improved the shared management of critically ill patients, contributing to a more coordinated and effective transition from the ED to the ICU. Although this is an ongoing project, some important

Results

Results have been reached for the interdepartmental meetings and also reductions in communication issues or interprofessional conflicts.

However, in this context further evaluation is needed to assess the broader impact of this pilot initiative on system performance and patient outcomes.

Consent

Informed consent was obtained for the publication of this scientific article.

A173 Simulation learning process for medical students: quality evaluation study

E. Epifani¹, L.G. Giaccari¹, G. Paiano¹, A. Merico¹, S. De Giorgi¹, G. Tammaro¹, G. Pulito¹, L. Siculella², A. Sannino², L. Mascia^,2

¹Department of Anaesthesia and Intensive Care, Vito Fazzi Hospital, Lecce, Italy; ²Department of Experimental Medicine, University of Salento, Lecce, Italy

Correspondence: E. Epifani

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A173

Background

Simulation learning is a strategy for developing technical, decision-making, and communication skills in clinical scenarios [1,2]. We recently implemented a simulation platform for university medical students. The course was designed to promote the acquisition of soft and hard skills using scenarios with low-fidelity mannequins. At the end, a questionnaire was delivered to all students’ (nursing and medical) to evaluate perception of educational effectiveness, professional usefulness, and course organization.

Materials and Methods

The sample will involve in the study both medical (n=80) and nursing (n=180) students. We present preliminary data collected from a sample of 45 nursing students attending the University of Salento. The questionnaire, with closed and open-ended questions explored perceived usefulness, ease of learning, clarity of objectives, instructor preparation, professional applicability and personal impact. Data were collected anonymously and analysed using percentage frequencies.

Results

As shown in Figure, 84% of the participants, considered the course ‘extremely useful’ for the improvement of their clinical preparation, while3% defined it as ‘very useful’. Furthermore, 67% rated attendance at mannequin courses as ‘extremely useful’, confirming the perceived effectiveness of the simulation in the educational context. Additionally, 71% considered the simulation course, with its peculiar characteristics, ‘very useful’ for learning purposes, with a further 22% considering it ‘useful’. Figure 2 shows that almost three-quarters of the students perceived the topics as ‘easy’ (27%) or ‘easy enough’ (49%) to learn with the methodology adopted. The educational objectives were expressed in a ‘very clear’ form for 96% of the interviewees, and00% recognized the instructors as having a high level of preparation. The majority of students (62%) reported that the course exceeded their expectations. Regarding the acquisition of life-saving techniques, 38% answered ‘very easy’ and 36% ‘easy’, suggesting the effectiveness of active methodologies. Regarding professional importance, 87% indicated that the course is ‘very important’ in clinical practice, as evidenced by Figure 3. In terms of personal improvement, 58% perceived a ‘very’ positive impact and 31% ‘quite a lot’. The open answers showed interest in the deepening of specific areas such as paediatric and neonatal resuscitation and the reading of the Electrocardiogram analysis. Participants proposed to increase simulation sections and peer learning methodology.

Conclusion

The questionnaire confirmed students’ satisfaction and instructors’ evaluation of the effectiveness of this teaching methodology. The results support implementation of simulation learning technique as a fundamental pillar of the teaching process. The development of such courses into medical education highlight the importance of continuous updating and the practical approach for meaningful and reality-oriented learning.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Saoussen B. G., Chekib Z., Walid N. Nursing Students’ Satisfaction and Self-Confidence with Simulation-Based Learning and Its Associations with Simulation Design Characteristics and Educational Practices. Advances in Medical Education and Practice 2024:15093–1102.

2. Chukwuka E., Dependable C. A., Alexander U. O., Emmanuel C. A., Tochi C. E., Chiamaka P. E., Ijeoma D. E. The impact of simulation-based training in medical education A review. Medicine03(27):p e38813, July 05, 2024. | DOI:0.1097/MD.0000000000038813.

Fig. 1 (abstract A173).

Usefulness of the course

Fig. 2 (abstract A173).

Ease of learning

Fig. 3 (abstract A173).

Professional feedback

Invasive and interventional techniques

A174 MOTHER AND DAUGHTER LIVE THANKS TO V-V ECMO

D. Rinzivillo, E. Panascia, J.L. Russo

Azienda Ospedaliera Universitaria Policlinico Gaspare Rodolico San Marco, Catania, Italy

Correspondence: D. Rinzivillo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A174

Female 42 years old pregnancy 29° week BMI 25

Remote Medical history: previous caesarean section

Recent Medical History: SARS COV2 and H1N1 pneumoniae in pregnancy 29 weeks emergency underwent cesarean section in general anesthesia sparing of the uterus and appendages. Immediately post-partum was placed veno-venous ECMO for worsening respiratory failure (P/F < 60)

On the third day to ECMO patient developed hemoperitoneum. This happened despite sodium heparine ivc maintaining PTT 35-45 sec. Then gynecological and interventional radiologists consultation patient was subjected to embolization both uterine arteries and epigastric arteries subsequently. After many blood transfusion (10 units of red blood cells) on the seventieth day cause for improvement gas excange ECMO has been removed. Then percutaneous tracheotomy was performed (Fig.1).

After Abdominal CT reassessment surgical woud revision was carried out.

Finally in eighteenth day patient in spontaneous breathing put on and was coming pneumology department.

Thirty days after the birth patient was discharged to his home in good condition, tracheotomy tube removed and she was able to hug her little girls again.

Conclusion: Use of sodium heparine ivc necessary in ECMO V-V can cause bleeding expecially in obstetric postoperative patients. Careful monitoring and rapid intervention can make a difference as well the multidisciplinary approach to the clinical case and the excellent understanding between neonatologist, gynaecologists, intensivist, ecmo-team and interventional radiologist leading to the success.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A174).

Chest CT Pre-post V-V ECMO

A175 Ecmo in exceptional circumstances

J.L. Russo, E. Panascia, D. Rinzivillo

Azienda Ospedaliera Universitaria Policlinico Gaspare Rodolico San Marco, Catania, Italy

Correspondence: J.L. Russo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A175

35 year old, BMI 26

Remote Medical History: drug-taking (cannabis/cocaine)

Recent Medical History: patient victim of road accident with head trauma from occipital parietal theca fracture (bilateral frontal and left temporal ESA flap, contusive parenchymal petechiae, subdural hematoma 6 cm left temporal and blood imbibition falx cerebri), fracture of nasal bones and walls of the sphenoid sinus with hemosinus. Thoracic trauma without fractures but with bilateral alveolar hemorrhage, splenic laceration, bilateral infraction of the ischiopubic branch. Inoperable to neuro surgery.

After 8 days from the trauma the patient experienced respiratory worsening (alredy on mechanical ventilation), he started NO therapy and prone position and finallyhe was placed in femoro-femoral veno-venous ECMO and transfered to our ICU.

We started sodium heparine ivc maintaining PTT 35-40 sec. Cause of generalized clonus despite sedaxion he immediately underwent a brain CT scan which showed an unichanged parenchymal injury. Therefore he started antiepileptic therapy

After 8 days ECMO has been removed and percutaneous tracheotomy, anticytokine filter cycle was performed.

Gradual weaning of sedation, with slow awakening complicated by “withdrawal symptoms” treated with opioids and antipsychotics. New brain CT re-evaluation0 days after hospitalijection (reduction of hemorrhagic contusive areas), EEG and subsequent RMN was subjected. PEG placement despite gradual resumption of oral feeding (not possible sng positioning due to risk of sinusitis and encephalitis)

After 24 days the patient was transfered awake, alert, oriented in spontaneous breathing on tracheostoma with oxygen support to neuromotor rehabilitation. Further 30 days the patient was discharged to his home with complete recovery of his motor and cognitive functions, PEG and tracheotomy tube removed.

Conclusion

ECMO hasn’t worsened cerebral hemorrhage and it allowed recover respiratory function.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A175).

Pre post ECMO V-V brain CT scan

Transfusion, Hemostasis, and Thrombosis

A176 Eme-ecmo: thresholds for transfusion practice during ecmo support. A systematic review and network meta-analysis

A. Zambianchi¹, S. Gazzea¹, G. Carofiglio¹, E.A. Lanzafame¹, G. Fulvio Aviani¹, S. Mustaj¹, G. Coniglio¹, A.C. Cremone¹, C.A. Bertoncello¹, F. Monteleone², T. Pettenuzzo¹, A. Boscolo^,2, A. De Cassai², D. Ruggerini¹, L. Beria¹, G. Lumetti¹, P. Navalesi^,2, V. Fincati¹, N. Sella², E. Pistollato²

¹Department of Medicina, University of Padua, Padova, Italy; ²Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padova, Italy

Correspondence: A. Zambianchi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A176

Background

The optimal hemoglobin threshold to trigger packed red blood cell (PRBC) transfusion in patients supported by extracorporeal membrane oxygenation (ECMO) remains controversial. The ELSO guidelines suggest that, as with any critically ill patient, the goal is to maintain adequate hematocrit, normal body weight, and normal blood volume. We conducted a systematic review and network meta-analysis to evaluate different transfusion trigger thresholds and their associations with patient outcomes.

Methods: A comprehensive literature search was performed using PubMed, Embase, and Scopus. We included randomized and non-randomized controlled trials (RCTs) enrolling adult patients (>/=18 years old) receiving ECMO in the intensive care unit (ICU), in which participants were randomized to receive PRBC transfusions based on either restrictive or liberal hemoglobin thresholds. The primary outcome was the number of PRBC transfusions administered during ECMO support. Secondary outcomes included the number of fresh frozen plasma (FFP) and platelets transfusions, ICU and hospital mortality, ICU and hospital length of stay, duration of invasive mechanical ventilation and ECMO support, and use and maximum dosage of vasoconstrictors and inotropes.

Results

Five non-RCTs (1339 patients) were included, with 453 patients undergoing a restrictive PRBC transfusion approach, while 886 a liberal approach. The network meta-analysis showed that a hemoglobin threshold of 7 g/dL was associated with fewer RBC transfusions. A reduced use of FFP and platelets was observed at both 7 g/dL and 9 g/dL thresholds. A 9 g/dL threshold was associated with a shorter duration of ECMO support. No significant differences in survival were observed among the various transfusion thresholds. When stratifying patients by ECMO configuration and including the 8 g/dL threshold group from the study by Pratt et al., a significantly lower use of PRBC transfusions was also observed at the 9 g/dL threshold. After excluding studies with a critical risk of bias, the significance of findings related to the 7 g/dL threshold was no longer evident.

Conclusions

A transfusion strategy based on clearly defined hemoglobin thresholds may reduce the use of blood components and shorten ECMO support duration. Notably, hemoglobin thresholds of 7 g/dL and 9 g/dL appear to reduce the risk of transfusion-associated coagulopathy.

Consent

Informed consent was obtained for the publication of this scientific article.

A177 Anesthetic management of hemorrhagic shock in a doacs-treated patient undergoing splenectomy due to atraumatic splenic rupture for unexpected viscerale leishmanioasis

P. Ruggiano, S. Stefanini, G. Ruggiano, D. Conti

Azienda USL Toscana centro, OSMA, Bagno a Ripoli(FI), Italy

Correspondence: P. Ruggiano

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A177

Background

Hemorrhagic shock in patients on direct oral anticoagulants (DOACs) represents a complex clinical and anaesthesiological challenge, especially in emergency settings.

Recently, Andexanet alfa, a modified recombinant inactive factor Xa (FXa) was designed to specifically reverse FXa inhibitor anticoagulation for the treatment of acute bleeding1. Although, it was firstly approved for the reversal of anticoagulation predominantly with apixaban and rivaroxaban in life-threatening or uncontrolled bleeding, evidences in major abdominal bleeding needing emergiency surgery are lacking..

Case presentation

We present the case of a 69-year-old man who came to the Emergency department (ED) with epigastralgic pain, cold sweating and haemodynamic instability (BP 85/45 mmHg, HR 60 bpm, lactates 4 mmol/l). He was on chronic therapy with clopidogrel and rivaroxaban (intake 2 hours before admission). At eFAST there was evidence of abdominal free fluid. Computer tomography scan confirmed haemoperitoneum from spontaneous spleen rupture. Despite initial haemodynamic stabilisation with vasopressor support (norepinephrine 0,5 mcg/kg/min), Rh negative GRC 0, tranexamic acid (1 gr), we decided to administrate andexanet alfa (Ondexxya®)(800-mg bolus IV during a 30-minute period and a follow-up 2-hour infusion of 960 mg). The patient underwent emergency splenectomy with stabilization of the clinical picture with discharge 4 days later. However, the patient was readmitted in hospital for fever and malaise. Histological examination of the spleen revealed the presence of Leishmania amastigotes, leading to the diagnosis of visceral leishmaniasis. The patient was treated with liposomal amphotericin B, with full clinical recovery.

Discussion

The case showed an effettive use of andexanet alfa in emergency surgery for splenectomy for bleeding control. Current literature, recommend the use of pharmacological reversal strategy in the management major intracranical and gastrointestinal bleeding in DOAC-treated patients (2). However, particularly regarding the use of andexanet alfa—in emergency surgical settings remains under investigation. Furthermore, in this setting the administration of the drug should take into account the timing of the last DOAC intake. To our knowledge, there are no other reported cases where andexanet alfa was used to control bleeding in patients undergoing splenectomy. Its use allowed for effective hemorrhage control and safe transfer to the operating room, with no postoperative complications. Its pharmacokinetic profile – with a rapid reduction in unbound FXa inhibitors within two minutes of the end of the bolus, maintained during continuous infusion, and gradually increasing again approximately two hours after infusion – made it feasible to use the drug in an emergency setting as a bridging strategy to surgery. The case also underlines the need to consider atypical infectious causes, such as leishmaniasis, in the differential diagnosis of non-traumatic splenic rupture. In conclusion, timely hemostatic treatment—including use of andexanet alfa—probably played a decisive role with favorable outcome in patient undergoing emergency splenectomy.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Milling TJ Jr, et al. ANNEXA-4 Investigators. Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors. Circulation 2023.

A178 Microfluidic assessment of platelet function in critical care: a preliminary evaluation of the anysis pro device in septic and postoperative patients

G. Corica^1,2, E. Bellavia^1,2, A.G. Motta^1,2, A. Rosati^1,2, G. Grasselli^1,3, M. Panigada¹

¹Department of Anesthesia, Critical Care and Emergency. Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy; ²School of Specialization in Anesthesia, Intensive Care, and Pain Management, University of Milan, Italy; ³Department of Pathophysiology and Transplantation, University of Milan, Italy

Correspondence: G. Corica

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A178

Background

Point-of-care platelet function assessment has proven valuable in identifying bleeding risk associated with residual antiplatelet therapy in cardiac surgery. While sepsis is characterized by progressive thrombocytopenia, findings regarding platelet reactivity in this context remain inconsistent. The novel automated Anysis Pro (RheoMeditech, Inc., Seoul, Korea) microfluidic analyzer evaluates platelet function by measuring blood migration distance and velocity through microchannels, mimicking in vivo hemodynamic conditions. Its predecessor (Anysis-200) demonstrated concordance with the widely utilized PFA-200 test [1]. This preliminary study aimed to determine whether:) Anysis Pro Results are platelet count-dependent in critical care settings, and 2) specific test parameters could differentiate between septic and postoperative populations.

Materials and Methods

Sixteen consecutive patients (11 postoperative, 5 with septic shock) enrolled in the POCEFIS study [https://clinicaltrials.gov/study/NCT06312488] were included. Informed consent was obtained prior to enrollment from conscious patients, with deferred consent for unconscious patients per applicable regulations. Standard laboratory tests, including platelet count and thromboelastographic evaluation of clot firmness (VCM-MCF) with the Viscoelastic Coagulation Monitor (Entegrion, Durham, NC, USA), were performed within2 hours of ICU admission. Concurrently, citrated (3.2%) blood samples were analyzed with Anysis Pro assays (EPI and ADP), with migration distance (mm) and velocity (mm/sec) recorded. Longer migration distance and higher velocity indicate decreased platelet reactivity to the respective agonist.

Results

No patients received antiplatelet agents. Platelet count (x0^9/L) and VCM-MCF (mm) did not differ significantly between postoperative and septic shock patients (228.0 [185.0-301.0] vs74.0 [110.0-187.0], p=0.156; and 38.5 [37.0-45.0] vs 43.0 [36.0-44.0], p=0.951, respectively). No Anysis Pro parameters were influenced by platelet count; however, stronger clot formation at VCM test moderately correlated with lower ADP migration distance (rho=−0.51, p=0.05). ADP Velocity was significantly lower in postoperative compared to septic shock patients (1.1 [0.8-1.2] vs 2.5 [1.7-3.2] mm/sec, p=0.041), indicating impaired platelet reactivity in septic shock. This parameter demonstrated strong discriminatory performance between postoperative and septic shock patients (AUC=0.85, SE=0.15; empirical optimal cutpoint 2.05 mm/sec, Liu method).

Conclusion

Despite the limited sample size, our preliminary findings suggest that Anysis Pro parameters are independent of platelet count, while ADP migration distance may be influenced by clot strength as measured by viscoelastic testing. The ADP velocity parameter shows promise as a point-of-care indicator for platelet dysfunction in sepsis. A larger cohort is necessary to confirm these findings.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Park SJ, Yoon J, Seo HS, Lim CS. Performance evaluation of the Anysis-200 platelet function analyzer in cardiac patients. Clin Hemorheol Microcirc. 2022;80(1):17-24.

Invasive and non-invasive ventilation

A179 Impact of dyspnea and diaphragmatic function in acute respiratory failure

N. Porcari¹, G. Melone¹, F. Polzoni¹, V. Alvis¹i, G. Scaramuzzo¹, C.A. Volta¹, M. Dres², S. Spadaro¹

¹Università degli studi di Ferrara, Ferrara, Italy; ²Sorbonne University, Parigi, FRANCE

Correspondence: G. Melone

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A179

Background

Acute respiratory failure (ARF) remains a leading cause of admissions to intensive care units. It is characterized by a partial pressure of oxygen (PaO2) below 60 mmHg and may be accompanied by hypercapnia. Pathophysiologically, ARF can result from two primary mechanisms: lung failure, due to impaired gas exchange, and pump failure, stemming from ventilatory pump dysfunction, often related to diaphragmatic impairment [1]. Clinically, ARF patients presents dyspnea, tachypnea, use of accessory respiratory muscles, cyanosis, and systemic cardiovascular or neurological disturbances.

This study aims to evaluate dyspnea and diaphragmatic activity during the early phase of ARF, comparing intubated and non-intubated patients at baseline (H0), and at 2, 4, and 48 hours. The primary outcome is the requirement for intubation within 7 days.

Methods

Adult patients with ARF were eligible for inclusion if they presented with a PaO2/FiO2 ratio below 300 mmHg and a respiratory rate exceeding 25 breaths per minute while breathing spontaneously with oxygen support of >10 L/min. Dyspnea was evaluated using the MV-RDOS (Mechanical Ventilation Respiratory Distress Observation Scale) or IC-RDOS (Intensive Care Respiratory Distress Observation Scale) scales, and diaphragmatic function was assessed by ultrasound, measuring diaphragmatic displacement (DD) and thickening fraction (TF) during both inspiration and expiration. Statistical analyses included the use of medians and interquartile ranges, means with standard deviations, relative risk calculations, and p-values, with a significance level set at 0.05. Informed consent was obtained from all enrolled patients in accordance with current regulations.

Results

A total of 40 patients were included, with2.5% requiring intubation. Demographics and comorbidities were similar between groups. In non-intubated patients, the main cause of respiratory failure was postoperative recovery (71%), while intubated patients had more varied causes.

Dyspnea scores (IC-RDOS) and subjective perceptions of breathlessness showed no significant differences over time between groups. (Table)

At baseline (H0), mean diaphragmatic excursion was2.3 mm in non-intubated vs.0 mm in intubated patients. By 48 hours (H48), the gap widened to2.2 mm vs. 8.2 mm. (table)

Inspiratory diaphragmatic thickness at H0 was 2.2 mm (non-intubated) and 3.6 mm (intubated), decreasing to 2.7 mm at H48 in the intubated group.

Intubation occurred more often in patients with abnormal diaphragmatic excursion:9% in reduced, 33% in increased, compared to 6.6% in those with normal values. (table 2)

Mortality rising to9% in those with reduced and 33% in those with increased excursion.

Conclusions

In the early phase of acute respiratory failure, diaphragmatic activity differs between intubated and non-intubated patients, despite similar dyspnea scores. Abnormal diaphragmatic excursion was associated with higher rates of intubation and mortality. Diaphragmatic ultrasound may offer valuable insights for early risk stratification.

References

1. Dres M, Goligher EC, Heunks LMA, Brochard LJ. Critical illness-associated diaphragm weakness. Intensive Care Med. 2017;43(10):1441-1452.

2. Aikawa, Gen et al. “Assessment of Dyspnea in Critically Ill Patients: A Comparative Analysis of Evaluation Scales.” Cureus vol. 16,1 e52751. 22 Jan. 2024

Table 1 (abstract A179).

Variables in intubated and non intubated patients

	h0		h2		h4		h48
Variables	Not Intubated	Intubated	Not Intubated	Intubated	Not Intubated	Intubated	Not Intubated	Intubated
IC-RDOS (IQR)	2.53 (1.21)	2.45 (1)	2.5 (1.2)	2.47 (0.8)	2.55 (1.92)	2.5 (4)	2.54 (1)	2 (3.3)
Subjective Dyspnea (IQR)	20 (30)	60 (20)	20 (20)	60 (50)	20 (30)	50 (30)	10 (20)	50 (20)
Diaphragm Excursion (IQR)	12.3 (5)	7.7 (1.7)	9 (2.4)	2.4 (1.2)	12 (7)	10 (3.3)	12.2 (8)	8.2 (3.5)
Inspiratory Thickening (IQR)	2.2 (0.9)	3.6 (1.7)	2.5 (0.7)	1.7 (0.7)	2.2 (1.2)	2.9 (0.3)	2.3 (1)	2.7 (0.1)
Expiratory Thickening (IQR)	1.8 (0.5)	2.7 (1.1)	1.9 (0.2)	0.2 (0.2)	1.7 (0.7)	1.8 (0.2)	1.6 (0.8)	1.9 (0.7)
O2 Mask (%)	24.2	0.0	21.2	0.0	27.3	0.0	42.4	0.0
HFNC (%)	78.8	21.2	75.0	69.7	69.7	40.0	39.4	80.0
NIV (%)	0.0	60.0	0.0	30.3	0.0	60.0	12.1	0.0
IOT (%)	0.0	0.0	0.0	0.0	0.0	0.0	0.0	80.0

Table 2 (abstract A179).

Outcome and diaphragmatic function

Variables	Normal Excursion (12–21)	Altered Excursion (< 12 or > 21)	p-value	Reduced Excursion (< 12)	p-value	Increased Excursion (> 21)	p-value
% of sample	47	53		45		8
Incidence of intubation (%)	6.6	19		16		33
Incidence of NIV (%)	13	23		22		33
Mortality (%)	0	19	0.04	16	0.08	33	0.42
Length of stay in ICU	9.5 ± 8	9 ± 7	1.26	7 ± 5	0.44	17 ± 15	0.47
Ventilator-free days	7.5 ± 6	4 ± 3	0.16	5 ± 4	0.19	4 ± 3	0.18
Relative risk of intubation (CI)		2.85 (0.35—23.82)	0.29	2.5 (0.29—21.1)	0.38	5 (0.41—59.65)	0.18
Relative risk of NIV (CI)		1.78 (0.4–8)	0.43	1.67 (0.35–7.87)	0.51	2.5 (0.32–19.52)	0.4

A180 Ecco2r (extracorporeal carbon dioxide removal) in severe acute asthma: a case report

R. Russo, M. Bova, A. Buono, A. Carbone, F. Macrì, L. Noviello, N. Zarrillo

ASL Caserta P.O. San Rocco, Sessa Aurunca, CE, Italy

Correspondence: R. Russo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A180

Introduction

Severe acute asthma is a medical emergency characterized by severe expiratory airflow limitation, leading to hypercapnic and hypoxic respiratory failure. Despite mechanical ventilation, the mortality rate can be up to 7%. Extracorporeal Carbon Dioxide Removal (ECCO2R) is a rescue therapy for patients with persistent air trapping and hyperinflation, which are potential causes of barotrauma and hemodynamic instability.

Case Report

We present the case of a 30-year-old female patient with a history of bronchial asthma on pharmacological treatment, admitted to our emergency department with severe respiratory failure and asthmatic exacerbation.

Upon clinical examination, she presented with dyspnea, diffuse expiratory wheezing, SpO2 of 60% on a Venti-mask with FiO200%, and hemodynamic stability. Initial arterial blood gas analysis (ABG) showed pH 7.07, PCO2 95 mmHg, PaO2 51 mmHg, lactate 0.3 mmol/L, and HCO3 26.4 mmol/L.

Due to severe respiratory distress refractory to nebulized salbutamol and ipratropium therapy, and evident involvement of accessory respiratory muscles, rapid orotracheal intubation was performed. The ventilator was set for Lung Protective Ventilation (LPV): VT 350 ml (4-6 mL/kg IBW), ZEEP (PEEP 0), I:E:4, RR2 breaths/min. Dynamic hyperinflation was assessed by occlusion maneuvers, revealing a Plateau Pressure (PPlateau) of 33 cmH2O, Peak Pressure (PPicco) of 52 cmH2O, intrinsic PEEP (PEEPi) of5 cmH2O, static compliance (Cstat) of2 ml/cmH2O, and trapped volume (Vtrap) of 59.5 ml.

Following repeated episodes of bronchoconstriction and hypoventilation, despite therapy with salbutamol 30 mcg/min via continuous inhalation, methylprednisolone 40 mg/day, and MgSO4 2 gr, sevoflurane.5% via inhalation and epinephrine 0.05 mcg/Kg/min via continuous intravenous infusion were added.

After 24 hours of LPV and pharmacological therapy, ABG showed worsening: pH < 7.00, PCO2 >25 mmHg. Therefore, under ultrasound guidance, a3.0 Fr HF double-lumen catheter was inserted into the femoral vein, and ECCO2R (Prismalung Baxter) was initiated with a blood flow (Qb) of 300-350 ml/min, anticoagulation with sodium heparin, and an inflammatory cytokine adsorbing membrane"Oxiris".

Within 24 hours of ECCO2R and LPV, there was an improvement in ABG: pH 7.16, PCO2 56 mmHg, PaO296 mmHg. ECCO2R treatment was continued for six days until clinical stabilization and improvement, resolution of auto-PEEP, normalization of Peak, Plateau, and Driving Pressures, and normocapnia. ABG monitoring allowed for the assessment of gas exchange, showing a progressive and gradual improvement in hypercapnia and blood pH. On the seventh day of invasive ventilation, the patient underwent tracheostomy, was subsequently weaned from the ventilator, and discharged.

Conclusions

The early use of ECCO2R proved to be an effective life-saving strategy in ensuring adequate CO2 removal, allowing for a protective approach to invasive mechanical ventilation. Early initiation should be considered for refractory status asthmaticus when severe dynamic hyperinflation or persistent respiratory acidosis remain despite conventional management, also considering the low-risk profile of extracorporeal techniques. The heterogeneity of asthmatic exacerbation phenotypes should be taken into consideration during ECCO2R treatments as it may influence the duration of therapy.

Consent

Informed consent was obtained for the publication of this scientific article.

A181 Failure of high flow nasal cannula (HFNC) treatment in critically ill patients

C. Biuzzi¹, M.S. Crugliano¹, G. Carinci¹, G. Morandini¹, E. Zeri¹, B. Bidi¹, D. Marianello², F. Franchi², S. Scolletta¹

¹Department of Medical Science, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital Siena, Italy; ²Department of Medical Science, Surgery and Neurosciences, Cardiothoracic and Vascular Anesthesia and ICU, Siena, Italy

Correspondence: G. Morandini

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A181

Introduction

High Flow Nasal Cannula (HFNC) is a respiratory support that involves the delivery of a heated and humidified mixture of air and oxygen at high flow rates (>30 L/min) through nasal or a tracheostomy cannula and allows the administration of an inspired oxygen fraction (FiO2) of up to00%. As this is a relatively recent respiratory support method, predictors of failure in critically ill patients have not yet been fully clarified. The aim of this study was to identify potential clinical variables associated with failure of HFNC treatment.

Materials and Methods

We retrospectively enrolled 53 patients treated with HFNC at the Anesthesia and Intensive Care, Emergency, Trauma and Organ Failure Unit of Siena University Hospital. Patients were divided into two groups: failure of HFNC treatment group (FG, n=13) or success group (SG, n=40). Failure was defined as the need to switch to invasive and/or non-invasive mechanical ventilation within 48 hours from HFNC initiation. For each group, respiratory parameters (flow rate; FiO2, SpO2, respiratory rate - RR -; Rox Index - RI -, PaO2 and PaCO2, SpO2 to FiO2 ratio - S/F - and PaO2 to FiO2 ratio - P/F -), hemodynamic variables (systolic, mean, and diastolic blood pressure - SBP, MAP, DBP respectively - and heart rate, HR), and Glasgow Coma Scale (GCS) were collected before (T0) and 24 hours (T1) after the start of HFNC.

Results

The mean age was 63±20 years, 34 patients were male. All patients were admitted at the ICU for respiratory failure. The mean hospital stay was5±17 days. The mean duration of HFNC treatment was 2.0±1.3 days in the SG and 0.70±0.9 in the FG (p=0.001). SpO2 measured at T0 was 98.0±1.5 for SG and 93.9±7.8 for FG (p=0.002), but no statistically differences emerged at T1. PaCO2 at T0 was not different between SG and FG, while at T1 it was 37.9±5.7 for SG and 42.7±9.2 for FG (p=0.03). GCS at T0 was3±2 for SG vs0±4 for FG (p=0.001), while at T1 it was3.8±1.8 for SG and0±4.6 for FG (p=0.001). RR was significantly different at T0 (SG9.6±5.0 vs FG 23.6±6.4, p=0.025). No statistically differences were observed for FiO2, RI, S/F, SBP, MAP, DBP, and HR between the two groups.

Conclusions

In our cohort of patients admitted to ICU for respiratory failure and undergoing to HFNC treatment, low SpO2, low GCS, high RR values at the beginning of therapy (T0), and high PaCO2 values at T1 seem to be associated with failure of HFNC treatment and the need to switch to a different ventilatory management (invasive or non-invasive). Future and larger studies are warranted to confirm our findings.

Consent

Informed consent was obtained for the publication of this scientific article.

A182 Sigh35 and end-expiratory occlusion test for assessing fluid responsiveness in critically ill patients undergoing pressure support ventilation: the setup study

G.M. Matronola¹, A. Messina¹, L. Calabrò¹, F. Benedetto¹, A. Villa², A. Brunati¹, J.L. Teboul³, X. Monnet⁴, M. Cecconi¹

¹Anesthesia and Intensive Care, Humanitas Research Hospital, Milan, Italy; ²Anesthesia and Intensive Care, University Bicocca, Milan, Italy; ³Paris-Saclay Medical School, Paris-Saclay University, Le Kremlin-Bicêtre, Paris, France; ⁴Réanimation médicale, CHU de Bicêtre, Le Kremlin- Bicêtre, Paris, France

Correspondence: G.M. Matronola

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A182

Introduction

The ability of dynamic indices to predict fluid responsiveness (FR) is often unreliable in patients under pressure support ventilation (PSV), due to the interference of spontaneous breathing activity. Two alternative bedside tests—SIGH and the end-expiratory occlusion test (EEOT)—have been proposed. Their comparative performance in this setting remains unclear.

Methods

This prospective monocentric study enrolled PSV patients requiring volume expansion (VE) and presenting variable inspiratory efforts, quantified by airway occlusion pressure (P0.1). Hemodynamic variables were recorded with the MOSTCARE® system. Patients received 4 ml/kg crystalloids over0 minutes. FR was defined as at least0% increase in cardiac output (CO) post-VE. A 4-second 35 cmH2O SIGH (SIGH35) and a5-second EEOT were applied in random order. The hemodynamic effect of EEOT was evaluated by comparing the mean CO of the0 beats preceding EEOT (baseline) with the highest CO at test end (CO zenith). The effect of SIGH35 was assessed by comparing the mean pulse pressure (PP) of the0 beats before SIGH with the lowest post-SIGH value (PP nadir). These methods are illustrated in Figure 1.

Figure 1. The hemodynamic effect of EEOT was evaluated by considering the mean of cardiac output values of the 10 beats before EEOT start (EEOT baseline; lower panel of the figure) and highest CO value recorded at the end of the test (CO zenith). The hemodynamic effect of SIGH35 was evaluated by considering the mean of PP values of the 10 beats before SIGH35start (SIGH35 baseline; upper panel of the figure) and the lowest value of PP recorded after SIGH3 application (PP nadir).

Results

Of 60 patients enrolled, 56 were analysed; 4 were excluded for extrasystoles or asynchrony. The AUC for PP variation after SIGH35 was 0.93 (0.84–0.99), with 93.1% sensitivity (78.0–98.7%) and 91.6% specificity (73.0–98.9%) at a −25% cut-off (grey zone: −15% to −35%). The AUC for CO variation after EEOT was 0.67 (0.52–0.81); the difference in CO between responders and non-responders was not significant (5.6% vs −0.35%, p < 0.07). Figure 2 (upper panel) displays the ROC curves in the overall population, while Figure 2 (lower panel) shows the subgroup with P0.1 < 1.5 cmH2O, where SIGH35 (AUC 0.98) and EEOT (AUC 0.89) performed similarly (p = 0.26).

Figure 2. The upper part of the Figure shows the ROC curves of the changes of PP after the SIGH35 [AUC = 0.93 (0.84 - 0.99)] and after the EEOT [AUC = 0.67 (0.52 - 0.81)] in the overall population. The lower part of the Figure shows the ROC curves of the changes of PP after the SIGH35 [AUC = 0.98 (0.94 - 0.99)] and after the EEOT [AUC = 0.89 (0.72 - 0.99)] in the subgroup of patients having a small extent of inspiratory efforts.

Conclusions

SIGH35 is a reliable predictor of fluid responsiveness in PSV patients and outperforms EEOT overall, although both tests are valid in patients with low inspiratory effort.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A182).

Didascalie

Fig. 2 (abstract A182).

Didascalie

A183 Clinical impact of pulmovista® 500 use in the management of critically ill patients: a pilot comparative study

D. Interdonato, D. Floridia, V. La Torre, E. Melissari, R. Corallini, U. Bisignano, L. Cavallaro, S. Leonardi

IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy

Correspondence: D. Interdonato

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A183

Effective monitoring and adjustment of mechanical ventilation parameters are essential in critically ill patients to minimize ventilator-induced lung injury (VILI) and improve clinical outcomes. Electrical impedance tomography (EIT), as implemented in the PulmoVista® 500 (Dräger), offers real-time, non-invasive visualization of regional lung ventilation. This study aimed to evaluate the clinical impact of PulmoVista® 500 use in a heterogeneous cohort of intensive care unit (ICU) patients.

A prospective observational pilot study was conducted on0 ICU patients requiring invasive mechanical ventilation. Five patients (PulmoVista group) were monitored using the PulmoVista® 500, while five patients (control group) received standard care without EIT monitoring. Patients included suffered from diverse conditions, including acute respiratory distress syndrome (ARDS), pneumonia, sepsis-related respiratory failure, and post-operative complications. Ventilation settings, duration of mechanical ventilation, extubation success rates, and key prognostic outcomes (ICU length of stay, mortality) were compared between groups.

Use of PulmoVista® 500 enabled continuous, detailed monitoring of ventilation distribution. In the PulmoVista group, adjustments to ventilator settings were performed based on regional ventilation data, targeting optimized alveolar recruitment and minimizing regional overdistension. This approach facilitated the adoption of lung-protective strategies, including lower driving pressures and better individualized positive end-expiratory pressure (PEEP) titration.

Patients monitored with PulmoVista demonstrated a 20% reduction in driving pressure compared to controls (driving pressure mean:2 vs5 cm of water), higher rates of successful extubation at first attempt (80% vs 40%), shorter median duration of mechanical ventilation (5 days vs 8 days) and a reduced ICU length of stay (7 days vs1 days). Moreover, lower incidence of ventilator-associated complications emerged, such as atelectasis and volutrauma. No significant difference in ICU mortality was observed, likely due to the small sample size.

PulmoVista® 500 use allowed for a more accurate assessment of ventilation distribution, enabling anesthesiologists and intensivists to fine-tune ventilator settings in real-time according to individual lung physiology. The resulting optimization of ventilation strategies contributed to reduced pulmonary stress, facilitated earlier weaning from mechanical ventilation, and improved short-term clinical outcomes. Although preliminary and based on a limited sample, these findings suggest that incorporating EIT-guided ventilation into routine ICU practice could enhance patient management. Further large-scale studies are warranted to confirm these Results

Consent

Informed consent was obtained for the publication of this scientific article.

A184 A rare case report of a 75-year-old female with osteogenesis imperfecta with acute respiratory failure

M. Leonardi, R. Tangari, T. Perricelli, V. Alagna, A. Zumpano, F. Galeno, A. Monardo

Ospedale Lamezia Terme, Catanzaro, Italy

Correspondence: M. Leonardi

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A184

A rare case report of a 75-year-old female with osteogenesis imperfecta admitted to the emergency department of our hospital in Lamezia Terme (Catanzaro) with acute hypoxemic and hypercapnic respiratory failure and a P/F ratio <100. The patient had been affected by osteogenesis imperfecta since birth and had undergone many corrective orthopedic surgical procedures during childhood. She also had arterial hypertension and diabetes.

She was hospitalized and underwent a chest CT scan, which showed bilateral pulmonary pneumonia with bibasilar pleural effusion. She was admitted to our ICU and placed on oxygen therapy with NIV, along with broad-spectrum antibiotic therapy. After a failed NIV trial, she was intubated using a videolaryngoscope in anticipation of difficult airway management due to possible anatomical anomalies. After pre-oxygenation via NIV, a 7 mm cuffed endotracheal tube was placed. A sample of bronchial BAS was collected and sent to the microbiology laboratory with a request for FilmArray to obtain a rapid diagnosis and initiate targeted antimicrobial therapy.

Multidisciplinary care was started. Cardiac ultrasound showed good cardiac performance, with normal left ventricular contractility.

The ABG analysis after intubation revealed a P/F ratio of approximately15, so we started protective ventilation with a tidal volume of 6 ml/kg IBW, low PEEP, I:E ratio:2, and FiO2 70%. We selected the best PEEP based on optimal compliance and maintained a driving pressure <13.

After 4 days, ABG analysis showed improved gas exchange with a P/F ratio >250, a valid cough reflex, and a GCS of5. Therefore, we decided to extubate the patient and initiate HFNC to improve oxygenation.

However, after one day, the patient developed acute respiratory failure and experienced a severe episode of bronchospasm that was refractory to drug therapy. We decided to reintubate the patient. Following intubation, SpO2 dropped below 70% and P/F <100, raising suspicion of pneumothorax. An urgent bedside chest X-ray revealed right mainstem selective intubation with total left lung atelectasis. The endotracheal tube was repositioned.

After 3 days, following a successful weaning trial, we extubated the patient again with HFNC. Due to improvement in chest X-ray imaging, P/F ratio, and respiratory mechanics, she was transferred after5 days to the pneumology department.

To our knowledge, this is a rare case of an elderly patient with osteogenesis imperfecta. With this case report, we aim to highlight the potential challenges in managing such patients, both in terms of pulmonary complications and difficult airway management.

Consent

Informed consent was obtained for the publication of this scientific article.

A185 Petco2 to Paco2 ratio: a complementary tool for the evaluation of ards patients

I. Grava¹, S. Cattaneo², B. Donati¹, M. Caronna¹, G. Gazzè¹, E. Rollo¹, L.M. Titherington¹, C. Chiumiento¹, W. Gallese¹, S. Gattarello¹, F. Collino³

¹Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Germany; ²Pediatric Anesthesiology and Intensive Care Unit, ASST Papa Giovanni XXIII, Bergamo, Italy; ³Department of Surgical Sciences, University of Turin, Italy

Correspondence: I. Grava

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A185

Introduction

The central criterion for the definition of ARDS is oxygenation; however, respiratory mechanics, CO2 related variables and risk of ventilator-induced lung injury (VILI) have never been included in the definition of the syndrome, or in the assessment of its severity. It is evident that in the latest updates on ARDS management, clinical interventions are still primarily based on oxygenation parameters, even though the CO2 is increasingly being taken into account. Due to the complexity of this syndrome, we investigated whether the PETCO2/PaCO2 ratio could serve as a complementary tool for the evaluation and clinical management of ARDS patients.

Methods

This secondary analysis included 203 ARDS patients from three prior studies [1,2,3], all of whom met the Berlin definition and were supported with protective mechanical ventilation (VT 6-8ml/IBW, plateau pressure < 25 cmH2O). We analyzed patients with moderate and severe ARDS (P/F < 200; moderate = n.134, severe = n.69) collecting simultaneous PETCO2 and PaCO2 values at PEEP level of 5 cmH2O.

Results

In a regression model we found that PETCO2/PaCO2 ratio was statistically correlated with venous admixture (p<0.001) and respiratory system compliance (p0.002)(Fig1. panels A, B). In our cohort, a PETCO2/PaCO2 ratio below 0.72 (identified using the Youden index for outcome prediction) defined a subgroup of patients with worse gas exchange, as evidenced by significantly higher venous admixture and alveolar dead space (p<0.001)(Fig2. panels A, B). These patients also exhibited impaired respiratory mechanics, characterized by reduced respiratory system compliance (p0.007)(Fig3. panel A), and a higher risk of VILI, as indicated by mechanical power ratio (p0.007)(Fig4. panel A). Notably, statistically differences in respiratory mechanics (p0.9) and risk of VILI (p0.11) were not observed when using a PaO2/FiO2 threshold of00 to assess severity (Fig3,4. panel B). These alterations in physiological and anatomical parameters are reflected in the clinical outcomes: ARDS patients with a PETCO2/PaCO2 ratio below 0.72 had a mortality rate of 64.1%, compared to 35.3% in those with higher PETCO2/PaCO2 ratio values (p < 0.001)(Fig 5).

Conclusion

In this cohort, a PETCO2/PaCO2 ratio below 0.72 was significantly associated with worse gas exchange, impaired respiratory mechanics, higher risk of VILI, and increased mortality. In contrast, the PaO2/FiO2 does not fully capture the pathophysiological complexity of ARDS. To summarized, the PETCO2/PaCO2 ratio could be used as a valuable complementary tool for assessing disease severity, guiding clinical management, and contributing to outcome evaluation in ARDS patients.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. M.Bonifazi et al.“End-tidal to arterial PCO2 ratio as gas exchange marker,”Intensive Care Med. Exp., vol. 9, 2021, 10.1186/s40635-021-00377-9.

2. D.Chiumello et al.”CT-scan study of COVID-19 vs ARDS,”Intensive Care Med., vol. 46, pp. 2187–2196, 2020, 10.1007/s00134-020-06281-2.

3. S.Rossi et al.“Oxygenation response to proning in COVID-19,”Intensive Care Med., vol. 48, pp. 56–66, 2022, 10.1007/s00134-021-06562-4

Fig. 1 (abstract A185).

Association between PETCO2/PaCO2 ratio and venous admixture(Panel A) or respiratory system compliance(Panel B)

Fig. 2 (abstract A185).

Venous admixture(Panel A) and dead space(Panel B) according to PETCO2/PaCO2 and PaO2/FiO2 threshold

Fig. 3 (abstract A185).

Respiratory system compliance according to PETCO2/PaCO2(Panel A) and PaO2/FiO2 threshold(Panel B)

Fig. 4 (abstract A185).

Mechanical power ratio according to PETCO2/PaCO2(Panel A) and PaO2/FiO2 threshold(Panel B)

Fig. 5 (abstract A185).

Mortality rate according to PETCO2/PaCO2 threshold of 0.72

A186 Effects of body habitus, lateral decubitus and pneumoperitoneum on respiratory system mechanical power during robotic nephrectomy: an observational study

G. Gazzè¹, E. Rollo², W. Gallese¹, L.M. Titherington³, M. Caronna¹, C. Chiumiento⁴, I. Grava⁵, B. Donati⁶, V. Ceccarelli⁷, S. Orlando⁷, F. Pizzi¹, S. Gattarello⁸, C. Claroni⁷, M. Covotta⁷, G. Torregiani⁷

¹Department of Anesthesia, Critical Care and Pain Medicine, Policlinico Umberto I, Sapienza University of Rome, Italy; ²Department of Anesthesia and Intensive Care, University of Bari Aldo Moro, Bari, Italy; ³Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy; ⁴Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, Italy; ⁵Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy; ⁶Department of Health Sciences, University of Milan, Italy; ⁷Department of Anesthesia, Intensive Care and Pain Therapy, IRCCS - Regina Elena National Cancer Institute, Rome, Italy; ⁸Department of Anesthesiology and Intensive Care, University Medical Centre Göttingen, Germany

Correspondence: G. Gazzè

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A186

Background

Mechanical power (MP), the energy transferred to the respiratory system during mechanical ventilation, has been proposed as an independent predictor of ventilator-induced lung injury. During laparoscopic and robotic surgery, pneumoperitoneum and lateral positioning increase respiratory system load, with potential variation across body mass index (BMI) categories. Evidence on MP dynamics across BMI groups during robotic surgery remains limited, especially in real-life settings where ventilatory management is left to the anesthesiologist’s discretion.

This study investigates intraoperative variations in MP, MP normalized to baseline, and MP ratio (observed-to-predicted MP) across BMI categories during robotic partial nephrectomy, with a focus on lung-protective ventilation.

Materials and Methods

Secondary analysis of a prospective single-center study on 66 patients undergoing robotic partial nephrectomy. Patients were stratified into four BMI categories: underweight (<18.5kg/m²), normal weight (18.5–24.9kg/m²), overweight (25–29.9kg/m²), and obese (>=30kg/m²). Hemodynamic, ventilatory, and respiratory mechanics variables, including MP, MP normalized to baseline, and MP ratio, were collected at three standardized intraoperative timepoints: baseline, post-intubation (Ti), after lateral positioning and pneumoperitoneum (Tp), and after pneumoperitoneum desufflation, in supine position (Ts).

Generalized Estimating Equations were used to assess the effects of BMI and time (p<0.05), with Bonferroni-adjusted pairwise comparisons (p*<0.001). All patients provided written informed consent.

Results

Time (p<0.001) and time × BMI interaction (p<0.001) significantly affected MP (Figure1).

At Ti, MP was higher in overweight and obese patients than in underweight (+2.98 and +2.58J/min; p*<0.001). At Tp, MP increased in normal weight (+1.77J/min, +22.6%), overweight (+1.86J/min, +18.3%), and obese patients (+1.98J/min, +20.3%) versus Ti (all p*<0.001). At Ts, MP remained elevated across all BMI groups compared to Ti, with the highest increase in normal weight and obese individuals (+4.70J/min, +59.8% and +3.66J/min, +37.5%; p*<0.001).

Normalized MP increased intraoperatively in all BMI groups (Figure2). In normal weight, increases versus Ti were +24.1% at Tp (p*<0.001) and +65.5% at Ts (p*<0.001). Overweight and obese showed significant increases at Tp (+26.3% and +27.3%; p*<0.001), with further, non-significant increases at Ts (+35.9% and +41.7% respectively). Changes in underweight were minimal.

MP ratio progressively increased in normal weight, overweight, and obese patients (Figure3). In normal weight individuals, MP ratio grew by +21.6% at Tp and +57.8% at Ts compared to Ti (p*<0.001). Overweight and obese showed similar trends, though without significant intra-group differences. In the underweight group, the MP ratio remained stable throughout.

Conclusions

MP, its normalized values, and MP ratio increased progressively during the intraoperative course of robotic nephrectomy, particularly in normal weight, overweight, and obese patients, while remaining stable in underweight individuals. These findings support a shift from fixed absolute thresholds towards dynamic, patient-specific markers that account for inter-individual variability and physiological reserve. Monitoring MP relative to baseline or predicted values may more accurately reflect ventilatory damage and help guide personalized ventilation strategies, especially in robotic surgery where intraoperative mechanical stress differs substantially across BMI categories.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A186).

MP across BMI categories and intraoperative phases

Fig. 2 (abstract A186).

MP normalized to baseline across BMI categories and intraoperative phases

Fig. 3 (abstract A186).

MP ratio across BMI categories and intraoperative phases

A187 Effect of the timing of end-inspiratory pressure measurement on the risk of ventilator-induced lung injury in mechanically ventilated patients: the p1-p2 decay study

V. Fincati¹, T. Pettenuzzo², A. Boscolo^,2,3, P. Navalesi^2,3, A. Zambianchi¹, A. Bolzon¹, E. Vidal¹, A. Zanaga¹, M. Toniolo¹, S. Mustaj¹, I. Paiusco¹

¹Department of Medicine, University of Padua, Italy; ²Institute of Anesthesia and Intensive Care, University Hospital of Padua, Italy; ³Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Italy

Correspondence: V. Fincati

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A187

Background

Mechanical ventilation, while life-saving for patients with acute respiratory failure, may cause ventilator-induced lung injury (VILI). Driving pressure (<delta>P), calculated as the difference between end-inspiratory airway pressure and total positive end-expiratory pressure (PEEP), is a key predictor of VILI and mortality. However, after applying an end-inspiratory pause during volume-controlled ventilation, airway pressure declines from the initial pressure at zero flow (P1) to a plateau (P2) due to the viscoelastic properties of the lung and pendelluft, i.e., the P1–P2 decay. We aimed to assess whether the timing of end-inspiratory airway pressure measurement is associated with different <delta>P values and clinical outcomes, and whether lung heterogeneity, assessed by electrical impedance tomography (EIT), affects P1–P2 decay.

Materials and Methods

This multicenter prospective observational study enrolled patients receiving controlled mechanical ventilation. End-inspiratory airway pressures were measured at multiple time points during a 5-second inspiratory pause: P1 (zero flow), P0.5s (at 0.5 s), P2s (at 2 s), P3s (at 3 s), and P2 (at 5 s). Associations between these measurements and <delta>P, as well as clinical outcomes (duration of mechanical ventilation and intensive care unit [ICU] length of stay, and mortality), were analyzed. In a patient subgroup, lung heterogeneity was evaluated using EIT.

Results

Two-hundred and sixty-nine patients were included. End-inspiratory airway pressures and corresponding <delta>P values varied significantly depending on the timing of measurement. Patients with <delta>P > o uguale a5 cmH2O when calculated using P1, but <15 cmH2O when using P2, had higher ICU mortality than those with <delta>P <15 cmH2O at both time-points.

Conclusions

The timing of end-inspiratory pressure measurement significantly influences <delta>P calculation. Using P1 rather than P2 may improve prognostic stratification and aid in optimizing protective ventilator settings.

Consent

Informed consent was obtained for the publication of this scientific article.

A188 Comprehensive ultrasound assessment for predicting weaning success from mechanical ventilation: a prospective observational study

M. Ciniero, A. Fogagnolo, M. Bonanni, V. Alvisi, C.A. Volta, G. Scaramuzzo, S. Spadaro

Università degli Studi di Ferrara, Ferrara, Italy

Correspondence: M. Ciniero

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A188

Introduction

Mechanical ventilation (MV) is a cornstore in the management of respiratory failure. [1] However, weaning remains challenging, often associated with risks such as prolonged ventilation, extended hospital stays, and increased mortality. [2]. Conventional weaning strategies that rely on respiratory parameters, (oxygenation, lung function, gas exchange) have shown limited predicted predictive limitations [3], especially in patients with difficult or prolonged weaning. Emerging evidence suggests that a multimodal approach, including the evaluation of diaphragmatic function, which may be impaired by prolonged ventilation, [4]. Ultrasound has become an evaluable tool to evaluate real time the diaphragmatic activity, lung ventilation and cardiopulmonary interactions, and including weaning pulmonary oedema [5]. The aim of this study was to test whether a comprehensive multimodal evaluation during the spontaneous breathing trial (SBT) can more accurately predict weaning outcomes compared to isolated parameters.

Methods

Eighty-nine patients (52 male, 37 female) undergoing MV for >48 hours were prospectively enrolled. Lung ultrasound (LUS) was performed across 6 regions per lung (score 0–36), alongside diaphragmatic ultrasound (displacement and thickening fraction [TF%] at rest and forced breathing), and echocardiographic evaluation (LV systolic function, transmitral flow, and tissue Doppler imaging). Clinical and instrumental variables were analysed using Wilcoxon and Chi-square/Fisher’s tests. Univariate logistic regression and ROC analysis assessed the predictive capacity of individual variables. Elastic Net logistic regression with cross-validation was used to build the final predictive model, which was internally validated via bootstrapping (1,000 iterations). Performance metrics included AUC, sensitivity, specificity, and overall accuracy. A Shiny web application was developed to facilitate clinical implementation. Informed consent was obtained from all enrolled patients in accordance with current regulations.

Results

Among enrolled patients, median MV duration was 6 [IQR 3–10] days. Weaning failure occurred in 39% (17 during SBT; 18 post-extubation). ICU and 180-day mortality rates did not significantly differ between successful and failed weaning groups. Diaphragmatic excursion and E/e′ ratio demonstrated the highest sensitivity (0.89 and 0.87) [Table 1], while TAPSE and handgrip strength had strong specificity (0.77 and 0.74). Multivariate analysis identified eight key predictors encompassing diaphragmatic, cardiac, muscular, and pulmonary domains. The integrated model achieved an AUROC of 0.92 (95% CI: 0.85–0.96) [Figure 1], with a positive predictive value (PPV) of 97.9% and a negative predictive value (NPV) of 85.6%, outperforming any single parameter.

Conclusions

This study supports the use of a multimodal assessment strategy during SBT, as a superior predictor of weaning success in critically ill patients. The findings highlight the added value of comprehensive, ultrasound-based evaluation over conventional single-parameter approaches.

References

1. Sterr A, Goligher E. Advances in weaning protocols: The role of multimodal monitoring. Crit Care Med. 2024;52(1):e125-e136.

2. Smith J, et al. Multifactorial determinants of weaning success: A review. Respir Care. 2021;66(5):763-772.

3. Nava S, et al. Noninvasive ventilation for weaning from mechanical ventilation. Ann Intensive Care. 2017;7(1):11.

4. Capdevila X. Respiratory muscle function in critically ill patients. Intensive Care Med. 2024;50(1):21-32.

5. Rego F, et al. Ultrasound evaluation of diaphragmatic function in critically ill patients. J Ultrasound Med. 2020;39(9):1787-1795.

Table 1 (abstract A188).

Descriptive predictive assessment of the clinical judgement selected predictors. According to the Youden index, there are optimal cut-off points, accuracy, sensitivity, specificity, and area under the curve (AUC) for various physiological predictors of weaning success. Values are presented with 95% confidence intervals

	Optimal Cut point	Accuracy	Sensitivity	Specificity	Area Under Curve
TF/MIP	370	0.66 (0.55—0.81)	0.65 (0.29—1)	0.69 (0.29—1)	0.7 (0.59—0.81)
Diaphragm Displacement (mm)	1.07	0.69 (0.51—0.78)	0.89 (0.23—1)	0.37 (0.21—1)	0.64 (0.52—0.76)
Hand Grip Strength (Kg)	13	0.65 (0.6—0.8)	0.59 (0.46—1)	0.74 (0.28—0.9)	0.69 (0.57—0.8)
Lung Ultrasound Score (LUS)	9	0.6 (0.52—0.74)	0.5 (0.22—0.98)	0.74 (0.22—0.98)	0.63 (0.51—0.75)
Ejection Fraction	53	0.59 (0.45—0.7)	0.54 (0.17—0.76)	0.67 (0.44—0.94)	0.56 (0.43—0.69)
RR/TV (RSBI)	32	0.54 (0.4—0.7)	0.48 (0.05—0.87)	0.63 (0.29—1)	0.53 (0.41—0.65)
E/e'lateral (cm/sec)	8.5	0.79 (0.71—0.88)	0.87 (0.79—0.98)	0.66 (0.46—0.82)	0.76 (0.65—0.86)
TAPSE (mm)	21	0.67 (0.6—0.8)	0.61 (0.49—0.94)	0.77 (0.39—0.92)	0.71 (0.6—0.82)

Fig. 1 (abstract A188).

Model Results. Evaluation of the weaning success prediction model. Panel A presents the model performance through a receiver operating characteristic (ROC) curve, indicating an area under the curve (AUC) of 0.88, along with key performance metrics such as accuracy, sensitivity, and specificity at the optimal cut point

A189 Patient-ventilator synchrony during noninvasive ventilation in pediatric acute respiratory failure: impact of circuit and ventilator configuration

G. Chidini¹, C. Villa¹, C. Villa¹, T. Marchesi, S. Scalia Catenacci¹, T. Langer², D. De Luca³

¹Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milano, Italy; ²Niiguarda Hospital, Milano, Italy³South Paris University Hospitals, A.Beclere, Paris, FRANCE

Correspondence: G. Chidini

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A189

Background and Aims

Patient-ventilator synchrony is a key determinant of noninvasive ventilation (NIV) success, especially in pediatric patients with acute respiratory failure (ARF). Detecting asynchronies in children is particularly challenging, and systematic data are limited. Studies evaluating patient-ventilator interaction in this population using esophageal pressure (Pes) are exceedingly rare, due to technical and ethical concerns. This study aimed to compare the asynchrony index (AI) during NIV delivered with different ventilator types and circuit configurations, using an advanced monitoring technique based on Pes tracing.

Methods

This was a prospective, randomized, crossover study conducted in a Pediatric Intensive Care Unit. The study was approved by the local Institutional Review Board and registered on ClinicalTrials.gov (ID: NCT04017780). Children with ARF requiring NIV were enrolled and underwent three 30-minute randomized NIV trials with the following setups:

Double-limb circuit (DLC) with an integrated expiratory valve, ICU ventilator (Babylog VN500);

Single-limb circuit (SLC) with intentional leak, turbine ventilator (Astral50);

DLC with integrated expiratory valve in turbine ventilator (Astral50).

A 6Fr esophageal balloon catheter was positioned to monitor Pes. Simultaneous recordings of flow, airway pressure, and Pes were acquired and anonymized. Tracings were independently analyzed offline by two blinded senior physicians to identify asynchrony events and calculate AI.

Results

Ten children were included. The AI was significantly lower during NIV delivered via the SLC-turbine configuration compared to both DLC setups (11 [3.5–15] vs8 [15–33] and 39 [12–78]; p=0.0063, Friedman test with Bonferroni post-hoc correction). The mean number of asynchronies per minute was lower in the SLC-turbine group (5.6) than in the DLC-ICU (8.4) and DLC-turbine (10) groups, although without statistical significance. (figure 1-2)

Conclusions

This study confirms the feasibility of using esophageal pressure monitoring to assess patient-ventilator interaction during NIV in children. The SLC-turbine configuration was associated with better synchrony compared to both DLC setups, regardless of ventilator type. These findings support a more tailored approach to NIV in pediatrics and open the way for larger trials evaluating synchrony-driven strategies to optimize outcomes.

Conflict of Interest Statement

The authors declare no conflicts of interest.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A189).

Asynchrony Index Across Ventilator Configurations. Boxplot showing the distribution of the Asynchrony Index (%) in pediatric patients with acute respiratory failure during noninvasive ventilation delivered through three different configurations: SLC-Turbine, PICU Ventilator (DLC), and DLC-Turbine. The Asynchrony Index was significantly lower with the SLC-Turbine configuration (p = 0.0063, Friedman test with Bonferroni correction)

Fig. 2 (abstract A189).

Distribution of Asynchrony Types by Ventilator Configuration. Bar chart representing the mean number of each type of asynchrony per minute: Ineffective Efforts (IE), Auto-Triggering (AT), and Double Triggering (DT), across the three ventilator setups. The SLC-Turbine configuration was associated with fewer auto-triggering and double-triggering events compared to DLC-based configurations

A190 Bedside physiological approach to personalize peep in spontaneously breathing patients with ards: a secondary analysis on the optimal selection variables

V. Chiavieri¹, M. Leali¹, E. Spinelli¹, F. Madotto¹, G. Scaramuzzo³, S. Spadaro³, D.L. Grieco⁴, M. Antonelli⁴, G. Grasselli^1,2, T. Mauri^1,2

¹Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research) Ca Granda Maggiore, Milan, Italy; ²Department of Pathophysiology and Transplantation, University of Milan, Italy; ³Department of translational medicine, University of Ferrara, Italy; ⁴Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinic, Rome, Italy

Correspondence: V. Chiavieri

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A190

Background

Spontaneous breathing has benefits for the patients with the acute respiratory distress syndrome (ARDS), including improved ventilation-perfusion matching and hemodynamics, but it also carries the risk of patient self-inflicted lung injury (PSILI). Personalized positive end-expiratory pressure (PEEP) plays a fundamental role in modulating inspiratory effort, thus reducing the risk for PSILI(1). We explored the reliability of different bedside physiological variables to set personalized PEEP based on advanced respiratory monitoring. As secondary outcome we investigated whether specific patient categories could benefit more from a dedicated method.

Methods

Thirty ARDS patients on pressure support ventilation underwent a decremental PEEP trial (18 to 4cmH2O, 2cmH2O and 2 minutes for each step), with synchronised monitoring of airway pressure (Paw), esophageal pressure (Pes) and EIT, after informed consent acquired. Twelve advanced respiratory physiological variables (3 obtained by combined Pes, EIT and Paw, 3 by EIT only, 3 by Pes and Paw and 3 by Paw only) were measured at each step and the influence of PEEP on their variations was evaluated to verify if their variability during the trial had the potential to select optimal PEEP (mixed effects models and marginal R2-mR2). Secondarily, we compared relevant effects of each method by two-way ANOVA for repeated measures in specific subgroups of patients.

Results

The difference between overdistention and collapse measured by EIT, and end-expiratory transpulmonary pressure (Plung_ee) measured by Paw and Pes, varied significantly during the PEEP trial (p<0.0001) and presented very high mR2 values (27.85% and9.55%, respectively) as compared to all other variables (Figure1). Thus, they were identified as best candidate variables to select optimal PEEP.

When we compared physiological variables at the two personalized PEEP levels, pressure time product (111.88±42.64 vs21.73±46.72cmH2O p=0.3973), driving Plung (14.61±4.23 vs4.65±3.96cmH2O p=0.8245) and the magnitude of pendelluft (10.62±8.07 vs 9.42±7.86% p=0.4964) did not differ.

Dividing patients in subgroups according to median respiratory rate at enrolment, we disclosed a difference in dPlung, comparing values selected in patients subgroups by the two methods (p=0.0479). The amount of pendelluft differed, instead, in patients subgroups identified by median PaO2/FiO2 at enrolment (p=0.0375). Finally, pressure time product of subgroups divided by median ventilatory ratio at the enrolment differed, too (p=0.0462) (Figure2).

Conclusions

Lowest difference between overdistension and collapse and lowest distance of Plung_ee from zero cmH2O could be 2 accurate methods to set personalized PEEP in ARDS patients on pressure support, with similar effects on lung and diaphragm protection. Patients with higher respiratory rate,

PaO2/FiO2, and ventilatory ratio at the enrolment, seems to benefit more from PEEP selected by overdistension-collapse method, in terms of lower lung stress, pendelluft and work of breathing.

Consent

Informed consent was obtained for the publication of this scientific article.

Mauri et al. ICM-2024.

Fig. 1 (abstract A190).

Variables assessed during decremental PEEP trial

Fig. 2 (abstract A190).

Effects of each method analyzed using two-way ANOVA for repeated measures in specific subgroups of patients

A191 Evaluation of aerosol drug delivery during hfnc using the asymmetrical optiflow nasal cannula

G. Bennett

Georgia Deely, Galway

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A191

Introduction and Aim

High flow nasal cannula (HFNC) is a non-invasive respiratory support for spontaneously breathing patients in critical care settings. It facilitates simultaneous inline delivery of aerosolised medications for the treatment of respiratory disorders. This study evaluated the performance of asymmetrical and symmetrical nasal cannulas used in combination with a vibrating mesh nebuliser (VMN) and HFNC to deliver aerosolised medication to a simulated adult patient.

Research methodology

2000µg of salbutamol (2.5mg/2.5mL, ALDO, ESP) was nebulised using the Aerogen Solo nebuliser and Aerogen Pro-X controller (Aerogen, IRE). The nebuliser was integrated into the Airvo2 HFNC system using the approved nebuliser adapter. Aerosol was delivered via an asymmetrical nasal cannula (OPT964 Medium Adult) and a symmetrical nasal cannula (OPT944 Medium Adult) to a 3D-printed anatomically correct adult head model connected to a breathing simulator (ASL5000, IngMar Medical, USA) using a normal adult breathing pattern (BR:5BPM, Vt: 500mL, I:E ratio:1) [1]. Testing was conducted at flow rates of 30, 50, and 60LPM. A capture filter was placed at the tracheal level. Tracheal dose was determined by quantifying the mass of drug captured on the filter using UV spectrophotometry at 276nm.

Results

Results for the tracheal dose are expressed as a percentage of the nominal dose placed in the medication cup and are presented in Figure.

Conclusion

This study indicated that the asymmetrical nasal cannula resulted in a higher tracheal dose at 50LPM (p = 0.041) and 60LPM (p = 0.002). There was no significant difference between cannula types at 30LPM (p = 0.135). Flow rate had a significant impact on aerosol delivery, with an increased tracheal dose (%) observed at 30LPM when compared to 50LPM and 60LPM for both cannula types.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A191).

Effects of flow rate on the tracheal dose (%) (Mean ± SD) when comparing asymmetrical and symmetrical F&P nasal cannulas

Airways

A192 Four-handed intubation using glidescope® and fiberoptic bronchoscope: a combined technique for difficult airway management in thoracic surgery

F. Russo, F. Coppolino, A. Izzo, G.M. Rizzi, M.B. Passavanti, P. Sansone, V. Pota, M.C. Pace

Università degli studi della Campania Luigi Vanvitelli, Napoli, Italy

Correspondence: F. Russo

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A192

Background

Airway management in thoracic surgery can be particularly complex in patients with anatomical abnormalities such as mediastinal masses, tracheomalacia, or spinal deformities. Traditional intubation methods may be insufficient in these cases. This report describes a novel, elective airway management approach employing a four-handed technique combining videolaryngoscopy and flexible fiberoptic bronchoscopy to facilitate double-lumen tube (DLT) placement in a patient with a predicted difficult airway.

Case report

A 63-year-old female with a BMI of 31 and symptomatic orthopnea was scheduled for thymectomy via median sternotomy due to an invasive anterior mediastinal mass (thymoma). Preoperative evaluation revealed a Mallampati score of III, limited mouth opening (2.5 cm), and significant rightward tracheal deviation on imaging. Anticipating a challenging airway, a combined approach was planned. After preoxygenation in a semi-upright position and administration of light sedation with topical anesthesia, a Glidescope® videolaryngoscope was inserted by the primary operator, allowing partial visualization of the glottis and confirming airway deviation. Concurrently, a second operator introduced a fiberoptic bronchoscope preloaded with a 37 F Robertshaw DLT. Coordinated guidance under direct visualization allowed atraumatic and successful placement of the DLT, which was confirmed bronchoscopically. No peri-intubation complications occurred. [Fig.] This case highlights the efficacy of a four-handed intubation technique utilizing a videolaryngoscope to provide an overview of the distorted upper airway while enabling the bronchoscope operator to navigate and position the DLT accurately. [1,2] The method is especially advantageous in patients with tracheal deviation, limited mouth opening or cervical immobility and in elective procedures requiring lung isolation. Key benefits of this approach include enhanced airway visualization, improved control during DLT placement, and reduced risk of airway trauma. Moreover, it serves as an effective educational tool in teaching complex airway management techniques. Limitations include the requirement for advanced equipment and skilled personnel capable of coordinated manipulation.

Conclusion

The combined use of a Glidescope® and fiberoptic bronchoscope in a four-handed technique offers a safe, precise, and reproducible method for managing predicted difficult airways in thoracic surgery. [3] This approach enhances visualization and control during DLT placement and should be considered in elective cases where airway challenges are anticipated.

Consent

Informed consent was obtained for the publication of this scientific article.

References

1. Maracaja L, Coffield A, Smith LD, et al. A novel combined approach to placement of a double lumen endobronchial tube using a video laryngoscope and fiberoptic bronchoscope: a retrospective chart review. BMC Anesthesiol. 2024;24(1):142. Published 2024 Apr2. 10.1186/s12871-024-02525-6

2. Brodsky JB. Lung separation and the difficult airway. Br J Anaesth. 2009;103 Suppl:i66-i75. 10.1093/bja/aep262

3. Doyle DJ. GlideScope-assisted fiberoptic intubation: a new airway teaching method. Anesthesiology. 2004;101(5):1252. 10.1097/00000542-200411000-00046

Fig. 1 (abstract A192).

Combining videolaryngoscopy and flexible fiberoptic bronchoscopy

A193 Conservative treatment of tracheoesophageal fistula with extra-long tracheostomy tube: case report

L. Zazzaro¹, C. Posillipo¹, P. Diglio¹, E. Tornincasa¹, F. Imperatore²

¹Asl Napoli 2 nord, Frattamaggiore, Italy; ²AORN Cardarelli, Napoli, Italy

Correspondence: L. Zazzaro

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A193

Tracheoesophageal fistula (TEF) is an abnormal opening between trachea and esophagus leading oral and gastric secretions into the respiratory tract.[1] In adults most TEFs are acquired, they are rare complication of prolonged mechanical ventilation (PMV), with a incidence of 0.3-3% [2] Tracheostomy tube cuff volumes and pressures require constant monitoring. [3]

Case report

A 79-year-old female with a history of tetrarigidity and advanced parkinson's disease, dysthyroidism, hypertensive heart disease and supraventricular tachycardia was admitted to our hospital in December 2023 for inoperable cerebral hemorrhage. She was subjected to percutaneous tracheostomy and Percutaneous Endoscopic Gastrostomy (PEG), after she was transferred to home with integrated home care.

In July 2024 she was admitted to our hospital for acute respiratory failure with desaturation, coma, hemoptysis, malena and hematemesis through PEG. The CT scan (Fig.1) (computerized axial tomography) reported bilateral pneumonia with catarrhal material in the left main bronchus and lobar branches, esophageal ectasia in the proximal tract, and bloody discharge within the gastric lumen. The esophagogastroduodenoscopy (Fig.2-3) showed the tracheostomy tube cuff at the level of the ectasic portion of the esophagus near its proximal tract.

Subsequently, bronchoscopy was performed and it confirmed the clinical suspicion of tracheoesophageal fistula (TEF) about 6 cm.

Considering the patient's poor condition and the extremely high surgical risk, family refused all surgical repair and tracheal stent. The tracheostomy was replaced with an extra-long tracheal tube (15.5 cm in length) that was inserted0 cm deep into the trachea to bypass the TEF, with bronchoscopic evidence of the cuff resting on the healthy portion of the trachea below the fistula. Conservative therapeutic measures were adopted. The patient was fed through PEG, for minimizing gastroesophageal reflux. The bed was raised to approximately 30 degrees to reduce the risk of aspiration. Gastric proton pump inhibitors and prokinetics were used. The infusion rate of enteral nutrition was also modulated to avoid gastric overdistension. In addition, ventilatory parameters were optimized. Antibiotic therapy was administered until resolution of aspiration pneumonia. After approximately0 days, the patient was transferred to her home. The extra-long tracheostomy tube was changed every month at home by a flexible bronchoscope to verify its correct position.

Conclusion

Actually, the main treatments for TEF is surgery. The surgical procedures including fistula repair, with pedicled muscle flap or omentum major, esophageal bypass surgery and lesion resection [4]. In this patient, we used conservative measures and a long tracheostomy tube to bypass the fistula, avoiding invasive procedures. The immediate complete resolution of the patient's symptoms was a reassuring indicator of the success of the procedure. After six months of observation, the patient recovered well and no new complications related to tracheoesophageal fistula occurred.

Consent

Informed consent was obtained for the publication of this scientific article.

Reference

1. Kim HS, Khemasuwan D, Diaz-Mendoza J, Mehta AC. Management of tracheo-oesophageal fistula in adults. Eur Respir Rev. 2020 Nov 5;29(158):200094. doi:0.1183/16000617.0094-2020. PMID: 33153989;.

2. Couraud L, Ballester MJ, Delaisement C. Acquired tracheoesophageal fistula and its management. Semin Thorac Cardiovasc Surg.996 Oct;8(4):392-9.

3. Hameed AA, Mohamed H, Al-Mansoori M. Acquired tracheoesophageal fistula due to high intracuff pressure. Ann Thorac Med. 2008 Jan;3(1):23-5. doi:0.4103/1817-1737.37950. PMID:9561879;.

4. Paraschiv M. Tracheoesophageal fistula--a complication of prolonged tracheal intubation. J Med Life. 2014 Oct-Dec;7(4):516-21. PMID: 25713612.

Fig. 1 (abstract A193).

Videobronchoscopic images

Fig. 2 (abstract A193).

Esophagogastroduodenoscopy

Fig. 3 (abstract A193).

Esophagogastroduodenoscopy

A194 Managing airway obstruction in postoperative neck hematoma: a case of front-of-neck access (Fona) in a can’t intubate can't oxygenate (Cico) emergency

L. Carenzo, O. Credendino, A. Guidi, F. Ferreli, F. Piccioni, E. Costantini, M. Cecconi

IRCCS Humanitas Research Hospital, Rozzano, Italy

Correspondence: O. Credendino

Journal of Anesthesia, Analgesia and Critical Care 2025,5(1):A194

The medical emergency team was called at:30AM for a 79-year-old male patient following a total parotidectomy and modified radical neck dissection. The patient presented with acute surgical site hematoma, voice alteration, and respiratory distress. Conscious with an SpO2 of 99% on supplemental O2, the surgical wound was opened for decompression, and the patient was transferred for revision surgery.

While being transported, the patient's respiratory condition deteriorated. He lost the ability to speak and developed stridor, with a large bulging hematoma both at the surgical site and on the right side of his neck. Emergent intubation was necessary. Following Ketamine and Rocuronium administration, videolaryngoscopy revealed an oral hematoma displacing the glottis and compressing the vocal folds (FigureA). Attempts to intubate were unsuccessful, and a'Can’t Intubate, Can’t Oxygenate'(CICO) situation was declared. A decision for Front-Of-Neck Access (FONA) was made, but no palpable anatomical structures were found in the neck.

The anesthesiologist performed a0 cm longitudinal midline incision from the submandibular region to the sternal notch. Subcutaneous tissue was bluntly dissected by hands. The larynx was localized by palpation, displaced to the left of the midline. A horizontal incision was made blindly, and the index finger was inserted into the airway to maintain the landmark. A Frova was then inserted a 6.0-cuffed orotracheal tube was placed, with confirmation of EtCO2 (FigureB). Oxygenation was rapidly restored, and no hypotension occurred.

Upon the ENT surgeon's arrival, a thorough revision of the surgical site was performed, with clot evacuation and hemostasis. A tracheal cannula was placed in the cricothyroid membrane, and the patient was transferred to the ICU. The following morning, the cannula was removed, and a surgical tracheostomy was performed. By day5, the patient was spontaneously breathing, weaning from the tracheostomy, had intact swallowing function, and was discharged to the ward. Written informed consent for publication was collected from the patient.

This case highlights several critical lessons that should be considered in training.

1. Decision-making: Early anticipation and proactive decisions were vital. Transferring the patient early and preparing a surgical kit in advance were essential for success in managing the airway.

2. Anatomical challenges: The hematoma displaced the larynx, making identification of anatomical structures difficult. A percutaneous technique would have failed. The role of the finger as a placemark was found to be paramount.

3. Training: Although the team had formal FONA training this scenario was highly unusual and had not been previously practiced in simulation. Impalpable neck anatomy FONA should be added to standardized airway training.

The case highlights decision-making, early anticipation, and training. Also the ability to adjust techniques in real-time to manage unexpected challenges and ultimately save the airway.

Consent

Informed consent was obtained for the publication of this scientific article.

Fig. 1 (abstract A194).

A Laryngoscopic view during intubation attempt. The arrow indicates the intraoral hematoma, which is displacing and compressing the glottis, causing it to appear folded and inaccessible

Fig. 2 (abstract A194).

FONA. The blue dotted line represents the midline incision of the neck. The purple dotted line shows the displaced airway, pushed to the left by the expanding hematoma