Current state of critically ill patients sedation with volatile anesthetics. Its role in renal and hepatic toxicity

Summary The anesthetic-conserving device (AnaConDa™) facilitated, from a technical viewpoint, the routine use of volatile anesthetics in intensive care patients using ICU ventilators. To date, its use is currently time-limited by clinicians due to the potential renal and hepatic toxicity associated with the production of plasma fluoride after its metabolism, despite its advantages. We reviewed the available human and animal studies literature examining the use of volatile anesthetics as sedative agents and its role in renal and/or hepatic toxicity. We have very few studies concerning the prolonged administration of sevoflurane through the AnaConDa™ and its effect on renal and hepatic functi…

Integridad renal y hepática tras la sedación prolongada con sevoflurano administrado a través del dispositivo AnaConDa®: comparación con la sedación intravenosa con propofol en modelo animal

Resumen Introduccion En la actualidad la sedacion de los pacientes criticos se realiza mediante agentes intravenosos. La utilizacion de agentes inhalatorios, como alternativa a la sedacion intravenosa, se encuentra limitada por su potencial riesgo de toxicidad. El incremento de los niveles de fluoruros inorganicos, tras su metabolizacion, ha sido considerado potencialmente nefrotoxico. Por otro lado, la afectacion hepatica despues de la administracion prolongada de sevoflurano no ha sido estudiada. Se evaluo la potencial toxicidad renal y hepatica causada por la administracion prolongada (72 h) de sevoflurano. Metodos Estudio experimental, prospectivo, aleatorizado y controlado. Veintidos a…

Limb Ischemic Conditioning Induces Oxidative Stress Followed by a Correlated Increase of HIF-1α in Healthy Volunteers.

Background Local and remote ischemic preconditioning has been used as a protective intervention against ischemia/reperfusion (I/R) damage in several preclinical and clinical studies. However, its physiological mechanisms are not completely known. I/R increases the production of reactive oxygen species, which also serve as messengers for a variety of functions. Hypoxia-inducible factor 1 alpha (HIF-1α) is probably the most important transcription factor mediator of hypoxic signaling. Objective We hypothesized that limb ischemic conditioning (LIC) induces a local oxidative/nitrosative stress and a correlated increase of HIF-1α plasma levels. Methods An observational, prospective, and single-c…

WHO needs high FIO2?

World Health Organization and the United States Center for Disease Control have recently recommended the use of 0.8 FIO2 in all adult surgical patients undergoing general anaesthesia, to prevent surgical site infections. This recommendation has arisen several discussions: As a matter of fact, there are numerous studies with different results about the effect of FIO2 on surgical site infection. Moreover, the clinical effects of FIO2 are not limited to infection control. We asked some prominent authors about their comments regarding the recent recommendations.

Stratification for Identification of Prognostic Categories In the Acute RESpiratory Distress Syndrome (SPIRES) Score.

OBJECTIVES: To develop a scoring model for stratifying patients with acute respiratory distress syndrome into risk categories (Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score) for early prediction of death in the ICU, independent of the underlying disease and cause of death. DESIGN: A development and validation study using clinical data from four prospective, multicenter, observational cohorts. SETTING: A network of multidisciplinary ICUs. PATIENTS: One-thousand three-hundred one patients with moderate-to-severe acute respiratory distress syndrome managed with lung-protective ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN …

Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial

Background There is no proven specific pharmacological treatment for patients with the acute respiratory distress syndrome (ARDS). The efficacy of corticosteroids in ARDS remains controversial. We aimed to assess the effects of dexamethasone in ARDS, which might change pulmonary and systemic inflammation and result in a decrease in duration of mechanical ventilation and mortality. Methods We did a multicentre, randomised controlled trial in a network of 17 intensive care units (ICUs) in teaching hospitals across Spain in patients with established moderate-to-severe ARDS (defined by a ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen of 200 mm Hg or less assesse…

Hiperoxia perioperatoria: mitos y realidades

Intraoperative positive end-expiratory pressure and postoperative pulmonary complications: a patient-level meta-analysis of three randomised clinical trials

BACKGROUND: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperati…

Whole-Blood Mitochondrial DNA Copies Are Associated With the Prognosis of Acute Respiratory Distress Syndrome After Sepsis

Acute respiratory distress syndrome (ARDS) is an inflammatory process of the lungs that develops primarily in response to pulmonary or systemic sepsis, resulting in a disproportionate death toll in intensive care units (ICUs). Given its role as a critical activator of the inflammatory and innate immune responses, previous studies have reported that an increase of circulating cell-free mitochondrial DNA (mtDNA) is a biomarker for fatal outcome in the ICU. Here we analyzed the association of whole-blood mtDNA (wb-mtDNA) copies with 28-day survival from sepsis and sepsis-associated ARDS. We analyzed mtDNA data from 687 peripheral whole-blood samples within 24 h of sepsis diagnosis from unrelat…

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (V(T)). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES: Women and men were compared with respect to use o…

Aumento de presión en la vía aérea durante la ventilación mecánica: más allá del broncoespasmo

Perioperative hyperoxia: Myths and realities

Remote Ischemic Preconditioning Decreases Oxidative Lung Damage After Pulmonary Lobectomy

BACKGROUND:During lobectomy in patients with lung cancer, the operated lung is often collapsed and hypoperfused. Ischemia/reperfusion injury may then occur when the lung is re-expanded. We hypothesized that remote ischemic preconditioning (RIPC) would decrease oxidative lung damage and improve gas e

Individualised perioperative open-lung approach versus standard protective ventilation in abdominal surgery (iPROVE): a randomised controlled trial

Background The effects of individualised perioperative lung-protective ventilation (based on the open-lung approach [OLA]) on postoperative complications is unknown. We aimed to investigate the effects of intraoperative and postoperative ventilatory management in patients scheduled for abdominal surgery, compared with standard protective ventilation. Methods We did this prospective, multicentre, randomised controlled trial in 21 teaching hospitals in Spain. We enrolled patients who were aged 18 years or older, were scheduled to have abdominal surgery with an expected time of longer than 2 h, had intermediate-to-high-risk of developing postoperative pulmonary complications, and who had a bod…

Neurally adjusted ventilatory assist: An update

Summary Neurally adjusted ventilatory assist (NAVA) is a new ventilation mode that provides a proportional assistance to the inspiratory effort of the patients. It is based on the use of the diaphragm electromyographic activity (Edi) for the control of the ventilation assistance. The ability of NAVA to improve the limitations of the conventional assisted ventilator modes has been assessed in clinical studies and discussed in this report, as the latest applications of NAVA in children and non-invasive ventilation, due to the improvement of the patient–ventilator interactions delivered by NAVA. We also review the most recent literature on a new trend to use the Edi as a predictor of weaning s…

Pathophysiology of respiratory failure

Summary Respiratory failure (RF) is defined as a disturbance in gas exchange in the respiratory system which produces in arterial BGA a PaO 2 2  > 50 mmHg (hypercapnia). However hypoxaemic normocapnic (or hypocapnic) RF due to the failure in gas exchange is very common and should be separated from mechanical RF. Respiratory failure (hypercapnic) with or without hypoxaemia related to a failure in the respiratory pump. This review is focused on the pathophysiology of the mechanical RF less well known amongst anaesthesiologists.

A noninvasive postoperative clinical score to identify patients at risk for postoperative pulmonary complications: The air-test score

BACKGROUND: Postoperative pulmonary complications (PPCs) negatively affect morbidity, healthcare costs and postsurgical survival. Preoperative and intraoperative peripheral oxyhemoglobin saturation (SpO2) levels are independent risk factors for postoperative pulmonary complications (PPCs). The air-test assesses the value of SpO2 while breathing room-air. We aimed at building a clinical score that includes the air-test for predicting the risk for PPCs. METHODS: This is a development and validation study in patients -randomly divided into two cohorts- from a large randomized clinical trial (iPROVE) that enrolled 964 intermediate-to-high risk patients scheduled for abdominal surgery. Arterial …

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

Background Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. Methods/design The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multice…

Renal and hepatic integrity in long-term sevoflurane sedation using the anesthetic conserving device: A comparison with intravenous propofol sedation in an animal model

Abstract Introduction Critically ill patients are sedated with intravenous agents because the use of inhaled agents is limited by their potential risk of toxicity. Increasing levels of inorganic fluorides after the metabolism of these agents have been considered potentially nephrotoxic. However, hepatic involvement after prolonged administration of sevoflurane has not yet been studied. The present study evaluated the potential renal and hepatic toxicity caused by prolonged administration (72 h) of sevoflurane. Methods For this experimental, prospective, randomized, controlled trial, 22 Landrace × Large-White female pigs were randomly assigned to two groups: intravenous propofol (P) or inhal…