Flavia Petrini

Early Use of Polymyxin B Hemoperfusion in Abdominal Septic Shock: The EUPHAS Randomized Controlled Trial

CONTEXT Polymyxin B fiber column is a medical device designed to reduce blood endotoxin levels in sepsis. Gram-negative-induced abdominal sepsis is likely associated with high circulating endotoxin. Reducing circulating endotoxin levels with polymyxin B hemoperfusion could potentially improve patient clinical outcomes. OBJECTIVE To determine whether polymyxin B hemoperfusion added to conventional medical therapy improves clinical outcomes (mean arterial pressure [MAP], vasopressor requirement, oxygenation, organ dysfunction) and mortality compared with conventional therapy alone. DESIGN, SETTING, AND PATIENTS A prospective, multicenter, randomized controlled trial (Early Use of Polymyxin B Hemoperfusion in Abdominal Sepsis [EUPHAS]) conducted at 10 Italian tertiary care intensive care units between December 2004 and December 2007. Sixty-four patients were enrolled with severe sepsis or septic shock who underwent emergency surgery for intra-abdominal infection. INTERVENTION Patients were randomized to either conventional therapy (n=30) or conventional therapy plus 2 sessions of polymyxin B hemoperfusion (n=34). MAIN OUTCOME MEASURES Primary outcome was change in MAP and vasopressor requirement, and secondary outcomes were PaO(2)/FIO(2) (fraction of inspired oxygen) ratio, change in organ dysfunction measured using Sequential Organ Failure Assessment (SOFA) scores, and 28-day mortality. RESULTS MAP increased (76 to 84 mm Hg; P = .001) and vasopressor requirement decreased (inotropic score, 29.9 to 6.8; P < .001) at 72 hours in the polymyxin B group but not in the conventional therapy group (MAP, 74 to 77 mm Hg; P = .37; inotropic score, 28.6 to 22.4; P = .14). The PaO(2)/FIO(2) ratio increased slightly (235 to 264; P = .049) in the polymyxin B group but not in the conventional therapy group (217 to 228; P = .79). SOFA scores improved in the polymyxin B group but not in the conventional therapy group (change in SOFA, -3.4 vs -0.1; P < .001), and 28-day mortality was 32% (11/34 patients) in the polymyxin B group and 53% (16/30 patients) in the conventional therapy group (unadjusted hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.20-0.94; adjusted HR, 0.36; 95% CI, 0.16-0.80). CONCLUSION In this preliminary study, polymyxin B hemoperfusion added to conventional therapy significantly improved hemodynamics and organ dysfunction and reduced 28-day mortality in a targeted population with severe sepsis and/or septic shock from intra-abdominal gram-negative infections. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00629382.

Guidelines for safety and quality in anaesthesia practice in the European Union

Anaesthesia is a medical specialty that is particularly concerned with the safety of the patient who is undergoing a surgical procedure. This is a prerequisite in order to provide quality of care, which is based on good clinical practice, on a sound organization, on an agreement on best practice and on adequate communication with other healthcare workers involved. Providing a safe environment for those working in healthcare is at least as important as other factors serving that objective. A working party on Safety and Quality in Anaesthesiological Practice in the Section and Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS) has prepared guidelines that were amended and approved recently.

Supraglottic Airway Devices: the Search for the Best Insertion Technique or the Time to Change Our Point of View?

In the crowded world of supraglottic airway devices (SADs), many papers compare the easiness of insertion based on the different endpoints of an operators satisfaction: first pass success, ventilation effectiveness, complications and morbidity. Proseal LMA™ (Laryngeal Mask Airway, Teleflex Medical, Dublin, Ireland) has been extensively studied because on one hand it has a steeper learning curve and more complex insertion when compared with other SADs and on the other hand many alternative techniques are available to facilitate insertion. This research is part of a larger body of studies exploring the issue that some devices are more difficult to insert because of many features related to sizing, constructive material, airway conduit and cuff design, performance and last but not least experience. Nevertheless, the biggest question might be the search for a systematic categorization of insertion difficulty features and identification of criteria allowing the choice for the best device and consequently for the best insertion technique. Given that, as a result of many intrinsic characteristics of the device we are using, insertion might become the secondary issue to be considered only after we clearly identify what makes it difficult, and to be counterbalanced on the results we expect from the device, performance we can achieve and degree of airway protection it could grant. The aim of this narrative review is to consider which factors might affect or condition SAD insertion difficulty and to try identifying some criteria addressing physicians pertaining to the use of SADs in clinical practice.

European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults

&NA; Procedural sedation and analgesia (PSA) has become a widespread practice given the increasing demand to relieve anxiety, discomfort and pain during invasive diagnostic and therapeutic procedures. The role of, and credentialing required by, anaesthesiologists and practitioners performing PSA has been debated for years in different guidelines. For this reason, the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology have created a taskforce of experts that has been assigned to create an evidence-based guideline and, whenever the evidence was weak, a consensus amongst experts on: the evaluation of adult patients undergoing PSA, the role and competences required for the clinicians to safely perform PSA, the commonly used drugs for PSA, the adverse events that PSA can lead to, the minimum monitoring requirements and post-procedure discharge criteria. A search of the literature from 2003 to 2016 was performed by a professional librarian and the retrieved articles were analysed to allow a critical appraisal according to the Grading of Recommendations Assessment, Development and Evaluation method. The Taskforce selected 2248 articles. Where there was insufficiently clear and concordant evidence on a topic, the Rand Appropriateness Method with three rounds of Delphi voting was used to obtain the highest level of consensus among the taskforce experts. These guidelines contain recommendations on PSA in the adult population. It does not address sedation performed in the ICU or in children and it does not aim to provide a legal statement on how PSA should be performed and by whom. The National Societies of Anaesthesiology and Ministries of Health should use this evidence-based document to help decision-making on how PSA should be performed in their countries. The final draft of the document was available to ESA members via the website for 4 weeks with the facility for them to upload their comments. Comments and suggestions of individual members and national Societies were considered and the guidelines were amended accordingly. The ESA guidelines Committee and ESA board finally approved and ratified it before publication.

Survey of Knowledge and Attitudes about Obstructive Sleep Apnoea Among Italian Anaesthetists

OBJECTIVE As the care of Obstructive Sleep Apnoea (OSA) patients remains heterogeneous, we hypothesized that it may reflect insufficient OSA knowledge/awareness among clinicians. METHODS OSA Knowledge/Attitude Questionnaire (OSAKA) was translated into Italian and distributed to anaesthetists attending SIAARTI National Congress and Airways courses and Hands-on Workshops from October 2012 to June 2013. RESULTS In total, 370 anaesthetists returned the questionnaires (response rate, 62%); the median (interquartile range [IQR]) knowledge score was 12 (10-14), and the range was 1-17 with no difference by gender, age, professional title or years of practice. The knowledge items achieved a mean rate of corrected response of 66%±0.14%. With regard to attitude items, median (IQR) score was 15 (13-17) and range was 0-20. Females and anaesthetists with >15 years of practice reached higher scores, while anaesthesia residents showed a lower attitude score. Gender and professional title were statistically associated with the attitude score (gender: F=14.6, p=0.0002; professional title: F=4.72, p=0.0099), whereas a weak association was observed within years in practice and attitude score (F=2.6, p=0.0519). Knowledge score correlated positively with attitude score (r=0.4, p<0.0001). For knowledge domains, there was a positive correlation between pathophysiology (mid-grade: r=0.3, p<0.0001), symptoms (low grade: r=0.2, p<0.0001), diagnosis (mid grade: r=0.3, p<0.0001) and the attitude score. Correlation close to zero was observed for epidemiology and treatment domains (r=0.09, p=0.06; r=-0.01, p=0.78, respectively). CONCLUSION The results of our survey demonstrate lack of knowledge about OSA and its treatment, revealing the need to update the syllabus of teaching in medical practice and in national health care policies to improve perioperative care.

Ultrasound: not the best 'soundtrack' for a 'cannot ventilate - cannot intubate' scenario.

The first issue concerns the model. The authors fixed a depth of 28 mm according to Ezri et al. This could be a limitation because in the obese, ‘difficult’ patient, this distance can be even higher and because the anatomical model considered a ‘cut of beef’, not including – unless undeclared – fat tissue (such in the obese neck), which is known to have different reflecting properties to ultrasound.

Prehospital Airway Management

Recently, however, various different works have been published which have cast doubt on the real efficacy of tracheal intubation, a maneuver which is considered to be the gold standard in airway management. In some cases the management of prehospital tracheal intubation has been attributed to potentially worsening the critical patient’s final outcome. Unfortunately, an analysis of prehospital airway management studies, especially the more recently published articles, has created more questions than answers.

Difficult to intubate, mandatory to oxygenate

EDITOR: We read with great interest the paper by Slater and Bhatia [1]. In patients such as the one described in which surgery could represent a potential physical conflict for airway management, airway preoperative evaluation should be rigorous and precise, so as to allow planning of first-line strategy and of a ‘plan B’ in case of failure. In this case, no such information was available for the reader except for an ‘unremarkable’ preanaesthetic evaluation and a generic ‘some limitations of mouth opening’. According to the Italian Difficult Airway Management Guidelines [2], and representing general commonsense, mouth opening limitation represents, even as an isolated finding, a prediction of potential major difficulty requiring very careful considerations and strategies. In fact, a reduction in mouth opening, especially in the presence of limited mandibular protrusion, represents a critical step not only for intubation (no space for laryngoscope insertion and/or airway manoeuvres) [3] but also for ventilation with both face-mask [4] or laryngeal mask or other extraglottic devices. So, despite this ‘unremarkable’ isolated finding, the safest strategy would have been, in our opinion, awake fibreoptic intubation or, in the event of lack of patient cooperation, by fibreoptic intubation in a sedated but spontaneously breathing patient. This is especially so considering of the concomitant presence of facial deformity due to previous surgery and radiotherapy (before which, presumably, ventilation was uneventful). Insertion of a laryngeal mask in cases of difficult ventilation is an appropriate choice although it may be inadvisable to remove it to perform laryngoscopy, place it again and then finally remove it before proceeding to an asleep fibreoptic intubation. These manoeuvres could have compromised further ventilation or fibreoptic intubation because of bleeding, secretions or minor pharyngo-laryngeal trauma. Italian guidelines prefer direct vision techniques to blind attempts, though recognizing the value of a bougie or, better, of hollow introducers [2]. Particularly, in this case, fibreoptic intubation via a laryngeal mask using the Aintree catheter (Cook Critical Care, Bloomington, IN, USA), once the laryngeal mask was placed and ventilation was guaranteed [5], could have been the best option. Asleep fibreoptic intubation, we believe, could have led to dangerous desaturation, especially if performed in an apnoeic patient without dedicated devices such as a Berman-like cannula or endoscopy mask. We would finally consider protected extubation (such as over an airway exchange catheter under local anaesthesia) [2] as a strategy for similar cases. Our message is hopefully clear – might intubation be difficult, guarantee oxygenation first. If either ventilation or intubation is predicted to be difficult, safety first. The fibreoptic awake intubation technique is the definitive choice, particularly in elective situations.