Daily Anesthesiology Research Analysis

OBJECTIVE: These European Society of Intensive Care Medicine (ESICM) guidelines provide recommendations for the diagnosis of shock and hemodynamic monitoring for adult critically ill patients. METHODS: An international panel of experts formulated PICO-formatted questions, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess evidence and formulate recommendations. In the absence of strong evidence, panelists issued ungraded good practice statements (UGPS). RESULTS: Panelists issued 50 statements. Among others, skin perfusion should be monitored using the assessment of capillary refill time, and this may be complemented by the assessment of skin temperature and mottling (UGPS). In patients with a central venous catheter, serial measurements of (central) venous oxygen saturation and of the veno-arterial difference in carbon dioxide partial pressure should be performed (UGPS). In patients with persistent shock after initial fluid resuscitation, fluid responsiveness should be assessed before continuing fluid resuscitation (UGPS). It is recommended to use dynamic variables over static markers of preload for predicting fluid responsiveness, when applicable (graded statement). Cardiac output (CO) and/or stroke volume should be monitored in patients who do not respond to initial therapy (UGPS). Arterial pressure should be monitored with an arterial catheter in shock that is not responsive to initial therapy and/or requiring vasopressor infusion (UGPS), and central venous pressure should be measured in patients who have a central venous catheter (UGPS). Panelists suggest using echocardiography as the first-line imaging modality to assess the type of shock (graded statement). Echocardiographically defined phenotypes of left and right ventricular dysfunction may be of prognostic significance (UGPS). CONCLUSIONS: The panel made 50 recommendations on shock diagnosis and hemodynamic monitoring.

BACKGROUND AND OBJECTIVES: Ultrasound-guided axillary block (USGAB) is currently an accepted anesthesia technique for surgery of the hand, wrist or elbow. Recently, a new strategy for upper extremity surgery has emerged-Wide-Awake Local Anesthesia, No Tourniquet (WALANT). This prospective, randomized, single-center, double-blind, non-inferiority trial compared WALANT versus USGAB to provide surgical anesthesia in outpatient endoscopic carpal tunnel release (CTR). METHODS: Patients undergoing endoscopic CTR (n=130) were randomly allocated to WALANT or USGAB using lidocaine. The primary outcome was the success rate of WALANT versus USGAB in providing surgical anesthesia. A successful block was defined as adequate anesthesia for surgery without the need for supplementation. RESULTS: The proportion of subjects who achieved a successful block was 89% in the USGAB group versus 100% in the WALANT group. Non-inferiority of WALANT with respect to USGAB was confirmed (p<0.05). Postoperative function was similar in both groups except for the ability to dress, which was improved in the WALANT group compared with the USGAB group (92% vs 58%; p<0.001). No statistical differences regarding regional anesthesia satisfaction scores were observed except that the discomfort elements were improved in the WALANT group (p<0.05). Surgical assessment of intraoperative bleeding was similar in both groups (p=0.37). CONCLUSIONS: For outpatient endoscopic CTR, the success rate of WALANT technique is non-inferior to USGAB. TRIAL REGISTRATION NUMBER: NCT06040840.

PURPOSE: This study aimed to determine whether sugammadex use is associated with lower postoperative urinary retention (POUR) incidence than neostigmine-glycopyrrolate reversal in patients undergoing laparoscopic hernia repair. METHODS: This retrospective cohort study used the TriNetX research network database to analyze adult patients who underwent laparoscopic hernia repair. Patients receiving rocuronium/vecuronium were divided into sugammadex (n = 92,543) or neostigmine-glycopyrrolate (n = 11,723) reversal groups. After 1:1 propensity score matching, 11,722 matched pairs were analyzed. The primary outcome was POUR within 30 days. The secondary outcomes included pneumonia, hospital readmission, and emergency department (ED) visits. Subgroup analyses were used to examine the effects of age and sex. RESULTS: In the matched cohort (n = 23,444), sugammadex was associated with a significantly lower risk of POUR (OR 0.23, 95% CI 0.18-0.31; p < 0.001) and ED visits (OR 0.76, 95% CI 0.66-0.87; p < 0.001). No significant differences were found in pneumonia or readmission rates. The POUR reduction was consistent across sexes (males: OR 0.32; females: OR 0.33) but more pronounced in patients aged >50 years (OR 0.35) than in younger patients (OR 0.50, p = 0.067). Among male patients receiving sugammadex, older age (OR, 1.01), history of urinary retention (OR, 9.94), and benign prostatic hyperplasia (OR, 4.04) were significant independent risk factors for POUR. CONCLUSIONS: Sugammadex use is associated with a 77% reduction in POUR and 24% fewer ED visits than neostigmine following hernia repair, suggesting that it may be the preferred reversal agent, particularly for older adults who gain the most benefit.