COVID-19 pandemic in the intensive care unit:Psychological implications and interventions,a systematic review

BACKGROUND The coronavirus disease 2019(COVID-19) pandemic produced changes in intensive care units(ICUs) in patient care and health organizations. The pandemic event increased patients’ risk of developing psychological symptoms during and after hospitalisation. These consequences also affected those family members who could not access the hospital. In addition, the initial lack of knowledge about the virus and its management, the climate of fear and uncertainty, the increased workload and the risk of becoming infected and being contagious, had a strong impact on healthcare staff and organizations. This highlighted the importance of interventions aimed at providing psychological support to ICUs, involving patients, their relatives, and the staff;this might involve the reorganisation of the daily routine and rearrangement of ICU staff duties.AIM To conduct a systematic review of psychological issues in ICUs during the COVID-19 pandemic involving patients, their relatives, and ICU staff.METHODS We investigated the PubMed and the ClinicalTrials.gov databases and found 65 eligible articles,upon which we commented.RESULTS Our results point to increased perceived stress and psychological distress in staff, patients and their relatives and increased worry for being infected with severe acute respiratory syndrome coronavirus-2 in patients and relatives. Furthermore, promising results were obtained for some psychological programmes aiming at improving psychological measures in all ICU categories.CONCLUSION As the pandemic limited direct inter-individual interactions, the role of interventions using digital tools and virtual reality is becoming increasingly important. All considered, our results indicate an essential role for psychologists in ICUs.

Efficacy of Different Fluids Preload on Propofol Injection Pain:A Randomized,Controlled,Double-blinded Study

Injection pain of propofol remains a common clinical problem. Previous studies demonstrated that propofol injection pain was alleviated by applying nitroglycerin ointment to the skin of injection site, which inspires us to test whether venous vasodilation induced by fluid preload could alleviate the pain. Different types or volumes of fluid preload were compared. 200 ASA Ⅰ-Ⅱ adult patients were randomly assigned to five groups of 40 each. A 20 G cannula was established on the dorsum or wrist of the hand. When fluid preload given with Plasma-Lyte A 100 m L（P100 group）, 250 m L（P250 group）, 500 m L（P500 group）, 0.9% saline 500 m L（N500 group） or Gelofusine 500 m L（G500 group） was completed within 30 min, respectively, Propofol（0.5 mg/kg, 1%） was injected at a rate of 0.5 m L/s. A blind investigator assessed the pain using a four-point scale. Incidence of pain in P100, P250, and P500 groups was 87.5%, 57.5% and 35%, respectively（P〈0.05）. The median pain intensity score was significantly lower in P500 group than that in P250 and P100 groups（P〈0.05 and P〈0.01, respectively）. Comparison of the effect of different types of solution preload indicated that the highest incidence of pain was in N500 group（62.5%）（N500 vs. P500, P=0.014; N500 vs. G500, P=0.007）. The median pain intensity score in N500 group was higher than that in P500 group（P〈0.05） and G500 group（P〈0.05）. There was no significant difference between P500 and G500 groups. It is suggested that Plasma-Lyte A or Gelofusine preload with 500 m L before propofol injection is effective in alleviating propofol-induced pain.

Anesthesia of a patient with congenital cataract,facial dysmorphism,and neuropathy syndrome for posterior scoliosis:A case report

BACKGROUND Congenital cataract,facial dysmorphism,and neuropathy(CCFDN)syndrome is an extremely rare multiorgan disorder.Characteristics include congenital cataracts,facial deformation,extremity deformities,and demyelinating neuropathy.CCFDN syndrome is associated with increased risk during anesthesia including rhabdomyolysis or epileptic seizures.There is a lack of published information about difficult airways in these patients.Difficult airways during intubation represent one of the most dreaded anesthesia complications:A"can not intubate,can not oxygenate"scenario.Presented herein is the first described successful endotracheal intubation of a CCFDN syndrome patient.CASE SUMMARY We report the anesthetic management of a 13-year-old girl with CCFDN syndrome scheduled for posterior neuromuscular scoliosis correction surgery.The patient suffered from extensive progressive neuromuscular scoliosis with a Cobb angle of 83°.Her limitations included neuropathy and a scoliotic curve.This condition negatively impacted her quality of life.This case reflects the potential anesthetic complications for posterior scoliosis correction and CCFDN syndrome.The challenge for our anesthetic team was the limited amount of data about anesthetic management of this condition.In total,one case report without any data about endotracheal intubation of patients with this condition was available.Endotracheal intubation in our case was uncomplicated.Another focus of our case was the prevention of possible complications associated with this syndrome,including rhabdomyolysis and seizures.Rhabdomyolysis can be triggered by some types of anesthetic agents like suxamethonium or volatile anesthetics,especially in patients with certain types of myopathies.CONCLUSION Adequate understanding of the anesthetic management of CCFDN syndrome can reduce perioperative complications and improve patient outcome after surgery.

Balance of Concerns: Satisfactory Pre-Anesthetic Patient Education and the Extent of Patient Worries

Controversy exists whether or not patient’s concerns regarding anesthetics can be reduced by face-to-face pre-assessment with an anesthetist. Thus we were looking at concerns patients had before and after such a consultation. Patient satisfaction was rated by a validated questionnaire. A four-staged Likert-scale was used to quantify the extent of patients concerns. The totaling 461 patients were overall highly satisfied. 448 patients had “nil” to “minimal” concerns. After the assessment, 106 patients stated their concerns had been lessened (p 0.001). Having gone through the anesthetic pre-assessment center, 99.1% of all patients reported no considerable concerns regarding anesthetics whatsoever. A high level of patient satisfaction does not constitute a low level of concerns patients may hold over anesthetics, although a pre-operative consultation mitigated these concerns by 23%, whilst for 9% of all patients this pre-assessment led to a higher level of concerns.

Algorithm-based arterial blood sampling recognition increasing safety in point-of-care diagnostics

AIM To detect blood withdrawal for patients with arterial blood pressure monitoring to increase patient safety and provide better sample dating.METHODS Blood pressure information obtained from a patient monitor was fed as a real-time data stream to an experimental medical framework. This framework was connected to an analytical application which observes changes in systolic, diastolic and mean pressure to determine anomalies in the continuous data stream. Detection was based on an increased mean blood pressure caused by the closing of the withdrawal three-way tap and an absence of systolic and diastolic measurements during this manipulation. For evaluation of the proposed algorithm, measured data from animal studies in healthy pigs were used.RESULTS Using this novel approach for processing real-time measurement data of arterial pressure monitoring, the exact time of blood withdrawal could be successfully detected retrospectively and in real-time. The algorithm was able to detect 422 of 434(97%) blood withdrawals for blood gas analysis in the retrospective analysis of 7 study trials. Additionally, 64 sampling events for other procedures like laboratory and activated clotting time analyses were detected. The proposed algorithm achieved a sensitivity of 0.97, a precision of 0.96 and an F1 score of 0.97.CONCLUSION Arterial blood pressure monitoring data can be used toperform an accurate identification of individual blood samplings in order to reduce sample mix-ups and thereby increase patient safety.

Self-Reported Use of Personal Protective Equipment during the SARS-CoV-2 Pandemic in Emergency Medical Service Employees in Germany—A Survey

Background: Multicentric prospective cohort investigation survey conducted between 1st of March and 1st of April 2021on SARS-CoV-2 occupational risk for German Emergency Medical Services (EMS) personnel. Study Objectives: Primary: The objective is to take stock of the use and availability of Personal Protective Equipment (PPE) in German EMS, both at managerial and employee level, during the SARS-CoV-2 pandemic. Secondary: Generate additional data on individual perceptions of risk of infection and occurrence of infections at respective places of service. Methods: Multicentric prospective cohort investigation survey conducted online at two levels of German EMS personnel—EMS managers and EMS employees, both medical and paramedical—with questions adapted slightly to fit the respective study population. Results: A total of 34 responses were received in the managerial group;a total of 2389 responses were received in the group of employees. Self-reported PPE adherence of EMS employees for confirmed SARS-CoV-2 positive patients: use of gloves (99.8%), FFP2 or FFP3 masks (99.8%), gowns or coveralls (99.1%), goggles (89.7%), face shields (24.0%), surgical masks (0.0%). Self-reported PPE adherence of EMS employees for suspected SARS-CoV-2 positive patients: gloves (98.8%), FFP2 or FFP3 masks (total: 99.4%), gowns or coveralls (total: 95.9%), goggles (85.6%), face shields (19.2%), surgical masks (0.2%). Conclusions: Findings included an overall improved self-reported adherence to PPE compared to studies that were conducted before the pandemic. Self-reported general adherence to PPE recommendations when attending to confirmed SARS-CoV-2 positive patients was good, with the exception of goggles. Self-reported adherence to PPE recommendations dropped when attending to suspected SARS-CoV-2 positive patients.

Rapamycin Ameliorates Neuropathic Pain by Activating Autophagy and Inhibiting Interleukin-1β in the Rat Spinal Cord

Autophagy acts as an important homoeostatic mechanism by degradation of cytosolic con- stituents and plays roles in many physiological processes. Recent studies demonstrated that autophagy can also regulate the production and secretion of the proinflammatory cytokine interleukin-1β （IL-1β）, which plays a critical role in the development and maintenance ofneuropathic pain. In the present study, the paw withdrawal threshold （PWT） and paw withdrawal latency （PWL） were significantly decreased after spinal nerve ligation （SNL）, and the changes were accompanied by inhibited autophagy in the spi- nal microglia and increased mR.NA and protein levels of IL-1β in the ipsilateral spinal cord. We then investigated the antinociceptive effect of rapamycin, a widely used autopahgy inducer, on SNL-induced neuropathic pain in rats and found that treatment with intrathecal rapamycin significantly attenuated the mechanical allodynia and thermal hyperalgesia. Moreover, rapamycin significantly enhanced autophagy in the spinal microglia, whereas it reduced the mRNA and protein levels of IL-1β in the ipsilateral spinal cord. Our results showed that rapamycin could ameliorate neuropathic pain by activating autophagy and inhibiting IL-1β in the spinal cord.

Cost-utility of molecular adsorbent recirculating system treatment in acute liver failure

AIM:To determine the short-term cost-utility of mo-lecular adsorbent recirculating system(MARS) treatment in acute liver failure(ALF).METHODS:A controlled retrospective study was conducted with 90 ALF patients treated with MARS from 2001 to 2005.Comparisons were made with a historical control group of 17 ALF patients treated from 2000 to 2001 in the same intensive care unit(ICU) specializing in liver diseases.The 3-year outcomes and number of liver transplantations were recorded.All direct liver disease-related medical expenses from 6 mo before to 3 years after ICU treatment were determined for 31 MARS patients and 16 control patients.The health-related quality of life(HRQoL) before MARS treatment was estimated by a panel of ICU doctors and after MARS using a mailed 15D(15-dimensional generic healthrelated quality of life instrument) questionnaire.The HRQoL,cost,and survival data were combined and the incremental cost/quality-adjusted life years(QALYs) was calculated.RESULTS:In surviving ALF patients,the health-related quality of life after treatmeant was generally high and comparable to the age-and gender-matched general Finnish population.Compared to the controls,the average cost per QALY was considerably lower in the MARS group(64 732€ vs 133 858€) within a timeframe of 3.5 years.The incremental cost of standard medical treatment alone compared to MARS was 10 928€,and the incremental number of QALYs gained by MARS was 0.66.CONCLUSION:MARS treatment combined with standard medical treatment for ALF in an ICU setting is more cost-effective than standard medical treatment alone.

Fatty acid metabolism and acyl-CoA synthetases in the liver-gut axis

Fatty acids are energy substrates and cell components which participate in regulating signal transduction,transcription factor activity and secretion of bioactive lipid mediators.The acyl-CoA synthetases(ACSs)family containing 26 family members exhibits tissue-specific distribution,distinct fatty acid substrate preferences and diverse biological functions.Increasing evidence indicates that dysregulation of fatty acid metabolism in the liver-gut axis,designated as the bidirectional relationship between the gut,microbiome and liver,is closely associated with a range of human diseases including metabolic disorders,inflammatory disease and carcinoma in the gastrointestinal tract and liver.In this review,we depict the role of ACSs in fatty acid metabolism,possible molecular mechanisms through which they exert functions,and their involvement in hepatocellular and colorectal carcinoma,with particular attention paid to long-chain fatty acids and small-chain fatty acids.Additionally,the liver-gut communication and the liver and gut intersection with the microbiome as well as diseases related to microbiota imbalance in the liver-gut axis are addressed.Moreover,the development of potentially therapeutic small molecules,proteins and compounds targeting ACSs in cancer treatment is summarized.

Effect of intra-abdominal pressure on respiratory function in patients undergoing ventral hernia repair

AIM: To determine the influence of intra-abdominal pressure(IAP) on respiratory function after surgical repair of ventral hernia and to compare two different methods of IAP measurement during the perioperative period. METHODS: Thirty adult patients after elective repair of ventral hernia were enrolled into this prospective study.IAP monitoring was performed via both a balloontipped nasogastric probe [intragastric pressure(IGP), Ci MON, Pulsion Medical Systems, Munich, Germany] and a urinary catheter [intrabladder pressure(IBP), Uno Meter Abdo-Pressure Kit, Uno Medical, Denmark] on five consecutive stages:(1) after tracheal intubation(AI);(2) after ventral hernia repair;(3) at the end of surgery;(4) during spontaneous breathing trial through the endotracheal tube; and(5) at 1 h after tracheal extubation. The patients were in the complete supine position during all study stages.RESULTS: The IAP(measured via both techniques) increased on average by 12% during surgery compared to AI(P < 0.02) and by 43% during spontaneous breathing through the endotracheal tube(P < 0.01). In parallel, the gradient between РаСО2 and Et CO2 [Р(а-et)CO2] rose significantly, reaching a maximum during the spontaneous breathing trial. The PаO2/Fi O2 decreased by 30% one hour after tracheal extubation(P = 0.02). The dynamic compliance of respiratory system reduced intraoperatively by 15%-20%(P < 0.025). At all stages, we observed a significant correlation between IGP and IBP(r = 0.65-0.81, P < 0.01) with a mean bias varying from-0.19 mm Hg(2SD 7.25 mm Hg) to-1.06 mm Hg(2SD 8.04 mm Hg) depending on the study stage. Taking all paired measurements together(n = 133), the median IGP was 8.0(5.5-11.0) mm Hg and the median IBP was 8.8(5.8-13.1) mm Hg. The overall r2 value( n = 30) was 0.76(P < 0.0001). Bland and Altman analysis showed an overall bias for the mean values per patient of 0.6 mm Hg(2SD 4.2 mm Hg) with percentage error of 45.6%. Looking at changes in IAP between the different study stages, we found an excellent concordance coefficient of 94.9% comparing IBP and IGP( n = 117).CONCLUSION: During ventral hernia repair, the IAP rise is accompanied by changes in Р(а-et)CO2 and PаO2/Fi O2-ratio. Estimation of IAP via IGP or IBP demonstrated excellent concordance.

Effect of clonidine on the cutaneous silent period during spinal anesthesia

AIM To investigate the effect of clonidine on the cutaneous silent period(CSP) during spinal anesthesia. METHODS A total of 67 adult patients were included in this randomized, prospective, single-center, double-blind trial. They did not have neurological disorders and were scheduled for inguinal hernia repair surgery. This trial was registered on ClinicalTrials.gov(NTC03121261). The patients were randomized into two groups with regards to the intrathecally administered solution:(1) 15 mg of 0.5% levobupivacaine with 50 μg of 0.015% clonidine, or(2) 15 mg of 0.5% levobupivacaine alone. There were 34 patients in the levobupivacaine-clonidine(LC) group and 33 patients in the levobupivacaine(L) group. CSP and its latency were measured four times: prior to the subarachnoid block(SAB), after motor block regression to the 0 level of the Bromage scale, with ongoing sensory blockade, and both 6 and 24 h after SAB.RESULTS Only data from 30 patients in each group were analyzed. There were no significant differences between the groups investigated preoperatively and after 24 h. The CSP of the L group at the time point when the Bromage scale was 0 was 44.8 ± 8.1 ms, while in the LC group it measured 40.2 ± 3.8 ms(P = 0.007). The latency in the L group at the time point when the Bromage scale was 0 was 130.3 ± 10.2 ms, and in the LC group it was 144.7 ± 8.3 ms(P < 0.001). The CSP of the L group after 6 h was 59.6 ± 9.8 ms, while in the LC group it was 44.5 ± 5.0 ms(P < 0.001). The latency in the L group after 6 h was 110.4 ± 10.6 ms, while in LC group it was 132.3 ± 9.7 ms(P < 0.001).CONCLUSION Intrathecal addition of clonidine to levobupivacaine for SAB in comparison with levobupivacaine alone resultsin a diminished inhibitory tonus and shortened CSP.

Expert consensus on the perioperative management of patients with sepsis

INTRODUCTION Sepsis is defined as an infection associated with systemic manifestations of inflammation, which has become the most common complication in the perioperative period caused by severe burn/trauma and major surgical operation.[1,2] The incidence of sepsis in adults is estimated to be 149–240/100 000 per year, and that of severe sepsis and septic shock is 56–91/100 000 per year. In the last decade, the short-term mortality of sepsis has declined to around 20% in developed countries partly due to the international Surviving Sepsis Campaign （SSC）, while the mortality remains very high （50%–80%） in 1–5 years after discharge from hospitals.[3–7] Thus, sepsis and its subsequent severe sepsis and septic shock are currently major issues in the field of medical and health care.

Effects of mineralocorticoid receptor antagonists on responses to hemorrhagic shock in rats

AIM To evaluate the effects of mineralocorticoid receptor(MR) antagonists on mortality and inflammatory responses after hemorrhagic shock(HS) in rats.METHODS One hundred and two male Sprague–Dawley rats were randomly assigned to one of the following three groups: Control, spironolactone (SPL), and eplerenone(EP) groups. HS was induced by the removal of blood. One half of rats were evaluated to determine mortality, hemodynamics, plasma tumor necrosis factor-alpha(TNF-α) concentrations, and arterial blood gas at 8 h afterHS recovery. In the remainder of rats, the expression levels of genes encoding cytokines were evaluated in liver tissue samples at 1 h after HS recovery. RESULTS The survival rates 8 h after HS recovery were 71%, 94%, and 82% in the control, SPL, and EP groups, respectively. There were no significant differences in survival rates among the three groups (P = 0.219). Furthermore, there were no significant differences in gene expression levels in the liver or plasma TNF-α concentrations among the three groups(P = 0.888).CONCLUSION Pretreatment with MR antagonists did not improve mortality or cytokine responses in the liver after HS recovery in rats.

Anesthesia and acupuncture

Using acupuncture instead of anesthetics to induce analgesia was performed in China many years ago in surgical anesthetization. Although many medical units in China's cities and rural areas are applying these techniques in operations, it should be pointed out that acupuncture anesthesia is still in the process of development and is of next to no practical and even less scientific value in the western world. However, acupuncture-assisted anesthesia can be useful also in countries other than China.

Argon: a novel therapeutic option to treat neuronal ischemia and reperfusion injuries?

Neuronal injury and neuroprotection：Ischemia and reperfusion injuries in neuronal cells such as acute ischemic stroke-represent the third leading cause of death in the world.Current therapeutic concepts mainly aim to re-establish cerebral blood flow within a time window of less than 3 hours with the goal of limiting secondary brain injury.

Anesthetic Management for a Patient of Gorham’s Syndrome: The Vanishing Bone Disease

Gorham-Stout (GS) syndrome or the vanishing bone disease is a very rare chronic disease characterized by the destruction of the osseous matrix and proliferation of vascular structures. Review of the general anesthesia showed only a few cases till date. We report general anesthesia for tooth extraction in a 21-year-old male patient with Gorham-Stout syndrome. In this case, the most concerning issue was limited mouth opening due to mandible osteolysis and difficult intubation was anticipated. To anticipate difficult airway management, it is very important to consider the preoperative airway assessment including the cervical spine screening. In this case, the McGrath video laryngoscope prevented the anticipated difficult intubation due to the limited mouth opening due to mandible osteolysis.

Developing Customized Evaluation Software for Clinical Trials: An Example with Obstructive Lung Diseases

Corresponding customized software tool is usually unavailable, which increases the time and workload for evaluating the results of a clinical trial. In the present paper, we demonstrate the development process of a customized software for one clinical trial on patients with obstructive lung disease. Over hundred patients and volunteers as controlled were included in the clinical trial. They were examined by spirometry and EIT in a seated position during spontaneous tidal breathing. Subsequently, standard vital capacity maneuver and forced full expiration maneuver were performed. In order to evaluate the offline data, a customized software was developed. The requirements of the software were defined by investigators. The software was then tested on patients’ data and refined based on feedbacks of the investigators. We finalized the customized software with analysis of various disease-specific parameters and indices. Compared to the data process with device specific programs and other commercial software, the customized software is more flexible, user-friendly and extendable. As conclusion, customized software simplifies the evaluation process distinctly and helps physicians to focus on study design and result interpretation.

Paravertebral Block in Thoracotomy—Comparison between Single-Shot and Catheter Methods

Aim: Thoracic paravertebral block is increasingly used as a method of postoperative analgesia in thoracic surgery. We aimed to compare two different methods of implementation: paravertebral thoracic block with a catheter placed in the epidural space, and a single injection of anesthetic at the end of surgery. Methods: We randomized 60 patients undergoing VATS, in 17 (group A) single-dose paravertebral block, and in another 21 (group B) catheter technique and postoperative infusion of local anesthetic were used, and in the latter, the control group (C) of 22 patients, analgesia was performed according to a standardized protocol with non-steroidal analgesics and opioids as needed. In all patients, in the early postoperative 48 hours, we measured the intensity of pain and opioid consumption. Results: There were no statistically significant differences between the collected preoperative data in the three groups of patients. There were no significant differences in subjective pain sensations in the early postoperative period (up to 12 hours). However, the number of opioids used was significantly lower in groups A and B compared to the control group, and in group B (with catheter technique) after the 12th to 48th hour after surgery there was almost no need for strong analgesics. Conclusion: Continuous infusion of local anesthetic in the area of the surgical incision provides much better pain relief than a single paravertebral block in the area of the incision.