Parathyroid hormone serum concentration kinetic profile in critically ill patients undergoing continuous renal replacement therapies: a prospective observational study

Introduction: Elevated serum parathormone (PTH) levels have been observed in acute kidney injury and are related to calcium-phosphate metabolism disturbance, decreased renal production of 1,25 dihydroxyvitamin D3, impaired renal PTH excretion, and other renal-independent factors. There are no data regarding PTH concentration kinetics in critically ill patients undergoing continuous renal replacement therapies (CRRT) in an intensive care setting. The primary objective of this study was to investigate trends in PTH serum levels in critically ill patients with multiorgan failure undergoing CRRT, by performing periodic PTH measurements in the acute phase of critical illness. Material and methods: This was a single-centre, prospective, observational study conducted in an mixed, university-affiliated intensive care unit. Critically ill patients who fulfilled all of the following criteria were included: respiratory failure; circulatory failure; acute kidney injury treated by CRRT; and sequential organ failure assessment score (SOFA score) of 5 or more. Patients who met any of the following criteria were excluded: acute liver failure; hypercalcemia at admission (total calcium serum level > 10.6 mg/dL; total ionized calcium plasma level > 1.35 mmol/L); parathyroid gland disease; end-stage renal disease; patients undergoing therapeutic plasma exchange or extracorporeal membrane oxygenation procedures; aged under 18 years;  pregnant; and life expectancy after admission to the intensive care unit anticipated to be less than 72 hours as assessed by the investigator. Results: Thirty patients met the inclusion criteria. A statistically significant change in PTH over time was observed (Friedman ANOVA; p = 0.0001). The post-hoc test showed a statistically significant decrease in PTH: measurements 5–8 relative to measurement 1, and measurements 4–8 relative to measurement 2 (p < 0.05). No significant correlations between 25 hydroxyvitamin D3 deficiency, age, diagnosis, SOFA score, and PTH levels were observed. A statistical test indicated that serum concentrations of PTH were significantly higher in the de novo sepsis group (p < 0.05). Conclusions: The PTH serum concentration decreases during the course of CRRT in the majority of patients. When the course of the disease starts to be complicated by sepsis, PTH serum levels then remain high. A probable reason for this is the existence of the inflammatory state triggered by sepsis

Infraclavicular access to the axillary vein — new possibilities for the catheterization of the central veins in the intensive care unit

  Central vein cannulation is one of the most commonly performed procedures in intensive care. Traditionally, the jugular and subclavian vein are recommended as the first choice option. Nevertheless, these attempts are not always obtainable for critically ill patients. For this reason, the axillary vein seems to be a rational alternative approach. In this narrative review, we evaluate the usefulness of the infraclavicular access to the axillary vein. The existing evidence suggests that infraclavicular approach to the axillary vein is a reliable method of central vein catheterization, especially when performed with ultrasound guidance.    Central vein cannulation is one of the most commonly performed procedures in intensive care. Traditionally, the jugular and subclavian vein are recommended as the first choice option. Nevertheless, these attempts are not always obtainable for critically ill patients. For this reason, the axillary vein seems to be a rational alternative approach. In this narrative review, we evaluate the usefulness of the infraclavicular access to the axillary vein. The existing evidence suggests that infraclavicular approach to the axillary vein is a reliable method of central vein catheterization, especially when performed with ultrasound guidance.

Porównanie wpływu indukcji znieczulenia ogólnego, opartej na małej dawce opioidu, z wykorzystaniem deksmedetomidyny i indukcji znieczulenia ze standardową dawką opioidu na reakcję wywołaną intubacją tchawicy u osób otyłych

  BACKGROUND: Anaesthesiologists are facing the problem of an increasing population of morbidly obese patients. In order to minimize the risk of opioid-induced postoperative respiratory failure, the intraoperative administration of opioids should be reduced or replaced with other drugs. The purpose of this study was to compare haemodynamic response elicited by intubation in morbidly obese patients between two variants of anaesthesia induction: fentanylbased or low-opioid using dexmedetomidine. METHODS: Forty-two morbidly obese patients scheduled for bariatric surgery were randomly assigned to two groups: low-opioid using dexmedetomidine (DEX) or fentanyl-based (FNT) anaesthesia. Patients were premedicated with 100 μg of fentanyl i.v. In the DEX group, a 10 minute infusion of a loading dose of 200 μg of dexmedetomidine was started. In the FNT group, 2 mg of intravenous midazolam was given. Thereafter, propofol was used in both groups. In the FNT group, patients received a dose of fentanyl up to 5 μg kg-1 of ideal body weight. Following administration of rocuronium, laryngoscopy and tracheal intubation were performed. Haemodynamic parameters, including systolic (SBP), diastolic (DBP) and mean arterial (MAP) blood pressure, as well as heart rate (HR), were recorded before and after intubation. Patients who were not intubated at first attempt were excluded from the study. RESULTS: Data from 33 patients were analysed. There were no statistically significant differences between the DEX and FNT groups regarding demographic data. Haemodynamic response to intubation was defined as mean change (d) in values of analysed parameters that occurred during intubation. The following differences were observed: dSBP FNT +11.6 mm Hg vs. DEX +0.4 mm Hg (P = 0.15); dDBP FNT +3.7 mm Hg vs. DEX +3.5 mm Hg (P = 0.98); dMAP FNT +8.6 mm Hg vs. DEX +1.4 mm Hg (P = 0.36); dHR FNT +2 beats min-1 vs. DEX −1 beat min-1 (P = 0.30). None of these comparisons yielded significant differences. CONCLUSIONS: The study revealed no advantage of fentanyl over low opioid dexmedetomidine-based induction of general anaesthesia in attenuating cardiovascular response to intubation in morbidly obese patients.    BACKGROUND: Anaesthesiologists are facing the problem of an increasing population of morbidly obese patients. In order to minimize the risk of opioid-induced postoperative respiratory failure, the intraoperative administration of opioids should be reduced or replaced with other drugs. The purpose of this study was to compare haemodynamic response elicited by intubation in morbidly obese patients between two variants of anaesthesia induction: fentanylbased or low-opioid using dexmedetomidine. METHODS: Forty-two morbidly obese patients scheduled for bariatric surgery were randomly assigned to two groups: low-opioid using dexmedetomidine (DEX) or fentanyl-based (FNT) anaesthesia. Patients were premedicated with 100 μg of fentanyl i.v. In the DEX group, a 10 minute infusion of a loading dose of 200 μg of dexmedetomidine was started. In the FNT group, 2 mg of intravenous midazolam was given. Thereafter, propofol was used in both groups. In the FNT group, patients received a dose of fentanyl up to 5 μg kg-1 of ideal body weight. Following administration of rocuronium, laryngoscopy and tracheal intubation were performed. Haemodynamic parameters, including systolic (SBP), diastolic (DBP) and mean arterial (MAP) blood pressure, as well as heart rate (HR), were recorded before and after intubation. Patients who were not intubated at first attempt were excluded from the study. RESULTS: Data from 33 patients were analysed. There were no statistically significant differences between the DEX and FNT groups regarding demographic data. Haemodynamic response to intubation was defined as mean change (d) in values of analysed parameters that occurred during intubation. The following differences were observed: dSBP FNT +11.6 mm Hg vs. DEX +0.4 mm Hg (P = 0.15); dDBP FNT +3.7 mm Hg vs. DEX +3.5 mm Hg (P = 0.98); dMAP FNT +8.6 mm Hg vs. DEX +1.4 mm Hg (P = 0.36); dHR FNT +2 beats min-1 vs. DEX −1 beat min-1 (P = 0.30). None of these comparisons yielded significant differences. CONCLUSIONS: The study revealed no advantage of fentanyl over low opioid dexmedetomidine-based induction of general anaesthesia in attenuating cardiovascular response to intubation in morbidly obese patients

The quality of recovery after erector spinae plane block in patients undergoing breast surgery: a randomized controlled trial

Abstract Background The erector spinae plane (ESP) block has recently been shown to effectively alleviate postoperative pain and reduce opioid consumption in breast surgery patients. However, data are still limited concerning the quality of recovery in patients following this procedure. Methods This study was a randomized controlled trial (RCT) performed in a university hospital. We randomly allocated patients to one of three groups: ESP, SHAM, and control (CON). Procedures in the ESP and SHAM blocks were performed ipsilaterally with 0.375% ropivacaine or 0.9% saline (0.4 mL/kg). Our primary outcome was the assessment of the patient’s improvement with quality-of-recovery 40 (QoR-40) a day after surgery. Other outcome assessments included postoperative pain evaluation on the visual analog scale (VAS), 24-hour opioid consumption with patient-controlled analgesia (PCA), time to the first opioid demand, and global satisfaction with perioperative treatment. Results Overall, patients in the ESP group had improved QoR-40 compared to the CON group, 186 [177–193] vs. 175 [165–183] (medians and interquartile ranges). Pain severity was significantly higher in the CON group compared to the ESP group at hours 2 (38 [23–53] vs. 20 [7–32]) and 4 (30 [18–51] vs. 19 [7–25]). Moreover, we observed lower oxycodone consumption after 24 hours with the PCA pump between the ESP (4 [2–8] mg) and the CON (9.5 [5–19]) groups. Patients in the CON group used PCA sooner than those in the ESP group. Participants in the ESP group were more satisfied with treatment than those in the CON group. We found no statistical difference between SHAM and the other groups. Conclusions Compared to the CON group, the ESP block improved the quality of recovery, alleviated pain intensity, and lowered opioid consumption in patients undergoing breast surgery. However, we did not observe this superiority in comparison with the SHAM group. Trial registration NCT04726878