Search Results (73)

Sedation and anesthesia are integral components of modern gastrointestinal endoscopy, enhancing patient comfort and procedural success while adding risks such as respiratory and cardiovascular complications. Accurate monitoring of sedation depth is essential to balance safety and procedural efficacy. This narrative literature review synthesizes current evidence on monitoring depth of anesthesia during endoscopic procedures, including clinical assessment scales, capnography, and processed electroencephalogram (pEEG)-based technologies. The effects of commonly used sedative agents on monitoring parameters and the impact of different monitoring strategies on clinical outcomes are also discussed. Current evidence indicates that clinical assessment remains the cornerstone of monitoring during moderate sedation, while capnography improves early detection of respiratory compromise during deep sedation. pEEG-based monitoring may provide additional value in selected high-risk or prolonged procedures but should complement, not replace, clinical evaluation. A multimodal monitoring approach tailored to sedation depth and patient risk profile is likely to be the most effective strategy for optimizing patient safety. Future research should focus on standardizing monitoring protocols and identifying populations most likely to benefit from advanced monitoring techniques. Full article

Background: Delirium is a frequent and serious complication in intensive care units (ICUs), associated with increased mortality, prolonged mechanical ventilation, extended length of stay, and long-term cognitive impairment. This study aimed to assess ICU nurses’ knowledge and practices regarding delirium management in Cyprus and to identify predictors of knowledge. Methods: A cross-sectional study was conducted among nurses working in adult ICUs in Cyprus. Data were collected using a structured self-administered questionnaire that included demographic characteristics, sedation and analgesia practices, and an adapted Delirium Knowledge Questionnaire incorporating ICU-specific items. Results: A total of 70 ICU nurses participated, most of whom were female (60%) with a mean ICU experience of 5.1 years. Only 27.1% reported daily delirium screening, although 65.2% perceived delirium as frequent. Sedation protocols were reported by 34.3%, sedation scales were used by 44.3%, and daily sedation interruption by 61.4%. Only 15.7% had received formal delirium training, while 87.1% expressed the need for further education. Knowledge scores were moderate to high (68.5–84.0%), with higher scores among nurses with prior training and female nurses (p = 0.003). Hospital type was associated with sedation practices, with greater use of sedation scales in public ICUs (p < 0.001) and propofol more commonly used as first-line sedation compared with midazolam in private ICUs (p = 0.018). Conclusions: Although ICU nurses demonstrated moderate knowledge of delirium, systematic screening and protocolized management remain suboptimal. Structured education and standardized implementation strategies are required to strengthen patient safety in critical care settings. Full article

The objective of this study was to evaluate, in client-owned dogs, the postoperative analgesic efficacy of the centrally acting analgesic tramadol following femoral head and neck excision (FHNE). Thirty-eight dogs were diagnosed with coxofemoral disease and underwent FHNE. The sample was randomly divided into two groups. Postoperatively, dogs in Group A received robenacoxib (2 mg kg⁻¹ bodyweight, sid, per os) until they achieved final weight-bearing of the operated limb, whereas dogs in Group B received the same regimen of robenacoxib in combination with tramadol (5 mg kg⁻¹ bodyweight, tid, per os) for fifteen days. All animals were premedicated, sedated, and anesthetized following the same standardized protocol to ensure consistency between groups. Postoperative evaluations were conducted on days 15 and 30, and subsequently at monthly intervals, until full weight-bearing of the affected limb was achieved. Clinical assessments included observation of pain-related behaviors, lameness scoring, and time to initial weight-bearing (TIWB) and time to final weight-bearing (TFWB). Data normality was assessed using the Shapiro–Wilk test, and differences between groups were evaluated using the independent samples T-test (p = 0.05). Statistical analysis revealed no significant differences between the two groups regarding time to initial (p = 0.087) or final weight-bearing. However, a moderate effect size (d = 0.570) was observed for TIWB, suggesting a clinically interesting trend toward faster early recovery in the multimodal group. These findings indicate that while adding tramadol did not confer a statistically significant additional advantage in this study, the observed clinical trend warrants further investigation in larger, higher-powered cohorts to determine its definitive clinical impact. Full article

Background/Objectives: Behavior management is a major challenge in pediatric dentistry, particularly during the first dental visit, when anxiety, fear, and negative expectations can compromise cooperation and clinical outcomes. While evidence-based behavior guidance techniques are well established, their effectiveness depends on early identification of behavioral risk and individualized planning. This study aimed to develop and clinically evaluate a parent-completed digital pre-visit tool to support individualized behavior management and targeted use of digital distraction in pediatric dentistry. Methods: A web-based application was developed using HTML, CSS, and JavaScript. It was applied to a prospective observational cohort of 90 pediatric patients aged 4–8 years (mean 6.1 ± 1.2), including 48 girls and 42 boys. Parents completed a pre-visit questionnaire covering four domains: child’s age, previous dental experiences, reactions to unfamiliar situations, and individual interests, including stimuli to avoid. Based on predefined decision rules, the tool generated recommended clinical approaches, including behavior guidance techniques, digital distraction, and inhalation sedation. Results: Over 90% of children were successfully managed during their first visit. Children in low- and moderate-risk groups had significantly higher odds of treatment success compared to high-risk children. Low-risk children almost universally completed treatment at the first visit, while a substantial portion of moderate-risk children were successfully managed without an adaptation visit. Digital distraction, particularly when tailored to individual interests, enhanced cooperation and tolerance of procedures. Conclusions: The digital pre-visit tool enables early identification of behavioral risk and supports targeted application of digital distraction and sedation. This approach can improve child cooperation, reduce anxiety, optimize clinical efficiency, and contribute to positive early dental experiences. Full article

Background: 22q11.2 deletion syndrome (22q11.2 DS) is a rare genetic syndrome characterized by high phenotypic variability, with an incidence of approximately 1:4000 live births. Most of the existing literature consists of case reports or case series, making it challenging to obtain large cohorts for data comparison and drawing generalizable conclusions. Aim: The aim of this article is to share the clinical experience of patients with 22q11.2 DS who were previously evaluated by Child Neuropsychiatry and underwent odontoiatric procedures at the Dental Unit of the Policlinico di Bari. Methods: We report three clinical cases of pediatric patients with 22q11.2 DS who were managed at the University Dental Unit of the Policlinico di Bari for dental procedures, including pre/post-treatment images and child neuropsychiatric characteristics. Results: Cleft lip and cleft palate are the most commonly encountered facial malformations. Enamel hypoplasia and hypomineralizations, caries, dental agenesis, and hypodontia are reported with variable frequency in almost all studies considering the oral health of these patients. Our experience is coherent with the data present at the moment. The clinical examinations showed diffuse hypomineralization and several caries, concordant with the literature. One patient received moderate sedation and another received general anesthesia; oral prophylaxis, fluoride application, pulp therapy, extractions of hopeless teeth and restorations of carious and hypomineralized teeth were performed. Conclusions: 22q11.2 DS is a genetic condition with a variable prognosis, but current trends show that patients often reach adulthood, primarily due to advancements in cardiology, which was previously the leading cause of mortality in these patients. From this perspective, collaboration among various medical specialties is crucial to implement holistic patient management programs and early interventions. Full article

Effective pain management is central to anesthesia, critical care, and perioperative medicine, and opioids remain essential agents for moderate-to-severe pain despite ongoing concerns regarding their safety and misuse. This narrative review synthesizes the current knowledge on opioid mechanisms, clinical indications, safety considerations, and evolving strategies aimed at optimizing their use. Opioids exert their analgesic effects primarily through μ-, δ-, and κ-opioid receptors, which modulate central and peripheral nociceptive pathways. They maintain a well-established role in acute postoperative and cancer-related pain, whereas their use in chronic non-cancer pain remains controversial. Contemporary evidence suggests that physiological dependence and addiction are less frequent in appropriately selected and monitored patients, although the risk increases in the presence of psychological comorbidity, prior substance use, or adverse social determinants of health. Unequal access, prescribing variability, and persistent disparities further complicate global opioid management strategies. Recent advances, including partial agonists such as buprenorphine, dual-mechanism agents such as tapentadol, individualized titration, opioid rotation, and the integration of multimodal analgesia, support safer and more tailored prescribing. Non-pharmacological interventions, including behavioral and physical therapies, increasingly complement pharmacological strategies to minimize opioid exposure and improve functional outcomes. Clinicians must balance analgesic efficacy with adverse effects, such as tolerance, opioid-induced hyperalgesia, sedation, and respiratory depression, particularly in perioperative and critically ill populations. Opioids remain indispensable for selected indications but should be incorporated into a comprehensive, patient-centered, multimodal analgesic approach that prioritizes safety, ongoing reassessment, and individualized risk mitigation. Full article

In acute respiratory distress syndrome (ARDS), spontaneous breathing is often encouraged to preserve lung function, yet excessive patient-generated inspiratory effort can paradoxically worsen injury, a phenomenon termed patient self-inflicted lung injury (P-SILI). In mechanically heterogeneous lungs, uncontrolled effort amplifies regional stress, strain, and mechanical power, driving alveolar overdistension, cyclic recruitment–derecruitment, pendelluft, and inflammation. Cardiovascular consequences include elevated right ventricular afterload, impaired left ventricular filling, and exacerbation of pulmonary edema. While moderate spontaneous breathing may improve aeration in mild injury, evidence shows that vigorous effort in severe ARDS accelerates histological damage and regional lung stress. Early bedside assessment of respiratory drive and inspiratory effort identifies patients at highest risk, enabling targeted interventions. Strategies to preserve protective spontaneous breathing while limiting injurious effort include individualized positive end-expiratory pressure, titrated sedation, prone positioning, and short-term neuromuscular blockade. By integrating continuous physiological monitoring with personalized ventilatory management, clinicians can mitigate P-SILI, protect the diaphragm, and optimize outcomes. Future studies are needed to test physiology-guided interventions and establish evidence-based approaches to safely harness the benefits of spontaneous breathing in ARDS. Full article

Opioids play a central role in pain management and sedation in Intensive Care Units (ICUs), where critically ill patients frequently experience moderate-to-severe pain due to illness and invasive procedures or devices. Uncontrolled pain exacerbates stress responses, contributing to clinical deterioration and adverse outcomes. Although analgesics and sedatives can mitigate these effects, their use must be carefully individualized to avoid complications such as delirium, prolonged mechanical ventilation, and increased mortality. Evidence now shows that excessive or poorly controlled analgosedation can prolong ICU length of stay and delay recovery. Current guidelines recommend opioids as first-line agents for severe acute pain in the ICU, preferably within a multimodal analgesia framework to optimize pain control while minimizing adverse effects. Opioids are also essential for improving tolerance to invasive and noninvasive mechanical ventilation. Modern ICU practice emphasizes an analgesia-first or “analgosedation” strategy, prioritizing pain control with intravenous opioids before adding sedatives. This approach aims to achieve light sedation, reduce ventilator days, and improve overall outcomes. Commonly used opioids include fentanyl, morphine, hydromorphone, sufentanil, and remifentanil, with short-acting agents favored when rapid titration is required. Our narrative review aims to evaluate the clinical impact of opioid use in critically ill patients, including post-ICU outcomes, and to explore the role of opioid stewardship in optimizing patient care. Full article

Background: Long-term cognitive impairment is common among ICU patients who required invasive mechanical ventilation (IMV). Its etiology is likely multifactorial. This preregistered study examined the association between the duration of IMV and cognitive function post-ICU, as well as the moderating effects of age and cognitive reserve. Methods: A secondary analysis was conducted using data from a published study of COVID-19 ICU survivors. One year after discharge, participants underwent a neuropsychological assessment. Linear regression models were used to evaluate associations between the variables. Results: Among patients who received IMV via endotracheal intubation, ventilation duration was not significantly associated with cognitive performance. In contrast, among tracheostomized patients, longer IMV duration was associated with better cognitive outcomes (Cohen’s f² = 0.21). Age had a small negative main effect; in combination with IMV duration, f² increased to 0.31. Cognitive reserve showed a strong positive association with cognitive outcome; in combination with IMV duration, f² increased to 0.67. The interaction terms were negligible in both cases. Conclusions: We hypothesize that, compared to endotracheal intubation, IMV via tracheostoma may not only reduce the need for sedation, but also provide a more efficient respiratory support, therefore contributing to positive cognitive outcomes. However, IMV via tracheostomy still represents a form of positive pressure ventilation (PPV), which carries risks, such as ventilator-induced lung injury and reduced cardiac output and brain perfusion. These concerns about PPV, combined with our findings, indicate that alternative, non-invasive modes, such as negative pressure ventilation (NPV), warrant evaluation in future trials. Full article

Background/Objectives: Flexible bronchoscopy (FB) enables airway exploration and diagnosis of various respiratory pathologies, but the sedation and instrumentation required during the procedure raise oxygen demand while reducing ventilation, which can lead to hypoxemia. Conventional oxygen therapy (COT) may not adequately prevent desaturations in high-risk groups, as patients with moderate respiratory deficiency. High-flow nasal cannula (HFNC) can deliver heated, humidified oxygen at high flow rates, generating low-level positive airway pressure, improving oxygenation, reducing dead-space, and enhancing procedure tolerance. Prior studies have shown that HFNC can improve gas exchange and reduce desaturations during bronchoscopy. However, evidence remains limited for patients with moderate respiratory deficiency, who are particularly vulnerable. Evaluating the feasibility and safety of HFNC in this population is essential to guide safe procedural practice. Methods: A retrospective observational study including patients undergoing FB with HFNC support between January and May 2025. Inclusion criteria were BMI between 18 and 30; age > 18 years old; moderate respiratory dysfunction, defined by pulse oximetry, Pulmonary Functional Tests (PFTs) and Arterial Blood Gas (ABG) analysis. Exclusion criteria were intolerance/contraindication to HFNC. Procedures were performed under basic monitoring. Primary outcome was occurrence of severe hypoxemia (SpO2 < 90%). Secondary outcomes were needed for rescue maneuvers, interruption for conversion to other ventilatory strategies, and hemodynamic instability. Results: No severe desaturations were recorded, all procedures were completed without rescue maneuvers or other ventilatory strategies, and no hypoxemia occurred. Mean duration of the procedure was 9 min. Vital parameters were maintained within the normal ranges, with a mean SpO₂ during bronchoscopy of 98%. Conclusions: HFNC enables oxygenation and ventilation without adverse events in sedations for FB in patients with moderate respiratory deficiency. Full article

Background: Delirium is a common complication in patients receiving extracorporeal membrane oxygenation (ECMO), but its prevalence and determinants remain uncertain due to variable clinical practices. We conducted a systematic review and meta-analysis to estimate the pooled prevalence of delirium in ECMO-supported patients, evaluate the influence of diagnostic tools and ECMO modality, and synthesize evidence on associated risk factors and outcomes. Methods: We systematically searched PubMed, Embase, and Web of Science up to May 2025 for studies reporting delirium prevalence in adult ECMO patients. Subgroup analyses were stratified by ECMO modality and delirium assessment tool. Meta-regression was performed to explore potential moderators. Publication bias was assessed visually using funnel plots and statistically using Egger’s and Begg’s tests via the metabias command. Results: Thirteen studies involving 8679 adult ECMO patients were included. The pooled prevalence of delirium was 40.54% (95% CI: 23.01–58.06%), with substantial heterogeneity (I² = 98%; τ² = 0.29; p < 0.01). Subgroup prevalence was 56.83% (95% CI: 41.52–72.14%) for VA-ECMO, 32.84% (95% CI: 3.39–62.29%) for VV-ECMO, and 37.24% (95% CI: 13.71–60.77%) for mixed cohorts; differences were not statistically significant. Delirium prevalence varied by assessment tools, ranging from 57% with NuDESC to 7% with ICD-10 coding. Meta-regression showed a negative but non-significant association between sample size and delirium prevalence (β = −0.000049; p = 0.088). Sensitivity analyses confirmed the robustness of pooled estimates. Conclusions: Delirium affects a substantial proportion of ECMO-supported patients and is linked to considerable clinical and neurocognitive morbidity. The marked heterogeneity in prevalence reflects differences in diagnostic tools and clinical management practices, including sedation strategies. These findings underscore the urgent need for standardized, ECMO-specific delirium assessment protocols and proactive prevention strategies. Well-designed prospective studies with uniform methodologies and long-term follow-up are essential to clarify the trajectory and impact of delirium in this high-risk population. Full article

Background and Objectives: Analgesia and sedation are a major challenge in pediatric intensive care. The COMFORT-B scale and the Bispectral Index (BIS) are commonly used to assess the degree of sedation. The aim of this study was to investigate the correlation between the COMFORT-B and BIS and to evaluate the predictive validity of the BIS scale. Materials and Methods: Mechanically ventilated children (n = 41) diagnosed with acute bronchiolitis and treated with fentanyl and midazolam were included in the study. COMFORT-B and BIS scores were recorded over a 7-day observation period. Patients were divided into subgroups based on chronological age, neuromuscular blocker use, and level of sedation. Statistical analyses included correlation analysis by subject and time, simple moving average trend analysis, linear mixed-effects modeling and random forest. Results: Conventional correlation analysis revealed a weak to moderate correlation between the two scales in the entire cohort (Spearman rho of patients’ means 0.42, p = 0.007). The longitudinal correlation analysis by individual patient showed no significant relationship between the two scales in the entire cohort (CCF 0-lag 0.23; p = 0.33) or any subgroup. Linear mixed-effects model analysis showed that BIS score was associated with COMFORT-B score (slope = 0.799, p = 0.0002). The random forest model explained 19.6% of the variance. Both models yielded similar prediction errors (RMSE 10.6 and 11.3, respectively). Conclusions: We found a weak correlation between the two scales, which does not allow for reliable and valid predictions between the two scales. The BIS scale is suitable for the assessment of deep sedation, whereas the COMFORT-B scale is suitable for the assessment of moderate sedation. Full article

Background: Renal allograft biopsy is essential in the follow-up of pediatric kidney transplant recipients, but the optimal sedation strategy remains uncertain. Methods: We retrospectively reviewed 711 ultrasound-guided biopsies in 251 children and adolescents (2009–2024), comparing oral conscious sedation with midazolam to deep intravenous (IV) sedation with propofol, midazolam, and ketamine. Outcomes included tissue yield, diagnostic success, complications, and cost-effectiveness. Results: IV sedation was used in 77.1% of procedures and was associated with longer cortical cores (median 1.8 vs. 1.5 cm, p < 0.001) and more glomeruli (16 vs. 8, p < 0.001), improving tissue yield and consequently increasing diagnostic success from 75% to 88.5% (p < 0.001; OR 2.6). Biopsy-related complications occurred in 12.9% of cases, with no difference between groups. Sedation-related complications, all mild or moderate, occurred only with IV sedation (4.9%). The improved tissue yield reduced the cost per successful diagnosis (EUR 1243 vs. EUR 1467), making IV sedation the dominant strategy. Conclusions: IV sedation enhances the diagnostic quality and cost-effectiveness of pediatric kidney allograft biopsies without increasing overall risk, though prospective studies should also assess patient anxiety and comfort. Full article

Remifentanil is a potent opioid characterized by a unique pharmacokinetic profile that makes it well-suited for analgesia in obstetrics. When administered in a patient-controlled analgesia (PCA) modality, remifentanil has become a recognized and versatile alternative for labor pain relief in cases where epidural analgesia is contraindicated or is declined by the parturient. It offers mild to moderate pain relief, effectively decreasing pain from severe levels to a more manageable, moderate intensity. Remifentanil can be administered promptly and acts quickly, making it particularly useful in rapidly progressing or advanced labor. It can also benefit women with anxiety or tokophobia, as its sedative, anxiolytic, and euphoric effects help reduce pain perception and facilitate coping during labor. While it is not superior to epidural analgesia in terms of analgesic efficacy, remifentanil-PCA has obtained a role as a complementary pain-relieving option in several obstetric situations. Remifentanil-PCA is associated with high patient satisfaction, which is closely linked to realistic counseling and proper expectation management. The safety profile for both mother and neonate has been established; however, safety depends on cautious incremental dosing tailored to sedation levels, the use of supplemental oxygen, rigorous monitoring, and avoiding background infusion. Vigilant supervision by healthcare providers is essential, ideally supported by the continuous presence of an anesthesia team in the labor ward. Full article

Background/Objectives: Post-intensive care syndrome (PICS) includes new or worsening physical, cognitive, and mental impairments following intensive care unit (ICU) admission. However, its predictors remain poorly defined. This study aimed to identify the predictors of PICS among ICU survivors 30 days after discharge. Methods: This prospective, monocentric, observational study was conducted from September 2023 to March 2024. Adult ICU survivors were assessed using the Healthy Ageing Brain Care Monitor to evaluate their physical, cognitive, and mental dimensions. The predictors included age, sex, coma, sedation, clinical severity (APACHE score), risk of ICU delirium (PREDELIRIC score), infection, hospital length of stay, and mechanical ventilation duration. Multivariate linear regression was used to identify independent predictors (p < 0.05). Results: A total of 90 ICU survivors were enrolled in the study. Higher clinical severity (B = 0.17, p = 0.001) and high delirium risk (PREDELIRIC score: B = 3.11, p = 0.007) were associated with worse cognitive PICS. Functional PICS was predicted by clinical severity (B = 0.36, p = 0.002) and moderate delirium risk (PREDELIRIC score: B = 7.12, p = 0.009). Behavioural PICS was inversely associated with coma (B = −6.74, p = 0.023) but positively associated with sedation (B = 7.64, p = 0.013) and moderate delirium risk (B = 2.24, p = 0.031). Conclusions: Clinical severity, PREDELIRIC score, sedation, and coma were significant predictors of PICS subdomains. Multidisciplinary teams may be more effective by prioritising targeted screening to identify ICU survivors at elevated risk for PICS using validated predictors such as clinical severity and the PREDELIRIC score, and delivering focused interventions to those most likely to benefit. Full article