Monitoring of tissue perfusion is an essential step in the management of acute circulatory failure. The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension. Monitoring of tissue perfusion includes biomarkers of global tissue perfusion and measures for assessment of perfusion in non-vital organs.The presence of poor tissue perfusion in a shocked patient is usually associated with worse outcome. Persistently impaired perfusion despite adequate resuscitation is also associated with worse outcome. Thus, normalization of some perfusion indices has become one of the resuscitation targets in patients with septic shock.Although the collective evidence shows the clear relation between impaired peripheral perfusion and mortality, the use of different perfusion indices as a resuscitation target needs more research.

This randomised, controlled, double-blind study investigated the effects of different doses of perineural dexmedetomidine on the pharmacodynamic profile of femoral nerve block in patients undergoing arthroscopic knee surgery. Ultrasound-guided femoral nerve block was performed before general anaesthesia using 25 ml of bupivacaine 0.5% combined with normal saline in the control group, and 25 μg, 50 μg or 75 μg of dexmedetomidine in three treatment groups (n = 15 for each group). All patients received a standard general anaesthetic and multimodal postoperative analgesic regimen. The use of the 50 μg and 75 μg dose levels of dexmedetomidine was associated with reduction of the onset time, extension of the duration of block, prolonged time to the first postoperative request for rescue analgesia, and reduced postoperative morphine requirements. The times to first request for postoperative analgesia were mean (SD) 10.8 (1.6) h in the control group and 11.0 (7.1), 21.8 (3.0) and 28.6 (10.0) in the 25 μg, 50 μg and 75 μg treatment groups, respectively. These times were significantly longer in the 50 μg and 75 μg treatment groups compared with the 25 μg (p < 0.0001) and control group (p < 0.0001). The total 24-h postoperative morphine consumption was 7.6 (5.1) mg in the control group, and 6.5 (3.5), 3.9 (3.4), 1.8 (2.6) in the 25 μg, 50 μg and 75 μg treatment groups, respectively. Postoperative morphine consumption was significantly higher in the control group compared with the 50 μg (p = 0.045) and the 75 μg (p = 0.001) treatment groups. The best analgesic profile was achieved at the 75 μg dose, but this was associated with increased risk of hypotension.

No abstract

Background: This study aimed to investigate the analgesic efficacy and motor block profile of single-shot transmuscular quadratus lumborum block (QLB) in comparison with those of suprainguinal fascia iliaca block (FIB) in patients undergoing hip arthroplasty. Methods: This randomized, double-blinded, controlled trial included adult patients undergoing hip arthroplasty under spinal anesthesia. Patients were allocated to one of two groups according to the regional block received: FIB group (n=19) or QLB group (n=17). Both study groups were compared with regard to the duration of analgesia (primary outcome), block performance time, pain during positioning for spinal anesthesia, total morphine consumption in the first postoperative 24-h period, quadriceps muscle power, and static and dynamic visual analog scale. Results: Thirty-six patients were included in the final analysis. Both study groups had comparable durations of analgesia. Postoperative visual analog scale (static and dynamic) values were comparable between the two groups in most readings. The block performance time was shorter in the FIB group. The number of patients with pain during positioning for the subarachnoid block was lower in the QLB group. The total morphine requirement during the first 24 h was marginally lower in the FIB group, whereas the quadriceps motor grade was higher in the FIB group than in the QLB group at 4 h and 6 h after surgery. Conclusion: Both single-shot blocks, namely the suprainguinal FIB and transmuscular QLB, provide effective postoperative analgesia after hip arthroplasty. FIB showed slightly lower 24-h morphine consumption, while QLB showed better quadriceps motor power. Clinical Trial Registration: The study was registered at clinical trials registry system before enrollment of the first participant (NCT04005326; initial release date, 2 July 2019; https://clinicaltrials.gov/ct2/show/NCT04005326).

Introduction: Ventilator-associated pneumonia [VAP] is associated with increased morbidity and mortality especially when caused by extensive drug resistant [XDR] pathogens. Till now, little is known regarding the exact pathogenesis of XDR Acinetobacter baumannii [XDR-AB] infection. The aim of the present study was to identify prevalence and risk factors for VAP caused by XDR-AB in our intensive care unit, and to test the susceptibility pattern of tigecycline, carbapenems, and Colistin among the isolates. Methods: A prospective cohort study was conducted to enroll patients who developed VAP over 18-month period. All possible risk factors were documented as well as patient outcome. Susceptibility testing for the isolates was performed using inhibitory concentrations [MICs] determined by Epsilometer tests (E-tests) to Carbapenems, Tigecycline, and Colistin. Results: Among 544 consecutive patients admitted to our ICU during 18 months, Forty-seven patients developed VAP. The prevalence of XDR-AB was 63.8% (30 patients). No specific factor was associated with increase of the risk of acquisition of AB-VAP in our cohort either by univariate or by multivariate analysis. Carbapenems showed poor activity against all isolates [MIC range 10-128 mg/L]. Tigecycline showed good activity against only 15 isolates [MIC range 0.25-2 mg/L]. Colistin demonstrated potent in vitro activity against all isolates of AB [MIC range 0.016-1 mg/L]. Conclusions: XDR AB-VAP is endemic in our ICU without a definite factor associated with increased risk of infection. Given that almost half of the strains are also resistant to tigecycline, colistin appears to be an appropriate first-line antimicrobial drug in critically ill patients developing VAP based on invitro results.