Background Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone. Methods Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP. Results A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p = 0.92]. Conclusion In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries.

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Las mujeres embarazadas experimentan cambios fisiológicos e inmunológicos que les hacen más susceptibles a infecciones víricas o bacterianas por lo que se les ha considerado grupo vulnerable frente al SARS-CoV-2. Así mismo, pueden desarrollar una forma grave de la enfermedad que requiera finalizar la gestación para mejorar la situación respiratoria o para salvaguardar el bienestar fetal que puede verse afectado por el estado crítico de la madre. En este contexto, cualquier intervención demanda una minuciosa planificación por parte del equipo quirúrgico en general y del anestesiólogo en particular tanto para asegurar el bienestar materno-fetal como para evitar posibles contagios del personal sanitario. Describimos el caso de una gestante de 37 semanas ingresada en la Unidad de Reanimación con soporte ventilatorio mediante alto flujo por insuficiencia respiratoria severa debida a COVID-19 que precisa ser sometida a cesárea urgente.

Background: Effective treatment of acute high blood pressure in neurocritical diseases is a current recommendation of guidelines to reduce mortality and severe disability. Clevidipine is a calcium channel blocker that showed effectiveness and safety for acute high blood pressure control in neurocritical patients. Materials and methods: Retrospective, observational and cross-sectional study in adult patients admitted to Intensive Care Unit for neurocritical disease requiring surgical or interventional treatment and presenting acute high blood pressure requiring urgent treatment with clevidipine as first line or rescue therapy after failure of different intravenous antihypertensive drugs. Primary endpoint was effectiveness of clevidipine treatment. Secondary endpoint was safety of clevidipine treatment. Analysis of subgroups described patient and treatment variables on effectiveness and safety of clevidipine, mortality, functional situation and major neurologic complications. Hematoma expansion, rebleeding and vasospasm were specific neurological complications described. Comparisons was made using Fisher, chi-square, t or Mann Whitney U test. Significance was set at the 5% level. Analysis was made using IBM SPSS Statistics 23.0 Results: thirty-three patients admitted to Intensive Care Unit fulfilled inclusion criteria and were included. Clevidipine showed a higher effectiveness and safety for acute high blood pressure control in our patients. Effectiveness was higher in patients with larger brain hematomas and severe aneurysmal subarachnoid hemorrhages treated with first line and early began of clevidipine within 24 hours of admission. Adverse events were mild, transient and more frequent in patients with first line treatment. Early and effective treatment were safe with lower major neurological complications. Mortality was lower in patients with first line and effective treatment. Hematoma expansion was seen in a higher number of patients. Rebleeding and vasospasm were less frequent. Conclusion: Clevidipine was effective and safe treatment of acute high blood pressure in neurocritical patients. Severity of neurocritical disease is a key factor but early and effective treatment could contribute to reduce mortality and major neurological complications. Nevertheless, our results need to take with caution because little size and design of our study. Trial registration: NCT05168059