Among critically ill patients with acute pancreatitis, mortality at 30 days was lower in patients who received epidural analgesia than in comparable patients who did not. These findings support ongoing research on the use of epidural analgesia as a therapeutic intervention in acute pancreatitis.

Editor-Some case reports have suggested the use and efficacy of sugammadex during rocuronium-induced anaphylactic shock. 1-3 This was associated with rapid restoration (under 2 min) of the clinical signs of shock. We report a case who required a longer resuscitation after similar treatment. The patient gave approval to publish the case. A female patient of 65 yr age, 70 kg, 1.60 m was to undergo a colectomy for adenocarcinoma. Her medical history included previous hysterectomy, and ventricular extrasystoles treated with flecainide (stopped the morning of surgery). She gave no history of any allergies. The day before the surgery, she received an oral premedication with hydroxyzine 50 mg. Routine monitoring was used and the variables were recorded every 5 min. On arrival in the operating theatre, the baseline observations were: arterial pressure (AP) 145/96 mm Hg, heart rate (HR) 78 beats min 21 , and oxygen saturation (Sp O 2) 99%. General anaesthesia was induced with midazolam (2 mg), sufentanil 25 mg (0.35 mg kg 21), propofol 150 mg (2.2 mg kg 21), and ketamine 20 mg (0.3 mg kg 21). Rocuronium 50 mg (0.7 mg kg 21) was then administered to facilitate tracheal intubation. No antibiotic was administered. Two minutes after receiving rocuronium, the patient developed sinusal tachycardia (130 beats min 21), hypotension (65/45 mm Hg), hypocapnia, bronchospasm, and oxygen desaturation (92%). Airway pressures increased. These clinical signs suggested a rocuronium-induced, grade II anaphylactic reaction. The patient was treated with oxygen 100%, i.v. epinephrine 100 mg and 10 mg (repeated 10 times), and a rapid infusion of 1000 ml Ringer's lactate solution. Thirteen minutes after appearance of the first clinical signs of anaphylaxis, and despite these treatment, AP was not measurable. With evolution to a grade III anaphylactic reaction, we increased the intermittent bolus dose of epinephrine to 100 mg and administered an i.v. bolus of sugammadex 1000 mg (14 mg kg 21). The train-of-four count increased from 0/4 to 4/4 over 1 min. In a 7 min period after sugammadex administration, the patient was still being treated with i.v. epinephrine 100 mg ×3 and rapid infusion of 500 ml 0.9% NaCl and 500 ml hydroxyethylamidon. Ten minutes after sugammadex, the haemodynamic variables were: HR 118 beats min 21 , AP 47/28 mm Hg, Sp O 2 no trace, FE ′ CO 2 2 kPa. The inflation pressures remained high. The clinical improvement from the signs of anaphylaxis was seen after two boluses of epinephrine 1 mg. Fifteen minutes after sugammadex injection, haemodynamics parameters were: HR 115 beats min 21 , AP 85/35 mm Hg, Sp O 2 92%, FE ′ CO 2 4 kPa. The inflation pressures decreased. Continuous epinephrine was then given at 2 mg h 21 until tracheal extubation 2 h later. Surgery was deferred. The patient made an uncomplicated recovery and was informed that a likely anaphylactic reaction had occurred during anaesthesia.

Background Hypotension and blood pressure (BP) variability during endovascular therapy (EVT) for acute ischemic stroke (AIS) due to an anterior large vessel occlusion (LVO) is associated with worse outcomes. However, the optimal BP threshold during EVT is still unknown given the lack of randomized controlled evidence. We designed the DETERMINE trial to assess whether an individualized BP management during EVT could achieve better functional outcomes compared to a standard BP management. Methods The DETERMINE trial is a multicenter, prospective, randomized, controlled, open-label, blinded endpoint clinical trial (PROBE design). AIS patients with a proximal anterior LVO are randomly assigned, in a 1:1 ratio, to an experimental arm in which mean arterial pressure (MAP) is maintained within 10% of the first MAP measured before EVT, or a control arm in which systolic BP (SBP) is maintained within 140–180 mm Hg until reperfusion is achieved or artery closure in case of EVT failure. The primary outcome is the rate of favorable functional outcomes, defined by a modified Rankin Scale (mRS) between 0 and 2 at 90 days. Secondary outcomes include excellent outcome and ordinal analysis of the mRS at 90 days, early neurological improvement at 24 h (National Institutes of Health Stroke Scale), final infarct volume, symptomatic intracranial hemorrhage rates, and all-cause mortality at 90 days. Overall, 432 patients will be included. Discussion DETERMINE will assess the clinical relevance of an individualized BP management before reperfusion compared to the one size fits all approach currently recommended by international guidelines. Trial registration ClinicalTrials.gov, NCT04352296. Registered on 20th April 2020.

Background Therapeutic failure is a frequent issue in the management of post-operative peritonitis. Objectives A post hoc analysis of the prospective, multicentre DURAPOP trial analysed the risk factors for failures in post-operative peritonitis following adequate source control and empirical antibiotic therapy in critically ill patients. Patients and methods Overall failures assessed post-operatively between Day 8 and Day 45 were defined as a composite of death and/or surgical and/or microbiological failures. Risk factors for failures were assessed using logistic regression analyses. Results Among the 236 analysed patients, overall failures were reported in 141 (59.7%) patients, including 30 (12.7%) deaths, 81 (34.3%) surgical and 95 (40.2%) microbiological failures. In the multivariate analysis, the risk factors associated with overall failures were documented piperacillin/tazobactam therapy [adjusted OR (aOR) 2.10; 95% CI 1.17–3.75] and renal replacement therapy on the day of reoperation (aOR 2.96; 95% CI 1.05–8.34). The risk factors for death were age (aOR 1.08 per year; 95% CI 1.03–1.12), renal replacement therapy on reoperation (aOR 3.95; 95% CI 1.36–11.49) and diabetes (OR 6.95; 95% CI 1.34–36.03). The risk factors associated with surgical failure were documented piperacillin/tazobactam therapy (aOR 1.99; 95% CI 1.13–3.51), peritoneal cultures containing Klebsiella spp. (aOR 2.45; 95% CI 1.02–5.88) and pancreatic source of infection (aOR 2.91; 95% CI 1.21–7.01). No specific risk factors were identified for microbiological failure. Conclusions Our data suggest a predominant role of comorbidities, the severity of post-operative peritonitis and possibly of documented piperacillin/tazobactam treatment on the occurrence of therapeutic failures, regardless of their type.