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About 20% of Covid-19 patients develop acute respiratory distress syndrome (ARDS), with mortality ranging from 20 to 50%. Since the publication of the PROSEVA study [1], prone positioning (PP) has become a cornerstone of management of mechanically ventilated severe ARDS patients. Lung recruitability in SARS-CoV-2 associated acute respiratory distress syndrome: a single-center, observational study. Influence of positive end-expiratory pressure titration on the effects of pronation in acute respiratory distress syndrome: a comprehensive experimental study.

Background Quality of life (QoL) is a multifactorial concept that assesses physical and mental health. We prospectively studied the quality of life of patients undergoing coronary artery bypass graft (CABG) surgery using the Short-Form 36-item questionnaire (SF-36) up to 10 years after surgery. Methods Between January 2000 and December 2002, all patients undergoing elective isolated CABG in the cardiac & thoracic surgery department of a large university hospital in Eastern France underwent initial QoL evaluation with the SF-36. The same questionnaire was mailed to every patient annually (± 2 weeks around the date of surgery) up to 10 years after their operation. We recorded socio-demographic and clinical variables at inclusion. Predictors of impaired QoL at 10 years were identified by logistic regression. Results A total of 272 patients (213 men, 59 women) were enrolled; mean age at inclusion was 65 ± 10 years. At 10 years post-surgery, 81 patients had died (29.7%). The physical component summary (PCS) score was significantly higher at 5 years after surgery than at baseline ( p  < 0.01), and significantly lower at 10 years than at 5 years (p < 0.01), although there remained a significant difference between 10-year PCS and baseline score ( p  = 0.004). The mental component summary (MCS) score was significantly higher at 5 years than at the time of surgery ( p  < 0.001), and remained significantly higher compared to baseline at 10 years after surgery ( p  = 0.010). By multivariate analysis, diabetes and dypsnea were both associated with worse PCS at 10 years, while lower age was associated with better 10-year PCS. Only diabetes was associated with impaired MCS at 10 years. Conclusions Cardiac surgery appears to durably and positively affect both physical and mental components of quality of life.

IntroductionIntraoperative complications contribute significantly to morbidity and mortality, and reducing their risk is a primary objective for all operating room’s healthcare professionals. Many of these complications are predictable and could be anticipated by the surgeon or anaesthesiologist. Various clinical scores were developed to assess cardiovascular risk, acute kidney injury or acute respiratory failure preoperatively. However, these scores require time for calculation and are not designed to be adjusted in real time during surgery, based on physiological signals and new intraoperative events. Besides, some events remain unpredictable because they are multifactorial.In recent decades, Artificial Intelligence (AI)-based algorithms have been tested for the real-time prediction of intraoperative complications. These algorithms have the potential to continuously analyse patient data and provide early warnings, enabling professionals to intervene more effectively.The aim of this review is to address the question: ‘What is the performance of AI models in predicting intraoperative complications during surgery using baseline and real-time data?’.Methods and analysisThe review will follow the Transparent Reporting of multivariable prediction models for Individual Prognosis or Diagnosis: Checklist for Systematic Reviews and Meta-Analyses and BMJ guidelines. MEDLINE, Embase, CENTRAL (Cochrane), IEEE Xplore and Google Scholar databases will be explored for peer-reviewed papers up to 25 March 2025. First, two reviewers will independently screen titles, abstracts and full texts based on the inclusion and exclusion criteria. A third reviewer will resolve any disagreements. Eligibility criteria include AI models that predict or forecast intraoperative complications or immediate postoperative complications (up to the stay in the Post-Anaesthesia Care Unit) involving any patient undergoing surgery or interventional procedures with general or locoregional anaesthesia. The primary target is the algorithm’s performance, depending on the choice of the authors. Key items from the CHARMS 2014 checklist will be extracted using a standardised form. Risk of bias assessment will be performed using the PROBAST+AI tool. If possible, meta-analysis will be conducted by implementing a random effects meta-analysis model.Ethics and disseminationEthical approval is not required. The results will be published in a peer-reviewed journal and presented at national and international conferences.Trial registration numberPROSPERO registration number: CRD420250599920. Any future amendments will be updated in the PROSPERO record.

During refractory cardiogenic shock and cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to restore a circulatory output. However, it also impacts significantly arterial oxygenation. Recent guidelines of the Extracorporeal Life Support Organization (ELSO) recommend targeting postoxygenator partial pressure of oxygen (P POST O 2 ) around 150 mmHg. In this narrative review, we intend to summarize the rationale and evidence for this P POST O 2 target recommendation. Because this is the most used configuration, we focus on peripheral VA-ECMO. To date, clinicians do not know how to set the sweep gas oxygen fraction (F S O 2 ). Because of the oxygenator’s performance, arterial hyperoxemia is common during VA-ECMO support. Interpretation of oxygenation is complex in this setting because of the dual circulation phenomenon, depending on both the native cardiac output and the VA-ECMO blood flow. Such dual circulation results in dual oxygenation, with heterogeneous oxygen partial pressure (PO 2 ) along the aorta, and heterogeneous oxygenation between organs, depending on the mixing zone location. Data regarding oxygenation during VA-ECMO are scarce, but several observational studies have reported an association between hyperoxemia and mortality, especially after refractory cardiac arrest. While hyperoxemia should be avoided, there are also more and more studies in non-ECMO patients suggesting the harm of a too restrictive oxygenation strategy. Finally, setting F S O 2 to target strict normoxemia is challenging because continuous monitoring of postoxygenator oxygen saturation is not widely available. The threshold of P POST O 2 around 150 mmHg is supported by limited evidence but aims at respecting a safe margin, avoiding both hypoxemia and severe hyperoxemia.

Background The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients. Methods Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h. Intervention: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea. Results Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44–65] versus 55[40–65] years) and GCS (6[3–7] versus 5[3–7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78–1.42); p  = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day ( p  = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day ( p  < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis ( p  = 0.21), and 16% versus 8% patients suffered from diarrhea ( p  = 0.11). No patient presented vomiting in either group. Conclusion Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition. Trial registration EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).

Background Expertise involves a high level of knowledge or skill in a specific area. Medical expertise encompasses knowledge, technical skills, and socio-cognitive skills like clinical reasoning, essential for accurate diagnosis and treatment. Although traditionally seen as technicians, anaesthesiologists are vital cognitive experts in the operating room, where situational awareness and decision-making are crucial in high-risk, fast-paced situations prone to cognitive bias. Properly defining the cognitive aspects of anaesthetic expertise is challenging, hindering research and educational consistency. This study aims to identify, appraise, and synthesize how expertise within clinical reasoning among anaesthetists is conceptualized in the literature. Methods We will search Medline, Embase, and Cochrane databases for peer-reviewed papers up to July 1, 2024, focusing on anaesthesiology, expertise, and clinical reasoning. Our searches will include related terms and citations. According to the PRISMA flow chart, two reviewers will independently screen titles, abstracts, and full texts against inclusion criteria, excluding papers focusing solely on technical expertise. A third reviewer will resolve any disagreements. Information on references, article type, research area, anaesthetic field, and conceptualizations of clinical reasoning expertise will be extracted using a standardized form. To achieve an operational synthesis, a two-stage qualitative analysis will be conducted. The first stage involves a comprehensive semantic analysis to identify patterns and thematic clusters. The second stage follows the Thomas and Harden approach for formal thematic synthesis, using codes to develop categories that lead to descriptive themes. The resulting multi-layered tree structure will ultimately enable generating analytical themes. Discussion A clear concept synthesis of clinical reasoning expertise among anaesthetists could enhance research, education, and guidelines, thereby improving patient safety. The proposed systematic review and qualitative thematic synthesis aims to clarify this complex concept by analysing data from diverse scientific literature. A broad research strategy will be employed, followed by rigorous qualitative analysis, including semantic analysis and thematic synthesis, to capture the multifaceted nature of clinical reasoning. This study will be the first to propose a global approach, facilitating improved pedagogical interventions and integrating insights into AI models for enhanced training and clinical decision-making. Systematic review registration PROSPERO registration number CRD42024510184.

Background Early postoperative glycemic variability is associated with worse outcome after cardiac surgery, but the underlying mechanisms remain unknown. This study aimed to describe the relationship between postoperative glycemic variability and endothelial function, as assessed by serum endocan level in cardiac surgery patients. Methods We performed a post hoc analysis of patients included in the single-center observational ENDOLUNG study. Adult patients who underwent planned isolated coronary artery bypass graft surgery were eligible. Postoperative glycemic variability was assessed by calculating the coefficient of variability (CV) of blood glucose measured within 24 (CV 24 ) and 48 (CV 48 ) hours after surgery. Serum endocan level was measured at 24 (Endocan 24 ) and 48 (Endocan 48 ) hours after surgery. Pearson’s correlation coefficient with 95% confidence interval (95% CI) was calculated between CV 24 and Endocan 24 , and between CV 48 and Endocan 48 . Results Data from 177 patients were analyzed. Median CV 24 and CV 48 were 18% (range 7 to 39%) and 20% (range 7 to 35%) respectively. Neither CV 48 nor CV 24 were significantly correlated to Endocan 48 and Endocan 24 respectively (r (95% CI) = 0.150 (0.001 to 0.290; and r (95% CI) = 0.080 (-0.070 to 0.220), respectively). Conclusions Early postoperative glycemic variability within 48 h after planned cardiac surgery does not appear to be correlated with postoperative serum endocan level. Clinical trial registration number NCT02542423.

Background Glycemic variability is associated with worse outcomes after cardiac surgery, but the prognosis value of early glycemic variability after transcatheter aortic valve implantation is not known. This study was therefore designed to analyze the prognosis significance of post-procedural glycemic variability within 30 days after transcatheter aortic valve implantation. Methods A post hoc analysis of patients from our center included in the FRANCE and FRANCE-2 registries was conducted. Post-procedural glycemic variability was assessed by calculating the mean daily δ blood glucose during the first 2 days after transcatheter aortic valve implantation. Major complications within 30 days were death, stroke, myocardial infarction, acute heart failure, and life-threatening cardiac arrhythmias. Results We analyzed 160 patients (age (median [interquartile] = 84 [80–88] years; diabetes mellitus (n) = 41 (26%) patients; logistic Euroscore = 20 [12–32]). The median value of mean daily δ blood glucose was 4.3 mmol l −1 . The rate of major complications within 30 days after procedure among patients with the lowest quartile of glycemic variability was 12%, increasing from 12 to 26%, and 39% in the second, third, and fourth quartiles, respectively. In multivariate analysis, glycemic variability was independently associated with an increased risk of major complications within 30 days after the procedure (odds ratio [95% CI] = 1.83 [1.19–2.83]; p = 0.006). Conclusions This study showed that post-procedural glycemic variability was associated with an increased risk of major complications within 30 days after transcatheter aortic valve implantation. Trial registration Clinical trial registration number https://www.clinicaltrials.gov/ ; identifier: NCT02726958; date: April 4th, 2016

Background The aim of the study was to investigate whether intravenous (iv) infusion of exenatide, a synthetic GLP-1 receptor agonist, could provide a protective effect against myocardial ischemia-reperfusion injury after coronary artery bypass graft (CABG) surgery. Methods A sub study analysis of patients > 18 years admitted for elective CABG and included in the ExSTRESS trial was conducted. Patients were randomized to receive either iv exenatide (1-h bolus of 0.05 µg min −1 followed by a constant infusion of 0.025 µg min −1 ) (exenatide group) or iv insulin therapy (control group) for blood glucose control (target range 100–139 mg dl −1 ) during the first 48 h after surgical incision. All serum levels of troponin I measured during routine care in the Cardiac Surgery ICU were recorded. The primary outcome was the highest value of plasma concentration of troponin I measured between 12 and 24 h after ICU admission. The proportion of patients presenting an echocardiographic left ventricular ejection fraction (LVEF) > 50% at the follow-up consultation was compared between the two groups. Results Finally, 43 and 49 patients were analyzed in the control and exenatide groups, respectively {age: 69 [61–76] versus 71 [63–75] years; baseline LVEF < 50%: 6 (14%) versus 16 (32%) patients; on-pump surgery: 29 (67%) versus 33 (67%) patients}. The primary outcome did not significantly differ between the two groups (3.34 [1.06–6.19] µg l −1 versus 2.64 [1.29–3.85] µg l −1 in the control and exenatide groups, respectively; mean difference (MD) [95% confidence interval (95% CI)] 0.16 [− 0.25; 0.57], p = 0.54). The highest troponin value measured during the first 72 h in the ICU was 6.34 [1.36–10.90] versus 5.04 [2.39–7.18] µg l −1 , in the control and exenatide groups respectively (MD [95% CI] 0.20 [− 0.22; 0.61], p = 0.39). At the follow-up consultation, 5 (12%) versus 8 (16%) patients presented a LVEF < 50% in the control and in the exenatide groups respectively (relative risk [95% CI] 0.68 [0.16; 2.59], p = 0.56). Conclusions Postoperative iv exenatide did not provide any additional cardioprotective effect compared to iv insulin in low-risk patients undergoing scheduled CABG surgery. Trial registration ClinicalTrials.gov Identifier NCT01969149, date of registration: January 7th, 2015; EudraCT No. 2009-009254-25 A, date of registration: January 6th, 2009