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Objective: To comprehensively assess relevant institutional variations in anesthesia and intensive care management during left ventricular assist device (LVAD) implantation., Design: The authors used a prospective data analysis., Setting: This was an online survey., Participants: Participants were from LVAD centers in Europe and the US., Interventions: After investigating initial interest, 91 of 202 European and 93 of 195 US centers received a link to the survey targeting institutional organization and experience, perioperative hemodynamic monitoring, medical management, and postoperative intensive care aspects., Measurements and Main Results: The survey was completed by 73 (36.1%) European and 60 (30.8%) US centers. Although most LVAD implantations were performed in university hospitals (>5 years of experience), significant differences were observed in the composition of the preoperative multidisciplinary team and provision of intraoperative care. No significant differences in monitoring or induction agents were observed. Propofol was used more often for maintenance in Europe (p < 0.001). The choice for inotropes changed significantly from preoperatively (more levosimendan in Europe) to intraoperatively (more use of epinephrine in both Europe and the US). The use of quantitative methods for defining right ventricular (RV) function was reported more often from European centers than from US centers (p < 0.05). Temporary mechanical circulatory support for the treatment of RV failure was more often used in Europe. Nitric oxide appeared to play a major role only intraoperatively. There were no significant differences in early postoperative complications reported from European versus US centers., Conclusions: Although the perioperative practice of care for patients undergoing LVAD implantation differs in several aspects between Europe and the US, there were no perceived differences in early postoperative complications., Competing Interests: Declaration of Competing Interest This research itself did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. J.M.B. received honoraria for lectures from Edwards Lifesciences. K.B. received funding from the Agency for Healthcare Research and a grant from the National Institutes of Health. O.B. received honoraria for lectures from Medtronic, Livanova, and Werfen. M.L.B. received research funding from the US Department of Defense. B.A.B. received consulting fees from CSL Behring. J.L.B. received an SCA/IARS mid-career research grant. E.D.A. received travel expenses from GE and Carmat. E.E.C.d.W. received honoraria for lectures and research grants from Abbott and Cytosorbents. D.A.E. received payment for expert testimony from Cornelius & Collins and Husch Blackwell. P.G. received consulting fees from Abbott and honoraria for lectures from Abbott and Eurosets. F.G. received honoraria for lectures from Abbott, Amomed, Edwards, Masimi, Orion, Orphan, and Teleflex. M.H. received honoraria for lectures from AOP Health, Medtronic, and Orion Pharma. L.M.J. received an educational grant from Abbott and participated in the DSMB of Carmat. L.M.K. received honoraria for grand round presentations and for a continuing medical education lecture and payment for an expert witness review from Shumaker Law firm. Z.N.K. has stock options from Edwards and Abbott. P.K. received research grants from Netzwerk Universitätsmedizin, APEPTICO, and BMBF; consulting fees from TEVA Ratiopharm, Amicus Ltd, and Senzyme; honoraria for lectures from TEVA Ratiopharm, Vifor, Sintetica, CSL Behring, and Senzyme; and payment from Ulsenheimer Friedrich Law Firm. D.J.K. owns exchange-traded funds with diversified holdings. M.M. received honoraria for lectures from Abbott Vascular, Boston Scientific, and Edwards Lifesciences. A.K.M. received consulting fees from Attgeno AB. N.M. received consulting fees from Edwards, Air Liquide, and Attgeno; honoraria for lectures from Edwards, Cytosorbents, and SOL; and travel expenses from Cytosorbents. M.A.M. received consulting fees from Octapharma and Hemosonics, honoraria for grand rounds of Mass General, and payment for expert testimony from Goodell Devries. V.K.M. participates in the Advisory Board of Tell Health and Fize Medical. J.P.O. had a consulting agreement with Third Pole Therapeutics and received a consulting fee from La Jolla Pharmaceutical. A.O. received consulting fees from Nordic Pharma, Isep, Baxter, Orion Pharma, VIFOR Pharma, and Medtronic and participated in the DSMB of the NaPar registry organized by Nordic Pharma. S.R. received honoraria for lectures from Abiomed, Edwards Lifesciences, Orion, and Nordic. H.R. received honoraria and travel expenses from Abbott. A.R. has stock or stock options from Clinical Gene Networks AB. P.S. received financial support for attending an expert German Intensive Care Society meeting. R.E.S. received travel expenses from Phillips. S.E.S. received an Abbott investigator grant and a consulting fee for manuscript writing with Lincoln Heart and Vascular Research Institute. M.S.S. received honoraria for lectures from Medtronic. K.S. received grants for research and royalties from Springer. A.S. received consulting fees from Baxter and honoraria for lectures from Amomed. M.t.H. had a speakers agreement with CSL Behring. V.v.D. received honoraria for lectures and travel expenses from Edwards Lifesciences and Orion Pharma. B.J.W. received a research grant from Haemonetics. M.S.C., M.D., N.M.G., and B.M. did not disclose their conflict of interests. None of the other authors have any disclosures to report., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Objective: Regional anesthesia with thoracic wall blocks could represent an opioid-sparing alternative for mitral valve surgery in right minithoracotomy (mini-MVS). For the present study, an opioid-free analgesia using continuous deep serratus anterior plane block was compared with intravenous morphine., Design: Prospective, observational cohort study., Setting: Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Italy., Participants: The present study enrolled patients who underwent mini-MVS from March to October 2019 (63 patients) and divided them into the following 2 groups, according to pain control strategy: a morphine group and a serratus anterior plane (SAP) group., Interventions: Primary outcomes were pain evaluation and total postoperative opioid consumption, and secondary outcomes were incidence of postoperative nausea and vomiting, time to extubation, mechanical ventilation duration, and bowel dysfunction., Measurements and Main Results: The mean number rating scale at 24 hours was 2.15 (95% confidence interval [CI] 1.22-3.09) in the SAP group versus 3.23 (95% CI 2.28-4.29) in the morphine group (p = 0.07), whereas the mean number rating scale at 48 hours was significantly less in the SAP group compared with the morphine group (1.77 [95% CI 0.99-2.54] v 3.23 [95% CI 2.13-4.33], respectively; p = 0.03). Mean morphine consumption at 48 postoperative hours was 12.98 mg (95% CI 10.90-15.05 mg) in the morphine group and 2.22 mg (95% CI 0.99-3.44 mg) in the SAP group; p < 0.01. Cumulative morphine consumption at 24 postoperative hours was 10.44 mg (95% CI 8.36-12.52) in the morphine group and 1.16 mg (95% CI 0.37-1.95) in the SAP group; p < 0.01. There were no significant differences for secondary outcomes., Conclusions: Continuous deep serratus anterior plane block seems to be a valid alternative to intravenous opioids in terms of efficacy for patients undergoing mini-MVS with a lower opioid requirement., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings., Design: A systematic review of the literature followed by a consensus-based voting process., Setting: A web-based international consensus conference., Participants: Two hundred fifty-one physicians from 46 countries., Interventions: The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines., Measurements and Main Results: The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed., Conclusion: The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The authors aimed to identify interventions documented by randomized controlled trials (RCTs) that reduce mortality in adult critically ill and perioperative patients, followed by a survey of clinicians' opinions and routine practices to understand the clinicians' response to such evidence. The authors performed a comprehensive literature review to identify all topics reported to reduce mortality in perioperative and critical care settings according to at least 2 RCTs or to a multicenter RCT or to a single-center RCT plus guidelines. The authors generated position statements that were voted on online by physicians worldwide for agreement, use, and willingness to include in international guidelines. From 262 RCT manuscripts reporting mortality differences in the perioperative and critically ill settings, the authors selected 27 drugs, techniques, and strategies (66 RCTs, most frequently published by the New England Journal of Medicine [13 papers], Lancet [7], and Journal of the American Medical Association [5]) with an agreement ≥67% from over 250 physicians (46 countries). Noninvasive ventilation was the intervention supported by the largest number of RCTs (n = 13). The concordance between agreement and use (a positive answer both to "do you agree" and "do you use") showed differences between Western and other countries and between anesthesiologists and intensive care unit physicians. The authors identified 27 clinical interventions with randomized evidence of survival benefit and strong clinician support in support of their potential life-saving properties in perioperative and critically ill patients with noninvasive ventilation having the highest level of support. However, clinician views appear affected by specialty and geographical location., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: A careful choice of perioperative care strategies is pivotal to improve survival in cardiac surgery. However, there is no general agreement or particular attention to which nonsurgical interventions can reduce mortality in this setting. The authors sought to address this issue with a consensus-based approach., Design: A systematic review of the literature followed by a consensus-based voting process., Setting: A web-based international consensus conference., Participants: More than 400 physicians from 52 countries participated in this web-based consensus conference., Interventions: The authors identified all studies published in peer-reviewed journals that reported on interventions with a statistically significant effect on mortality in the setting of cardiac surgery through a systematic Medline/PubMed search and contacts with experts. These studies were discussed during a consensus meeting and those considered eligible for inclusion in this study were voted on by clinicians worldwide., Measurements and Main Results: Eleven interventions finally were selected: 10 were shown to reduce mortality (aspirin, glycemic control, high-volume surgeons, prophylactic intra-aortic balloon pump, levosimendan, leuko-depleted red blood cells transfusion, noninvasive ventilation, tranexamic acid, vacuum-assisted closure, and volatile agents), whereas 1 (aprotinin) increased mortality. A significant difference in the percentages of agreement among different countries and a variable gap between agreement and clinical practice were found for most of the interventions., Conclusions: This updated consensus process identified 11 nonsurgical interventions with possible survival implications for patients undergoing cardiac surgery. This list of interventions may help cardiac anesthesiologists and intensivists worldwide in their daily clinical practice and can contribute to direct future research in the field., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To identify all interventions that increase or reduce mortality in patients with acute kidney injury (AKI) and to establish the agreement between stated beliefs and actual practice in this setting., Design and Setting: Systematic literature review and international web-based survey., Participants: More than 300 physicians from 62 countries., Interventions: Several databases, including MEDLINE/PubMed, were searched with no time limits (updated February 14, 2012) to identify all the drugs/techniques/strategies that fulfilled all the following criteria: (a) published in a peer-reviewed journal, (b) dealing with critically ill adult patients with or at risk for acute kidney injury, and (c) reporting a statistically significant reduction or increase in mortality., Measurements and Main Results: Of the 18 identified interventions, 15 reduced mortality and 3 increased mortality. Perioperative hemodynamic optimization, albumin in cirrhotic patients, terlipressin for hepatorenal syndrome type 1, human immunoglobulin, peri-angiography hemofiltration, fenoldopam, plasma exchange in multiple-myeloma-associated AKI, increased intensity of renal replacement therapy (RRT), CVVH in severely burned patients, vasopressin in septic shock, furosemide by continuous infusion, citrate in continuous RRT, N-acetylcysteine, continuous and early RRT might reduce mortality in critically ill patients with or at risk for AKI; positive fluid balance, hydroxyethyl starch and loop diuretics might increase mortality in critically ill patients with or at risk for AKI. Web-based opinion differed from consensus opinion for 30% of interventions and self-reported practice for 3 interventions., Conclusion: The authors identified all interventions with at least 1 study suggesting a significant effect on mortality in patients with or at risk of AKI and found that there is discordance between participant stated beliefs and actual practice regarding these topics., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: With more than 220 million major surgical procedures performed annually, perioperative interventions leading to even minor mortality reductions would save thousands of lives per year. This international consensus conference aimed to identify all nonsurgical interventions that increase or reduce perioperative mortality as suggested by randomized evidence., Design and Setting: A web-based international consensus conference., Participants: More than 1,000 physicians from 77 countries participated in this web-based consensus conference., Interventions: Systematic literature searches (MEDLINE/PubMed, June 8, 2011) were used to identify the papers with a statistically significant effect on mortality together with contacts with experts. Interventions were considered eligible for evaluation if they (1) were published in peer-reviewed journals, (2) dealt with a nonsurgical intervention (drug/technique/strategy) in adult patients undergoing surgery, and (3) provided a statistically significant mortality increase or reduction as suggested by a randomized trial or meta-analysis of randomized trials., Measurements and Main Results: Fourteen interventions that might change perioperative mortality in adult surgery were identified. Interventions that might reduce mortality include chlorhexidine oral rinse, clonidine, insulin, intra-aortic balloon pump, leukodepletion, levosimendan, neuraxial anesthesia, noninvasive respiratory support, hemodynamic optimization, oxygen, selective decontamination of the digestive tract, and volatile anesthetics. In contrast, aprotinin and extended-release metoprolol might increase mortality., Conclusions: Future research and health care funding should be directed toward studying and evaluating these interventions., (Copyright © 2012 Elsevier Inc. All rights reserved.)