International Journal of Anesthesiology & Pain Medicine

Description

In conditions with a severe inflammatory response, such as sepsis, acute respiratory distress syndrome (ARDS), cardiac surgery, and, more recently, coronavirus disease (COVID-19), the use of extracorporeal hemoadsorption has been suggested as a potential treatment. Complex cellular and biochemical interactions are primarily mediated by cytokines in the pathophysiology of these diseases. As a result, it has been hypothesized that removing those proteins from the blood will improve clinical outcomes. In spite of the fact that a number of blood purification devices have been used experimentally in sepsis and septic shock for the past 30 years, their efficacy is uncertain, and these treatments have not yet entered routine clinical practice. In a population of more than 1100 septic patients, polymyxin B-immobilized fiber column hemoadsorption was tested without high-quality evidence that it improved survival. Additionally, industry-driven research has dominated the extracorporeal blood purification therapies for sepsis research.

The porous polymer sorbent bead technology of CytoSorb® (CytoSorbents, Monmouth Junction, NJ, USA) is a medical device that is hemocompatible and biocompatible. It is possible to incorporate it into heart-lung machines, extracorporeal membrane oxygenation (ECMO), and renal replacement therapy in an extracorporeal pump circuit. In vitro, CytoSorb® lowers the concentration of cytokines that promote and inhibit inflammation as well as pathogen-associated molecular pattern molecules. Theoretically, those effects ought to carry over into the real world, reducing physiological shock and enhancing clinical outcomes. Without significant safety concerns, numerous case series and observational studies reported beneficial effects like shock reversal and decreased mortality in various patient populations. Conflicting findings from propensity score matching studies include: While some studies found that hemodynamic stabilization and mortality were positively correlated, others did not find any significant correlations. This device was also suggested for high-risk cardiac surgery, and non-randomized trials suggested that it might improve outcomes.

Effects of Propofol

However, the RCTs that have been conducted with CytoSorb® so far have produced disappointing outcomes. Septic patients with hemoadsorption mortality was found to be higher in the largest RCT ever conducted. Additionally, CytoSorb® was found to have a higher mortality rate in recent small randomized trials involving ECMO patients. These findings raised some concerns regarding the device's mortality and safety. As a result, we conducted a meta-analysis and systematic review of randomized trials to assess the efficacy and safety of CytoSorb® therapy. In adult critically ill patients, we hypothesized that the use of CytoSorb® hemoadsorption would result in an increase in both mortality and adverse events.

analyzed the mortality and adverse effects of extracorporeal blood purification using the CytoSorb® device in critically ill patients with hyperinflammatory conditions in a comprehensive systematic review and meta-analysis. Using data from 16 randomized trials, we discovered that the CytoSorb® treatment group had a higher mortality risk at the longest possible follow-up. According to evidence from 11 trials, mortality at 30 days or while still in the hospital was also higher. Nonsignificant statistical results were obtained when using TSA to attempt to control for random error. In general, this hemoadsorption technique's safety profile and mortality effects could not be determined with sufficient certainty from the available evidence.

The use of CytoSorb® may increase mortality in critically ill patients, according to weak evidence. Adverse events did not differ between groups, but they were not systematically evaluated and were underreported. Conflicts of interest and funding from the industry were common. Before using CytoSorb® hemoadsorption on a regular basis, additional high-quality randomized trials are required due to the substantial uncertainty surrounding the findings. Systematic evaluation of adverse events and mortality is necessary.

Propofol (2.0 mg kg-1) and remifentanil (0.5 mg kg-1) were used to induce anesthesia and cisatracurium facilitated endotracheal intubation were used to intubate patients prior to surgery. Infusions of propofol (5–10 mg kg-1 h) and remifentanil (1.75–2.25 mg h) were used to maintain anesthesia. An epidural catheter was positioned at interspaces Th8–Th10, and a central venous catheter was inserted into the right internal jugular vein. Lack of response to 4 ml of 2% lidocaine/adrenaline and continuous infusion of 3–4 ml of bupivacaine (0.25% or 0.5% at 4–5 ml h1) activated epidural anesthesia, ruling out extravascular or spinal placement. Pulse contour analysis (Nexfin, BMEYE BV) was used to obtain intraoperative hemodynamic variables (MAP, HR, SV, and CO) from a catheter inserted into the non-dominant arm's radial artery. In addition, minutes of blood pressure below 60 mmHg (MAP) or 90 mmHg (systolic) were used to indicate hypotension during the operation.

Postoperative Complications

The Dindo-Clavien classification and the score assigned by two reviewers were used to describe postoperative complications: Grade 1–3a (minor complications) was given to pharmacological treatments and interventions that did not require general anesthesia. As with admission to the intensive care unit and death, complications requiring surgical, endoscopic, or radiological intervention were categorized as Grade 3b–5 (major complications). Additionally, a comprehensive complication index was constructed, with the sum of all complications being weighted in terms of severity.

We confirm the efficacy of our numbing cream, comfort positioning, and distraction regimen in this large multicenter randomized trial: During venous cannulation, the average pain score was 20 mm/100 mm, the procedure took 2 minutes, there were few side effects, and both the child and the parent were happy (80–90 percent).

Despite research indicating that VR reduces pain and anxiety when compared to standard treatment or other distractions, we were unable to find any difference between the two groups in our primary outcome of pain or patient satisfaction. Additionally, a recent review from 2021 demonstrated the advantages of VR by demonstrating a significant reduction in pain scores. The majority of studies with small sample sizes were found to have a low risk of performance and detection bias as well as a high risk of selection bias. In addition, we made the ethical decision to use numbing cream and comfort positioning as standard of care in both study groups because both interventions are proven to reduce pain during pediatric needle procedures. Our hypothesis is that the implementation of these pain-relieving measures may obscure the VR's effectiveness in our study.

Children and adolescents still report experiencing pain and distress from venous cannulation. As a result, it is necessary to continue looking for ways to lessen the pain. We have implemented a standard of care in our clinic to enhance the procedural experience, which includes distraction.