Summary: Remimazolam, a short‐acting benzodiazepine, may be used for induction and maintenance of total intravenous anaesthesia, but its role in the management of patients with multiple comorbidities remains unclear. In this phase 3 randomised controlled trial, we compared the anaesthetic efficacy and the incidence of postinduction hypotension during total intravenous anaesthesia with remimazolam vs. propofol. A total of 365 patients (ASA physical status 3 or 4) scheduled for elective surgery were assigned randomly to receive total intravenous anaesthesia with remimazolam (n = 270) or propofol (n = 95). Primary outcome was anaesthetic effect, quantified as the percentage of time with Narcotrend® Index values ≤ 60, during surgery (skin incision to last skin suture), with a non‐inferiority margin of ‐10%. Secondary outcome was the incidence of postinduction hypotensive events. Mean (SD) percentage of time with Narcotrend Index values ≤ 60 during surgery across all patients receiving remimazolam (93% (20.7)) was non‐inferior to propofol (99% (4.2)), mean difference (97.5%CI) ‐6.28% (‐8.89–infinite); p = 0.003. Mean (SD) number of postinduction hypotension events was 62 (38.1) and 71 (41.1) for patients allocated to the remimazolam and propofol groups, respectively; p = 0.015. Noradrenaline administration events (requirement for a bolus and/or infusion) were also lower in patients allocated to remimazolam compared with propofol (14 (13.5) vs. 20 (14.6), respectively; p < 0.001). In conclusion, in patients who were ASA physical status 3 or 4, the anaesthetic effect of remimazolam was non‐inferior to propofol.

Background: Mechanical ventilation, a crucial intervention for acute respiratory distress syndrome (ARDS), can lead to ventilator-induced lung injury (VILI). This study focuses on individualizing mechanical power (MP) in mechanically ventilated patients to minimize VILI and reduce ICU mortality. Methods: A retrospective analysis was conducted using the Amsterdam University Medical Centers Database (AmsterdamUMCdb) data. The study included patients aged 18 and older who needed at least 48 hours of pressure-controlled mechanical ventilation. Patients who died or were extubated within 48 hours and those with inadequate data were excluded. Patients were categorized into hypoxemia groups based on their PaO2/FiO2 ratio. MP was calculated using a surrogate formula and normalized to ideal body weight (IBW). Statistical analyses and machine learning models, including logistic regression and random forest, were used to predict ICU mortality and establish safe upper limits for IBW-adjusted MP. Results: Out of 23,106 admissions, 2,338 met the criteria. Nonsurvivors had a significantly higher time-weighted average MP (TWA-MP) than survivors. Safe upper limits for IBW-adjusted MP varied across hypoxemia groups. The XGBoost model showed the highest predictive accuracy for ICU mortality. An individualization method for mechanical ventilation settings, based on real-time physiological variables, demonstrated reduced predicted mortality in a subset of patients. Discussion: Elevated TWA-MP is associated with increased ICU mortality, underscoring the need for personalized mechanical ventilation strategies. The study highlights the complexity of VILI and the multifactorial nature of ICU mortality. Further studies to define a safe upper limit for IBW-adjusted MP may help clinicians optimize mechanical ventilation settings and decrease the risk of VILI and mortality. Conclusions: Despite the fact that the study’s retrospective design and reliance on a single-center database may limit the generalizability of findings, this study offers valuable insights into the relationship between mechanical power and ICU mortality, emphasizing the need for individualized mechanical ventilation strategies. The findings suggest a potential for more personalized, data-driven approach in managing mechanically ventilated patients, which could improve patient outcomes in critical care settings.

Massive transfusion of blood products poses challenges in determining the need for transfusion and the appropriate volume of blood products. This review explores the use of machine learning (ML) models to predict transfusion risk during surgical procedure, focusing on the methodology, variables, and software employed to predict transfusion. This scoping review investigates the development and current state of machine learning models for predicting transfusion risk during surgical procedure, aiming to inform physicians about the field’s progress and potential directions. The review was conducted using the databases Cochrane, Embase, and PubMed. The search included keywords related to blood transfusion, statistical models, and surgical procedures. Peer-reviewed articles were included, while literature reviews, case reports, and non-human studies were excluded. A total of 40 studies met the inclusion criteria. The most frequently studied biological variables included haemoglobin, platelet count, international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen, creatinine, white blood cells, and albumin. Clinical variables of importance included age, sex, surgery type, blood pressure, weight, surgery duration, american society of anesthesiology (ASA) status, blood loss, and body mass index (BMI). The software employed varied, with Python, R, SPSS, and SAS being the most commonly used. Logistic regression was the predominant methodology used in 20 studies. Our scoping review highlights the need for improved reporting and transparency in methodology, variables, and software used. Future research should focus on providing detailed descriptions and open access to codes of respective models, promoting reproducibility, and enhancing the clinical relevance of transfusion risk prediction models.

Acquired factor XIII (FXIII) deficiency is a very rare haemostatic defect that can be either immune (rare development of an autoantibody targeting FXIII epitopes) or nonimmune (diminished synthesis or increased consumption of the same factor). The aim of this study is to review the symptomatology, the diagnostic method used, but above all to determine the most frequently used and potentially most effective treatment for acquired FXIII deficiency. PubMed, Medline, embase/Ovid databases were queried from 1 January 2012 to 3 April 2022. Data extraction was performed using the keywords ‘Acquired FXIII deficiency.’ The systematic search identified 474 records. After screening titles and abstracts, only 36 articles met the eligibility criteria. The mean age of all patients was 57.6 [range, 1–84] years. The male to female ratio was 35 : 25. The majority of cases described were due an autoimmune reaction with antibody production (24 manuscripts), only six manuscripts described consumption. The most prevalent symptoms were local haematoma (31). Six cases died, two from haemorrhagic shock, two from haemorrhagic stroke, one from respiratory distress, and 1 from septic shock. Given the patient outcomes, this review confirms that the most appropriate treatment consists of one of the following elements or a combination of several of these elements: FXIII concentrate, corticosteroids, cyclophosphamide, rituximab for autoimmune cases, and FXIII concentrate supplementation only in case of consumption.

Introduction: Virtual reality (VR) is an active distraction method that serves as a non-pharmacological adjunct treatment for pain and anxiety. It offers the potential to be integrated into a multimodal clinical approach. The implantation of a subcutaneous implantable access port (PAC) is a painful procedure for which there is no established sedation protocol. The objective of this study was to evaluate the level of anxiety in patients who underwent PAC implantation outside of the operating room. Materials and methods: A prospective, monocentric, randomized, controlled interventional study was conducted, involving 80 patients, with 40 in the VR group and 40 in the control group. The primary objective of our study was to measure postoperative anxiety levels using the State-Trait Anxiety Inventory (STAI). Secondary objectives included the assessment of pain using the Visual Analog Scale (VAS), patient satisfaction measured by the Net Promoter Score (NPS), and midazolam consumption. Results: Regarding our primary objective, we observed a reduction in postoperative state anxiety in the VR group, decreasing from 38.8 to 30.30 ( p = 0.004). However, there was no significant difference between the two groups, with the mean postoperative STAI value being 30.60 for the VR group and 32.65 for the control group ( p = 0.37). We also noted a non-significant reduction in the NPS score in the VR group compared to the control group. Conversely, midazolam consumption was significantly reduced, with a median of 1.65 mg in the control group and 0.325 mg in the VR group ( p < 0.01). Conclusion: In conclusion, our results suggest that virtual reality may serve as a non-pharmacological alternative to reduce anxiety during PAC implantation, decrease sedation requirements, and maintain patient satisfaction regarding the quality of care.