Purpose: Ketamine is a N-methyl-D-aspartate (NMDA) antagonist with strong analgesic properties. Its addition to the treatment of neuropathic pain may reduce pain intensity and improve overall quality of life. A systematic review and meta-analysis of randomized controlled trials was performed to investigate the addition of ketamine to the treatment of patients with neuropathic pain. Patients and Methods: GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to rate the overall certainty of the evidence for each outcome. Eighteen (18) randomized controlled trials including 706 participants were included for further analysis. Results: Ketamine addition to standard treatment of neuropathic pain (NP) resulted in a statistically significant reduction of pain intensity at one week after the end of treatment with ketamine (MD − 2.14, 95% CI − 2.65 to − 1.63; p< 0.00001) and after 30 days after the end of treatment with ketamine (MD − 1.68, 95% CI − 2.25 to − 1.12; p< 0.00001) and a statistically significant increase in discomfort (RR 4.06; 95% CI 1.18 to 13.95; p=0.03), and psychedelic effects (RR 4.94; 95% CI 2.76 to 8.84; p< 0.00001). Conclusion: There is a statistically significant pain reduction by adding ketamine to the treatment of chronic NP when compared to the standard treatment. However, such pain reduction comes at the expense of adverse outcomes, especially psychedelic effects related to the administration of ketamine. However, the overall quality of certainty of evidence is low due to the clinical heterogeneity among the intervention characteristics of the trials analyzed (different administration routes, dosing regimen, therapy durations, different clinical characteristics of the population investigated). Future large multi-centered trials are necessary to confirm or not the results of the present review.

Background: It remains elusive how the characteristics, the course of disease, the clinical management and the outcomes of critically ill COVID-19 patients admitted to intensive care units (ICU) worldwide have changed over the course of the pandemic.Methods: Prospective, observational registry constituted by 90 ICUs across 22 countries worldwide including patients with a laboratory-confirmed, critical presentation of COVID-19 requiring advanced organ support. Hierarchical, generalized linear mixed-effect models accounting for hospital and country variability were employed to analyse the continuous evolution of the studied variables over the pandemic.Results: Four thousand forty-one patients were included from March 2020 to September 2021. Over this period, the age of the admitted patients (62 [95% CI 60–63] years vs 64 [62–66] years,p < 0.001) and the severity of organ dysfunction at ICU admission decreased (Sequential Organ Failure Assessment 8.2 [7.6–9.0] vs 5.8 [5.3–6.4],p < 0.001) and increased, while more female patients (26 [23–29]% vs 41 [35–48]%,p < 0.001) were admitted. The time span between symptom onset and hospitalization as well as ICU admission became longer later in the pandemic (6.7 [6.2–7.2| days vs 9.7 [8.9–10.5] days,p < 0.001). The PaO₂/FiO₂at admission was lower (132 [123–141] mmHg vs 101 [91–113] mmHg,p < 0.001) but showed faster improvements over the initial 5 days of ICU stay in late 2021 compared to early 2020 (34 [20–48] mmHg vs 70 [41–100] mmHg,p = 0.05). The number of patients treated with steroids and tocilizumab increased, while the use of therapeutic anticoagulation presented an inverse U-shaped behaviour over the course of the pandemic. The proportion of patients treated with high-flow oxygen (5 [4–7]% vs 20 [14–29],p < 0.001) and non-invasive mechanical ventilation (14 [11–18]% vs 24 [17–33]%,p < 0.001) throughout the pandemic increased concomitant to a decrease in invasive mechanical ventilation (82 [76–86]% vs 74 [64–82]%,p < 0.001). The ICU mortality (23 [19–26]% vs 17 [12–25]%,p < 0.001) and length of stay (14 [13–16] days vs 11 [10–13] days,p < 0.001) decreased over 19 months of the pandemic.Conclusion: Characteristics and disease course of critically ill COVID-19 patients have continuously evolved, concomitant to the clinical management, throughout the pandemic leading to a younger, less severely ill ICU population with distinctly different clinical, pulmonary and inflammatory presentations than at the onset of the pandemic.

Introduction-Aim: Newer methods, such as infrared digital pupillometry and electrodermal activity (EDA) measurement have been suggested as good alternatives for analgesia monitoring in critically ill patients. This study analyzed EDA changes due to pain stimulus in sedated adult critical care patients Methods: Skin conductance variability, selected hemodynamic and respiratory parameters, Bispectral index (BIS) and ambient noise level, were monitored during 4 hour routine daytime in an adult ICU. 4h-Measurements were divided into 2 groups, based upon the sedation level of the patients: Group A – Ramsay Sedation Score 2–4 and Group B – Ramsay Sedation Score of 5–6. Selected recordings before and after pain stimulus were performed. The stimulus chosen was the pressure applied to nail bed for 10 sec, which was performed routinely during neurological examination. Patients’ demographics, laboratory exams and severity scores were recorded. Pain status evaluation before every event was also performed by 2 independent observers via Critical Care Pain Observation Tool (CPOT) and Adult Non Verbal Pain Score (ANVPS) Results: In both groups the rate of EDA changes was greater than other monitoring parameters: more in Group A than in Group B. Yet, the difference between groups was not statistically significant. Conclusion: EDA measurements are greater to pain stimuli, than cardiovascular, respiratory or even BIS monitoring. These encouraging results suggest that, further studies are needed to better define EDA role in ICU.

Fournier's gangrene is an acute, rapidly progressive, and potentially fatal, infective necrotizing fasciitis affecting the external genitalia, perineal or perianal regions. Lemierre's syndrome is a condition characterized by thrombophlebitis of the internal jugular vein and bacteremia caused by primarily anaerobic organisms, following a recent oropharyngeal infection. Although the literature about either of them is rich, there is no report about co-appearance of the two syndromes. We present the case of a young healthy female patient who suffered concomitantly from Fournier's gangrene and Lemierre's syndrome after minor surgery.

Electrodermal activity is originated from the activation of sweat glands in the skin in response to stress or other stimuli and thought to reflect the activity of the sympathetic nervous system, or physiological arousal. Though it has been studied since the late 19th century, it still does not make the transition into everyday clinical application. Improvement of recording and analyzing measurement data has recently increased the interest for possible applications in various clinical settings-operation room, recovery and intensive care unitwhere monitoring of autonomous nervous system activity is vital. This paper presents the applications of electrodermal activity measurements, in both adult and pediatric patients. It especially reviews the results of studies carried out in perioperative setting and reviews their results. Although no final conclusion can be drawn safely, it seems that in adult populations electrodermal activity monitoring has the role of stress detector, while in pediatric populations it works more efficiently as algesimeter. Possible future applications in intensive care are also discussed.

Background: Endotracheal suctioning of respiratory secretions is one of the most common causes of pain and discomfort in Intensive Care Unit environment. The electrical properties of the skin, also known as electrodermal activity (EDA), are considered as an indirect measure of autonomous nervous system. Aim: This study explores EDA changes during endotracheal suction in sedated adult critical care patients; and compares these changes to other monitoring parameters. Materials and methods: Skin conductance variability, selected hemodynamic and respiratory parameters, bispectral index (BIS) and ambient noise level, were monitored during 4 hour routine daytime intensive care nursing and treatment in an adult Intensive Care Unit. 4h-measurements were divided into 2 groups, based upon the sedation level (group A: Ramsay sedation scale 2-4 and group B: 5-6 respectively) of the patients. Selected recordings before and after endotracheal suction (stress events) were performed. Seven stress events from Group A and 17 from Group B were included for further analysis. Patients’ demographics, laboratory exams and severity scores were recorded. Pain status evaluation before every event was also performed via 2 independent observers. Results: In both groups the rate of EDA changes was greater than in other monitoring parameters. Yet, in group A only selected parameters were significantly changed after the start of the procedure, while in group B, every parameter showed significant change (p<0.05). Groups were similar for other co-founding factors. Conclusion: EDA measurements are more sensitive to stress stimuli, than cardiovascular, respiratory or even BIS monitoring. Deeper sedation seems to affect more the intensity of EDA changes during suction.