Anesthesiology and Perioperative Science最新文献

High-flow nasal cannula (HFNC) has been widely promoted during the COVID-19 pandemic to circumvent invasive mechanical ventilation. While there are several reported benefits, randomized trials demonstrate inconsistent variable success. We hypothesize that this is due to variable stopping criteria. This systematic review’s purpose is to review these criteria and investigate any associations with HFNC outcomes. We searched PubMed and EMBASE for all English-language randomized controlled trials (RCTs) published from January 1, 2007, to December 31, 2022, focusing on respiratory rate as a threshold for escalation of respiratory support. Subgroup analysis was conducted based on trial failure criteria, and intubation and mortality benefits were studied. Fisher’s exact test was performed following a 5% level of significance. Of the 22 RCTs included, 4 (18.2%) reported significant intubation benefits and 1 (0.05%) reported significant mortality benefit. The presence of objective failure criteria with a prespecified high respiratory rate threshold (35 breaths per minute or higher) had a significant effect on intubation rate reduction (P = 0.02). However, this result might be limited by the heterogeneity of the included studies. Further RCTs are required to confirm this conclusion. Given that a high respiratory rate threshold was associated with a reduction of intubation without increasing mortality, we hypothesize that among patients receiving HFNC who were eventually not intubated, the avoidance of intubation led to better clinical outcomes, while among eventually intubated patients, delays led to poorer outcomes.

With advancements in sedation techniques,painless gastrointestinal endoscopy has expanded from a diagnostic role to surgeries. This study aims to explore strategies for enhancing patient satisfaction, improving safety, and reducing complications. Tailoring preoperative assessments beyond American Society of Anesthesiologists classification is crucial, especially for the elderly and pediatric populations. Integration of scales and point-of-care testing (POCT) provides a precise baseline evaluations. Optimizing anesthetic strategies through improved drug selection and enhanced perioperative monitoring follows accurate patient evaluations. While post-procedural follow-up is essential, existing studies in this area are limited. This article outlines current painless gastrointestinal endoscopy technology, emphasizing POCT establishment, personalized monitoring, and optimized anesthesia strategies for a positive impact on patient outcomes.

Purpose

Ventilator care bundles are effective in the prevention of ventilator-associated pneumonia (VAP). However, the compliance of these bundles in intensive care units (ICUs) remains poorly studied. This study investigates the Medical Information Mart for Intensive Care (MIMIC)-IV cohort’s compliance with the Institute for Healthcare Improvement (IHI) bundle and its resulting association with VAP incidence.

Methods

This is a retrospective cohort study of the MIMIC-IV database. Patients with > 48 h of invasive mechanical ventilation (IMV) were included. Diagnosis of VAP was identified with the International Classification of Diseases (ICD)-9 and ICD-10 codes. Compliance rates to the IHI bundle were extracted. The association of the IHI bundle and its individual interventions with VAP incidence was analyzed with univariate and multivariate analysis.

Results

8270 patients were included, of which 1328 (16.1%) had VAP. 25 patients (0.3%) had full compliance to the IHI bundle. 137 patients (1.7%) received no interventions from the bundle. Gastroprophylaxis had the lowest (2.1%) while head elevation had the highest (89.3%) compliance rates. In patients receiving the IHI bundle, each additional intervention was associated with lower VAP incidence (OR [odds ratio] = 0.906, 95% CI [confidence interval] 0.847–0.969). Appropriate sedation levels (OR = 0.765, 95% CI 0.661–0.885) and the use of heat and moisture exchanger (HME) filters (OR = 0.862, 95% CI 0.745–0.998) were individually associated with reduced VAP incidence, while active humidification was individually associated with increased VAP incidence (OR = 1.139, 95% CI 1.001–1.296).

Conclusion

The use of the IHI bundle was associated with a lower incidence of VAP, but compliance with the bundle was poor. Appropriate sedation and HME filters were individually associated with reduced VAP incidence. Better compliance with the IHI bundle may reduce VAP rates in mechanically ventilated patients.

Graphical Abstract

Purpose

The addition of intrathecal morphine to general anesthesia for laparoscopic colorectal surgery is an effective method of providing analgesia. However, the analgesia duration of approximately 24 hours poses the risk of rebound pain on the second postoperative day. Therefore, this study aimed to investigate the patients' perception on postoperative pain management using the International Pain Outcomes questionnaire on both the first and second postoperative day.

Methods

This prospective single-center cohort study was conducted between November 2020 and March 2021 and included forty patients. The primary outcome was a difference in postoperative pain on the first and second postoperative day. Secondary outcomes included opioid consumption, interference of pain with activities, side effects, and patients’ perception and satisfaction with pain treatment.

Results

The intensity of postoperative pain did not increase on the second postoperative day NRS [numeric rating scale] 5 (2–7 [0–10]) vs 5 (3–7 [1–10]), p=0.414), but the percentage of time spent in severe pain increased (20% (10-40 [0-90]) vs 30% (20-50 [0-80]), p=0.010). There was no difference in opioid consumption (6 mg (0–12) [0–42] vs 6 mg (0–12) [0–29], p=0.914). Pruritis (NRS 2 (0–6 [0–10]) vs 0 (0–3 [0–8]), p=0.001) and dizziness (NRS 2 (0–7 [0–10]) vs 0 (0–2 [0–9]), p=0.002) decreased on the second postoperative day. Patients reported high satisfaction during the first two days after surgery (NRS 8 (7–9) [0–10] vs 8 (7–9) [0–10], p=0.395).

Conclusion

Intrathecal morphine is a suitable analgesic modality in laparoscopic colorectal surgery within an enhanced recovery after surgery program, without causing important rebound pain. Pain scores, however, may be further reduced by adding non-opioid analgesics.

The ependymal epithelium forms the cerebrospinal fluid barrier, separating the brain and spinal cord from the cerebrospinal fluid. However, in specific regions of the central nervous system, there are neurons that directly interface with the cerebrospinal fluid, including neuronal bodies, dendrites, or axons, This constitutes what is referred to as the "cerebrospinal fluid contacting neurons system (CSF-CNS)". The research team led by Professor Zhang has successfully utilized cholera toxin subunit B coupled horseradish peroxidase complex (CB-HRP) to selectively label the specialized neuron system that interfaces with cerebrospinal fluid, pioneeringly designating it as the "cerebrospinal fluid-contacting nucleus", commonly referred to as the "CSF-contacting nucleus". For the first time, the discovery of the CSF-contacting nucleus provides compelling morphological evidence for the existence of a distinct neural structure within the brain parenchyma that establishes a connection with the cerebrospinal fluid, thereby suggesting its potential significance in facilitating material and information exchange between the brain parenchyma and cerebrospinal fluid. After conducting a comprehensive series of studies on the morphological structure, material expression, gene analysis and functional aspects of the CSF-contacting nucleus in rodents and non-human primates, it has been revealed that there are fibrous connections between the CSF-contacting nucleus and the cerebral cortex and subcortical nuclei being involved in the regulatory mechanisms of pain, cognition, learning and memory, emotion, addiction, stress and anxiety responses, visceral activity, olfaction, vision processing and perception, auditory processing, perception, motor control and coordination, homeostasis regulation including maintenance of body energy and fluid balance, as well as the control of sleep–wake cycles and synchronization of biological rhythms. Current experiments have confirmed that the CSF-contacting nucleus is related to pain, morphine dependence and withdrawal, learning and memory, as well as stress. This present article offers a comprehensive review of the neurobiological characteristics and recent advancements in pain regulation of the CSF-contacting nucleus. The aim is to provide novel insights into the investigation of pain regulation within bidirectional regulatory pathway between the brain and cerebrospinal fluid, with a specific focus on elucidating the role of the CSF-contacting nucleus as a bridge structure. Additionally, the objective of this research is to propose innovative strategies for pain management and associated disorders in the future.

To summarize the existing evidence on the effects of ultrasound-guided recruitment maneuver (RM) during perioperative period on atelectasis, oxygenation and other clinical outcomes in adult patients undergoing abdominal surgery. In this systematic review and meta-analysis, PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, and WanFang databases were searched from inception to May 2023 for relevant randomized controlled trials (RCTs) comparing the perioperative use of ultrasound-guided RM with a control group in adult patients undergoing abdominal surgery. The primary outcome was the incidence of early postoperative atelectasis (within 24 h after surgery). A total of 12 RCTs with 895 patients were included. The ultrasound-guided RM significantly reduced the incidence of postoperative atelectasis (RR [risk ratio]: 0.44, 95% CI [confidence interval]: 0.34 to 0.57, P < 0.001), with a median fragility index of 4. Prespecified subgroup analyses demonstrated the consistent findings. Additionally, ultrasound-guided RM could decrease postoperative lung ultrasound score (MD [mean difference]: − 3.02, 95% CI: − 3.98 to − 2.06, P < 0.001), reduce the incidence of postoperative hypoxemia (RR: 0.32, 95% CI: 0.18 to 0.56, P < 0.001), improve postoperative oxygenation index (MD: 45.23 mmHg, 95% CI: 26.54 to 63.92 mmHg, P < 0.001), and shorten post-anesthesia care unit (MD: − 1.89 min, 95% CI: − 3.14 to − 0.63 min, P = 0.003) and hospital length of stay (MD: − 0.17 days, 95% CI: − 0.30 to − 0.03 days, P = 0.02). However, there was no significant difference in the incidence of atelectasis at the end of surgery between two groups (RR: 0.99, 95% CI: 0.86 to 1.14, P = 0.89). The use of ultrasound-guided RM perioperatively reduced the risk of atelectasis and improve oxygenation after abdominal surgery. Strategies to reduce the development of perioperative atelectasis are presented to highlight areas for future research.

Purpose

This study aims to provide a comprehensive overview of anesthesia management strategies employed in pediatric lung transplantation.

Methods

A retrospective analysis was conducted on data from 14 pediatric patients who underwent lung transplantation at the Wuxi Center between September 2019 and November 2022. Patient demographics, surgical particulars, airway management, utilization of extracorporeal support, fluid administration, blood gas and electrolyte profiles, and postoperative outcomes were systematically documented and subsequently summarized.

Results

Of the 14 patients, 7 received extracorporeal membrane oxygenation (ECMO) and 1 received cardiopulmonary bypass (CPB). The average operation time was 303 ± 53 min, with the median extubation time of 26 h. The entirety of pediatric lung transplant procedures was executed successfully, resulting in the discharge of thirteen patients postoperatively. Regrettably, one patient died due to infectious shock on the fourth postoperative day.

Conclusion

The achievement of successful pediatric lung transplantation necessitates effective perioperative anesthesia management, with a focal emphasis on circulatory control. Real-time measurements serve as the cornerstone for decision-making. Proactive administration of vasoactive agents is integral to sustaining hemodynamic stability. The judicious assessment of ECMO necessity is paramount, favoring central ECMO during the surgical intervention.