Anesthesia and pain medicine最新文献

Background: Accurate core temperature measurement in children is crucial; however, measuring esophageal temperature (TE) using a supraglottic airway device (SAD) can be challenging. Second-generation SADs, which have a gastric channel, can measure TE, and reduce gastric air volume. This study aimed to compare TE, measured using a probe inserted through the SAD gastric channel, with tympanic membrane (TTM) and forehead (TZHF) temperatures, measured using a zero-heat-flux cutaneous thermometer, with rectal temperature (TR).

Methods: Temperature was recorded at 10-min intervals from 10 min after probe insertion until completion of surgery. We performed an equivalence test to evaluate whether the TE, TTM, and TZHF were equivalent to TR, with a margin of 0.3°C. Additionally, intraclass correlation coefficients (ICC) were calculated to assess the reliability of TE and TR at each time point.

Results: We included 41 patients in the final analysis. In all patients, the esophageal probe was successfully inserted through the gastric channel of the SAD. When assessing agreement with TR as a reference, TE demonstrated equivalent results at all time points (P < 0.001 at 0, 10, 20, 30, and 40-min intervals and P = 0.018 at the 50-min interval), except at the completion of surgery (P = 0.697). TE also demonstrated good reliability with TR as a reference throughout the surgery (ICC > 0.75).

Conclusions: In children with SAD insertion, TE can be accurately and feasibly measured through the SAD's gastric channel, making it suitable for routine application.

Background: This study aims to establish the individual contributions of blood pressure variability (BPV) indexes, categorized into overall and linked variability, to mortality following intracerebral hemorrhage (ICH) by examining the risk factors.

Methods: Patients with spontaneous ICH (n = 1,036) were identified with valid blood pressures (BP) from the first 24-h systolic BP records in the Medical Information Mart for Intensive Care IV version 2.2 database (MIMIC IV). Information on the baseline characteristics, including age, sex, initial Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores, ICH location, Charlson comorbidity index score, and presence of diabetes with or without complications, were collected. Three indexes of BPV-range, standard deviation (SD), and generalized BPV (GBPV)-were calculated using the first 24-h systolic BPs. An automated stepwise variable-selection procedure was used to develop the final logistic model for predicting in-hospital mortality.

Results: Out of 1,036 patients, 802 (77.4%) survived and were discharged after spontaneous ICH. Factors associated with mortality included age; male sex; ICH in the brainstem, ventricle, or multiple locations; low GCS score (< 9); high NIHSS score (> 20); and diabetes with complications. Mean systolic BP, SD, and GBPV were also linked to mortality. Higher GBPV notably increased the risk of in-hospital death, with an odds ratio of 3.21 (95% confidence interval, 2.10 to 4.97) for every + 10 mmHg/h change in GBPV.

Conclusions: This study underscores the additional impact of GBPV, herein linked to BPV, on mortality following ICH, providing further insights into the management of blood pressure in the early stages of ICH treatment.

Background: Airway management in children is challenging because of the smaller size, different proportions of anatomical structures compared to adults, and a higher risk of hypoxemia. Efforts to improve the efficiency of pediatric intubation can be made by manually twisting a spiral endotracheal tube (ETT) using a flexible stylet to manipulate its shape and angle.

Methods: This controlled trial randomized fifty children aged one month to six years who underwent elective surgery under general anesthesia into two groups (spiral ETT [sETT] and no-stylet ETT/standard ETT). The sETT was formed by twisting the ETT using a handmade tool. The primary objective was to determine the effectiveness of the sETT compared to the standard ETT in reducing intubation time. Secondary objectives were ETT placement accuracy, first-attempt intubation success rate, and adverse effects.

Results: The mean total tube handling time in the sETT group was significantly shorter compared to the no-stylet ETT group (sETT 16.8 ± 3.6 vs. standard ETT 18.8 ± 3.7 seconds; P = 0.049). sETT placement had a significantly greater central placement accuracy (odds ratio, 4.846; 95% confidence interval, 1.287-18.255; P = 0.015). However, first-attempt successful intubation rate (sETT 80% vs. standard ETT 64%, P = 0.208) and total intubation time (sETT: 46.5 ± 5.2 vs. standard ETT 48.4 ± 4.9 seconds; P = 0.205) were not significantly different. No adverse effects were observed for either ETT type.

Conclusions: Spiral ETT effectively reduces total tube handling time and improves ETT placement accuracy in children using video laryngoscopy.

Background: Double-lumen endotracheal tubes (DLT) are essential for one-lung ventilation during thoracic surgery. Bronchoscopy is crucial for correct placement of a DLT to avoid complications such as hypoxemia. This study evaluated the effectiveness of the triple-cuffed DLT (tcDLT) in the supine and lateral positions for correct placement without bronchoscopic guidance.

Methods: This prospective observational study included 167 patients scheduled for elective thoracic surgery requiring one-lung ventilation. The incidence of successful placement of left-sided tcDLTs was compared between the supine and lateral decubitus positions under bronchoscopic surveillance. Successful tcDLT placement was defined as the placement of the proximal end of the bronchial cuff within 5 mm of the carina.

Results: Among 153 patients who completed the study, the successful tcDLT placement rate in the lateral position (70.6%) was significantly higher than that in the supine position (50.3%). The rate of difference was 20.3% (95% confidence interval [CI], 10.6-29.9%). The extended successful placement rate, including slightly deeper placements, showed no significant differences between the positions (88.9%; 95% CI, 83.9‒93.9% in supine, 86.3%; 95% CI, 80.8‒91.7% in lateral).

Conclusions: tcDLT facilitates correct tube placement in both the supine and lateral positions, with a higher lateral success rate. This finding supports the idea that tcDLTs offer a reliable alternative for lung separation when bronchoscopy is not feasible.

Background: Cardiothoracic anesthesiology training presents learners with unique challenges, procedural skills, and the management of high-intensity critical scenarios. An effective relationship between educator and learner can serve as the backbone for effective learning, which is crucial for the development of budding anesthesiologists. Strengthening this educational alliance between teachers and trainees involves understanding the educational values educators and learners find most important to their learning experiences. This study aimed to identify the key educational values related to cardiothoracic anesthesia for both learners and educators. By identifying these values in separate cohorts (learners and educators), the importance of various educational values can be examined and compared between the trainees and teachers.

Methods: Two separate surveys (one for learners and one for teachers) were adapted from the Pratt and Collins Teaching Perspectives Inventory to establish the importance of various educational values related to cardiothoracic anesthesia. Surveys were sent to 165 Accreditation Council for Graduate Medical Education-accredited anesthesiology residency training programs in the United States to trainees (residents and cardiothoracic anesthesiology fellows) and educators (board-certified cardiothoracic anesthesiologists).

Results: Analysis of survey results from 19 educators and 57 learners revealed no statistical differences across the two groups, except Q15: "Let trainee perform critical technical steps" (P value = 0.02).

Conclusions: While learners and educators in cardiothoracic anesthesia hold similar values regarding cardiac anesthesia education, they differ in the degree to which critical technical steps should be performed by learners.

Low back pain (LBP) is a prevalent and debilitating condition, particularly among older adults, with degenerative spinal disease being a major contributor. Regenerative therapy, which aims to repair and regenerate damaged spinal structures, has shown promise in providing long-term pain relief and functional improvement. This review focuses on the application and efficacy of regenerative therapies such as mesenchymal stem cells, platelet-rich plasma, and atelocollagen in older patients with LBP. Despite the potential benefits, there is a notable scarcity of studies specifically targeting the older population, and those available often have small sample sizes and limited age-related analyses. Our findings underscore the need for more comprehensive and well-designed clinical trials to evaluate the effectiveness of these therapies in older patients. Future research should prioritize larger age-specific studies to establish regenerative therapy as a viable and effective treatment option for LBP in the aging population.

Background: Conventional fascial plane block approaches for upper abdominal surgeries spare the lateral cutaneous nerve. An external oblique intercostal block (EOIB) may be suitable for upper abdominal incisions as it blocks the lateral and anterior branches of the intercostal nerves T6-T10. However, there is a paucity of studies evaluating this block in clinical settings. The study aimed to compare the analgesic efficacy of combined EOIB and rectus sheath block with local infiltration analgesia (LIA) in laparoscopic cholecystectomy (LC).

Methods: After obtaining written informed consent, 70 patients were randomly allocated to undergo right-sided EOIB with 20 ml and left-sided RSB with 10 ml of 0.25% bupivacaine at the end of surgery (group ER, n = 35). Patients in the LIA group (n = 35) underwent local infiltration at the port site using 20 ml of the same solution (group LIA, n=35).

Results: The visual analog scale scores with combined EOI and RSB were significantly lower than those with LIA at 1, 2, 4, 8, and 12 h (P < 0.001). Rescue analgesics were required by 65.7% and 14.3% of the patients in the LIA and block groups, respectively (P < 0.001). The time to first rescue analgesic was significantly greater in the ER group than that in the LIA group (2.8 ± 1.10 vs. 1.6 ± 0.50 h; P = 0.012). The number of times rescue analgesia was required was significantly lower in the ER group than that in the LIA group (1.00 ± 0.00 vs. 1.83 ± 0.72; P = 0.015). Nausea and vomiting scores were higher in the LIA group than those in the ER group (P < 0.001). Patient satisfaction scores were higher in the ER group than those in the LIA group.

Conclusions: EOIB combined with RSB provides superior analgesia compared with LIA and should be considered for LC.

Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.

Managing hemophilia in patients undergoing joint replacement surgery requires a comprehensive approach encompassing preoperative assessment, meticulous intraoperative care, and tailored postoperative management. Evaluation of joint integrity, bleeding history, and inhibitor presence guides surgical planning and hemostatic therapy selection to optimize outcomes. During surgery, careful attention to factor replacement, antibiotic prophylaxis, anesthetic techniques, and orthopedic strategies minimizes bleeding risk and enhances surgical success. Postoperatively, effective pain management, continued hemostatic therapy, and individualized rehabilitation programs are vital for facilitating recovery and preventing complications. Close monitoring for potential complications, such as periprosthetic joint infection and recurrent hemarthrosis, allows for prompt intervention when necessary. Overall, a collaborative approach involving hematologists, orthopedic surgeons, anesthesiologists, and rehabilitation specialists ensures comprehensive care tailored to the unique needs of patients with hemophilia undergoing joint replacement surgery, ultimately optimizing outcomes and improving quality of life. This holistic approach addresses the multifaceted challenges posed by hemophilia and joint replacement surgery, providing patients with the best possible chance for successful outcomes and long-term joint function. By integrating specialized expertise from multiple disciplines and implementing evidence-based strategies, healthcare providers can effectively manage hemophilia in the context of joint replacement surgery, mitigating risks and maximizing benefits for patients.