Anesthesia and pain medicine最新文献

Pain management in lung cancer resection has undergone a paradigm shift from opioid-centric approaches to multimodal analgesia, and more recently, personalized strategies that integrate the principles of precision medicine. Historically, opioids have been the mainstay of perioperative analgesia. However, concerns regarding opioid-related adverse effects, including respiratory depression, immunosuppression, and potential oncologic implications, have driven the adoption of opioid-sparing techniques. Current strategies emphasize multimodal analgesia, combining nonsteroidal antiinflammatory drugs, acetaminophen, regional anesthesia, and adjunctive agents to enhance pain control while minimizing opioid exposure. However, growing evidence suggests that perioperative analgesics may differentially influence tumor biology depending on molecular and genetic factors, necessitating a more tailored approach. This has led to the emergence of precision oncoanesthesia, which aims to integrate tumor-specific genomic insights into perioperative pain management. Although promising, the clinical implementation of precision oncoanesthesia remains in its early stages, with key challenges including the lack of large-scale prospective studies, limited real- time genomic profiling in anesthetic planning, and variability in patient responses to analgesics. Future research should focus on identifying biomarkers that predict individual responses to perioperative analgesia and establishing evidence-based guidelines for precision- based pain management. By evolving beyond traditional opioid reliance and standard analgesic protocols, perioperative pain management in lung cancer surgery can align with emerging precision medicine approaches, ensuring effective pain control and optimized oncologic outcomes.

Background: Anterior suprascapular nerve block is widely used for postoperative shoulder pain management. Although cadaveric studies show the spread and smudging of the phrenic nerve, our cadaveric injection investigation was conducted to investigate the pathway of diffusion of the dye toward the phrenic nerve from a more distal injection at the suprascapular nerve.

Methods: We injected 5 ml of 0.1% methylene blue dye into the proximal portion of the suprascapular nerve (infra-omohyoid in the posterior triangle) in 12 neck specimens from six cadavers. Following meticulous dissection, we assessed the spread of the dye along the brachial plexus to the nerve roots and traced the phrenic nerve for staining.

Results: The phrenic nerve was stained in 41.7% of the cases, the inferior trunk of the brachial plexus was unstained in all cases (100%), and the posterior division and suprascapular nerve were stained in all cases (100%). The nerves to the subclavius, dorsal aspect of the superior trunk, and C5 and C6 roots were stained in all cases. Anterior division of the superior trunk was observed in 75% of the specimens. The dye-spread pathway along the brachial plexus was dorsal, sparing the ventral aspect.

Conclusions: Our study demonstrated that the dye-spread pathway from the suprascapular nerve at the infra-omohyoid level to the phrenic nerve is dorsal to the brachial plexus.

Permissive strategies in the intensive care unit (PSICU) intentionally allow certain physiological parameters to deviate from traditionally strict control limits to mitigate the risks associated with overly aggressive interventions. These strategies have emerged in response to evidence that rigid adherence to normal physiological ranges may cause harm to critically ill patients, leading to iatrogenic complications or exacerbation of underlying conditions. This review discusses several permissive strategies, including those related to hypotension, hypercapnia, hypoxemia, and lower urinary output thresholds. The key principles of these strategies require careful balancing and close monitoring to ensure that the benefits outweigh the risks for each patient. This approach emphasizes individualized care, thoughtful decision-making, and flexible application of guidelines. The use of a PSICU may help minimize the side effects of treatment while addressing the primary condition of the patient and allowing for a more holistic view of critically ill patients.

Immunonutrition, which uses specific nutrients to modulate the immune response, has emerged as a vital adjunct to perioperative care. Surgery-induced stress triggers immune responses that can lead to complications, such as infections and delayed wound healing. Traditional nutritional support often overlooks the immunological needs of surgical patients. Immunonutrition addresses this oversight by providing key nutrients, such as arginine, omega-3 fatty acids, glutamine, nucleotides, and antioxidants (vitamins C and E) to enhance immune function and support tissue repair. This review examined the efficacy and safety of immunonutrition in surgical settings, guided by the recommendations of the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism. Both organizations recommend immunonutrition for high-risk or malnourished patients undergoing major surgery and support its use in reducing complications and improving recovery. The key nutrients in immunonutrition aim to improve immune cell function, reduce inflammation, and enhance wound healing. Clinical studies and meta-analyses have demonstrated that immunonutrition lowers the infection rate, shortens the length of hospital stay, and accelerates recovery. Challenges hindering the clinical application of immunonutrition include cost, logistics, and a lack of standardized and personalized protocols. Future studies should focus on biomarker-driven approaches, pharmacogenomics, and innovative nutrient formulations. Addressing these issues will help to integrate immunonutrition into clinical practice, ultimately improving surgical outcomes and patient recovery.

Background: Failed back surgery syndrome is a common problem faced by chronic pain management specialists. Steroid-only epidural injections have modest efficacy because of excessive scarring. Epidural hyaluronidase (HA), functions as a depolymerizing agent, successfully breaking down adhesions and collagen bundles, whereas dexmedetomidine (DEX) helps to reduce inflammation.

Methods: The current study is a randomized, double blind, clinical trial. The study cohort included population with persistent (> 6 months) back and/or radicular lower limb pain after laminectomy. Group I (HA group) received bupivacaine 0.5% (5 mg), triamcinolone 40 mg, sterile saline (2 ml), and HA (1500 IU) instilled in 1 mL of distilled water. Group II (DEX group) received bupivacaine 0.5% (5 mg), triamcinolone 40 mg (1 ml), DEX (0.5 mcg/kg), and sterile saline (2 ml).

Results: Both groups showed significant reductions in VAS scores at all follow-ups compared to the pre-injection values. At 6 months, the DEX group experienced a significantly greater reduction in pain scores than the HA group (P = 0.003). In terms of the MODI, both groups showed significant reductions in disability scores at all follow-ups relative to the pre-injection values. The DEX group showed greater improvement in MODI values than the HA group. No significant complications were reported.

Conclusions: Both DEX and HA yielded significant improvements in pain and disability scores compared with pre-injection levels. The DEX group showed a more substantial and long-term reduction in both pain scores and disability index than the HA group.

Background: Living-donor liver transplantation (LDLT) is a viable alternative to deceased-donor liver transplantation. Enhanced recovery after surgery protocols that include early extubation offer short-term benefits; however, the effect of immediate extubation in the operating room (OR) on long-term outcomes in patients undergoing LDLT remains unknown. We hypothesized that immediate OR extubation is associated with improved long-term outcomes in patients undergoing LDLT.

Methods: This retrospective cohort study included 205 patients who underwent LDLT. The patients were classified based on the extubation location as OREX (those extubated in the OR) or NOREX (those extubated in the intensive care unit [ICU]). The primary outcome was overall survival (OS), while secondary outcomes included ICU stay, hospital stay duration, and various postoperative outcomes.

Results: Among the 205 patients, 98 (47.8%) underwent extubation in the OR after LDLT. Univariate analysis revealed that OR extubation did not significantly affect OS (hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.24-1.05; P = 0.066). Furthermore, multivariate analysis revealed no statistically significant association between OR extubation and OS (HR: 0.79, 95% CI: 0.35-1.80; P = 0.580). However, OR extubation was significantly associated with a lower incidence of 30-day composite complications and shorter ICU and hospital stays. Multivariate analysis indicated that higher preoperative platelet counts, increased serum creatinine levels, and a longer surgery duration were associated with poorer OS.

Conclusions: Immediate OR extubation following LDLT surgery was associated with fewer 30-day composite complications and shorter ICU and hospital stays; however, it did not significantly improve OS compared with ICU extubation.

Continuous peripheral nerve blocks using perineural catheters are increasingly used because they are the only well-established techniques that can provide prolonged analgesia. Although the novel indications and benefits of each type of continuous peripheral nerve block have been well described in several review articles, there is a lack of recent publications focusing on the use of perineural catheters. Numerous clinical challenges are associated with the use of catheters for pain management. This narrative review discusses the currently available perineural catheter designs, catheter fixation methods, perineural catheter-related complications, and management strategies.

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: As the global population ages, medical professionals are also aging. This study investigates the status of Korean anesthesiologists over the age of 60.

Methods: Anesthesiologists aged 60 and older, residing and working in Korea, were invited to participate in this study via e-mail from February to March 2021 and by mail from June to August 2021. The survey consisted of 40 questions covering 10 topics, including health status, residence, work style, and economic status. Depending on the type of question, answers were ranked on a scale of 1, 2, and 3, with the most preferred response being selected.

Results: A total of 63 responses were received, resulting in a response rate of 26.5%. Among the respondents, 56 were currently practicing as anesthesiologists and reported satisfaction with their clinical practice and life status. On average, they treated 24 patients per day without experiencing significant discomfort or inconvenience in their roles as senior physicians. Twenty-four respondents acknowledged physical discomfort related to aging, and nine expressed cautions regarding age-related changes. Fifty-two respondents indicated that reeducation for advanced medical practice as anesthesiologists was necessary.

Conclusions: Senior anesthesiologists in Korea are primarily working in secondary and tertiary hospitals and are satisfied with their current life status. A comprehensive evaluation of reeducation programs for advanced clinical practice and retirement strategies for senior anesthesiologists is needed to address the growing number of aging physicians in the workforce.