European Journal of Anaesthesiology最新文献

Background: Children are more susceptible to postoperative pulmonary complications (PPCs) due to their smaller functional residual capacity and higher closing volume; however, lung-protective ventilation (LPV) in children requiring one-lung ventilation (OLV) has been relatively underexplored.

Objectives: To evaluate the effects of LPV and driving pressure-guided ventilation on PPCs in children with OLV.

Design: Randomised, controlled, double-blind study.

Setting: Single-site tertiary hospital, 6 May 2022 to 31 August 2023.

Patients: 213 children aged < 6 years, planned for lung resection secondary to congenital cystic adenomatoid malformation.

Interventions: Children were randomly assigned to LPV ( n  = 142) or control ( n  = 71) groups. Children in LPV group were randomly assigned to either driving pressure group ( n  = 70) receiving individualised positive end-expiratory pressure (PEEP) to deliver the lowest driving pressure or to conventional protective ventilation group ( n  = 72) with fixed PEEP of 5 cmH 2 O.

Main outcome measures: The primary outcome was the incidence of PPCs within 7 days after surgery. Secondary outcomes were pulmonary mechanics, oxygenation and mechanical power.

Results: The incidence of PPCs did not differ between the LPV (24/142, 16.9%) and the control groups (15/71, 21.1%) ( P  = 0.45). The driving pressure was lower in the driving pressure group than in the 5 cmH 2 O PEEP group (15 vs. 17 cmH 2 O; P   =  0.001). Lung compliance and oxygenation were higher while the dynamic component of mechanical power was lower in the driving pressure group than in the 5 cmH 2 O PEEP group. The incidence of PPCs did not differ between the driving pressure (11/70, 15.7%) and the 5 cmH 2 O PEEP groups (13/72, 18.1%) ( P   =  0.71).

Conclusions: LPV did not decrease the occurrence of PPCs compared to non-protective ventilation. Although lung compliance and oxygenation were higher in the driving pressure group than in the 5 cmH 2 O PEEP group, these benefits did not translate into significant reductions in PPCs. However, the study is limited by a small sample size, which may affect the interpretation of the results. Future research with larger sample sizes is necessary to confirm these findings.

Trial registration: ChiCTR2200059270.

Background: Chest wall surgery for the correction of pectus excavatum or pectus carinatum has gained increased interest in recent years. Adequate pain treatment, respiratory physiotherapy and early ambulation are key to improving the outcomes. Although thoracic epidural analgesia is highly effective, its safety is controversial, leading to extensive scrutiny and questioning of its role.

Objectives: We hypothesise that thoracic epidural analgesia is effective and well tolerated to use in adolescents, with a high success rate and low pain scores.

Design: Observational retrospective cohort study.

Setting: All adolescent cases in a high-volume academic tertiary chest wall surgery centre between March 1993 and December 2017 were included.

Patients: A total of 1117 patients aged from 12 to 19 years of age and receiving either Ravvitch, Nuss or Abramson chest wall reconstruction for pectus excavatum were identified in our institutional chest wall surgery database. After applying selection and exclusion criteria, 532 patients were included in the current analysis.

Main outcome measures: The primary endpoint of this study was the safety of epidural analgesia, assessed by the incidence of acute adverse events. Secondary endpoints were block success rates using a specific novel definition, and analgesic efficacy using recorded postoperative pain scores.

Results: More than 60% of patients experienced one or more adverse events. However, all events were minor and without consequences. No serious or long-term adverse events were detected. The success rate of thoracic epidural placement was 81%. Low postoperative pain scores were observed.

Conclusion: Thoracic epidural analgesia is an extremely effective pain control technique, with a surprisingly high number of minor adverse events but safe with regard to serious adverse events.

Trial registration: The local research ethics committee approved and registered this study on 16 May 2022 (registration number: S66594).

Background: The European Diploma of Anaesthesiology and Intensive Care (EDAIC) Part II examination is a supranational examination for anaesthesiologists.

Objectives: We explore the impact of examiner pairing on leniency and stringency, commonly referred to as the 'hawk-dove effect'. We investigate the potential variations in grading approaches, resulting from different examiner pairs and their implications for candidate performance.

Design: Retrospective cohort, observational design.

Setting: EDAIC Part II examination data from 2021 to 2023.

Participants: Three hundred and twenty-five examiners across 122 EDAIC Part II single-day examination sessions.

Interventions: We analysed the influence of examiner leniency and examiner pairing on candidate performance in the EDAIC Part II using many-facet Rasch modelling.

Main outcome measures: The study's main outcome measure was determining a leniency score among the examiner population. The study also aimed to assess how examiner pairing influenced candidate performance, as measured by their scores in the examination.

Results: During the study period, the number of examiners who participated in 2021, 2022 and 2023 were 253, 242 and 247, respectively. The median [IQR] single-day sessions attended were 7.0 [3 to 10]. The examination data revealed a mean leniency score of 0 (95% confidence interval (CI) -0.046 to 0.046), with the standard deviation being one-third that of the candidates' ability scores. There were 1424 different pairs of examiners, with most pairs (97%) having only a one-point difference in marking. The mean leniency score for the pair of examiners was -0.053 (95% CI -0.069 to -0.037).

Conclusion: The variations in grading approaches associated with different pairings emphasise the potential for the 'hawk-dove effect' to influence candidate performance and outcomes. Understanding these variations can guide curriculum development, examiner training and coupling, ensuring a balanced and equitable assessment process.

Trial registration: None.

Background: Intra-operative urine output (UO) has been shown to predict postoperative acute kidney injury (AKI) in adults; however, its significance in children undergoing cardiac surgery remains unknown.

Objective: To explore the association between intra-operative UO and postoperative AKI in children with congenital heart disease.

Design: A retrospective observational study.

Setting: A tertiary hospital.

Patients: Children aged >28 days and <6 years who underwent cardiac surgery at Fuwai Hospital from 1 April 2022 to 30 August 2022.

Main outcome measures: AKI was identified by the highest serum creatinine value within postoperative 7 days using Kidney Disease Improving Global Outcomes (KDIGO) criteria.

Results: In total, 1184 children were included. The incidence of AKI was 23.1% (273/1184), of which 17.7% (209/1184) were stage 1, 4.2% (50/1184) were stage 2, and others were stage 3 (1.2%, 14/1184). Intra-operative UO was calculated by dividing the total intra-operative urine volume by the duration of surgery and the actual body weight measured before surgery. There was no significant difference in median [IQR] intra-operative UO between the AKI and non-AKI groups (2.6 [1.4 to 5.4] and 2.7 [1.4 to 4.9], respectively, P  = 0.791), and multivariate logistic regression analyses showed that intra-operative UO was not associated with postoperative AKI [adjusted odds ratio (OR) 0.971; 95% confidence interval (CI), 0.930 to 1.014; P  = 0.182]. Regarding the clinical importance of severe forms of AKI, we further explored the association between intra-operative UO and postoperative moderate-to-severe AKI (adjusted OR 0.914; 95% CI, 0.838 to 0.998; P  = 0.046).

Conclusions: Intra-operative UO was not associated with postoperative AKI during paediatric cardiac surgery. However, we found a significant association between UO and postoperative moderate-to-severe AKI. This suggests that reductions in intra-operative urine output below a specific threshold may be associated with postoperative renal dysfunction.

Trial registration: Clinicaltrials.gov identifier: NCT05489263.

Background: Spinal anaesthesia is frequently used in surgical procedures involving the lower abdomen and extremities, however, the occurrence of hypotension remains a common and clinically important adverse effect. Unilateral spinal anaesthesia seems to be a promising approach to minimise this complication but the effectiveness of this remains controversial.

Objective: A meta-analysis was undertaken to evaluate the superiority of unilateral spinal anaesthesia over bilateral spinal anaesthesia with regard to the incidence of hypotension and other complications.

Design: Systematic reviews and meta-analysis of randomised controlled trials (RCTs).

Date sources: PUBMED, Embase, Web of Science and Cochrane Central Register of Controlled Trials databases were searched from their inception to 5 March 2024.

Eligibility criteria: Randomised controlled trials (RCTs) comparing unilateral spinal anaesthesia with bilateral spinal anaesthesia were eligible for inclusion. Observational studies, case reports, case series, and studies not conducted in humans were excluded. The incidence of hypotension, vasopressor requirement, and other complications were compared. Heterogeneity was assessed by subgroup analyses and sensitivity analysis.

Results: Twenty-one trials involving 1358 patients undergoing unilateral lower extremity surgery or lower abdominal surgery were included in the meta-analysis. Hyperbaric solutions were used in most trials. The Mantel-Haenszel random-effect model was used for the analysis of binary endpoints, reported as relative risk (RR) with a 95% confidence interval (CI). The incidence of hypotension was significantly lower in the unilateral spinal anaesthesia group compared with the bilateral spinal anaesthesia (RR 0.38, 95% CI 0.27 to 0.55; P < 0.001; I2 = 38%). Subgroup analysis shows that the occurrence of hypotension was significantly lower in the unilateral subgroup, regardless of dosage, surgical site, adjuvants to the local anaesthetics, and different definitions of hypotension.

Conclusions: Unilateral spinal anaesthesia is associated with a significant reduction in the occurrence of hypotension, despite variations in the definition of hypotension, adjuvants, and site of surgery. These results favour the use of lateral spinal anaesthesia in patients undergoing unilateral lower abdominal or lower limb surgery. However, the GRADE assessment of the quality of evidence was 'low' due to the high risk of bias and heterogeneity. All the results should be treated with caution.

Background: Total intravenous anaesthesia guided by electroencephalography and neurophysiological monitoring may be used for carotid endarterectomy. Reduction of brain metabolic demand during cross-clamping of the internal carotid artery with propofol titrated to burst suppression requires effect-site concentrations that may delay emergence and interfere with intraoperative neurophysiological monitoring.

Objective: To test the hypothesis that dexmedetomidine decreases the effect-site concentration of propofol required for burst-suppression in patients undergoing carotid endarterectomy.

Design: Randomised controlled trial.

Participants: Patients undergoing carotid endarterectomy.

Setting: University Hospital of Berne, Switzerland, from October 2018 to September 2024.

Interventions: Patients were randomised into a control (n = 23) and a dexmedetomidine groups (n = 22). Total intravenous anaesthesia was administered to both groups. Patients in the dexmedetomidine group received an intravenous bolus of dexmedetomidine (0.4 μg kg-1 over 10 min) before induction, followed by a continuous intravenous infusion (0.4 μg kg-1 h-1). The effect-site concentrations of propofol were titrated against frontal electroencephalography parameters. Burst suppression was induced with propofol during cross-clamping of the internal carotid artery.

Outcome measures: The primary outcome was the effect-site concentration of propofol required for burst-suppression. The secondary outcomes were the requirement for vasoactive substances, neurophysiological monitoring parameters, and postoperative delirium.

Results: The effect-site concentration of propofol required for burst suppression was 4.0 μg ml-1 [3.50 to 4.90] (median [interquartile range]) in the dexmedetomidine group compared with 6.0 μg ml-1 [5.5 to 7.3] in the control group (P < 0.001). Less norepinephrine was required in the dexmedetomidine group (total 454 μg [246 to 818] compared with 1000 μg [444 to 1326] (P = 0.015) in the control group). Dexmedetomidine did not affect intraoperative neurophysiological monitoring.

Conclusion: Co-administration of dexmedetomidine to total intravenous anaesthesia for carotid endarterectomy decreased the effect-site concentrations of propofol required for burst suppression by 33%. The propofol-sparing effect and peripheral alpha-agonism of dexmedetomidine may explain the reduced requirement for vasopressors.

Trial registration: Clinicaltrials.gov identifier: NCT04662177.

Background: The inability to measure the force applied during cricoid pressure is an important limitation in clinical practice. We developed a novel device to measure this force and provide real-time feedback to the operator.

Objectives: To test the hypothesis of superior oesophageal occlusion during cricoid pressure when guided by the novel device as compared with conventional practice.

Design: A prospective randomised controlled trial.

Setting: Tertiary University Hospital, May to December 2021.

Patients: Sixty-five ASA I/II adult patients of either sex scheduled for elective surgery under general anaesthesia requiring tracheal intubation. Patients with comorbidities involving the neck, those at risk of pulmonary aspiration, anticipated difficult airway and BMI at least 35 kg  m-2 were excluded.

Intervention: Operators applied cricoid pressure with their fingers in both groups. Participants were randomised into 'feedback group' where the operator adjusted this force based on the force measured by the novel device, and 'control group' where the force measured by the device was shielded from the operator.

Main outcome measures: The primary outcome was the rate of occlusion of oesophageal opening assessed by whether a 12 CH orogastric tube could be inserted into the oesophageal entrance during videolaryngoscopy. Secondary outcomes included the magnitudes of force measured during cricoid pressure, oesophageal diameter measured ultrasonographically during cricoid pressure and intubation parameters.

Results: Sixty-four patients completed the study. The oesophageal opening was occluded in significantly more patients in the feedback group compared with the control group (94 vs. 6%; P = 0.001). The mean ± SD force (N) applied was significantly better and consistent at all time points in the feedback group compared to the control group (22.65 ± 7.81 vs. 14.57 ± 11.13, P < 0.001). The median [IQR] anteroposterior diameter of the oesophagus during cricoid pressure was less in the feedback group compared to the control group (0.49 [0.36 to 0.56] vs. 0.57 [0.48 to 0.65], P = 0.006).

Conclusions: The use of the novel sensor device achieved a significantly high rate of oesophageal occlusion during application of cricoid pressure.

Trial registration: Clinical Trial Registry of India (CTRI/2021/05/033484).