European Journal of Anaesthesiology最新文献

Background: Neuraxial anaesthesia is commonly used for caesarean delivery, but intra-operative sensations such as pain, pressure and touch remain frequent and may affect patient experience.

Objective: To map intra-operative sensation during caesarean delivery under spinal anaesthesia, characterising sensation modality, intensity, anatomical location and bothersomeness across surgical phases.

Design: Dual-centre, prospective cohort study.

Setting: Two tertiary care hospitals in Israel (Rabin Medical Centre and Soroka University Medical Centre).

Patients: One hundred and forty-six women aged at least 18 years undergoing elective caesarean delivery with spinal anaesthesia and uterine exteriorisation.

Intervention: None.

Main outcome measures: Incidence and characteristics of pain, pressure and touch sensations measured using Verbal Numeric Scale (VNS); bothersomeness rates; temporal distribution across surgical phases.

Results: Pain occurred in 22/146 patients (15.1%), most commonly during uterine exteriorisation (5.5%) and its reinsertion (5.2%) median maximum intensity was 5.0. Only two patients received analgesia. Pressure was reported by 134/146 patients (91.8%) and touch by 82/146 (56.2%), both most frequently during baby delivery. Median maximum intensity for both was 5.0. Despite high prevalence, pressure and touch were rarely bothersome (7.5 and 4.3% of events, respectively). Only four patients (2.7%) reported no sensations. Pain never occurred in isolation but was always accompanied by pressure and/or touch sensations.

Conclusions: Intra-operative sensation during caesarean delivery under spinal anaesthesia is common but usually well tolerated. Most patients experience pressure and touch, especially during delivery, but few find this distressing. These findings support tailored pre-operative counselling to improve maternal experience.

Background: Use of neuromuscular blocking agents (NMBAs) is recommended by European Society of Anaesthesiology and Intensive Care in neonates (<1 month) and infants (<1 year) to facilitate tracheal intubation, but the use in other paediatric age groups is still debated.

Objective: We assessed the effects of avoidance versus use of NMBA for facilitation of tracheal intubation in children and infants. The primary outcome was incidence of difficult tracheal intubation.

Design: A systematic review of randomised controlled trials with meta-analyses and trial sequential analysis.

Eligibility criteria: Paediatric patients undergoing tracheal intubation (oral or nasal) using direct laryngoscopy or video laryngoscopy with or without NMBAs for any type of procedure requiring general anaesthesia.

Data sources: A systematic search up to 8 July 2025 in Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), the Cochrane Central Register of Controlled Trials (CENTRAL), BioSciences Information Service of Biological Abstracts (BIOSIS), International Web of Science and Advanced Google and Cumulative Index to Nursing & Allied Health Literature (CINAHL). Trial registries were explored to uncover unpublished data or supplementary trials, http://links.lww.com/EJA/B253.

Results: We identified 47 randomised clinical trials (n = 2276). Three trials were categorised as 'low risk of bias'. Thirty trials reported the primary outcome. Avoidance of NMBAs was associated with increased risk of difficult tracheal intubation with a risk ratio (RR) of 3.47 [95% confidence interval (CI), 2.52 to 4.77, P < 0.001, I2 = 18%] and moderate certainty of evidence. The trial sequential analysis resulted in α-spending adjusted RR of 3.68 when avoiding NMBAs (95% CI, 2.22 to 6.11; α = 5%, β = 90%). We found no significant increased risk of serious adverse events comparing avoidance and use of NMBA (very low certainty of evidence).

Conclusion: Using NMBAs for facilitation of tracheal intubation reduces the incidence of difficult tracheal intubation compared to avoidance of NMBA in children and infants.

Background: Haemodynamic management and fluid administration constitute a challenging cornerstone of intra-operative care to counteract hypotension. Observational studies remain a vital source of evidence regarding the associations of fluids and vasopressors with peri-operative outcomes.

Objective: To evaluate dynamic treatment regimens (DTRs) of balanced crystalloids on the incidence of intra-operative hypotension. DTRs constitute a statistical framework to evaluate the causal impact of different treatment strategies (e.g. fluid administration) on an outcome (e.g. hypotension) whilst accounting for time-dependent treatments and treatment-confounder feedbacks.

Design: Analysis of observational data using modern causal inference methods.

Setting: Tertiary institution in South Korea during January 2011 to December 2020 (INSPIRE dataset).

Patients: N = 23 305 patients undergoing elective surgery under general anaesthesia.

Interventions: The DTRs refer to thresholds of mean invasive arterial blood pressure (MAP) to guide a hypothetical administration of 250 ml of balanced crystalloids. As example, a DTR implies administering 250 ml of balanced crystalloids if MAP drops below a 70 mmHg threshold, and to administer no crystalloids otherwise. MAP thresholds of 60, 65, 70 and 75 mmHg were evaluated.

Main outcome measures: Primary endpoint was intra-operative hypotension defined as a MAP below 65 mmHg averaged in 15-min windows.

Results: The DTRs resulted in clinically similar incidences of intra-operative hypotension for surgeries shorter than 2 h. For surgeries lasting longer, the DTRs with early fluid administration resulted in a reduction of hypotension of more than 4% towards the end of the surgery. As higher MAP-thresholds imply higher amounts of fluid, our findings suggest there is in general a positive effect of fluid administration on intra-operative hypotension.

Conclusions: Using modern causal inference methods, we demonstrated the clinical utility of idealised DTRs to study the impact of time-dependent haemodynamic management on the incidence of intra-operative hypotension in idealised settings. Future studies are required to investigate more complex DTRs mirroring clinical practice and to assess the robustness of the findings with respect to the different surgical populations.

Background: Circadian rhythm disruption, as a modifiable risk factor, has been increasingly recognised for its potential impact on adverse health outcomes, particularly in surgical populations where its implications warrant further investigation.

Objectives: To investigate associations between postoperative outcomes and preoperative rest-activity rhythm metrics from accelerometry.

Design: A cohort analysis of UK Biobank participants undergoing major surgery within 1 year of accelerometer monitoring.

Setting: UK Biobank, a large population-based cohort in the United Kingdom.

Patients: These were 5654 adults (37 to 73 years) completing 7-day preoperative wrist accelerometry.

Exposure: Rest-activity rhythm relative amplitude was analysed both as a continuous variable and as a categorical variable. For the categorical analysis, a low relative amplitude group was defined as more than 2 standard deviations below the cohort mean: all other participants served as the high relative amplitude group.

Main outcome measures: The primary composite outcome included 30-day postoperative complications and 90-day mortality. Multivariable logistic regression was used to adjust for comorbidities, demographics and surgical risk factors.

Results: Participants with a low relative amplitude ( n  = 225) demonstrated significantly higher rates of adverse outcomes compared with the remainder of the participants ( n  = 5429), with an absolute risk difference of 6.1% (9.8 vs. 3.7%), P  < 0.001). Multivariable analysis revealed a dose-response relationship: each standard deviation decrease in relative amplitude increased risk by 23% {adjusted odds ratio, aOR: 1.23 [95% confidence interval (CI), 1.06 to 1.42]}. The low amplitude group had double the risk of adverse outcomes compared with the remainder of the participants: adjusted OR: 2.16 (95% CI, 1.25 to 3.73).

Conclusions: A lower preoperative circadian relative amplitude is associated with increased postoperative morbidity and mortality. Accelerometry-based circadian monitoring may provide a novel, cost-effective strategy for preoperative risk stratification.