European Journal of Anaesthesiology最新文献

Background: Postoperative immunosuppression is a well known phenomenon associated with infectious complications. Peri-operative immune dysregulation is likely induced by surgical damage and anaesthetics, but remains far from comprehensively characterised. To address this, the effects of individual drugs on immune function must be explored. Sugammadex, a cyclodextrin that encapsulates rocuronium, also binds other drugs and structures and may influence the inflammatory response.

Objective: Investigate the potential immunomodulatory effect of sugammadex.

Design: An in-vitro experiment, randomised controlled pilot study and retrospective cohort study.

Setting: Tertiary teaching hospital.

Patients: Twelve healthy donors, 20 adults undergoing total hip arthroplasty and 1000 major abdominal surgery patients.

Intervention: In vitro: isolated peripheral blood mononuclear cells were exposed to sugammadex and rocuronium before stimulation with Escherichia coli lipopolysaccharides (LPS).Pilot study: patients undergoing total hip arthroplasty under single shot spinal anaesthesia randomised to sugammadex (8 mg kg-1) or placebo at the end of surgery.

Main outcome measure: In vitro: TNF, IL-1β and IL-6 production capacity.Pilot study: Ex-vivo cytokine production capacity after whole blood stimulation with LPS.Retrospective cohort: sugammadex as a predictor of postoperative infectious complications.

Results: In vitro: rocuronium suppressed TNF and IL-1β production capacity. Higher doses of sugammadex (100 and 1000 μg ml-1; 100 μg ml-1 corresponds to plasma concentration reached upon 8 mg kg-1 sugammadex) restored suppression of TNF and IL-1β.Pilot study: no differences in ex-vivo cytokine production capacity between the sugammadex and placebo group at the end of surgery or on postoperative day 1.Retrospective cohort study: no association between sugammadex and postoperative infectious complications (OR = 1.000, 95% CI 0.998 to 1.002).

Conclusion: Sugammadex preserved cytokine production capacity of TNF and IL-1β in vitro. The clinical pilot study and retrospective cohort study revealed no early postoperative immunomodulatory effects for sugammadex in the clinically used dosing range.

Trial registration: clinicaltrials.gov identifier: NCT05723406 and NCT05244655.

Background: The incidence of hepatocellular carcinoma (HCC) is on the rise worldwide, due to the increasing prevalence of liver diseases associated with metabolic dysfunction and better management of cirrhosis and its complications. The diversification of HCC treatments has recently increased, with the choice of strategy based on HCC characteristics, liver function and comorbidities. The combination of new therapies has transformed the prognosis, with up to 70% survival at 5 years.

Objective: The aim of this review was to analyse the most recent data on preoperative evaluation, peri-operative anaesthetic management of liver resection, liver transplantation and other types of procedures, and to highlight the multidisciplinary aspect of such management.

Main findings and discussion: The importance of preanaesthetic evaluation will depend largely on the procedure proposed, associated co-morbidities and the stage of liver disease. This assessment should verify stabilisation of all comorbidities, and evaluate the degree of portal hypertension, cirrhosis severity and sarcopenia. Liver resection and liver transplantation for HCC present specific surgical challenges, and minimally invasive techniques improve recovery. Nonsurgical procedures considered as therapeutic (ablation) or standby (regional embolisation) are diverse, and all expose patients to specific intra-anaesthetic complications, sometimes requiring intensive care management. Peri-operative anaesthetic strategies deployed in the management of liver resection or nonsurgical procedures involve specific management of fluids, coagulation, narcosis and analgesia, which can impact on patients' overall, and cancer prognosis. Lastly, new down-staging strategies combining several types of procedure and possibly immunotherapy, also call for collegial reflection on posthepatic transplant immunosuppression, which must remain tailored to each individual patient.

Background: Brugada syndrome (BrS) is a genetic disorder that increases the risk of ventricular tachyarrhythmias and sudden cardiac death (SCD). Certain drugs (propofol, local anaesthetics), fever, bradycardia, increased vagal tone and electrolyte imbalances can trigger or worsen BrS arrhythmias.

Objective: To evaluate the incidence of malignant ventricular arrhythmias during the perioperative period in patients with BrS, hypothesising that common anaesthetic drugs may be safe to use during daily clinical practice.

Design: The BRUGANAES study was an observational, retrospective project including BrS patients who underwent various types of anaesthesia.

Setting: BrS patients undergoing any type of anaesthesia intervention from 1 January 2006, to 31 December 2023, from a tertiary hospital in Barcelona.

Main outcome measures: The primary outcome was the occurrence of malignant ventricular arrhythmias and/or SCD during and up to 30 days postanaesthesia. Secondary outcomes included adverse events during hospitalisation, 30-day readmission rates and 30-day mortality rates.

Results: Among 652 BrS patients registered in the hospital, 111 patients and 189 procedures were analysed. General anaesthesia was administered in 51.3% of cases, sedation in 36% and regional/neuraxial anaesthesia exclusively in 12.7%. Overall, nonrecommended drugs (propofol, ketamine and local anaesthetics) were used in 129 (68.3%) procedures, either bolus and/or continuous infusion. Epidural blocks were performed in 34% of regional anaesthesia cases, mostly in obstetrics, and subarachnoid blocks in 31.8%. The primary outcome occurred in two patients intraoperatively (1% of procedures): one with bradycardia-induced ventricular fibrillation after a nonrecommended drug and one with transient ventricular tachycardia after a drug not listed as potentially harmful.

Conclusion: To date, this is one of the largest cohorts describing the perioperative approach for BrS patients, including a wide range of anaesthesia procedures and drugs. Most of the patients undergoing anaesthesia for an interventional procedure received an anaesthetic drug classified as not recommended.

Background: Postdural puncture headache (PDPH) is a common complication of neuraxial block resulting from either intentional dural puncture (IDP) or accidental dural puncture (ADP).

Objectives: The primary objective was to estimate the rate of PDPH and ADP following introduction of a real-time documentation system in April 2018. Secondary objectives included examining the use of epidural blood patch (EBP) and investigating risk factors associated with ADP and PDPH.

Design: Retrospective cohort study.

Setting: Secondary care at a tertiary hospital from January 2017 to April 2022.

Patients: Three hundred and eleven adult parturients after neuraxial block, with PDPH or a reported ADP, were identified during the procedure or postpartum.

Interventions: Implementation of a real-time documentation system in April 2018 to improve PDPH and ADP documentation.

Main outcome measures: Rates of PDPH and ADP, performance of epidural blood patch, and risk factors associated with PDPH and ADP.

Results: The overall rate of PDPH was 0.4% (164/39888), 95% confidence intervals (CI) 0.0036 to 0.0049, and the rate of ADP was 0.9% (284/31635), 95% CI 0.0078 to 0.0099. During the real-time documentation period, the rates were 0.44% (157/35376), 95% CI 0.0038 to 0.0052, and 0.99% (279/28121), 95% CI 0.0088 to 0.0111, for PDPH and ADP respectively. Thirty-two (10.3%) cases had IDP, and 279 (89.7%) had ADP. Among 279 ADP cases, 76.3% were identified during the procedure, 10.4% suspected and 13.3% identified postpartum. Cases of ADP identified postpartum had more emergency room visits (19%). Epidural blood patch (EBP) was administered in 72% of PDPH cases, with a high first-time success rate (89.5%); 11 women received epidural blood patch after IDP.

Conclusions: Postdural puncture headache remains a significant concern. In our cohort, 13.3% of ADP cases were detected postpartum, posing an increased challenge and underscoring the critical importance of follow-up care. We confirm that epidural blood patch may be required following any neuraxial block.

Trial registration: Not applicable.

Background: Breast surgery is frequently associated with significant acute postoperative pain, necessitating effective pain management strategies. Both thoracic paravertebral block (PVB) and interpectoral plane and pectoserratus plane (IP+PS) blocks have been used to relieve pain after breast surgery.

Objective: In this systematic review and meta-analysis with trial sequential analysis, we aimed to identify the optimal analgesic technique for achieving effective pain relief in breast surgery. The primary outcome of this study was postoperative opioid consumption expressed as morphine milligram equivalent (MME) at 24 h. Secondary outcomes included resting and movement pain scores at 0, 6, 12 and 24 h, postoperative nausea and vomiting (PONV), and rescue analgesic requirements within the first 24 h.

Design: A meta-analysis of randomised controlled trials (RCTs) with meta-regression and trial sequential analysis (TSA).

Data search: We systematically searched Pubmed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar, Medline (from inception to until 1 October 2024).

Eligibility criteria: RCTs that include patients undergoing breast surgery with PVB or IP+PS block, with no language restriction.

Results: Eighteen RCTs with 924 patients were included. No significant difference in MME consumption at 24 h was observed between the two techniques; mean difference (MD) -1.94 (95% confidence interval (CI) -4.27 to 0.38, P = 0.101). Subgroup analyses revealed a minor advantage for IP+PS in patients without axillary involvement; MD -2.42 (95% CI -3.56 to -1.29, P < 0.001), though below the threshold of clinical significance. Secondary outcomes, including pain scores, PONV incidence and rescue analgesic requirements were comparable. Trial sequential analysis (TSA) confirmed sufficient sample size, suggesting further studies may not alter conclusions.

Conclusion: PVB and IP+PS blocks offer comparable analgesic efficacy and opioid-sparing effects after breast surgery, with no meaningful differences in 24-h MME consumption, pain scores, or PONV incidence.

Background: After cardiac surgery, complete heparin reversal with protamine is essential. Accordingly, there is a need for an accurate and precise point-of-care device to detect possible residual heparin after protamine administration.

Objectives: To compare two different activated clotting time (ACT) tests and thromboelastometry in detecting postprotamine heparin activity after cardiac surgery.

Design: A single-centre prospective, observational study.

Setting: University Hospital from September 2021 to February 2023.

Participants: Fifty-five adult, elective cardiac surgical patients.

Interventions: The ACT-LR and ACT+ tests of Hemochron Signature Elite device, and the coagulation time (CT) ratio from INTEM and HEPTEM tests of ROTEM Sigma device, were analysed after protamine administration and compared to baseline values.

Main outcome measures: Based on postprotamine antifactor Xa (anti-fXa) activity, the patients were divided into heparin (anti-fXa ≥0.2 IU ml-1) and no heparin (anti-fXa ≤0.1 IU ml-1) groups.

Results: There was a mean bias of 44 [95% confidence interval (CI) 40 to 47] celite seconds between ACT-LR and ACT+ measurements. The absolute changes in ACT-LR, ACT+ and INTEM:HEPTEM CT ratio were variable and did not differ between the groups. The mean ± SD percentage changes between postprotamine and baseline ACT-LR and ACT+ values were 5.9 ± 17.5 and 5.9 ± 16.9% in the no residual heparin group, compared to 1.4 ± 8.4 and 9.9 ± 12.5% in the residual heparin group. Receiver operator characteristic curves for postprotamine INTEM:HEPTEM CT ratio and for percentage changes in ACT-LR and ACT+ to detect an anti-fXa at least 0.2 IU ml-1 had areas under the curve of 0.496 (95% CI, 0.329 to 0.663), 0.425 (95% CI, 0.260 to 0.591) and 0.583 (95% CI, 0.417 to 0.749), respectively.

Conclusion: Both the ACT-LR and ACT+ tests of Hemochron Signature Elite device and the INTEM:HEPTEM CT ratio of ROTEM Sigma device have poor ability to detect residual heparin shortly after protamine administration.

Background: Treatment programs designed to enhance recovery after caesarean delivery include multimodal analgesia to ensure optimal analgesia while reducing exposure to systemic opioids. Evidence for the effectiveness of continuous wound infiltration with local anaesthetic after unplanned caesarean delivery is needed.

Objective: To determine whether continuous ropivacaine wound infiltration has noninferior analgesic properties compared to epidural morphine, while reducing side effects related to opioids.

Design: Triple-blinded, noninferiority, randomised controlled trial.

Setting: One university hospital, between February 2015 and August 2021.

Patients: Eighty-one women undergoing unplanned lower segment caesarean section under epidural anaesthesia.

Intervention: At the end of the procedure, randomly assigned patients received either an epidural bolus of 0.9% saline with 48 h continuous ropivacaine wound infusion (ropivacaine group) or an epidural bolus of morphine with 48 h 0.9% saline wound infusion (morphine group).

Main outcome measures: Pain during mobilisation at 24 h postsurgery was assessed using the visual analogue pain scale (VAS 0 to 10) with no indication of the allocated group.

Results: Pain scores were 4.4 (95% CI, 3.6 to 5.1) in the ropivacaine group versus 3.1 (95% CI, 2.4 to 3.9) in the morphine group. The mean VAS pain difference between the two groups was 1.2 (95% CI, 0.2 to 2.3), which exceeded the prespecified noninferiority margin of 1. The differences between the two groups at rest and during mobilisation at 6 and 24 h were statistically significant. The ropivacaine group received rescue morphine more frequently, and were less satisfied despite fewer morphine-related side effects. Continuous wound infiltration was not technically feasible in 18% of the patients.

Conclusions: We failed to show that continuous ropivacaine wound infiltration was noninferior to epidural morphine in providing analgesia after unplanned caesarean delivery. Because of a significant rate of technical failures, continuous wound infiltration should only be considered when neuraxial morphine is contraindicated.

Background: Midazolam and propofol are frequently used for procedural sedation. Remimazolam may provide a more controllable sedation with fewer adverse effects.

Objective: To assess the sedation success rate and respiratory and cardiovascular complications of remimazolam versus placebo and other sedatives in adults undergoing procedural sedation.

Design: A systematic review of randomised controlled trials (RCTs) with meta-analyses, trial sequential analyses (TSA), and GRADE evaluations of the certainty of evidence.

Data sources: We searched Medline, Embase, CENTRAL, BIOSIS, CINAHL, and Web of Science Core Collection from their inception to 22 June 2024.

Eligibility criteria: RCTs allocating participants undergoing procedural sedation to remimazolam versus placebo or any active comparator.

Results: We included 63 trials randomising 13 953 participants. All included trial results were judged to be at high risk of bias. The sedation success rate was similar with remimazolam versus active comparators, relative risk (RR) 1.04, [97.5% confidence interval (CI), 0.96 to 1.14; TSA-adjusted CI, 0.95 to 1.18], P  = 0.26, GRADE: very low. Subgroup analyses indicated that remimazolam versus midazolam increased sedation success rate, while the risks were similar with remimazolam versus comparators. Remimazolam versus active comparators decreased the risk of respiratory complications, RR 0.47, (97.5% CI, 0.36 to 0.61; TSA-adjusted CI, 0.35 to 0.61), P < 0.01; and cardiovascular complications, RR 0.46, (97.5% CI, 0.37 to 0.56; TSA-adjusted CI, 0.38 to 0.57), P < 0.01. Subgroup analyses indicated that remimazolam versus propofol reduced respiratory and cardiovascular complications, while the risks were similar versus midazolam.

Conclusion: Remimazolam seems to provide a similar sedation success rate as other active comparators (propofol, ciprofol, midazolam, dexmedetomidine, etomidate), although subgroup analyses indicated that remimazolam increased sedation success rate compared to midazolam. Remimazolam compared to propofol may decrease the risk of respiratory and cardiovascular complications. The certainty of the evidence was very low to low, and firm conclusions could not be drawn.

Background: Fibrinolytic activity contributes to bleeding after cardiopulmonary bypass (CPB).

Objective: Our objectives were, in a group of infants undergoing cardiac surgery with CPB: to document the extent of peri-operative fibrinolysis using rotational thromboelastometry (ROTEM) and standard biomarkers; to compare the agreement between these fibrinolytic measures; to assess whether fibrinolytic activity is associated with early postoperative mediastinal bleeding and assess whether supplementation with fibrinogen concentrate affected fibrinolysis.

Design: Prospective cohort, mechanistic substudy, nested within the FIBrinogen CONcentrate (FIBCON) randomised controlled trial.

Setting: Single centre, tertiary paediatric cardiac surgery and paediatric intensive care units.

Patients: Ninety infants (median age 6.3 months) undergoing cardiac surgery, who all received routine intra-operative tranexamic acid. The infants were randomised to receive either an individualised dose of fibrinogen concentrate (n = 60) or placebo (n = 30) during CPB.

Main outcome measures: We measured the ROTEM variable maximum clot lysis (ML), and fibrinolytic biomarkers including plasmin-antiplasmin (PAP) and tissue plasminogen activator antigen (tPA-Ag). Blood was sampled pre-CPB, on-CPB and post-CPB, and 4 h after PICU admission.

Results: tPA-Ag, PAP and ROTEM ML increased significantly after CPB despite the use of tranexamic acid. The two fibrinolytic biomarkers t-PA and PAP, correlated (P = 0.001) but neither correlated with ROTEM ML. Early postoperative blood loss was inversely associated with PAP levels. Each 100 μg l-1 rise in PAP was associated with a 7.9% reduction in mean blood loss. Fibrinogen concentrate supplementation as expected did not affect tPA-Ag but was temporally associated with an increase in PAP levels and a decrease in ROTEM fibrinolytic activity.

Conclusion: Fibrinolysis is activated after paediatric cardiac CPB surgery as indicated by increased tPA-Ag and ROTEM ML. The substantial increase in tPA-Ag post-PICU admission is probably accompanied by a similar rise of plasminogen activator inhibitor 1 (PAI-1) as part of the acute phase response to surgery, thereby limiting clinical fibrinolysis. Supplementation of fibrinogen concentrate was associated with increased PAP activity and less clinical bleeding, consistent with the known role for fibrinogen in being a substrate for plasmin.

Trial registration: ISCTRN:50553029, Eudract:2013-003532-68.