European Journal of Anaesthesiology最新文献

Background: The integration of enhanced recovery after surgery (ERAS) protocols into the peri-operative management of video-assisted thoracic surgery (VATS) has facilitated rapid patient recovery, enabling discharge within 48 h. However, postoperative pulmonary complications (PPCs) postdischarge pose significant concerns for patient welfare. Despite the established utility of lung ultrasound (LUS) in diagnosing the causes of dyspnoea, the effectiveness of quantitative LUS in predicting PPCs after VATS remains uncertain.

Objectives: To determine whether quantitative LUS performed 24 h after surgery can identify patients with a higher risk of developing PPCs within 30 days after discharge from hospital.

Design: Single-centre prospective cohort study.

Setting: Academic tertiary care medical centre.

Patients: Adults scheduled for elective VATS under general anaesthesia from November 2022 to January 2023.

Main outcome measures: This primary aim was to verify the association between lung ultrasound score (LUSS) on postoperative day 1 (POD1) and PPCs. The secondary aim was to identify other relevant peri-operative factors closely related to PPCs and establish a model capable of predicting the risk of PPCs in patients undergoing fast-track VATS.

Results: Of the 200 recruited patients, 182 completed the LUS examination and 30-day follow-up. Of these, 66 (36.2%) developed various types of PPCs. These patients had a higher LUSS on POD 1 (P < 0.001), and more subpleural consolidation areas compared to those without PPCs (P < 0.001). Receiver-operating characteristics (ROC) analysis identified the optimal LUSS cut-off value at 6 points for predicting the occurrence of PPCs, with an area under the curve (AUC) of 0.838 (95% CI, 0.768 to 0.909). Patients with PPCs had higher rates of immune system diseases and ARISCAT score, longer hospital stay and procalcitonin levels, increased frequency of lobar resection, longer durations of surgical and mechanical ventilation, and greater incidence of unplanned hospital readmissions within 30 days postdischarge, compared with those without PPCs (all P < 0.001). Multivariable logistic regression analysis indicated that the comorbidity of immune system disease, along with postoperative 24 h LUSS, were independent risk factor for PPCs within 30 days after VATS.

Conclusion: LUSS on POD 1 emerged as an independent risk factor for PPCs in fast-track VATS patients and reliably predicted the occurrence of PPCs within 30 days of hospital discharge.

Trial registration: ClinicalTrials. gov No. ChiCTR2200065865.

Background: The win ratio analysis method might provide new insight on the impact of positive end-expiratory pressure (PEEP) on clinical outcomes.

Objective: The aim is to re-analyse the results of the 'Re-evaluation of the effects of high PEEP with recruitment manoeuvres vs. low PEEP without recruitment manoeuvres during general anaesthesia for surgery' (REPEAT) study using the win ratio analysis.

Design: Individual patient data meta-analysis.

Setting: Three international multicentre randomised trials.

Participants: Patients undergoing general anaesthesia for surgery.

Intervention: High vs. low PEEP.

Main outcome measure: Hierarchical composite endpoint of: all-cause hospital mortality; hospital length of stay; need for postoperative mechanical ventilation; severe pulmonary complications; and mild pulmonary complications.

Results: A total of 3774 patients undergoing general anaesthesia for surgery were included in this analysis. The median (interquartile range [IQR]) age was 57 [45 to 68] years and 2077 (55%) were women. A total of 3 560 720 comparison pairs were produced. The high PEEP group had a higher percentage of losses than wins in hospital mortality (1.1 vs. 0.9%) and hospital length of stay (33.8 vs. 33.2%), comparable percentages of losses and wins in postoperative invasive mechanical ventilation (0.2 vs. 0.2%), a higher percentage of wins in severe complications (2.5 vs. 2.1%) and a higher percentage of ties in mild complications (18.7 vs. 3.9% wins vs. 3.3% losses). The win ratio for high PEEP compared with low PEEP group was 1.00 (95% CI 0.92 to 1.09).

Conclusion: No beneficial effects of high PEEP compared with low PEEP were found in this win ratio analysis.

Registration: Clinicaltrials.gov (study identifier NCT03937375).

Background: Previous studies have explored tools for evaluating the effects of positive fluid balance, with recent emphasis, and controversies, on venous ultrasound parameters and composite scores. The portal vein pulsatility index and the renal venous pattern have emerged as the most promising indicators of volume-induced venous congestion. But in the general intensive care unit (ICU), numerous factors influence cardiovascular homeostasis, affecting venous function.

Objectives: This study aimed to evaluate the factors associated with portal vein pulsatility index in general ICU patients. Secondary objectives were to examine the correlations between pulsatility index and additional markers of congestion.

Design: This exploratory study was a post hoc analysis of a prospective, multicentric, observational database.

Setting: The data collection was performed in four ICUs in university-affiliated or tertiary hospitals.

Patients: This study included adult patients within 24 h of general ICU admission with an expected ICU length of stay of more than 2 days.

Intervention: Patients underwent clinical, biological, and echocardiographic assessments at several times: ICU admission, day 1, day 2, day 5 and the last day of ICU.

Main outcome measure: The study primary endpoint was the portal vein pulsatility index during the course of the patients' stay on the ICU.

Results: One hundred forty-five patients and 514 haemodynamic evaluations were analysed. The mean age of the patients was 64 ± 15 years, 41% were women, with a median [IQR] admission simplified acute physiology score II of 46 [37 to 59]. The univariable followed by multivariable mixed-effects linear regression analyses demonstrated an association between portal vein pulsatility index, heart rate [estimate -0.002 (95% CI, -0.003 to -0.001), P < 0.001] and the cumulative fluid balance [estimate 0.0007 (95% CI, 0.00007 to 0.001), P = 0.024]. Portal vein pulsatility index showed no agreement with CVP of at least 12 mmHg (kappa correlation -0.008, P = 0.811), negative passive leg raising (kappa correlation -0.036, P = 0.430), mean inferior vena caval (IVC) diameter greater than 2 cm (kappa correlation -0.090, P = 0.025), maximal IVC diameter greater than 2 cm (kappa correlation -0.010, P = 0.835), hepatic vein systolic/diastolic ratio less than 1 (kappa correlation 0.043, P = 0.276), or renal vein pulsatile pattern (kappa correlation -0.243, P < 0.001).

Conclusion: The study findings emphasise the unique sensitivity of portal vein pulsatility index in assessing fluid balance in general ICU patients. The lack of correlation between portal vein pulsatility index and other parameters of venous congestion underscores its potential to provide distinctive insights into venous congestion.

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.