European Journal of Anaesthesiology最新文献

Background: Arthroscopic shoulder surgery is frequently conducted in the beach chair position. Haemodynamic instability with hypotension and reduction of cerebral perfusion has been widely reported.

Objective: To determine whether a continuous noninvasive blood pressure monitoring using a finger-cuff reduces hypotension during arthroscopic shoulder surgery compared to standard oscillometric brachial pressure monitoring.

Design: Randomised controlled trial.

Setting: Orthopaedic operating theatre of IRCCS Fondazione Policlinico Universitario Agostino Gemelli of Rome, Italy.

Patients: Sixty patients (30 per group) scheduled for arthroscopic shoulder surgery in beach chair position under brachial plexus block plus general anaesthesia.

Interventions: All patients received noninvasive continuous haemodynamic monitoring with finger-cuff. Patients were then randomised to unblinded continuous finger-cuff arterial pressure monitoring or to intermittent oscillometric arterial pressure monitoring.

Main outcome measures: Primary outcome measure was time-weighted average mean arterial pressure under the threshold of 65 mmHg during surgery. Secondary outcomes were the incidence of cerebral oxygen desaturation episodes, the incidence of severe hypotensive episodes, and the time to correct the hypotensive episode in minutes.

Results: The time weighted average mean [IQR] arterial pressure under the threshold of 65 mmHg was 0.41 [0.04, 0.98] mmHg in the finger-cuff group and 0.69 [0.21, 2.20] mmHg in the Control group, with a Hodges-Lehman estimator of -0.24 (95% confidence interval: - 0.75 to 0.07) mmHg ( P  = 0.137).No difference in the incidence of severe hypotensive events, defined as a mean arterial pressure less than 50 mmHg, was detected between the two groups ( P  = 0.017). Cerebral tissue oxygen saturation values were stable throughout the vast majority of the monitoring period, with absolute values less than 60% and relative values less than 10% of the baseline being uncommon in the two cohort of patients. A positive correlation between simultaneous tissue oxygen saturation values and mean arterial pressure was found ( r  = 0.298 95% confidence interval 0.283 to 0.312, P <  0.001).

Conclusions: Continuous noninvasive arterial pressure monitoring is not effective in reducing the amount of intra-operative hypotension during shoulder surgery performed in the beach chair position compared to intermittent oscillometric monitoring.

Trial registration: ClinicalTrials.gov identifier: NCT05143632.

Increasing numbers of older patients will be undergoing surgery in the future, with benefits including symptom relief and extended longevity. Despite these advantages from successful surgery, geriatric patients are at risk of adverse perioperative events, particularly those who are frail. Anatomical and physiological changes due to ageing occur in all organ systems and can have a profound impact on the surgical stress response and recovery. Deciding whether older patients will benefit from surgery can be a difficult task. Due to the diversity of age-related physiological changes and comorbidities in individual patients, differentiation between the fit and the frail elderly is an important step. Despite older age, some studies demonstrated that preoperative optimisation can improve the odds of a favourable outcome. Better outcomes are beneficial for patients and can also relieve the growing burden on the healthcare system. A patient-centred care plan, understanding an individual patient's potential risks and integrating a multidisciplinary approach are key principles of good perioperative care. Also, the patient's willingness and short- and long-term goals, such as maintaining functional independence, or pain relief must be considered. However, if surgical treatment is deemed futile and death is to be expected as an unavoidable outcome, multidisciplinary collaboration in guiding patient care and supporting the family can be of great value. It helps to relieve suffering, and supports a dignified and meaningful dying process. This narrative review aims to explore key aspects of perioperative care in older surgical patients, with particular attention to frailty, shared decision-making, and advance care planning.