European Journal of Anaesthesiology最新文献

Background: Inter-scalene block (ISB) is associated with an inevitable risk of hemi-diaphragmatic paresis (HDP). To reduce the risk of HDP, an upper trunk block (UTB) has been proposed at the brachial plexus division level.

Objective: We hypothesised that UTB would be associated with a lower incidence of HDP than ISB while providing sufficient analgesia following arthroscopic shoulder surgery.

Design: Randomised controlled trial.

Setting: A tertiary teaching hospital.

Patients: Seventy patients aged 20 to 80 years undergoing arthroscopic rotator cuff repair.

Intervention: Ultrasound-guided ISB or UTB was performed with 5 ml 0.75% ropivacaine.

Main outcome measures: The primary outcome was the incidence of complete HDP, assessed by diaphragm excursion using ultrasound, defined as a decrease to 25% or less of baseline or occurrence of paradoxical movement. Postoperative pulmonary function change, pain scores, opioid consumption and pain-related outcomes were the secondary outcomes.

Results: The UTB group had a significantly lower incidence of complete HDP than the ISB group [5.9% (2/34) vs. 41.7% (15/36); absolute difference, 35.8%; 95% confidence interval (CI), 17.8 to 53.7%; P  < 0.001]. The postblockade decline in pulmonary function was more pronounced in the ISB group than that in the UTB group. The pain score at 1 h postoperatively was not significantly different between the groups (ISB vs. UTB group: median 0 vs. 1; median difference, -1; 95% CI, -2 to 0.5). No significant difference was observed in any other secondary outcomes.

Conclusion: UTB was associated with a lower incidence of HDP compared with ISB while providing excellent analgesia in arthroscopic shoulder surgery.

Trial registration: Clinical Trial Registry of Korea ( https://cris.nih.go.kr ) identifier: KCT0007002.

Irb number: Chungnam National University Hospital Institutional Review Board No. 2021-12-069.

Background: Elderly patients comprise an increasing proportion of patients undergoing surgery, and they require special attention due to age-related physiological changes. Propofol is the traditional agent for anaesthesia, and recently, remimazolam, a novel ultra-short-acting benzodiazepine, has emerged as an alternative to propofol in general anaesthesia.

Objectives: We aim to compare remimazolam vs . propofol for general anaesthesia in elderly patients regarding hypotension, induction characteristics, haemodynamics and recovery outcomes.

Design: Meta-analysis with sensitivity and trial sequential analyses (TSA) to assess inconsistencies. Risk ratios and mean differences with 95% confidence intervals (95% CIs) were computed using a random effects model. Subgroups and meta-regression according to anaesthesia methods were also performed.

Data sources: We systematically searched MEDLINE, Embase and Cochrane for randomised controlled trials (RCTs) up to January 1, 2024.

Eligibility criteria: Patients at least 60 years old, comparing remimazolam vs . propofol for general anaesthesia.

Results: Eleven RCTs (947 patients) were included. Compared with propofol, remimazolam was associated with lower postinduction and intra-operative hypotension (RR 0.41, 95% CI 0.27 to 0.62, P  < 0.001) and incidence of bradycardia (risk ratio 0.58, 95% CI 0.34 to 0.98, P  = 0.04), with a higher heart rate ( P  = 0.01). The incidence of injection pain was lower ( P  < 0.001), but remimazolam was associated with a longer time to loss of consciousness ( P  < 0.001) and a higher bispectral index at loss of consciousness ( P  = 0.04). No differences were found for mean arterial pressure, emergence time, extubation time and incidence of emergence agitation. The TSA was consistent and achieved the required information size for hypotension.

Conclusions: Remimazolam significantly reduced the risk of hypotension, bradycardia and injection pain, despite an increase in the time to loss of consciousness. Remimazolam appears to be an effective and well tolerated alternative to propofol in elderly patients undergoing general anaesthesia.

Background: Drug challenge is the gold standard for identifying causative agents of drug allergies. Although clinical guidelines have recently been published, they do not recommend neuromuscular blocking agent (NMBA) drug challenges. NMBA challenges are rendered difficult by the lack of homogeneity of routine allergy work-ups and the necessity of a specialised setting. Several scenarios support NMBA challenges, such as an ambiguous allergy work-up, a high suspicion of a false-positive skin test or identification of a well tolerated alternative NMBA strategy. Furthermore, routine allergy work-ups may not recognise non-IgE mechanisms, such as IgG or MRGPRX2, whereas drug challenges may reveal them. Finally, if the culprit NMBA is not identified, subsequent anaesthesia regimens will be challenging to implement, resulting in increased risk.

Objectives: This literature review discusses the indications, strategies, doses, monitoring methods, limitations, and unresolved issues related to drug challenges for NMBAs.

Design: The literature review included randomised controlled trials, observational studies, reviews, case reports, series, and comments on humans.

Data sources: Studies were retrieved from databases (PubMed) and electronic libraries (OVID, EMBASE, Scopus, etc.).

Eligibility criteria: All studies that referred to the NMBA challenge were included without publication date limitations.

Results: NMBA challenge may be considered in NMBA anaphylaxis patients with inconclusive or ambivalent IgE diagnostic work-up under controlled conditions (presence of anaesthetists and allergists with continuous monitoring in a secured environment). To illustrate its utility, a case report of a double NMBA challenge in a patient with NMBA cross-reactivity is presented, along with biological explorations to detect subclinical cellular activation, a novel aspect of this procedure.

Conclusion: Drug challenges could be implemented during the NMBA allergy work-up under strict safety conditions at specialised centres with close collaboration between anaesthetists and allergists. This could decrease uncertainty and contribute to defining a safer strategy for subsequent anaesthetic drug regimens.

Background: As a local anaesthetic adjunct, the systemic absorption of perineural dexamethasone in the lower limb could be restricted because of decreased vascularity when compared with the upper limb.

Objectives: To compare the pharmacodynamic characteristics of intravenous and perineural dexamethasone in the lower limb.

Design: Systematic review of randomised controlled trials with meta-analysis.

Data sources: Systematic search of Central, Google Scholar, Ovid Embase and Ovid Medline to 18 July 2023.

Eligibility criteria: Randomised controlled trials, which compared the intravenous with perineural administration of dexamethasone as a local anaesthetic adjunct in peripheral nerve blocks for surgery of the lower limb.

Results: The most common peripheral nerve blocks were femoral, sciatic and ankle block. The local anaesthetic was long acting in all trials and the dose of dexamethasone was 8 mg in most trials. The primary outcome, the duration of analgesia, was investigated by all nine trials ( n  = 546 patients). Overall, compared with intravenous dexamethasone, perineural dexamethasone increased the duration of analgesia from 19.54 to 22.27 h, a mean difference [95% confidence interval (CI) of 2.73 (1.07 to 4.38) h; P  = 0.001, I2  = 87]. The quality of evidence was moderate owing to serious inconsistency. However, analysis based on the location of the peripheral nerve block, the type of local anaesthetic or the use of perineural adrenaline showed no difference in duration between intravenous and perineural dexamethasone. No differences were shown for any of the secondary outcomes related to efficacy and side effects.

Conclusion: In summary, moderate evidence supports the superiority of perineural dexamethasone over intravenous dexamethasone in prolonging the duration of analgesia. However, this difference is unlikely to be clinically relevant. Consideration of the perineural use of dexamethasone should recognise that this route of administration remains off label.

Background: Remimazolam is not only associated with a lower incidence of respiratory depression than propofol but also in itself has the risk of respiratory depression.

Objective: We investigated respiratory depression following remimazolam infusion, targeting different effect-site concentrations using target-controlled infusion.

Design: A prospective, double-blind, randomised controlled study.

Setting: Tertiary hospital, Suwon, South Korea, from April 2022 to November 2022.

Participants: One hundred and seven patients scheduled for general anaesthesia were randomised into three groups targeting remimazolam effect-site concentrations of 500 (RMZ-500) ( n  = 36), 1000 (RMZ-1000) ( n  = 35) and 1500 ng ml -1 (RMZ-1500) ( n  = 36).

Interventions: Remimazolam was solely infused for 10 min according to target effect-site concentrations. According to the degree of SpO 2 decrease, oxygen desaturations were managed with the following respiratory supports: jaw-thrust for SpO 2 less than 97%, 100% oxygen delivery for SpO 2 less than 93% and assisted ventilation for SpO 2 less than 90%.

Main outcome measures: The incidence of each respiratory support, along with respiratory variables (at baseline, 5 min and 10 min after remimazolam infusion) and loss of consciousness were observed for 10 min after remimazolam target-controlled infusion.

Results: Both RMZ-1000 and RMZ-1500 required more frequent respiratory support than RMZ-500 (both P  < 0.001), with nearly identical frequencies between RMZ-1000 and RMZ-1500. In terms of respiratory support, the incidence of assisted ventilation was significantly lower in RMZ-500 (2.8%) than RMZ-1000 (48.6%) and RMZ-1500 (50%) ( P  < 0.001). RMZ-1000 and RMZ-1500 achieved loss of consciousness in all patients; RMZ-500 only achieved loss of consciousness in 86.1% of patients ( P  = 0.010). In patients who maintained spontaneous respiration, tidal volume decreased by 41 to 48% and respiratory rate increased by 118 to 158% at 5 and 10 min, significantly compared to baseline in all groups ( P  < 0.001).

Conclusions: Remimazolam infusion, like that of other benzodiazepines, led to respiratory depression, which was more prominent at higher target effect-site concentrations. Therefore, appropriate countermeasures should be developed to prevent oxygen desaturation.

Trial registration: CRIS ( https://cris.nih.go.kr ), identifier: KCT0006952.

Background: For nearly 20 years, in international guidelines, mild therapeutic hypothermia (MTH) was an important component of postresuscitation care. However, recent randomised controlled trials have questioned its benefits. At present, international guidelines only recommend actively preventing fever, but there are ongoing discussions about whether the majority of cardiac arrest patients could benefit from MTH treatment.

Objective: The aim of this study was to compare the outcome of adult patients treated with and without MTH after cardiac arrest.

Design: Observational cohort study.

Setting: German Resuscitation Registry covering more than 31 million inhabitants of Germany and Austria.

Patients: All adult patients between 2006 and 2022 with out-of-hospital or in-hospital cardiac arrest and comatose on admission.

Main outcome measures: Primary endpoint: hospital discharge with good neurological outcome [cerebral performance categories (CPC) 1 or 2]. Secondary endpoint: hospital discharge. We used a multivariate binary logistic regression analysis to identify the effects on outcome of all known influencing variables.

Results: We analysed 33 933 patients (10 034 treated with MTH, 23 899 without MTH). The multivariate regression model revealed that MTH was an independent predictor of CPC 1/2 survival and of hospital discharge with odds ratio (95% confidence intervals) of 1.60 (1.49 to 1.72), P < 0.001 and 1.89 (1.76 to 2.02), P < 0.001, respectively.

Conclusion: Our data indicate the existence of a positive association between MTH and a favourable neurological outcome after cardiac arrest. It therefore seems premature to refrain from giving MTH treatment for the entire spectrum of patients after cardiac arrest. Further prospective studies are needed.