European Journal of Anaesthesiology最新文献

Background: Phenylephrine is recommended for the management of hypotension after spinal anaesthesia for women undergoing caesarean delivery. Norepinephrine, an adrenergic agonist with weak β-adrenergic activity, has been reported to have a more favourable haemodynamic profile than phenylephrine. However, there are concerns that norepinephrine may be associated with higher risk of fetal acidosis which can be serious in an already compromised foetus.

Objective: This study aimed to test the hypothesis that in terms of the umbilical artery base excess norepinephrine is not inferior to phenylephrine when it is used to prevent spinal hypotension during caesarean delivery.

Design: A prospective, randomised, double-blind trial.

Setting: Operating room of Tertiary Care Hospital in Northern India from January 2022 to November 2022.

Patients: Parturients with non-reassuring fetal heart rate undergoing nonelective caesarean delivery under spinal anaesthesia.

Intervention: Equipotent prophylactic infusions of either phenylephrine 80 μg min -1 or norepinephrine 6 μg min -1 were administered to maintain maternal systolic BP between 90 and 110% of baseline using a predefined algorithm.

Main outcome measures: The primary outcome was umbilical arterial base excess comparing the limits of the 95% confidence interval with a predefined noninferiority margin of -0.05 mmol l -1 . The incidence of fetal acidosis was also evaluated for norepinephrine and phenylephrine group.

Results: Data were analysed from 104 patients. The mean ± SD umbilical arterial base excess was higher in norepinephrine group than the phenylephrine group: -6.85 ± 2.20 mmol l -1vs. -7.95 ± 2.99 mmol l -1 , respectively ( P   =  0.034). Norepinephrine was found to be noninferior as the lower limit of 95% CI of mean difference between base excess of two groups was 1.10 (95% CI, 0.084 to 2.123) mmol l -1 , P   =  0.034) which did not cross our predefined noninferiority margin of -0.05 mmol l -1 . No significant difference in the incidence of fetal acidosis was observed between norepinephrine and phenylephrine groups: 62% vs. 75% ( P   =  0.140).

Conclusion: Prophylactic norepinephrine infusion (6 μg min -1 ) was found to be noninferior to phenylephrine infusion (80 μg min -1 ) in terms of umbilical arterial base excess values. A similar incidence of fetal acidosis was observed in both groups.

Trial registration: CTRI/2022/01/039343.

Background: The ageing surgical population underscores the need for routine postoperative delirium (POD) screening, particularly in the immediate postoperative period. The postanaesthesia care unit (PACU) presents a critical window for early detection and intervention, yet the clinical significance of PACU-diagnosed POD (PACU-POD) remains underexplored.

Objectives: To examine whether PACU-POD is associated with subsequent ward-POD and other adverse postoperative outcomes.

Design: Retrospective cohort study.

Setting: Tertiary academic hospital, single-centre, conducted between 2020 and 2022.

Patients: Three thousand seven hundred and eighty-one patients aged at least 70 years who underwent elective noncardiac, noncranial surgery under general anaesthesia. POD was assessed using the 4AT and supplemented by CHART-DEL review.

Main outcome measures: Primary outcome: ward-POD. Secondary outcomes: in-hospital falls, unplanned ICU admission, nonhome discharge and 30-day mortality. Exploratory outcomes: PACU and hospital length of stay.

Results: PACU-POD was diagnosed in 9.1% of patients (341/3781), who were more likely to be older, 77.1 (73.7 to 82.7) vs. 75.7 (72.9 to 80.6) years; frailer (52 vs. 40%); cognitively impaired (36 vs. 18%); and undergoing high-risk (52 vs. 27%); prolonged surgeries, 196 (133 to 275) vs. 142 (95 to 204) minutes (all P < 0.001). Ward-POD occurred in 6.2% of patients (234/3781) and was significantly more common among those with PACU-POD (24.6 vs. 4.3%, P < 0.001). PACU-POD was independently associated with ward-POD [adjusted odds ratio (aOR) 4.4; 95% confidence interval (CI), 3.2 to 6.3], in-hospital falls (aOR 2.3; 95% CI, 1.2 to 4.4) and 30-day mortality (aOR 4.4; 95% CI, 1.5 to 13.0), as well as prolonged PACU, 185 [144 to 265] vs. 150 [115 to 210] minutes, P < 0.001, and hospital stays, 6 [3 to 10] vs. 3 [2 to 6] days, P = 0.01.

Conclusion: PACU-POD is a strong early marker of increased risk for ward-POD and other postoperative complications. Routine PACU screening enables early diagnosis, risk stratification and targeted interventions. Future studies should evaluate whether early intervention starting during the PACU stay can improve the trajectory of POD and related complications.

Research that assesses causal relations based on observational data remains challenging because of the well known tension between natural causal thinking and classic statistical association methods. This tension, over a period of decades, has generated the development of a statistical framework, with specific methods and reasoning, to allow the drawing of causal inference. A part of this framework is the directed acyclic graph (DAG), a specific type of causal diagram that is based on graph theory. This intuitive representation of the mechanistic processes of a specific problem, and the logical consequences that come with it, closes the gap between observed associations and causality. The advantage of integrating DAGs into observational research has been emphasised in several reviews. This review is an anaesthetist-friendly (re-)introduction to this graphical reasoning. We provide some examples of how this framework can be used beyond observational data and studies. We explain how important aspects of randomised controlled trials like covariate adjustments, handling of missing data and protocol violations can be both understood and taught by drawing and interpreting a DAG. We consider the case of the titration paradox and show how combining knowledge of how a specific dataset was built, with pharmacology, into a more advanced DAG, can help solve and understand these seemingly paradoxical findings. In all of this, we use anaesthesia-oriented examples to illustrate how DAGs can be a valuable scientific language that helps us to understand, organise and communicate study results and research questions.

Backgrounds: In patients with cardiac surgery under cardiopulmonary bypass (CPB), postoperative inflammation is a driver of adverse outcomes. Endotoxaemia is one of the factors thought to trigger this inflammatory response. The mechanism behind high endotoxin activity (increased translocation vs. reduced inactivation capacity) has never been elucidated and may imply different therapeutic candidates.

Objectives: We aimed to evaluate, in patients with cardiac surgery with prolonged CPB, mechanisms and consequences of endotoxaemia and the efficacy of haemo-adsorption to reduce the endotoxin burden.

Design: Ancillary analysis of a randomised controlled trial. Patients scheduled for cardiac surgery with prolonged CPB were assigned to receive either intra-operative haemo-adsorption or standard of care. Endotoxin mass and activity were measured before surgery, at the end of CPB, 6, 24 and 48 h after the end of surgery.

Setting: Operating room, Amiens University Hospital.

Patients: Adults scheduled for cardiac surgery under CPB with an expected CPB time more than 90 min.

Intervention: Patients were randomised to receive either haemo-adsorption or standard care during CPB.

Main outcome measures: Endotoxin activity.

Results: Two hundred and ninety-five samples from 66 patients were analysed. Following CPB, we observed a reduction in endotoxin mass accompanied by a relative increase in endotoxin activity. High postoperative endotoxin activity was associated with intra-operative dobutamine requirement, increased postoperative inflammatory biomarkers and organ injury. Endotoxin plasma concentration and activity were not lower in patients treated with haemo-adsoprtion.

Conclusion: The capacity of individuals to inactivate endotoxin rather than raw endotoxin mass (i.e. Quantity) seemed to be a determinant of endotoxin noxious effect in cardiac surgery and CBP. Haemo-adsorption was not associated with a reduction of endotoxin plasma mass or activity in patients with cardiac surgery under CPB.

Trial registration: ClinicalTrials.gov, NCT04201119NCT04201119.

Background: The left head rotation (LeHeR) manoeuvre has been proposed to improve the laryngoscopic view based on case reports of unexpectedly difficult intubation under emergency conditions.

Objectives: To evaluate the potential of the LeHeR manoeuvre to improve the direct laryngoscopic view under elective surgical conditions and to investigate the dependence on patient- and examiner-dependent factors.

Design: Single-centre prospective cohort study.

Setting: This study was conducted at the Department of Anesthesiology of Saarland University Hospital between November 2022 and March 2023. Laryngoscopy findings in the Jackson position and after the application of the LeHeR manoeuvre were recorded during the routine surgical program by the responsible anaesthetists in the presence of a study physician.

Patients: One hundred and two adult patients scheduled for elective surgery, general anaesthesia with endotracheal intubation, and without a particular risk of aspiration.

Main outcome measures: primary outcome was the laryngoscopic view graded according to the modified Cormack and Lehane classification score (CLS) and subsequently in the percentage of glottic opening (POGO) score before and after application of the LeHeR manoeuvre. The secondary outcomes were the differences in laryngoscopic views according to both scores (ΔCLS, ΔPOGO).

Results: With the improved Jackson-position, the median laryngoscopic view was CLS grade 2a [1 to 2a], with a POGO score of 80 [42.5 to 100]. With LeHeR, the median laryngoscopic view was CLS grade 2a [1 to 2b], with a POGO score of 70 [42.5 to 90], indicating a reduced laryngoscopic view (CLS, P < 0.001; POGO, P = 0.041). While patient characteristics had no influence on the difference in laryngoscopic views, longer professional experience correlated significantly with an improvement in the laryngoscopic view according to the POGO (r = 0.242, P = 0.018), but not the Cormack and Lehane scores (r = -0.29, P = 0.004).

Conclusions: The LeHeR manoeuvre failed to significantly improve the direct laryngoscopic view compared to the improved Jackson-position under standard conditions for elective surgery. However, experienced anaesthetists achieved better results with this manoeuvre than novice anaesthetists.

Trial registration: This study was prospectively registered in the German Clinical Trials Register (DRKS00029944).

Background: Acute kidney injury (AKI) is a common complication after surgery. Greater fluid administration has been related to an increased incidence in patients undergoing major surgery but there are no large series of patients in specific perioperative settings showing relationship between fluid balance and the occurrence of AKI.

Objective: This study tested the hypothesis that higher perioperative fluid balance was associated with an increased risk of postoperative AKI.

Design: Prospective observational study. Predefined secondary sub-study of the Postoperative Outcomes Within Enhanced Recovery After Surgery (POWER) study.

Setting: A pre-planned secondary analysis of a multicentre study in 80 hospitals in Spain during a single period of 2 months of recruitment between September and December 2017.

Patients: Patients undergoing elective primary colorectal surgery with a planned overnight stay were included if they had complete data regarding postoperative fluid balance. Patients who underwent urgent or emergency surgery or with estimated glomerular filtration rate less than 30 ml min-1 were excluded.

Main outcomes measures: The primary outcome was the occurrence of AKI (mild, moderate, or severe) at 30 days following surgery. AKI was defined according to KDIGO and EPCO guidelines, incorporating serum creatinine and urine output criteria.

Results: A total of 1139 patients were included in the study. Of these, 73 patients (6.4%) developed acute kidney injury in the postoperative period. The adjusted relative risks (RR) that compared the quartile with the lowest perioperative fluid balance (Q1) with other quartiles were 4.10 [95% confidence interval (CI), 1.60 to 10.51] for Q3 and 4.81 (95% CI, 1.91 to 12.11) for Q4. In the Poisson loglinear model after adjusting by sex, ASA grade, Enhanced Recovery After Surgery (ERAS) adherence and intraoperative bleeding, RR for AKI were higher with a higher positive perioperative fluid balance (quadratic nonlinear P < 0.01).

Conclusions: In this secondary analysis, we found that higher positive perioperative fluid balance during the first 24 h was associated with an increased risk of postoperative acute kidney injury in patients undergoing elective colorectal surgery.

Trial registration: Clinicaltrials.com identifier: NCT03012802.

Background: International guidelines recommend preoperative clear liquid fasting for 2 h before anaesthesia. However, excessive fasting times remain widespread, potentially contributing to patient discomfort and adverse clinical outcomes.

Objective: To evaluate current preoperative liquid fasting practices among adults undergoing elective procedures across multiple European centres.

Design: Prospective, observational, multicentre study.

Setting: Forty-six centres in 12 European countries, conducted between November and December 2024.

Patients: A total of 5100 adults undergoing elective surgery or interventional procedures under general anaesthesia, regional anaesthesia or sedation.

Main outcome measures: Self-reported duration of preoperative liquid fasting; incidence of prolonged fasting duration (defined as liquid fasting times of more than 4 h). Median [IQR] fasting time was calculated, with subgroup analyses by country and procedure type.

Results: The median [IQR] preoperative liquid fasting time was 12 [10 to 14.6] h. Only 4% of patients consumed clear liquids within 2 to 4 h, and 0.8% within 2 h. Fasting durations were consistently prolonged across most countries and procedures, except for notably shorter times in Albania. Overall, 95% of patients fasted beyond 4 h.

Conclusions: Excessive preoperative liquid fasting remains highly prevalent across Europe, with poor implementation of established guidelines. These findings underscore the need for educational, institutional, and quality improvement interventions to align clinical practice with evidence-based recommendations and enhance patient-centred care.

Trial registration: ClinicalTrials.gov identifier: NCT06527703.