European Journal of Anaesthesiology最新文献

Background: Postpartum depression impacts maternal health, child development, and overall family well being. General anaesthesia has been suggested as a potential risk factor.

Objective: To assess the association between anaesthetic methods and postpartum depression in women undergoing Caesarean section.

Design: Systematic review with meta-analysis.

Data sources: We searched PubMed, Embase and Web of Science through 16 April 2025, and included seven studies comprising 1 482 355 patients.

Eligibility criteria: Randomised controlled trials and cohort studies comparing postpartum depression outcomes in women undergoing Caesarean section with general anaesthesia versus non-general anaesthesia.

Results: Our results showed that general anaesthesia significantly increased the risk of both overall postpartum depression [odds ratio (OR) = 1.64, 95% confidence interval (CI), 1.23 to 2.19] and severe postpartum depression (OR = 1.41, 95% CI, 1.35 to 1.47). Subgroup analysis stratified by timing of postpartum depression diagnosis revealed an elevated risk within one-year postpartum (OR = 1.22, 95% CI, 1.02 to 1.46) and an even higher risk within seven-day postpartum (OR = 4.68, 95% CI, 1.21 to 18.09).

Conclusion: These findings highlight the importance of anaesthetic choices for Caesarean section and suggest that minimising general anaesthesia exposure may optimise both physical and mental health outcomes.

Postpartum haemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. While coagulation disorders are seldom the primary cause of PPH and are rare early in PPH, the incidence of coagulation abnormalities increases when blood loss escalates. Acute obstetric coagulopathy (AOC), with an incidence of one in 1000 deliveries, has emerged as a distinct coagulopathy in PPH, highlighting the need for timely coagulation testing and intervention. This narrative review examines the current evidence on the use of visco-elastic haemostatic assays (VHAs) to guide treatment in PPH, and further explores the prophylactic and therapeutic roles of fibrinogen and tranexamic acid (TXA). VHAs have shown potential in PPH management, with large prospective and retrospective cohort studies demonstrating reductions in transfusions and transfusion-related complications. However, these findings have not been consistently replicated, possibly due to variations in study design and statistical power. This review explores the benefits and limitations of VHAs in the context of PPH management. Until large, well designed studies suggest otherwise, women with PPH might benefit from access to VHAs, given their potential to improve clinical outcomes in large cohorts without evidence of associated harm. Fibrinogen replacement is essential in PPH management. VHAs have been shown to be as effective as the Clauss fibrinogen assay in guiding fibrinogen substitution during PPH. Recent updates to ROTEM Sigma cartridges have led to new FIBTEM A5 thresholds, with the Obstetric Bleeding Strategy (OBS) group of Wales proposing a FIBTEM A5 of 8 mm or less as the new trigger for fibrinogen replacement in PPH. Fibrinogen concentrate offers advantages over cryoprecipitate and may be preferred when both are available. Effective fibrinogen substitution not only corrects VHA results but also helps to control bleeding. TXA is a cornerstone in the treatment of PPH and should be administered promptly at a dose of 1 g as soon as PPH is diagnosed, regardless of VHA results, and always within three hours of onset. A second dose may be given if bleeding persists or recurs. However, high-quality randomised trials have consistently shown no benefit from prophylactic TXA in low-risk caesarean section or in vaginal births across all risk groups. Data on the prophylactic use of TXA in high-risk caesarean section are limited and its use in these cases should be based on clinical judgement and individual risk assessment.

Background: Caesarean delivery can cause severe postoperative pain that can adversely affect recovery. However, balancing effective pain management while minimising the risk of opioid-related adverse effects remains a clinical challenge.

Objective: In this nationwide study, we aimed to describe the incidence and severity of acute pain and adverse effects of opioid administration following the first hours and days after elective caesarean delivery.

Design: Prospective nationwide Danish multicentre cohort study.

Setting: All maternity hospitals in Denmark over a 6-month period during 2023-2024.

Patients: Patients having elective caesarean delivery.

Intervention: Patient-reported outcomes on pain [Numeric Rating Scale (NRS) 0 to 10] and opioid-related adverse effects were collected using text message-based questionnaires via smartphone contact at 6, 12, 18, 24, and 48 h postcaesarean delivery, and on days 7 and 30.

Main outcome measures: The two primary outcomes were pain on mobilisation at 24 h, and adverse events of opioid administration (namely, nausea, vomiting, dizziness, pruritus and urinary retention) within 24 h.

Results: In total, 738 patients were included from 19 of 22 Danish maternity hospitals. Median [IQR] pain during mobilisation 24 h postcaesarean delivery was NRS 5 [3 to 6], peaking at 12 h postoperatively with NRS 6 [5 to 8]. Median oral morphine equivalents (OME) within the first 24 h were 30 [20 to 50] mg. Adverse effects peaked 6 h postoperatively, with pruritus being the most common. Within the first 24 h 59 [95% confidence interval (CI), 55 to 63]% reported severe pain (NRS ≥ 7) and 55 (95% CI, 51 to 59)% reported opioid-related adverse effects.

Conclusions: In Denmark, severe pain after caesarean delivery affects more than half the patients within the first 24 h, peaking at 12 h. Additionally, most report moderate or severe opioid-related adverse effects. These results underscore the need to optimise pain management, particularly during the first 24 h when pain is highest. The results can inform both patients and healthcare providers about expected pain trajectories and serve as the foundation for future research, and guide interventions.

Trial registration: www.clinicaltrials.gov , NCT06012747.

Background: Hydroxyethyl starch (HES) is often used for maintaining vascular volume during major surgery. Long-term high-dose HES in septic patients promotes renal injury, whereas meta-analyses of current HES products in surgical patients do not show such effects.

Objective: We studied if the peri-operative use of HES is noninferior to crystalloids in terms of acute kidney injury. Secondary outcome was the noninferiority of HES on worsening of renal injury and/or the incidence of a composite endpoint of major complications and mortality until postoperative day 90.

Design: Randomised double-blind trial in patients undergoing elective abdominal surgery with expected blood loss at least 500 ml.

Setting: Multicentre trial at 53 study sites in 10 European countries.

Patients: One thousand nine hundred and eighty-five (HES 977, crystalloid-only 981) patients aged 40 to 85 years with ASA status II-III.

Intervention: Either 6% HES 130/0.4 or a crystalloid solution. Dosing was guided by mean arterial pressure and/or routine haemodynamic variables.

Main outcome measure: Change from pre-operative to lowest cystatin C-based eGFR during the first 3 postoperative days. Key secondary outcome was a composite endpoint of mortality and major postoperative complications after 90 days.

Results: Mean change in eGFR from baseline to minimum was -3.4 ± 17.7 ml min -1  1.73 m -2 in HES patients and -1.0 ± 17.1 ml min -1 1.73 m -2 in crystalloid-only patients ( P  < 0.001 for noninferiority). The key secondary endpoint occurred in 35% of patients in each group. There were no clinically relevant differences in any safety endpoint including 90-day renal function. Any cause mortality-difference until the end of 1-year follow-up was not significantly different (8.6% in HES and 10.1% in crystalloid patients).

Conclusion: Peri-operative use of HES was noninferior to crystalloids in short-term renal function or a composite of mortality and major complications at 90 days. PHOENICS provides robust evidence that peri-operative in-label use of HES is well tolerated.

Trial registration and funding: EudraCT no. 2016-002162-30, clinicaltrials.gov ID NCT03278548.

Background: Bariatric surgery, particularly laparoscopic sleeve gastrectomy, is an effective and pivotal treatment for obesity. Patients undergoing laparoscopic sleeve gastrectomy commonly experience moderate pain in the immediate postoperative period. Therefore, optimal pain management is crucial.

Objective: The aim of this review was to update the recommendations for pain management following laparoscopic sleeve gastrectomy, building upon the 2019 guidelines.

Design: A systematic review was conducted using the PROSPECT methodology.

Data sources: Randomised controlled clinical trials (RCTs) and systematic reviews concerning analgesic, anaesthetic and operative interventions, focusing on pain management for patients undergoing laparoscopic sleeve gastrectomy, were identified through searches in MEDLINE, EMBASE and Cochrane Databases from September 2018 until February 2024. Primary outcome included pain scores. We used the Rob 2 tool as our method to assess the risk of bias in the included studies.

Results: The previous review included data from 18 RCTs. Since then, 188 eligible studies were identified, of which 39 RCTs and two meta-analyses met our inclusion criteria. In addition to paracetamol and NSAIDs or cyclooxygenase (COX)-2 specific inhibitors, ultrasound or laparoscopic-guided bilateral transversus abdominis plane (TAP) blocks and port-site local anaesthetic infiltration are recommended. In addition, intra-operative intravenous dexamethasone is recommended for analgesia and prevention of postoperative nausea and vomiting. Opioids are reserved for rescue treatment.

Conclusions: This systematic review identified an evidence-based analgesic regimen for laparoscopic sleeve gastrectomy. Our current recommendations differ from the previous ones in that a TAP block is now recommended, and gabapentinoids are no longer advised.

Prospero registration number: CRD42023487108.

Background: Total intravenous anaesthesia (TIVA) is widely recognised as a less environmentally harmful alternative to volatile anaesthesia. However, TIVA is often perceived as a more expensive technique, raising questions about its cost-effectiveness in routine practice.

Objective: This study models the environmental impact and cost-effectiveness of TIVA versus sevoflurane anaesthesia.

Design: Retrospective simulation-based observational study.

Patients: Surgical cases of 11 909 consecutive patients, older than 5 years, observed in a tertiary Belgian hospital.

Intervention: The economic cost and carbon dioxide equivalent (CO 2 e) emissions of maintenance using sevoflurane versus propofol of anaesthesia were calculated, using local tender prices and the lifecycle assessment for all drugs and disposable materials involved in each scenario.

Main outcome measure: The economic cost and CO 2 e emissions of different scenarios for maintenance of anaesthesia.

Results: For every 1000 procedures, CO 2 e emissions and costs were: TIVA - 963 kg at a cost of €4300; minimal-flow sevoflurane - 25 562 kg at a cost of €6772; sevoflurane [2 l min -1 fresh gas flow (FGF)] - 59 483 kg at a cost of €11 933.

Conclusion: Our simulations indicate that minimal flow sevoflurane produces 26.5 times more CO 2 e than TIVA, rising to 61.8 times more at 2 l min -1 FGF. TIVA also costs significantly less, at 36% and 63% of sevoflurane anaesthesia costs with minimal flow and 2 l min -1 FGF, respectively.These findings highlight not only TIVA's marked superiority in reducing carbon emissions but also its notable cost advantages over traditional volatile anaesthetic methods. The stark contrast in emissions - where TIVA produces just a fraction of the CO 2 e compared to even the most environmentally conscious sevoflurane protocols - underscores the critical role anaesthetic choice plays in healthcare sustainability. Moreover, the substantial difference in costs challenges the prevailing perception that TIVA is prohibitively expensive. As hospitals worldwide face mounting pressure to align clinical practices with environmental stewardship, these results advocate for a critical reassessment of routine anaesthetic protocols.