Journal of Anesthesia最新文献

Purpose: Predicting postpartum hemorrhage risk can be useful in clinical settings. We aimed to develop and validate a clinical prediction model for postpartum hemorrhage in patients who undergo elective cesarean section.

Methods: This retrospective observational study included patients who underwent elective cesarean section between January 2008 and September 2021. The primary outcome to be predicted was postpartum hemorrhage, defined as blood loss of ≥ 1500 mL during surgery. We used data prior to January 2018 for the development cohort and after for the validation cohort. We then constructed a multivariate logistic regression model. The model performance, including discrimination and calibration, was evaluated and its diagnostic ability was assessed.

Results: Of the 4070 patients, 860 (21.0%) had postpartum hemorrhage. The predictors were twin pregnancy, benign uterine disease, assisted reproduction, gestational diabetes mellitus, placenta previa, nulliparity, and neonatal weight > 3000 g. In the validation cohort, the prediction model C-statistic was 0.780 (95% confidence interval [CI] 0.745-0.816). We developed a simple scoring system to divide the patients into three risk groups (low, moderate, and high). If the cut-off risk score was set to moderate, the negative likelihood ratio was low (0.221, 95% CI 0.108-0.374); conversely, if the cut-off risk score was set to high, the positive likelihood ratio was high (5.882, 95% CI 3.750-9.333).

Conclusion: The model we developed can stratify the risk of postpartum hemorrhage and assist in clinical decision-making. Future studies are required to validate the performance of our model.

Purpose: Weaning from invasive mechanical ventilation (IMV) is challenging and has multiple causes. The diaphragm is the main respiratory muscle for inspiration. This prospective study aimed to determine the value of standardized diaphragm ultrasound (DUS) measurements [diaphragm excursion (DE), diaphragm thickness fraction (DTF), diaphragmatic rapid shallow breathing index (D-RSBI), rapid shallow diaphragmatic index (RSDI)] in predicting extubation success in intensive care patients, both individually and in combination with conventional indices [rapid shallow breathing index (RSBI), dynamic compliance (Cdyn), airway occlusion pressure, semi-quantitative cough strength score]. To isolate diaphragm contribution, only neurologically intact patients (Glasgow Coma Scale > 14) with adequate airway protection reflexes were included. The second aim was to examine the relationship between IMV and DUS measurements.

Methods: 151 patients on IMV for > 24 h and eligible for spontaneous breathing trial (SBT) were evaluated. Following exclusion criteria, patients underwent SBT in pressure support ventilation mode (positive end-expiratory pressure 5 cmH₂O, pressure support 8 cmH₂O). During SBT, mechanical ventilation parameters and diaphragm ultrasound measurements were recorded. Extubation failure was defined as need for reintubation or non-invasive ventilation.

Results: DE and DTF were significantly higher, D-RSBI was lower in patients with successful extubation. There was no difference in RSDI. Multivariate logistic regression was statistically significant, odds ratios (10.018, 1.109, 1.094) were found for DE, DTF, Cdyn, respectively. The only significant correlation between IMV and DUS was DTF-tidal volume (r = - 0.500).

Conclusion: A standardized multiparametric model, combining DUS with conventional indices, provides moderate predictive accuracy for extubation success. Integrating DUS into weaning protocols can improve extubation readiness.

Purpose: Home oxygen therapy (HOT) is administered to patients with impaired pulmonary function who cannot adequately oxygenate themselves to meet systemic metabolic demands. Although regional anesthesia (RA) is beneficial for patients requiring HOT, comparative evidence between regional and general anesthesia (GA) is lacking. Thus, this study aimed to compare postoperative outcomes between RA and GA in patients requiring HOT.

Methods: We collected data from a nationwide hospital-based database spanning from April 2014 to June 2022. We included patients who received HOT before limb or lower abdominal surgery and divided them into those who received GA and those who received RA. The primary outcome was 30-day hospital-free days. Secondary outcomes included 30-day mortality, postoperative pulmonary complications, and non-pulmonary complications. Additionally, we calculated the propensity scores and applied the overlap weighting method. Unmeasured confounders were addressed using high-dimensional propensity scores.

Results: Among 1064 included surgeries, 565 and 499 were assigned to the GA and RA groups, respectively. Post-adjustment, no significant difference in hospital-free days was observed between the GA (10.46 days) and RA (11.29 days) groups (hospital-free day difference: 0.83; 95% confidence interval: - 0.56 to 2.23; p = 0.24). No significant between-group differences were observed in secondary outcomes, including 30-day mortality (odds ratio = 0.97; 95% confidence interval: 0.61-1.56; p = 0.67) and postoperative pulmonary complications (OR = 1.00; 95% CI 0.68-1.48; p = 0.99). Additionally, no difference was noted between the main analysis and the high-dimensional propensity score results for primary and secondary outcomes.

Conclusions: Our findings suggest no association between the anesthesia method used and the 30-day hospital-free days among patients requiring HOT.

Purpose: Congenital heart disease (CHD) affects 9.3 per 1000 live births in Asia, with 25% being cyanotic. Advanced imaging such as CT angiography is essential, but requires effective sedation in this high-risk group. While parental presence is known to reduce anxiety during mask induction in operating rooms, its effect on intravenous sedation in non-operating room anesthesia (NORA) settings, particularly for diagnostic imaging, has not been studied. This trial evaluates the effect of parental presence during intravenous procedural sedation on ketamine requirements for children with cyanotic CHD undergoing CT angiography in a NORA environment.

Methods: This prospective, randomized trial included 60 children aged 6 months to 3 years with cyanotic CHD. Participants were randomized to receive sedation either on their mother's lap (n = 30) or on the CT table (n = 30). The primary outcome was ketamine dose required for a pediatric sedation state scale of 2. Secondary outcomes included preoperative anxiety scores, episodes of oxygen desaturation, time to achieve sedation, and recovery time.

Results: Children sedated on their mother's lap required significantly lower ketamine doses compared to those on the CT table (- 0.15 mg/kg, 95% CI - 0.29 to - 0.01; p = 0.03). The mother's lap group also had lower preoperative anxiety scores and shorter recovery times (- 3 min, 95% CI - 4.08 to - 1.92), with no increase in adverse events.

Conclusion: This is the first randomized trial to demonstrate that parental presence during intravenous procedural sedation in a NORA setting reduces sedative requirements, anxiety, and recovery times in high-risk children undergoing CT angiography.

Clinical trial registration: Clinical trial registration: CTRI/2023/11/059539, https://www.ctri.nic.in/.

Purpose: Cardiac arrest due to a sharp increase in serum potassium one minute after reperfusion in liver transplantation (LT) is fatal. We sought to compare prophylactic nebulized salbutamol versus glucose-insulin for decreasing potassium during reperfusion and to guide the selection of potassium reduction strategies in LT.

Methods: We conducted a randomized, double-blind trial, enrolled patients undergoing LT with preoperative baseline serum potassium levels ≥ 4 mmol/L. Patients were randomized into two groups to receive either glucose-insulin (Group A) or nebulized salbutamol (Group B) as preventive potassium reduction regimens. The primary outcome was the incidence of hyperkalemia (defined as serum potassium > 5.5 mmol/L) 30 s after reperfusion (Rep1).

Results: One hundred participants were included in the analysis. The incidence of hyperkalemia at Rep1 was significantly lower in Group B than in Group A (36% vs. 56%, P = 0.045). Following administration and prior to reperfusion, the lowest potassium levels were achieved at 30 min in Group A and 45 min in Group B, respectively. The maximum decrease in the serum potassium level was significantly greater in Group B (P < 0.001). No significant differences in the incidence of postreperfusion syndrome were observed between the groups. Surprisingly, Group B had milder blood glucose fluctuations, higher heart rate and mean arterial pressure, lower driving pressure, and lower incidence of postoperative atelectasis.

Conclusion: Nebulized salbutamol is superior to glucose-insulin for preventing acute hyperkalemia during the reperfusion period and may benefit patients undergoing LT.

Clinical trial notation: Trial registration no. NCT05589441 ClinicalTrials.gov.