Journal of Clinical Anesthesia最新文献

Background: Residual neuromuscular block (NMB) after anesthesia poses significant risk to patients, which can be reduced by adhering to evidence-based practices for the dosing, monitoring, and reversal of NMB. Incorporation of best practices into routine clinical care remains uneven across providers and institutions, prompting the need for effective implementation strategies.

Methods: An interdisciplinary quality improvement initiative aimed to optimize NMB reversal practices across a large multi-campus urban medical center. Using the Institute for Healthcare Improvement (IHI) framework, interventions were designed to increase Train-of-Four (TOF) monitoring and promote evidence-based and cost-effective use of the NMB reversal agents. Process and outcome measures were tracked through Plan-Do-Study-Act (PDSA) cycles. Qualitative interviews provided insights into clinician perspectives.

Results: The study encompassed 35,198 surgical cases utilizing NMB agents. The interventions led to a sustained increase in TOF monitoring from 42 % to 83 %. Significant increases were also observed in TOF ratio documentation and utilization of sugammadex. Postoperative respiratory complication rates decreased by 41 % (RR 0.59, 95 % CI 0.32-0.96) over the course of the initiative. The most pronounced increases in TOF monitoring were associated with financial incentives for the achievement of department-wide target monitoring rate.

Conclusion: This initiative demonstrates successful large-scale integration of quantitative TOF monitoring and evidence based NMB management across a diverse medical center, while highlighting important barriers in implementation. These findings contribute to the broader discussion on translating evidence into practice, offering insights for improving patient care and safety through tailored implementation strategies.

Cognitive impairment following surgery is a significant complication, affecting multiple neurocognitive domains. The term "perioperative neurocognitive disorders" (PND) is recommended to encompass this entity. Individuals who develop PND are typically older and have increases in serum and brain pro-inflammatory cytokines notwithstanding the type of surgery undergone. Surgical trauma induces production of small biomolecules, damage-associated molecular patterns (DAMP), particularly the DAMP known as high molecular group box 1 protein (HMGB1). Mechanistically, peripheral surgical trauma promotes pro-inflammatory cytokines that stimulate central nervous system (CNS) inflammation by disrupting the blood-brain barrier (BBB) causing functional neuronal disruption that leads to PND. PND is strongly linked to elevations in serum and CNS pro-inflammatory cytokines interleukin-1 beta (IL-1β), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNFα); these cytokines cause further release of HMGB1 creating a positive feedback loop that amplifies the inflammatory response. The cytokine IL-6 is necessary and sufficient for PND. Dehydroepiandrosterone (DHEA) is a principal component of the steroid metabolome and is involved in immune homeostasis. DHEA has been shown to suppress expression of several pro-inflammatory cytokines by regulation of the NF-kB pathway. Bromo-epi-androsterone (BEA) is a potent synthetic analog of DHEA; unlike DHEA, it is non-androgenic, non-anabolic and is an effective modulator of immune dysregulation. In a randomized, placebo-controlled clinical trial, BEA effected significant and sustained decreases in IL-1β, TNFα and IL-6. This article presents BEA as a potential candidate for clinical trials targeting PND and further suggests the use of BEA in elective total hip arthroplasty as a well-documented surgical entity relevant to the management of PND.

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication of cardiac surgery and is associated with increased morbidity and mortality. Recent guidelines emphasize the need for new monitoring methods to facilitate targeted CSA-AKI prevention and treatment strategies. In vivo real-time measurement of mitochondrial oxygen tension (mitoPO₂), could potentially fulfil this role during cardiac surgery, as suggested in our previous pilot study.

Methods: In this prospective observational study, we investigated 75 cardiac surgery patients with an increased preoperative CSA-AKI risk. The primary aim of this study was to assess whether patients who developed CSA-AKI experienced prolonged periods of mitoPO₂ < 20 mmHg during surgery. mitoPO₂ was measured intraoperatively, and CSA-AKI was defined according to the Kidney Disease: Improving Global Outcomes criteria. Four additional mitoPO₂ thresholds (<25, <30, <35, and < 40 mmHg) were analyzed, including the predictive capacity of all thresholds for CSA-AKI.

Results: This study found that patients who developed CSA-AKI had a significantly longer intraoperative time with mitoPO₂ <20 mmHg and <25, <30, <35, and <40 mmHg. Subsequently, we tested all thresholds for their association with the risk of CSA-AKI, with the <25 mmHg threshold demonstrating the highest significant odds ratio. Every minute spent below <25 mmHg increased the risk of CSA-AKI by 0.7 % (P = 0.021).

Conclusions: This study highlighted the association between mitoPO₂ and the onset of CSA-AKI. Extended durations below the mitoPO₂ threshold of 25 mmHg significantly correlate with an elevated CSA-AKI risk. Using mitoPO₂ as a monitoring tool shows promise in potentially predicting and possibly preventing CSA-AKI when used as a treatment trigger in cardiac surgery patients.

Background: Iron deficiency anemia in the perioperative setting is treated predominantly with intravenous iron formulation, of which ferric carboxymaltose may induce hypophosphatemia by modulating fibroblast growth factor 23.

Methods: In this single-center, prospective, randomized, double-blind trial, we consented 92 adult patients scheduled for elective major abdominal or thoracic surgery. These patients either had isolated iron deficiency (plasma ferritin <100 ng/mL or transferrin saturation < 20 %) or iron deficiency anemia (hemoglobin (Hb) 100-130 g/L with plasma ferritin <100 ng/mL or transferrin saturation < 20 %). Preoperatively, participants received a single preoperative intravenous dose of ferric carboxymaltose and were then randomly assigned to receive either phosphate or placebo, administered orally three times a day for 30 days corresponding to an 18 mmol dose of daily phosphate supplementation in the intervention group. The primary endpoint was the minimum serum phosphate concentration during follow-up visits. The key secondary efficacy endpoint was mean perioperative hemoglobin concentration of postoperative days 0, 2 and 4, assessing the non-inferiority of additional phosphate supplementation.

Results: We randomly consented 46 patients in each group (mean ± SD age 56 ± 17 years, 57 % female). Minimal phosphate concentration was 0.49 ± 0.21 mmol/L in the treatment group and 0.42 ± 0.17 mmol/L in the placebo group (p = 0.12, two-sided p-value). Average mean hemoglobin was 110 ± 16 g/L in the treatment and 113 ± 13 g/L in the placebo group (p = 0.023, one-sided p-value for non-inferiority). Hypophosphatemia occurred in 32 patients (70 %) of the treatment group and in 39 patients (85 %) of the placebo group (odds ratio 0.15, 95 % CI from 0.02 to 0.77, p = 0.014). Secondary outcomes, such as rescue medication use, core muscle strength and MOCA test scores, did not differ between groups.

Conclusion: Co-administration of oral phosphate supplementation to ferric carboxymaltose cannot prevent hypophosphatemia. However, hypophosphatemia occurs in fewer patients. Phosphate co-administration did not impede the treatment of iron deficiency anemia with ferric carboxymaltose.

Study objective: To assess whether, in a lung resection cohort with a low probability of confounding by indication, higher FiO₂ is associated with an increased risk of impaired postoperative oxygenation - a clinical manifestation of lung injury/dysfunction.

Design: Pre-specified registry-based retrospective cohort study.

Setting: Two large academic hospitals in the United States.

Patients: 2936 lung resection patients with an overall good intraoperative oxygenation (median intraoperative SpO₂ ≥ 95 %).

Measurements: We compared patients with a higher (≥0.8) and lower (<0.8) median intraoperative FiO₂ after propensity score-weighting for 75 perioperative variables based on a causal inference framework. The primary outcome of impaired oxygenation was defined as at least one of the following within seven postoperative days: (1) SpO₂ < 92 %; (2) imputed PaO₂/FiO₂ < 300 mmHg [(1) or (2) at least twice within 24 h]; (3) intensive oxygen therapy (mechanical ventilation or > 50 % oxygen or high-flow oxygen).

Main results: Among the 2936 included patients, 2171 (73.8 %) received median intraoperative FiO₂ ≥ 0.8. Impaired postoperative oxygenation occurred in 1627 (74.9 %) and 422 (55.2 %) patients in the higher and lower FiO₂ groups, respectively. In a propensity score-weighted analysis, higher intraoperative FiO₂ was associated with an 84 % increase in the likelihood of impaired postoperative oxygenation (OR 1.84; 95 % CI 1.60 to 2.12; P < 0.001).

Conclusions: Despite plausible harm from hyperoxia, high intraoperative FiO₂ is extremely common during lung resection. Nearly three-quarters of lung resection patients with acceptable oxygenation received median intraoperative FiO₂ ≥ 0.8. Such higher FiO₂ was associated with an increased risk of impaired postoperative oxygenation - a clinically relevant manifestation of lung injury or dysfunction. This observation supports the administration of a lower (< 0.8) intraoperative FiO₂ and its further assessment in clinical trials.

Study objective: We developed an innovative method for ultrasound-assisted thoracic epidural catheter placement and assessed its potential to reduce procedural duration for trainees.

Design: A cadaveric observational study and a clinical randomized controlled trial.

Setting: Sapporo Medical University Hospital.

Patients: A total of 52 adult patients scheduled for thoracic or abdominal surgery and four cadavers.

Interventions: Patients were randomly assigned to either group receiving conventional palpation (conventional group) or combination of the ultrasound examination and conventional palpation (ultrasound group).

Measurements: The primary outcome was total procedure time (sum of skin marking time and needling time) by trainees. The secondary outcomes were (1) skin marking time, (2) needling time, (3) multiple skin punctures, (4) needle redirection, (5) complications, and (6) failed cases.

Main results: Through dissection of four cadavers, the most dorsal site of the transverse process root was identifiable by ultrasound and the reliable indicator of the interlaminar space. We devised ultrasound-assisted middle thoracic epidural catheter placement utilizing the most dorsal sites of bilateral transverse process roots as anatomical landmarks. Trainees in the ultrasound group had significantly longer skin marking time and significantly shorter needling time than those in the conventional group (107 [87-158] vs 46 s [34-54] s, p < 0.001 and 197 [156-328] vs 341 [303-488] s, p = 0.003). Consequently, there was no significant difference between the two groups in total procedure time (326 [263-467] s vs 391 [354-533] s, p = 0.167). Moreover, the probability of trainee failure in epidural anesthesia was significantly lower in the ultrasound group (2/26 [17.7 %] vs 10/26 [38.5 %], p = 0.019).

Conclusions: Our novel technique for thoracic epidural catheter placement resulted in expedited needling and enhanced success rates among trainees, although there was no significant difference between total procedure time when using ultrasound guidance and that when using conventional palpation.

Background: Patients receiving intraoperative ventilation during general anesthesia often have low end-tidal CO₂ (etCO₂). We examined the association of intraoperative etCO₂ levels with the occurrence of postoperative pulmonary complications (PPCs) in a conveniently-sized international, prospective study named 'Local ASsessment of Ventilatory management during General Anesthesia for Surgery' (LAS VEGAS).

Methods: Patients at high risk of PPCs were categorized as 'low etCO₂' or 'normal to high etCO₂' patients, using a cut-off of 35 mmHg. The primary endpoint was a composite of previously defined PPCs; the individual PPCs served as secondary endpoints. The need for unplanned oxygen was defined as mild PPCs and severe PPCs included pneumonia, respiratory failure, acute respiratory distress syndrome, barotrauma, and new invasive ventilation. We performed propensity score matching and LOESS regression to evaluate the relationship between the lowest etCO₂ and PPCs.

Results: The analysis included 1843 (74 %) 'low etCO₂' patients and 648 (26 %) 'normal to high etCO₂' patients. There was no difference in the occurrence of PPCs between 'low etCO₂' and 'normal to high etCO₂' patients (20 % vs. 19 %; RR 1.00 [95 %-confidence interval 0.94 to 1.06]; P = 0.84). The proportion of severe PPCs among total occurring PPCs, were higher in 'low etCO₂' patients compared to 'normal to high etCO₂' patients (35 % vs. 18 %; RR 1.16 [1.08 to 1.25]; P < 0.001). Propensity score matching did not change these findings. LOESS plot showed an inverse relationship of intraoperative etCO₂ levels with the occurrence of PPCs.

Conclusions: In this cohort of patients at high risk of PPCs, the overall occurrence of PPCs was not different between 'low etCO₂' patients and 'normal to high etCO₂' patients, but severe PPCs occurred more often in 'low etCO₂', with an inverse dose-dependent relationship between intraoperative etCO₂ levels and PPCs.

Funding: This analysis was performed without additional funding. LAS VEGAS was partially funded and endorsed by the European Society of Anesthesiology and Intensive Care (ESAIC) and the Amsterdam University Medical Centers, location 'AMC'.

Registration: LAS VEGAS was registered at Clinicaltrials.gov (NCT01601223), first posted on May 17, 2012.