Journal of Clinical Anesthesia最新文献

Study objectives

Ciprofol is a novel agonist at the gamma-aminobutyric acid-A (GABA_A) receptor, exhibiting better cardiovascular stability and rapid recovery. The objective of this study was to compare the efficacy and safety of ciprofol and propofol for endoscopic retrograde cholangiopancreatography (ERCP) anesthesia in older patients.

Design

A single-center, randomized, parallel controlled clinical study.

Setting

General Hospital of Northern Theater Command.

Patients

We recruited 284 patients and intended to conduct ERCP from November 2021 to June 2022.

Interventions

Patients scheduled for ERCP were randomly assigned to two groups (n = 142 each): ciprofol group (anesthesia induction 0.3–0.4 mg/kg, anesthesia maintenance 0.8–1.2 mg/kg/h) and propofol group (anesthesia induction 1.5–2.0 mg/kg, anesthesia maintenance 4-12 mg/kg/h).

Measurements

The primary outcome was sedation success rate, defined as the proportion of patients with successful anesthesia induction. Secondary outcomes encompassed the time of successful induction, the time of complete recovery, the time of leaving the room and the incidence rate of adverse events (hypoxemia, hypotension and injection pain).

Main results

The success rate of sedation in both groups was 100 %. The 95 % CI of the difference of sedation success rate was (− 2.63 %, 2.63 %), and the lower limit was greater than the non-inferiority limit of −8 %.The time of successful sedation induction in ciprofol group (38.4 ± 6.5 s) was longer than that in propofol group (30.6 ± 6.2 s, p < 0.05).The time of complete recovery in ciprofol group (12.8 ± 5.8 min) was shorter than that in propofol group (16.9 ± 5.0 min, p < 0.05). The time of leaving the room in ciprofol group (21.8 ± 5.8 min) was shorter than those in propofol group (25.9 ± 5.1 min, p < 0.05). The incidence of injection pain in ciprofol group (2 %) was lower than that in the propofol group (25 %, p < 0.05). Other outcomes didn't show statistical differences.

Conclusions

Compared with propofol, ciprofol exhibited a comparable level of sedation in older patients undergoing ERCP, and recovery was safe and rapid with less injection pain.

Trial registration: www.chictr.org.cn (Registration number ChiCTR2100053386, Registration date November 20, 2021).

Study Objective

To decrease the occurrence of remifentanil waste of 1 mg or more (1 full vial) by 25 % in our surgical division while maintaining satisfaction of 60 % of providers by using a remifentanil mixing workflow.

Design

A time series–design quality improvement initiative targeted preventable remifentanil waste. A period of active interventions, followed by a pause and reinstatement of a system intervention, was used to validate its effectiveness.

Setting

An academic medical center in the US with 1219 inpatient beds, performing 144,418 surgical cases in 2019 and 127,341 surgical cases in 2020, in 148 operating rooms.

Interventions

Individual- and system-level interventions provided education on the issues of preventable waste, access to a remifentanil dose calculator, and an automated dispensing cabinet (ADC) alert to halt wasteful practice.

Measurements

Preventable remifentanil waste was identified as disposing of intravenous infusion bags containing 1 mg or more or 1 full vial or more of unused medication. Data were retrieved from ADC reports. A preimplementation and postimplementation survey of anesthesia providers assessed workflow attitudes, perceptions, and satisfaction surrounding remifentanil mixing.

Main Results

Preventable remifentanil waste (≥1 mg or ≥ 1 full vial) decreased significantly from 22.0 % of cases using remifentanil at baseline to 16.7 % of cases using remifentanil (odds ratio, 0.71; 95 % CI, 0.60–0.84; P < .001) during the final data collection. Individual-level interventions of education, remifentanil dose calculator, and practice champions did not significantly affect waste while unpaired from the system intervention of the ADC alert.

Conclusions

The implementation of an ADC alert reduced preventable remifentanil waste among anesthesia providers.

Purpose

Impacted fetal head (IFH) can be defined as the deep engagement of the fetal head in the maternal pelvis at the time of cesarean delivery that leads to its difficult or impossible extraction with standard surgical maneuvers. In this narrative review, we aimed to ascertain its incidence, risk factors, management and complications from the perspective of the anesthesiologist as a multidisciplinary team member.

Methods

Databases were searched from inception to 24 January 2023 for keywords and subject headings associated with IFH and cesarean delivery.

Results

IFH has an incidence of 2.9–71.8 % in emergency cesarean section. Maternal risk factors are advanced cervical dilatation, second stage of labor and oxytocin augmentation. Anesthetic and obstetric risk factors include epidural analgesia and trial of instrumental delivery and junior obstetrician, respectively. Neonatal risk factors are fetal malposition, caput and molding. Current evidence indicates a lack of confidence in the management of IFH across the multidisciplinary team. Simple interventions in IFH include lowering the height or placing the operating table in the Trendelenburg position, providing a step for the obstetrician and administering pharmacological tocolysis. Maternal complications are postpartum hemorrhage and bladder injury while neonatal complications include hypoxic brain injury, skull fracture and death. Surgical complications are reviewed to remind the anesthesiologist to anticipate and prepare for potential problems and manage complications in a timely manner.

Conclusion

The anesthesiologist has a fundamental role in the facilitation of delivery in IFH. We have proposed an evidence based management algorithm which may be referred to in this emergency situation.

Study objective

This study aimed to investigate the effect of liposomal bupivacaine in transversus abdominis plane block (TAP) on recovery quality after cesarean delivery.

Design

A randomized trial.

Setting

An operating room, a post-anesthesia care unit, and a hospital ward.

Patients

A total of 147 women scheduled for cesarean delivery under spinal anesthesia were enrolled and randomized to receive a TAP block with plain bupivacaine (bupivacaine group), liposomal bupivacaine (liposomal group), or a mixture of plain bupivacaine and liposomal bupivacaine (mixture group).

Interventions

The bupivacaine group received bilateral TAP blocks with plain bupivacaine 50 mg alone. The liposomal group received bilateral TAP blocks with liposomal bupivacaine 266 mg alone. The mixture group received bilateral TAP blocks with plain bupivacaine 50 mg followed by liposomal bupivacaine 266 mg.

Measurements

The primary outcome was the Quality of Recovery−15 (QoR − 15) score assessed 24 h postoperatively. Secondary outcomes encompassed the QoR − 15 score at 48 h post-surgery, the VAS pain score at rest and with movement at 24, 48, and 72 h postoperatively, opioid consumption within the 0–24 h and 24–48 h periods following surgery, as well as patient's satisfaction with analgesic.

Main results

The QoR − 15 score at 24 h postoperatively was significantly higher in both the liposomal group and the mixture group compared to the bupivacaine group. Specifically, the QoR − 15 score for the liposomal group versus the bupivacaine group (median [IQR]: 120 [107, 128] vs. 109 [104, 120]; median difference, 7; 95 % CI, 2 to 13; P = 0.011) and for the mixture group versus the bupivacaine group (median [IQR]: 122 [112, 128] vs. 109 [104, 120]; median difference, 9; 95 % CI, 4 to 14; P = 0.001). The QoR − 15 score in both the liposomal group and the mixture group were also higher than those in the bupivacaine group at 48 h postoperatively, though the difference was not clinically meaningful. Additionally, both the liposomal and mixture groups exhibited lower pain score at 24 h and 48 h postoperatively compared to the bupivacaine group, but no significant clinical differences were achieved in either pain scores or opioid consumption. Patients in both the liposomal and mixture groups reported higher satisfaction score with analgesia than those in the bupivacaine group.

Conclusions

TAP block using either liposomal bupivacaine or a mixture of plain bupivacaine and liposomal bupivacaine provided superior quality of recovery at 24 h after cesarean delivery compared to using plain bupivacaine alone.