Journal of Clinical Anesthesia最新文献_第6页

Impact of implementing a thromboelastometry-guided transfusion strategy on fibrinogen supplementation and transfusion in women with postpartum hemorrhage 实施血栓弹性测量指导输血策略对产后出血妇女纤维蛋白原补充和输血的影响

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-12 DOI: 10.1016/j.jclinane.2025.112102

Anne Zheng , Valérie Chamouard , Christophe Nougier , François-Pierrick Desgranges , Charles-Hervé Vacheron , Lionel Bouvet

Study objective

Coagulopathy is a key determinant of maternal prognosis in case of postpartum hemorrhage. We sought to assess the impact of implementing a thromboelastometry-based coagulopathy management protocol on fibrinogen concentrate use and transfusion strategies.

Design

Retrospective study.

Setting

Tertiary care obstetric unit, university hospital, Lyon, France.

Patients

Adult women with postpartum hemorrhage (≥500 mL blood loss within 24 h postpartum) at a gestational age ≥ 22 weeks.

Interventions

Three distinct periods were analyzed: Period 1 (2016–2018, no viscoelastic test available), Period 2 (2019–2020, thromboelastometry available in our maternity unit) and Period 3 (2021–2023, implementation of a thromboelastometry-based coagulopathy management protocol).

Measurements

The primary endpoint was the proportion of patients receiving fibrinogen concentrate in each period. Secondary endpoints were the proportions of patients transfused with blood products within the first 24 h in each period. Adjusted odds ratios (aOR) for each outcome were estimated using bidirectional stepwise regression in a final model that included 12 preselected confounders.

Main results

A total of 3899 patients were analyzed. Period 3 and Period 2 were independently associated with significantly lower odds of fibrinogen concentrate administration compared to Period 1. The aOR was 0.19 (95 %CI: 0.14 to 0.28) for Period 3 and 0.70 (95 %CI: 0.50 to 0.98) for Period 2. Period 3 was also independently associated with significantly lower odds of transfusion of red blood cells (aOR = 0.25 [95 %CI: 0.19 to 0.33]), fresh frozen plasma (aOR = 0.17 [95 %CI: 0.09 to 0.33]) and platelet concentrates (aOR = 0.23 [95 %CI: 0.08 to 0.62]) compared to Period 1. The frequency of massive postpartum hemorrhage (≥2500 mL) did not change significantly across the three periods.

Conclusions

Implementing a thromboelastometry-guided protocol was associated with significantly reduced use of fibrinogen concentrate, red blood cells, fresh frozen plasma, and platelet concentrates, without increasing the risk of progression to massive hemorrhage. Further assessments of maternal outcomes and cost-effectiveness are required.

研究目的凝血功能障碍是影响产后出血产妇预后的重要因素。我们试图评估实施基于血栓弹性测量的凝血病管理方案对浓缩纤维蛋白原使用和输血策略的影响。DesignRetrospective研究。法国里昂大学医院三级护理产科。孕龄≥22周的成年女性产后出血（产后24小时内出血量≥500 mL）。干预措施分析了三个不同的时期：第1期（2016-2018年，没有可用的粘弹性测试），第2期（2019-2020年，我们的产科病房有血栓弹性测量）和第3期（2021-2023年，实施基于血栓弹性测量的凝血病管理方案）。主要终点是每个时期接受浓缩纤维蛋白原治疗的患者比例。次要终点是在每个时间段的前24小时内输注血液制品的患者比例。在包含12个预选混杂因素的最终模型中，使用双向逐步回归估计每个结果的调整优势比（aOR）。主要结果共分析3899例患者。与第1期相比，第3期和第2期单独使用浓缩纤维蛋白原的几率显著降低。第3期的aOR为0.19 (95% CI: 0.14至0.28)，第2期为0.70 （95% CI: 0.50至0.98）。与第1期相比，第3期输血红细胞（aOR = 0.25 [95% CI: 0.19至0.33]）、新鲜冷冻血浆（aOR = 0.17 [95% CI: 0.09至0.33]）和血小板浓缩物（aOR = 0.23 [95% CI: 0.08至0.62]）的几率也显著降低。产后大出血（≥2500 mL）的发生频率在三个时期内无明显变化。结论实施血栓弹性测量指导方案可显著减少纤维蛋白原浓缩物、红细胞、新鲜冷冻血浆和血小板浓缩物的使用，且不会增加发展为大出血的风险。需要进一步评估产妇结局和成本效益。

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引用次数: 0

The clinical effectiveness of preoperative screening and post-screening interventions for obstructive sleep apnea: A systematic review and meta-analysis 阻塞性睡眠呼吸暂停术前筛查和筛查后干预的临床效果：系统回顾和荟萃分析。

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-11 DOI: 10.1016/j.jclinane.2025.112084

Rushil Parikh HBSc , Linor Berezin MD , Aparna Saripella MSc , Ellene Yan HBSc , Bianca Pivetta MD , Khashayar Poorzargar MSc , Emmanuel Olaonipekun BSc , Marina Englesakis MLIS , Majid Nabipoor PhD , Frances Chung MD

Objectives

The objective of this systematic review and meta-analysis is to evaluate the clinical utility of preoperative screening for obstructive sleep apnea (OSA) and determine the impact of targeted interventions on reducing postoperative adverse outcomes in surgical patients identified as high risk of OSA (HR-OSA).

Methods

A comprehensive literature search was conducted across multiple databases for studies evaluating the utilization of validated OSA screening tools and OSA interventions within the surgical setting. Primary outcomes included postoperative adverse respiratory and cardiac events, delirium, length of stay (LOS), intensive care unit (ICU) admissions, 30-day readmissions, and mortality. Interventions included continuous positive airway pressure (CPAP) or auto-titration positive airway pressure (APAP) use, sleep consultation, OSA safety protocols, wrist bands, and patient education. Certain studies used a combination of these interventions for HR-OSA patients.

Results

Fifty-four studies (324,935 patients) were included. The odds of adverse postoperative respiratory complications (OR 3.59, 95 % CI: 1.73–7.43) and cardiac complications (OR 2.82, 95 % CI: 1.62–4.92) events were significantly higher, and hospital LOS was significantly longer (mean difference: 0.79 days, 95 % CI: 0.42–1.15) for HR-OSA patients than those at low risk of OSA (LR-OSA). The odds of delirium, ICU admission, and 30-day readmission were not significantly increased for HR-OSA patients. In contrast, for HR-OSA patients who received post-screening interventions such as safety protocols, education and other targeted interventions, no significant differences in respiratory complications (OR 0.86, 95 % CI: 0.56–1.31), delirium (OR 0.69, 95 % CI: 0.12–4.06), escalation of care (OR 0.86, 95 % CI: 0.62–1.18), or composite adverse events (OR 0.81, 95 % CI: 0.61–1.08) were found compared to OSA patients who received no intervention.

Conclusions

Our findings confirm HR-OSA as a risk factor for postoperative adverse events. Preoperative screening for OSA and subsequent targeted perioperative interventions and management strategies may contribute to a reduction in postoperative adverse outcomes. The current evidence regarding the efficacy of targeted interventions is limited by significant heterogeneity and sparsity of high-quality data and should be interpreted as exploratory.

目的：本系统综述和荟萃分析的目的是评估阻塞性睡眠呼吸暂停（OSA）术前筛查的临床应用，并确定有针对性的干预措施对减少OSA （HR-OSA）高危手术患者术后不良结局的影响。方法：在多个数据库中进行了全面的文献检索，以评估经过验证的OSA筛查工具和OSA干预措施在手术环境中的使用情况。主要结局包括术后不良呼吸和心脏事件、谵妄、住院时间（LOS）、重症监护病房（ICU）入院、30天再入院和死亡率。干预措施包括持续气道正压（CPAP）或自动滴定气道正压（APAP）使用、睡眠咨询、OSA安全协议、腕带和患者教育。某些研究对HR-OSA患者使用了这些干预措施的组合。结果：纳入54项研究（324,935例患者）。HR-OSA患者术后不良呼吸并发症（OR 3.59, 95% CI: 1.73-7.43）和心脏并发症（OR 2.82, 95% CI: 1.62-4.92）事件的发生率明显高于低风险OSA （LR-OSA）患者，住院时间明显更长（平均差异：0.79天，95% CI: 0.42-1.15）。HR-OSA患者谵妄、ICU住院和30天再入院的几率没有显著增加。相比之下，对于接受筛查后干预（如安全方案、教育和其他针对性干预）的HR-OSA患者，与未接受干预的OSA患者相比，呼吸并发症（OR 0.86, 95% CI: 0.56-1.31）、谵妄（OR 0.69, 95% CI: 0.12-4.06）、护理升级（OR 0.86, 95% CI: 0.62-1.18）或复合不良事件（OR 0.81, 95% CI: 0.61-1.08）均无显著差异。结论：我们的研究结果证实HR-OSA是术后不良事件的危险因素。术前筛查OSA和随后有针对性的围手术期干预和管理策略可能有助于减少术后不良后果。目前关于目标干预有效性的证据受到高质量数据的显著异质性和稀疏性的限制，应该被解释为探索性的。

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引用次数: 0

On the Cover - Mogianos et al 封面——莫吉阿诺斯等人

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-11 DOI: 10.1016/S0952-8180(25)00347-2

引用次数: 0

Evaluating sedation strategies in acute respiratory distress syndrome: A meta-analysis of inhaled versus intravenous agents 评估急性呼吸窘迫综合征的镇静策略：吸入与静脉注射药物的荟萃分析。

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-10 DOI: 10.1016/j.jclinane.2025.112100

Sandesh Raja , Azzam Ali , Afeera Bashir , F.N.U. Kashish , Haniah Mahboob

Introduction

Acute respiratory distress syndrome (ARDS), often requires deep sedation to facilitate lung-protective ventilation. While intravenous sedatives (e.g., propofol, midazolam) are standard, inhaled agents (e.g., sevoflurane, isoflurane) have emerged as potential alternatives and may offer advantages in titratability and lung protection. This meta-analysis compares their efficacy in ARDS management.

Methods

Following PRISMA guidelines, we systematically searched multiple databases (inception–May 2025) for randomized and observational studies comparing inhaled versus intravenous sedation in ARDS. Outcomes included ICU length of stay, ventilator-free days (VFDs), mortality, and respiratory parameters. Risk of bias was assessed using ROB-2 and Newcastle-Ottawa tools. Random-effects meta-analyses were conducted for pooled estimates.

Results

Seven studies (1349 patients) were included. Inhaled sedation significantly reduced ICU stay (mean difference [MD]: −2.07 days; 95 % CI: −3.72 to −0.41; p = 0.01) and duration of mechanical ventilation (MD: −2.62 days; 95 % CI: −4.48 to −0.76; p = 0.006). However, Inhaled sedation was associated with significantly fewer VFDs (MD: −1.82; 95 % CI: −3.41 to −0.24; p = 0.02). No mortality difference was observed (p = 0.18). Inhaled agents improved PEEP on day 1 (p < 0.00001) but increased PaCO₂ (p < 0.00001) and reduced arterial pH (p = 0.001).

Conclusion

Inhaled sedation with volatile anesthetics may offer advantages over intravenous sedation in reducing ICU stay and mechanical ventilation duration in ARDS patients. However, the associated alterations in gas exchange parameters warrant cautious interpretation. Further large-scale studies are needed to confirm these findings and to optimize sedation strategies in this population.

Clinical trial registration

Not required.

Registration

This review is registered with PROSPERO (CRD420251049792).

简介：急性呼吸窘迫综合征（ARDS），通常需要深度镇静以促进肺保护性通气。虽然静脉注射镇静剂（如异丙酚、咪达唑仑）是标准的，但吸入剂（如七氟醚、异氟醚）已成为潜在的替代品，可能在滴定性和肺保护方面具有优势。本荟萃分析比较了他们在ARDS管理中的疗效。方法：遵循PRISMA指南，我们系统地检索了多个数据库（启动至2025年5月），以比较吸入镇静和静脉镇静在ARDS中的随机和观察性研究。结果包括ICU住院时间、无呼吸机天数（vfd）、死亡率和呼吸参数。使用rob2和Newcastle-Ottawa工具评估偏倚风险。随机效应荟萃分析用于汇总估计。结果：纳入7项研究（1349例患者）。吸入镇静显著减少ICU住院时间（平均差[MD]: -2.07天；95% CI: -3.72 ~ -0.41; p = 0.01）和机械通气持续时间（MD: -2.62天；95% CI: -4.48 ~ -0.76; p = 0.006）。然而，吸入镇静与vfd显著减少相关（MD: -1.82; 95% CI: -3.41至-0.24;p = 0.02）。死亡率无差异（p = 0.18）。结论：挥发性麻醉药吸入镇静在减少ARDS患者ICU住院时间和机械通气时间方面优于静脉镇静。然而，气体交换参数的相关变化需要谨慎解释。需要进一步的大规模研究来证实这些发现并优化这一人群的镇静策略。临床试验注册：不需要。注册：本综述已在PROSPERO注册（CRD420251049792）。

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引用次数: 0

Editorial Board w/barcode 编辑委员会/条形码

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-10 DOI: 10.1016/S0952-8180(25)00349-6

引用次数: 0

Methodological quality of systematic reviews on the quadratus lumborum block for cesarean section: An overview of systematic reviews 剖宫产术腰方肌阻滞系统评价的方法学质量：系统评价综述。

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-10 DOI: 10.1016/j.jclinane.2025.112098

Burhan Dost , Muzeyyen Beldagli , Yunus Emre Karapinar , Esra Turunc , Engin İhsan Turan , Alessandro De Cassai

引用次数: 0

Hope or erosion? Humor, cynicism, and the leadership challenge in perioperative medicine 希望还是侵蚀？幽默、玩世不恭和围手术期医学的领导力挑战。

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-09 DOI: 10.1016/j.jclinane.2025.112096

Benjamin Martens , Silke Mischke , Markus M. Luedi

The operating theater is an emotionally and cognitively demanding arena where anesthesiologists and surgeons operate under time pressure, uncertainty, and responsibility. Team interactions in such settings frequently reveal humor, irony, or cynicism, behaviors that represent underlying ego defense mechanisms.

We explore how defense mechanisms such as humor and cynicism affect perioperative culture, teamwork, and leadership; and to argue that self-awareness, mindfulness, and relational maturity indirectly improve clinical outcomes.

This conceptual analysis integrates psychoanalytic theories (Freud, Jung, Vaillant), developmental leadership frameworks, and empirical studies of coping, mindfulness, and culture from medicine, sport, and organizational psychology. Data from nursing and acute care suggest that psychological safety, emotional intelligence, and reflective practice correlate with performance and safety.

Defensive patterns in professional behavior are not merely interpersonal; they shape patient care. Humor, sublimation and mindfulness reflect mature defenses that sustain connection and safety. Cynicism, an immature defense, isolates and fragments teams. A mindful, reflective culture in perioperative medicine is therefore an unmeasured determinant of clinical excellence.

手术室是一个对情感和认知都有要求的场所，麻醉医师和外科医生在时间压力、不确定性和责任下进行手术。在这样的环境下，团队互动经常表现出幽默、讽刺或玩世不恭，这些行为代表了潜在的自我防御机制。我们探讨幽默和玩世不恭等防御机制如何影响围手术期文化、团队合作和领导能力；并认为自我意识，正念和关系成熟间接地改善了临床结果。这一概念分析整合了精神分析理论（弗洛伊德、荣格、瓦伦特）、发展型领导框架，以及来自医学、体育和组织心理学的应对、正念和文化的实证研究。来自护理和急症护理的数据表明，心理安全、情商和反思性实践与表现和安全相关。职业行为中的防御模式不仅仅是人际关系；他们塑造了病人的护理。幽默、升华和正念反映了维持联系和安全的成熟防御。玩世不恭是一种不成熟的防御，会孤立和分裂团队。因此，围手术期医学中有意识的、反思的文化是临床卓越的不可衡量的决定因素。

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引用次数: 0

Effect of intravenous dexamethasone on duration of analgesia following popliteal nerve block in pediatric ankle surgery: A randomized, triple-blinded clinical trial 静脉地塞米松对小儿踝关节手术腘神经阻滞后镇痛持续时间的影响：一项随机、三盲临床试验

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-05 DOI: 10.1016/j.jclinane.2025.112094

Tomasz Reysner M.D. , Bahadir Ciftci Assoc Prof., M.D. , Pawel Pietraszek M.D. , Tomasz Purat M.D. , Milud Shadi M.D. Ph.D , Bartosz Musielak M.D. Ph.D , Maciej Idzior M.D. Ph.D , Przemyslaw Daroszewski M.D. Ph.D , Malgorzata Reysner M.D. Ph.D

Background

Effective postoperative pain control in pediatric foot and ankle surgery remains challenging. Popliteal nerve blocks are widely used but limited by their short duration. Systemic dexamethasone may prolong analgesia, yet evidence in pediatric regional anesthesia remains sparse.

Objective

To assess the analgesic efficacy and safety of two intravenous dexamethasone doses (0.1 mg/kg and 0.2 mg/kg) administered before a single-shot popliteal nerve block in children undergoing ankle or foot surgery.

Methods

In this randomized, triple-blinded clinical trial, 90 pediatric patients were allocated to receive either placebo, 0.1 mg/kg, or 0.2 mg/kg dexamethasone intravenously prior to popliteal nerve block. The primary outcome was time to first opioid requirement. Secondary outcomes included total opioid consumption, FLACC pain scores, inflammatory markers (NLR, PLR), blood glucose, and time to motor recovery.

Results

Both dexamethasone groups had significantly longer opioid-free intervals compared to placebo (12.3 ± 2.4 h and 13.7 ± 2.6 h vs. 7.5 ± 2.2 h; p < 0.0001). Opioid consumption was lowest in the 0.2 mg/kg group (p = 0.0292). Pain scores and inflammatory markers were consistently lower in dexamethasone groups. However, blood glucose levels increased dose-dependently, with the highest values in the 0.2 mg/kg group. Motor recovery was also delayed with dexamethasone use.

Conclusion

Intravenous dexamethasone effectively prolongs analgesia and reduces opioid requirements after pediatric foot and ankle surgery. While 0.2 mg/kg provides maximal benefit, 0.1 mg/kg may offer an optimal balance between efficacy and metabolic safety.

Trial registration: ClinicalTrials.gov (NCT05887765).

儿童足部和踝关节手术后有效的疼痛控制仍然具有挑战性。腘窝神经阻滞被广泛应用，但其持续时间短。全身性地塞米松可能会延长镇痛时间，但在小儿区域麻醉中的证据仍然很少。目的评价儿童踝关节或足部手术行腘窝神经阻滞前两次静脉注射地塞米松（0.1 mg/kg和0.2 mg/kg）的镇痛效果和安全性。方法在这项随机、三盲临床试验中，90例儿童患者在腘神经阻滞前静脉注射安慰剂、0.1 mg/kg或0.2 mg/kg地塞米松。主要终点是到达第一次阿片类药物需求的时间。次要结局包括阿片类药物总消耗量、FLACC疼痛评分、炎症标志物（NLR、PLR）、血糖和运动恢复时间。结果与安慰剂组相比，地塞米松组的无阿片类药物间隔均明显延长（分别为12.3±2.4 h和13.7±2.6 h vs. 7.5±2.2 h; p < 0.0001）。0.2 mg/kg组阿片类药物消耗最低（p = 0.0292）。地塞米松组疼痛评分和炎症指标均较低。然而，血糖水平呈剂量依赖性增加，0.2 mg/kg组血糖水平最高。使用地塞米松也延迟了运动恢复。结论静脉注射地塞米松可有效延长小儿足踝手术后的镇痛时间，减少阿片类药物的需用。虽然0.2 mg/kg提供最大的效益，但0.1 mg/kg可能提供功效和代谢安全性之间的最佳平衡。试验注册：ClinicalTrials.gov （NCT05887765）。

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引用次数: 0

Comparison of pericapsular nerve group block and supra-inguinal fascia iliaca compartment block for preoperative analgesia in elderly patients with hip fracture: A prospective, randomized controlled study 一项前瞻性、随机对照研究：囊周神经群阻滞与腹股沟上筋膜髂隔室阻滞用于老年髋部骨折患者术前镇痛的比较。

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-01 DOI: 10.1016/j.jclinane.2025.112082

Haiming Liao , Zhen Wan , Jingjing Su, Dong Han, Wentao Lin, Muzhao Yu, Ge Sun, Fuhu Song, Jun Zhou

Background

Position changes due to the implementation of neuraxial anesthesia before hip fracture surgery may cause severe pain, and increases the occurrence of perioperative adverse events, especially for weak elderly patients with cardiovascular and other diseases. Iliaca fascia block (FICB) is commonly used method to control the pain caused by position changes, and has been proven to have a good analgesic effect. However, pain control is not ideal due to ultrasound positioning and fascia diffusion of anesthetic. The pericapsular nerve group (PENG) block is a new method for pain control after hip fracture surgery. And also performed in emergency departments for early multimodal analgesia and is increasingly being taught to emergency physicians[1, 2]. However, there are few studies on analgesia before spinal anesthesia in hip fracture surgery, and there is a lack of comparison of the analgesic effect and benefits between the PENG block and FICB in elderly patients with hip fracture. This study employed ultrasound-guided supra-inguinal fascia iliaca block (sFICB), aimed to compare the analgesic effects of PENG and sFICB before spinal canal block in elderly patients with hip fractures undergoing surgery.

Methods

This was a single-center, observer-blind, prospective, and randomized controlled study. A total of 64 elderly patients with hip fractures ≥65 years old were enrolled. Before undergoing intrathecal block, the patients were randomly divided into 2 groups: P group (PENG block)and F group(sFICB block).

Results

The success rate was 68.75 % in the F group, and 90.62 % in the P group (P < 0.05). Compared with the F group, the numeric rating scale (NRS) scores of the P group were significantly decreased (P < 0.05), and the time to perform the nerve block and spinal anesthesia were shorter (P < 0.05) in the P group. There was no significant difference in vital signs, pain relief, morphine consumption within 2 days after the operation, and adverse reactions between the 2 groups.

Conclusion

PENG block before spinal anesthesia has a better analgesic effect in elderly patients undergoing hip fracture surgery as compared to sFICB. The success rate of PENG is also significantly greater than that of sFICB.

背景：髋部骨折手术前实施轴向麻醉导致体位改变，可能引起剧烈疼痛，并增加围手术期不良事件的发生，尤其是老年体弱合并心血管等疾病患者。髂筋膜阻滞（FICB）是控制体位变化引起疼痛的常用方法，已被证明具有良好的镇痛效果。然而，由于超声定位和麻醉的筋膜扩散，疼痛控制并不理想。囊周神经阻滞是髋骨骨折术后疼痛控制的一种新方法。也在急诊科进行早期多模态镇痛，并越来越多地被教授给急诊科医生[1,2]。然而，关于脊柱麻醉在髋部骨折手术前镇痛的研究较少，且缺乏对老年髋部骨折患者PENG阻滞与FICB镇痛效果和获益的比较。本研究采用超声引导下腹股沟上筋膜髂阻滞（sFICB），目的是比较老年髋部骨折手术患者椎管阻滞前PENG与sFICB的镇痛效果。方法：这是一项单中心、观察者盲、前瞻性、随机对照研究。共纳入64例≥65岁的老年髋部骨折患者。在行鞘内阻滞前，将患者随机分为2组：P组（PENG阻滞）和F组（sFICB阻滞）。结果：F组成功率为68.75%，P组成功率为90.62%。(P)结论：腰麻前PENG阻滞对老年髋部骨折手术患者的镇痛效果优于sFICB。PENG的成功率也明显大于sFICB。

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引用次数: 0

Comparing multiple people each to the grand mean of log-normally distributed endpoints 将多人与对数正态分布端点的均值进行比较

IF 5.1 2区医学 Q1 ANESTHESIOLOGY

Journal of Clinical Anesthesia

Pub Date : 2025-12-01 DOI: 10.1016/j.jclinane.2025.112083

Pei-Fu Chen MD, PhD, Franklin Dexter MD, PhD

Background

Multiple anesthesiology endpoints follow log-normal distributions, including surgical times, anesthesia times, epidural placement times, extubation times, and post-anesthesia care unit times. These can be compared among people (e.g., anesthesiologists or surgeons), hospitals, or clinical trial centers to detect outliers. We consider comparisons of each group, henceforth referred to as a “person,” with the grand mean.

Methods

Monte-Carlo simulations were performed to evaluate risks of false detection (Type I errors) using generalized linear models, generalized pivotal methods, and mixed effects models with empirical Bayes means and standard errors predicted from the random effects. Models were evaluated with and without heteroscedastic consistent (robust) standard errors.

Results

Errors were > 10-fold when fixed effects models lacked Bonferroni correction for multiple comparisons. Šidák adjustments had small incremental inaccuracy because the comparisons being made were not statistically independent of one another. Robust variance estimates were more accurate than the default observed information matrix method. However, the sample size of 10 cases per person was too small for the robust variance method, resulting in large inaccuracy. With Bonferroni adjustment, robust variance estimation, and log link, there also were large errors with unequal sample sizes, even with a median of 60 cases per person. When a mixed effects model was used instead (i.e., shrinkage estimates), Bonferroni adjustment yielded highly inaccurate results. Without adjustment, errors were small to moderate. Generalized pivotal inference applied individually for each person compared with the grand mean had very small errors when used with Šidák adjustment.

Conclusions

For log-normally distributed continuous outcomes, with sample sizes of 100's of cases per person, consider fixed effect models with Bonferroni adjustment and robust variance estimation. Otherwise, we recommend generalized pivotal inference with Šidák adjustment.

多个麻醉终点遵循对数正态分布，包括手术次数、麻醉次数、硬膜外放置次数、拔管次数和麻醉后护理单位次数。这些数据可以在人与人（如麻醉师或外科医生）、医院或临床试验中心之间进行比较，以发现异常值。我们考虑将每一组（因此称为“人”）与总均值进行比较。方法采用广义线性模型、广义枢纽方法和混合效应模型，采用经验贝叶斯均值和随机效应预测的标准误差，进行蒙特卡罗模拟，评估误检（I型错误）的风险。模型在有和没有异方差一致（稳健）标准误差的情况下进行评估。结果固定效应模型缺乏Bonferroni校正进行多重比较时，误差为10倍。Šidák调整有小的增量误差，因为正在进行的比较在统计上不是相互独立的。稳健方差估计比默认的观察信息矩阵方法更准确。然而，每人10例的样本量对于稳健方差法来说太小了，导致了很大的不准确性。通过Bonferroni调整、稳健方差估计和log链接，即使中位数为每人60例，样本量不等也存在较大误差。当使用混合效应模型（即收缩估计）时，Bonferroni调整产生了非常不准确的结果。未经调整，误差从小到中等。当使用Šidák调整时，对每个人单独应用的广义枢纽推断与大平均值相比误差很小。对于对数正态分布的连续结果，在每人100例的样本量下，可以考虑采用Bonferroni调整和稳健方差估计的固定效应模型。否则，我们建议广义枢纽推理与Šidák调整。

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引用次数: 0