Pub Date : 2025-11-03DOI: 10.1016/j.jclinane.2025.112062
Qingxia Xue , Bei Zhang , Zhicong Xing , Fudong Sun , Quan Zhao , Shengjun Mu
Objective
Anemia is common in the perioperative period, with approximately one-third of surgical patients presenting with preoperative anemia and even higher rates of anemia postoperatively due to blood loss. The comparative efficacy and safety of different intravenous iron preparations for perioperative anemia remain unclear. This study aims to evaluate their efficacy and safety by a comprehensive network meta-analysis (NMA).
Methods
A systematic search of PubMed, Embase, and the Cochrane Library was conducted from inception to December 10, 2024, to identify randomized controlled trials (RCTs) involving intravenous iron administration in the perioperative period. Two independent researchers extracted and cross-checked the data. Outcomes included transfusion rate, hemoglobin (Hb) concentrations, adverse events, quality of life (QoL), hypersensitivity reactions, and hypophosphatemia. A Bayesian NMA was performed.
Results
Thirty-four RCTs with a total of 4688 participants were included in the NMA. Ferric carboxymaltose (FCM, mean difference [MD] 0.76 g/dL, 95 % credible interval [CrI] 0.56 to 0.96) and iron isomaltoside (IIM, MD 0.65 g/dL, 95 % CrI 0.33 to 0.97) significantly increased Hb concentrations compared with placebo. However, only FCM reduced transfusion requirements (odds ratio [OR] 0.72, 95 % CrI 0.55 to 0.91). The safety analysis revealed no significant differences in adverse events between the groups. Descriptive analysis indicated improved QoL with FCM compared to placebo for fatigue and dyspnea (QLQ-C30) and physical functioning (SF-36). For NMA, no significant inconsistencies were found between direct and indirect evidence.
Conclusions
FCM improves perioperative Hb concentrations and reduces transfusion requirements. All intravenous iron preparations demonstrated acceptable safety profiles. Further research is needed to validate these findings and refine perioperative iron supplementation strategies.
{"title":"Efficacy and safety of intravenous iron supplementation for perioperative iron deficiency anemia: a systematic review and network meta-analysis of randomized controlled trials","authors":"Qingxia Xue , Bei Zhang , Zhicong Xing , Fudong Sun , Quan Zhao , Shengjun Mu","doi":"10.1016/j.jclinane.2025.112062","DOIUrl":"10.1016/j.jclinane.2025.112062","url":null,"abstract":"<div><h3>Objective</h3><div>Anemia is common in the perioperative period, with approximately one-third of surgical patients presenting with preoperative anemia and even higher rates of anemia postoperatively due to blood loss. The comparative efficacy and safety of different intravenous iron preparations for perioperative anemia remain unclear. This study aims to evaluate their efficacy and safety by a comprehensive network meta-analysis (NMA).</div></div><div><h3>Methods</h3><div>A systematic search of PubMed, Embase, and the Cochrane Library was conducted from inception to December 10, 2024, to identify randomized controlled trials (RCTs) involving intravenous iron administration in the perioperative period. Two independent researchers extracted and cross-checked the data. Outcomes included transfusion rate, hemoglobin (Hb) concentrations, adverse events, quality of life (QoL), hypersensitivity reactions, and hypophosphatemia. A Bayesian NMA was performed.</div></div><div><h3>Results</h3><div>Thirty-four RCTs with a total of 4688 participants were included in the NMA. Ferric carboxymaltose (FCM, mean difference [MD] 0.76 g/dL, 95 % credible interval [CrI] 0.56 to 0.96) and iron isomaltoside (IIM, MD 0.65 g/dL, 95 % CrI 0.33 to 0.97) significantly increased Hb concentrations compared with placebo. However, only FCM reduced transfusion requirements (odds ratio [OR] 0.72, 95 % CrI 0.55 to 0.91). The safety analysis revealed no significant differences in adverse events between the groups. Descriptive analysis indicated improved QoL with FCM compared to placebo for fatigue and dyspnea (QLQ-C30) and physical functioning (SF-36). For NMA, no significant inconsistencies were found between direct and indirect evidence.</div></div><div><h3>Conclusions</h3><div>FCM improves perioperative Hb concentrations and reduces transfusion requirements. All intravenous iron preparations demonstrated acceptable safety profiles. Further research is needed to validate these findings and refine perioperative iron supplementation strategies.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112062"},"PeriodicalIF":5.1,"publicationDate":"2025-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145445018","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-03DOI: 10.1016/j.jclinane.2025.112051
Yanxia Sun , Zhenghao Wen , Yi Ren , Zhen Hua
Background
Perioperative hyperglycemia is common during cardiac surgery and has been linked to an increased risk of surgical site infections (SSIs). However, the benefits of perioperative tight glucose control (TGC) remain debated, largely due to concerns about hypoglycemia. This systematic review assessed the effects and safety of TGC on SSIs in adults undergoing cardiac surgery.
Methods
We searched MEDLINE, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing TGC (upper blood glucose target ≤150 mg/dL or 8.3 mmol/L) with conventional glucose management in adults undergoing cardiac surgery. The primary outcome was incidence of SSIs. Secondary outcomes included hypoglycemia, length of intensive care unit (ICU) stay, incidence of neurological deficits and all-cause mortality within 30 days after surgery. The certainty of evidence was evaluated using the GRADE approach.
Results
Twenty-six RCTs including 17,990 participants were analyzed. TGC compared with control group was associated with reducing the risk of SSIs (risk ratio [RR]: 0.53; 95 % confidence interval [CI]: 0.42–0.68; I2 = 0 %; low certainty evidence), particularly when initiated at the start of surgery (RR: 0.50, 95 %CI: 0.39–0.66, I2 = 0; low certainty evidence) but not postoperatively (RR = 0.80, 95 % CI: 0.39–1.66; I2 = 0; very low certainty evidence). TGC also shortened ICU stay by 7.03 h compared to the control group (95 % CI: −10.83 to −3.22; very low certainty evidence), though heterogeneity was considerable (I2 = 92 %). However, TGC was associated with a higher risk of hypoglycemia (RR: 3.14; 95 % CI: 2.37–4.16; I2 = 0; moderate certainty evidence). No significant effects were observed on neurological deficits or all-cause mortality.
Conclusion
This systematic review of the available evidence suggests that perioperative TGC, particularly when initiated at the start of surgery, may reduce the risk of SSIs following cardiac surgery. However, it increases the risk of hypoglycemia and does not significantly impact neurological outcomes and all-cause mortality.
{"title":"Perioperative tight glucose control regimens for preventing surgical site infections following cardiac surgery-a systematic review and metanalysis of randomized controlled trials","authors":"Yanxia Sun , Zhenghao Wen , Yi Ren , Zhen Hua","doi":"10.1016/j.jclinane.2025.112051","DOIUrl":"10.1016/j.jclinane.2025.112051","url":null,"abstract":"<div><h3>Background</h3><div>Perioperative hyperglycemia is common during cardiac surgery and has been linked to an increased risk of surgical site infections (SSIs). However, the benefits of perioperative tight glucose control (TGC) remain debated, largely due to concerns about hypoglycemia. This systematic review assessed the effects and safety of TGC on SSIs in adults undergoing cardiac surgery.</div></div><div><h3>Methods</h3><div>We searched MEDLINE, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing TGC (upper blood glucose target ≤150 mg/dL or 8.3 mmol/L) with conventional glucose management in adults undergoing cardiac surgery. The primary outcome was incidence of SSIs. Secondary outcomes included hypoglycemia, length of intensive care unit (ICU) stay, incidence of neurological deficits and all-cause mortality within 30 days after surgery. The certainty of evidence was evaluated using the GRADE approach.</div></div><div><h3>Results</h3><div>Twenty-six RCTs including 17,990 participants were analyzed. TGC compared with control group was associated with reducing the risk of SSIs (risk ratio [RR]: 0.53; 95 % confidence interval [CI]: 0.42–0.68; I<sup>2</sup> = 0 %; low certainty evidence), particularly when initiated at the start of surgery (RR: 0.50, 95 %CI: 0.39–0.66, I<sup>2</sup> = 0; low certainty evidence) but not postoperatively (RR = 0.80, 95 % CI: 0.39–1.66; I<sup>2</sup> = 0; very low certainty evidence). TGC also shortened ICU stay by 7.03 h compared to the control group (95 % CI: −10.83 to −3.22; very low certainty evidence), though heterogeneity was considerable (I<sup>2</sup> = 92 %). However, TGC was associated with a higher risk of hypoglycemia (RR: 3.14; 95 % CI: 2.37–4.16; I<sup>2</sup> = 0; moderate certainty evidence). No significant effects were observed on neurological deficits or all-cause mortality.</div></div><div><h3>Conclusion</h3><div>This systematic review of the available evidence suggests that perioperative TGC, particularly when initiated at the start of surgery, may reduce the risk of SSIs following cardiac surgery. However, it increases the risk of hypoglycemia and does not significantly impact neurological outcomes and all-cause mortality.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112051"},"PeriodicalIF":5.1,"publicationDate":"2025-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145445002","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.jclinane.2025.112064
Jan Albert Nicolaas Groot , Ankie Maxelante Harmsze , Eric Hendricus Paulus Adrianus van Dongen , Catherijne Anette Jantine Knibbe , Helena Johanna Blussé van Oud-Alblas
Despite advances in perioperative medicine, variability in patient responses to commonly administered anesthetic and analgesic agents remains a clinical challenge. Genetic factors are increasingly proposed contributors to these interindividual differences, yet much of the supporting evidence remains preliminary, heterogeneous or insufficiently validated. Pharmacogenetics has emerged as a promising field to improve therapeutic precision. However, its clinical application in perioperative care remains limited. This narrative review critically appraises pharmacokinetic and pharmacodynamic drug–gene interactions that influence responses to routinely administered agents. Genetic variations affect multiple aspects of perioperative care, including drug metabolism and receptor sensitivity, pain processing, autonomic function, and susceptibility to complications such as postoperative nausea and vomiting and opioid-induced respiratory depression. A better understanding of drug–gene interactions may help anesthesiologists identify patients with atypical sensitivity or resistance to commonly used agents, as well as those at increased risk for perioperative complications. Integration of pharmacogenetic data into perioperative decision-making may facilitate individualized care, but broader implementation will require replication in diverse cohorts, prospective clinical validation and development of evidence-based guidelines.
{"title":"Pharmacogenetics in perioperative care: Understanding the impact of genetic variants on patient management","authors":"Jan Albert Nicolaas Groot , Ankie Maxelante Harmsze , Eric Hendricus Paulus Adrianus van Dongen , Catherijne Anette Jantine Knibbe , Helena Johanna Blussé van Oud-Alblas","doi":"10.1016/j.jclinane.2025.112064","DOIUrl":"10.1016/j.jclinane.2025.112064","url":null,"abstract":"<div><div>Despite advances in perioperative medicine, variability in patient responses to commonly administered anesthetic and analgesic agents remains a clinical challenge. Genetic factors are increasingly proposed contributors to these interindividual differences, yet much of the supporting evidence remains preliminary, heterogeneous or insufficiently validated. Pharmacogenetics has emerged as a promising field to improve therapeutic precision. However, its clinical application in perioperative care remains limited. This narrative review critically appraises pharmacokinetic and pharmacodynamic drug–gene interactions that influence responses to routinely administered agents. Genetic variations affect multiple aspects of perioperative care, including drug metabolism and receptor sensitivity, pain processing, autonomic function, and susceptibility to complications such as postoperative nausea and vomiting and opioid-induced respiratory depression. A better understanding of drug–gene interactions may help anesthesiologists identify patients with atypical sensitivity or resistance to commonly used agents, as well as those at increased risk for perioperative complications. Integration of pharmacogenetic data into perioperative decision-making may facilitate individualized care, but broader implementation will require replication in diverse cohorts, prospective clinical validation and development of evidence-based guidelines.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112064"},"PeriodicalIF":5.1,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145418670","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.jclinane.2025.112060
Yixu Deng , Jing Dong , Congxia Pan , Lingling Deng , Zhiyong He , Li Yang , Jie Hua , Jun Zhang
Study objective
Our study aims to test the hypothesis that intraoperative methylene blue reduces the incidence of postoperative delirium (POD) following major abdominal surgery, and to evaluate the inflammatory biomarkers as potential mediators.
Design
A randomized, single blind clinical trial.
Setting
University cancer center.
Patients
Three hundred and fourteen patients scheduled for pancreatic surgery.
Interventions
Patients were randomly assigned to methylene blue group, who receiving intravenous infusion of 2 mg kg-1 methylene blue within 60 min immediately after anesthetic induction, followed by infusion of 1 mg kg-1 methylene blue within 30 min before the end of surgery, or control group, who receiving equal volume saline.
Measurements
The primary outcome was POD incidence. The secondary outcomes included plasma interleukin 6 (IL-6) and interleukin 8 (IL-8) concentrations before and after surgery, gene expressions in human brain microvascular endothelial cells (hCMEC/d3) and peripheral blood mononuclear cells (PBMCs) adhesion to hCMEC/d3. Perioperative adverse events were also documented.
Main results
A total of 55 patients (17.5%) experienced POD, with a lower POD incidence in the methylene blue group than in the control group (11.5% vs. 23.6%, p = 0.005). The adverse events in the two groups were comparable. And postoperative plasma IL-6 but not IL-8 concentration was lower in the methylene blue group. Furthermore, endothelial TNF-α, MCP-1 and VCAM1 expressions were lower when treated with serum from the methylene blue group, and the number of PBMCs adhesion to hCMEC/d3 cells was also less in the methylene blue group.
Conclusion
Intraoperative methylene blue use effectively and safely reduced the POD incidence in patients undergoing pancreatic surgery, which may be associated with decrease in systemic inflammation and immunovascular interactions.
研究目的本研究旨在验证术中亚甲基蓝降低腹部大手术术后谵妄（POD）发生率的假设，并评估炎症生物标志物作为潜在介质的作用。设计一项随机、单盲临床试验。大学癌症中心。病人314名病人计划进行胰腺手术。干预措施随机分为亚甲基蓝组，麻醉诱导后60分钟内静脉输注2 mg kg-1亚甲基蓝，手术结束前30分钟内静脉输注1 mg kg-1亚甲基蓝，对照组输注等体积生理盐水。主要观察指标为POD发生率。次要结果包括手术前后血浆白细胞介素6 （IL-6）和白细胞介素8 （IL-8）浓度、人脑微血管内皮细胞（hCMEC/d3）基因表达和外周血单核细胞（PBMCs）与hCMEC/d3的粘附。围手术期不良事件也有记录。主要结果55例（17.5%）患者发生POD，亚甲基蓝组POD发生率低于对照组（11.5% vs. 23.6%, p = 0.005）。两组的不良事件具有可比性。亚甲基蓝组术后血浆IL-6浓度较低，IL-8浓度未见下降。亚甲基蓝组内皮细胞TNF-α、MCP-1和VCAM1表达较低，亚甲基蓝组PBMCs粘附hCMEC/d3细胞的数量也较少。结论术中使用亚甲基蓝可有效、安全地降低胰腺手术患者POD的发生率，这可能与全身炎症和免疫血管相互作用的减少有关。
{"title":"Intraoperative methylene blue infusion reduces postoperative delirium in patients undergoing pancreatic surgery: A randomized controlled clinical trial","authors":"Yixu Deng , Jing Dong , Congxia Pan , Lingling Deng , Zhiyong He , Li Yang , Jie Hua , Jun Zhang","doi":"10.1016/j.jclinane.2025.112060","DOIUrl":"10.1016/j.jclinane.2025.112060","url":null,"abstract":"<div><h3>Study objective</h3><div>Our study aims to test the hypothesis that intraoperative methylene blue reduces the incidence of postoperative delirium (POD) following major abdominal surgery, and to evaluate the inflammatory biomarkers as potential mediators.</div></div><div><h3>Design</h3><div>A randomized, single blind clinical trial.</div></div><div><h3>Setting</h3><div>University cancer center.</div></div><div><h3>Patients</h3><div>Three hundred and fourteen patients scheduled for pancreatic surgery.</div></div><div><h3>Interventions</h3><div>Patients were randomly assigned to methylene blue group, who receiving intravenous infusion of 2 mg kg<sup>-1</sup> methylene blue within 60 min immediately after anesthetic induction, followed by infusion of 1 mg kg<sup>-1</sup> methylene blue within 30 min before the end of surgery, or control group, who receiving equal volume saline.</div></div><div><h3>Measurements</h3><div>The primary outcome was POD incidence. The secondary outcomes included plasma interleukin 6 (IL-6) and interleukin 8 (IL-8) concentrations before and after surgery, gene expressions in human brain microvascular endothelial cells (hCMEC/d3) and peripheral blood mononuclear cells (PBMCs) adhesion to hCMEC/d3. Perioperative adverse events were also documented.</div></div><div><h3>Main results</h3><div>A total of 55 patients (17.5%) experienced POD, with a lower POD incidence in the methylene blue group than in the control group (11.5% vs. 23.6%, <em>p</em> = 0.005). The adverse events in the two groups were comparable. And postoperative plasma IL-6 but not IL-8 concentration was lower in the methylene blue group. Furthermore, endothelial TNF-α, MCP-1 and VCAM1 expressions were lower when treated with serum from the methylene blue group, and the number of PBMCs adhesion to hCMEC/d3 cells was also less in the methylene blue group.</div></div><div><h3>Conclusion</h3><div>Intraoperative methylene blue use effectively and safely reduced the POD incidence in patients undergoing pancreatic surgery, which may be associated with decrease in systemic inflammation and immunovascular interactions.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112060"},"PeriodicalIF":5.1,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145418715","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-31DOI: 10.1016/j.jclinane.2025.112058
Krister Mogianos MD , Josefine Holgersson , Johan Undén M.D PhD , Anna K.M. Persson M.D PhD
Objective
To evaluate if opioid-free anaesthesia (OFA), is non-inferior to standard of care (SOC), in patients at low risk for acute postoperative pain (APOP).
Design: Patient- and assessor-blinded, non-inferiority, randomised, controlled trial.
Setting
Single centre between March 2022 to February 2024.
Patients
154 adult patients, ASA I – II, planned for elective laparoscopic surgery and risk-classified as low risk for APOP based on perceived pain during venous cannulation (VAS < 2.0).
Intervention
Patients were randomised to receiving OFA, including sevoflurane, dexmedetomidine, esketamine and lidocaine, or standard of care (SOC), a traditional GABAA and opioid-based strategy. Patients were subjected to the intervention from time to arrival at the day of surgery until discharge from the PACU.
Measurements
Primary outcome: worst pain intensity in the PACU. Secondary outcomes: worst pain, and proportion having NRS ≥ 4, at 24 h (during rest and movement), worst pain and proportion having NRS ≥ 1, at 3- and 6-months (during rest and movement), postoperative recovery at 24 h, PONV in the PACU and at 24 h. Rescue dose opioids in the PACU was an exploratory outcome.
Results
Pain scores were 4.8 in the OFA group and 4.6 in SOC group (P = 0.67). At 24 h, worst pain at rest was 5.7 vs 5.0 (P = 0.11), and during movement 5.6 vs 5.3 (P = 0.43). Proportion of patients with NRS ≥ 4 in the PACU was 66 % vs 69 % (P = 0.65) and at 24 h 76 % vs 60 % at rest (P = 0.042) and 73 % vs 69 % during movement (P = 0.65). There was no significant difference in PPOP at 3 or 6 months, either at rest (P = 0.51, P = 0.56) or movement (P = 0.72, P = 0.48), PONV (PACU: P = 0.93), at 24 h: (P = 0.52) or postoperative recovery at 24 h (99 vs 102, P = 0.44). OFA group required less rescue opioids in the PACU (3.4 mg vs 5.1 mg, P = 0.039).
Conclusion
When individualising anaesthesia based on predicted risk for APOP, OFA is non-inferior to a traditional GABAA and opioid-based anaesthesia strategy, for patients with a low risk for APOP undergoing laparoscopic surgery. No secondary advantages, i.e. lower PONV, less PPOP, better quality of recovery, was associated with OFA.
目的评价无阿片类药物麻醉（OFA）在低风险急性术后疼痛（APOP）患者中的应用是否优于标准护理（SOC）。设计：患者和评估者双盲、非劣效性、随机对照试验。在2022年3月至2024年2月之间设置单一中心。患者：154例成人患者，ASA I - II，计划进行选择性腹腔镜手术，根据静脉插管过程中感知到的疼痛（VAS < 2.0）将APOP风险分类为低风险。干预：患者随机接受OFA治疗，包括七氟醚、右美托咪定、艾氯胺酮和利多卡因，或标准护理（SOC），传统的GABAA和阿片类药物治疗。患者从手术当天到PACU出院时一直接受干预。主要结果：PACU中疼痛强度最大。次要结局：24小时（休息和运动期间）疼痛最严重，NRS≥4的比例最大，3个月和6个月（休息和运动期间）疼痛最严重，NRS≥1的比例最大，24小时术后恢复，PACU和24小时的PONV。PACU的救援剂量阿片类药物是一个探索性结局。结果OFA组西班牙评分为4.8分，SOC组为4.6分（P = 0.67）。24 h时，静息时最痛5.7 vs 5.0 (P = 0.11)，运动时最痛5.6 vs 5.3 （P = 0.43）。PACU中NRS≥4的患者比例为66%对69% (P = 0.65)， 24小时时为76%对60% (P = 0.042)，运动时为73%对69% （P = 0.65）。3个月或6个月的PPOP，无论是休息（P = 0.51, P = 0.56）或运动（P = 0.72, P = 0.48）， 24小时的PONV (PACU: P = 0.93) （P = 0.52）或24小时的术后恢复（99 vs 102, P = 0.44）均无显著差异。OFA组在PACU中需要较少的阿片类药物（3.4 mg vs 5.1 mg, P = 0.039）。结论在预测APOP风险的基础上进行个体化麻醉时，对于腹腔镜手术低风险APOP患者，OFA的麻醉效果不逊于传统的GABAA和阿片类药物麻醉策略。与OFA无关的次要优势，即较低的PONV，较低的PPOP，较好的恢复质量。
{"title":"Opioid-free versus opioid-based anaesthesia and analgesia for patients at low risk for acute postoperative pain undergoing laparoscopic surgery: A randomised controlled trial","authors":"Krister Mogianos MD , Josefine Holgersson , Johan Undén M.D PhD , Anna K.M. Persson M.D PhD","doi":"10.1016/j.jclinane.2025.112058","DOIUrl":"10.1016/j.jclinane.2025.112058","url":null,"abstract":"<div><h3>Objective</h3><div>To evaluate if opioid-free anaesthesia (OFA), is non-inferior to standard of care (SOC), in patients at low risk for acute postoperative pain (APOP).</div><div><em>Design</em>: Patient- and assessor-blinded, non-inferiority, randomised, controlled trial.</div></div><div><h3>Setting</h3><div>Single centre between March 2022 to February 2024.</div></div><div><h3>Patients</h3><div>154 adult patients, ASA I – II, planned for elective laparoscopic surgery and risk-classified as low risk for APOP based on perceived pain during venous cannulation (VAS < 2.0).</div></div><div><h3>Intervention</h3><div>Patients were randomised to receiving OFA, including sevoflurane, dexmedetomidine, esketamine and lidocaine, or standard of care (SOC), a traditional GABA<sub>A</sub> and opioid-based strategy. Patients were subjected to the intervention from time to arrival at the day of surgery until discharge from the PACU.</div></div><div><h3>Measurements</h3><div>Primary outcome: worst pain intensity in the PACU. Secondary outcomes: worst pain, and proportion having NRS ≥ 4, at 24 h (during rest and movement), worst pain and proportion having NRS ≥ 1, at 3- and 6-months (during rest and movement), postoperative recovery at 24 h, PONV in the PACU and at 24 h. Rescue dose opioids in the PACU was an exploratory outcome.</div></div><div><h3>Results</h3><div>Pain scores were 4.8 in the OFA group and 4.6 in SOC group (<em>P</em> = 0.67). At 24 h, worst pain at rest was 5.7 vs 5.0 (<em>P</em> = 0.11), and during movement 5.6 vs 5.3 (<em>P</em> = 0.43). Proportion of patients with NRS ≥ 4 in the PACU was 66 % vs 69 % <em>(P</em> = 0.65) and at 24 h 76 % vs 60 % at rest (<em>P</em> = 0.042) and 73 % vs 69 % during movement (<em>P</em> = 0.65). There was no significant difference in PPOP at 3 or 6 months, either at rest (<em>P</em> = 0.51, <em>P</em> = 0.56) or movement (<em>P</em> = 0.72, <em>P</em> = 0.48), PONV (PACU: <em>P</em> = 0.93), at 24 h: (<em>P</em> = 0.52) or postoperative recovery at 24 h (99 vs 102, <em>P</em> = 0.44). OFA group required less rescue opioids in the PACU (3.4 mg vs 5.1 mg, <em>P</em> = 0.039).</div></div><div><h3>Conclusion</h3><div>When individualising anaesthesia based on predicted risk for APOP, OFA is non-inferior to a traditional GABA<sub>A</sub> and opioid-based anaesthesia strategy, for patients with a low risk for APOP undergoing laparoscopic surgery. No secondary advantages, i.e. lower PONV, less PPOP, better quality of recovery, was associated with OFA.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112058"},"PeriodicalIF":5.1,"publicationDate":"2025-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145418714","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-31DOI: 10.1016/j.jclinane.2025.112057
Scott Kutscher MD , Eysteinn Finnsson MSc , Lu Tian PhD , Periklis Panousis MD, PhD , Benjamin I. Chung MD , Anthony G. Doufas MD, PhD
Objective
While supplemental O2 corrects hypoxemia and promotes respiratory stability during sleep, its effect on post-anesthesia ventilation is unknown. Using home sleep apnea testing (HSAT) equipment, we previously found that hyperoxia improved obstructed breathing in post-anesthesia patients by primarily reducing desaturation-based hypopnea events. This trial tested the hypothesis that hyperoxia will improve disordered breathing during recovery from anesthesia, independent of oxygenation-based scoring criteria.
All patients underwent a HSAT recording during two 40-min-long interventions when inhalation of an O2/air mixture targeted an SpO2 > 96 % (Liberal O2), or an SpO2 90–94 % (Conservative O2). Continuous transcutaneous (TcPCO2) and intermittent arterial (PaCO2) measurements of CO2 were performed. Apnea/hypopnea index (AHIflow) was measured using standard criteria, except hypopneas were defined solely by standard airflow reduction without requiring associated desaturation or arousal. StanpumpR was utilized to simulate analgesic effect of administered opioids, expressed as percentage of minimum effective analgesic concentration (MEAC), which was then used to adjust the comparison between the two interventions.
Main results
AHIflow decreased significantly from 36 ± 23 (mean ± Std) events per hour during Conservative O2, to 25 ± 17 in the Liberal O2 session (paired t-test, P = 0.0069 adjusted for the area under the MEAC-time curve). Pairwise comparisons did not show any significant difference in the TcPCO2 or PaCO2 levels between the two treatment sessions, while the percentage of time spent with TcPCO2 > 45 mmHg was also comparable between the two interventions.
Conclusions
Oxygenation-independent assessment showed that hyperoxia improved disordered breathing immediately following anesthesia, primarily by decreasing the number of hypopneas.
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Pub Date : 2025-10-30DOI: 10.1016/j.jclinane.2025.111878
Nikola Anusic MD , Alper Gulluoglu MD , Elyad Ekrami MD , Edward J. Mascha PhD , Shuyi Li MS , René Coffeng , Alparslan Turan MD , Amber Clemens BSN, RN , Christine Perez RN , John W. Beard MD , Daniel I. Sessler MD , the COSMOS Pilot Investigators
<div><h3>Study objectives</h3><div>Alerts for vital sign abnormalities seek to identify meaningful patient instability while limiting alarm fatigue. Optimal vital sign alarm settings for postoperative patients remain unknown, as is whether alerts lead to effective clinical responses reducing vital sign disturbances. We conducted a 2-phase pilot study to identify thresholds and delays and test the hypothesis that alerts from continuous monitoring reduce the duration of vital sign abnormalities.</div></div><div><h3>Design</h3><div>Two-phase pilot.</div></div><div><h3>Patients</h3><div>250 adults having major non-cardiac surgery.</div></div><div><h3>Setting</h3><div>Surgical wards.</div></div><div><h3>Intervention</h3><div>All patients had routine vital sign monitoring by nurses at 4-h intervals. We initially continuously recorded clinician-blinded saturation, heart rate, and respiratory rate in 100 patients. In the second phase, we randomized 150 patients to blinded versus unblinded continuous vital sign monitoring. In unblinded patients, nurses were verbally alerted to abnormal vital signs.</div></div><div><h3>Measurements</h3><div>In the first phase, we modeled expected alarm counts using 6082 h of continuous oxygen saturation, heart rate, and respiratory rate data. Thresholds and delays targeting a limited number of meaningful alerts were selected for phase two. The primary analysis in phase 2 assessed the effect of unblinded monitoring across a 5-component composite of cumulative durations of vital sign abnormalities. Secondary outcomes included a fraction of alerts deemed meaningful by nurses and number of clinical interventions.</div></div><div><h3>Results</h3><div>In phase one, we identified alarm settings that yielded an average of 1.0 alerts per patient per day. In phase two, there were an average of 0.45 alerts per patient per day, with fewer alerts presumably resulting because nurses were allowed to alter the initial notification thresholds. The median [Q1, Q3] duration of SpO₂ <85 % was 6.7 [1.2, 18] minutes in unblinded patients vs. 4.6 [0.83, 40] in the blinded group. For RR <4 breaths/min, durations were 0 [0,0] vs. 0 [0, 0.15] (unblinded vs. blinded). RR >30 was 9.0 [2.4, 23] vs. 11 [2.6, 22] minutes. HR <45 bpm lasted 0.02 [0, 1.2] vs. 0.44 [0, 2.2] minutes. HR >130 bpm was 0 [0, 1.3] vs. 0 [0, 0.9] minutes. The average relative effect ratio of geometric means for duration of vital signs exceeding thresholds was 0.72 [95 % CI: 0.47, 1.1], <em>P</em> = 0.11. Among the 73 alarms, 60 (82 %) were considered useful in unblinded patients, leading to 49 interventions in the unblinded group, compared to 30 interventions in the blinded group.</div></div><div><h3>Conclusions</h3><div>Using the continuous saturation, heart rate, and respiratory rate thresholds established in Phase 1, we generated approximately 0.45 alerts per patient per day during Phase 2, nearly all of which were considered useful by nurses Although the diffe
{"title":"Corrigendum to ‘Continuous Vital Sign Monitoring on Surgical Wards: The COSMOS Pilot","authors":"Nikola Anusic MD , Alper Gulluoglu MD , Elyad Ekrami MD , Edward J. Mascha PhD , Shuyi Li MS , René Coffeng , Alparslan Turan MD , Amber Clemens BSN, RN , Christine Perez RN , John W. Beard MD , Daniel I. Sessler MD , the COSMOS Pilot Investigators","doi":"10.1016/j.jclinane.2025.111878","DOIUrl":"10.1016/j.jclinane.2025.111878","url":null,"abstract":"<div><h3>Study objectives</h3><div>Alerts for vital sign abnormalities seek to identify meaningful patient instability while limiting alarm fatigue. Optimal vital sign alarm settings for postoperative patients remain unknown, as is whether alerts lead to effective clinical responses reducing vital sign disturbances. We conducted a 2-phase pilot study to identify thresholds and delays and test the hypothesis that alerts from continuous monitoring reduce the duration of vital sign abnormalities.</div></div><div><h3>Design</h3><div>Two-phase pilot.</div></div><div><h3>Patients</h3><div>250 adults having major non-cardiac surgery.</div></div><div><h3>Setting</h3><div>Surgical wards.</div></div><div><h3>Intervention</h3><div>All patients had routine vital sign monitoring by nurses at 4-h intervals. We initially continuously recorded clinician-blinded saturation, heart rate, and respiratory rate in 100 patients. In the second phase, we randomized 150 patients to blinded versus unblinded continuous vital sign monitoring. In unblinded patients, nurses were verbally alerted to abnormal vital signs.</div></div><div><h3>Measurements</h3><div>In the first phase, we modeled expected alarm counts using 6082 h of continuous oxygen saturation, heart rate, and respiratory rate data. Thresholds and delays targeting a limited number of meaningful alerts were selected for phase two. The primary analysis in phase 2 assessed the effect of unblinded monitoring across a 5-component composite of cumulative durations of vital sign abnormalities. Secondary outcomes included a fraction of alerts deemed meaningful by nurses and number of clinical interventions.</div></div><div><h3>Results</h3><div>In phase one, we identified alarm settings that yielded an average of 1.0 alerts per patient per day. In phase two, there were an average of 0.45 alerts per patient per day, with fewer alerts presumably resulting because nurses were allowed to alter the initial notification thresholds. The median [Q1, Q3] duration of SpO₂ <85 % was 6.7 [1.2, 18] minutes in unblinded patients vs. 4.6 [0.83, 40] in the blinded group. For RR <4 breaths/min, durations were 0 [0,0] vs. 0 [0, 0.15] (unblinded vs. blinded). RR >30 was 9.0 [2.4, 23] vs. 11 [2.6, 22] minutes. HR <45 bpm lasted 0.02 [0, 1.2] vs. 0.44 [0, 2.2] minutes. HR >130 bpm was 0 [0, 1.3] vs. 0 [0, 0.9] minutes. The average relative effect ratio of geometric means for duration of vital signs exceeding thresholds was 0.72 [95 % CI: 0.47, 1.1], <em>P</em> = 0.11. Among the 73 alarms, 60 (82 %) were considered useful in unblinded patients, leading to 49 interventions in the unblinded group, compared to 30 interventions in the blinded group.</div></div><div><h3>Conclusions</h3><div>Using the continuous saturation, heart rate, and respiratory rate thresholds established in Phase 1, we generated approximately 0.45 alerts per patient per day during Phase 2, nearly all of which were considered useful by nurses Although the diffe","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 111878"},"PeriodicalIF":5.1,"publicationDate":"2025-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145409218","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-29DOI: 10.1016/j.jclinane.2025.112029
Nikola Anusic , Alper Gulluoglu , Elyad Ekrami , Edward J. Mascha , Shuyi Li , René Coffeng , Alparslan Turan , Amber Clemens , Christine Perez , John W. Beard , Daniel I. Sessler , the Cosmos Pilot Investigators
{"title":"Corrigendum to “Continuous vital sign monitoring on surgical wards: The COSMOS pilot” [J. Clin. Anesth. 99C (2024) 111661]","authors":"Nikola Anusic , Alper Gulluoglu , Elyad Ekrami , Edward J. Mascha , Shuyi Li , René Coffeng , Alparslan Turan , Amber Clemens , Christine Perez , John W. Beard , Daniel I. Sessler , the Cosmos Pilot Investigators","doi":"10.1016/j.jclinane.2025.112029","DOIUrl":"10.1016/j.jclinane.2025.112029","url":null,"abstract":"","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112029"},"PeriodicalIF":5.1,"publicationDate":"2025-10-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145733481","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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