Journal of Clinical Anesthesia最新文献

Background

Breast cancer is the most frequent type of cancer and the second leading cause of cancer-related mortality in women. Mastectomies remain a key component of the treatment of non-metastatic breast cancer, and strategies to treat acute postoperative pain, a complication affecting nearly all patients undergoing surgery, continues to be an important clinical challenge. This study aimed to determine the impact of intraoperative methadone administration compared to conventional short-acting opioids on pain-related perioperative outcomes in women undergoing a mastectomy.

Methods

This single-center retrospective study included adult women undergoing total mastectomy. The primary outcome of this study was postoperative pain intensity on day 1 after surgery. Secondary outcomes included perioperative opioid consumption, perioperative non-opioid analgesics use, duration of surgery and anesthesia, time to extubation, pain intensity in the postanesthesia care unit (PACU), anti-emetic use in PACU, and length of stay in hospital. We used the propensity score-based nearest matching with a 1:3 ratio to balance the patient baseline characteristics.

Results

133 patients received methadone, and 2192 patients were treated with short-acting opioids. The analysis demonstrated that methadone was associated with significantly lower intraoperative and postoperative opioid consumption as measured by oral morphine equivalents and lower average pain intensity scores in the postanesthesia care unit. Moreover, methadone was also shown to reduce the use of non-opioid analgesia during surgery.

Conclusion

Our study suggests that the unique pharmacological properties of methadone, including a short onset of action when given intravenously, long-acting pharmacokinetics, and multimodal effects, are associated with better acute pain management after a total mastectomy.

Background

The video laryngoscope (VLS) has been proven to be an effective insertion device for airway management. However, no laryngoscope has been specifically designed for the placement of the laryngeal mask airway (LMA). We improved the current VLS and developed a novel VLS method. This study aimed to evaluate the clinical efficacy of an improved VLS for inserting a flexible laryngeal mask airway (F-LMA) compared with the standard blind method.

Methods

One hundred and fifty-seven patients who underwent F-LMA insertion under general anesthesia were randomly assigned to either the standard blind insertion technique (group B) or VLS -assisted insertion (group VL). First attempt success rates were recorded. Secondary outcomes included oropharyngeal leakage pressure (OLP), fiberoptic view, insertion time, position adjustment, reinsertion rate, and postoperative airway morbidity.

Results

The first-attempt success rate was higher in group VL than that in group B (99% vs. 86%; p = 0.002). The OLP was significantly higher in the VLS-guided technique (26.4 ± 5.1 vs 23.8 ± 4.4 cmH₂O, p = 0.002). The fiberoptic view was significantly better in the group VL (p < 0.001) and required less readjustment and reinsertion to establish an effective airway (p < 0.001). The insertion time was shorter in the group B than that in group VL (33.9 vs 41.3 s, p < 0.001). Hemodynamic stress responses and postoperative airway complications did not differ between the two groups.

Conclusions

The new VLS-guided insertion technology has a high success rate, achieves greater OLP, and provides an ideal anatomical position with minimal adjustment, without increasing the risk of hemodynamic stress or adverse events.

Trial registration

Chinese Clinical Trial Registry (registration number: ChiCTR2300075866; https://www.chictr.org.cn).

Study objective

To compare the effects of neostigmine/glycopyrrolate (a traditional agent) and sugammadex on bowel motility recovery and the occurrence of digestive system complications after colorectal surgery.

Design

Prospective, randomized controlled trial.

Setting

A single tertiary center.

Patients

111 patients undergoing laparoscopic colorectal surgery.

Interventions

Patients were randomized into two groups based on the block reversal agent: 1) a mixture of 50 μg.kg⁻¹ of neostigmine and 10 μg.kg-1 of glycopyrrolate (neostigmine group) and 2) 2 mg.kg⁻¹ of sugammadex (sugammadex group).

Measurements

The primary outcome was the time from the surgery's completion to the first flatus.

The time to the first postoperative defecation, incidences of postoperative nausea or vomiting, ileus, and dry mouth, as well as postoperative length of stay, were also assessed.

Main results

The time to the first flatus was significantly shorter in the sugammadex group than in the neostigmine group (59 [42–79] h vs 69 [53–90] h, P = 0.027). The time to the first defecation and the incidences of postoperative nausea or vomiting and ileus did not differ between the groups, nor did the postoperative length of stay. However, the incidence of postoperative dry mouth was significantly lower in the sugammadex group than in the neostigmine group (7 patients [13%] vs 39 patients [71%], P < 0.001).

Conclusions

The time to the first flatus was shorter using 2 mg.kg⁻¹ sugammadex to reverse the neuromuscular block for laparoscopic colorectal surgery compared to reversal with conventional neostigmine/glycopyrrolate.

ChatGPT4 is a leading large language model (LLM) chatbot released by OpenAI in 2023. ChatGPT4 can respond to free-text queries, answer questions and make suggestions regarding virtually any topic. ChatGPT4 has successfully answered anesthesia and even obstetric anesthesia knowledge-based questions with reasonable accuracy. However, ChatGPT4 has yet to be challenged in obstetric anesthesia clinical decision-making. Study Objective: In this study, we evaluated the performance of ChatGPT4 in the management of clinical labor analgesia scenarios compared to expert obstetric anesthesiologists. Intervention: Eight clinical questions with progressively increasing medical complexity were posed to ChatGPT4. Measurements: The ChatGPT4 responses were rated by seven expert obstetric anesthesiologists based on safety, accuracy and completeness of each response using a five-point Likert rating scale. Main Results: ChatGPT4 was deemed safe in 73% of responses to the presented obstetric anesthesia clinical scenarios (27% of responses were deemed unsafe). None of the ChatGPT4 responses were unanimously deemed to be safe by all seven expert obstetric anesthesiologists. Moreover, ChatGPT4 responses were overall partly accurate (score 4 out of 5) and somewhat incomplete (score 3.5 out of 5). Conclusions: In summary, approximately one quarter of all responses by ChatGPT4 were deemed unsafe by expert obstetric anesthesiologists. These findings may suggest the need for more fine-tuning and training of LLMs such as ChatGPT4 specifically for clinical decision making in obstetric anesthesia or other specialized medical fields. These LLMs may come to play an important future role in assisting obstetric anesthesiologists in clinical decision making and enhancing overall patient care.

Study objective

Hypoxemia is the most frequent adverse event observed during gastrointestinal endoscopy under procedural sedation. An optimum oxygen therapy has still not been conclusively determined.

Design

A systematic review and network meta-analysis of randomized clinical trials.

Setting

Digestive Endoscopy Center.

Patients

Adults (≥18 years old and of both sexes) during gastrointestinal endoscopy under procedural sedation.

Interventions

Pubmed, MEDLINE, Web of Science, Embase, and Clinicaltrials.gov. were searched until June 30, 2023. Randomized clinical trials (RCTs) comparing any oxygen therapy with another oxygen therapy or with placebo (nasal cannula, NC) were included.

Measurement

The primary outcome was the incidence of hypoxemia, defined as the pulse oxygen saturation (SpO₂). Random-effects network meta-analyses were performed. Data are reported as odds ratios (OR), prediction intervals (PrI) and 95% CI. Bias risk was evaluated following the guidelines outlined by the Cochrane Collaboration. The quality of evidence was evaluated through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

Main results

We included 27 RCTs with a total of 7552 patients. Compared to the use of NC, non-invasive positive pressure ventilation (NIPPV) demonstrated superior efficacy in mitigating hypoxemia (NIPPV vs. NC, OR = 0.16, 95% CI: 0.08–0.31, 95% PrI: 0.06–0.41), followed by Wei nasal jet tube (WNJT) (WNJT vs. NC, OR = 0.17, 95% CI: 0.10–0.30, 95% PrI: 0.07–0.42). The efficacy for preventing hypoxemia was ranked as follows: NIPPV > WNJT > oropharynx/nasopharyngeal catheter > high-flow nasal oxygenation > nasal mask > NC.

Conclusions

During gastrointestinal endoscopy under procedural sedation, all other advanced oxygen therapies were found to be more efficacious than nasal cannula. NIPPV and WNJT appear to be the most efficacious oxygen therapy for preventing hypoxemia. Additionally, clinicians should make a choice regarding the most suitable oxygen therapy based on the risk population, type of endoscopy and adverse events.