Best Practice & Research-Clinical Anaesthesiology最新文献

Pediatric intensive care medicine is a rapidly evolving field of medicine, with recent publication of landmark papers specific for the pediatric population. Progress has been made in modes of mechanical ventilation, including noninvasive ventilation in pediatric ARDS and after extubation failure, with updated guidelines on ventilator liberation. Improved technology and advancements in hemodynamic support allow for better care of our patients with heart disease. Sepsis burden in children remains high and continued efforts are made to improve survival. A nutritional plan with a tailored approach, focusing on individualized needs, could offer benefits for our patients. Sedation practices and guidelines have been updated, focusing on minimizing delirium and facilitating early mobility. This manuscript highlights some of the most recent advances and updates.

Pediatric regional anesthesia has been in existence for over 125 years, but significant progress and widespread use has occurred in the last few decades, with the increasing availability of ultrasound guidance. Evidence supporting the safety of regional anesthesia when performed under general anesthesia has also allowed the field to flourish. Newer techniques allow for more precise nerve blockade and in general this has resulted in more peripheral blocks replacing central blocks, such as caudal epidurals and spinal anesthesia. Current controversial topics in the field include the method of obtaining loss of resistance when placing epidural catheters, the role of regional anesthesia in compartment syndrome and post-hypospadias repair complications, and utility of test doses.

The care for lung transplantation patients is a complex, multidisciplinary coordination of physician and non-physician teams throughout the perioperative period. The diversity of etiologies of recipient end-stage lung disease further complicate care, as recipients often present with concomitant end-stage cardiac disease. Recently, the use of extracorporeal membrane oxygenation has become the mechanical circulatory support of choice to provide cardiopulmonary stability throughout the perioperative period. This review will focus specifically on the anesthetic considerations for perioperative extracorporeal membrane oxygenation in lung transplantation throughout preoperative bridge to transplantation, intraoperative management, and postoperative utilization.

The utilization of extracorporeal membrane oxygenation (ECMO) in complex thoracic surgery has become more frequent in recent years due to advances in technology, increased availability, and improved outcomes. ECMO has emerged as a vital tool to facilitate thoracic surgery for patients who would have otherwise been deemed unsuitable candidates. It has redefined the boundaries of surgical possibility where conventional methods fall short. ECMO is typically employed in specific thoracic surgery where conventional ventilation is either inadequate or it interferes with the surgical field, and in procedures demanding both ventilatory and hemodynamic support.

Innovations and challenges for lung separation or isolation have evolved during the last few years. In this chapter, we present the up-to-date, robust evidence available during the previous five years supporting the positions of the different devices, techniques, and tricks for their use in adult and pediatric patients undergoing various thoracic surgical interventions. Additionally, we presented an update on lung isolation in patients with airway difficulty and the suggested training level to master these techniques.

This review documents the importance of postoperative interventions that accelerate the functional recovery of the thoracic surgical patient. Enhanced recovery after surgery (ERAS) pathways aim to mitigate the harmful surgical stress response. Improvements to the entire patient pathway, by removing unnecessary care elements while introducing evidence-based interventions, have synergistic effects. At the same time, some key care elements appear to be more important than others, including early removal of chest tubes, early mobilization, and the limited use of opioids. These care elements are all intertwined. The goals of early mobilization and opioid-sparing analgesia are more readily achieved once a chest tube has been removed. A focus on achieving these goals earlier, including on the day of surgery, may benefit a patient's recovery further. The result is superior patient outcomes including a quicker restoration of normal function, fewer complications, reduced opioid requirements, reduced costs, and a shorter length of stay.

Lung cancer is among one of the most commonly diagnosed malignancies and is the leading cause of cancer-related mortality in both men and women globally, with an estimated 1.8 million deaths annually. Moreover, it is also the leading cause of cancer related deaths in the United States (U.S.), with an estimated 127,000 deaths annually. Approximately 50% of patients who undergo chest Computed Tomography (CT) are found to have a pulmonary nodule (PN), albeit 95% of these PNs are subsequently found to be benign. Further complicating the challenge of timely detection of lung cancer, is made more difficult by the fact that most patients are totally asymptomatic in early stage of disease.

However, given that sponsored studies by National Cancer Institute (NCI) and other organizations showed a 20% reduction in lung cancer specific mortality with low dose CT scanning in patients at risk, it is reasonable to assume that clinicians will confront this clinical scenario more frequently. Consequently, due to these significant findings, the United States Preventive Services Task Force (USPSTF) recommended annual screening of high-risk patients. Therefore, as result of these recommendations, 240,000 new lung cancers were diagnosed in the U.S. in 2020, with an estimated 238,000 new cases in 2023. Given the multitude of challenges, the practice guidelines and recommendations for the management of these PNs are often tailored to available resources and trained personnel familiar with the various techniques and technologies.

This review will discuss the evolution of various advancements when tissue biopsy is required: from sputum cytology, nonguided bronchoscopy, percutaneous CT guided biopsy, guided advanced bronchoscopic techniques such as endobronchial ultrasound (EBUS), radial Endobronchial Ultrasound (rEBUS) to the latest advancement of robotic-assisted bronchoscopy (RAB). Furthermore, as many of the aforementioned techniques require anesthesia, as integral members of the multidisciplinary team, anesthesiologists are often in the unique position of facilitating diagnosis and subsequent treatment by other subspecialists when providing anesthetic care for these patients with PNs.

Additionally, the common anesthetic considerations and implications for the preoperative, intraoperative, and postoperative periods will be elucidated further, with special emphasis on the unique considerations for RABs. Combined hybrid procedures with RAB, EBUS and surgery will also be reviewed, as they offer potential reduction in time of diagnosis to definitive treatment. Lastly, the strategies employed to mitigate some of the commonly encountered challenges faced by anesthesiologists when caring for these patients will also be reviewed.

The objectives of this minireview are two-fold. The first is to discuss the evolution of opioid analgesia in perioperative medicine in the context of thoracic non-cardiac surgery. Current standard-of-care, aiming to optimize analgesia and limit undesirable side effects, is discussed in the context of multimodal analgesia, specifically enhanced recovery after thoracic surgery pathways. The second is to review a developing research program that may ultimately add another element to the personalization of analgesic plans for individual cancer patients based on optimizing oncological outcomes. Termed “precision oncoanalgesia,” this emerging field aims to elucidate how individual patient-specific tumor omics (genomics, transcriptomics, etc.) may mediate the effects of analgesic drugs on oncological recurrence and survival.

Health care workers are at risk of infection from aerosolization of respiratory secretions, droplet and contact spread. This has gained great importance after the COVID19 pandemic.

Intra-operative aerosol-generating procedures are arguably unavoidable in the routine provision of thoracic anesthesia. Airway management for such patients during the COVID-19 pandemic including tracheal intubation, lung isolation, one-lung ventilation and flexible bronchoscopy may pose a significant risk to healthcare professionals and patients.

The thoracic anesthetic community has been confronted with the need to modify existing techniques to maximize safety for patients and healthcare professionals.