Best Practice & Research-Clinical Anaesthesiology最新文献

英文中文

Utility of ultrasound in thoracic anesthesia 超声波在胸腔麻醉中的应用

IF 4.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-03-01 DOI: 10.1016/j.bpa.2024.04.003

Stefaan Bouchez

The use of ultrasound (US) in the perioperative clinical management should be goal-directed, rapid, and reproducible. Thoracic US enables detailed examinations of vital structures, such as the airway, lung, pleural space, diaphragm, and heart. This chapter focuses on the value of US as a bedside tool to assess anatomy, guide procedures, and monitor vital organ function in patients undergoing thoracic surgery.

在围手术期临床管理中使用超声波（US）应具有目标导向性、快速性和可重复性。胸腔超声可对气道、肺部、胸膜腔、膈肌和心脏等重要结构进行详细检查。本章重点介绍 US 作为床旁工具在评估胸腔手术患者的解剖结构、指导手术和监测重要器官功能方面的价值。

引用次数: 0

Challenges in acute postoperative pain management in thoracic surgery 胸外科术后急性疼痛管理面临的挑战

IF 4.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-03-01 DOI: 10.1016/j.bpa.2024.01.002

Benu Makkad , Bessie Kachulis

Effective pain control is crucial in the management of thoracic surgical patients since it reduces postoperative morbidity and promotes recovery. These patients have co-existing respiratory diseases and impaired pulmonary function, which may be further impaired by surgery. With the adoption of minimally invasive surgical techniques and an emphasis on enhancing recovery after surgery, multimodal analgesia has gained popularity as a way to reduce perioperative opioid use and its associated adverse events such as respiratory depression. The literature related to opioid-sparing analgesia in thoracic surgery is still evolving. This review summarizes the latest research related to the use of various intravenous, oral, and perineural pharmacological agents as a part of multimodal analgesic regimen for pain relief in patients undergoing thoracic surgery and provides a summary for their application in clinical practice.

有效的疼痛控制对胸外科病人的治疗至关重要，因为它能降低术后发病率并促进康复。这些患者同时患有呼吸系统疾病，肺功能受损，手术可能会进一步损害他们的肺功能。随着微创手术技术的采用和对术后恢复的重视，多模式镇痛作为一种减少围手术期阿片类药物使用及其相关不良反应（如呼吸抑制）的方法，已逐渐受到人们的青睐。胸外科手术中阿片类药物保留镇痛的相关文献仍在不断发展。本综述总结了有关使用各种静脉、口服和硬膜外药剂作为多模式镇痛方案的一部分来缓解胸外科手术患者疼痛的最新研究，并对其在临床实践中的应用进行了总结。

引用次数: 0

Preoperative iron therapy: Where are we? 术前铁疗法:进展如何?

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2023-12-01 DOI: 10.1016/j.bpa.2023.10.003

Beth MacLean , Angela Weyand , Jayne Lim , Toby Richards

Preoperative anemia affects one-third of patients undergoing major surgery and is associated with worse perioperative and postoperative outcomes; including length of hospital stay, allogeneic blood transfusion, morbidity, and mortality. Iron deficiency is the most common cause of anemia, and associative data suggests that preoperative correction of iron deficiency anemia could improve postoperative patient outcomes. However, data from randomized controlled trials (RCTs) do not appear to support the routine use of iron therapy to treat preoperative anemia. We present a literature review of large RCTs examining the efficacy of preoperative intravenous iron. We discuss the observation that although preoperative intravenous iron treatment can increase hemoglobin concentration prior to surgery in certain patient groups, the data do not clarify whether there is a direct benefit to patients. We address that preoperative intravenous iron may not be a feasible option and highlight the need to explore the mechanism and management of iron deficiency anemia in surgical patients.

术前贫血影响三分之一的大手术患者，并与较差的围手术期和术后结果相关;包括住院时间、异基因输血、发病率和死亡率。缺铁是贫血最常见的原因，相关数据表明术前纠正缺铁性贫血可以改善术后患者的预后。然而，随机对照试验(RCTs)的数据似乎不支持常规使用铁疗法治疗术前贫血。我们提出了一项大型随机对照试验的文献综述，以检查术前静脉注射铁的疗效。我们讨论了以下观察结果:尽管术前静脉铁治疗可以提高某些患者在手术前的血红蛋白浓度，但数据并未阐明是否对患者有直接益处。我们认为术前静脉注射铁可能不是一个可行的选择，并强调有必要探索手术患者缺铁性贫血的机制和管理。

引用次数: 0

ESAs in perioperative anemia management: Who, what, how and why? esa在围手术期贫血管理中的作用:谁、做什么、怎么做、为什么?

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2023-12-01 DOI: 10.1016/j.bpa.2023.10.002

Sigismond Lasocki , Maëva Campfort , Maxime Leger , Emmanuel Rineau

Preoperative anemia is frequent and is associated with poor patient outcomes and higher transfusion rates. Perioperative blood transfusion is also associated with poor outcomes. These observations justify efforts to increase hemoglobin levels in anemic patients before surgeries with a moderate to high bleeding risk.

Erythropoiesis-stimulating agents (ESAs) were developed in the 80s and are now widely used for the treatment of renal and cancer-related anemia. In the perioperative settings, ESAs were successfully proposed for preoperative blood donation programs in the 90s. Since then, substantial evidence has been available demonstrating that high-dose ESAs associated with iron (ideally intravenously), administered 3–4 weeks before surgery, increase perioperative hemoglobin levels and reduce the need for blood transfusion in some surgeries. Different strategies might be proposed ranging from a systematic treatment for all patients with hemoglobin below 13 g/dL (especially in orthopedic and cardiac surgeries) to a more personalized approach to anemia treatment (targeting anemia related to inflammation or renal insufficiency). ESAs might increase the risk of adverse events, including thromboembolism, and the benefit-risk ratio must be carefully weighted for high-risk patients (particularly for those undergoing cancer surgery). The cost-effectiveness of ESA use remains to be evaluated.

术前贫血是常见的，与患者预后差和较高的输血率有关。围手术期输血也与不良预后相关。这些观察结果证明了在中度至高度出血风险的贫血患者手术前提高血红蛋白水平的努力是合理的。促红细胞生成剂(ESAs)是在20世纪80年代发展起来的，现在广泛用于治疗肾性和癌症相关性贫血。在围手术期，ESAs在20世纪90年代被成功地提出用于术前献血计划。从那时起，有证据表明，在手术前3-4周给予高剂量esa与铁(理想情况下静脉注射)，可提高围手术期血红蛋白水平，并减少某些手术的输血需求。可能会提出不同的策略，从对所有血红蛋白低于13 g/dL的患者进行系统治疗(特别是在骨科和心脏手术中)到更个性化的贫血治疗方法(针对炎症或肾功能不全相关的贫血)。esa可能会增加不良事件的风险，包括血栓栓塞，对于高风险患者(特别是接受癌症手术的患者)，必须仔细权衡风险-收益比。使用欧空局的成本效益仍有待评价。

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引用次数: 0

Roads travelled: The journey to Patient Blood Management at 35 years 走过的路:35年的病人血液管理之旅

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2023-12-01 DOI: 10.1016/j.bpa.2023.10.001

James P. Isbister

Patient Blood Management evolved in recent years, focusing on the haematopoietic system as relevant to all disciplines of medicine. The allogeneic blood supply chain travels from donation, to fractionation, preservation, and storage, to therapeutic, established treatments, or prophylactics for a wide range of medical conditions. This supply chain ‘connects’ altruistic blood donors to patients in need, symbolising a ‘gift relationship’, emphasising the empathetic bond between donor and recipient.

In 1988, the author proposed a paradigm shift in blood transfusion and, in 2005, introduced the term Patient Blood Management (PBM). PBM's origins are traceable to the late 19th century, when blood transfusion wasn't feasible for managing exsanguinating haemorrhage or critical anaemia. Landsteiner's discovery of the ABO blood groups firmly established blood component therapy into medical therapeutics. This article recounts the journey from a pre-blood transfusion era patient-centred approach, through the 20th century's blood product focus, and thenceforth back to the patient with the advent of PBM.

近年来，患者血液管理的发展重点是与所有医学学科相关的造血系统。同种异体血液供应链从捐献到分离、保存和储存，再到治疗、建立治疗或预防各种疾病的方法。这条供应链将无私的献血者与有需要的患者“连接”起来，象征着一种“礼物关系”，强调了献血者和接受者之间的同理心。1988年，作者提出了输血的范式转变，并于2005年引入了患者血液管理(PBM)一词。PBM的起源可以追溯到19世纪末，当时输血对于治疗失血过多或严重贫血是不可行的。兰德斯坦纳对ABO血型的发现使血液成分疗法成为医学疗法。这篇文章叙述了从输血前时代以病人为中心的方法，通过20世纪的血液产品的重点，然后回到病人与PBM的到来的旅程。

引用次数: 0

Intra-operative tranexamic acid: A standard of care? 术中使用氨甲环酸：护理标准？

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2023-12-01 DOI: 10.1016/j.bpa.2023.11.006

Nicole Relke , Grace H. Tang , Michelle Sholzberg

Peri-operative bleeding is a major cause of morbidity and mortality in patients undergoing surgery. Tranexamic acid, an antifibrinolytic agent, is effective for prevention and treatment of bleeding in a variety of different surgical populations. This review summarizes the evidence supporting the use of tranexamic acid in major surgical settings including cardiac surgery, obstetrics, orthopedic surgery, and non-cardiac surgery. We discuss potential adverse effects with use of tranexamic acid including the theoretical risk of thrombosis. Lastly, we discuss other potential benefits of tranexamic acid including prevention of infection and maintenance of blood-brain barrier integrity.

引用次数: 0

Does one unit really matter? Immunological effects of transfusion after universal leucodepletion 一个单位真的重要吗?输注对白细胞普遍清除后的免疫效应。

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2023-12-01 DOI: 10.1016/j.bpa.2023.10.004

Arun Muthukumar , Juan Jose Guerra-Londono , Juan P. Cata

Patients with cancer who receive allogeneic red blood cell transfusions are at risk of adverse reactions of varying severity. One of these reactions is immunomodulation, also known as transfusion-related immunomodulation. With the exact mechanism of transfusion related immunomodulation being unclear, storage lesions (both the cellular and cytokine component) are considered a major contributor. Leucocytes are believed to be implicated in storage lesions and immunomodulation. However, the efficacy of leucodepletion in reducing immunomodulation is controversial. The theoretical link between these three interconnected events - storage lesions, immunomodulation and cancer progression remain controversial and poorly understood. This article summarizes the available evidence on efficacy of leucodepletion, storage lesions and transfusion related immunomodulation, while rationalizing the possible association between an immunomodulation triggering transfusion ‘dose’ in cancer patients and subsequent cancer recurrence.

接受异体红细胞输注的癌症患者存在不同程度不良反应的风险。其中一种反应是免疫调节，也称为输血相关免疫调节。由于输血相关免疫调节的确切机制尚不清楚，储存损伤(包括细胞和细胞因子成分)被认为是一个主要因素。白细胞被认为与储存损伤和免疫调节有关。然而，白细胞消耗在降低免疫调节中的功效是有争议的。这三个相互关联的事件-储存病变，免疫调节和癌症进展之间的理论联系仍然存在争议和知之甚少。本文总结了白细胞消耗、储存病变和输血相关免疫调节的有效性的现有证据，同时合理化了免疫调节触发癌症患者输血“剂量”与随后癌症复发之间的可能关联。

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引用次数: 0

How low can you go: Restrictive transfusion strategies in major surgery and physiological triggers

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2023-12-01 DOI: 10.1016/j.bpa.2023.11.005

Gregory MT Hare , Ahmad Alli , Helen Jiang , C David Mazer

Anemia and red blood cell transfusion are associated with adverse outcomes. Large randomized trials have demonstrated that restrictive transfusion strategies can safely reduce patient exposure to transfusion, forming a foundational pillar of patient blood management. The restrictive transfusion thresholds in these trials ranged from 7 to 8 g/dL for different populations and this variability is reflected in recent guideline recommendations for transfusion triggers. Such variability implies heterogeneity among populations with respect to the transfusion threshold for optimal outcomes. Individual variability (tolerance to anemia, risk of tissue hypoxia, risk of red blood cell transfusion) has not been addressed by population-based trials, supporting the argument for ‘physiological transfusion triggers’ indicative of inadequate organ perfusion. However, physiological triggers have only been assessed in small feasibility trials without convincing outcome data. This review summarizes data from recent transfusion trials and transfusion guidelines, and reviews potential physiological triggers which could further refine transfusion practices and minimize risks of tissue hypoxia and adverse outcomes.

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引用次数: 0

Diagnosing iron deficiency: Controversies and novel metrics 诊断缺铁症：争议与新指标

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2023-12-01 DOI: 10.1016/j.bpa.2023.11.001

Jody A. Rusch , Diederick J. van der Westhuizen , Robert S. Gill , Vernon J. Louw

Iron deficiency, a pervasive global health issue, necessitates precise and reliable diagnostic methods, especially in clinical and surgical settings. This review examines an array of established markers of iron status, encapsulating parameters such as serum iron, ferritin, transferrin, and transferrin saturation alongside novel biomarkers like soluble transferrin receptor, zinc protoporphyrin, and hepcidin. We further scrutinise the potential and limitations of routine and novel diagnostic tools and strategies in distinguishing different anaemic conditions, such as iron deficiency anaemia, iron-restricted erythropoiesis, and anaemia of inflammation. Through a critical lens, we elucidate the current paradigms and pressing questions surrounding the diagnostic criteria and clinical ramifications of iron metabolism. By weaving together the nuances and diverging perspectives within the domain of iron deficiency diagnosis and management, this review aspires to foster a clearer understanding that can steer improved patient care and shape the trajectory of future research in this vital field.

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引用次数: 0

Magic in a bottle? A Focused review of factor concentrates for the intraoperative treatment of acquired coagulopathy – Fibrinogen concentrate, prothrombin complex concentrate, and recombinant activated factor VII 瓶子里的魔法?术中治疗获得性凝血病的浓缩因子——纤维蛋白原浓缩物、凝血酶原复合浓缩物和重组活化因子VII的重点综述

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2023-12-01 DOI: 10.1016/j.bpa.2023.11.003

Amir Zabida , Justyna Bartoszko , Keyvan Karkouti

Goal-directed administration of blood components including red cells, platelets, plasma, and factor concentrates plays a critical role in the management of intraoperative coagulopathy. Increasingly commonly used, purified and recombinant factor concentrates are being recognized for their logistical advantages and potentially superior efficacy. Three- and four-factor prothrombin concentrates, fibrinogen concentrates and activated factor VII have an evolving evidence base relative to frozen plasma and cryoprecipitate. This review discusses these compounds, compares them to conventional blood products, discusses the trial data supporting their use, and reviews indications for intraoperative transfusion based on point-of-care testing and conventional laboratory results. While factor concentrates have become an increasingly popular option for treating acquired factor deficiency in surgical patients, evidence is evolving and clinical trial data in one surgical patient population may not be transferable to another. High quality clinical studies will help optimize management of coagulopathy and improve patient outcomes while decreasing any associated risks.

目标导向的血液成分管理，包括红细胞、血小板、血浆和因子浓缩物，在术中凝血病的管理中起着关键作用。越来越普遍使用的纯化和重组因子浓缩物因其物流优势和潜在的优越功效而得到认可。三因子和四因子凝血酶原浓缩物，纤维蛋白原浓缩物和活化因子VII相对于冷冻血浆和低温沉淀有一个不断发展的证据基础。本综述讨论了这些化合物，将其与传统血液制品进行了比较，讨论了支持其使用的试验数据，并根据护理点检测和传统实验室结果回顾了术中输血的指征。虽然因子浓缩已成为治疗手术患者获得性因子缺乏症的一种日益流行的选择，但证据正在不断发展，一个手术患者群体的临床试验数据可能无法转移到另一个手术患者群体。高质量的临床研究将有助于优化凝血病的管理，改善患者的预后，同时降低任何相关的风险。

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