Best Practice & Research-Clinical Anaesthesiology最新文献

英文中文

Local anaesthetics and regional anaesthesia and outcome in cancer patients – What is the clinical evidence? 局部麻醉和区域麻醉对癌症患者的影响-临床证据是什么？

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2025-03-01 DOI: 10.1016/j.bpa.2025.05.001

Mohd S. Ramly , Daniela Ionescu , Donal J. Buggy

Cancer remains a large healthcare and socio-economic burden worldwide. New cancer cases are predicted to increase to over 35 million cases in 2050. Surgery remains the mainstay curative approach for solid tumour. Despite advancements in surgery and oncology diagnostics and therapeutics, cancer often recurs. Surgery and anaesthesia produce significant physiological changes that may dampen immune function, thus promoting cancer progression. The effects of regional anaesthesia and local anaesthetics have been explored to mitigate the risk of cancer recurrence. In this review, we summarise the current evidence of regional anaesthesia and local anaesthetics on cancer outcomes. Despite positivity in preclinical trials, prospective randomised trials have not produced convincing results. Other than the peritumoral local anaesthetic infiltration, studies have only suggested a neutral effect on long term outcome. Until new positive studies are available, regional anaesthesia and local anaesthetic use should be based on clinical grounds, not on potential oncological outcome benefit.

癌症仍然是世界范围内一个巨大的医疗保健和社会经济负担。预计到2050年，新的癌症病例将增加到3500多万例。手术仍然是治疗实体瘤的主要方法。尽管外科和肿瘤学的诊断和治疗取得了进步，但癌症经常复发。手术和麻醉会产生显著的生理变化，可能会抑制免疫功能，从而促进癌症的进展。区域麻醉和局部麻醉的作用已被探讨，以减轻癌症复发的风险。在这篇综述中，我们总结了目前区域麻醉和局部麻醉对癌症预后的影响。尽管在临床前试验中有积极的结果，但前瞻性随机试验尚未产生令人信服的结果。除了肿瘤周围的局部麻醉浸润外，研究只表明对长期结果的影响是中性的。在获得新的阳性研究之前，区域麻醉和局部麻醉的使用应基于临床依据，而不是基于潜在的肿瘤预后益处。

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引用次数: 0

Prehabilitation: Stepping beyond exercise in patients with frailty and cancer 康复：在虚弱和癌症患者中超越运动

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2025-03-01 DOI: 10.1016/j.bpa.2025.03.008

Zhaosheng Jin , Jonathan Aminov , Giancarlo Sabetta , Jacob Gordon , Sergio D. Bergese

Cancer is one of the leading causes of morbidity and mortality. In patients who require oncological surgery, frailty is associated with increased risk of perioperative adverse events, which can lead to delay in subsequent oncological care. Additionally, cancer and neoadjuvant therapy both contribute to diminished physiological reserve and increased incidence of frailty. Prehabilitation involves a bundle of preoperative intervention with the goal of improving patients’ physiological reserve and promoting better recovery after surgery. While prehabilitation is frequently associated with the delivery of preoperative physical exercise interventions, there is increasing recognition that a multimodal approach should be employed to optimize outcomes.

Nutritional, educational and psychobehavioral interventions are commonly employed as components of multimodal prehabilitation. There are also other emerging novel interventions, including cognitive prehabilitation. As with all effective perioperative initiatives, effective implementation of prehabilitation often requires a multidisciplinary effort. This review will discuss both the established and the novel prehabilitation interventions, as well as the interaction between prehabilitation and other perioperative pathways.

癌症是发病率和死亡率的主要原因之一。在需要肿瘤手术的患者中，虚弱与围手术期不良事件的风险增加有关，这可能导致后续肿瘤治疗的延迟。此外，癌症和新辅助治疗都会减少生理储备，增加虚弱的发生率。预康复包括一系列术前干预，目的是提高患者的生理储备，促进术后更好的恢复。虽然康复通常与术前体育锻炼干预有关，但越来越多的人认识到，应该采用多模式方法来优化结果。营养、教育和心理行为干预通常被用作多模式康复的组成部分。还有其他新兴的新型干预措施，包括认知康复。与所有有效的围手术期举措一样，有效实施康复通常需要多学科的努力。本文将讨论现有的和新的康复干预措施，以及康复与其他围手术期途径之间的相互作用。

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引用次数: 0

Volatiles vs. TIVA – Is there a difference in cancer patients 挥发物与TIVA -在癌症患者中有区别吗

IF 4.7 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2025-03-01 DOI: 10.1016/j.bpa.2025.03.002

Bente FH. Dubois, Markus W. Hollmann

Cancer incidence continues to rise, with 20 million new cases and 9.7 million cancer-related deaths reported in 2022. With the vast majority of these patients requiring anaesthesia. However, despite surgical resection, nearly one-third of patients experience local recurrence or distant metastases. Perioperative factors, including surgical stress and anaesthetic technique, may influence recurrence, though tumour biology remains not fully understood.

The impact of total intravenous anaesthesia (TIVA) versus inhalation anaesthesia (IA) on oncological outcomes has attracted growing interest. While some studies suggest a potential advantage of propofol-based TIVA, the probability of a clinically significant effect remains low. The existing literature consists mainly of retrospective studies and small randomised trials (RCT's) with methodological limitations.

Currently, there is no strong evidence that TIVA or IA has a meaningful impact on cancer-free survival. This review critically examines the available research and presents an alternative perspective on this controversial topic.

癌症发病率继续上升，2022年报告有2000万新病例和970万癌症相关死亡。绝大多数病人需要麻醉。然而，尽管手术切除，近三分之一的患者出现局部复发或远处转移。围手术期因素，包括手术压力和麻醉技术，可能影响复发，尽管肿瘤生物学仍未完全了解。全静脉麻醉（TIVA）与吸入麻醉（IA）对肿瘤预后的影响引起了越来越多的关注。虽然一些研究表明基于异丙酚的TIVA具有潜在的优势，但临床显著效果的可能性仍然很低。现有文献主要包括回顾性研究和小型随机试验（RCT’s），方法上存在局限性。目前，没有强有力的证据表明TIVA或IA对无癌生存有意义的影响。这篇综述批判性地考察了现有的研究，并提出了对这一有争议的话题的另一种观点。

引用次数: 0

Nitrous oxide waste and why we should abandon reticulated delivery systems 一氧化二氮的浪费和为什么我们应该放弃网状输送系统

IF 2.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-12-01 DOI: 10.1016/j.bpa.2025.01.001

Gwen Morgan , Vivian Ip , Jane Muret , Pui San Loh , Craig D. McClain , Seema Gandhi

In the face of the unfolding climate crisis, addressing the substantial greenhouse gas emissions which stem from healthcare systems has become an emergency. Nitrous oxide (N₂O) is used as an anaesthetic and analgesic adjuvant, however it is also an important greenhouse gas and ozone depleting agent. Clinical use of N₂O has decreased over the past decade owing to its limited clinical utility, risk of adverse effects and concern regarding occupational exposure. Yet N₂O procurement has not followed this downward trend. Most hospitals rely upon highly inefficient reticulated N₂O supply systems, in which a large majority of supplied N₂O is lost or wasted through systemic leaks, poor stock management, uneconomical clinical practice or theft. This wastage comes at high financial and environmental cost and offers no clinical benefit. Such costs can be mitigated by abandoning centralised N₂O supply systems in preference for more efficient point-of-care cylinders.

面对不断发展的气候危机，解决医疗系统产生的大量温室气体排放已成为当务之急。一氧化二氮（N2O）被用作麻醉和镇痛的辅助剂，但它也是一种重要的温室气体和臭氧消耗剂。在过去十年中，由于N2O的临床用途有限、存在不良反应风险以及对职业暴露的担忧，N2O的临床使用量有所减少。然而，一氧化二氮的采购并没有遵循这种下降趋势。大多数医院依赖效率极低的网状一氧化二氮供应系统，其中大部分供应的一氧化二氮由于系统泄漏、库存管理不善、不经济的临床实践或盗窃而丢失或浪费。这种浪费带来了高昂的财政和环境成本，而且没有临床效益。这种成本可以通过放弃集中的N2O供应系统，而选择更有效的点护理钢瓶来减轻。

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引用次数: 0

Greening the operating room: A narrative review of existing initiatives and future opportunities in anaesthesia 手术室绿化：麻醉领域现有举措和未来机遇的叙述性回顾

IF 2.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-12-01 DOI: 10.1016/j.bpa.2025.04.003

Harold Mulier , Steffen Rex , An Teunkens

The environmental impact of operating rooms is significant, with these facilities generating approximately two-thirds of a hospital's waste. This narrative review explores existing initiatives and future opportunities to enhance environmental sustainability in anaesthesia.

The European Society of Anaesthesiology and Intensive Care (ESAIC) Glasgow Declaration of 2023 underscores the urgent need for sustainable practices in anaesthesia and intensive care, aiming to minimise environmental harm. Key focus areas include waste management, recycling, reuse of materials, and energy consumption in operating rooms. This review highlights the potential for waste reduction through evidence-based adjustments to sterilization protocols and an emphasis on recycling and proper waste segregation. It also discusses the environmental implications of different sterilisation methods and the energy consumption associated with HVAC systems and other equipment in operating rooms.

By adopting sustainable practices, healthcare professionals can significantly contribute to reducing the environmental footprint of operating rooms in order to support global climate goals.

手术室对环境的影响是巨大的，这些设施产生的废物约占医院废物的三分之二。这篇叙述性综述探讨了现有的举措和未来的机会，以提高麻醉的环境可持续性。欧洲麻醉和重症监护学会（ESAIC）《2023年格拉斯哥宣言》强调了麻醉和重症监护中可持续实践的迫切需要，旨在最大限度地减少对环境的危害。重点关注的领域包括废物管理、回收、材料再利用和手术室的能源消耗。这篇综述强调了通过循证调整灭菌方案以及强调回收和适当的废物分类来减少废物的潜力。它还讨论了不同灭菌方法的环境影响，以及与手术室暖通空调系统和其他设备相关的能源消耗。通过采用可持续实践，医疗保健专业人员可以为减少手术室的环境足迹做出重大贡献，以支持全球气候目标。

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引用次数: 0

Environmental sustainability in healthcare: Managerial concerns and solutions 医疗保健中的环境可持续性：管理问题和解决方案

IF 2.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-12-01 DOI: 10.1016/j.bpa.2025.03.006

Pascal Verdonck , Isabel Verniers

Healthcare's substantial environmental footprint demands targeted strategies across the sector for reducing emissions and optimising resource use. Effective governance structures, such as board involvement and/or designated sustainability officers, are essential for embedding low-carbon procurement, energy-efficient infrastructure, and waste-reduction initiatives across healthcare operations. Lean management practices and active staff engagement foster a culture of sustainability, enhancing efficiency and minimising waste. Patient-centred programs, sustainable food sourcing, and telemedicine integration further support the shift toward environmentally responsible practices. These combined strategies enable healthcare organisations to progress toward global sustainability goals without compromising patient care quality. Broader adoption of sustainable healthcare practices requires ongoing research into implementation challenges, measurable outcomes, and cost-effectiveness. Such efforts will be crucial in establishing robust, scalable models of sustainability that can produce enduring positive impacts on both the environment and healthcare delivery standards.

医疗保健行业巨大的环境足迹要求整个行业制定有针对性的战略，以减少排放和优化资源利用。有效的治理结构，如董事会参与和/或指定的可持续性官员，对于在整个医疗保健业务中嵌入低碳采购、节能基础设施和减少废物举措至关重要。精益管理实践和积极的员工参与培养了可持续发展的文化，提高了效率，减少了浪费。以患者为中心的项目、可持续食品采购和远程医疗整合进一步支持了向对环境负责的做法的转变。这些综合策略使医疗保健组织能够在不影响患者护理质量的情况下实现全球可持续性目标。更广泛地采用可持续医疗实践需要对实施挑战、可衡量的结果和成本效益进行持续研究。这些努力对于建立健全的、可扩展的可持续性模式至关重要，这些模式可以对环境和医疗保健提供标准产生持久的积极影响。

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引用次数: 0

Volatile capture technology in the operating room: How does it work, what are the technical limitations and what does it mean for clinical practice? 手术室的挥发性捕获技术：它是如何工作的，技术限制是什么，它对临床实践意味着什么？

IF 2.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-12-01 DOI: 10.1016/j.bpa.2025.04.001

Sebastian Gibb , Martin Schuster , Linda Grüßer

Volatile anaesthetics (VA) are potent greenhouse gases and a major contributor to the environmental footprint of the operating room. Vapour capture technology (VCT) is a promising technique for reducing the environmental impact of VA. This review provides an overview of the different types of VCT and their limitations. It evaluates the current evidence for the different techniques in simulated, laboratory and clinical settings. Finally, practical recommendations for more environmentally friendly VA-based anaesthesia with VCT are presented.

挥发性麻醉剂（VA）是强效的温室气体，是手术室环境足迹的主要贡献者。蒸汽捕集技术（VCT）是一种很有前途的减少VA对环境影响的技术。本文综述了不同类型的VCT及其局限性。它评估了目前在模拟、实验室和临床环境中不同技术的证据。最后，提出了更环保的基于VCT的va麻醉的实用建议。

引用次数: 0

Climate science for anaesthetists: PK/PD of volatile anaesthetics in the atmosphere 麻醉师气候科学：大气中挥发性麻醉药的PK/PD

IF 2.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-12-01 DOI: 10.1016/j.bpa.2024.12.001

Alain Frederic Kalmar , Pascal Verdonck , Steffen Rex

Volatile anaesthetics contribute to climate change through greenhouse gas emissions. Early concerns about their ecological impact emerged in the 1990s, but significant attention was only garnered post-2010 when studies revealed nitrous oxide (N₂O) and desflurane's high greenhouse effect, prompting recommendations for their reduced use in favour of less harmful alternatives like total intravenous anaesthesia (TIVA) or regional techniques.

Anaesthesiologists are encouraged to balance environmental sustainability with clinical effectiveness, but in order to draw substantiated conclusions, they must understand the scientific principles behind greenhouse effects and climate change. Some awareness of positive climate feedback mechanisms is also valuable for assessing the urgency of climate action, which should influence clinical decision making.

The calculation of the environmental impact of volatile anaesthetics involves using the ideal gas law to measure anaesthetic consumption and applying climate physics to calculate CO₂-equivalents based on global warming potential (GWP). The challenge with GWP lies in equating short-lived anaesthetics with long-lived CO₂ due to differing atmospheric lifetimes, leading to debates on the most appropriate time horizon for GWP calculations or whether other metrics like radiative forcing better reflect the true climate impact.

挥发性麻醉剂通过温室气体排放加剧了气候变化。早在20世纪90年代就出现了对其生态影响的担忧，但直到2010年后，当研究发现一氧化二氮（N₂O）和地氟醚的高温室效应时，才引起了人们的重视，这促使人们建议减少使用它们，转而使用危害较小的替代品，如全静脉麻醉（TIVA）或区域技术。麻醉师被鼓励在环境可持续性和临床效果之间取得平衡，但为了得出确凿的结论，他们必须了解温室效应和气候变化背后的科学原理。对气候积极反馈机制的一些认识对于评估气候行动的紧迫性也很有价值，这应该影响临床决策。挥发性麻醉剂对环境影响的计算包括使用理想气体定律来测量麻醉剂的消耗量，并根据全球变暖潜势（GWP）应用气候物理学来计算二氧化碳当量。由于不同的大气寿命，全球暖化潜能值的挑战在于将短期麻醉与长期CO₂等同起来，这导致了关于计算全球暖化潜能值最合适的时间范围的争论，或者其他指标如辐射强迫是否能更好地反映真实的气候影响。

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引用次数: 0

Optimal fresh gas flow during total intravenous anaesthesia 全静脉麻醉时最佳新鲜气体流量

IF 2.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-12-01 DOI: 10.1016/j.bpa.2025.03.004

Jennifer Jouwena , Hugo Carvalho , Steffen Rex , Alain F. Kalmar

Total intravenous anaesthesia (TIVA) has a significantly lower climate impact than volatile agents. However, finding the optimal fresh gas flow (FGF) is complex due to varied anaesthesia workstation designs and regional differences in energy use. We aim to identify the most eco-friendly and cost-effective FGF setting for TIVA by considering ventilator types, oxygen concentration, ventilatory minute volume (VCO₂), and local electricity carbon intensity.

Soda lime consumption decreases with FGF, becoming negligible when FGF matches minute volume for most ventilators. CO₂ equivalent (CO₂e) emissions of soda lime dominate at low FGF; CO₂e of O₂ and air production dominates at higher flows, especially with a high O₂ fresh gas setting and where electricity has a high carbon intensity.

The most ecologically and economically optimal FGF in most workstations is achieved when FGF equals the minute volume and is set to a low O₂ concentration.

The active anaesthetic gas scavenging system (AGSS) should be unplugged when volatile anaesthetics are not in use, as this action significantly contributes to reducing both CO₂e emissions and costs.

全静脉麻醉（TIVA）对气候的影响明显低于挥发性药物。然而，由于不同的麻醉工作站设计和能源使用的区域差异，找到最佳的新鲜气体流量（FGF）是复杂的。我们的目标是通过考虑呼吸机类型、氧气浓度、通风分气量（VCO2）和当地电力碳强度，确定最环保和最具成本效益的FGF设置。钠石灰消耗随着FGF的减少而减少，当FGF与大多数通风机的微小体积相匹配时，钠石灰消耗可以忽略不计。低FGF时，钠石灰的CO2当量（CO2e）排放量占主导地位；二氧化碳当量和空气产量在高流量下占主导地位，特别是在高氧新鲜气体设置和电力具有高碳强度的情况下。在大多数工作站中，当FGF等于分钟体积并设置为低氧浓度时，可以实现最生态和最经济的FGF。当不使用挥发性麻醉剂时，应拔掉主动麻醉气体清除系统（AGSS）的插头，因为这一行动大大有助于减少二氧化碳排放和成本。

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引用次数: 0

Environmental impact of propofol: A critical review of ecotoxicity and greenhouse effects 异丙酚的环境影响：生态毒性和温室效应综述

IF 2.8 3区医学 Q1 ANESTHESIOLOGY

Best Practice & Research-Clinical Anaesthesiology

Pub Date : 2024-12-01 DOI: 10.1016/j.bpa.2024.12.003

Alain F. Kalmar , Steffen Rex , Thimo Groffen , Hugo Vereecke , An Teunkens , Geertrui Dewinter , Harold Mulier , Michel MRF. Struys

There is an imbalance in the current discussion around the environmental impact of total intravenous anaesthesia (TIVA) versus volatile anaesthetics. The discourse often leans heavily towards scrutinising the greenhouse gas emissions linked to volatile anaesthetics. Although propofol has a much smaller impact on global warming compared to volatile anaesthetics, some argue it may not be a suitable alternative for maintaining anaesthesia due to concerns about its potential ecotoxic effects on aquatic life. This review focuses on the ecotoxicity of propofol, remediation techniques, pharmaceutical waste management and the greenhouse gas emission linked to propofol.

目前关于全静脉麻醉（TIVA）与挥发性麻醉对环境影响的讨论存在不平衡。讨论往往严重倾向于审查与挥发性麻醉剂有关的温室气体排放。尽管与挥发性麻醉剂相比，异丙酚对全球变暖的影响要小得多，但一些人认为，由于担心其对水生生物的潜在生态毒性，它可能不是维持麻醉的合适选择。本文综述了异丙酚的生态毒性、修复技术、医药废弃物管理以及与异丙酚相关的温室气体排放。

引用次数: 0

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