Anaesthesia Critical Care & Pain Medicine最新文献

Paediatric airway management in critically ill children presents unique challenges for paediatricians and anaesthetists. However, it is the physiological disorder that presents the main risk of adverse events in the PICU beyond anatomical considerations, a concept known as the "physiologically difficult airway". Recent registry data reported a first-attempt success rate of only two-thirds in the PICU, with severe adverse events occurring in 15% of children and cardiac arrest in nearly 6% of those with physiologically difficult airway risk factors. Even children with normal anatomy may have unstable physiology (hypoxaemia, hypotension, raised ICP, and acidosis), which can make intubation unsafe. The main implications are respiratory (risk of rapid desaturation) and cardiovascular (collapse from induction drugs, loss of sympathetic tone, and positive pressure ventilation). For these reasons, management should focus on optimising conditions before intubation, such as providing fluids and vasopressors, ensuring preoxygenation and apnoeic oxygenation, and choosing medications wisely to reduce the risk. Practitioners should also optimise the technique itself, considering paediatric specificities, to ensure first-pass success. It is also important to secure the procedure by using checklists and protocols that take into account both physiological and anatomical difficult airways and the specificities of airway management in children. This review aims to synthesize current evidence and provide expert opinion for clinicians managing the airway in critically ill children.

Rapid sequence intubation (RSI) remains a cornerstone of airway management in critically ill patients, aiming to optimize oxygenation and ventilation, reduce the risk of secondary brain injury, and prevent gastric aspiration. Originally designed to minimize the interval between loss of airway reflexes and airway protection, while also limiting hemodynamic complications, RSI is now widely used in the operating room, intensive care unit, and emergency department. While aspiration prevention has historically been a central rationale for RSI, emerging evidence suggests that RSI may not significantly reduce this risk and may, in fact, be associated with increased rates of hypoxemia and hemodynamic instability. Pharmacological approaches, airway management techniques, and team-based preparation must be tailored to mitigate these complications. Contemporary RSI involves thorough preintubation assessment, preparation, and teamwork, emphasizing first-pass intubation success, patient positioning, apneic oxygenation, and gentle ventilation when appropriate. Several interventions have shown a clinically significant reduction of adverse events, such as the use of a video laryngoscope, apneic bag mask ventilation, or non-invasive ventilation for pre-oxygenation. The main recommended medications include a sedative (etomidate or ketamine are favored over propofol in hemodynamically unstable patients) and a paralytic (rocuronium or succinylcholine). Human factors, team-based preparation, and first-pass success remain key determinants of RSI outcomes. This narrative review synthesizes current evidence on RSI, highlighting pharmacological strategies, airway management techniques, and human factors, reflecting a shift from rigid protocols toward a more flexible, patient- and team-centered approach that balances aspiration risk with the prevention of desaturation and hypotension.

Background: Hip arthroplasty is a standard surgical procedure to decrease joint pain. Opioid-based regimens have historically been used to treat postoperative pain; however, opioid-free regimens are increasingly employed due to the increased risk of dependence and adverse events. This systematic review aimed to compare patient outcomes following opioid-based and opioid-free perioperative regimens in hip arthroplasty.

Methods: We systematically searched PubMed, Web of Science, Scopus, and Cochrane Central from inception to December 2024 and updated the search in May 2025. Only clinical trials comparing opioid-based and opioid-free regimens in which adult patients underwent total hip arthroplasty were included. The co-primary outcomes were the rest visual analog scale (VAS) pain score and the movement VAS pain score. The secondary outcomes were nausea, vomiting, pruritus, cumulative opioid consumption at 24 h, antiemetic administration, headache, urinary retention, operation time, and blood loss. We used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework to assess the quality of evidence for the main outcomes.

Results: We identified 6,354 articles, with 28 trials involving 1,787 patients (opioid-based group: 889, opioid-free group: 898) that met the inclusion criteria. For the co-primary outcomes, the opioid-free group experienced lower scores on the movement VAS at both 12 and 24 hours compared to the opioid-based group, showing a mean difference (MD -1.43, 95% CI: -2.66 to -0.20, p =  0.022) and (MD -1.18, 95% CI: [-2.25 to -0.10], p =  0.032), respectively. Furthermore, the opioid-free group had lower scores on the resting VAS at 12 and 24 hours compared to the opioid-based group (MD -1.51, 95% CI: -2.89 to -0.13, p =  0.032) and (MD -1.12, 95% CI: -1.94 to -0.29, p =  0.008), respectively.

Conclusion: This study found that the opioid-free regimens, compared to the opioid-based, were associated with lower VAS pain scores, though with considerable variability. Also, opioid-free analgesia decreased postoperative side effects, especially opioid side effects like nausea and pruritus. However, there was no difference in outcomes, including vomiting, headache, urinary retention, antiemetic use, and overall satisfaction. For the VAS scores, the GARDE assessment ranged from very low to low certainty; on the other hand, the certainty of evidence for vomiting, nausea, and pruritus ranged from moderate to high.

Registration: PROSPERO (CRD420250637286).

Introduction: Tracheal intubation in adult patients with anticipated difficult airways is a critical challenge in anaesthesia practice, with direct implications for patient safety and outcomes. Hyperangulated videolaryngoscope blades are designed to enhance glottic visualization and increase first-pass success in anatomically constrained airways. However, clinical evidence comparing their performance with Macintosh-geometry blades remains inconsistent. This systematic review aimed to compare hyperangulated to Macintosh videolaryngoscopic blades in adult patients with anticipated difficult airways.

Methods: We searched PubMed, Scopus, and Web of Science for randomized controlled trials enrolling adults with anticipated difficult airways that directly compared hyperangulated and Macintosh videolaryngoscopic blades.

Results: Four RCTs (n = 412 patients) were included. In anticipated difficult airways, hyperangulated blades showed higher first-pass success compared with Macintosh-style videolaryngoscopes (largest trial: 97%vs. 67%) and provided superior glottic views. Intubation time was often longer with hyperangulated blades, while complication rates and hemodynamic responses were generally comparable between blade geometries.

Discussion: In adult patients with anticipated difficult airways, hyperangulated blades outperform Macintosh-geometry videolaryngoscopes in glottic visualization and first-pass success without increasing complications. Although intubation may be modestly slower, the clinical advantages in high-risk scenarios appear to outweigh this limitation.

Introduction: Recruitment for clinical trials in acute care settings, including intensive care units (ICUs), emergency departments, and peri-operative environments, presents distinctive ethical and practical challenges. These include time-sensitive decision-making, impaired patient capacity, complex consent processes, and reliance on surrogate decision-makers (SDMs). Despite growing attention to research ethics, there is a limited synthesis of how these challenges impact patient consent and trial recruitment.

Methods: Following PRISMA-ScR guidance, a systematic search of PubMed/MEDLINE (2010-2025) was conducted, supplemented by a targeted ClinicalTrials.gov search to identify ongoing and completed trials. Data were extracted and classified into overarching domains to map the breadth of barriers and proposed solutions.

Results: Fifteen studies were included, spanning randomised controlled trials, qualitative studies, surveys, and reviews. Key barriers were: (1) timing and capacity constraints in high-pressure environments; (2) comprehension challenges with technical consent documents, especially in minority populations; (3) regulatory variability limiting harmonisation of alternative models (e.g., deferred and staged consent); and (4) under-representation of vulnerable groups, leading to selection bias. Nine additional randomised clinical trials identified in ClinicalTrials.gov explored innovative consent tools such as digital aids and AI chatbots; two had published results. Promising strategies included multimodal consent, culturally tailored materials, early SDM engagement, and patient and public involvement (PPI).

Discussion: Acute-care and anaesthetic trials require adaptive consent frameworks that balance ethical rigour with operational feasibility. Adoption of inclusive recruitment strategies and harmonised international standards may enhance both equity and efficiency in future critical-care research.

Background: Postoperative central nervous system (CNS) infections pose a significant challenge in neurosurgery. While linezolid may offer advantages over vancomycin, its optimal dosing for critically ill patients remains unclear. This study aims to optimize linezolid treatment in ICU patients with postoperative CNS infections using pharmacokinetic/pharmacodynamic modeling and simulation.

Methods: ICU population PK models were analyzed using Monte Carlo simulations (n = 1,000) to evaluate six LZD regimens: 600 mg q12 h, 600 mg q8h, 600 mg q6h, and equivalent total daily doses by continuous infusion. Probability of target attainment (PTA) was calculated for time above MIC (%T > MIC) ≥85% and AUC/MIC > 100 in plasma and cerebrospinal fluid. MIC distributions of common pathogens were incorporated to estimate the cumulative fraction of response (CFR) for each regimen.

Results: Standard 600 mg q12 h dosing failed to achieve > 90% PTA at MIC = 1 mg/L in all models. Intensified regimens (600 mg q8h, q6h, or continuous infusion) improved target attainment. A 2400 mg/day continuous infusion was required to consistently cover pathogens with MIC = 2 mg/L, albeit with a non-negligible toxicity risk. As approximately 90% of clinical isolates show linezolid MICs of 1-2 mg/L, CFR analysis suggested that ∼50% of ICU patients may be underdosed with the standard regimen.

Conclusions: Standard linezolid dosing appears inadequate for postoperative CNS infections in ICU patients. Optimized regimens are necessary to reliably target pathogens with MIC ≥ 1 mg/L. Due to linezolid's narrow therapeutic window and toxicity risk at higher doses, individualized dosing and therapeutic drug monitoring may be recommended in neurocritical care settings.

Introduction: Postoperative complications substantially increase morbidity and healthcare costs. Preoperative oral hygiene has been proposed to reduce postoperative complications, yet its use remains inconsistent across surgical practices.

Methods: This systematic review and meta-analysis evaluated the effect of preoperative oral hygiene on adverse postoperative outcomes. MEDLINE, Embase, Cochrane Central, and Cochrane Database of Systematic Reviews were searched for randomised controlled trials and prospective cohort studies in adults undergoing elevated-risk elective surgery. Interventions included any preoperative oral hygiene measures. Primary outcomes were pneumonia, infection (nosocomial, surgical site, respiratory, urinary tract), hospital and ICU length of stay (LOS), and all-cause mortality. Risk of bias was assessed using the Cochrane ROB tool and Newcastle-Ottawa Scale (NOS), with certainty of evidence rated using GRADE. Meta-analyses used pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs).

Results: Nineteen studies (5,757 patients) were included. Preoperative oral hygiene significantly reduced pneumonia (OR: 0.42; 95% CI [0.27, 0.66], p < 0.001); nosocomial (OR: 0.56; 95% CI [0.44-0.71], p < 0.001), surgical site (OR: 0.62; 95% CI [0.42, 0.92], p = 0.02), and respiratory infections (OR: 0.62; 95% CI [0.41, 0.93], p = 0.02). Hospital LOS (MD: -1.09 days; 95% CI [-1.73, -0.45], p < 0.001) and ICU LOS (MD: -0.14 days; 95% CI [-0.27, -0.00], p = 0.04) were also reduced. No significant association was identified with urinary tract infections or mortality.

Conclusions: Preoperative oral hygiene significantly decreases postoperative infections and shortens hospital and ICU stay. Routine implementation in preoperative protocols may improve surgical outcomes.

Registration: PROSPERO CRD42025638150.

Background: The number of meta-analyses (MAs) evaluating the erector spinae plane (ESP) block has increased rapidly; however, their methodological quality remains uncertain.

Methods: A systematic search was conducted in PubMed, Embase, Scopus, Web of Science, and the Cochrane Library for ESP block MAs published from 2016 to 2025. Methodological quality was assessed using the AMSTAR-2 tool, whereas study overlap across reviews was quantified using the corrected covered area (CCA). Multivariate analyses were used to explore the potential predictors of quality.

Findings: Ninety-seven MAs were included. Most evaluated single-injection techniques (91.8%) in adults (87.6%), predominantly thoracic-level blocks (48.5%), and abdominal surgeries (33%). Based on AMSTAR-2, 7 reviews (7.2%) were high quality, 9 (9.3%) were moderate, 41 (42.3%) were low, and 40 (41.2%) were critically low quality. Frequent deficiencies included missing funding statements (98%), absence of excluded study lists (40%), and inadequate assessment of publication bias. Across all reviews, 1,214 randomized trials were identified, of which 571 were unique (CCA: 1.17%). No significant predictors of the methodological quality were identified.

Conclusions: Although the ESP block is widely supported by existing literature, the methodological quality of most MAs remains suboptimal. Improved adherence to established reporting and appraisal standards is required to support reliable clinical decision-making.

Prospero registration number: CRD420251081933.

Background: Preoperative anaesthetic consultation is essential for perioperative care, involving risk assessment, treatment optimisation, and planning of anaesthetic strategies according to established guidelines. Large language models (LLMs) could offer decision-support in this setting, but their autonomous capability to generate comprehensive, guideline-based anaesthetic plans remains unassessed in France and uncertain worldwide.

Methods: In this simulation study, 100 synthetic clinical cases spanning various surgical specialties were evaluated. Three AI models-ChatGPT, Mistral, and a domain-specific LLM (Dougall GPT)-were prompted to generate preoperative anaesthetic assessment and plans based on French guidelines. Outputs were compared with expert anaesthesiologist reference plans using structured expert scoring across multiple domains, including guideline adherence and clinical safety.

Results: Among 1,200 evaluated data fields across 100 cases, ChatGPT showed the highest overall guideline conformity, measured using a 0-4 expert-derived ordinal scale per domain (4 = guideline-concordant). ChatGPT provided the most complete outputs (98% of requested items) and achieved the highest median agreement scores in seven of the 12 anaesthesia domains. Dougall GPT performed moderately, whereas Mistral LeChat showed lower conformity and the highest proportion of unsafe or potentially unsafe outputs (scores ≤2).

Conclusions: Current LLMs demonstrate encouraging potential to support preoperative anaesthetic planning for routine cases. However, their reliability remains insufficient for high-risk or complex patients without further fine-tuning and safety controls. These findings underscore both the potential and the current limitations of AI in perioperative decision support.

Background: This systematic review and meta-analysis investigated the effectiveness and safety of perioperative ketamine/esketamine in patients undergoing laparoscopic cholecystectomy (LC).

Methods: A literature search was conducted across Medline, Embase, Google Scholar, and clinicaltrials.gov until April 2025. Forty-eight randomized controlled trials (RCTs) comparing ketamine/esketamine with a control in LC patients and assessing postoperative pain scores were included. Statistical analysis was performed using R.

Results: This review included a total of 48 RCTs (n = 3,508). Pooled analysis revealed that intervention significantly reduced postoperative pain at 4 (mean difference [MD]: -1.11, I² = 97.8%, p = 0.044, very low-certainty evidence) and 6 hours (MD: -0.40, I²=86.1%, p=0.019, very low-certainty evidence), 24-hours opioid consumption (MD: -4.10, I²=98.3%, p = 0.024, very low-certainty evidence) and need for rescue analgesia (risk ratios [RR]: 0.64, I²=36%, p = 0.006, very low-certainty evidence) compared to the control. According to subgroup analysis on the basis of regimen, esketamine significantly reduced postoperative pain at 1 (MD: -0.67, I²=0%, p = 0.034) and 2 hours (MD: -0.91, I²=79.3%, p = 0.008). Ketamine significantly reduced 24-hour opioid consumption (MD: -5.35, I²=96%, p = 0.01) and the need for rescue analgesia (RR: 0.64, I²=41.7%, p = 0.011). Safety analysis revealed the significantly increased risk of hallucinations, diplopia, and nystagmus with the intervention.

Conclusion: With a very low level of certainty, this meta-analysis demonstrated that ketamine/esketamine might help reduce acute postoperative pain and postoperative opioid needs in patients undergoing LC. Furthermore, ketamine may slightly increase the risk of some adverse events. However, dose-related meta-regression for adverse events was not performed due to inconsistent reporting across studies.

Registration: PROSPERO (CRD420251035913).