Anaesthesia Critical Care & Pain Medicine最新文献

Background: Postoperative pulmonary complications (PPCs) are frequent and serious complications after esophagectomy. Our aim was to determine intraoperative ventilatory parameters that are independently associated with PPCs during one-lung ventilation (OLV) and two-lung ventilation (TLV) phases.

Methods: This retrospective single-center cohort study included 454 patients undergoing elective esophagectomy with combined abdominal and thoracic approaches. The primary outcome was the occurrence of PPCs within seven postoperative days. Separate predictive models were established for OLV and TLV using multivariable logistic regressions with ventilatory parameters.

Results: PPCs occurred in 194 patients (42.7%). Plateau pressure (Pplat) and driving pressure (DP) were independently associated with PPCs during both phases (Pplat: OR = 1.73, 95%CI: 1.25-2.38, p <  0.001 in OLV; OR = 1.38, 95%CI: 1.00-1.92, p =  0.05 in TLV; DP: OR = 1.17, 95%CI: 1.05-1.30, p =  0.005 in OLV; OR = 1.14, 95%CI: 1.06-1.23, p <  0.001 in TLV). Respiratory rate (RR) was also associated (OR up to 1.62). In TLV, duration of ventilation (OR between 1.39 and 1.41) was associated with PPCs, while positive end-expiratory pressure (PEEP) was protective (OR 0.73). In OLV only, higher tidal volume (VTe) (OR 1.31, 95%CI: 1.303, 1.66, p =  0.02) and mechanical power (MP) (OR = 1.29, 95%CI: 1.00-1.64, p =  0.05) were associated with PPCs. Model discrimination was acceptable (AUC 0.70-0.76).

Conclusions: Pplat, RR, and DP were associated with PPCs in both ventilation phases. During TLV, duration increased and PEEP decreased PPC risk, whereas during OLV, VTe and MP were associated with PPCs.

Objective: The Société Française d'Anesthésie et de Réanimation (SFAR) and the Collège d'Anesthésie-Réanimation en Obstétrique (CARO) have collaborated to propose a set of guidelines for the pain management in childbirth: neuraxial analgesia and drug alternatives.

Design: A consensus committee of 32 experts was convened. A formal conflict-of-interest policy (DPI santé) was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. These recommendations have undergone a certification process by the French National Authority for Health (HAS).

Methods: Five areas were defined: 1) Placement of neuraxial analgesia; 2) Initiation of neuraxial analgesia; 3) Maintenance of neuraxial analgesia; 4) Management of neuraxial analgesia insufficiency and failure; 5) Drug alternatives to neuraxial analgesia. For each field, the aim of the recommendations was to answer a number of questions formulated by the experts according to the PICO model ('Population, Intervention, Comparison, Outcome'). Based on these questions, an extensive literature search covering the last 24 years was carried out using predefined keywords according to the PRISMA recommendations. Data quality was analyzed using the GRADE method. The recommendations were formulated using the GRADE method, then voted on by all the experts using the GRADE grid method.

Results: The experts' synthesis work and the application of the GRADE® method resulted in 39 recommendations. Among the formalized recommendations, 12 have high levels of evidence (GRADE 1+) and 10 have low levels of evidence (GRADE 2+). For 13 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any evidence in the literature. After 3 rounds of scoring and amendment, strong agreement was reached for all the recommendations.

Conclusions: There was strong agreement among the experts to provide recommendations for improving the management of pain in childbirth using neuraxial analgesia or alternative drug.

Left Ventricular Outflow Tract Obstruction (LVOTO) is a dynamic and often underrecognized cause of hemodynamic instability in critically ill patients. While more common in those with anatomical features like septal hypertrophy or hypertrophic cardiomyopathy, it can also occur in hyperdynamic states such as septic shock, stress-induced cardiomyopathy, acute hemorrhage/hypovolemia, or after excessive inotrope administration-even in patients without any anatomical predisposition. Its clinical presentation is often subtle and can mimic other causes of shock, making early recognition essential. A high index of suspicion and a systematic echocardiographic approach are crucial for early diagnosis, identifying features such as hypercontractility, systolic anterior motion of the mitral valve, LVOT narrowing, and flow acceleration on Color Doppler Imaging. Doppler imaging-particularly color flow mapping and continuous-wave (CW)-is vital for confirming and localizing the obstruction. A "dagger-shaped", late-peaking waveform of CW Doppler is pathognomonic. In cases with limited acoustic windows, transesophageal echocardiography represents an alternative. Management focuses on reversing underlying triggers and optimizing myocardial loading conditions. Discontinuation of pro-obstructive agents (e.g., inotropes), fluid resuscitation to enhance preload, and afterload augmentation using pure alpha-agonists (e.g., phenylephrine) can be very effective in further decreasing the LVOT pressure gradient. Selective use of short-acting beta-blockers might be considered to reduce contractility and heart rate. Lowering positive end-expiratory pressure (PEEP) may also benefit preload-dependent patients. We propose the "LVOTO bundle" to facilitate the treatment by summarizing key therapeutic steps. Timely and bundled-targeted interventions are vital to reverse this potentially life-threatening condition and improve outcomes in critically ill patients.

Background: Qualitative and quantitative ultrasonography can reliably differentiate between a full and empty stomach. However, no prior studies have correlated gastric volume with actual intraoperative regurgitation or aspiration events. This study investigated the relationship between ultrasonographically measured gastric antral cross-sectional area and the occurrence of regurgitation in parturients, to inform ultrasonographic diagnostic criteria for predicting regurgitation risk.

Methods: Eighty parturients undergoing urgent cesarean section under general anesthesia were enrolled. Upon arrival in the operating room, patients were positioned in a semirecumbent position for gastric ultrasound assessment. Subsequently, an esophageal pH electrode was inserted nasally. After rapid sequential induction intubation, anesthesia was maintained with sevoflurane and nitrous oxide. Mid-esophageal pH was monitored in real time until 10 min after extubation to detect occult regurgitation. The receiver operating characteristic curve assessed the predictive ability of antral cross-sectional area for regurgitation in parturients; associations between potential covariates and regurgitation occurrence were assessed using multivariable logistic regression.

Results: Regurgitation was observed in 34 parturients (one overt and 33 occult), with no cases of clinically significant aspiration occurring. The optimal antral cross-sectional area cut-off for predicting regurgitation was 487.7 mm² (area under the receiver operating characteristic curve: 0.876; 95% confidence interval: 0.80-0.95). In addition to cross-sectional area, other independent risk factors included the interval from last clear fluid intake to surgery and the last oral intake after labor onset.

Conclusions: Antral cross-sectional area ≥487.7 mm² accurately predicts occult regurgitation in urgent cesarean section under general anesthesia. Incorporating additional risk factors may improve risk stratification.

Registration: Chinese Clinical Trial Registry (ChiCTR2400090328).

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.