Anaesthesia Critical Care & Pain Medicine最新文献

Background: Airway management can be challenging in obese patients. The intubation sequence should facilitate rapid achievement of optimal intubation conditions. In some patients, neuromuscular blocking agents (NMBAs) must be avoided. Therefore, an alternative intubation sequence is required. The objectives of this study were to evaluate the intubation conditions achieved with an NMBA-free intubation sequence using propofol and remifentanil, and to assess whether a higher dose of remifentanil improved these conditions.

Methods: We conducted a prospective, single-centre, randomised, double-blind pilot trial involving obese patients undergoing bariatric surgery. Patients were allocated to two groups to receive either remifentanil 3 µg kg^-1 or 3 µg kg^-1 + 30%, both in association with propofol. The primary outcome was the percentage of patients with excellent intubation conditions. Secondary outcomes included intubation difficulty, respiratory and haemodynamic effects, and traumatic complications.

Results: Intubation conditions were excellent in 32.8% of patients and acceptable (excellent or good) in 86.2%. Increasing the remifentanil dose did not significantly modify intubating conditions (P-value = 0.548). Intubation was rated as easy in 89.7% of patients. No serious complications occurred, although haemodynamic instability was frequent (arterial hypotension 93.1%; bradycardia 48.3%).

Conclusion: An NMBA-free induction sequence with remifentanil may be feasible in obese patients, providing acceptable, easy, and atraumatic intubating conditions. Increasing the remifentanil dose does not appear to significantly improve these conditions. This sequence may represent an alternative when NMBAs must be avoided. However, before routine clinical use, further studies are now warranted to optimise it, particularly regarding haemodynamic safety.

Registration: ClinicalTrials.gov (NCT05026125).

Background: The Interscalene block offers adequate anesthesia and analgesia to the shoulder. Ipsilateral phrenic nerve paralysis is a common and generally well-tolerated consequence of the interscalene block. However, it may become clinically significant in patients with pre-existing respiratory conditions or limited pulmonary reserve. We hypothesized that a slow infusion of an interscalene block over 10 min would reduce the incidence of a complete phrenic nerve block.

Methods: This randomized controlled trial included 83 patients who underwent arthroscopic shoulder surgery. Patients were randomly allocated into one of two groups: single shot (n = 42), who received an interscalene block as a 10 mL 0.5% bupivacaine over 1 min, or slow infusion (n = 41), who received 10 mL 0.5% bupivacaine over 10 min via an indwelling catheter using a syringe pump. An experienced operator examined the corresponding hemidiaphragm for diaphragmatic excursion at baseline and 10-minute intervals for 30 min after the interscalene block. The main outcome variable was the incidence of complete phrenic nerve block.

Results: Eighty-three patients were included in the final analysis. Demographic data, including age, body mass index, sex, type, and duration of surgery, were not significantly different between the groups. The slow-infusion and single-shot groups showed 7% and 83% complete phrenic nerve block, respectively. Additionally, Forced Expiratory Volume at 1 sec (FEV1) and Forced Vital Capacity (FVC) at 30 min after block administration were significantly lower in the single-shot group. Notably, 24 h resting NRS score and morphine consumption were comparable between the groups, indicating preserved 24 h postoperative analgesic efficacy.

Conclusion: In adult patients undergoing arthroscopic shoulder surgery, continuous interscalene block reduced the incidence of complete phrenic nerve block to 7% compared to 83% in the single-shot block with comparable 24 h postoperative analgesic efficacy. Additionally, it preserved pulmonary function in terms of FEV1 and FVC without reducing analgesic efficacy compared with the single-shot approach.

Trial registration: ClinicalTrials.gov (NCT06820853).

Background: Intraoperative hemodynamic management may influence cerebral perfusion and neurological recovery in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS). This study aimed to identify intraoperative blood pressure and heart rate patterns associated with three-month functional outcomes in AIS patients treated under general anesthesia, using a machine learning approach capable of capturing nonlinear relationships and variable interactions.

Methods: We conducted a post hoc analysis of a prospectively maintained cohort of consecutive patients with anterior circulation stroke who underwent MT under general anesthesia at a tertiary stroke center between March 2014 and June 2019. The primary outcome was functional independence at three months (modified Rankin Scale [mRS] score 0-2). Intraoperative hemodynamic variables were analyzed across pre- and post-reperfusion phases. An eXtreme Gradient Boosting (XGBoost) model was trained to predict outcomes, and SHapley Additive exPlanations (SHAP) were used to identify the most influential predictors.

Results: Among the 229 patients included, 101 (44.1%) achieved an mRS score of ≤2. Increased time spent with mean arterial pressure <80 mmHg and systolic blood pressure <140 mmHg before reperfusion was associated with unfavorable outcomes. Elevated intraoperative heart rate in the same phase also emerged as a strong marker of poor prognosis. The model demonstrated good predictive performance (AUC ROC = 0.85) with internal validation.

Conclusions: These findings highlight distinct intraoperative hemodynamic patterns associated with outcome after thrombectomy under general anesthesia and support further investigation into heart rate as a relevant physiological indicator during anesthetic care.

Introduction: Mixed cardiogenic-vasodilatory shock carries high mortality. Vasopressin and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are used in refractory cases, but evidence on the optimal timing of vasopressin initiation remains limited.

Methods: This bicentric retrospective cohort study included 480 patients with mixed shock treated with vasopressin (n = 191) and VA-ECMO. Patients were categorized into no vasopressin (n = 289), early (<6 hours after VA-ECMO initiation; n = 98), and late (≥6 hours; n = 93) vasopressin groups. The primary outcome was new-onset or worsening AKI within 30 days. Analyses included multivariate logistic regression and propensity score-based inverse probability of treatment weighting (IPTW).

Results: Early vasopressin recipients had higher baseline norepinephrine-equivalent requirements than late vasopressin group and no vasopressin group (1.12 µg kg^-1 min^-1 [0.41;2.29] vs. 0.55 µg kg^-1 min^-1 [0.17;1.20], vs. 0.33 µg kg^-1 min^-1 [0.12;0.90], p < 0.001). In the overall cohort, early vasopressin use was associated with lower AKI incidence (49 patients (50.0%) vs. 216 patients (74.7%) %), and 49 patients (50.0%) vs. 73 patients (78.5%), p = 0.001), compared to no vasopressin use. The association was confirmed with unadjusted (OR: 0.35 [CI₉₅%: 0.21-0.59], p =  0.001 vs. no vasopressin use), and adjusted multivariate logistic regression (OR: 0.42 [CI₉₅%: 0.231-0.771], p =  0.005 vs. no vasopressin use). The rate of digestive ischemia and mortality did not differ between the three groups of patients.

Conclusions: Early vasopressin administration in VA-ECMO-supported mixed shock may reduce the incidence of acute kidney injury compared with no vasopressin use, without increasing adverse events. Prospective studies are warranted to confirm these findings and to determine the optimal timing of vasopressin therapy in this high-risk population.

Background: When cricoid pressure was introduced in pediatric anesthesia, the cricoid force was not defined, leading pediatric anesthesiologists to question its necessity, effectiveness, and safety. We hypothesized that airway complications encountered in clinical practice may have resulted from the exertion of excessive cricoid force.

Methods: Using a novel instrument, we measured cricoid force during Glidescope® videolaryngoscopy in three groups of 40 anesthetized children: Group 1 (3 to 5 years), Group 2 (6 to 8 years), and Group 3 (9 to 14 years). A biased-coin up-and-down design was employed to estimate the median force required to prevent the insertion of a suction catheter into the esophagus.

Results: There were no instances of difficult endotracheal intubation. The median cricoid force required to prevent suction catheter insertion into the esophagus in 90% of patients was 4.85 Newton (N) (95% CI 4.12 to 7.34) in Group 1, 8.74 N (95% CI 8.30 to 9.73) in Group 2, and 13.0 N (95% CI 11.2 to 16.9) in Group 3.

Conclusions: Age-appropriate cricoid force applied under videolaryngoscopic guidance effectively occludes the esophageal entrance without compromising endotracheal intubation. These forces are substantially lower than the thresholds known to cause airway distortion or obstruction in children and are lower than the force recommended for adults. These findings may have implications for the use of cricoid pressure as a component of the rapid sequence intubation (RSI) technique in children at risk of pulmonary aspiration.

Trial registration: ClinicalTrials.gov (NCT05290844).

Introduction: Intraoperative hypoxemia is a frequent complication during one-lung ventilation (OLV) and may contribute to postoperative morbidity. Although hypoxemic events are often transient, their cumulative physiological impact remains poorly understood. This study evaluated the association between cumulative hypoxemia during OLV and postoperative pulmonary complications in patients undergoing lung surgery.

Methods: We conducted a retrospective cohort study of adult patients (≥18 years) who underwent thoracic surgery with OLV between January 2017 and February 2022. Cumulative hypoxemic burden was calculated as the area under the curve (AUC) below a peripheral oxygen saturation (SpO₂) of 90% using trapezoidal integration. The primary outcome was a composite of severe pulmonary complications, including reintubation, prolonged mechanical ventilation, acute respiratory distress syndrome, extended non-invasive ventilatory support, and pneumonia. Multivariable logistic regression analysis was used to assess associations with outcomes, adjusting for potential confounders based on univariate analysis and biological plausibility.

Results: A total of 2,748 patients were included in this cohort, of which 60% underwent lung wedge resections, 25% lobectomies, and 14% segmentectomies. The incidence of severe pulmonary complications was 2.5%. In multivariable analysis adjusting for confounders, AUC of SpO₂ < 90% was independently associated with the composite outcome with an estimated odds ratio (OR) of 1.21 (95% confidence interval [CI] 1.02 - 1.44) per 1% x hour increase in AUC (Fig. 2). There was no significant association between AUC of hypoxemia and secondary outcomes such as acute kidney injury (OR 1.14, 95%CI 0.96 - 1.36, P = 0.130), atrial fibrillation (OR 0.94, 95%CI 0.71 - 1.25, P = 0.680), delirium (OR 1.10, 95%CI 0.82 - 1.48, P = 0.523), and five-year all-cause mortality (hazard ratio 0.95, 95%CI 0.77-1.17, P = 0.620).

Conclusions: Cumulative hypoxemia during OLV is independently associated with increased risk of severe postoperative pulmonary complications. Prolonged hypoxemia (≥ 30 min) may be clinically significant and portend pulmonary complications. Further studies are warranted to explore features mediating this association.

Objective: Sometimes, there is an urgent need to administer inhaled adrenaline to children, awake, sedated or anaesthetised to treat asthma, bronchospasm, croup, and suspected laryngeal/pharyngeal oedema or stridor, which can become severe or even life-threatening. To better inform emergency dosing and administration guidelines, we aimed to quantify the amount of adrenaline delivered for inhalation from a nebuliser, in a simulated experimental delivery set-up for spontaneously breathing children and adults, either via an anaesthetic face mask, a Laryngeal Mask Airway (LMA) or an Endotracheal tube (ETT).

Methods: Adrenaline was delivered using a jet or vibrating-mesh nebuliser as per standard hospital protocols for each patient's weight: 3, 12, 30 and 75 kg, using age and weight-appropriate LMA, ETT or facemask, and collected on a filter to represent the inhaled dose. Adrenaline was rinsed from the filter and stored at 4 degrees Celsius until quantified using liquid chromatography.

Results: The facemask delivered a smaller inhaled mass percentage (2-10%) compared to an LMA (8-15%) with any patient weight (p < 0.001), and an ETT (12-32%) delivered 2 times more than an LMA (p <  0.001).

Conclusion: The dose delivered using an LMA was approximately four times that of the facemask for infants and young children, and ETT was two times more than LMA. Future research should consider improving the delivery efficiency of nebulised adrenaline via LMA for children of all sizes in appropriate circumstances and investigate improving drug delivery to children via facemask, as well as the safety and efficacy of higher-dosage regimens.