Anaesthesia Critical Care & Pain Medicine最新文献

Background: Mechanical ventilation and selecting optimal positive end-expiratory pressure (PEEP) in patients across a wide range of body mass indexes (BMI) is challenging. Adjusting PEEP to BMI using the equation BMI divided by 3 ('BMI / 3') or setting a PEEP of 10 cmH₂O in obesity has been proposed; our objective is to describe the difference between 'BMI / 3' and PEEP 10 cmH₂O as compared to optimal PEEP by esophageal manometry.

Methods: Esophageal manometry was used in patients undergoing laparoscopic abdominal surgery to estimate pleural pressure, transpulmonary pressure, and optimal physiological PEEP across a range of BMIs. Methods of estimating optimal PEEP in patients with normal and elevated BMI, namely 'BMI / 3' and PEEP of 10 cmH₂O, were compared to estimates of optimal physiological PEEP as measured by an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cmH₂O.

Results: A total of 109 patients were included for analysis. Thirty-seven percent had 'BMI / 3' estimated PEEP values within ±2 cmH₂O of optimal physiological PEEP measured by esophageal pressure-based transpulmonary pressure. A set PEEP of 10 cmH₂O correctly estimated optimal physiologic PEEP (± 2 cmH₂O) in only 27% of patients. The mean optimal physiologic PEEP measured by esophageal pressure-based transpulmonary pressure is closely approximated by the mean estimated PEEP derived by 'BMI / 3'. However, the ranges of individualized optimal physiologic PEEP are wider than PEEP estimated by 'BMI / 3' across BMI categories.

Conclusions: BMI / 3' estimated the mean optimal PEEP as measured by esophageal pressure-based transpulmonary pressure and may serve as a starting point for PEEP in patients with increased BMI. However, this purely anthropometric method fails to capture the individual variability of the chest wall and pleural pressure and most often results in inadequate or excessive PEEP as compared to optimal PEEP based on esophageal manometry.

Background: Post-induction hypotension (PIH) is a frequent complication of general anesthesia, especially with propofol, and may result from systemic vasodilation, reduced cardiac output, and decreased myocardial contractility. Given the superficial location and ease of access of the brachial artery, we hypothesized that Doppler-derived indices of the brachial artery could serve as early predictors of PIH.

Methods: In this prospective observational study, 90 ASA I adult patients (aged 20-60 years) undergoing abdominal or pelvic surgery were evaluated. Doppler ultrasound of the right brachial artery was performed before and after the induction of anesthesia. The pulsatility index (PI) and resistive index (RI) were analyzed using the autotrace function. Simultaneously, the waveform was evaluated for the change in shape from a triphasic pattern to a monophasic wave (ΔM). PIH was defined as a >20% decrease in the mean arterial pressure within 10 min of induction.

Results: PIH occurred in 39% of the patients. Both PI and RI decreased following induction, with significantly greater reductions in hypotensive patients. Baseline PI demonstrated good predictive ability for PIH, with an area under the curve (AUC) of 0.86 and an optimal cutoff value of >5.22. Dynamic changes in ΔPI, ΔRI, and ΔM showed strong predictive accuracy, with AUCs of 0.93, 0.83, and 0.92, respectively. The optimal thresholds were 13.6% for ΔPI and 12% for ΔRI, respectively. Notably, the presence of waveform morphological changes from a triphasic to a monophasic pattern predicted PIH with 100% sensitivity and 84% specificity.

Conclusion: Among adult patients undergoing abdominal or pelvic surgery, dynamic changes in brachial artery Doppler indices, specifically a ΔPI greater than 21% and a ΔRI > 12%, demonstrated a strong predictive value for PIH. Additionally, the baseline PI was a reliable predictor of PIH, with a cutoff value of >5.22. Notably, the transition in waveform morphology from a triphasic to monophasic pattern confirmed the occurrence of PIH with 100% sensitivity and 84% specificity.

Background: Chronic postsurgical pain (CPSP) affects up to 60% of breast cancer surgery patients, substantially impairing quality of life. Although erector spinae plane block (ESPB) provides effective acute analgesia with superior safety compared to traditional regional techniques, its efficacy in preventing CPSP remains unclear. This trial evaluated whether preoperative single-injection ESPB prevents CPSP following breast cancer surgery.

Methods: This double-blind, randomized controlled trial enrolled 198 women undergoing unilateral breast cancer surgery in China. Patients received ultrasound-guided ESPB with either 30 mL of 0.5% ropivacaine or placebo at the T5 level before general anesthesia. The primary outcome was CPSP incidence at three months. Secondary outcomes included six-month CPSP incidence, 24 -h morphine consumption, postoperative pain scores, and recovery quality.

Results: ESPB did not reduce CPSP incidence at three months [primary outcome: 38/ 99 (38.4%) versus 43/99 (43.4%); relative risk 0.88, 95% confidence interval (CI) 0.63 to 1.24, p = 0.470] or six months [23/99 (23.2%) versus 31/99 (31.3%); relative risk 0.74, 95% CI 0.47 to 1.18, p = 0.202]. However, ESPB reduced 24-hour morphine consumption (median 8.0 mg [interquartile range (IQR) 4.0 to 12.0] versus 18.0 mg [IQR 14.0 to 22.0]; median difference -10.0 mg, 95% CI -10.0 to -8.0, p < 0.001) and acute pain scores at rest and during movement (both p < 0.001). One ESPB patient (1/99, 1.0%) experienced transient metallic taste. No serious adverse events occurred.

Conclusions: Single-injection ESPB does not prevent CPSP after breast cancer surgery. ESPB should be used exclusively for acute postoperative analgesia and cannot be recommended for CPSP prevention.

Registration: Chinese Clinical Trial Registry (ChiCTR1900027772).

Introduction: In thoracic surgery, all respiratory muscles have a significant increase in workload, and recruitment of these muscles may be important, especially in the presence of diaphragmatic dysfunction. Evaluating diaphragmatic and expiratory muscles ultrasound measurements as potential predictors of postoperative pulmonary outcome.

Methods: Prospective observational study conducted in a single university hospital. We enrolled 101 adult patients aged ≥ 65 years scheduled for elective pulmonary lobectomy. Preoperative ultrasonographic assessments of respiratory muscles were performed, including diaphragm thickness and thickening fraction, diaphragmatic excursion, total thickness of expiratory muscles, and total thickness of accessory respiratory muscles. Respiratory function tests, postoperative complications, and vital status were also recorded. Patients were then compared according to the occurrence or absence of postoperative respiratory complications.

Results: Thickness of diaphragm (2.4 [2.0;2.9] vs. 2.8 [2.2;3.6], p = 0.020), expiratory muscles (12.5 ± 3.8 vs. 14.2 ± 3.5, p = 0.028), and accessory muscles (34.2 ± 7.5 vs. 37.2 ± 5.7, p = 0.027) are significantly higher in patients with post-operative pulmonary complications. Diaphragm thickening fraction is higher in patients with respiratory complications 52% [32;89] vs. 76% [48;106], p = 0.019. Nevertheless, diaphragm excursion remains the same in both groups. Pulmonary function tests were associated with poor outcomes.

Conclusions: An increase in mass and function of the respiratory muscle was more frequent in patients with decreased Respiratory Functional Explorations. This increase did not reduce the prevalence of post-operative pulmonary complications.

Registration: ClinicalTrials.gov (NCT05146908).

Background: Even though tremendous effort has been undertaken within the past 40 years, both sepsis incidence and mortality remain high. The concept of various immune responses in sepsis, ranging from immune paralysis to severe hyperinflammation, has gained more and more attention. As such, the hyperinflammatory phenotype macrophage activation-like syndrome (MALS) became the cornerstone in the latest intervention trials. Our study sought to systematically investigate MALS patients, including their definitions, respective bone marrow markers and monocytic HLA-DR expressions.

Methods: In this secondary analysis of a retrospective observational study, we included all patients aged ≥18 years and admitted to any adult ICU at Charité - Universitätsmedizin Berlin between January 2006 and August 2018, who had hyperferritinemia (≥500 μg/L) and sepsis, but no diagnosis of hemophagocytic lymphohistiocytosis. For diagnosis of MALS, we used the latest definition of ferritin ≥4420 µg/L.

Results: 1629 patients were included, of whom 322 were diagnosed with MALS (19.8 %). In-hospital mortality was 62.4 % in MALS patients compared to 30.5 % in those without MALS. MALS patients had increased macrophage counts and higher rates of activated macrophages in bone marrow biopsies. HLA-DR expression did not differ significantly between the groups. In multivariable logistic regression analysis, MALS showed the highest odds ratio associated with in-hospital mortality. Different definitions of MALS identified largely distinct patient populations.

Conclusions: MALS increased in-hospital mortality in sepsis patients. Our results underscore the urgent need for targeted research and therapeutic strategies. While promising insights into immune modulation have emerged, further studies are essential to refine treatment approaches and improve outcomes in this vulnerable patient population.