Current Opinion in Anesthesiology最新文献

To update published data about adjuvants and examine their evolution in use over the last 2 years. This scoping review highlights current and updated published evidence on using adjuvants and future research directions.Regional techniques (including peripheral nerve blocks) have become relevant for pain relief and postoperative quality recovery. Examples of adjuvant drugs for regional techniques include dexamethasone, alpha-2 agonists, buprenorphine, ketamine, magnesium, and so on. Adding adjuvants we can modify the characteristics of the blocks. We have made significant progress in understanding the mechanism of action of specific adjuvants, and we made a summary. Considering the review above, it can be observed that there has been an increasing trend in recent years to publish articles on dexmedetomidine; however, interest in dexamethasone may wane because of the moderate evidence. It is interesting to note that there has been an increase in the number of studies involving the use of opioids as adjuvants. All adjuvants have shown different levels of efficacy.Understanding the role of adjuvants is crucial to better pain control, as well as using a less local anaesthetic or less analgesic drugs. Despite the increasing number of articles on dexmedetomidine, the evidence remains lower than that for dexamethasone.

Purpose of review: Artificial intelligence (AI) represents a transformative opportunity for pain medicine, offering potential solutions to longstanding challenges in pain assessment and management. This review synthesizes the current state of AI applications with a strategic framework for implementation, highlighting established adaptation pathways from adjacent medical fields.

Recent findings: In acute pain, AI systems have achieved regulatory approval for ultrasound guidance in regional anesthesia and shown promise in automated pain scoring through facial expression analysis. For chronic pain management, machine learning algorithms have improved diagnostic accuracy for musculoskeletal conditions and enhanced treatment selection through predictive modeling. Successful integration requires interdisciplinary collaboration and physician coleadership throughout the development process, with specific adaptations needed for pain-specific challenges.

Summary: This roadmap outlines a comprehensive methodological framework for AI in pain medicine, emphasizing four key phases: problem definition, algorithm development, validation, and implementation. Critical areas for future development include perioperative pain trajectory prediction, real-time procedural guidance, and personalized treatment optimization. Success ultimately depends on maintaining strong partnerships between clinicians, developers, and researchers while addressing ethical, regulatory, and educational considerations.

Purpose of review: Artificial intelligence (AI) is having an increasing impact on healthcare. In ultrasound-guided regional anesthesia (UGRA), commercially available devices exist that augment traditional grayscale ultrasound imaging by highlighting key sono-anatomical structures in real-time. We review the latest evidence supporting this emerging technology and consider the opportunities and challenges to its widespread deployment.

Recent findings: The existing literature is limited and heterogenous, which impedes full appraisal of systems, comparison between devices, and informed adoption. AI-based devices promise to improve clinical practice and training in UGRA, though their impact on patient outcomes and provision of UGRA techniques is unclear at this early stage. Calls for standardization across both UGRA and AI are increasing, with greater clinical leadership required.

Summary: Emerging AI applications in UGRA warrant further study due to an opaque and fragmented evidence base. Robust and consistent evaluation and reporting of algorithm performance, in a representative clinical context, will expedite discovery and appropriate deployment of AI in UGRA. A clinician-focused approach to the development, evaluation, and implementation of this exciting branch of AI has huge potential to advance the human art of regional anesthesia.

Purpose of review: This review is timely as it addresses the ongoing challenge of developing an ideal short-acting, nondepolarizing muscle relaxant. It emphasizes the need for agents that combine a rapid onset, brief duration of action, and a favorable safety profile-paralleling succinylcholine's speed while reducing adverse effects.

Recent findings: Recent investigations have identified promising compounds such as gantacurium and its analogs (CW002 and CW001), which enable rapid reversal of neuromuscular blockade via L-cysteine-mediated chemical antagonism. In addition, novel encapsulation agents such as sugammadex and calabadions have emerged, offering dose-dependent and effective recovery of neuromuscular transmission even at deeper levels of blockade, with minimal hemodynamic impact.

Summary: The emerging data suggest that these novel agents could significantly enhance clinical outcomes by improving the precision and safety of neuromuscular blockade management during surgery. Further research is warranted to optimize dosing protocols and verify long-term safety, potentially leading to refined anesthetic practices and better postoperative recovery.

Purpose of the review: The purpose of this review is to explore emerging pharmacological strategies for neuromuscular blockade (NMB) reversal, focusing on their mechanisms of action, efficacy, and potential advantages over existing agents like sugammadex and neostigmine.

Recent findings: Several novel reversal agents are under investigation: calabadions, synthetic molecular containers that effectively reverse aminosteroidal and benzylisoquinolinium neuromuscular blocking agents (NMBAs) with rapid clearance; l -cysteine adduction, a promising method for reversing ultrashort-acting NMBAs by accelerating metabolism; adamgammadex, a modified γ-cyclodextrin with improved binding to rocuronium and reduced hypersensitivity risks, showing noninferiority to sugammadex; acyclic cucurbit[ n ]urils, broad-spectrum reversal agents with superior water solubility and biocompatibility; and ClC-1 channel blockers, a novel approach that enhances muscle excitability rather than directly binding to NMBAs.

Summary: Emerging NMBA reversal agents offer potential improvements in safety, efficacy, and broader NMBA compatibility. These alternatives to sugammadex and neostigmine show promise in preclinical and early clinical trials. Further studies are necessary to confirm their clinical applicability and regulatory approval.

Purpose of the review: This review will discuss the current pharmacologic strategies for mitigation of perioperative myocardial injury. State-of-the-art benefits and harms of pharmacologic interventions to delineate knowledge gaps in current guidelines and clinical practice will be presented.

Recent findings: Beta-blockers are known to reduce major adverse cardiac events but inappropriate preoperative initiation results in adverse outcomes. Renin-Angiotensin-Aldosteron System (RAAS) inhibitors once universally discontinued before surgery are now under reconsideration as continuation seems not to be associated with increased risk. Statins continue to be the cornerstone due to their pleiotropic effect. Continuation of aspirin is supported perioperatively if the bleeding risk due to surgery is low to moderate. A few studies have investigated a strategy of strict intraoperative blood pressure control but failed to observe a meaningful effect on outcome. Whether prompt intensification of treatment in case of diagnosis of myocardial injury after noncardiac surgery improves outcome remains to be established. Since the MANAGE trial, no new studies have prospectively addressed this question.

Summary: New data have questioned previous ideas and suggest a more nuanced, personalized approach to perioperative management. Accordingly, future studies should address refinement in risk stratification, optimization of pharmacologic strategies, and the development of novel therapies in attempting to enhance outcomes in high-risk surgical populations.

Purpose of review: Remimazolam represents a novel intravenous anesthetic agent whose use began in 2020. As a new ultrashort-acting benzodiazepine, it has unique pharmacokinetic properties, such as remifentanil, designed to be active and easily transformed into inactive metabolites by tissue esterases. The purpose is to search the literature and evidences to use this new medication in neurosurgery.

Recent findings: Currently, it is allowed for procedural sedation and general anesthesia in a few countries. More advantages of this new drug are predictable onset, short duration, rapid recovery profile, low liability for respiratory depression, cardiovascular depression, lack of injection pain, and known reversible agent, flumazenil. A literature search led to the conclusions that remimazolam may maintain better hemodynamic stability and reduce the episodes of hypotension during coil embolization of cerebral aneurysm and that general anesthesia with remimazolam does not alter cerebral metabolism, cerebral blood flow, and cerebral blood volume. Also, because it facilitates safe and quick arousal, it can be a suitable medication for awake craniotomy.

Summary: With more desirable properties such as reduced risk of prolonged sedation and reliable safety margin, it is expected to increase the safety of sedation and general anesthesia in future.

Purpose of review: Maintaining hemostasis in pediatric patients undergoing major surgery presents unique challenges for the anesthesiologist. This review presents the most recent updates on pediatric perioperative bleeding and hemostasis management.

Recent findings: Patient blood management (PBM) programs remain scarcely implemented, but recent evidence for restrictive transfusion thresholds and reduction in allogeneic blood products in the pediatric population is growing. Notable updates include support for pediatric PBM programs, restrictive transfusion thresholds, increased use of viscoelastic testing, safety and efficacy of whole blood, and management of coagulopathy in trauma.

Summary: PBM programs and their key components have gained traction in the pediatric population in recent years: treating preoperative anemia, optimizing coagulation, and tolerating physiologic anemia through restrictive transfusion thresholds. Further evidence in the pediatric population is needed to guide the anesthesiologist.

Purpose of the review: The collection and analysis of large amounts of data has revolutionized almost every aspect of our lives. In this review, we will explore several of the databases that are providing data on pediatric anesthesiology practice and the recent reports that have been published.

Recent findings: Studies from various multicenter databases provide information on outcomes from multiple aspects of pediatric anesthesia care provision. Large databases or registries include detailed information on individual anesthetic practice, airway management, regional anesthetic practice, adverse events, and cardiac anesthesia. These collaboratives are also providing information on health systems and benchmarking of effectiveness and efficiency of care.

Summary: For medical professionals, the ability to collect and learn from large datasets is not new but continues to evolve and improve as technology improves and the science of data analytics has been revolutionized. While the detail and accuracy of observational large data collaboratives may be limited, their ability to describe practice patterns, provide benchmarking for performance, and analyze outcome parameters has the potential to revolutionizing the practice of anesthesia in the future.

Purpose of review: Telehealth is a popular way for health care providers to connect with patients and is utilized by anesthesiologists across the world for preoperative evaluations. The purpose of this review is to outline the latest literature about telehealth use within obstetric anesthesia.

Recent findings: Utilization of telehealth significantly increased during the Coronavirus disease 2019 (COVID-19) pandemic and has proven to be a useful and reliable way to conduct antenatal obstetric anesthesia consultations in high-risk patient groups. Recent publications indicate the reliability and utility of telehealth, especially to reach remote patient populations. This can help anesthesiologists reach patients referred to tertiary centers from remote areas, which can improve the quality and safety of patient care. Furthermore, with hospital-provided infrastructure, the majority of obstetric patients are able to connect with providers via telehealth.

Summary: Obstetric anesthesiologists play a pivotal role in the perioperative planning for high-risk pregnant women, and telehealth can serve as a tool to make this easier and more efficient with high patient and provider satisfaction.