Current Opinion in Anesthesiology最新文献

Purpose: The purpose of this review is to highlight important ethical aspects of informed consent in the unconsentable patient or participant.

Recent findings: Recent research and guidelines stress the need for detailed and honest communication respecting patient autonomy and the standards of informed consent. Emphasis is placed on full disclosure and guidance. This includes informing patients and participants of the use of data collected and individuals involved in therapy or research.

Summary: Informed consent is a legal process and there are standards that must be maintained. Whether in clinical practice before a procedure or therapy, or within research participation, informed consent must be obtained from individuals with mental capacity. However, in those who lack such capacity, an emergency exception can be used in dire situations but only once a concerted effort is made to locate a surrogate. Even so, the decision made must be in keeping with respecting the individual's prior known wishes.

Purpose of review: Penetrating firearm-related injury has increased mortality rates in children in the USA. This article summarizes trends in pediatric injury patterns, the unique coagulation system of infants, and key components of hemostatic resuscitation in children.

Recent findings: Firearm-associated penetrating trauma increased mortality and led to higher rates of pediatric massive transfusions. Patients may be the victim of previous gun violence or live with an adult who purchased a firearm for the first time during the COVID-19 pandemic. Platelet dysfunction and hypocalcemia are important considerations that may lead to higher transfusion requirements if not addressed. Pediatric massive transfusion protocols have become more standardized, and the use of whole blood has increased. Low-titer group O whole blood has shown benefit to improve coagulopathy and shock-associated indices when compared with conventional component therapy.

Summary: Traumatic hemorrhage is potentially life-threatening in children and requires prompt hemostatic resuscitation. Massive transfusion protocols that target trauma-induced coagulopathy and account for the unique pediatric coagulation system are imperative. Ongoing and future research is important to standardize pediatric resuscitation practices.

Purpose of review: In recent years, initiation techniques for neuraxial labor analgesia have focused on enhancing analgesic quality while minimizing complications. This review aims to summarize recent evidence on the standard epidural (EPL), combined spinal-epidural (CSE), and dural puncture epidural (DPE) techniques, emphasizing their benefits, risks, and relevance in contemporary obstetric anesthesia care.

Recent findings: The DPE technique offers unique values, combining the advantages from CSE and EPL techniques. DPE and CSE, compared with EPL, techniques involve a dural puncture with a spinal needle, and the resulting epidural-intrathecal conduit enables translocation of analgesic agents, providing faster onset, earlier sacral coverage, better catheter function, and more rapid epidural extension to surgical anesthesia. Moreover, by limiting the intrathecal dose administered with the CSE technique, the DPE technique lowers the risks of fetal bradycardia and pruritus.

Summary: EPL and CSE techniques are widely used for neuraxial labor analgesia. The DPE technique offers a novel alternative, delivering high-quality analgesia with minimal complications. While the benefits of the DPE technique are increasingly being recognized, additional comparative research will better support anesthesiologists in selecting the most appropriate technique across diverse clinical scenarios.

Purpose of review: Although less common than in adults, pediatric organ transplantation has seen significant recent innovations in surgical techniques, perioperative management, and postoperative outcomes. These advances, which we will delve into in this review, are at the forefront of improving the survival and quality of life of pediatric transplant recipients.

Recent findings: Advances in donor utilization (e.g. donation after circulatory death and split-liver grafts) and surgical approaches (partial heart transplants and novel multiorgan procedures) have expanded the donor pool and enhanced graft viability. Improved perioperative care, including refined anesthetic monitoring, fluid management, and immediate extubation, reduces the incidence of complications. Research into model-informed precision dosing for antibiotics addresses under- or overdosing in critically ill children, whereas emerging immunosuppressants offer potential benefits over conventional regimens. Nonetheless, coagulopathy, hemodynamic instability, and developmental variations remain major challenges.

Summary: Optimization of pediatric transplantation is a complex task that requires multidisciplinary collaboration. This review underscores the importance of standardizing perioperative protocols, advancing precision medicine, and refining surgical and anesthetic techniques. It also highlights the need for dedicated pediatric transplant registries and multicenter trials to generate robust data, minimize practice variability, and improve outcomes.

Purpose of review: Pain during cesarean delivery (PDCD) has been overlooked and underreported and is associated with a traumatic birth experience and long-term morbidity. We review the studies reporting on PDCD and summarize available guidance providing roadmaps for anesthesiologists caring for patients during cesarean delivery.

Recent findings: PDCD is a patient-reported outcome and should not be defined by interventions mitigating insufficient neuraxial anesthesia, such as supplemental analgesic medication or general anesthesia. Depending on the cohorts studied and definitions used, current reported rates of PDCD range between 2 and 36%. Preoperative patient counseling, risk stratification, and testing of neuraxial block are mitigating strategies; ultimately, if pain occurs, it should be managed skillfully applying shared decision-making with a supportive follow-up to reduce psychological trauma. Statements from three international organizations offer guidance to prevent and treat PDCD.

Summary: This review provides strategies to mitigate the occurrence of PDCD, with targeted approaches to better prevent and manage PDCD.

Purpose of review: This review provides an updated overview of neonatal resuscitation practices relevant to obstetric anesthesiologists, with a focus on term and late preterm neonates (>34 weeks' gestation). Key topics include umbilical cord management, temperature regulation, airway strategies, and pharmacological interventions, emphasizing evidence-based approaches.

Recent findings: Delayed cord clamping enhances neonatal outcomes, including improved blood volume and oxygenation. Positive pressure ventilation remains the cornerstone of neonatal resuscitation, with early initiation reducing mortality. Supraglottic airways are emerging as effective alternatives to face masks. Advances in epinephrine administration and dosing show promise, though evidence gaps persist. Simulation-based training, telemedicine, and artificial intelligence are advancing skill retention and resuscitation support.

Summary: Recent advancements in neonatal resuscitation focus on precision in ventilation, thermoregulation, and airway management. Obstetric anesthesiologists play a critical role in neonatal emergencies, underscoring the need for continuous training and the integration of emerging technologies like artificial intelligence to optimize neonatal outcomes.

Purpose of the review: The aim is to provide a comprehensive review of regional anesthesia techniques to control ventricular arrhythmias.

Recent findings: While promising, the use of stellate ganglion block (SGB) for arrhythmia control is still under investigation, and further clinical trials are warranted to fully understand its efficacy, long-term outcomes, suitable patient group, and safety profile. Nevertheless, it remains a potential adjunctive therapy in the management of ventricular arrhythmias in select patients. Continuous stellate ganglion block (C-SGB) offers an alternative to single-shot SGB and thoracic epidural anesthesia for effective management in the reduction of ventricular arrhythmias until definitive treatment; it is safe and may reduce the need to repeat the single-shot block.

Summary: SGB has been described in the literature as a successful adjunct therapy to reduce arrhythmia load. Blocking the stellate ganglion can provide transient sympathetic blockade for controlling refractory ventricular arrhythmias, otherwise uncontrolled with medication management. By regulating the sympathetic nervous system, the stellate ganglion affects the electrical conductance of the heart, and thus inhibition of the ganglion can modulate the autonomic balance with subsequent reduction in ventricular arrhythmias. These studies until 2017 were limited to case reports and case series; meta-analysis by Fudim et al . supports the use of left-sided SGB to manage ventricular arrhythmias. Recent clinical trials further strengthen the findings and favor the trend of catheter use for continuous SGB. Further studies are warranted to identify suitable patient groups and when to initiate SBG or C-SGB.

Purpose of review: The review provides a comprehensive analysis of coaching within residency training programs, with a focus on examining foundational theoretical frameworks, exploring implementation strategies, and evaluating the impacts on learner competencies and overall well-being. The analysis aims to bridge gaps in the current lack of anesthesiology coaching literature and provide evidence-based insights to optimize the role of coaching in medical education and professional development.

Recent findings: Coaching programs emphasize learner-centered education and the facilitation of professional growth. This review examines various coaching models, including communication-focused coaching, near-peer coaching, and the PRACTICE framework. The successful implantation of these models requires tailoring to the learner group to mitigate challenges and optimize acquisition of competencies, such as enhanced technical proficiency and communication skills. Evidence from coaching programs in nonanesthesiology specialties highlights their adaptability and potential applicability to the training of anesthesiology residents.

Summary: Coaching programs in medical education show promise for adaption to anesthesiology, addressing its unique demands. Tailored approaches can improve technical skills, communication, and resident well-being. Embedding coaching within competency-based frameworks, tied to milestones and entrustable professional activities supports professional development and educational goals. Successful implantation depends on faculty training, interdepartmental collaboration, and ongoing evaluation, ensuring that coaching programs enhance resident performance and ultimately improve patient outcomes.

Purpose of review: Fetal surgery has evolved into a transformative field, offering hope for the management of complex prenatal conditions. The purpose of this review is two-fold: to provide a brief overview of fetal anesthetic considerations, and to examine recent advancements which have significantly improved maternal safety and expanded the scope of treatable fetal anomalies.

Recent findings: Enhanced imaging technologies, such as high-resolution ultrasound and fetal MRI, have enabled precise diagnoses and surgical planning to improve outcomes. Innovations in techniques, expanded indications for fetal surgery, and adoption of maternal anesthesia protocols have all helped to minimize complications and enhance recovery. Placental research shows no immune response or pathology from fetal surgery, suggesting it does not contribute to preterm delivery.

Summary: Advancements in fetal intervention collectively underscore the field's commitment to delivering optimal outcomes for both mother and child while paving the way for future breakthroughs in prenatal care.

Purpose of review: Cancer burden remains a global medical and financial challenge. Advances in surgical management have resulted in increased oncological surgeries that often involve anesthetic administration. This review aims to inform on anesthetic considerations when caring for cancer patients in the perioperative period.

Recent findings: There are various retrospective studies and, more recently, several randomized controlled trials that have explored whether the choice of anesthesia (total intravenous anesthesia vs. inhaled anesthetic) results in a significant difference in cancer outcomes, mortality, cancer recurrence, and metastasis. To date, no definitive proof has been made, and the current conclusion remains that the anesthetic technique does not influence survival or overall long-term outcomes.

Summary: Comprehensive risk assessment is essential in cancer patients before elective surgeries due to a variety of concerns such as malnutrition, aspiration risk, postradiation airway compromise, and antineoplastic systemic effects. Oncologic patients' exposure to chemotherapy and radiation causes immunosuppression and multiorgan toxicity that places them at increased perioperative risk for morbidity and mortality. Other concerns include the challenges of adequate pain management and pre-existing chronic pain.