Current Opinion in Anesthesiology最新文献

Purpose of review: Postoperative delirium (POD) is a common and serious complication after surgery. It is associated with postoperative neurocognitive disorder (PNCD). The vagal cholinergic anti-inflammatory pathway (CAP) has been hypothesized to play a role in POD/PNCD and may be a target for interventions such as transcutaneous auricular stimulation (taVNS). We aim to review associations of heart rate variability (HRV) as an indicator of vagal function with POD and postoperative immune reaction as well as taVNS as a potential preventive intervention for POD.

Recent findings: Autonomous nervous system (ANS) dysfunction was a common finding in studies analysing HRV in POD and postoperative cognitive dysfunction, but results were heterogeneous. There was no evidence from HRV analysis that vagal activity prevents overshooting postoperative immune activation, but HRV may help to identify patients at risk for postoperative infections. Animal studies and preliminary trials suggest that taVNS may be used to prevent POD/PNCD.

Summary: Our review provides no evidence that CAP suppression is associated with POD/PNCD. Future studies should consider that high vagal tone may also mediate immunosuppression in surgical patients, yielding an increased risk for postoperative infections. Although taVNS is a promising approach to prevent POD/POCD, future studies should take these concerns into account.

Purpose of review: Circulatory and respiratory support with extracorporeal membrane oxygenation (ECMO) has gained widespread acceptance during high-end thoracic surgery. The purpose of this review is to summarize the recent knowledge and give an outlook for future developments.

Recent findings: A personalized approach of ECMO use is state of the art for monitoring during surgery. Personalization is increasingly applied during anesthesia for high-end surgery nowadays. This is reflected in the point of care testing (POCT) for anticoagulation and cardiac function during surgery on ECMO combining specific patient data into tailored algorithms. For optimizing protective ventilation MP (mechanical power) is a promising parameter for the future. These personalized methods incorporating numerous patient data are promising for the improvement of morbidity and mortality in high-end thoracic surgery. However, clinical data supporting improvement are not available to date but can be awaited in the future.

Summary: Clinical practice during surgery on ECMO is increasingly personalized. The effect of personalization on morbidity and mortality must be examined in the future. Undoubtedly, an increase in knowledge can be expected from this trend towards personalization.

Purpose of review: There is mounting and convincing evidence that patients with postoperative troponin elevation, with or without any clinical symptoms, are at higher risk for both, short- and long-term morbidity and mortality. Myocardial injury after noncardiac surgery (MINS) is a relatively newly described syndrome, and the pathogenesis is not fully understood yet. MINS is now an established syndrome and multiple guidelines address potential etiologies, triggers, as well as preventive and management strategies.

Recent findings: Surveillance in high-risk patients is required, as most MINS would otherwise be missed. There is no reliable and established preventive strategy, but several potentially avoidable triggers like hypotension, pain and anemia have been identified. Managing patients with MINS postoperatively includes minimizing triggers (such as hemodynamic abnormalities and anemia) that can continue the damage. Long-term pharmacologic strategies include beta-blockers, statins, antiplatelet agents, and anticoagulation.

Summary: MINS affects up to 20% of surgical patients, remains clinically mostly silent, but is associated with elevated morbidity and mortality. A multidisciplinary approach, that includes involvement of anesthesiologists, for the prevention, diagnosis, and treatment of MINS is recommended.

Purpose of review: Perioperative risk scores aim to risk-stratify patients to guide their evaluation and management. Several scores are established in clinical practice, but often do not generalize well to new data and require ongoing updates to improve their reliability. Recent advances in machine learning have the potential to handle multidimensional data and associated interactions, however their clinical utility has yet to be consistently demonstrated. In this review, we introduce key model performance metrics, highlight pitfalls in model development, and examine current perioperative risk scores, their limitations, and future directions in risk modelling.

Recent findings: Newer perioperative risk scores developed in larger cohorts appear to outperform older tools. Recent updates have further improved their performance. Machine learning techniques show promise in leveraging multidimensional data, but integrating these complex tools into clinical practice requires further validation, and a focus on implementation principles to ensure these tools are trusted and usable.

Summary: All perioperative risk scores have some limitations, highlighting the need for robust model development and validation. Advancements in machine learning present promising opportunities to enhance this field, particularly through the integration of diverse data sources that may improve predictive performance. Future work should focus on improving model interpretability and incorporating continuous learning mechanisms to increase their clinical utility.

Purpose of review: Although there are a lot of studies examining the effects of different blocks for postoperative analgesia after video-assisted thoracic surgery (VATS), the results are controversial.

Recent findings: Paravertebral block, serratus anterior plane block and erector spinae plane block appear to be effective and beneficial for post-VATS analgesia, but probably in different manners.

Summary: All three blocks can be suggested for daily practice, the choice should be based on personal experience and preference of the anesthetist. Better studies are required for objective decision.

Purpose of review: During treatment in the ICU, patients, relatives, as well as staff members are exposed to a variety of potentially traumatic experiences. The study explores current concepts to prevent negative effects on mental health resulting from intensive care treatment.

Recent findings: Most healthcare systems rely on consultation or liaison services to address mental health issues provided by mental health experts based outside of the ICU. Those services usually react to manifest comorbid mental conditions, but are less effective to prevent mental health issues. Integrated psychosocial support (IPS) models acknowledge the fact that psychosocial demands are inherent to ICU treatment rather than an individual concern. First experiences support the assumption that clinical psychologists embedded within the ICU team effectively address the need of early identification of mental health issues, and are able to intervene timely and appropriately to traumatic events on the unit. They professionalize psychosocial support structures and facilitate low-threshold support for team members.

Summary: Psychologists integrated in the ICU team can effectively target psychosocial needs of patients and relatives with varying complexity. They support the ICU team by taking on those tasks, and contribute to the overall resilience of the ICU team and its members.

Purpose of review: Climate change is the biggest threat to human health and survival in the twenty-first century. Emissions associated with healthcare contribute to climate change and there are many personal and professional actions that can reduce carbon emissions. This review highlights why action is necessary and what anaesthetists and healthcare workers can do.

Recent findings: Encouraging continuing research regarding sustainable anaesthesia and expanding education at all levels to include climate action is key. Professionally, actions include limiting use of single-use equipment, reducing reliance on volatile gas inhalational anaesthesia, and adopting low fresh gas flow techniques. Personal actions such as climate-conscious travelling, spending, and eating are important, especially when shared to create climate positive movements.

Summary: This article shows that, while patient safety and quality of care must remain healthcare's top priority, considering the climate implications of care is part of that duty. Many actions that reduce the carbon impact of care simultaneously improve the quality of care and reduce financial cost. More research into sustainable healthcare is needed. Departments and hospitals and must create environments in which climate conversations are welcomed and can result in positive advancements.

Purpose of review: Acute postsurgical pain after cardiac surgery is challenging to treat. Adverse effects related to the high dose opioids which have traditionally been used perioperatively in cardiac surgery have led to the adoption of alternative analgesic strategies. This review aims to highlight current evidence-based approaches to managing pain after cardiac surgery.

Recent findings: Current evidence and international guidelines support the use of multimodal analgesics for managing perioperative pain after cardiac surgery. Regional anaesthesia in the form of fascial plane blocks, such as the erector spinae plane and parasternal intercostal plane blocks, are effective and safe techniques for anticoagulated cardiac surgery patients. Transitional pain services are multidisciplinary programmes that bridge the gap between inpatient and outpatient care for these patients.

Summary: This paper reviews advancements in perioperative pain management for cardiac surgery patients, emphasising the shift from high-dose opioids to multimodal analgesia and regional anaesthetic techniques, and highlighting the role of multidisciplinary transitional pain services.

Purpose of the review: The mediastinal mass syndrome (MMS) can occur after induction of anesthesia, intraoperatively or even days after the surgical procedure. The focus of this review is on the management of pediatric and adult patients with a significant mediastinal mass.

Recent findings: The age distribution of patients with mediastinal lesions suggests a bimodal shape, with an increased incidence among children under 10 years old and adults aged 60-70 years old. The traditional approach to avoid general anesthesia and mechanical ventilation has been challenged recently. Induction of general anesthesia may be achieved by a titrated intravenous infusion of propofol, with the patient positioned in a semi-sitting position. Mechanical ventilation with a prolonged I:E ratio, low respiratory rate and rigid or flexible bronchoscopy to stent the obstructed airway can facilitate expiration of tidal volume. Continuous video bronchoscopy recordings of the compromised portion of the airway have shown that positive pressure ventilation and neuromuscular blockade can induce an increase in the mean airway patency score.

Summary: Meticulous planning, implementation of anesthetic management protocols and protocols for emergency situations are essential to guarantee patient safety with a mediastinal mass.