Current Opinion in Anesthesiology最新文献

Purpose of review: Neuroanesthesia presents unique challenges that require up-to-date knowledge in identification and management and multidisciplinary collaboration for optimal patient outcomes. This review paper aims to enhance the reader's understanding and preparedness for intraoperative emergencies based on current literature updates and consensus recommendations.

Recent findings: Recent findings in traumatic brain injury (TBI) emphasize the importance of controlling intracranial pressure (ICP) and maintaining cerebral perfusion. However, they also challenge the efficacy of sole ICP targeting interventions, suggesting potential benefits from multimodal monitoring approaches. In the context of acute stroke, recent randomized trials have demonstrated that general anesthesia (GA) compared with sedation techniques results in higher recanalization rates, with no significant difference in complications or long-term outcomes. Furthermore, multiple trials and a meta-analysis have shown that intensive blood pressure management following recanalization with endovascular therapy (EVT) offers no benefit and may impose harm when compared with conservative blood pressure targets.

Summary: Optimal management of neuroanesthetic emergencies requires up-to-date knowledge, training, and interdisciplinary coordination to ensure the best possible outcomes. Significant research effort has been devoted to advancing neuroanesthesia practice, so that in the last 2 years, several fundamental management questions have benefitted from randomized controlled trials (RCTs) from multiple groups, as well as meta-analyses of these RCTs. These address ICP and complementary physiologic monitoring for intracranial compartment syndrome after TBI, GA versus sedation for EVT, and postrecanalization blood pressure management. In this review, we have highlighted this important work as well as the next steps in further refining answers to these questions.

Purpose of the review: Point-of-care ultrasound (POCUS) is increasingly recognized as a valuable tool in obstetric anesthesia. This review synthesizes key studies and reviews published within the last 2 years on its application in clinical practice with relevant supporting literature.

Recent findings: Handheld ultrasound-assisted neuraxial block placement modestly reduces periprocedure time compared with landmark-based techniques. Devices with integrated three-dimensional or artificial intelligence-guided software may improve first-attempt success, particularly in obese patients. Focused cardiac ultrasound has gained interest as a potential tool for predicting postspinal hypotension through predelivery inferior vena cava collapsibility assessment. POCUS is also valuable for evaluating shock and cardiovascular compromise, aiding in the diagnosis and clinical management of amniotic fluid embolism and maternal cardiomyopathy. Gastric ultrasound can be performed qualitatively, aids aspiration risk assessment, and can be used in studies evaluating drug effects on gastric contents and antral cross-sectional area. Robust training programs are essential to equip obstetric anesthesiologists with sustainable POCUS skill sets.

Summary: POCUS is associated with reduced neuraxial block placement times, provides critical hemodynamic data in patients with amniotic fluid embolism and cardiomyopathy, and allows gastric content evaluation for aspiration risk assessment. Expanding structured training and research is crucial to maximizing its clinical utility.

Purpose of review: This review aims to synthesize the current literature on the use of regional blocks to enhance and optimize postoperative recovery after cesarean delivery, highlighting key strategies, challenges, and emerging trends.

Recent findings: Recent developments in postoperative analgesia for cesarean delivery point toward more personalized treatment approaches. This involves identifying patients at high risk for severe postoperative pain and offering them tailored multimodal analgesic regimens.

Summary: Managing pain after cesarean delivery continues to pose a significant challenge. The overall prevalence of acute postoperative pain remains high (58%) and, even when strict adherence to established guidelines is ensured, approximately 25% of patients report inadequate pain control. Within a multimodal analgesic framework, when neuraxial morphine - still considered the gold standard - is not an option, the use of peripheral nerve and fascial plane blocks has demonstrated clear benefits. Recent literature suggests that quadratus lumborum block may serve as a promising alternative to intrathecal morphine for women who cannot tolerate opioids. Additionally, incorporating certain regional techniques alongside neuraxial morphine may further improve postoperative analgesia, especially for patients at high risk of severe postoperative pain and those who have contraindications to other analgesic modalities.

Purpose of review: Bleeding complications from pelvic injuries occur after high-energy trauma as well as after low-energy trauma in elderly patients and are the main contributors to mortality. Demographic changes necessitate focussing on both entities and targeted therapies throughout the course of management.

Recent findings: This article reviews the recent evidence and expertise on bleeding management for haemodynamically unstable patients with pelvic fractures with insights from prehospital care to trends in resuscitation and endovascular techniques and revival of older strategies, to challenges of definitive treatment. It also takes a closer look into pelvic fractures of the elderly and their most recent treatment options.

Summary: Bleeding management in pelvic trauma begins prehospitally with targeted transportation, infusion of crystalloids and blood products, and a differentiated use of pelvic binders. In the emergency department, care involves rapid evaluation, massive transfusion protocols and computed tomography (CT) angiography. Resuscitative Endovascular Balloon Occlusion of the Aorta can serve as bridging to diagnostics and bleeding control. Bleeding control management includes mechanical stabilization, preperitoneal pelvic packing or angioembolization. In elderly patients, rigid vessels and anticoagulation contribute to bleeding complications. Selective CT angiography is advised for certain injury patterns and haemodynamic instability. Depending on bleeding localization, selective angioembolization is preferred.

Purpose of review: With an increase in the number and complexity of procedures in nonoperating room anesthesia (NORA) locations, navigating the landscape of planning, scheduling, workflow, and patient and clinician safety adds to the challenges of NORA space, requiring coordination of multiple teams and regulatory platforms.

Recent findings: With the constant increase in cases performed in the NORA space, expected to reach 50% of all anesthetics in the next decade, significant strides must be made in assuring patients' and clinicians' safety. New procedures have been developed and approved in all procedural areas, and anesthesiologists are leading the charge in getting all stakeholders together. Anesthesia departments face increased demand for those services, so establishing a NORA leadership to collaborate and coordinate the efforts is very important.

Summary: The review summarizes new developments in different procedural areas and their anesthetic management, and new recommendations by the American Society of Anesthesiology and Anesthesia Patient Safety Foundation for the safe conduct of anesthesia in the NORA space.

Purpose of review: The prevalence and severity of pediatric obstructive sleep apnea syndrome (OSAS) is increasing, and patients with severe OSAS are at higher risk for perioperative adverse events because of an increased sensitivity to opioid medications. This review highlights new strategies for perioperative medication management for children presenting for adenotonsillectomy.

Recent findings: Fewer than 10% of patients presenting for adenotonsillectomy have undergone testing to determine the severity of their OSAS, despite cost-effective and practical diagnostic alternatives to polysomnography, such as nocturnal oximetry. With an increasing incidence of severe OSAS, recent research is focusing on opioid-sparing perioperative management including the use of alternative surgical techniques, regional anesthesia, and use of nonsteroidal anti-inflammatory medications that provide optimal analgesia with minimal adverse complications.

Summary: Severe OSAS increases perioperative risks for pediatric patients, but diagnostic techniques that stratify OSAS severity are underutilized preoperatively, leading to a lack of information on how best to care for patients on the day of surgery. Nonopioid analgesic adjuncts are becoming more common, improving safety for this patient population.

Purpose of review: This review delineates the benefits of minimally invasive surgery (MIS) and its utilization at surgical centers and our institution. It further explores the literature for comparative outcomes of performing MIS to traditional open surgery for a variety of surgical subspecialties.

Recent findings: In addition to its proven safety when compared to the open surgical technique, MIS has broad applications in many surgical subspecialties to enhance perioperative outcomes in both pediatric and adult patients.

Summary: Although there are certain disadvantages with regard to cost of implementation in nascent communities and total operating time when the surgical complexity increases (such as utilizing a robotic approach), the added benefit of improved patient outcomes due to smaller incision sites is repeatedly proven in the literature making this technique globally essential.

Purpose: This review aims to provide the practicing anesthesiologist with information on the pathophysiology, physiology, and management of patients with sickle cell disease. This includes the evaluation of common intraoperative management issues as well as perioperative concerns related to the disease. This review will also discuss the outpatient care of sickle cell patients concerning disease-modifying agents and chronic pain management.

Recent findings: There has been less funding for research on sickle cell disease and a relative deficit in treatment options for patients and their vaso-occlusive crises (VOC). In the chronic pain setting, adjuvants to therapy have been utilized, such as anti-inflammatories, neuropathic agents, and antihistamines; however, the mainstay of therapy for pain crises is the use of opioids. New medications for the treatment of VOCs include crinaluzimab and L-glutamine. In terms of intraoperative management, it is imperative to maintain homeostasis for the patients, and research does not show a benefit in preoperative blood transfusions when not clinically indicated.

Summary: The sociopolitical context and pathophysiology of sickle cell disease make it a unique disease to manage for the practicing anesthesiologist. Tailoring management via developing a patient-specific approach to maintain homeostasis and minimize the perioperative prevalence of VOCs.

Purpose of review: Traumatic childbirth can lead to childbirth-related post-traumatic stress disorder (CB-PTSD) or retraumatize those with prior trauma, contributing to long-term maternal and neonatal morbidity and mortality. This condition affects approximately 4-7% of postpartum patients. Given the concerningly high maternal morbidity and mortality rates in the USA, it is crucial to further analyze the risk factors and clinical management recommendations for the prevention of CB-PTSD.

Recent findings: Research highlights the negative outcomes and high costs associated with CB-PTSD. Studies have found that preexisting mental health conditions, patient perception of delivery, and certain obstetric and anesthetic complications may significantly impact CB-PTSD development.Additionally, screening tools are available, with some proven effective in this population.

Summary: Recent literature underscores the anesthesiologist's role in preventing and detecting CB-PTSD. Although there is a lack of standardized screening practices for CB-PTSD, awareness of this disorder is on the rise. By adopting a trauma-informed care model including anesthesia consultation, providing effective analgesia and anesthesia, maintaining a clinical practice that minimizes anesthetic complications, and identifying patients who perceive their experience as traumatic, anesthesiologists can help mitigate the prevalence of CB-PTSD, and thus its associated maternal morbidity and mortality.

Purpose of review: Fluid management in hemorrhagic shock is a controversial topic, and there are evolving clinical guidelines and evidence-based practice. This review aims to highlight the physiological aspects in the light of current evidence on which volume replacement solution to use.

Recent findings: Current evidence and international guidelines are shifting from a liberal to a restrictive volume resuscitation strategy, emphasizing the potential risks associated with aggressive fluid therapy. The 'lethal triad of trauma' (hypoperfusion, acidosis, and coagulopathy) plays a crucial role in the pathophysiology of hemorrhagic shock. While crystalloids are less effective at restoring intravascular volume, colloids (especially hydroxyethyl starch) have raised concerns about potential adverse effects on renal function and coagulation. Albumin remains controversial, as studies have shown no clear benefit and an increased mortality in traumatic brain injury patients. Fresh frozen plasma may be useful in massive transfusion situations but is not recommended for volume resuscitation.

Summary: The management of volume resuscitation evolves, with a trend toward more restrictive strategies. Crystalloids, although less effective for severe volume depletion, remain a cornerstone of initial resuscitation. Among the colloids, gelatin-based solutions and albumin can be used when crystalloids are inadequate, while hydroxyethyl starch is no longer recommended.