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: 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: 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: 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 review: Pain after craniotomy is often severe and undertreated. Providing adequate analgesia while avoiding medication adverse effects and physiological complications of pain remains a perioperative challenge.

Recent findings: Multimodal pain management includes regional anesthesia and analgesic adjuncts. Strategies aim to reduce or eliminate opioids and the associated side effects. Many individual pharmacologic interventions have been studied with beneficial effects on acute pain following craniotomy. Evidence has been accumulating in support of scalp blockade, nonsteroidal anti-inflammatory drugs (NSAIDs), dexmedetomidine, paracetamol, and gabapentinoids. The strongest evidence supports scalp block in reducing postcraniotomy pain and opioid requirements.

Summary: Improving analgesia following craniotomy continues to be a challenge that should be managed with multimodal medications and regional techniques. Additional studies are needed to identify the most effective regimen, balancing efficacy and adverse drug effects.

Purpose of review: Consequences of the expanding commercial spaceflight industry include an increase in total number of spaceflight participants and an accompanying surge in the average number of medical comorbidities compared with government-based astronaut corps. A sequela of these developments is an anticipated rise in acute and chronic pain concerns associated with spaceflight. This review will summarize diagnostic and therapeutic areas of interest that can support the comfort of humans in spaceflight.

Recent findings: Painful conditions that occur in space may be due to exposure to numerous stressors such as acceleration and vibration during launch, trauma associated with extravehicular activities, and morbidity resulting directly from weightlessness. Without normal gravitational forces and biomechanical stress, the hostile environment of space causes muscle atrophy, bone demineralization, joint stiffness, and spinal disc dysfunction, resulting in a myriad of pain generators. Repeated insults from abnormal environmental exposures are thought to contribute to the development of painful musculoskeletal and neuropathic conditions.

Summary: As humanity invests in Lunar and Martian exploration, understanding the painful conditions that will impede crew productivity and mission outcomes is critical. Preexisting pain and new-onset acute or chronic pain resulting from spaceflight will require countermeasures and treatments to mitigate long-term health effects.

Purpose of review: The anesthetic management of patients with Moyamoya disease (MMD) is challenging and continues to evolve. The goal of this review is to provide updated recommendations on the anesthetic management of adult MMD patients based on the relevant existing literature.

Recent findings: Key findings include the importance of aggressive hydration preoperatively to sustain cerebral perfusion. Hypertension induced intraoperatively may prevent cerebral hypoperfusion. Vigilance against cerebral hyperperfusion after revascularization is necessary, with specific blood pressure targets recommended. Fluid management should aim for normovolemia to mild hypervolemia. Maintaining body temperature helps prevent cerebral vasospasm induced by hypothermia. Maintaining adequate oxygen supply during surgery is crucial. In cases of ischemic stroke, managing hematocrit and oxygen carrying capacity is essential to prevent further ischemia. Extubation decisions should consider baseline neurological function, while postoperative normocapnia helps prevent cerebral hyperperfusion and hypertension. In intensive care, cautious blood pressure management is crucial to prevent secondary complications.

Summary: Strategies in the preoperative, intraoperative, and postoperative anesthetic management of MMD patients should aim to maintain adequate cerebral perfusion to prevent cerebral ischemia.

Purpose of review: Kratom is used commonly in the United States, usually to mitigate pain, opioid withdrawal, or fatigue. A comprehensive discussion on kratom, tailored to pain management physicians, is needed, given its associated risks and potential interactions.

Recent findings: Kratom and its main metabolites, mitragynine and 7-OH-mitragynine, bind to a variety of receptors including mu opioid receptors. Still, kratom cannot be described as a classic opioid. Kratom has been utilized without FDA approval as an alternative to traditional medications for opioid use disorder and opioid withdrawal. Lower doses of kratom typically cause opioid-like effects while higher doses can have sedating effects. Tolerance, dependence and withdrawal still occur, although kratom withdrawal appears to be more moderate than opioid withdrawal. Contamination with heavy metals and biological toxins is concerning and there is potential for serious complications, including seizures and death.

Summary: The use of kratom as an opioid-sparing alternative as a part of a multimodal pain regimen is not without significant risks. It is of utmost importance for pain physicians to be aware of the risks and adverse effects associated with kratom use.

Purpose of review: This paper is an update of the publications on Transitional Pain Services and explores the viability of a dedicated transitional pain service for women.

Recent findings: We address common pain pathologies establishing referral criteria, pathways, and effective strategies to decrease chronification of pain during pregnancy.

Summary: This review highlights the importance establishing transitional pain service models at every institution and in particular in obstetric population as pain is normalized by Society during pregnancy.

Purpose of review: Neuromodulation approaches have been a part of a revolution in migraine therapies with multiple devices approved or in development. These devices vary in the nerve(s) being targeted, implantable versus noninvasive form factors as well as their effectiveness for acute pain reduction or migraine prevention. This review will summarize these recent advancements and approaches that are being developed which build upon prior work and improved technology that may help enhance the effectiveness as well as the patient experience.

Recent findings: Both noninvasive and implantable devices primarily targeting cranial nerves have shown the ability to help alleviate migraine symptoms. Multiple prospective and retrospective studies have demonstrated clinically meaningful reductions in headache intensity with noninvasive approaches, while prevention of migraine demonstrates more modest effects. Implantable neuromodulation technologies focusing on occipital and supraorbital stimulation have shown promise in migraine/headache prevention in chronic migraine patients, but there is a need for improvements in technology to address key needs for surgical approaches.

Summary: Electrical neuromodulation approaches in the treatment of migraine is undergoing a transformation towards improved outcomes with better technologies that may suit various patient needs on a more individualized basis.