Current Opinion in Anesthesiology最新文献

Purpose of review: This review examines recent research on artificial intelligence focusing on machine learning (ML) models for predicting postoperative pain outcomes. We also identify technical, ethical, and practical hurdles that demand continued investigation and research.

Recent findings: Current ML models leverage diverse datasets, algorithmic techniques, and validation methods to identify predictive biomarkers, risk factors, and phenotypic signatures associated with increased acute and chronic postoperative pain and persistent opioid use. ML models demonstrate satisfactory performance to predict pain outcomes and their prognostic trajectories, identify modifiable risk factors and at-risk patients who benefit from targeted pain management strategies, and show promise in pain prevention applications. However, further evidence is needed to evaluate the reliability, generalizability, effectiveness, and safety of ML-driven approaches before their integration into perioperative pain management practices.

Summary: Artificial intelligence (AI) has the potential to enhance perioperative pain management by providing more accurate predictive models and personalized interventions. By leveraging ML algorithms, clinicians can better identify at-risk patients and tailor treatment strategies accordingly. However, successful implementation needs to address challenges in data quality, algorithmic complexity, and ethical and practical considerations. Future research should focus on validating AI-driven interventions in clinical practice and fostering interdisciplinary collaboration to advance perioperative care.

Purpose of review: To provide an evidence-informed review weighing the pros and cons of particulate vs. nonparticulate steroids for lumbar transforaminal epidural steroid injections (TFESI).

Recent findings: The relative use of nonparticulate vs. particulate steroids for lumbar TFESI has risen recently in light of catastrophic consequences reported for the latter during cervical TFESI. Among various causes of spinal cord infarct, an exceedingly rare event in the lower lumbar spine, embolization of particulate steroid is among the least likely. Case reports have documented cases of spinal cord infarct during lower lumbar TFESI with both particulate and nonparticulate steroids, with database reviews finding no difference in complication rates. There is some evidence for superiority of particulate over nonparticulate steroids in well-designed studies, which could lead to increase steroid exposure (i.e. more injections) and treatment failure resulting in surgical and/or opioid management when nonparticulate steroids are utilized.

Summary: Similar to a paradigm shift in medicine, a personalized approach based on a shared decision model and the consequences of treatment failure, should be utilized in deciding which steroid to utilize. Alternatives to ESI include high-volume injections with nonsteroid solutions, and the use of hypertonic saline, which possesses anti-inflammatory properties and has been shown to be superior to isotonic saline in preliminary clinical studies.

Purpose of review: Heart and lung transplantation evolution marked significant milestones. Pioneering efforts of Dr Christiaan Barnard with the first successful heart transplant in 1967, followed by advancements in heart-lung and single-lung transplants by Drs Bruce Reitz, Norman Shumway, and Joel Cooper laid the groundwork for contemporary organ transplantation, offering hope for patients with end-stage heart and pulmonary diseases.

Recent findings: Pretransplant opioid use in heart transplant recipients is linked to higher mortality and opioid dependence posttransplant. Effective pain control is crucial to reduce opioid-related adverse effects and enhance recovery. However, research on specific pain management protocols for heart transplant recipients is limited. In lung transplantation effective pain management is crucial. Studies emphasize the benefits of multimodal strategies, including thoracic epidural analgesia and thoracic paravertebral blocks, to enhance recovery and reduce opioid use. Perioperative pain control challenges in lung transplantation are unique and necessitate careful consideration to prevent complications and improve outcomes.

Summary: This review emphasizes the importance of tailored pain management in heart and lung transplant recipients. It advocates for extended follow-up and alternative analgesics to minimize opioid dependency and enhance quality of life. Further high-quality research is needed to optimize postoperative analgesia and improve patient outcomes.

Purpose of review: This article aims to empower the interventional pain physician to utilize RFA effectively by explaining the technical and electrophysiological features of monopolar, bipolar, and internally cooled RFA. Scientific data are used to provide advice on the effective, well tolerated, and rational application of these techniques. Moreover, physicians need to know how to analyze and generalize ex-vivo and in-vivo models to the clinical setting to optimize clinical outcomes.

Recent findings: Recent studies suggest that there are many ways to enhance the technical effectiveness of interventional pain medicine RFA through adjustments in the equipment selection and settings and the local tissue conditions specific to the targeted anatomical area. These modifications could assist in improving clinical and safety outcomes.

Summary: To optimize both the efficacy and safety of RFA, physicians must understand, conceptualize, interpret, and clinically translate the basic science of RFA. This knowledge is crucial for optimizing equipment selection and settings based on target location to enhance clinical outcomes and limit technical failures.

Purpose of review: To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting.

Recent findings: Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued.

Summary: In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.

Purpose of review: Pharmacokinetics of local anesthetics are one of the main determinants of success and safety of regional anesthesia and comprise local and systemic distribution phases. This review aims to summarize the latest research findings on this topic in the context of various regional blocks performed for different surgeries and patient populations.

Recent findings: Research into local kinetics and systemic absorption of local anesthetics has chiefly been focused on novel fascial plane blocks, especially the erector spinae plane block, as these are increasingly adopted for regional anesthesia and pain management. As their clinical efficacy is very dependent on injection of large volumes of local anesthetic, doses over typically recommended limits are often administered.

Summary: Fascial plane blocks are the regional anesthesia techniques in need of the most pharmacokinetic characterization, not only to better understand their complex mechanisms of action but also to avoid harm from excessive doses of local anesthetics. Further mapping of risk factors for systemic toxicity from administration in different block sites is crucial. Extremes of age and pregnancy are vulnerable patient populations but in whom regional anesthesia, including novel techniques, has been performed with few complications.

Purpose of review: It is estimated that approximately a third of patients undergoing certain surgeries may report some degree of persistent pain postoperatively. Chronic postsurgical pain (CPSP) reduces quality of life, is challenging to treat, and has significant socio-economic impact.

Recent findings: From an epidemiological perspective, factors that predispose patients to the development of CPSP may be considered in relation to the patient, the procedure or, the care environment. Prevention or management of transition from acute to chronic pain often need a multidisciplinary approach beginning early in the preoperative period and continuing beyond surgical admission. The current concepts regarding the role of central and peripheral nervous systems in chronification of pain may provide targets for future therapies but, the current evidence seems to suggest that a multimodal analgesic approach of preventive analgesia along with a continued follow-up and treatment after hospital discharge may hold the key to identify and manage the transitioning of acute to chronic pain.

Summary: A comprehensive multidisciplinary approach with prior identification of risk factors, minimizing the surgical insult and a culture of utilizing multimodal analgesia and continued surveillance beyond the period of hospitalization is an important step towards reducing the development of chronic pain. A transitional pain service model may accomplish many of these goals.

Purpose of review: The escalating opioid crisis has intensified the need to explore alternative pain management strategies for patients undergoing spine surgery. This review is timely and relevant as it synthesizes recent research on opioid alternatives for perioperative management, assessing their efficacy, side effects, and postoperative outcomes.

Recent findings: A systematic search was conducted to capture articles from the past 18 months that examined opioid-sparing strategies. Findings indicate that multimodal analgesia, incorporating nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, lidocaine, gabapentinoids, N-methyl-D-aspartate (NMDA) antagonists, dexmedetomidine, and emerging regional block techniques like the erector spinae block and TLIF (thoraco lumbar interfascial block), can significantly reduce opioid consumption without compromising pain relief. Additionally, these approaches reduce opioid-related side effects such as postoperative nausea, vomiting, and prolonged hospital stays.

Summary: The use of multimodal analgesia aligns with current pain management guidelines and addresses public health concerns related to opioid misuse. While effective, these alternatives are not without side effects, and the ultimate outcome depends on balancing benefits and risks. Future research should focus on the long-term outcomes of opioid alternatives, their effectiveness across diverse populations, and further validation and optimization of these strategies.

Purpose of review: Traumatic brain injury (TBI) presents complex clinical challenges, requiring a nuanced understanding of its pathophysiology and current management principles to improve patient outcomes. Anesthetists play a critical role in care and need to stay updated with recent evidence and trends to ensure high-quality treatment. The Brain Trauma Foundation Guidelines, last updated in 2016, have shown moderate adherence, and much of the current management relies on expert opinions. This literature review synthesizes the current evidence and provides insights into the role of anesthetists in TBI management.

Recent findings: Recent literature has emphasized the importance of tailored anesthetic management principles in treating TBI, focusing on minimizing secondary brain injury during neurosurgical interventions or extracranial surgery. Emerging trends include individualized intracranial pressure approaches and multimodal neuromonitoring for comprehensive assessment of cerebral physiology.

Summary: Anesthesia for TBI patients requires a comprehensive approach that balances anesthetic goals with the unique pathophysiological factors of brain injury. Despite recent research expanding our understanding, challenges remain in standardizing protocols and addressing individual patient response variability. Adherence to established management principles, personalized approaches, and ongoing research is crucial for improving the outcomes.

Purpose of review: 5-Aminolevulinic acid hydrochloride (5-ALA), available under the trade name Gleolan, is an orally administered fluorophore drug used to enhance visual differentiation of cancerous tissue from healthy tissue, primarily during surgical resection of high-grade gliomas. Although given preoperatively, 5-ALA has important implications for anesthetic care throughout the perioperative period. This article reviews pharmacology, safety concerns, and perioperative considerations for patients who receive oral 5-ALA.

Recent findings: Although approved for clinical use by the United States Food and Drug Administration in 2017, studies and case reports published since then have further delineated side effects of this medication and its mechanisms and pharmacokinetics.

Summary: Mitigating the possible side effects of 5-ALA requires an understanding of its basic mechanism as well as focused perioperative planning and communication. Administration of this medication may result in nausea, vomiting, photosensitivity, increase in serum concentration of liver enzymes, and hypotension. Patients who receive 5-ALA must be protected from prolonged light exposure during the first 48 h after consumption and administration of other photosensitizing agents should be avoided (Supplemental Video File/Video abstract).