Current Opinion in Anesthesiology最新文献

Purpose of review: The aim is to describe recent advances in pediatric enhanced recovery after surgery (ERAS) in all phases of care as well as the outcomes and impact of recent evidenced-based pathways in pediatric patients.

Recent findings: While profoundly impactful in the care of adult patients for nearly 3 decades, ERAS had a slower start in pediatric care that began approximately 10 years ago. Early outcomes were promising, and the multidisciplinary approach to perioperative care has gained momentum, with recent single-center studies of ERAS for pediatric patients showing reductions in both complications and length of stay. The first ERAS Society recommendations for pediatric patients were published in 2024, and two multicenter trials of pediatric ERAS, Pediatric urology recovery after surgery endeavor and ENhanced Recvovery in CHildren Undergoing Surgery (ENRICH-US), have completed enrollment and are expected to publish results in 2025.

Summary: ERAS in pediatric practice has made great strides in the past 5 years and has led to improved outcomes for young patients. Multicenter trial outcomes and the development of additional rigorous ERAS Society recommendations for children will guide future care.

Purpose of review: Thoracic injuries are directly responsible for 20-30% of deaths in severe trauma patients and represent one of the main regions involved in preventable or potentially preventable deaths. Controlling bleeding in thoracic trauma is a major challenge because intrathoracic hemorrhagic lesions can lead to hemodynamic instability and respiratory failure.

Recent findings: The aim of managing intrathoracic hemorrhagic lesions is to control bleeding as quickly as possible and to control any respiratory distress. Extended focus assessment with sonography for trauma enables us to identify intrathoracic bleeding much more quickly and to determine the most appropriate therapeutic strategy.

Summary: Thoracic bleeding can result from the diaphragm, intrathoracic vessels (aorta, but also inferior or superior vena cava, and suprahepatic veins), lung, cardiac, or chest wall injuries. Depending on thoracic lesions (such as hemothorax or hemopericardium), hemodynamic instability, and respiratory failure, a pericardial window approach, sternotomy, thoracotomy, or emergency resuscitation thoracotomy may be considered after discussion with the surgeon. Alongside treatment of injuries, managing oxygenation, ventilation, hemodynamic, and coagulopathy are essential for the patient's outcome.

Purpose of review: Mass casualty incidents (MCIs) strain available healthcare resources requiring unusual actions. Within a trauma system, hospitals receiving patients from an MCI have a defined key role in the care of the casualties and their preparedness is critical for patient outcome. The aim of this review is to address recent relevant literature to highlight important elements necessary for an adequate hospital response to an MCI.

Recent findings: That disaster preparedness is a prerequisite for success during an MCI is undisputable. Key components in the hospital response to an MCI like triage, communication, leadership, security, and surge capacity are areas that still need attention. There has been an increased focus on optimal treatment of children and their families, and the psychosocial support for patients and staff involved.

Summary: The complexity and unpredictability of MCIs demands a predefined strategy within every hospital. This strategy should include increased attention to the specific needs for children, physical security and psychological support but not at the expense of frequent training of staff. Involvement of dedicated clinical leadership both during disaster preparedness planning, training and during actual MCIs is irreplaceable.

Purpose of review: The management of noncompressible haemorrhage (NCH) remains a critical challenge in trauma care, with early mortality rates persistently high despite advances in trauma systems. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as a potential intervention to address severe haemorrhage in prehospital and hospital settings. This review examines the role of REBOA in remote damage control resuscitation, focusing on the 'golden hour' and the 'platinum 5 minutes' concepts that underscore the urgency of timely interventions.

Recent findings: Evidence from the UK-REBOA trial and related studies highlights the complexity of implementing REBOA in prehospital settings, emphasising the importance of early deployment, appropriate patient selection, and minimisation of delays. Technological innovations, including AI-assisted decision-making and automated partial REBOA systems, offer promising avenues for optimising REBOA's application. Furthermore, the concept of damage control prehospital care prioritises essential interventions tailored to individual patient needs, advocating for a streamlined approach to reduce on-scene time.

Summary: The integration of REBOA with advanced prehospital strategies holds the potential for reducing preventable deaths from traumatic haemorrhage, but further research is needed to refine protocols and enhance outcomes in this high-stakes domain.

Purpose of review: The labor and delivery unit poses unique challenges for the clinician faced with an ethical dilemma. Ethics training for physicians is heterogeneous and may not include specifics that are relevant to the obstetric anesthesiologist such as the implications of caring for a maternal-fetal dyad.

Recent findings: Rapid changes to the reproductive healthcare landscape have impacted healthcare professionals in recent years, who are at risk for moral distress when faced with ethical dilemmas in clinical care.

Summary: Principlism is the most commonly applied ethical theory in clinical medicine. The four principles are autonomy, beneficence, nonmaleficence, and justice. These principles are prima facie in that no one is defined as being consistently more important than another; it is the clinical situation that determines how to prioritize the principles. This framework allows the obstetric anesthesiologist to assess and manage each of these principles to provide ethically appropriate care for their patient. The aim of this article is to provide the obstetric anesthesiologist with an understanding of the foundational ethical principles that impact the ability to fulfill their fiduciary duty to advocate for patients by offering, and with informed consent, providing indicated and appropriate interventions.

Purpose of review: Hemorrhage and subsequent development of therapy refractory shock are the major cause of death in potentially salvageable trauma victims. Recent scientific work recognizes that there is an urgent need to develop new life-support strategies. From a variety of interventions and drugs with the potential to prolong the compensation phase or to reverse the decompensation phase of shock, arginine vasopressin (AVP) is one of the most promising and best evaluated drugs. Nonetheless, the efficacy of AVP administration in hemorrhagic shock is still to be proven. Thus, this umbrella review summarizes the current evidence of AVP in hemorrhagic shock.

Recent findings: Fifteen short reviews, narrative reviews, systematic reviews and meta-analysis addressing AVP in traumatic hemorrhagic shock were identified and included in this umbrella review. There is robust evidence deriving form 23 animal studies that AVP administration is effective in hemorrhagic shock, resulting in hemodynamic stabilization and improved survival. This observation is supported by six case reports but not confirmed by two retrospective observational studies and two randomized control trials.

Summary: In uncontrolled hemorrhagic shock, arginine vasopressin might be considered as a therapy of last resort in shock patients not responding to conventional therapy. Further research is needed to determine the potential benefits and optimal dosage/timing of vasopressin use in hemorrhagic shock.

Purpose of review: This review aims to summarize recent developments for the management of severe traumatic brain injury (TBI) in the ICU. Recent advancements in TBI ICU management emphasize a progression toward more multimodal approaches and mitigating secondary brain injury by increased focus on careful systemic management.

Recent findings: Invasive monitoring techniques such as continuous intracranial pressure (ICP) and brain tissue oxygen pressure (PbtO 2 ) monitoring are considered standard of care or may become crucial, respectively, for managing severe TBI. Technological advances in noninvasive techniques (e.g. quantitative pupillometry) are likely to advance our diagnostic and prognostic ability. Blood biomarkers, including glial fibrillary acidic protein, neurofilament light chain, and ubiquitin carboxy-terminal hydrolase L1, provide minimally invasive ways to better assess injury severity and predict outcomes. These advancements support personalized care, which will likely influence clinical management strategies in the future.

Summary: ICP monitoring remains a key component of severe TBI management in ICU. Emerging evidence is slowly changing and improving intensive care and patient outcomes and include both brain-targeted therapies and careful systemic intensive care management.

Purpose of the review: In this narrative review, we evaluate the recent evidence for benefits, cost-effectiveness, and ethical considerations of patient blood management (PBM) programs.

Recent findings: PBM programs are able to reduce the amount of red blood cell transfusion by 20-40% and the risk of reoperation. Lower morbidity and mortality due to PBM implementation were only shown in retrospective studies with a before-and-after design but not in randomized controlled trials. PBM is very likely to be cost-effective when reduced blood transfusion can be accomplished through low-cost interventions, such as administration of oral iron or antifibrinolytics. Further, cost-efficacy can also be achieved by reducing postoperative morbidity and length of hospital stay. Of note, cost-efficacy of PBM interventions might be better in patients at high bleeding risk. Finally, aiming to improve patient's outcome while minimizing transfusion-induced complications, PBM seems highly ethical.

Summary: PBM is an important concept as it promotes the rational use of allogeneic blood products and reduces transfusion and wastage of precious and limited blood products.