Current Opinion in Anesthesiology最新文献

Purpose of review: Improved perioperative patient monitoring is a crucial step toward better predicting postoperative outcomes. Wearable devices capable of measuring various health-related metrics represent a novel tool that can assist healthcare providers. However, the literature surrounding wearables is wide-ranging, preventing clinicians from drawing definitive conclusions regarding their utility. This review intends to consolidate the recent literature on perioperative wearables and summarize the most salient information.

Recent findings: Wearable devices measuring cardiac output and colonic motility have recently been piloted with mixed results. Novel measurement techniques for established metrics have also been studied, including photoplethysmography devices for heart rate and blood pressure along with resistance thermometers for temperature. Nuanced methods of synthesizing data have been piloted, including machine-learning algorithms for predicting adverse events and trajectory curves for step count progression. Wearable devices are generally well accepted, although adjuvant support systems have improved patient satisfaction.

Summary: Perioperative wearables are valuable tools for tracking postoperative health metrics, predicting adverse events, and improving patient satisfaction. Future research on removing barriers such as technological illiteracy, artifact generation, and false-positive alarms would enable better integration of wearables into the hospital setting.

Purpose of the review: The treatment of patients with traumatic brain injury (TBI) with subsequently evolving hemostatic failure and hemorrhagic lesion progression remains challenging. New studies highlight windows of opportunity for treatment optimization.

Recent findings: Results from recent randomized studies suggest an earlier treatment with antifibrinolytic tranexamic acid at a higher initial bolus dose. There seems to be a new window of opportunity for the early prehospital use of thawed plasma. Viscoelastic-based goal-directed treatment strategies are still not delivered timely in most patients although a recent meta-analysis has confirmed a survival benefit with this approach.

Summary: Mortality in TBI with subsequent evolving hemostatic failure can be reduced through treatment optimization delivering early prehospital high-dose tranexamic acid and in-hospital goal-directed treatment algorithms to timely correct coagulopathy and restore hemostasis.

Purpose of this review: To provide evidence for the use of prothrombin complex concentrate (PCC) as a potential hemostatic treatment for trauma-induced coagulopathy with and without anticoagulants.

Recent findings: PCC is effective in enhancing thrombin generation and achieving hemostasis in traumatized patients under anticoagulants. For vitamin K antagonist (VKA) reversal, it shows superior efficacy over fresh frozen plasma, achieving rapid normalization of the international normalized ratio normalization and reduced transfusion needs. In direct oral anticoagulant (DOAC)-associated bleeding, PCC offers an alternative when specific antidotes are unavailable. However, evidence from randomized trials in the field of trauma and coagulopathy is limited, and the results have shown conflicting outcomes in terms of mortality reduction. Further, following PCC application, thromboembolic risks remain a particular concern. Monitoring tools such as thrombin generation assays and point-of-care tests show promise but are not universally available.

Summary: PCC is a valuable option for managing coagulopathy in specific settings, especially VKA and DOAC reversal. Based on current evidence, we caution against the use of PCC as a versatile hemostatic agent suitable for indications involving multiple clotting factor deficiencies for uncontrolled coagulopathic bleeding in trauma or other clinical settings outside anticoagulation reversal. The risk vs. benefit profile should be carefully examined, similar to any other agent.

Purpose of review: This review aims to summarize current evidence on hemostatic management of bleeding trauma patients, with a focus on resuscitation strategies using either coagulation factor concentrates or fixed-ratio transfusion concepts. It discusses the potential benefits and limitations of both approaches.

Recent findings: Recent studies have shown that coagulopathy caused by massive traumatic hemorrhage often cannot be reversed by empiric treatment. During initial resuscitation, a fixed-ratio transfusion approach uses the allogeneic blood products red blood cells, plasma, and platelets to mimic 'reconstituted whole blood'. However, this one-size-fits-all strategy risks both overtransfusion and undertransfusion in trauma patients.Many European trauma centers have shifted toward individualized hemostatic therapy based on point-of-care diagnostics, particularly using viscoelastic tests. These tests provide rapid insight into the patient's hemostatic deficiencies, enabling a more targeted and personalized treatment approach.

Summary: Individualized, goal-directed hemostatic management offers several advantages over fixed-ratio transfusion therapy for trauma patients. However, there is a paucity of data regarding the direct comparison of these two approaches.

Purpose of review: Chronic obstructive pulmonary disease affects more than 65 million people worldwide. Lung transplantation is the only definitive treatment. However, donor availability is limited in meeting the demand.

Recent findings: Lung regeneration is a new therapeutic strategy that uses the patient's stem cells to replace dysfunctional tissue and restore functional lung tissue rather than alleviate symptoms. Organoids are a new promising target for human lung regeneration. The AEP cells are isolated from human lung tissue for growth. The 3D organ-like structures conserve the alveolar progenitor's capacity to proliferate and differentiate into various epithelial cell types.Bioengineered organs, from a patient's cells, allow for customized biocompatible organs-on-demand without the need for immunosuppressive therapy. The concept involves the creation of a form of 3D tissue scaffold, to be populated by cells of the desired tissue to be transplanted into the patient, allowing for function as closely to the native organ as possible.

Summary: The lung's ability to regenerate extensively after injury suggests that this capability could be promoted in diseases in which loss of lung tissue occurs. Lung bioengineering offers the potential to drastically extend life expectancy in patients with end-stage lung disease. If lung reengineering were successful, it would revolutionize the world of transplantation.

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: This review discusses nonintubated video-assisted thoracic surgery (NIVATS) by presenting its physiological, technical aspects and recent clinical data from the literature.

Recent findings: In the last two decades, NIVATS has gained traction as an alternative to traditional intubated thoracic surgery, offering potential benefits in terms of reduced complications, faster recovery times, and improved patient satisfaction. Several approaches to this technique have been described in the literature, mainly divided into the awake patient technique (awake-NIVATS) and the asleep patient technique (asleep-NIVATS). The availability of various sedatives, numerous devices to ensure good oxygenation, and the countless loco-regional techniques available today for pain control in the thoracic region offer the possibility to develop many anesthesia protocols in this context. Numerous studies have already shown that NIVATS is feasible and safe with proper patient selection and adequate collaboration of the surgical team. Some studies have also shown that NIVATS may improve patient outcomes, but the evidence is still limited.

Summary: Literature has demonstrated the feasibility of NIVATS and suggest that it can improve patient outcomes. High-quality international randomized multicenter studies comparing NIVATS and intubated video-assisted thoracic surgery are necessary for a strong comprehension to clarify whether it can be a technique that can guarantee safety and improve the perioperative course of patients.