Canadian Journal of Anesthesia-Journal Canadien D Anesthesie最新文献

Purpose: In this Continuing Professional Development module, we review the literature on postdural puncture headache (PDPH) in obstetrics. The pathophysiology, risk factors, diagnosis, and outcomes are discussed. We explore the evidence for prevention and treatment options of PDPH in obstetric patients and the importance of the anesthesiologist's role in caring for these patients.

Principal findings: A PDPH is any headache that develops after a dural puncture and is not better accounted for by another diagnosis. Risk factors for PDPH include young age and female sex, which, along with the high rate of neuraxial anesthesia use in the obstetric population, predispose these patients to this complication. A spinal anesthesia technique using a small-gauge pencil-point needle with an experienced operator decreases the risk of PDPH. Individuals with PDPH have an increased risk of major neurologic complications, such as subdural hematoma, cerebral venous sinus thrombosis, and bacterial meningitis. No pharmacological modalities have shown a benefit in preventing or treating PDPH. Epidural blood patch remains the most effective treatment for PDPH and should not be delayed in obstetric patients with severe symptoms.

Conclusions: Postpartum individuals cope with recovering from birth in addition to the demands of caring for a newborn. Often, the addition of a PDPH is incapacitating. Epidural blood patch should not be delayed in patients with early and severe symptoms. All individuals who experience PDPH should be assessed, receive appropriate treatment, and be reviewed by a member of the anesthesia team until symptoms have resolved, with appropriate follow-up instructions before discharge.

Purpose: We sought to evaluate the efficacy of intravenous dexamethasone in reducing rebound pain post-orthopedic wrist and hand surgery, administered prior to supraclavicular brachial plexus blockade.

Methods: We conducted a randomized placebo-controlled trial on 56 patients scheduled for elective wrist and hand surgery under supraclavicular brachial plexus blockade. We randomized participants into either a control group, receiving 0.9% of intravenous saline, or a dexamethasone group, receiving 0.11 mg·kg^-1 of intravenous dexamethasone. The primary outcome was the difference in pain scores before vs after block resolution. Secondary outcomes included the incidence of rebound pain, pain scores, cumulative opioid consumption, patient satisfaction with postoperative analgesia, and block-related complications in the first 24 hr postoperatively.

Results: The mean (standard deviation [SD]) pain score difference was significantly larger in the control group (7.3 [1.9]) compared with the dexamethasone group (4.7 [2.1]), with a mean difference between groups of 2.6 (95% confidence interval, 1.5 to 3.7; P < 0.001). The incidence of rebound pain was also significantly higher in the control group (79% vs 32%; P < 0.001). The cumulative opioid consumption in 24 hr was greater in the control group than in the dexamethasone group (median [interquartile range (IQR)], 72 [54-97] mg vs 25 [14-60] mg; P < 0.001). We found no significant differences in postoperative complications.

Conclusions: Preoperative administration of 0.11 mg·kg^-1 intravenous dexamethasone significantly reduced rebound pain within 24 hr after wrist and hand surgery under supraclavicular brachial plexus blockade. The results of our trial support the use of intravenous dexamethasone as an effective method for managing postoperative pain for wrist and hand surgery under supraclavicular brachial plexus blockade.

Study registration: www.CRIS.nih.go.kr ( KCT0007208 ); first submitted 5 April 2022.

Purpose: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is increasingly being used in patients with respiratory failure. The goal of this study was to characterize postdischarge psychological and functional outcomes of this patient population.

Methods: We conducted a historical cohort study of survivors who required VV-ECMO during the COVID-19 pandemic. Using telephone interviews, we assessed the following domains: disability (using the World Health Organization Disability Schedule [WHODAS 2.0] and modified Rankin Scale [mRS]), health-related quality of life (using the European Quality of Life 5 Dimensions 5 Level tool), cognition (using the telephone Montreal Cognitive Assessment tool), depression (using the Patient Health Questionnaire-9), and posttraumatic stress disorder symptoms (using the Impact of Event Scale-6). We used descriptive statistics to analyze our results.

Results: Twenty-six participants with a median [interquartile range (IQR)] age of 47 [42-59] yr and 6 (23%) of whom were female were evaluated at a median [IQR] of 22 [17-23] months after ECMO separation. Twenty-two (85%) had a diagnosis of COVID-19. The median [IQR] WHODAS 2.0 score was 26 [15-30] with the highest degree of disability in the mobility and participation domains. Of the 24 participants who were employed full-time, 12 (50%) were able to work in the same capacity. Of the 25 respondents who were living independently at baseline, 22 (88%) maintained complete independence for their activities of daily living (mRS < 3), one (4%) described persistent functional limitations (mRS = 3), and two (8%) required constant care (mRS = 4 or 5). Thirteen (52%) and nine (38%) reported at least moderate pain or anxiety, respectively. Ten (40%) and seven (28%) participants screened positive for symptoms of depression or posttraumatic stress disorder, respectively.

Conclusions: Patients who required VV-ECMO experienced significant functional disability, pain, cognitive challenges, mental health problems, and lower quality of life approximately two years after discharge.

Purpose: Pain management after cardiac surgery is imperative, as inadequate analgesia can increase the risk of myocardial ischemia, thromboembolism, and pulmonary complications. Nonsteroidal anti-inflammatory drugs (NSAIDs) are an important component of multimodal analgesia, but their use in the postoperative cardiac surgery population is controversial owing to concerns of acute kidney injury (AKI), thrombotic events, and bleeding. We aimed to evaluate the rate of AKI, major adverse cardiovascular events (MACE), and major bleeding in patients receiving NSAIDs early after cardiac surgery.

Methods: We conducted a single-centre historical cohort study, which included adult patients who underwent cardiac surgery with sternotomy or thoracotomy between 1 October 2020 and 30 September 2022 and received nonselective NSAIDs postoperatively. The primary outcome was the proportion of patients who developed AKI, MACE, or major bleeding within 7 days of the NSAID exposure during their hospitalization. We used machine learning to identify risk factors associated with adverse events. We assessed pain reduction by analyzing differences in pain scores, opioid use, and supplemental oxygen requirements.

Results: We included 431 patients in this study. After NSAID administration, 12% experienced AKI, 1% had MACE, and 3% developed major bleeding. Risk factors for AKI included older age; shorter height; a history of stroke; low preoperative estimated glomerular filtration rate (eGFR) and hemoglobin level; high preoperative platelet count, international normalized ratio, and blood urea nitrogen level; and reduced eGFR and platelet count before NSAID exposure.

Conclusion: In patients who received nonselective NSAIDs early after cardiac surgery, the rate of AKI was lower than reported in literature, likely due to selection bias. Baseline renal function emerged as the most important factor, with low preoperative eGFR being the strongest predictor of AKI following NSAID administration.

Purpose: The ideal sedative should have a rapid onset, short duration, and quick and predictable recovery. Despite the increasing use of the recently developed sedative remimazolam for intraoperative sedation, there is a paucity of research on its comparative recovery profile. Our aim was to compare the recovery profiles of intraoperative sedation with propofol, dexmedetomidine, and remimazolam in patients undergoing surgery under regional anesthesia.

Methods: We included 119 patients scheduled to undergo upper limb surgery under brachial plexus blockade in a randomized controlled trial. We randomized patients to receiving intraoperative sedation with propofol, dexmedetomidine, or remimazolam. The primary outcome was the recovery time (from the completion of infusion to attaining a Modified Observer's Assessment of Alertness and Sedation score of 5). As secondary outcomes, we assessed other recovery profiles, including length of stay, quality of recovery, and the Aldrete score.

Results: The mean (95% confidence interval [CI]) recovery time was 19 min (95% CI, 16 to 22) for patients in the dexmedetomidine group, 17 min (95% CI, 15 to 19) for the remimazolam group, and 12 min (95% CI, 10 to 13) for the propofol group (P < 0.001). Post hoc analysis revealed that the recovery time in the remimazolam group was longer compared to that in the propofol group (mean difference, 5 min; 95% CI, 3 to 8; Bonferroni adjusted P < 0.001). We found no significant differences among the three groups in the recovery-related secondary outcomes (all P > 0.05).

Conclusions: Patients in the propofol group exhibited the most rapid recovery time from intraoperative sedation under regional anesthesia, followed by those in the remimazolam and dexmedetomidine groups. We found no differences in the recovery-related secondary outcomes.

Study registration: ClinicalTrials.gov ( NCT05688345 ); first submitted 30 December 2022.