Journal of Anesthesia, Analgesia and Critical Care (Online)最新文献

Background: Cesarean delivery (CD) stands as one of the most prevalent surgical procedures for childbirth. Ensuring effective pain management during and after CD is paramount to safeguarding the well-being and comfort of the mother. The transversus abdominis plane (TAP) block is a widely used technique for postoperative pain control. To enhance the duration and quality of analgesia provided by TAP blocks, adjuvants such as ketamine and neostigmine have been investigated.

Methods: A prospective, double-blind randomized controlled study was adopted. Eighty patients scheduled for elective CS were randomized into two equal groups after receiving spinal anesthesia. Group K received postoperative TAP block with plain bupivacaine and ketamine and Group N received TAP block with bupivacaine and neostigmine.

Results: A significantly higher mean arterial blood pressure was observed at 18 h and 24 h in Group N compared to Group K. Comparing the postoperative visual analogue scale score, no significant differences were observed at 2 h, 4 h, and 6 h. At 12 h post-procedure, the mean VAS score was significantly higher for Group N compared to Group K. This trend continued at 18 and 24 h (p < 0.001).

Conclusion: Both adjuvants effectively controlled postoperative pain, with stable intraoperative hemodynamics and high patient satisfaction levels. Ketamine demonstrated superior analgesic efficacy compared with neostigmine in cesarean delivery patients undergoing TAP blocks. An individualized treatment approach is needed to tailor the selection of adjuvants to optimize outcomes.

Background: Strict postoperative blood pressure (BP) control within a narrow range is crucial after Carotid Endarterectomy (CEA) to minimize risks like stroke and hyperperfusion syndrome. Our institution targets a systolic BP (sBP) of 130-145 mmHg post-CEA. This study aimed to compare the efficacy of clevidipine versus standard intravenous antihypertensive treatment (labetalol ± urapidil) in maintaining this target range.

Materials and methods: This single-center, prospective cohort study included consecutive patients (> 18 years) undergoing CEA at Hospital Universitari de Girona Dr J Trueta, Girona, Spain, between August 2018 and October 2021. Patients received either clevidipine or non-clevidipine treatment (labetalol ± urapidil) based on physician preference. The primary outcome was the Area Under the Curve for sBP outside the target range (AUC-sBP), normalized per hour (mmHg x min/h), during the first six postoperative hours. Data were analyzed using non-parametric tests and adjusted linear regression.

Results: Data from 97 patients (44 clevidipine, 53 non-clevidipine [38 labetalol only, 15 labetalol + urapidil]) were analyzed. The clevidipine group had higher baseline sBP (144 ± 15 vs 140 ± 7 mmHg, SMD -0.34) and more comorbidities. Clevidipine use was associated with a significantly lower AUC-sBP compared to the non-clevidipine group (median [IQR]: 120 [92-150] vs 240 [240-300] mmHg x min/h, p < 0.00001). This association remained significant after adjusting for age, sex, and preoperative sBP (coef. -220 mmHg x min/h [95% CI -293 to -146], p = 0.0001). Mean cumulative clevidipine dose was 58 ± 86 mg over 14 ± 10 h. No significant differences were observed in secondary outcomes or pre-specified adverse events between groups.

Conclusion: In this cohort, clevidipine treatment was associated with significantly better adherence to the target sBP range during the first six hours post-CEA compared to standard therapy with labetalol ± urapidil, without an observed increase in adverse effects.

Background: Intensive care units (ICUs) and operating rooms (ORs) are resource-intensive hospital areas and major contributors to healthcare waste. Proper segregation of hazardous and residual waste reduces carbon-intensive disposal and supports sustainability, yet practices depend heavily on staff behavior and knowledge.

Methods: We conducted a prospective three-phase interventional study in the ICU and ORs of Merano Hospital, Italy (September 2023-May 2025). Baseline hazardous waste generation and staff knowledge/barriers were assessed (phase 1). Subsequently, low-cost behavioral nudges (enhanced bin visibility, labeling, placement-phase 2) and targeted online education on waste segregation (phase 3) were introduced in sequence. The primary outcome was the reduction in hazardous waste, normalized to ICU patient-days and surgical procedures; secondary outcomes included changes in perceived barriers and knowledge.

Results: Hazardous waste generation declined across all phases in both ICUs and ORs. In the ICU, waste decreased from 3.31 (± 1.07) to 2.97 (± 1.40) kg/patient-day after behavioral nudges (- 10.3%, p = 0.31) and further to 1.97 (± 1.33) after education, representing a 40.6% reduction versus baseline (p < 0.001). In ORs, waste fell from 5.84 (± 1.40) to 4.38 (± 2.58) kg/procedure post-nudges (- 25.0%, p = 0.027) and to 3.84 (± 1.46) post-education, corresponding to a 34.4% reduction (p < 0.001). Structured questionnaires identified limited bin availability and unclear sorting rules as key barriers; behavioral nudges addressed structural obstacles, while education improved knowledge and confidence.

Conclusions: Integrating low-cost behavioral nudges with targeted education effectively reduces hazardous waste in ICU and perioperative settings. Environmental changes improve waste practices, while education enhances staff knowledge, awareness, and confidence, emphasizing that infrastructure alone is insufficient without supportive training.

Background: Intraoperative fluid management during major abdominal oncologic surgery is complex and highly operator-dependent. Assisted Fluid Management (AFM) is an artificial intelligence-based decision support system designed to guide fluid challenges based on real-time Stroke Volume (SV) analysis. However, limited data are available on how AFM is adopted in routine clinical practice and how clinician interaction with the system evolves over time.

Methods: We conducted a retrospective observational study based on a prospectively maintained institutional database at a high-volume tertiary referral center. Adult patients undergoing major abdominal oncologic surgery with intraoperative AFM monitoring were included. Two consecutive time periods following AFM implementation were compared. Analyses were performed at the fluid-challenge level and focused on patterns of fluid challenge initiation (clinician-initiated vs AFM-suggested), hemodynamic effectiveness (SV response), and bolus characteristics, as markers of system adoption and learning curve. Postoperative clinical outcomes were not assessed.

Results: Fifty-nine patients were included, accounting for 404 fluid challenges. Over time, clinician-initiated boluses significantly decreased and AFM-suggested fluid challenges increased (p < 0.001). This shift was associated with higher overall effectiveness of fluid challenges and greater SV responses, particularly for AFM-suggested boluses, which showed a significant improvement in effectiveness and ΔSV over time (p < 0.05).

Conclusions: Progressive integration of AFM into routine anesthetic practice was associated with measurable changes in clinician behavior and improved physiological effectiveness of intraoperative fluid challenges over time, consistent with a learning curve effect. These findings support the role of AI-based decision support systems in promoting more consistent and physiologically targeted fluid management and provide a foundation for future prospective studies evaluating their impact on clinical outcomes.

Background: Retained placenta is a significant cause of postpartum hemorrhage (PPH) and maternal morbidity. Despite its clinical importance, limited data exists on the safety and effectiveness of different anesthetic techniques for manual removal of placenta (MROP). This study aimed to assess anesthesia-related outcomes and complications in a large tertiary care center with 20,000 to 22,000 annual deliveries.

Methods: A retrospective cohort study was conducted on women who underwent MROP in the operating room between January 2018 and September 2024. Institutional Review Board approval was obtained prior to data collection. Patient demographics, risk factors, anesthetic techniques, and clinical outcomes were collected and analyzed.

Results: During the study period, there were 130,338 vaginal deliveries at our institution. Among 1,366 women (1.05%) undergoing MROP, 860 required placental revision and 506 underwent manual placental removal. Vacuum-assisted delivery was performed in 99 cases (22%). Neuraxial anesthesia was the predominant modality (81.9%), with spinal anesthesia most frequently used (73.7%) and 25.7% subsequently converted to epidural anesthesia. General anesthesia (GA) (16.6%) and sedation (1.5%) were less commonly employed. Women receiving GA had significantly higher risks of blood transfusion (RR 6.0 for RBC, RR 19.5 for FFP, p < 0.0001), longer hospitalization (4.1 ± 2.3 vs. 3.5 ± 3.4 days, p < 0.002), and increased need for ICU/PACU monitoring (RR 20.9, p < 0.0001). Difficult intubation occurred in three cases, with one reported case of aspiration. No hysterectomies were required.

Conclusions: Neuraxial anesthesia was the preferred method for MROP, demonstrating a low failure rate. In contrast, GA was associated with increased morbidity, including higher transfusion requirements, prolonged hospitalization, and greater need for intensive monitoring. The occurrence of airway complications in GA cases underscores the importance of optimizing anesthetic management. Minimizing the use of GA, when feasible, may contribute to improved patient outcomes in MROP procedures.

Background: The optimal choice between calcium gluconate (CaGN) and calcium chloride (CaCl₂) for hypocalcaemia correction during paediatric critical illness and resuscitation remains debated. This literature review aimed to compare the efficacy and safety profiles of both preparations to determine an evidence-based clinical preference.

Methods: A comprehensive review of in vitro, in vivo, and clinical trials involving critically ill patients was conducted, focusing on the pharmacokinetics, therapeutic efficacy (measured by the rise in ionised calcium, iCa²⁺), and comparative adverse event profiles, particularly the risk of extravasation injury.

Results: Both CaGN and CaCl₂ effectively correct hypocalcaemia when equivalent elemental calcium doses are administered. CaCl₂ holds a significant dosing advantage in volume-restricted or extreme emergent scenarios due to its higher concentration of elemental calcium (27.2 mg/mL vs. 9.0 mg/mL for 10% solutions). Whilst the hepatic metabolism requirement for CaGN has been widely refuted, limited paediatric data suggest CaCl₂ may yield a greater response in mean arterial pressure (MAP) in critically ill children. Crucially, the safety profile favours CaGN; a substantial body of evidence indicates that the risk and severity of tissue necrosis following extravasation are markedly higher with CaCl₂.

Conclusion: The selection of a calcium preparation must be conditional and context-dependent. We recommend reserving CaCl₂ for central venous administration in volume-restricted or extreme emergent settings, whilst CaGN is the preferred choice for peripheral line administration or routine maintenance due to its superior safety profile.

Background: Neuraxial analgesia represents the gold standard for labor pain management, providing superior efficacy and safety for both mother and fetus. However, its use is not always feasible due to medical contraindications, technical difficulties, or patient preference. Fascial Plane Blocks (FPBs) have emerged as potential alternatives, yet evidence regarding their effectiveness in labor remains limited. The purpose of this study was to synthesize the current evidence on FPBs for labor analgesia and to offer expert insight into their potential role, benefits, and limitations within modern obstetric practice.

Material and methods: A systematic search of PubMed, EMBASE, and the Cochrane Library (1985-2025) was conducted following PRISMA guidelines. Eligible studies included laboring women aged ≥ 18 years undergoing analgesia with FPBs. Case reports, case series, and letters to the editor were included due to the scarcity of high-level evidence. Outcomes of interest were maternal pain scores, analgesic satisfaction, and maternal-fetal safety. Because of the marked heterogeneity in study designs, interventions, and outcome measures, a meta-analysis was not feasible; therefore, a narrative synthesis was performed, and qualitative methodological assessment was undertaken using validated tools.

Results: Eight studies met inclusion criteria. QLB demonstrated promising analgesia in the first stage of labor, while lumbar and thoracic ESPBs yielded variable effects and inconsistent coverage during the second stage. Sacral ESPB showed potential as an adjunct when neuraxial techniques failed or were contraindicated. No major complications were reported; however, methodological limitations, small sample sizes, and inconsistent reporting hindered definitive conclusions. Fetal outcomes were rarely reported, and no long-term follow-up data were available.

Conclusions: Current evidence does not support FPBs as replacements for neuraxial analgesia. Their use should be restricted to highly selected cases where neuraxial techniques are not feasible. Importantly, there is no predefined formula for managing labor pain-analgesic strategies must be individualized according to clinical context, patient preference, and available resources. High-quality prospective studies are necessary to clarify the role of FPBs in labor.