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

Background: Spinal cord stimulation is a validated approach for managing chronic pain syndromes. The stimulator placement typically requires sedation, and an awake phase is needed to ensure optimal lead positioning. We describe a novel multimodal sedation approach using target-controlled infusions of propofol, remifentanil, and dexmedetomidine, combined with boluses of ketamine, guided by electroencephalography and nociception-antinociception balance monitoring.

Methods: This retrospective, single-center cohort study reviewed all spinal cord stimulator procedures, including both trials and permanent implants. A standardized anesthetic protocol, administered by a single anesthesiologist, included target controlled infusions of propofol, remifentanil, and dexmedetomidine, with additional boluses of ketamine. Processed electroencephalogram guided sedation depth, and antinociception was assessed using the Analgesia Nociception Index. Data collected included drug doses, time to intraoperative awakening, hemodynamic stability, and airway management.

Results: A total of 25 procedures (11 trials, 14 permanent implants) were analyzed in 21 patients, with 4 patients undergoing both procedures. All patients received the same four-drug regimen. The median (interquartile range) minimum and maximum effect-site concentrations of propofol required to achieve an adequate level sedation (level - 4 of the Richmond Agitation-Sedation Scale) were 1 (0.5) µg/mL and 1.5 (0.8) µg/mL, respectively. The median (interquartile range) minimum and maximum effect-site remifentanil concentrations needed to achieve sufficient antinociception (Analgesia Nociception Index between 50 and 70) were 0.5 (0.3) ng/mL and 1.2 (0.4) ng/mL, respectively. The median (interquartile range) minimum and maximum effect-site concentrations of dexmedetomidine required to achieve adequate antinociception were 0.3 (0.1) ng/mL and 0.5 (0.1) ng/mL, respectively. The median (interquartile range) dose of ketamine was 25 (20) mg. The ketamine dose used during the implant was significantly higher than during the trial procedure (30 (30) vs. 20 (10) mg), p = 0.006. The average time to intraoperative awakening was 114 ± 56 s, and there was no significant difference between the trial and implant groups.

Conclusions: This study demonstrates the feasibility and safety of a multimodal sedation protocol for the placement of a spinal cord stimulator, combining propofol, remifentanil, dexmedetomidine, and ketamine, guided by electroencephalogram and nociception-antinociception monitoring.

Background: Opioid-free anesthesia (OFA) is an innovative approach to anesthesia management aimed at enhancing both the safety and the quality of perioperative outcomes. The efficacy and safety of these approaches are uncertain. The aim of our work was to compare the effectiveness and safety of different OFA regimens to opioid-based anesthesia (OBA).

Study design and methods: We conducted a systematic review and frequentist random-effects network meta-analysis of randomized controlled trials (RCTs). The primary outcome measure was the intensity of postoperative pain at 24 h, expressed in terms of numerical rating scale (NRS), visual analogue scale (VAS), or verbal rating scale (VRS) scores. The SUCRA was used to determine the likelihood that an intervention was ranked as the best. The certainty of the evidence was assessed according to the GRADE methodology for Network Meta-analysis (NMA).

Results: A total of 42 RCTs were included, for a total of 4666 patients. We have addressed the variety of available interventions. The random-effects network meta-analysis comparing OBA and different OFA regimens showed no difference in the pain intensity at 24 h. We performed the GRADE assessment for each comparison between each OFA regimen and OBA as a comparator. The certainty of evidence for the primary outcome ranges from moderate to very low among the different comparisons.

Conclusions: We have identified a significant heterogeneity in OFA regimens evaluated and a moderate to high risk of bias in over 70% of studies reporting the primary outcome. No OFA regimens showed a statistically significant effect over OBA in reducing postoperative pain within the first 24 h following surgery. Current evidence does not support the superiority of the analgesic efficacy of OFA in the immediate postoperative period compared to the use of opioids.

Trial registration: This study is registered in PROSPERO with the registration number CRD42024529236 (May 3, 2024).

Background: Limited resources during the COVID-19 pandemic made ICU admission decisions ethically complex. In Sweden, where ICU bed availability per capita is among the lowest in Europe, clinical judgment guided triage decisions, as prognostic scoring systems like the Clinical Frailty Scale (CFS) and Age-adjusted Charlson Comorbidity Index (ACCI) were not routinely used. This study aimed to compare patients considered eligible for intensive care with those for whom ICU admission was restricted and to evaluate whether a post hoc assessment of frailty and comorbidity aligned with clinical decision making.

Methods: This retrospective observational study included 204 COVID-19-positive patients admitted to a Swedish secondary hospital during the first pandemic wave. Patients were categorized as either eligible for intensive care (ICU group) or having a documented ICU admission restriction (ICU restriction group). Electronic medical records were reviewed to assign CFS and ACCI scores, and a combined score was calculated to better reflect overall frailty and comorbidity burden.

Results: The ICU group had a mean age of 68 years versus 83 years in the ICU restriction group. Of the ICU group, 26 out of 100 patients (26%) were ultimately admitted to intensive care. Median combined CFS + ACCI scores were 5 (IQR 5-6) in the ICU group and 12 (IQR 11-14) in the ICU restriction group; difference in score: 7 (95% CI, 6-8; p < 0.001). The combined score demonstrated clear separation between the groups with minimal overlap: in the ICU group, 95% of patients had a combined score below 8.3, while in the ICU restriction group, 95% of patients had a score above 8.4.

Conclusions: Marked contrasts in age, frailty, and comorbidity burden distinguished patients eligible for intensive care from those with an ICU admission restriction, reflecting a close correspondence between the prognostic scoring systems and clinical judgment. Integrating the CFS and ACCI into a single combined score sharpened the analysis and may prove useful in future research or as a triage tool, although further validation of this approach is warranted.

Background: Perineural dexamethasone is widely used as an adjuvant to local anesthetics in regional anesthesia to prolong analgesia. However, concerns persist regarding its potential neurotoxic effects, particularly when administered perineurally. This systematic review aims to synthesize preclinical evidence evaluating the neurotoxicity or neuroprotective properties of perineural dexamethasone.

Methods: A systematic search of PubMed, CENTRAL, Scopus, and Embase was conducted through May 22, 2025. Eligible studies included in vivo or in vitro preclinical models assessing the neurotoxic or neuroprotective effects of perineural dexamethasone compared to control conditions. Risk of bias was assessed using the SYRCLE tool for in vivo studies and a narrative evaluation for in vitro studies. A total of 14 studies (11 in vivo, 3 in vitro) met inclusion criteria.

Results: In vitro studies showed that dexamethasone alone was not neurotoxic at clinically relevant doses but could enhance cytotoxicity when combined with local anesthetics at higher concentrations. In vivo models generally demonstrated no significant long-term nerve inflammation, degeneration or demyelination, with some early protective effects observed in perineural dexamethasone groups. However, all in vivo studies were rated at high risk of bias. In nerve injury models, dexamethasone reduced apoptotic and inflammatory markers when administered immediately post-injury, with limited effect when delayed.

Conclusions: Preclinical evidence supports the general safety of low-dose, preservative-free perineural dexamethasone. Nonetheless, high-dose use, additives, and application in patients with neuropathies may pose risks. Given the high risk of bias in existing studies and minimal added benefit over systemic administration, clinical caution is advised.

Background: Proximal femur fractures in the elderly are a common and serious condition with high morbidity and mortality. Effective postoperative pain control reduces complications, hospital stay, and opioid use. The PEricapsular Nerve Group (PENG) block is a regional anesthesia technique offering motor-sparing analgesia, facilitating spinal anesthesia and early rehabilitation. However, higher local anesthetic (LA) doses may increase the risk of systemic toxicity, particularly in frail, sarcopenic patients. This study evaluates the analgesic efficacy and safety of two ropivacaine concentrations (0.375% vs 0.25%) in PENG blocks.

Methods: This prospective observational monocentric study included 217 patients (aged 65-100) undergoing surgery for osteoporotic proximal femur fractures. Patients received a 20-mL PENG block with either 0.375% or 0.25% ropivacaine prior to spinal anesthesia. Postoperative analgesia included paracetamol and ketorolac, with intramuscular morphine available as rescue. The primary endpoint was the proportion of patients requiring morphine; secondary outcomes included time to first rescue dose. Statistical analyses included chi-square testing, Kaplan-Meier estimates, and non-inferiority analysis (Δ = 0.05).

Results: The proportion of patients requiring rescue morphine was 23% in the 0.375% group and 25% in the 0.25% group (p = 0.87). Non-inferiority was demonstrated, with a difference of - 0.019 (95% CI: - 0.0344 to - 0.0036). No significant differences were observed in time to first rescue dose.

Conclusion: PENG block with 0.25% ropivacaine provides non-inferior analgesia compared to 0.375%, supporting its use in elderly patients to reduce opioid reliance and minimize the risk of local anesthetic systemic toxicity.

Trial registration: Not applicable.