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

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.

Efficiency in the operating room is often considered either in terms of clinical excellence or in terms of performance optimization through managerial approaches. However, these dichotomous models-clinician-centered versus engineer-led-fail to capture the complexity of modern surgical care. This paper therefore proposes a multidisciplinary model in which the anesthetist plays a central role, acting as an integrator of clinical needs and organizational logistics. As new technologies emerge, they should support a comprehensive vision that combines patient-centered care with organizational and technological considerations. This approach should complement, rather than replace, clinical judgment.

Background: Post-extubation sore throat (PEST), cough, and hoarseness are common complications of tracheal intubation. Several agents and techniques have been postulated to reduce their occurrence.

Aim: This study sought to compare the effects of intravenous and intra-cuff magnesium sulphate on the incidence and severity of PEST, cough and hoarseness of voice.

Materials and methods: This was a randomised single-blind study involving 90 surgical patients requiring endotracheal intubation. Patients were randomised into 3 groups: A (control), B (intra-cuff magnesium sulphate) and C (intravenous magnesium sulphate). Participants in Group A had the endotracheal tube cuff (ETTc) inflated with air to a pressure of 25 cmH₂O whilst those in Group B had the ETTc inflated with 2 g of magnesium sulphate solution and the pressure adjusted to 25 cmH₂O with top-ups of 0.9% normal saline. Participants in Group C had the ETTc filled with air to a pressure of 25 cmH₂O and received 2 g of intravenous magnesium sulphate in 20 ml of 0.9% normal saline perfused over 10 min immediately prior to the induction of general anaesthesia. The occurrence of PEST, cough and hoarseness of voice were recorded at 0, 4, 8, 12 and 24 h after surgery.

Results: The incidence of PEST on swallowing in the intra-cuff magnesium sulphate group compared to the intravenous magnesium sulphate group at 4, 8, and 12 h post-operatively were 51.7% vs 12.5%, 51.7% vs 18.8% and 51.7% vs 21.9% respectively. Compared to intra-cuff magnesium sulphate, intravenous magnesium sulphate significantly reduced the incidence and severity of PEST during swallowing at 4, 8, and 12 h. The incidence of PEST at rest in the intra-cuff magnesium sulphate group compared to the intravenous magnesium sulphate group at 0, 4, 8, 12 and 24 h post-operatively were 13.8% vs 9.4%, 20.7% vs 6.3%, 17.2% vs 6.3%, 13.8% vs 3.1% and 13.8% vs 3.1% respectively. Compared to intra-cuff magnesium sulphate, intravenous magnesium sulphate reduced the incidence of PEST at rest, though this was not statistically significant over first 24 h postoperative period. Intravenous magnesium sulphate had significantly lower PEST severity scores at rest at 12 h only compared to intra-cuff magnesium sulphate. There was no statistically significant difference in the incidence and severity of cough and hoarseness between the study groups.

Conclusion: Intravenous magnesium sulphate given at induction was found to be better compared to intra-cuff magnesium sulphate in lowering the incidence and severity of post-extubation sore throat on swallowing but not at rest. However, it does not significantly reduce the incidence or severity of post-extubation cough or hoarseness.

Trial registration: PACTR202211634990263.