Anaesthesia最新文献

We thank Liu et al. [1] for their careful reading of our article [2] and for their thoughtful comments. We are pleased to address the points raised and provide clarification. We acknowledge that node-split plots and the corresponding statistical outputs were not included in the published version of our article. This omission was not due to a lack of analysis and was instead to ensure only the most appropriate and relevant data and figures were included in the final version. We would be delighted to share any such data with anyone who requests it from the corresponding author.

We agree that consistency testing is an important aspect of any network meta-analysis. However, in this network, performing and reporting these results would not alter our main conclusions or affect the certainty ratings from the grading framework, which already classified most outcomes as low or very low certainty. Given the limited evidence base, we considered that further emphasis on consistency plots would add length without influencing interpretation materially. We nonetheless appreciate the reminder that such reporting enhances completeness and transparency.

We acknowledge that our discussion of publication bias could have been more wide-ranging. The Egger's test indicated a small-study effect, and we noted this limitation, but we agree that more explanation of possible sources and implications would have strengthened the discussion.

On the interpretation of the most effective intervention, the statement that the combination of dexmedetomidine and melatonin was the most effective intervention reflects the statistical output of surface area under the cumulative ranking curve and p score rankings, not a subjective assertion. We were careful to describe our findings with appropriate caution, noting the limited number of randomised trials and the low certainty of evidence.

On the apparent synergy between dexmedetomidine and melatonin, we appreciate the opportunity to clarify this point. Our discussion proposed potential synergism based on shared anti-inflammatory, neuroprotective and sedative mechanisms. However, we agree that further mechanistic exploration is warranted. The current literature provides only limited data to support specific pharmacodynamic interactions between these drugs.

On the diagnostic tools for delirium, most of the included trials indeed used the confusion assessment method (CAM) or CAM-ICU criteria. Unfortunately, several studies did not report their diagnostic tools clearly, which made subgroup analysis based on diagnostic methodology unfeasible without introducing further bias from missing data. We thank Liu et al. for their comments, which contribute to an important discussion on peri-operative neurocognitive protection. We hope that our clarifications address their concerns and reaffirm the transparency and methodological rigour of our work.

We thank Shah et al. for their comments [1] on the updated Association of Anaesthetists' safe vascular access guideline [2]. The lack of robust clinical evidence to support platelet transfusion thresholds has been acknowledged within the guidelines and supports the equipoise upon which the Thresholds for Platelets (T4P) trial is based. We await the future findings of this work, which will no doubt be invaluable in informing platelet thresholds in future guidelines. However, in the interim, the anaesthetic and critical care community requires guidance to support clinical decision-making, and our guidelines sought to advise the community based on knowledge and expertise that is currently available.

The use of viscoelastic testing has been well documented in cardiac surgery, liver transplant surgery and trauma [3]. Although there is no robust evidence for its use in central venous catheter insertion, it remains theoretically valid that it can provide valuable information regarding clot formation and strength. For example, the critical care population is highly heterogeneous, and coagulation abnormalities are common and varied [4]. The functional assessment of coagulation provided by viscoelastic testing is likely to be informative as well as a step towards the personalised care that these patients require. We recognise the use of viscoelastic testing in central venous catheter insertion as an area for further research and strongly encourage studies in this area. There is also a need to develop standardised protocols to guide use and interpretation due to a lack of familiarity with the technology and its output together with cost and resource constraints [5].

We reiterate that the updated safe vascular access guidelines are based on current available evidence, and we welcome initiatives such as the T4P trial which aims to provide the community with a strong evidence base to inform future guidelines.