Anesthesia and analgesia最新文献

Background: Childbirth can have a substantial impact on maternal health-related quality of life. Cesarean delivery is the most performed inpatient operation, yet little is known about normal postpartum recovery profiles. The primary aim of our study was to longitudinally evaluate global health visual analog scale (GHVAS; 0-100) scores up to 12 weeks after scheduled cesarean delivery and identify the time to plateau of scores. The secondary aims were to evaluate different domains of postpartum recovery using validated patient-reported outcome measures (Obstetric Quality of Recovery score [ObsQoR-10] and 5-level 5-dimensional EuroQol questionnaire [EQ-5D]).

Methods: After institutional review board approval, this single-center, prospective longitudinal study enrolled healthy women scheduled for cesarean delivery. Women were excluded for gestational age <32 weeks, neonatal demise, neonatal intensive care unit admission, inability to read or understand English, and if general anesthesia was used. Women completed baseline surveys before delivery and then at 24 and 48 hours after delivery. After hospital discharge, women completed surveys (including GHVAS, OBsQoR-10, EQ-5D, Edinburgh Postnatal Depression Scale, and activities of daily living) at 1 week, 3 weeks, 6 weeks, and 12 weeks postpartum. One-way repeated measures analysis of variance (ANOVA) was used to detect the difference in GHVAS and postpartum recovery outcomes with different follow-up time points.

Results: We enrolled 66 parturients and 3 were withdrawn. Response rates were 95%, 84%, 83%, and 76% at 1, 3, 6, and 12 weeks, respectively. Mean ± standard deviation [SD] GHVAS scores were 78 ± 16 at baseline, 64 ± 17 at 24 hours, 69 ± 15 at 48 hours, 75 ± 19 at 1 week, 88 ± 11 at 3 weeks, 88 ± 15 at 6 weeks, and 90 ± 12 at 12 weeks postpartum (P < .001). The global health VAS improved up until week 3 and then plateaued close to the maximum score between 3 weeks and 12 weeks postpartum. Mean ± SD ObsQoR-10 scores were 75 ± 15 at 24 hours, 85 ± 10 at 48 hours, and 81 ± 28 at 1 week postpartum (P = .003). The mean ± SD EQ-5D composite scores improved at 6 weeks (4.9 ± 2.9) and 3 months (4.2 ± 2.6) compared to baseline (6.5 ± 1.8) with usual activities (P = .001) and pain/discomfort (P < .001) showing significant improvement over time. ObsQoR-10 score at 24 hours correlated with ObsQoR-10 scores at 48 hours (r = 0.629, P < .001) and 1 week (r = 0.429, P < .001) but did not correlate with EQ-5D scores at 6 weeks and 12 weeks.

Conclusions: Our study demonstrates that GHVAS after scheduled CD plateaus at week 3. This data can be used to inform patients about the anticipated trajectory of key postpartum recovery domains up to 12 weeks postpartum.

Undertreated pain in children who undergo sternotomy for cardiac surgery can lead to cardiopulmonary complications, the development of chronic pain, and long-term maladaptive stress response. Opioids have dose-dependent side effects that may interfere with postoperative recovery. With the increasing availability of ultrasound, regional anesthesia is often included in multimodal analgesic approaches. Fascial plane blocks targeting the intercostal nerves or ventral rami are of particular interest for patients requiring full heparinization for cardiopulmonary bypass as they avoid manipulation of neuraxial and noncompressible paravertebral spaces. This narrative review summarizes the literature on fascial plane blocks for pediatric patients undergoing cardiac surgery via midline sternotomy and may serve as a guide for clinicians. Both prospective and retrospective studies are reviewed, as are prior review articles. We describe individual fascial plane block techniques including the transversus thoracic muscle plane, pectointercostal fascial plane, serratus anterior plane, and erector spinae plane blocks and provide clinical considerations for each block. Additionally, we provide an analysis of individual studies stratified by anterior or posterior approach and block type. The majority of described studies examine single-shot blocks; the existing catheter literature, which includes erector spinae plane block catheters, is also included. Our findings suggest that fascial plane blocks decrease intraoperative and postoperative opioid use, pain scores, time to extubation, and length of stay in the intensive care unit and hospital. Notably, prospective studies in this field are small, typically fewer than 100 patients, and overall include a homogenous patient population, focusing primarily on patients with acyanotic congenital heart defects. Nonetheless, despite the limitations of individual studies, there is substantial evidence to support the use of regional anesthesia, particularly for patients in whom early extubation is planned. There is a need for large, prospective multi-center studies to evaluate the effectiveness and safety of specific single-shot block types, optimal local anesthetic dosing strategies compared to active comparators, and generalizability of results across institutions. Future studies should also consider evaluating the role of regional block catheters for continuous local anesthetic infusion and the inclusion of additional surgical populations, including neonates, patients with cyanotic lesions, and those with longer postoperative mechanical ventilation courses.

Background: Advances in blood conservation have reduced the need for allogeneic transfusions in total knee and hip arthroplasty (TKA/THA). This study aimed to assess whether perioperative bleeding complications, including hemorrhage/hematoma, allogeneic transfusions, and postoperative anemia, occurred at similar rates between patients with hereditary bleeding disorders (BDs) and controls. Using a national health care database, we assessed the use of clotting factor concentrates (CFCs), perioperative outcomes, and resource utilization.

Methods: A retrospective cohort study was conducted using the Premier Health Database (2017-2021) to analyze differences in outcomes and costs between 1528 patients with hereditary BDs and 20,509 non-BD controls undergoing elective TKA and THA. Summary statistics, bivariate analyses, and odds ratios (ORs) were used to evaluate perioperative outcomes and resource use.

Results: Patients with hereditary BDs were slightly younger, predominantly female, and more often treated at larger, urban hospitals compared to controls. Bleeding complications, including hemorrhage and hematoma, were infrequent but higher in the BD group (1.1% vs 0.2%; P < .0001). Transfusion rates were higher in THA than TKA, with significantly increased odds for patients with hereditary BD: for THA, OR 2.7 (95% confidence interval [CI], 2.0-3.7; P < .0001); and for TKA, OR 2.6 (95% CI, 1.9-3.8; P < .0001). CFC exposures occurred in 16.4% of patients with hereditary BD compared to 0.03% in controls. Of 270 reported CFC exposures, factor VIII (FVIII) and von Willebrand factor (VWF) were most commonly used (49.6% and 23.0%, respectively), followed by FIX concentrate (12.6%) and bypassing agents, including FVIIa (8.5%) and anti-inhibitor coagulant complex (AICC; 3.7%). Antifibrinolytic therapy was administered in most cases. Pharmacy costs for patients with hereditary BD were significantly higher, with a mean of $23,792 (95% CI, $8722-$39,312), being over 30 times the mean cost in controls ($750; 95% CI, $739-$762). Other outcomes were not different, except for a higher incidence of venous thromboembolism in the BD group (OR 3.9, 95% CI, 2.4-6.1; P < .0001).

Conclusions: THA and TKA in patients with hereditary BDs are relatively safe, with most outcomes comparable to controls. However, higher rates of bleeding, transfusion, and VTE underscore the need for optimizing anemia management and targeted use of CFCs along with antifibrinolytic therapy.

Background: Critically ill patients who receive circulatory or respiratory assist using extracorporeal membrane oxygenation (ECMO) may develop hemolysis, which can complicate the delivery of supportive care and be a potential risk factor for increased morbidity and mortality. Clinically, hemolysis is often identified using laboratory markers such as cell-free hemoglobin (CFH) and haptoglobin (Hp). However, such measurements require photometry or enzyme-linked immunosorbent assay (ELISA) and are labor intensive. In contrast, metabolic downstream products of CFH, such as carboxyhemoglobin (CO-Hb) and methemoglobin (Met-Hb), can be regularly monitored via arterial blood gas analyses in the intensive care unit (ICU). We hypothesized that CO-Hb and Met-Hb values measured during ECMO would correlate with the presence of hemolytic events as measured by CFH values exceeding 50mg/dl. We further hypothesized that CO-Hb and Met-Hb levels would correlate with peri-ECMO mortality.

Methods: Retrospective analysis of 435 patients with acute respiratory distress syndrome (ARDS) and veno-venous ECMO admitted to a tertiary ARDS referral center. Plasma concentrations of CO-Hb and Met-Hb were correlated with hemolytic events. Cutoff values of mean CO-Hb (mCO-Hb) and mean Met-Hb (mMet-Hb) associated with increased ICU mortality were calculated with recursive binary partitioning. Single and multivariable regression models for HE and ICU mortality were trained and compared.

Results: Simple and multivariable models including potential confounders identified associations between Met-Hb and hemolytic events (adj. odds ratio [OR] 2.99 [95% confidence interval {CI}, 2.19-4.10], P < .001). A cutoff value with 90% specificity of a hemolytic event was estimated for Met-Hb (1.55%). Both, mean CO-Hb (OR 2.03 [95% CI, 1.60-2.61], P < .001) and Met-Hb (2.78 [1.59-5.09], P < .001) were associated with ICU mortality. Cutoff values for mortality were 2% for mean CO-Hb and 1.25% for mean Met-Hb. The multivariable regression model for mortality including the continuous markers mCO-Hb and mMet-Hb produced an area under the curve (AUC) of 0.803.

Conclusions: In patients with ARDS and ECMO, Met-Hb plasma concentrations were independently associated with hemolytic events. Both, mean CO-Hb and Met-Hb levels were associated with ICU mortality. These markers and their associated cutoff values might serve as a risk indicator in clinical practice.

Background: This study investigates the role of metabolic flexibility in determining perioperative outcomes. Metabolic flexibility, a key feature of metabolic health, is the ability to efficiently switch between different fuel sources (predominantly carbohydrates and fats) depending on energy demands and availability. Given the rapidly changing physiological conditions in the perioperative period, we hypothesized that good metabolic adaptability could mitigate postoperative complications.

Methods: We conducted a retrospective observational study utilizing a prospectively collected, single-center preoperative cardiopulmonary exercise testing (CPET) database of patients undergoing a range of major surgeries between 2012 and 2022. On day 3, patients were categorized into 3 groups based on their Postoperative Morbidity Survey (POMS) scores: 0 to 1, 2, and 3 to 6. Metabolic flexibility was evaluated through measurements of fat and carbohydrate oxidation during exercise testing (CPET). Associations were explored between metabolic flexibility, cardiorespiratory fitness, and postoperative outcomes.

Results: Of 585 patients, those with no or low postoperative day 3 morbidity (POMS 0-1; n = 204) demonstrated significantly higher fat oxidation early in exercise before anaerobic threshold (fatty acid oxidation [FATox] area under the curve [AUC] 826 [578-1147]) compared to both POMS 2 (658 [448-922; n = 268]) and POMS 3 to 6 (608 [414-845; n = 113]); both P < .001. POMS 0 to 1 patients also had more effective carbohydrate utilization at peak exercise intensity. Higher postoperative morbidity (POMS) categories were associated with diminished metabolic flexibility characterized by a reduced ability to switch between metabolic substrates-carbohydrate oxidation (CHOox) POMS 0 to 1 group AUC 10277 (interquartile range [IQR] 7773-13358) compared to POMS 2 AUC 8356 (IQR 6548-10377) and POMS 3 to 6 AUC 6696 (IQR 473-9392); both P < .001. Reduced metabolic flexibility correlated with increased postoperative complications and an extended hospital stay.

Conclusions: Metabolic flexibility may be a pivotal factor in determining postoperative outcomes. Patients with greater metabolic adaptability had fewer complications and shorter hospitalization by 4 days on average. This suggests that preoperative metabolic conditioning-something potentially achieved by targeted prehabilitation-could be linked to surgical recovery. Future research should focus on prospective studies to confirm these relationships and explore underlying mechanisms. If confirmed, metabolic flexibility assessments could be integrated into routine preoperative evaluation to better predict and improve patient outcomes.