Anesthesia and analgesia最新文献

Background: Obstetric patient blood management (PBM) strategies were used at Corniche Hospital in 2018, initially focusing on minimizing bleeding, with other clinical strategies implemented incrementally. This study assesses program outcomes in patients with major obstetric hemorrhage of 2000 mL or greater.

Methods: A retrospective study of 353 women admitted to The Corniche Hospital between 2018 and 2023 who experienced major obstetric hemorrhage of 2000 mL or greater. The primary outcome measure was units of red blood cell (RBC), fresh-frozen plasma (FFP), and platelet units transfused. Secondary outcomes included pretransfusion hemoglobin in patients with no active bleeding, hemoglobin levels 3 weeks postdischarge, anemia predelivery, blood product-acquisition cost savings, mortality, composite morbidity (transfusion reaction, acute lung injury, thrombosis, sepsis, postpartum hysterectomy), hospital and high-dependency unit length of stay, and all-cause emergency readmissions within 28 days.

Results: Comparing baseline (2018) with the final year (2023), the mean units of RBCs, FFP, and platelets transfused per admission decreased from 4.18 to 0.67 (P-trend <.001), resulting in blood acquisition savings of US$ 175,705. Over the same period the percentage of women anemic predelivery decreased from 40.3% to 23.8% (P-trend = 0.015) and the mean pretransfusion hemoglobin level in nonactively bleeding patients decreased from 7.54 g/dL to 6.35 g/dL (P-trend < .001). The mean hemoglobin rise 3 weeks postdischarge increased from 2.41 g/dL in 2018 to 4.26 g/dL in 2023. There were no changes in adjusted composite morbidity, hospital, or high-dependency unit length of stay.

Conclusions: In women with a major obstetric hemorrhage of 2000 mL or greater, the implementation of an obstetric PBM program was associated with reduced blood product utilization, reduced costs, reduced anemia, and increased hemoglobin rise postdischarge.

Background: Packed red blood cell (pRBC) transfusions in patients undergoing surgery for cancer are given to treat anemia or acute hemorrhage. Evidence indicates that pRBC transfusions are associated with poor perioperative and oncological outcomes. The ARCA-1 (Perioperative Care in the Cancer Patient-1) study was designed to test the association between perioperative pRBC transfusions and postoperative morbidity and mortality in patients undergoing cancer surgery. The primary hypothesis of our study was that perioperative pRBC transfusions have a negative impact on postoperative morbidity and 1-year mortality.

Methods: ARCA-1 was an international multicenter prospective observational cohort study. Participating centers enrolled a minimum of 30 consecutive adult patients with cancer who underwent surgery with curative intent. The primary end point was all-cause mortality 1 year after major cancer surgery. Secondary end points were rates of perioperative blood product use, 1-year cancer-specific mortality, overall survival, and 30-day morbidity and mortality. We performed a propensity score matching analysis to adjust for selection bias. A multivariable logistic regression model was fitted to estimate the effects of significant covariates on 1-year mortality, cancer-related mortality, and overall survival.

Results: A total of 1079 patients were included in the study. The rate of perioperative pRBC transfusions was 21.1%. Preoperative comorbidities, including anemia, American Society of Anesthesiologists (ASA) score of III to IV, a history of coronavirus disease 2019 (COVID-19), myocardial infarction, stroke, need for dialysis, history of blood transfusions, and metastatic disease were statistically significantly more frequent in transfused patients compared to nontransfused patients. The 1-year mortality rate was higher in transfused patients before (19.7% vs 6.5%; P < .0001) and after (17.4% vs 13.2%; P = .29) propensity score matching. 1-year mortality was 1.97 times higher in transfused than in no-transfused patients (odd ratio [OR], 1.97; 95% confidence interval [CI], 1.13-3.41). The odds of 1-year cancer mortality for patients who had perioperative pRBCs was 1.82 times higher (OR, 1.82; 95% CI, 0.97-3.43) compared to those who did not receive perioperative pRBC transfusion. The effect of perioperative pRBC transfusion on overall survival was also significant (hazard ratio [HR], 1.85; 95% CI, 1.15-2.99). Transfused patients also had a higher rate of 30-day postoperative mortality before (3.5% vs 0.7%; P = .0009) and after propensity score matching (4.2% vs 1.8%; P = .34).

Conclusions: This international, multicenter observational study showed that perioperative pRBC transfusion was associated with an increased mortality risk.

Background: Hypertensive disorders of pregnancy (HDP) are a major contributor to maternal morbidity, mortality, and accelerated cardiovascular (CV) disease. Comorbid conditions are likely important predictors of CV risk in pregnant people. Currently, there is no way to predict which people with HDP are at risk of acute CV complications. We developed and validated a predictive model for all CV events and for heart failure, renal failure, and cerebrovascular events specifically after HDP.

Methods: Models were created using the Premier Healthcare Database. The inclusion criteria for the model dataset were delivery with an HDP with discharge from October 1, 2015 to December 31, 2020. Machine learning methods were used to derive predictive models of CV events occurring during delivery hospitalization (Index Model) or during readmission (Readmission Model) using a training set (60%) to estimate model parameters, a validation set (20%) to tune model hyperparameters and select a final model, and a test set (20%) to evaluate final model performance.

Results: The total model cohort consisted of 553,658 deliveries with an HDP. A CV event occurred in 6501 (1.2%) of the delivery hospitalizations. Multilabel neural networks were selected for the Index Model and Readmission Model due to favorable performance compared to alternatives. This approach is designed for prediction of multiple events that share risk factors and may cooccur. The Index Model predicted all CV events with area under the receiver operating curve (AUROC) 0.878 and average precision (AP) 0.239 (cerebrovascular events: AUROC 0.941, heart failure: AUROC 0.898, and renal failure: AUROC 0.885). With a positivity threshold set to achieve ≥90% sensitivity, model specificity was 65.0%, 83.5%, 68.6%, and 65.6% for predicting all CV events, cerebrovascular events, heart failure, and renal failure, respectively. CV events within 1 year of delivery occurred in 3018 (0.6%) individuals. The Readmission Model predicted all CV events with AUROC 0.717 and AP 0.022 (renal failure: AUROC 0.748, heart failure: AUROC 0.734, and cerebrovascular events AUROC 0.698). Feature importance analysis indicated that the presence of chronic renal disease, cardiac disease, pulmonary hypertension, and preeclampsia with severe features had the greatest effect on the prediction of CV events.

Conclusions: Among individuals with HDP, our multilabel neural network model predicted CV events at delivery admission with good classification and events within 1 year of delivery with fair classification.

Cannabis has been used for recreation and medical purposes for more than a millennium across the world; however, its use's consequences remain poorly understood. Although a growing number of surgical patients are regular cannabis consumers, little is known regarding the pharmacological interactions between cannabis and general anesthetics; consequently, there is not a solid consensus among anesthesiologists on the perioperative management of these patients. The existing evidence about the molecular mechanisms underlying pharmacological interactions between cannabinoids and anesthetic agents, both in animal models and in humans, shows divergent results. While some animal studies have demonstrated that phytocannabinoids (tetrahydrocannabinol [THC], cannabidiol [CBD], and cannabinol [CBN]) potentiate the anesthetic effects of inhalation and intravenous anesthetics, while others have found effects comparable with what has been described in humans so far. Clinical studies and case reports have consistently shown increased requirements of GABAergic anesthetic drugs (isoflurane, sevoflurane, propofol, midazolam) to achieve adequate levels of clinical anesthesia. Several potential molecular mechanisms have been proposed to explain the effects of these interactions. However, it is interesting to mention that in humans, it has been observed that the ingestion of THC enhances the hypnotic effect of ketamine. Animal studies have reported that cannabinoids enhance the analgesic effect of opioids due to a synergistic interaction of the endogenous cannabinoid system (ECS) with the endogenous opioid system (EOS) at the spinal cord level and in the central nervous system. However, human data reveals that cannabis users show higher scores of postoperative pain intensity as well as increased requirements of opioid medication for analgesia. This review aims to improve understanding of the molecular mechanisms and pharmacological interactions between cannabis and anesthetic drugs and the clinical outcomes that occur when these substances are used together.

Background: This study aimed to investigate the associations of 2 preoperative muscle-related parameters, the third lumbar vertebra skeletal muscle index (L3 SMI) for muscle mass and the Hounsfield unit average calculation (HUAC) for muscle density, with the occurrence of postoperative complications among patients undergoing colorectal tumor resection surgery under general anesthesia. We hypothesized that muscle-related parameters are associated with the occurrence of postoperative complications.

Methods: This was a single-center, retrospective observational study. Adult patients who underwent colorectal tumor resection surgery under general anesthesia between 2018.09.01 and 2021.09.01 were enrolled. The last abdominal computed tomography (CT) scan images obtained within 3 months before surgery were used to calculate the L3 SMI and HUAC. The primary outcome was defined as the occurrence of any postoperative complications corresponding to Clavien-Dindo classification before discharge. The secondary outcome was defined as the occurrence of any severe postoperative complications (Clavien-Dindo grade ≥3) before discharge. Multivariable logistic regression analyses were used to estimate the association between muscle-related parameters and incidence of postoperative complications. Patients' baseline demographics, past medical history and intraoperative parameters were adjusted in the multivariable logistic regression analysis.

Results: A total of 317 patients with a median age of 66 (58-72) years were included. Sarcopenia (muscle mass reduction) patients in our cohort and myosteatosis (muscle density decline) were present in 254 (80.1 %) and 79 (24.9%) patients, respectively. A total of 135 patients (42.6 %) developed postoperative complications. According to the multivariable logistic regression, myosteatosis (odds ratio [OR], 1.8, 95% confidence interval [CI], 1.0-3.3, P = .039) was significantly associated with postoperative complications.

Conclusions: A significant association was observed between myosteatosis and postoperative complications (corresponding to Clavien-Dindo classification before discharge), especially severe postoperative complications (Clavien-Dindo grade ≥3) in patients undergoing colorectal tumor resection. Screening for myosteatosis with HUAC using the CT before surgery may help clinicians identify high-risk perioperative patients early.

Background: Mothers in Africa are 50 times more likely to die after cesarean delivery (CD) than in high-income countries, largely due to hemorrhage. It is unclear whether countries across Africa are adequately equipped to prevent and treat postpartum hemorrhage (PPH) during and after CD.

Methods: This was a cross-sectional survey of anesthesiologists and obstetricians across the African Perioperative Research Group (APORG). The primary objective was to determine readiness of the hospital system to implement the World Health Organization (WHO) recommendations for prevention and treatment of PPH during and after CD. The secondary objectives were to evaluate the availability of blood products, skilled human resources and establish available postoperative care after CD. Survey question format was close-ended or Likert scale, with options "always," "sometimes," or "never."

Results: Responses were analyzed from 1 respondent from each of 140 hospitals from 29 low- and middle-income countries across Africa. Most respondents completed every data field on the case report form. Regarding WHO recommendations on prevention of PPH, oxytocin and misoprostol were available in 130/139 (93.5%) and 101/138 (73.2%) hospitals, respectively. There was limited access to heat-stable carbetocin (12/138 [8.7%]) and ergometrine (35/135, [25.9%]). Controlled cord traction for removal of placenta was always performed in 133/135 (98.5%) hospitals. Delayed cord clamping when neonatal resuscitation was not indicated, was not performed universally (86/134 [64.2%]). Regarding the treatment of PPH, crystalloids were always available in 133/139 (95.7%) hospitals, and the preferred initial resuscitation fluid (125/138 [90.6%]). Uterine massage was always performed in 117/139 (84.2%) hospitals. Tranexamic acid was always available in 97/139 (69.8%) hospitals. The availability of intrauterine balloon tamponade devices was limited. Most had immediate access to theater (126/139 [90.6%]). Responses concerning organizational recommendations showed that 113/136 (83.1%) hospitals had written protocols for the treatment of PPH. Protocols for patient referral and simulation training were limited. Most hospitals had access to emergency blood (102/139 [73.4%]). There was limited access to blood component therapy, with platelets available at 32/138 (23.2%), cryoprecipitate at 21/138 (15.2%) and fibrinogen at 11/139 (7.9%) hospitals. In-person specialist cover was reduced after-hours.

Conclusions: Important WHO-recommended measures to reduce hemorrhage during and after CD, are not currently available in many hospitals across Africa. It is likely that the lack of a combination of factors leads to failure to rescue mothers in Africa from postoperative complications. These findings should facilitate codesign of quality improvement initiatives to reduce hemorrhage related to CD.

Earthquakes pose hazards to health care workers and patients in operating rooms. Proactive planning based on insights gained from past experiences is crucial for enhancing safety. Through a comprehensive literature review, we summarize challenges and lessons learned from real earthquake events to inform the development of effective safety measures in operating rooms. Additionally, we discuss the anesthesiologist's role in crisis management.