Anesthesia and analgesia最新文献

Background: Administration of cholinesterase inhibitors in combination with anticholinergic drugs for reversal of neuromuscular blocks may precipitate delirium through impairment of central cholinergic transmission, which could be avoided by using sugammadex. Therefore, we tested the primary hypothesis that postoperative delirium is less common when neuromuscular block is reversed with sugammadex than with neostigmine combined with glycopyrrolate or atropine.

Methods: We conducted a single-center retrospective cohort study, analyzing all adult patients having general anesthesia for noncardiac surgery who received neostigmine or sugammadex from January 2016 to March 2022. Inverse propensity score weighting and propensity score calibration were used to adjust for appropriate confounders. Our primary outcome was presence of delirium within the first 4 days after surgery, defined as at least 1 positive brief Confusion Assessment Method (bCAM) screening. The secondary outcome was the presence of early delirium within 24 hours of surgery.

Results: Among 49,468 cases in our analysis, 6881 received sugammadex and 42,587 received neostigmine. After propensity weighting, the incidence of delirium was 1.09% in the sugammadex group and 0.82% in the neostigmine group. The odds of postoperative delirium did not differ between the sugammadex and neostigmine groups, with an estimated odds ratio (95% confidence interval) of 1.33 (0.91-1.95), P = .147. A sensitivity analysis restricted to only include cases with at least 6 bCAM measurements over postoperative day (POD) 1 to 4 had consistent results, as sugammadex compared with neostigmine was associated with an estimated odds ratio for postoperative delirium of 1.20 (0.82-1.77), P = .346. Sugammadex was significantly associated with an increased incidence of early postoperative delirium, with an estimated odds ratio of 1.71 (1.07-2.72), P = .025. Further analysis showed no treatment-by-age interaction for either postoperative delirium ( P = .637) or postoperative early delirium ( P = .904).

Conclusions: Compared to neostigmine, use of sugammadex for reversal of neuromuscular block was not associated with an increased risk of postoperative delirium in this retrospective single-center study. Though sugammadex was associated with a statistically significant increased risk of postoperative early delirium, the difference was small and not clinically relevant, and may reflect the presence of unknown confounders.

The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.

James Watt (1736-1819) is remembered as a steam engine innovator and industrial magnate. A polymath, he was also a hands-on contributor to the Medical Pneumatic Institution of Thomas Beddoes. Watt recruited Humphry Davy, who there discovered analgesic action of inhaled nitrous oxide in 1799. Watt also built pneumatic equipment, and he introduced a gas mixture, dubbed hydro-carbonate, as a medical tonic. The bioactive component was carbon monoxide, a readily-lethal inhibitor of the transport and utilization of respiratory oxygen. Despite appreciable toxicity, carbon monoxide is an endogenous product of heme catabolism, and low doses of the gas are under laboratory investigation for therapeutic purposes. However, Watt's hydro-carbonate constituted a setback in the development of pharmacologically useful gases.

Background: Obstructive sleep apnea is associated with increased dementia risk, yet its role in postoperative neurocognitive disorders is unclear. Here, we studied whether the severity of untreated obstructive sleep apnea is associated with the severity of postoperative neurocognitive disorder.

Methods: In this single-center prospective cohort study, older noncardiac surgery patients aged 60 years and above underwent preoperative home sleep apnea testing, and pre- and postoperative delirium assessments and cognitive testing. Sleep apnea severity was determined using the measured respiratory event index (REI). Global cognitive change from before to 6 weeks (and 1 year) after surgery was used to measure postoperative neurocognitive disorder severity. Postoperative changes in individual cognitive domain performance along with subjective cognitive complaints and/or deficits in instrumental activities of daily living were used to measure postoperative neurocognitive disorder incidence.

Results: Of 96 subjects who completed home sleep apnea testing, 58 tested positive for sleep apnea. In univariable analyses, sleep apnea severity was not associated with increased postoperative neurocognitive disorder severity at 6 weeks (global cognitive change ; [95% confidence interval [CI], -0.02 to 0.03]; P = .79) or 1-year after surgery (; [95% CI, -0.02 to 0.03]; P = .70). Adjusting for age, sex, baseline cognition, and surgery duration, sleep apnea severity remained not associated with increased postoperative neurocognitive disorder severity at 6 weeks (; [95% CI, -0.02 to 0.04]; P = .40) or 1-year after surgery (; [95% CI, -0.02 to 0.04]; P = .55). In a multivariable analysis, sleep apnea severity was not associated with postoperative neurocognitive disorder (either mild or major) incidence at 6 weeks (odds ratio [OR] = 0.89, [95% CI, 0.59-1.14]; P = .45) or 1-year postoperatively (OR = 1.01, [95% CI, 0.81-1.24]; P = .90). Sleep apnea severity was also not associated with postoperative delirium in univariable analyses (delirium incidence OR = 0.88, [95% CI, 0.59-1.10]; P = .37; delirium severity ; [95% CI, -0.02 to 0.03]; P = .79) or in multivariable analyses (delirium incidence OR = 1.07, [95% CI, 0.81-1.38]; P = .74; delirium severity OR = 0.95, [95% CI, 0.81-1.10]; P = .48).

Conclusions: In this older noncardiac surgery cohort, untreated sleep apnea was not associated with increased incidence or severity of postoperative neurocognitive disorder or delirium.

Background: Postoperative esophageal pain occurs in 67% of patients after peroral endoscopic esophageal myotomy (POEM). Magnesium can act as a smooth muscle relaxant. This study investigated whether intraoperative magnesium can reduce postoperative esophageal pain in patients undergoing POEM.

Methods: In this double-blind, placebo-controlled trial, 92 patients were randomized to receive either magnesium sulfate as a 50 mg.kg -1 (total body weight) bolus followed by an infusion at 25 mg.kg -1 .hr -1 , or 0.9% saline. Intraoperative analgesia was standardized in all patients. The primary outcome was the score from a validated, modified Esophageal Symptoms Questionnaire (ESQ) in the postanesthesia care unit (PACU). Pain scores, opioid requirements, and questionnaire scores were collected through postoperative day 1.

Results: ESQ scores were significantly lower in the magnesium group in the PACU (median [25th-75th], 24 [18-31] vs 35 [28-42]; median difference [95% confidence interval, CI], 10 [6-13]; P < .0001) and on postoperative day 1 (16 [14-23] vs 30 [24-35]; P < .0001). Less opioids were needed in the magnesium group in the PACU (mean ± standard deviation [SD] [99% CI], 4.7 ± 10 [1-9] mg vs 29 ± 21 [21-37] mg; P < .0001) and on postoperative day 1 (1 ± 3.7 [0-2.5] mg vs 13 ± 23 [4-23] mg; P = .0009). Pain scores were lower in the magnesium group in the PACU (0 [0-3] vs 5 [5-7]; P < .0001) and on postoperative day 1 (0 [0-2] vs 4 [3-5]; P < .0001).

Conclusions: Patients undergoing POEM randomized to receive intraoperative magnesium had sustained reductions in esophageal discomfort severity and opioid requirements 24 hours after surgery.