Anesthesia and analgesia最新文献

Traumatically injured patients often require emergency intubation of their tracheas. Yet, they present distinct airway challenges, such as anatomic deformities, the need for cervical spine immobilization, diminished physiologic reserve, and logistical hurdles like limited equipment or personnel. In this patient population, both videolaryngoscopy and direct laryngoscopy offer distinct advantages and disadvantages, but current evidence remains inconclusive as to which approach is superior. We conducted a systematic review to determine whether videolaryngoscopy offered higher first-pass success rates than direct laryngoscopy for trauma patients requiring emergency intubation of their tracheas on arrival into the hospital setting. Although the data remain heterogeneous, videolaryngoscopy generally results in noninferior or improved first-pass success rates without significantly increasing complication rates. We conclude that, while providers should choose their initial airway device on an individualized basis, the use of videolaryngoscopy for initial airway management is a reasonable choice for intubation of traumatically injured patients' tracheas, particularly in the presence of cervical spine immobilization.

Background: Ultrasound-guided transforaminal (USF) injections have been proposed as a faster and more easily accessible alternative to traditional radioscopic methods for cervical radicular pain, but their efficacy and safety in cervical spine interventions remain uncertain.

Methods: Pubmed, Embase, and Cochrane Library were searched for studies comparing ultrasound (US)-guided cervical transforaminal injections versus traditional radioscopic methods of epidural injection for patients 1104. We computed standardized mean differences (SMD) for continuous pain outcomes, mean differences (MD) for neck disability index (NDI) and time procedure, odds ratios (OR) for binary outcomes, with 95% confidence intervals (CI).

Results: We included 7 studies, comprising 1104 patients. USF technique was used in 537 patients (48.6%). Pain and disability outcomes were comparable between groups, respectively (SMD = 0.15; 95% CI, -0.01 to 0.31; P = 0.04; I2 = 21%) and (MD = 0.56; 95% CI, -0.28 to 1.39; P = .03; I2 = 0%). US guidance significantly reduced vascular injection risk (OR = 0.13; 95% CI, 0.07-0.25; P < .00001; I2 = 0%) and reduced the procedure time (MD = -158; 95% CI, -228 to -90; P < .00001; I2 = 70%).

Conclusions: In 537 patients with cervical radicular pain, USF techniques were associated with a lower incidence of intravascular injection and a shorter procedure time compared with radioscopic-guided methods, while no significant differences were observed in pain or NDI outcomes.

Background: Preoperative fasting practices can influence patient outcomes. Prolonged fasting can occur due to unclear instructions, misunderstandings, anxiety, and scheduling uncertainty. The aim of this study was to determine preoperative fluid-fasting time (FFT) in clinical practice and to assess how shorter FFT could impact patients and healthcare resources.

Methods: A multicenter, retrospective observational analysis including 15,837 patients extracted from the Safe Brain Initiative care bundle (SBI-CB) database is presented. A part of the SBI-CB was to encourage FFT to be reduced to 2 hours as per guidelines. Four hospitals from Denmark and Turkey participated. Patients were >18 years old, scheduled for surgery, and able to communicate with healthcare staff. The primary outcomes were FFT, in hours, and the proportion of patients adherent to short FFT (2-4 hours) per month since the SBI-CB was initiated at each hospital. Secondary outcomes, comparing short with long (5-24 hours) FFT, included postoperative delirium in the recovery room, hospital length of stay in hours, and patient-reported outcome measures (PROMs) including thirst, pain, nausea/vomiting, stress/anxiety, and well-being. Sex, age, American Society of Anesthesia Physical Status Classification System category, surgery time, and use of general anesthesia were controlled for confounding effects by a one-to-many patient matching. Logistic and linear regressions were performed to adjust for the same confounding effects in addition to delirium at induction and site for the outcomes postoperative delirium and hospital stay.

Results: Median (Q1-Q3) FFT was 5 (4-8) hours with a mean of 6.3 hours. 40.3% of patients adhered to the short FFT protocol of 2 to 4 hours. Prolonged FFT of at least 12 hours was experienced by 11.9% of patients. A significant positive correlation between SBI-CB implementation month and adherence to short FFT was observed (r = 0.7, P < .001). When comparing matched patients with short and long FFT, median hospital stay was significantly reduced by 18.0 hours (P < .001). Using logistic regression, short FFT was associated with a significant reduction in postoperative delirium with a log odds ratio [95% confidence interval] of 0.7 [0.6-0.8], P < .001. All measured PROMs were improved significantly with most benefits observed postoperatively.

Conclusion: Adherence to a short FFT could be increased over time; however, many patients still experienced an FFT that should be considered too long. Implementation of short FFT was linked to enhanced patient outcomes and more efficient healthcare resource utilization. These findings underscore the importance of optimizing preoperative fasting practices to improve patient care and healthcare efficiency.

Background: Haptoglobin may reduce hemolysis-induced kidney injury in patients undergoing cardiovascular surgery with cardiopulmonary bypass (CPB). Haptoglobin may be given empirically when hemolytic urine is observed, or pre-emptively when detected by elevated free hemoglobin concentrations. In the present study, we investigated whether pre-emptive haptoglobin therapy guided by serum-free hemoglobin concentrations could prevent postoperative renal dysfunction in patients who underwent major cardiovascular surgery using CPB.

Methods: This study was a single-center, open-label, randomized controlled trial. Adult patients who underwent major cardiovascular surgery using CPB were included. Serum-free hemoglobin concentrations were measured in all patients who consented for this study. Patients with free hemoglobin concentrations that reached 0.05 g/dL were randomized to either (i) pre-emptive haptoglobin therapy group or (ii) standard of care group. Patients in the pre-emptive haptoglobin therapy group were administered 4000 U of haptoglobin when serum-free hemoglobin concentration reached 0.05 g/dL within 2 hours after the start of CPB. In the standard of care group, 4000 U of haptoglobin was administered when hemolytic urine was confirmed after the start of CPB. The primary outcome was the difference between the preoperative creatinine concentration and the maximum creatinine concentration within 48 hours after surgery (ΔCr).

Results: The study was terminated with the results of interim analysis due to patients' safety concerns. Finally, 34 patients in the pre-emptive haptoglobin therapy group and 33 in the standard of care group were included in the analysis. Median (interquartile range) ΔCr values were 0.20 (0.05-0.44) in the pre-emptive haptoglobin therapy group and 0.14 (0.04-0.19) in the standard of care group (P = .05). Multiple linear regression analysis with ΔCr as objective variable and preoperative estimated glomerular filtration rate (eGFR), age, and randomize group as explanatory variables revealed that pre-emptive administration of haptoglobin significantly increased ΔCr (P = .03).

Conclusions: The interim study results demonstrated that in patients undergoing major cardiovascular surgery using CPB, pre-emptive haptoglobin administration worsened Cr values and independently associated with increased ΔCr.

Background: The complexity of patients undergoing cardiac surgery underscores the need to improve understanding of the factors that augment or predict risks of adverse postoperative outcomes. Our study set out to determine the extent to which postoperative fluid imbalance is related to clinically important outcomes following elective cardiac surgery.

Methods: In this retrospective cohort study, we studied 2557 elective coronary artery bypass graft (CABG) and/or valve surgery patients at an academic medical center from 2015 to 2020. We examined the relationship between cumulative fluid balance during intensive care unit (ICU) stay and subsequent clinical outcomes. We considered cumulative fluid balance as both a continuous and categorical variable based on cohort-based tertiles: negative (

Results: The primary outcome occurred in 7.0% (n = 60), 2.3% (n = 20), and 9.3% (n = 79) of patients in the negative, neutral, and positive groups, respectively. In multivariable-adjusted analyses, cumulative fluid balance as a continuous variable demonstrated a U-shaped relationship with the primary outcome, with thresholds of significantly elevated risk observed at negative 1380 mL and positive 1700 mL. In multivariable-adjusted analyses of cumulative fluid balance as a categorical variable, patients who left the ICU with either negative (odds ratio 2.76 [95% confidence interval {CI}, 1.62-4.70]; P < .01) or positive cumulative fluid balance (3.53 [2.09-5.96]; P < .01) had higher risk for the primary outcome compared to those with a neutral cumulative fluid balance.

Conclusions: A negative or positive cumulative fluid balance on the day of ICU discharge was associated with ~3 to 4 times greater odds of adverse postoperative outcomes, respectively, which was further elevated when fluid imbalance exceeded ~1.5 L. Our findings suggest that postoperative cumulative fluid balance in real-world practice, particularly for elective cardiac surgery patients, warrants greater attention.

Background: Patients' perception of their health outcomes after surgery has become increasingly important in perioperative medicine. This study aimed to evaluate whether emergence delirium in the postanesthesia care unit (PACU) has a relevant impact on self-reported quality of recovery on the first postoperative day.

Methods: This prospective observational cohort study was conducted in a German tertiary care university hospital. Patients ≥60 years, scheduled for elective noncardiac surgery were included. Patients were screened for the presence of delirium signs 30 minutes after arrival in the PACU using the 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM). Self-reported quality of recovery after surgery was assessed with the German version of the Quality of Recovery-15 questionnaire (QoR-15GE), which patients completed preoperatively and on the first postoperative day. The association between emergence delirium and self-reported quality of recovery was analyzed using a linear multivariable regression model taking into account covariates with a potential impact on recovery after surgery.

Results: A total of 428 patients were tested for emergence delirium. Of these, 397 were assessed for self-reported quality of recovery on the first postoperative day. The incidence of emergence delirium was 32.9% (141/428). Patients with emergence delirium showed a greater decline in QoR-15GE sum scores from pre- to postoperative (difference between preoperative and postoperative QoR-15GE sum scores [ΔQoR-15GE]), with a mean difference (± standard deviation [SD]) of 32.8 ± 25.3, compared to 21.6 ± 26.6 in patients without emergence delirium. The between-group difference was 11.2 points (95% confidence interval [CI], 5.5-16.8; P < .001). After adjusting for potentially confounding covariates, the negative impact of emergence delirium on ΔQoR-15GE (adjusted effect 10.11 [95% CI, 4.99-15.23]; P < .001) remained significant.

Conclusions: In a heterogeneous cohort of elderly patients who underwent elective noncardiac surgery, we found a significant negative impact of emergence delirium on self-reported quality of recovery on the first postoperative day. Our findings suggest that the presence of delirium symptoms in the PACU may be an important determinant of patient comfort after surgery.