Anesthesia and analgesia最新文献

Pain management in pregnant and postpartum people with an opioid-use disorder (OUD) requires a balance between risks associated with opioid tolerance, including withdrawal or return to opioid use, considerations around social needs of the maternal-infant dyad, and the provision of adequate pain relief for the birth episode that is often characterized as the worst pain a person will experience in their lifetime. This multidisciplinary consensus statement between the Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal-Fetal Medicine (SMFM), and American Society of Regional Anesthesia and Pain Medicine (ASRA) provides a framework for pain management in obstetric patients with OUD. The purpose of this consensus statement is to provide practical and evidence-based recommendations and is targeted to health care providers in obstetrics and anesthesiology. The statement is focused on prenatal optimization of pain management, labor analgesia, and postvaginal delivery pain management, and postcesarean delivery pain management. Topics include a discussion of nonpharmacologic and pharmacologic options for pain management, medication management for OUD (eg, buprenorphine, methadone), considerations regarding urine drug testing, and other social aspects of care for maternal-infant dyads, as well as a review of current practices. The authors provide evidence-based recommendations to optimize pain management while reducing risks and complications associated with OUD in the peripartum period. Ultimately, this multidisciplinary consensus statement provides practical and concise clinical guidance to optimize pain management for people with OUD in the context of pregnancy to improve maternal and perinatal outcomes.

Niels Lassen's seminal 1959 cerebral autoregulation plot, a cornerstone in understanding the relationship between mean arterial pressure (MAP) and cerebral blood flow (CBF), was based on preexisting literature. However, this work has faced criticism for selective data presentation, leading to inaccurate interpretation. This review revisits and validates Lassen's original plot using contemporary data published since 2000. Additionally, we aim to understand the impact of vasoactive drug treatments on CBF, as Lassen's referenced studies used various drugs for blood pressure manipulation. Our findings confirm Lassen's concept of a plateau where CBF remains relatively stable across a specific MAP range in awake humans with normal brains. However, significant variations in cerebral autoregulation among different populations are evident. In critically ill patients and those with traumatic brain injury, the autoregulatory plateau dissipates, necessitating tight blood pressure control to avoid inadequate or excessive cerebral perfusion. A plateau is observed in patients anesthetized with intravenous agents but not with volatile agents. Vasopressor treatments have population-dependent effects, with contemporary data showing increased CBF in critically ill patients but not in awake humans with normal brains. Vasopressor treatment results in a greater increase in CBF during volatile than intravenous anesthesia. Modern antihypertensives do not significantly impact CBF based on contemporary data, exerting a smaller impact on CBF compared to historical data. These insights underscore the importance of individualized blood pressure management guided by modern data in the context of cerebral autoregulation across varied patient populations.

Background: Patient age is assumed to be an important risk factor for the occurrence of burst suppression, yet this has still to be confirmed by large datasets.

Methods: In this single-center retrospective analysis at a university hospital, the electronic patient records of 38,628 patients (≥18 years) receiving general anesthesia between January 2016 and December 2018 were analyzed. Risk factors for burst suppression were evaluated using univariate and multivariable analysis. We measured the incidence of burst suppression as indicated by the burst suppression ratio (BSR) of the Entropy Module, the maximum and mean BSR values, relative burst suppression duration, mean volatile anesthetic concentrations, and mean age-adjusted minimum alveolar concentrations (aaMAC) at burst suppression, and cases of potentially misclassified burst suppression episodes. Analyses were done separately for the total anesthesia period, as well as for the Induction and Maintenance phase. The association with age was evaluated using linear and polynomial fits and by calculating correlation coefficients.

Results: Of the 54,266 patients analyzed, 38,628 were included, and 19,079 patients exhibited episodes with BSR >0. Patients with BSR >0 were significantly older, and age had the highest predictive power for BSR >0 (area under the receiving operating characteristic [AUROC] = 0.646 [0.638-0.654]) compared to other patient or procedural factors. The probability of BSR >0 increased linearly with patient age (ρ = 0.96-0.99) between 1.9% and 9.8% per year. While maximal and mean BSR showed a nonlinear relationship with age, relative burst suppression duration also increased linearly during maintenance (ρ = 0.83). Further, episodes potentially indicating burst suppression that were not detected by the Entropy BSR algorithm also became more frequent with age. Volatile anesthetic concentrations sufficient to induce BSR >0 were negatively correlated with age (sevoflurane: ρ = -0.71), but remained close to an aaMAC of 1.0.

Conclusions: The probability of burst suppression during general anesthesia increases linearly with age in adult patients, while lower anesthetic concentrations induce burst suppression with increasing patient age. Simultaneously, algorithm-based burst suppression detection appears to perform worse in older patients. These findings highlight the necessity to further enhance EEG application and surveillance strategies in anesthesia.

Background: Closure of rural obstetric (OB) units has led to maternal care deserts, causing mothers to travel long distances for maternity care. Emergency departments (EDs) in hospitals where OB units have closed require regular training for personnel to maintain OB skills, as do rural Level-1 OB units with low volumes of maternity cases. We used a federal grant to develop an OB mobile simulation program to bring simulation-based training to rural providers. Our goal was to improve OB skills and standardize care through the framework of the Alliance for Innovation in Maternal Health (AIM) Patient Safety Bundles.

Methods: We conducted needs assessments and built a mobile simulation unit. We defined 2 groups of learners: those in Level-1 OB units and those in EDs without OB units. For Level-1 OB units, we created a train-the-trainer curriculum, to create a statewide cohort of simulation experts to implement simulations in their facilities between our visits. We gifted each Level-1 unit an OB task trainer, implemented virtual train-the-trainer simulation and task trainer workshops, and conducted post-workshop assessments. We then traveled to each Level-1 unit and helped the cohort implement in situ simulations for their staff using facility-specific resources. We conducted assessments for the cohort and the hospital staff after the simulations. For EDs, we delivered virtual didactics to improve basic OB knowledge, then traveled to ED units, implemented in situ simulations, and conducted post-simulation assessments. We chose a postpartum hemorrhage (PPH) scenario for our first round of simulations.

Results: After train-the-trainer simulation workshops, 98% of participants surveyed agreed that workshop goals and objectives were achieved. After the task trainer workshop, 95% surveyed agreed that their knowledge of using the simulator had improved. After implementing in situ simulations in Level-1 OB units, 98.8% of the train-the-trainer cohort found that their ability to implement simulations had improved. The hospital staff participating in the simulations identified a 30% increase in ability to manage PPH. For the ED staff, postdidactic evaluations identified that 95.4% of participants reported moderate improvement in basic OB knowledge and after participation in the simulations >95% reported better skills as an ED team member when caring for pregnant patients.

Conclusions: These results demonstrate improved skills of hospital staff in simulated PPH in Level-1 OB units and simulated OB emergencies in EDs that no longer have OB units. Further studies are warranted to assess improvement in maternal outcomes.