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: Previous work suggests that the gut microbiome can be disrupted by antibiotics, anesthetics, opiates, supplemental oxygen, or nutritional deprivation-all of which are common and potentially modifiable perioperative interventions that nearly all patients are exposed to in the setting of surgery. Gut microbial dysbiosis has been postulated to be a risk factor for poor surgical outcomes, but how perioperative care-independent of the surgical intervention-impacts the gut microbiome, and the potential consequences of this impact have not been directly investigated.

Methods: We developed a perioperative exposure model (PEM) in C57Bl/6 mice to emulate the most common elements of perioperative medicine other than surgery, which included 12 hours of nutritional deprivation, 4 hours of volatile general anesthetic, 7 hours of supplemental oxygen, surgical antibiotics (cefazolin), and opioid pain medication (buprenorphine). Gut microbial dynamics and inferred metabolic changes were longitudinally assessed before-and at 3 time points after-PEM by 16S rRNA amplicon sequencing. We then used fecal microbial transplant in secondary abiotic mice to test if, compared to preexposure microbiota, day 3 post-PEM microbial communities affect the clinical response to immune challenge in an endotoxemia model.

Results: We observed transient changes in microbiota structure and function after the PEM, including reduced biodiversity, loss of diverse commensals associated with health (including Lactobacillus , Roseburia , and Ruminococcus ), and changes in microbiota-mediated amino acid metabolic pathways. Mice engrafted with day 3 post-PEM microbial communities demonstrated markedly reduced survival after endotoxemia compared to those bearing preexposure communities (7-day survival of ~20% vs ~70%, P = .0002).

Conclusions: These findings provide the first clear evidence that the combined effects of common perioperative factors, independent of surgery, cause gut microbial dysbiosis and alter the host response to inflammation in the postoperative period.

Background: Spinal anesthesia with intrathecal morphine is often the preferred anesthetic modality for elective cesarean delivery. Side effects and drug shortages, however, prompted researchers to look into intrathecal hydromorphone as an alternative. These studies established the effective analgesic dose for 90% of patients (ED90) for both opioids for postcesarean analgesia, yet failed to demonstrate the superiority of morphine over hydromorphone. Nonetheless, the noninferiority of hydromorphone has yet to be determined.

Methods: In this noninferiority randomized blinded clinical trial, 126 patients undergoing elective cesarean delivery under spinal anesthesia received either morphine 150 µg or hydromorphone 75 µg (ED90). The primary outcome was the between-group difference of the mean Numeric Rating Scale (NRS) pain score (0-10) for the first 24 hours after cesarean delivery, with a preestablished threshold for noninferiority of 1. This 24-hour NRS pain score was defined as a single number obtained at the 24 hours postcesarean delivery interview, based on participant's recall of their overall pain experience during this period. Secondary outcomes included differences in NRS pain scores every 6 hours, cumulative 24 hour opioid consumption, time-to-first opioid request, quality of recovery as measured by the Obstetric Quality of Recovery Score-11 (ObsQoR-11), frequency of interventions for side effects, and Apgar scores.

Results: The mean (standard deviation [SD]) of the 24-hour NRS pain score was 4.0 (1.7) for morphine and 3.6 (1.5) for hydromorphone (between-group difference -0.46 (95% confidence interval [CI], -1.0 to 0.1). Given that the upper limit of the 95% CI did not exceed 1, noninferiority of hydromorphone was established. No statistically significant differences were found in mean (SD) 24 hour oral morphine consumption (morphine: 4.2 mg (6.5) vs hydromorphone: 4.1 (8.0) mg; P = .98), median [interquartile range {IQR}] ObsQoR-11 score (morphine: score 87 [75-97.5] vs hydromorphone: score 90 [80-96.5]; P = .51), median [IQR] time to first opioid request (morphine: 10.2 [3.2-15.5] h versus hydromorphone: 6.2 [3.1-12.4] h; P = .35), or proportion of patients requiring interventions for opioid-related pruritus (morphine: 0.316 (variance 0.216) vs hydromorphone: 0.321 (variance 0.218) ( P = .96) and opioid-related nausea and vomiting (morphine: 0.333 (variance 0.222) vs hydromorphone: 0.393 (variance 0.238) ( P = .51).

Conclusions: Intrathecally, hydromorphone is noninferior to morphine for analgesia after elective cesarean delivery when using the previously established ED90 for both opioids (morphine: 150 µg versus hydromorphone: 75 µg); hydromorphone provides effective analgesia and may be a suitable alternative to morphine.