Anesthesia and analgesia最新文献

Delirium is a serious acute neurocognitive condition that is common and debilitating in older people who undergo major surgery or are acutely ill. The nature of delirium, baseline comorbidity of older adults and related contextual factors present unique ethical challenges in delirium prevention and treatment trials; yet there is limited literature on how these challenges should be best addressed. The objective of this rapid review was to examine the reporting of key ethical processes for older adults (approval, recruitment, consent, retention) in delirium intervention trials. A rapid search in December 2023 with restricted key terms ("Delirium," "Randomized Controlled Trial"), databases (PubMed, CINAHL), older adult participants and English language, and a final publication date range of 2020 to 2023, resulted in 411 articles screened, 153 full-text reviews, and 51 randomized controlled trial (RCTs) reports (with 11 published protocols) included. Data extraction and synthesis aligned with general guidance for ethical approval, processes and reporting of clinical studies, including for people with key vulnerabilities for research participation. Trials were categorized by degree of ethical reporting and statistical tests explored associated trial characteristics. The 51 RCTs were conducted in diverse countries, with the most sizeable proportion in China (51%). Most trials evaluated a delirium prevention (96%) and/or pharmacological intervention (69%) and were individually randomized (88%), phase 3 (84%), and perioperative (75%). No trial fully reported all ethical processes. Most of the 51 trials fully reported who provided consent (88%), the consent approach (88%), and ethical approval details (63%); around half fully reported safety assessments (59%) and how, where and when participants were recruited (49%). However, few trials fully reported who recruited participants (31%), who obtained consent (22%); how trial information was provided (27%), whether capacity was assessed prior to consent (10%), how participants were supported though the trial design or processes (18%) or in-trial communications (8%). Compared to the 19 trials (37%) with little to no reporting of ethical processes, the 16 (31%) trials with fuller reporting more often had a separately published protocol (56% vs 0%, P < .001), were conducted outside of China (87.5% vs 11%, P < .001) and had lower median consent (56% vs 96%, P < .01) and retention rates (89% vs 96%, P < .05). These results will help inform future efforts focused on improving the conduct and reporting of ethical processes in delirium trials.

Background: Cognitive impairment is a highly prevalent but frequently overlooked issue among surgical patients preoperatively. This systematic review and meta-analysis aimed to (1) determine the perioperative prevalence of impaired cognitive domains in surgical patients, (2) explore perioperative changes in the different domains, and (3) examine postoperative outcomes associated with preoperatively impaired cognitive domains.

Methods: Five electronic databases were searched from inception to March 19, 2024. Inclusion criteria were (1) surgical patients ≥18 years of age; (2) preoperative cognitive assessments using a neuropsychological battery; (3) reported the prevalence of impairment in specific cognitive domains or changes perioperatively; and (4) sample size of ≥100 surgical patients. The exclusion criteria included studies involving neurological surgery; cross-sectional, case-control, and case series studies; non-English articles; and studies with overlapping data.

Results: In total, of the 12,082 articles identified from 5 databases, 21 studies (5725 patients, 11 non-cardiac surgery studies, and 10 cardiac surgery studies) were included. Among the 6 cognitive domains assessed preoperatively, the pooled prevalence of impairment was highest in executive function (18%; 95% CI, 13%-24%), visuospatial function (16%; 95% CI, 6%-26%), and attention/working memory/processing speed (14%; 95% CI, 9%-18%). Perceptual-motor control (13%; 95% CI, 9%-36%), language (13%; 95% CI, 8%-17%), and learning/memory (12%; 95% CI, 8%-16%) had lower pooled prevalence. The cognitive domains that were assessed postoperatively showed a high prevalence of impairment at 1 week, with 35% (95% CI, 4%-66%) in attention/working memory/processing speed, 34% (95% CI, 16%-51%) in executive function, and 28% (95% CI, 16%-40%) in learning/memory. The pooled prevalence subsequently decreased within 3 months to 16% (95% CI, 3%-35%) in attention/working memory/processing speed, 15% (95% CI, 6%-24%) in executive function, and 12% (95% CI, -2% to 25%) in learning/memory.

Conclusions: The prevalence of preoperatively impaired cognitive domains was the highest in executive function, followed by visuospatial function and attention/working memory/processing speed. Identifying commonly impaired cognitive domains may help optimize cognitive assessments in the perioperative setting. Further research is needed to clarify the clinical utility of assessing specific cognitive domains in surgical populations to improve postoperative outcomes and reduce cognitive deterioration.

Background: Many patients in intensive care units (ICUs) are clinically unstable during the first several days of ICU care. The goal of this study was to describe how the association between selected clinical variables and in-hospital mortality varied across short, sequential time periods during the early phase of ICU care.

Methods: Retrospective analysis of 19,439 ICU encounters among 17,769 patients, aged 18 to 102, who were treated in three ICUs at a single academic medical center during the years 2018 to 2023. Each encounter was segmented into brief intervals of care defined by time between complete blood count results. We analyzed 144,157 time intervals representing the early period of care up to the first 20 consecutive time intervals. For each time interval, we performed multivariable logistic regression to estimate the odds ratios of association between nine selected clinical variables and in-hospital death. Variables included patient demographics, laboratory results, and treatment modalities previously found to be associated with ICU survival in published studies. Both current and previous exposure to life-support treatments (mechanical ventilation, pressors, or dialysis) and interactions among life-support treatments were also investigated as variables.

Results: The mean duration of the analyzed time intervals of care was 512 ±215 minutes (median 574, IQR 326-720 minutes). One third of in-hospital mortality among ICU patients occurred during the first 20 time intervals of care. The odds ratios for death for age, sex, platelet count, hemoglobin, and transfusion ranged from 1.01 to 1.35 with small variations across periods of care, whereas the odds ratios for ventilator use, dialysis, pressors, and bilirubin varied more widely from 1.43 to 4.75.

Conclusion: The strength of association between selected clinical variables and in-hospital mortality varied with time during early periods of ICU care.

Background: The Eleveld pharmacokinetic/pharmacodynamic (PKPD) model for propofol encounters predictive difficulties in certain clinical scenarios. This might be a consequence of the linear model framework used in the development of compartmental models. We aimed to evaluate whether Eleveld's predicted effects correlate with the actual neurophysiological responses in patients before and after a brief burst suppression period that could be considered a pharmacological perturbation.

Methods: We conducted a nonrandomized dose-response study. Twenty-three healthy young patients scheduled for surgery under general anesthesia were included in the study. Following slow and titrated induction and tracheal intubation, we initiated a pharmacological perturbation by administrating a 15 mg·kg-1·h-1 propofol infusion until a 1% burst suppression rate was achieved. We then returned to the propofol concentration predicted by the Eleveld model needed to achieve unresponsiveness. We compared the actual bispectral index (BIS) with the predicted BIS by the Eleveld PKPD model throughout the study protocol. We also analyzed the electroencephalographic signal to compare the power spectrum and the delta-alpha phase-amplitude modulation before and after the perturbation.

Results: Before perturbation, there was no significant difference between the mean ± standard deviation (SD) observed and the predicted BIS (64.5 ± 10.7 vs 61.3 ± 8.7, respectively, paired t test P = .3). However, after pharmacological perturbation, actual BIS was consistently lower than the predicted BIS (38.2 ± 7.5 vs 55.5 ± 7.5, paired t test; P < .001). Accordingly, despite propofol effect-site concentration returned to the level before perturbation, alpha power remained lower and phase-amplitude modulation strength was significantly higher after the perturbation (0.16 ± 0.04 vs 0.21 ± 0.06; P = .01).

Conclusions: These findings suggest that current models are inadequate in explaining the dose-effect relationship of propofol's anesthetic properties. Specifically, linear models are unable to capture the nonlinear dynamics of brain activity and their response to disturbances, such as a brief period of burst suppression.