Anesthesia and analgesia最新文献

Background: Racial and ethnic differences in health care may result in significant morbidity. The objective of this study was to determine whether there was an association between a patient's race or ethnicity and the receipt of an antiemetic agent preoperatively, during surgery, and in the recovery room.

Methods: A single-institution retrospective study of adult patients (>18 years) who had undergone cancer-related operating room procedures under anesthesia between March 2016 and August 2021 was conducted. A multivariable logistic regression model was fitted to estimate the effects of covariates on antiemetic administration.

Results: Of the 60,595 patients included in the study, 3053 (5.0%) self-identified as Asian, 5376 (8.9%) as Black, 8431 (13.9%) as Hispanic or Latino, 42,533 (70.2%) as White, and 1202 (2.0%) as belonging to another racial or ethnic group. Multivariable analyses showed significant associations between a patient's race or ethnicity and the receipt of antiemetics in the preoperative holding area, operating room, and recovery room (all P < .001). In the preoperative holding area, White patients (8962 of 42,533 [21.1%]; odds ratio [OR], 1.188; 95% confidence interval [CI], 1.100-1.283; P < .001) had higher odds of receiving an antiemetic than Black patients (1006 of 5376 [18.7%]). Intraoperatively, the odds were significantly greater for Hispanic or Latino (7323 of 8431 [86.9%]; OR, 1.175; 95% CI, 1.065-1.297; P = .001) and patients who identified as belonging to another race (1078 of 1202 [89.7%]; OR, 1.582; 95% CI, 1.290-1.941; P < .001) than for Black patients (4468 of 5376 [83.1%]). In the recovery room, Asian (499 of 3053 [16.3%]; OR, 1.328; 95% CI: 1.127-1.561; P < .001), Hispanic or Latino (1335 of 8431 [15.8%]; OR, 1.208; 95% CI, 1.060-1.377; P < .005), and White patients (6533 of 42,533 [15.4%]; OR, 1.276; 95% CI, 1.140-1.427; P < .001) had significantly higher odds of receiving antiemetics than Black patients (646 of 5376 [12%]).

Conclusions: This retrospective study suggests significant differences between the administrations of antiemetics to patients of different races or ethnicities, with Black patients often being less likely to receive an antiemetic than patients belonging to all other races or ethnicities.

Background: Although high-opioid anesthesia was long the standard for cardiac surgery, some anesthesiologists now favor multimodal analgesia and low-opioid anesthetic techniques. The typical cardiac surgery opioid dose is unclear, and the degree to which patients, anesthesiologists, and institutions influence this opioid dose is unknown.

Methods: We reviewed data from nonemergency adult cardiac surgeries requiring cardiopulmonary bypass performed at 30 academic and community hospitals within the Multicenter Perioperative Outcomes Group registry from 2014 through 2021. Intraoperative opioid administration was measured in fentanyl equivalents. We used hierarchical linear modeling to attribute opioid dose variation to the institution where each surgery took place, the primary attending anesthesiologist, and the specifics of the surgical patient and case.

Results: Across 30 hospitals, 794 anesthesiologists, and 59,463 cardiac cases, patients received a mean of 1139 (95% confidence interval [CI], 1132-1146) fentanyl mcg equivalents of opioid, and doses varied widely (standard deviation [SD], 872 µg). The most frequently used opioids were fentanyl (86% of cases), sufentanil (16% of cases), hydromorphone (12% of cases), and morphine (3% of cases). 0.6% of cases were opioid-free. 60% of dose variation was explainable by institution and anesthesiologist. The median difference in opioid dose between 2 randomly selected anesthesiologists across all institutions was 600 µg of fentanyl (interquartile range [IQR], 283-1023 µg). An anesthesiologist's intraoperative opioid dose was strongly correlated with their frequency of using a sufentanil infusion (r = 0.81), but largely uncorrelated with their use of nonopioid analgesic techniques (|r| < 0.3).

Conclusions: High-dose opioids predominate in cardiac surgery, with substantial dose variation from case to case. Much of this variation is attributable to practice variability rather than patient or surgical differences. This suggests an opportunity to optimize opioid use in cardiac surgery.

Background: Patient outcomes are improved with physician-patient gender, racial, and ethnic concordance. However, female, Black, Hispanic or Latino, Native Hawaiian-Pacific Islander (NH-PI), and American Indian-Native Alaskan (AI-AN) physicians are underrepresented in anesthesiology. The American Association of Medical Colleges 2018 Diversity in Medicine Report revealed that women comprise only 35% of anesthesiologists yet nearly half of medical school graduates are women. More than 77% of anesthesiologists are White or Asian. Anesthesiology applicant and match trends may provide insights needed to address underrepresentation within anesthesiology. We hypothesized that proportionally fewer women and racially and ethnically minoritized applicants apply and match into anesthesiology.

Methods: This retrospective observational study identified 47,117 anesthesiology applicants among the 546,298 residency applicants in the Electronic Residency Application Service (ERAS) system between 2011 and 2022 and stratified applicants by self-reported gender, race, and ethnicity. The demographics of anesthesiology trainees reported in the 2014 to 2015, 2018 to 2019, and 2022 to 2023 Accreditation Counsel of Graduate Medical Education (ACGME) Data Resource Books were used as surrogates for matched applicants as demographics are not reported by the National Residency Match Program. To facilitate comparisons, ERAS applicants were grouped into 4-year epochs to align with consolidated ACGME reports corresponding to the application years. Odds ratios (OR); 95% confidence interval of applying to and matching into anesthesiology were analyzed.

Results: Women had lower odds of applying to anesthesiology compared to men overall (OR, 0.55; 95% CI, 0.54-0.56, P < .0001) and maintained significantly lowered odds of applying within each epoch. Women had similar odds of matching into anesthesiology residency compared to men (OR, 1.10; 95% CI, 1.06-1.14, P < .0001). Black, Hispanic or Latino, Asian and NH-PI, and AI-AN applicants had similar odds to White applicants of applying to anesthesiology but odds of matching were significantly lower overall (P < .0001) for Asian and NH-PI (OR, 0.66; 95% CI, 0.63-0.70), Black (OR, 0.49; 95% CI, 0.45-0.53), Hispanic or Latino (OR, 0.50; 95% CI, 0.46-0.54), and AI-AN (OR, 0.20; 95% CI, 0.15-0.28) applicants. The odds of matching among some minoritized applicants increased in the ACGME 2022 to 2023 report year.

Conclusions: From 2011 to 2022, women had lower odds of applying to anesthesiology residency than men yet had similar odds of matching. Racial and ethnic minoritized groups had significantly lower odds of matching compared to White applicants despite similar odds of applying. These findings highlight disparities in the anesthesiology match and may help identify opportunities to promote workforce diversity within the field. More detailed reporting

Transcatheter aortic valve replacement (TAVR) has become the dominant procedural modality for aortic valve replacement in the United States. The reported rates of neurological complications in patients undergoing TAVR have changed over time and are dependent on diagnostic definitions and modalities. Most strokes after TAVR are likely embolic in origin, and the incidence of stroke has decreased over time. Studies have yielded conflicting results when comparing stroke rates between TAVR and surgical aortic valve replacement (SAVR), especially due to differences in diagnostic criteria and neurocognitive testing. In this narrative review, we summarize the available data on the incidence of stroke, delirium, and cognitive decline after TAVR and highlight potential areas in need of future research. We also discuss silent cerebral ischemic lesions (SCILs) and their association with a decline in postoperative neurocognitive status after TAVR. Finally, we describe that the risk of delirium and postoperative decline is increased when nonfemoral access routes are used, and we highlight the need for standardized imaging and valid, repeatable methodologies to assess cognitive changes after TAVR.

Background: Gender equity is essential for improving health outcomes globally. Despite comprising 75% of the global health workforce and dominating academic global health programs, women remain underrepresented in leadership positions in global health organizations. Our study aimed to identify potential gender differences in the beliefs and attitudes regarding barriers that women anesthesiologists encounter in pursuing careers and leadership roles in global health and to identify recommendations for improving gender equity in global health.

Methods: We conducted a cross-sectional online survey focusing on career leadership opportunities and challenges uniquely faced by women clinicians in global health. We obtained permission from the World Federation of Societies of Anaesthesiologists to distribute our questionnaire to their leadership committee members during 2 months (May-July 2022).

Results: The questionnaire was distributed to 164 study participants with 67 individuals (44.8% female) based in 38 different countries completing the survey (response rate 40.9%). Overall, 47.8% of the participants aspired to a leadership position in global health and 58.2% agreed women face unique barriers to global health leadership (70.0% of women compared to 48.6% of men; P = .081). Female gender (odds ratio [OR], 19.22, P = .004) and divorced marital status (OR, 746.26, P = .004) were positively associated and African ethnicity (OR, 0.002, P = .017) was negatively associated with the perception of gender bias in their career growth. The main challenges included balancing work and family responsibilities, lack of female mentors or role models, gender-based discrimination, and limited opportunities for career advancement. Men acknowledged these challenges but reported personally experiencing them to a lesser extent, particularly concerning lack of opportunities (P = .005), inadequate pay (P = .000), and lack of training (P = .000).

Conclusions: Gender disparities exist in the pursuit of global health careers. This study underscored that more women than men perceive barriers in pursuing leadership roles in global health and that men generally encounter these obstacles to a lesser extent. Female representation in leadership positions could be supported through evidence-informed policies that promote work-life balance, improve mentorship, offer equal opportunities for career advancement and adequate pay, and combat gender-based discrimination.

Background: This study's purpose was to assess whether larger volumes of reinfused unwashed shed autologous blood (SAB) were associated with adverse events within 30 days for patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair. During TAAA repair, our institution uses a system wherein SAB is filtered, but not washed or centrifuged, and then returned to the patient via a rapid-infusion device. By reinfusing SAB, the system preserves the patient's autologous whole blood and may reduce the number of allogenic transfusions required during TAAA repair, but the end-organ effects of reinfusing unwashed SAB have not been extensively evaluated.

Methods: Using a prospectively maintained database, we retrospectively analyzed data from 972 consecutive patients who underwent open TAAA repair at our institution from 2007 to 2021 and who received SAB. Multivariable logistic regressions were performed to assess whether SAB reinfusion volume was associated with a composite outcome of adverse events, as well as operative mortality, a composite of cardiac complications, a composite of pulmonary complications, or persistent paraplegia, stroke, or postoperative renal failure.

Results: Among the cohort of 972 patients, the median volume of reinfused SAB was 4159 mL (quartile1-quartile3 [Q1-Q3]: 2524-6790 mL). Greater reinfusion volumes of unwashed SAB were not associated with greater odds of composite adverse events (odds ratio [OR], 1.02 per 1000 mL increase, 97.5% confidence interval [CI], 0.94-1.09, P = .624), nor with any individual outcome-operative mortality (OR, 1.02 per 1000 mL increase, 97.5% CI, 0.93-1.12, P = .617), a composite of cardiac complications (OR, 0.98 per 1000 mL increase, 97.5% CI, 0.93-1.04, P = .447), a composite of pulmonary complications (OR, 1.00 per 1000 mL increase, 97.5% CI, 0.94-1.06, P = .963), renal failure necessitating hemodialysis (OR, 1.01 per 1000 mL increase, 97.5% CI, 0.92-1.11, P = .821), persistent paraplegia (OR, 0.97 per 1000 mL increase, 97.5% CI, 0.84-1.13, P = .676), persistent stroke (OR, 0.85 per 1000 mL increase, 97.5% CI, 0.70-1.04, P = .070), or reoperation to control bleeding (OR, 0.99, 97.5% CI, 0.87-1.13, P = .900)-when adjusted for confounders.

Conclusions: For patients undergoing open TAAA repair, larger reinfusion volumes of unwashed SAB were not associated with greater odds of major early postoperative complications.