Anesthesia and analgesia最新文献

Background: Tracheal intubation in infants poses unique anatomical and physiological challenges and is particularly difficult for anesthesia trainees. Video laryngoscopy has been suggested to improve intubation success, yet evidence among novice providers remains limited. We aimed to evaluate whether anesthesia trainees had a higher first-attempt success rate for tracheal intubation in infants using traditional direct laryngoscopy (DL) with a Miller or Macintosh blade, or indirect video laryngoscopy with a McGrath video laryngoscope size 1 Macintosh blade (McGrath VL).

Methods: In this single-center, parallel-group, randomized controlled trial, infants (<1-year-old) scheduled for elective surgery requiring orotracheal intubation were randomly allocated to either McGrath VL or DL. All intubations were performed by anesthesia trainees under supervision. The primary outcome was the first-attempt intubation success rate. Secondary outcomes included intubation difficulty score, glottic visualization, time to intubation, and intubation-related complications.

Results: Between October 2021 and February 2024, 124 infants were enrolled and randomized (McGrath VL: n = 61; DL: n = 63). First-attempt success was achieved in 53/61 (86.9%) in the McGrath VL group and 47/63 (74.6%) in the DL group (risk difference 16.5%, 95% confidence interval [CI],3.0%-29.9%; P = .026). The Intubation Difficulty Score of 0 occurred in 30/61 (49.2%) in the McGrath VL group versus 20/63 (31.7%) in the DL group (risk difference 18.9%, 95% CI, 0.6%-37.2%), and a Percentage of Glottic Opening score of 100% was achieved in 37/61 (60.7%) in the McGrath VL group versus 23/63 (36.5%) in the DL group (risk difference 22.1%, 95% CI, 6.2%-37.9%). The overall incidence of intubation-related complications did not differ significantly between groups (McGrath VL: 5/61 [8.2%] vs DL: 7/63 [11.1%], risk difference -4.1%, 95% CI, -14.7%-6.4%); however, esophageal intubation occurred in 0/61 (0%) in the McGrath VL group versus 3/63 (4.8%) in the DL group.

Conclusion: The McGrath VL significantly improves first-attempt intubation success in infants when used by anesthesia trainees, especially among less experienced providers. Video laryngoscopy may enhance safety and effectiveness in infant airway management. These results support its routine use by novice providers in infant anesthesia.

Background: Latent safety threats (LSTs) in operating room (OR) crisis management contribute to serious events such as Local Anesthetic Systemic Toxicity (LAST) and represent critical yet often overlooked risks. Although prior research has focused on clinician education for diagnosing and treating LAST, far less attention has been directed toward work-system factors (eg, workflow design, communication processes, environmental supports), even though education alone is insufficient. This study advances understanding of OR crises by systematically identifying and characterizing LSTs across all phases of LAST response, from briefing and diagnosis to treatment and care planning, capturing the broader system factors that influence team performance and patient safety.

Methods: Thirty-eight staff (15 anesthesiologists, 16 nurses, 7 anesthesia assistants) participated in 8 simulations. Video recordings were analyzed to identify LSTs, which were inductively coded into themes/subthemes, categorized by clinical phase (briefing, diagnosis, management, treatment, care planning) and by system factor using a modified SEIPS framework (organization, environment, tasks, tools, teams, individuals).

Results: We identified 183 LSTs, with frequency varying by clinical phase (P < .001); nearly half (90/183; 49%) occurred during Management after diagnosis. LSTs spanned all SEIPS factors, most often Environment (55/183; 30.1%), Organization (54/183; 29.5%), and Tasks (38/183; 21.3%). The most common themes were Poor Physical Layout (43/183; 23.5%) and Role Allocation Deficiencies (42/183; 23%), both directly impairing performance (eg, delays retrieving the crash cart or administering intralipid). Additional LSTs included communication breakdowns, task overload, ambiguous dosing, tool usability issues, and unclear protocols. Knowledge gaps were least common and had minimal clinical impact.

Conclusion: The findings highlight that improving LAST crisis response requires more than clinician education. Many LSTs arise from how clinical environments are structured, how teams communicate, and how workflows unfold under pressure. To strengthen LAST crisis response and other emergency interventions, systems must be redesigned to reflect the realities of team-based care and to support clinical workflows across all phases of the response.

There are two different approaches to hemostatic resuscitation used in major hemorrhage protocols for critically bleeding trauma patients: A formulaic approach using fixed ratios of blood components and a targeted therapy approach guided by viscoelastic hemostatic assays. There is ongoing debate with differing opinions on what constitutes the most appropriate approach. There is also widespread variation in management approaches and options used. The aim of a major hemorrhage protocol is to guide a multidisciplinary multiple strategy approach to identify the source and cause of bleeding and control it expeditiously, correct coagulopathy, and normalize physiological derangement. Proponents of a fixed-ratio blood component approach to hemostatic resuscitation in traumatic hemorrhage argue that it provides the necessary blood components, reduces cognitive load on the trauma team and standardizes clinical practice. They also argue that the alternative of target-driven therapy is currently a utopian concept, delays care, and, if instituted, may result in harm to patients, carers, and the health system. Proponents of targeted therapy hold that a formulaic fixed-ratio approach does not treat specific deficits and may result in over-transfusion of components, exposing patients to the inherent risks of blood component transfusions. They propose that a targeted approach using viscoelastic hemostatic assays reduces exposure to blood components and reduces mortality. Both proposed strategies assume ready access to blood components and/or products, investigational tools, appropriately trained multidisciplinary staff and as such are targeted toward resuscitation of critical bleeding in advanced trauma systems.

Background: The use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) is increasing with the expansion of their indications. Their effect on pain and opioid use after surgery is unknown. We hypothesized that GLP-1RA use would be associated with reduced perioperative opioid consumption and pain scores.

Methods: This is a retrospective cohort study conducted at an academic center. Adult patients undergoing oncological surgery were included in the study. Patients were excluded if they had urgent surgery, were pregnant at the time of surgery, had nonoperating room procedures, or had biopsies or procedures not requiring general anesthesia. Patients who filled GLP-1RA prescriptions within 90 days of surgery were considered GLP-1RA users; those who did not fill prescriptions in the previous 12 months were controls. The association between the use of GLP-1RAs and perioperative opioid consumption and pain intensity after cancer surgery was investigated.

Results: 17,027 patients were included in the study. Of them, 486 patients who used GLP-1RA were matched with 486 non-GLP-1RA users. Intraoperative oral morphine equivalents (OME) were similar for patients on GLP-1RA (74.7 ± 125.51 mg) and non-GLP-1RA users (69.68 ± 123.5 mg; P =.55). In PACU (-0.94; 95% confidence interval [CI], -2.49 to 0.61; P =.23), postoperative day (POD)0 (-0.29; 95% CI, -1.21 to 0.62; P =.52) and POD1 (-1.18; 95% CI, -3.36 to 1.01; P =.29), the difference also did not reach statistical significance. However, we observed a statistically significant reduction in OME in POD2 (-1.98; 95% CI, -3.82 to -0.13, P =.04), and POD3 (-1.94; 95% CI, -3.57 to -0.31, P =.02) in patients taking GLP-1RAs. Our analysis showed no statistically significant differences in pain scores between groups. A linear mixed-effects model demonstrated that the interaction between the treatment cohort and postoperative time was not statistically significant for OME (P =.1) and pain scores (P =.86).

Conclusion: GLP-1RA use was not associated with clinically meaningful reductions in perioperative opioid use or pain scores. Further studies should assess if GLP-1RAs are associated with analgesic effects during the perioperative period in other patient populations.

Background: Post-dural-puncture headache (PDPH) is a common complication of neuraxial procedures used during labor and delivery, affecting about 1% of patients. Epidural blood patch (EBP) is the most effective treatment for PDPH, but few studies assess the success of an EBP based on the volume of injected blood, especially >20 mL. Our practice is injection until the patient feels persistent back pressure. We aimed to determine whether the volume of injected blood was associated with an improved outcome after an EBP in the obstetric population.

Methods: We reviewed records for patients receiving EBP after an obstetric epidural procedure over a 10-year period (May 2014-February 2024) at a single tertiary academic medical center. The primary outcome was failure of the first EBP, defined by the patient receiving a second EBP for treatment. Secondary outcome included the complete resolution of symptoms after the primary EBP. We used a binomial generalized model to identify factors associated with the success of the primary EBP. A value of P ≤.05 was considered statistically significant.

Results: Records from 317 patients were available, and we excluded 32 patients who received only single-shot spinal anesthesia from the primary analysis. Repeat EBP was performed in 65 (22.8%, 95% confidence interval [CI], 18.1%-28.1%) patients. In univariable analyses, the injected volume during EBP (median 28.0 mL, interquartile range [IQR] (22.0-32.0)), days from procedure to PDPH diagnosis, and from PDPH to EBP were associated with a successful EBP. In multivariable analyses, injected volume (odds ratio [OR] 0.96 per 1 mL, P =.028, 95% CI, 0.92-0.999) and days from PDPH diagnosis to EBP (OR 0.61 per day, P =.002, 95% CI, 0.43-0.81) were significantly associated with successful EBP. An analysis of the relationship between injected volume and repeated EBP suggested a dose-response relationship (P =.030). Complete symptomatic follow-up data documented for at least 3 days were available for 226 patients, and headache was completely resolved in 118 (52.2%, 95% CI, 45.5%-58.9%). In a multivariable analysis, a dichotomous division of the population revealed a significant association with headache resolution in the group receiving an injected volume of ≥30 mL compared with patients receiving <30 mL (OR 1.85, P =.049, 95% CI, 1.01-3.47).

Conclusion: We found that a larger injected volume of blood during an EBP was associated with a reduced likelihood of receiving a second EBP. Injection of 30 mL or more was significantly associated with complete resolution of headache symptoms after the first EBP. A prospective trial to determine the etiology of this relationship is warranted.

Background: Burnout among healthcare providers can adversely impact their performance and patient care. Vital Anaesthesia Simulation Training (VAST) Wellbeing is a 1-day course designed to promote personal and professional well-being and to reduce burnout for healthcare providers in low-resource settings. VAST Wellbeing has demonstrated benefits in this context but has never been evaluated in a conflict zone. This study assessed the influence of VAST Wellbeing among healthcare workers practicing in the EMERGENCY-NGO Salam Centre for Cardiac Surgery in Sudan amidst a conflict.

Methods: This mixed-methods study was designed to explore participants' experience of VAST Wellbeing offered in Sudan to learn about benefits and challenges to this training in a conflict zone. Our team used in-depth qualitative interviews with purposively selected course participants. Perceived social stigma of receiving mental health support and attitudes toward help seeking for mental health were also quantitatively assessed using the Stigma Scale for Receiving Psychological Help and the General Help-Seeking Questionnaire, respectively.

Results: Sixty healthcare providers attended the course; 35 completed quantitative measures, and 12 were interviewed. Stigma for receiving mental health support decreased comparing median [interquartile range {IQR}] precourse to postcourse scores (8.0 [6-9] versus 6.0 [3-8], P =.005). Willingness to seek help in the event of a mental health concern significantly increased when comparing precourse to postcourse scores (3.4 [2.6 to 3.9] versus 4.6 [3.9 to 5.0], P >.001). Three major themes and nine subthemes were identified during qualitative data analysis. Theme 1: The influence of conflict manifested as participants reporting persistent fear and stress and that the workplace was extremely strained. Theme 2: In social context it was noted that the training reduced social stigma, strengthened of a sense of community, and led to subtle changes in the workplace environment. Theme 3: The training contributed to new learning and practices, such as greater recognition of burnout and engaging in personal well-being practices. Acceptance of mindfulness was mixed, albeit with recognition of its positive effects. Despite many contextual challenges, participants reported the course to be needed and relevant.

Conclusion: The findings suggest that VAST Wellbeing was pertinent and impactful in a conflict zone. It helped to foster a stronger sense of community, reduce stigma around mental health discussions, increase the acceptability of help-seeking, and encourage participants to adopt strategies for self-care and well-being.