Anesthesia and analgesia最新文献

Background: Second-generation supraglottic airway (SGA) devices are widely used, but thought to have inferior safety performance to endotracheal tubes (ETTs), but might be equally efficacious while improving patient-centered outcomes. We compared second-generation SGAs with ETTs for perioperative safety, efficacy, and quality of recovery in adults undergoing abdominopelvic surgery under general anesthesia. Our primary objective was to assess safety in the form of major airway complications. Secondary objectives were other safety, efficacy, and quality of recovery outcomes.

Methods: We searched 4 databases for randomized controlled trials of adult patients having abdominopelvic surgery comparing second-generation SGAs and ETTs. After 2-person screening and data extraction, pairwise meta-analysis was conducted and the grading of recommendations, assessment, development, and evaluation (GRADE) approach was applied to assess the certainty of evidence.

Results: A total of 51 studies, randomizing 5110 patients, were included. Second-generation SGAs significantly reduced the risk of major perioperative airway complications (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.23-0.71; P = .007; low certainty), with no clear clinically relevant difference in regurgitation or pulmonary aspiration (low certainty). SGAs significantly increased the risk of inadequate ventilation (RR, 3.36; 95% CI, 1.43-7.89; P = .011; very low certainty); however, postoperative sore throat (RR, 0.52; 95% CI, 0.38-0.70; P < .001; moderate certainty), hoarseness (RR, 0.32; 95% CI, 0.231-0.48; P < .001; low certainty), coughing at the emergence of anesthesia (RR, 0.17; 95% CI, 0.08-0.36; P < .001; low certainty), and postoperative nausea and vomiting (RR, 0.64; 95% CI, 0.42-0.98; P = .042; very low certainty) were all less frequent with SGAs. No other clinically relevant differences were observed for other remaining outcomes.

Conclusions: Second-generation SGAs reduce the risk of major airway complications compared with ETTs in adults undergoing abdominopelvic procedures under general anesthesia, with no reported clinically relevant differences in the risk of regurgitation or pulmonary aspiration. Additionally, they improve the quality of postoperative recovery with lower risk of sore throat, hoarseness, and postoperative nausea and vomiting. These data provide an opportunity for clinicians to reassess the implications of conservative airway management, and potentially expand the role of second-generation SGAs in routine clinical practice.

Background: Different preparations of fibrinogen concentrate are currently available. Two in vitro studies demonstrated the superiority of FibCLOT (LFB) in increasing clot firmness with respect to RiaSTAP (CSL Behring). The present trial involved a clinical model to test the hypothesis of superiority, with the increase in clot firmness as the primary end point.

Methods: Forty cardiac surgery patients were randomly allocated to receive a dose of 30 mg/kg FibCLOT or RiaSTAP after protamine administration in the presence of microvascular bleeding and a FIBTEM maximum clot firmness (MCF) <10 mm. Viscoelastic parameters were measured before and after fibrinogen supplementation: FIBTEM MCF, EXTEM MCF, and EXTEM clotting time (CT).

Results: The mean increase in FIBTEM MCF was 4 ± 1.2 mm (mean and standard deviation) in the FibCLOT group and 4 ± 1.6 mm in the RiaSTAP group (P = 1.000); the mean decrease in CT was 11. 2 ± 12.2 (mean and standard deviation) seconds in the FibCLOT group and 14. 8 ± 13 seconds in the RiaSTAP group (P = .372). In both groups, fibrinogen supplementation induced a significant (P = .001) increase in the FIBTEM MCF and EXTEM CT. The proportions of patients who did not experience an increase of 4 mm in the RiaSTAP group and the FibCLOT group were not statistically significantly higher (35% vs 20%, respectively, relative risk 2.15, 95% confidence interval 0.52-9.00, P = .288).

Conclusions: In contrast to previous in vitro studies, we found that the effect of FibCLOT on MCF and CT was not significantly greater than that of RiaSTAP in cardiac surgery patients. Further studies in other clinical settings are warranted.

Background: The objective of this systematic review and meta-analysis was to update the body of evidence on the efficacy of prehabilitation with exercise interventions, in reducing postoperative complications and length of hospital stay after cancer surgery.

Methods: A comprehensive literature search was conducted on MEDLINE, Embase, The Cochrane Library, CINAHL, AMED, and PsycINFO to identify randomized controlled trials investigating the impact of prehabilitation with exercise interventions for patients undergoing cancer surgery. Primary and secondary outcomes assessed were postoperative complications and length of hospital stay, respectively. Risk of bias was evaluated using the Cochrane risk of bias tool, and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology was used to determine the strength of evidence. Relative risk and mean difference were calculated using random-effects meta-analysis.

Results: In this updated review, 32 trials (n = 2304 participants) were identified, with 5 trials focused on patients undergoing surgery for genitourinary cancer (n = 422 participants), 9 for lower gastrointestinal cancer (n = 639 participants), 6 for upper gastrointestinal cancer (n = 526), and 11 for lung cancer (n = 717 participants). The majority of included trials exhibited some risk of bias. Evidence of low-to-moderate quality indicated that prehabilitation with preoperative exercise significantly reduced postoperative complication rates by approximately 50% and decreased the length of hospital stay by 2.5 days in patients undergoing lung resection. Preoperative exercise did not demonstrate effectiveness in reducing postoperative complications or length of hospital stay for other cancer populations.

Conclusions: Evidence supports the efficacy of prehabilitation with exercise in reducing postoperative complications and length of hospital stay in patients undergoing lung cancer surgery. Further research is warranted to establish the efficacy of unimodal prehabilitation with exercise in genitourinary, lower gastrointestinal, and upper gastrointestinal cancer populations having cancer surgery.

Multiple systematic reviews have investigated the effectiveness of preoperative interventions for smoking-cessation, although relatively few have focused on the prevention of surgical complications. This overview of systematic reviews aimed to describe the types of smoking interventions studied to prevent postoperative complications, summarize the results, and evaluate the quality of the reviews and strength of evidence to inform clinicians, health practitioners, policy developers, and government bodies. Comprehensive searches of Cochrane Library, MEDLINE, EMBASE, CINAHL, and Johanna Briggs Institute databases were conducted to identify systematic reviews of preoperative smoking-cessation interventions to prevent surgical complications (inception-May 14, 2024). Search results were independently screened by 2 reviewers for articles meeting the eligibility criteria. Data on key review characteristics and included studies were extracted: aim, search strategy, included studies, risk of bias, population, sample size, intervention, comparator, main findings, and conclusions. Quality appraisal of the reviews was undertaken using the AMSTAR 2 tool and evidence certainty was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Sixty-seven full-text articles from 838 citations were screened, resulting in 6 included systematic reviews with 12 primary studies reporting postoperative complications. Four reviews which included all primary studies, provided moderate to high strength of evidence. There was high-certainty evidence suggesting interventions started ≥4 weeks before surgery incorporating multiple behavioral support sessions and pharmacotherapy are needed to prevent postoperative complications, particularly the incidence of surgical site infections. High-certainty evidence also indicates the duration of smoking-cessation is important, with benefits amplified for longer periods. However, medium- to high-certainty evidence suggests interventions initiated <4 weeks before surgery even with multiple behavioral support sessions (with or without pharmacotherapy), and interventions commenced >4 weeks before surgery but with only 1 interventional component, increase quit rates but do not reduce complications. This overview provides the most up-to-date summary and quality assessment of systematic review evidence on the effectiveness of preoperative smoking-cessation interventions to prevent surgical complications. The evidence supports providing smoking-cessation interventions which include multiple behavioral support sessions and pharmacotherapy implemented at least 4 weeks before surgery to reduce postoperative complications. Consequently, anesthesiologists need to work with primary care physicians, consultants, and surgeons to optimize smoking-cessation interventions way in advance of surgery.

Background: The impact of pain intensity on the progression trajectories of cardiometabolic multimorbidity (CMM) is not well understood. We attempted to dissect the relationship of short-term pain (STP) and chronic pain intensity with the temporal progression of CMM.

Methods: We conducted a prospective cohort study based on the UK Biobank participants. Incident cases of cardiometabolic diseases (CMDs) were identified based on self-reported information and multiple health-related records in the UK Biobank. CMM was defined as the occurrence of at least 2 CMDs, including heart failure (HF), ischemic heart disease (IHD), stroke, and type 2 diabetes (T2D). The pain intensity was categorized into 5 levels based on pain duration and the number of sites involved, including chronic widespread pain (CWSP), chronic multilocation pain (CMLP), chronic single-location pain (CSLP), STP, and free-of-pain (FOP). Multistate models were used to assess the impact of pain intensity on the CMM trajectories from enrollment to initial cardiometabolic disease (ICMD), subsequently to CMM, and ultimately to death.

Results: A total of 429,145 participants were included. Over the course of a 12.8-year median follow-up, 13.1% (56,137/429,145) developed ICMD, 19.6% (10,979/56,137) further progressed to CMM, and a total of 5.3% (22,775/429,145) died. Compared with FOP, CMLP (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.06-1.17) and CWSP (HR, 1.26; 95% CI, 1.13-1.42) elevated the risk of transitioning from ICMD to CMM. STP (HR, 0.89; 95% CI, 0.82-0.96), CSLP (HR, 0.88; 95% CI, 0.82-0.95), and CMLP (HR, 0.87; 95% CI, 0.81-0.93) lowered the risk of transition from ICMD to mortality, and STP also reduced the risk of transition from enrollment to mortality (HR, 0.94; 95% CI, 0.89-0.98). The results of disease-specific transitions revealed that the influence of pain intensity varied across transitional stages. Specifically, CMLP and CWSP heightened the risk of conversion from T2D or IHD to CMM, whereas only CWSP substantially elevated the transition risk from HF to CMM.

Conclusions: Our results highlighted reductions in chronic pain may mitigate both the onset and progression of CMM, potentially having an important impact on future revisions of cardiometabolic and pain-related guidelines.