Anesthesia and analgesia最新文献

This systematic review describes the available clinical practice guidelines (CPGs) for the anesthetic management of trauma and appraises the accessibility and quality of these resources. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted across 8 databases (MEDLINE, Embase, Web of Science, CABI Digital Library, Global Index Medicus, SciELO, Google Scholar, and National Institute for Health and Care Excellence) for guidelines from 2010 to 2023. Two independent reviewers assessed guideline eligibility and extracted data, which were audited by a third reviewer. Data regarding author demographics, accessibility, clinical topics, and quality were collected. The quality of guidelines was evaluated according to the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) Instrument. A total of 2426 articles were identified, of which 165 met eligibility criteria and were included. Guidelines were developed by 122 professional societies and authors from 51 countries. By region, Europe contributed with the most authors (61%), while Africa had the fewest (4%). Most CPGs were developed by authors from high-income countries (HIC) and only 12% had a first or last author from low- and middle-income countries (LMIC). The United States was the country with the most guideline authors. While 70% were open access, the average cost for paid access was US$36.61. Among the 8 languages identified, English was the most common. The most common topics were blood and fluid management, shock, and airway management. The overall quality of included guidelines was considered moderately high, with an average NEATS score of 3.13 of 5. Quality scores were lowest for involvement of patient perspectives, plans for updating, and presence of a methodologist. On logistic regression analysis, the involvement of a methodological expert was the only predictor of having a high-quality NEATS score, with no association observed with open accessibility, English language, society endorsement, first author from a HIC, or a multidisciplinary group composition. Though many countries and societies have contributed to the development of anesthesia CPGs for trauma, there has been a disproportionate lack of representation from LMICs, where the burden of trauma mortality is highest. In this study, we identify barriers to accessibility and areas for improving future guideline quality. We recommend ongoing efforts to incorporate perspectives from diverse settings and to increase the availability of high-quality, open-access guidelines to improve worldwide health outcomes in trauma.

Background: The rapid advancement of minimally invasive surgical techniques has made laparoscopy a preferred alternative because it reduces postoperative complications. However, inflating the peritoneum with CO2 causes a cranial shift of the diaphragm decreasing lung volume and impairing gas exchange. Additionally, CO2 absorption increases blood CO2 levels, further complicating mechanical ventilation when the lung function is already compromised. Standard interventions such as lung recruitment maneuvers or increasing positive end-expiratory pressures can counteract these effects but also increase lung parenchymal strain and intrathoracic pressure, negatively impacting cardiac output. The application of variability in tidal volume and respiratory rate during mechanical ventilation to mimic natural breathing has shown benefits in various respiratory conditions. Therefore, we aimed to evaluate the short-term benefits of variable ventilation (VV) on gas exchange, respiratory mechanics, and hemodynamics during and after capnoperitoneum, compared to conventional pressure-controlled ventilation (PCV).

Methods: Eleven anaesthetized rabbits were randomly assigned to PCV or VV. Oxygenation index (Pao2/FiO2), arterial partial pressure of carbon dioxide (Paco2), and respiratory mechanical parameters were assessed after a 15-minute-long ventilation period before, during, and after capnoperitoneum. According to a crossover design, after measurements at the 3 different stages, the ventilation mode was changed, and the entire sequence was repeated.

Results: Capnoperitoneum compromised respiratory mechanics, decreased oxygenation, and caused CO2-retention compared to baseline measurements under both ventilation modalities (P < .05, for all). Application of VV resulted in lower Pao2/FiO2 (405. 5 ± 34.1 (mean ± standard deviation [SD]) vs 370. 5 ± 44.9, P < .001) and higher Paco2 (48. 4 ± 5.1 vs 52. 8 ± 6.0 mm Hg, P = .009) values during capnoperitoneum compared to PCV. After abdominal deflation and a lung recruitment maneuver, VV proved more beneficial for CO2 removal than PCV (41. 0 ± 2.3 vs 44. 6 ± 4.3mmHg, P = .027). No significant difference was observed in the respiratory mechanical or hemodynamic parameters between the ventilation modalities under the same conditions.

Conclusions: The detrimental effects of capnoperitoneum on gas exchange were more pronounced with VV. However, after the release of capnoperitoneum, VV significantly improved CO2 clearance. Therefore, VV could possibly be considered as an alternative ventilation modality to restore physiological gas exchange after, but not during, capnoperitoneum.

Background: In the United States, Black and Hispanic patients have substantially worse maternal outcomes than non-Hispanic White patients. The goals of this study were to evaluate the association between the coronavirus disease-2019 (COVID-19) pandemic and maternal outcomes, and whether Black and Hispanic patients were disproportionately affected by the pandemic compared to White patients.

Methods: Multivariable logistic regression was used to examine in the United States the association between maternal outcomes (severe maternal morbidity, mortality, failure-to-rescue, and cesarean delivery) and the weekly hospital proportion of COVID-19 patients, and the interaction between race, ethnicity, payer status, and the hospital COVID-19 burden using US national data from the Vizient Clinical Database between 2017 and 2022.

Results: Among 2484,895 admissions for delivery, 457,992 (18.4%) were non-Hispanic Black (hereafter referred to as Black), 537,867 (21.7% were Hispanic), and 1489,036 (59.9%) were non-Hispanic White (hereafter referred to as White); mean (standard deviation [SD]) age, 29.9 (5.8). Mortality (adjusted odds ratio [AOR], 2.72; 95% confidence interval [CI], 1.28-5.8; P = .01) and failure-to-rescue (AOR, 2.89; 95% CI, 1.36-6.13, P = .01), increased during weeks with a COVID-19 burden of 10.1% to 20.0%, while rates of severe maternal morbidity and cesarean delivery were unchanged. Compared to White patients, Black and Hispanic patients had higher rates of severe maternal morbidity ([Black: OR, 1.97; 95% CI, 1.85-2.11, P < .001]; [Hispanic: OR, 1.37;95% CI, 1.28-1.48, P < .001]), mortality ([Black: OR, 1.92; 95% CI, 1.29-2.86, P < .001]; [Hispanic: OR, 1.51;95% CI, 1.01-2.24, P = .04]), and cesarean delivery ([Black: OR, 1.58; 95% CI, 1.54-1.63, P < .001]; [Hispanic: OR, 1.09;95% CI, 1.05-1.13, P < .001]), but not failure-to-rescue. Except for Black patients without insurance (1.3% of the patients), the pandemic was not associated with increases in maternal disparities. Odds of mortality (AOR, 1.96; 95% CI, 1.22-3.16, P = .01) and failure-to-rescue (AOR, 3.67; 95% CI, 1.67-8.07, P = .001) increased 2.0 and 3.7-fold, respectively, in Black patients without insurance compared to White patients with private insurance for each 10% increase in the weekly hospital COVID-19 burden.

Conclusions: In this national study of 2.5 million deliveries in the United States, the COVID-19 pandemic was associated with increases in maternal mortality and failure-to-rescue but not in severe maternal morbidity or cesarean deliveries. While the pandemic did not exacerbate disparities for Black and Hispanic patients with private or Medicaid insurance, uninsured Black patients experienced greater increases in mortality and failure-to-rescue compared to insured White patients.

Background: Rotational thromboelastometry (ROTEM) is widely used for point-of-care coagulation testing to reduce blood transfusions. Accurate interpretation of ROTEM data is crucial and requires substantial training. This study investigates the inter- and intrarater reliability of ROTEM interpretation among experts and compares their interpretations with a ROTEM-guided algorithm.

Methods: This study was conducted at Amsterdam University Medical Center and included 90 cardiac surgery patients. ROTEM data were collected at 4 surgical stages: before induction, after aortic declamping, postcoagulation correction, and within 2 hours of intensive care unit (ICU) admission. An international panel of 7 cardiovascular anesthesiologists and one intensivist interpreted the data. Interrater reliability was assessed using Fleiss' kappa for binary decisions and the simple matching coefficient (SMC) for multiple-choice questions. Intrarater reliability with the ROTEM-guided algorithm was also evaluated.

Results: Three hundred forty-three ROTEM measurements were analyzed. The interrater reliability for binary decisions was substantial to almost perfect, except after declamping (Fleiss' kappa = 0.34). The SMC for determining type of abnormality and interventions ranged from good to excellent across all ROTEM measuring moments (SMC ≥0.75). Intrarater reliability was almost perfect for binary questions (intraclass correlation coefficient [ICC] ≥0.81) and showed excellent agreement for multiple-choice questions. Comparing expert recommendations with the algorithm resulted in an average SMC of 0.70 indicating differences in intervention recommendations, with experts frequently recommending fibrinogen and protamine over the algorithm's suggestions of plasma and PCC.

Conclusions: This study demonstrates high inter- and intrarater reliability in ROTEM interpretation among trained professionals in cardiac surgery, with almost perfect agreement on abnormalities and interventions. However, differences between expert evaluations and the ROTEM-guided algorithm underscore the need for advanced clinical decision-making tools. Future efforts should focus on developing personalized, data-driven algorithms without predefined cutoff values to improve accuracy and patient outcomes.