Anesthesia and analgesia最新文献

Background: Haptoglobin may reduce hemolysis-induced kidney injury in patients undergoing cardiovascular surgery with cardiopulmonary bypass (CPB). Haptoglobin may be given empirically when hemolytic urine is observed, or pre-emptively when detected by elevated free hemoglobin concentrations. In the present study, we investigated whether pre-emptive haptoglobin therapy guided by serum-free hemoglobin concentrations could prevent postoperative renal dysfunction in patients who underwent major cardiovascular surgery using CPB.

Methods: This study was a single-center, open-label, randomized controlled trial. Adult patients who underwent major cardiovascular surgery using CPB were included. Serum-free hemoglobin concentrations were measured in all patients who consented for this study. Patients with free hemoglobin concentrations that reached 0.05 g/dL were randomized to either (i) pre-emptive haptoglobin therapy group or (ii) standard of care group. Patients in the pre-emptive haptoglobin therapy group were administered 4000 U of haptoglobin when serum-free hemoglobin concentration reached 0.05 g/dL within 2 hours after the start of CPB. In the standard of care group, 4000 U of haptoglobin was administered when hemolytic urine was confirmed after the start of CPB. The primary outcome was the difference between the preoperative creatinine concentration and the maximum creatinine concentration within 48 hours after surgery (ΔCr).

Results: The study was terminated with the results of interim analysis due to patients' safety concerns. Finally, 34 patients in the pre-emptive haptoglobin therapy group and 33 in the standard of care group were included in the analysis. Median (interquartile range) ΔCr values were 0.20 (0.05-0.44) in the pre-emptive haptoglobin therapy group and 0.14 (0.04-0.19) in the standard of care group (P = .05). Multiple linear regression analysis with ΔCr as objective variable and preoperative estimated glomerular filtration rate (eGFR), age, and randomize group as explanatory variables revealed that pre-emptive administration of haptoglobin significantly increased ΔCr (P = .03).

Conclusions: The interim study results demonstrated that in patients undergoing major cardiovascular surgery using CPB, pre-emptive haptoglobin administration worsened Cr values and independently associated with increased ΔCr.

Background: The complexity of patients undergoing cardiac surgery underscores the need to improve understanding of the factors that augment or predict risks of adverse postoperative outcomes. Our study set out to determine the extent to which postoperative fluid imbalance is related to clinically important outcomes following elective cardiac surgery.

Methods: In this retrospective cohort study, we studied 2557 elective coronary artery bypass graft (CABG) and/or valve surgery patients at an academic medical center from 2015 to 2020. We examined the relationship between cumulative fluid balance during intensive care unit (ICU) stay and subsequent clinical outcomes. We considered cumulative fluid balance as both a continuous and categorical variable based on cohort-based tertiles: negative (

Results: The primary outcome occurred in 7.0% (n = 60), 2.3% (n = 20), and 9.3% (n = 79) of patients in the negative, neutral, and positive groups, respectively. In multivariable-adjusted analyses, cumulative fluid balance as a continuous variable demonstrated a U-shaped relationship with the primary outcome, with thresholds of significantly elevated risk observed at negative 1380 mL and positive 1700 mL. In multivariable-adjusted analyses of cumulative fluid balance as a categorical variable, patients who left the ICU with either negative (odds ratio 2.76 [95% confidence interval {CI}, 1.62-4.70]; P < .01) or positive cumulative fluid balance (3.53 [2.09-5.96]; P < .01) had higher risk for the primary outcome compared to those with a neutral cumulative fluid balance.

Conclusions: A negative or positive cumulative fluid balance on the day of ICU discharge was associated with ~3 to 4 times greater odds of adverse postoperative outcomes, respectively, which was further elevated when fluid imbalance exceeded ~1.5 L. Our findings suggest that postoperative cumulative fluid balance in real-world practice, particularly for elective cardiac surgery patients, warrants greater attention.

Background: Patients' perception of their health outcomes after surgery has become increasingly important in perioperative medicine. This study aimed to evaluate whether emergence delirium in the postanesthesia care unit (PACU) has a relevant impact on self-reported quality of recovery on the first postoperative day.

Methods: This prospective observational cohort study was conducted in a German tertiary care university hospital. Patients ≥60 years, scheduled for elective noncardiac surgery were included. Patients were screened for the presence of delirium signs 30 minutes after arrival in the PACU using the 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM). Self-reported quality of recovery after surgery was assessed with the German version of the Quality of Recovery-15 questionnaire (QoR-15GE), which patients completed preoperatively and on the first postoperative day. The association between emergence delirium and self-reported quality of recovery was analyzed using a linear multivariable regression model taking into account covariates with a potential impact on recovery after surgery.

Results: A total of 428 patients were tested for emergence delirium. Of these, 397 were assessed for self-reported quality of recovery on the first postoperative day. The incidence of emergence delirium was 32.9% (141/428). Patients with emergence delirium showed a greater decline in QoR-15GE sum scores from pre- to postoperative (difference between preoperative and postoperative QoR-15GE sum scores [ΔQoR-15GE]), with a mean difference (± standard deviation [SD]) of 32.8 ± 25.3, compared to 21.6 ± 26.6 in patients without emergence delirium. The between-group difference was 11.2 points (95% confidence interval [CI], 5.5-16.8; P < .001). After adjusting for potentially confounding covariates, the negative impact of emergence delirium on ΔQoR-15GE (adjusted effect 10.11 [95% CI, 4.99-15.23]; P < .001) remained significant.

Conclusions: In a heterogeneous cohort of elderly patients who underwent elective noncardiac surgery, we found a significant negative impact of emergence delirium on self-reported quality of recovery on the first postoperative day. Our findings suggest that the presence of delirium symptoms in the PACU may be an important determinant of patient comfort after surgery.

In this Pro-Con commentary article, the Pro perspective advocates for the integration of opioid-free anesthesia (OFA) techniques in perioperative care, highlighting their benefits, including significant reductions in postoperative nausea and vomiting (PONV). Meta-analyses have shown that OFA protocols effectively reduce PONV rates despite variability in protocols and surgical populations. Furthermore, OFA techniques provide effective pain control, often demonstrating analgesic outcomes comparable to conventional opioid-based techniques. Conversely, the Con perspective raises concerns about the increased risk of adverse events associated with OFA protocols, such as bradycardia, hypotension, and prolonged recovery times, as evidenced by large randomized controlled trials. Critics emphasize the lack of standardization in OFA protocols, variability in definitions, and limited timeframe for outcome assessment, which complicates comparisons and generalizability. Additionally, they point out that while OFA reduces intraoperative opioid use, it does not necessarily translate into decreased opioid prescribing at discharge, a key factor in addressing persistent opioid use.

Background: Despite advancements in acute pain management and minimally invasive surgical techniques, persistent postsurgical pain can occur in up to 30% to 50% of patients. Psychological and social factors are increasingly recognized as contributors to pain outcomes, yet the impact of specific social determinants of health on persistent postoperative pain remains unclear.

Methods: We conducted a retrospective observational study using the All of Us Research Program database. Adults who underwent surgical procedures after the year 2000 were included if they had available social determinants of health (SDoH) survey data and no prior diagnosis of persistent postoperative pain. Persistent postoperative pain was defined via SNOMED codes as a diagnosis occurring at least 1 year after the surgery date. Multivariable logistic regression was performed to assess the association between 21 independent variables derived from All of Us SDoH survey items and persistent postoperative pain, controlling for age, sex, race, ethnicity, and surgery type. A Bonferroni-corrected significance threshold (P < .002) was applied.

Results: There were 8065 participants included in the final analysis with 641 (7.9%) developing persistent postoperative pain. Food insecurity had the strongest association with persistent postoperative pain (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.45-2.30, P < .001). Having greater social support (OR = 0.96, 95% CI, 0.94-0.99, P = .002) and lower residential density (OR = 0.72, 95% CI, 0.61-0.85, P < .001) was protective.

Conclusions: These findings underscore the importance of routinely assessing and addressing socioeconomic and psychosocial factors in perioperative care to help prevent long-term pain.

Background: Childbirth can have a substantial impact on maternal health-related quality of life. Cesarean delivery is the most performed inpatient operation, yet little is known about normal postpartum recovery profiles. The primary aim of our study was to longitudinally evaluate global health visual analog scale (GHVAS; 0-100) scores up to 12 weeks after scheduled cesarean delivery and identify the time to plateau of scores. The secondary aims were to evaluate different domains of postpartum recovery using validated patient-reported outcome measures (Obstetric Quality of Recovery score [ObsQoR-10] and 5-level 5-dimensional EuroQol questionnaire [EQ-5D]).

Methods: After institutional review board approval, this single-center, prospective longitudinal study enrolled healthy women scheduled for cesarean delivery. Women were excluded for gestational age <32 weeks, neonatal demise, neonatal intensive care unit admission, inability to read or understand English, and if general anesthesia was used. Women completed baseline surveys before delivery and then at 24 and 48 hours after delivery. After hospital discharge, women completed surveys (including GHVAS, OBsQoR-10, EQ-5D, Edinburgh Postnatal Depression Scale, and activities of daily living) at 1 week, 3 weeks, 6 weeks, and 12 weeks postpartum. One-way repeated measures analysis of variance (ANOVA) was used to detect the difference in GHVAS and postpartum recovery outcomes with different follow-up time points.

Results: We enrolled 66 parturients and 3 were withdrawn. Response rates were 95%, 84%, 83%, and 76% at 1, 3, 6, and 12 weeks, respectively. Mean ± standard deviation [SD] GHVAS scores were 78 ± 16 at baseline, 64 ± 17 at 24 hours, 69 ± 15 at 48 hours, 75 ± 19 at 1 week, 88 ± 11 at 3 weeks, 88 ± 15 at 6 weeks, and 90 ± 12 at 12 weeks postpartum ( P < .001). The global health VAS improved up until week 3 and then plateaued close to the maximum score between 3 weeks and 12 weeks postpartum. Mean ± SD ObsQoR-10 scores were 75 ± 15 at 24 hours, 85 ± 10 at 48 hours, and 81 ± 28 at 1 week postpartum ( P = .003). The mean ± SD EQ-5D composite scores improved at 6 weeks (4.9 ± 2.9) and 3 months (4.2 ± 2.6) compared to baseline (6.5 ± 1.8) with usual activities ( P = .001) and pain/discomfort ( P < .001) showing significant improvement over time. ObsQoR-10 score at 24 hours correlated with ObsQoR-10 scores at 48 hours (r = 0.629, P < .001) and 1 week (r = 0.429, P < .001) but did not correlate with EQ-5D scores at 6 weeks and 12 weeks.

Conclusions: Our study demonstrates that GHVAS after scheduled CD plateaus at week 3. This data can be used to inform patients about the anticipated trajectory of key postpartum recovery domains up to 12 weeks postpartum.