Anesthesiology最新文献

Simulation-based training is a proven modality for developing critical technical and nontechnical skills in anesthesiology. While simulation-based training has been linked to improved patient outcomes, team performance, and reduced malpractice risk, postresidency simulation remains underutilized. Drawing on parallels from other high-stakes professions and a faculty-focused simulation program developed by the authors, they propose a model for embedding simulation-based training into clinical practice using real-world quality data, subspecialty alignment, and interprofessional collaboration. When implemented, simulation-based training should become part of continuing professional development for attending anesthesiologists, supported by departmental leadership and enhanced by interprofessional collaboration.

Background: Since current opioid overdose deaths occur mainly from potent synthetic opioids with high affinity for the opioid receptor, such as fentanyl and carfentanil, it is important to determine the efficacy of naloxone, particularly the intranasal formulation, in reversing opioid-induced respiratory depression. This study evaluated effectiveness of 4 mg intranasal naloxone (Narcan®) in reversing moderate respiratory depression induced by fentanyl and sufentanil, in opioid-naïve individuals and self-reported daily opioid users. Sufentanil was compared to fentanyl because of its higher affinity for the opioid receptor than fentanyl.

Methods: In this prospective, crossover trial, 12 opioid-naïve individuals and 18 daily opioid users (morphine milligram equivalent of 291 (range 60-2250 mg/day) received continuous fentanyl or sufentanil infusions, titrated to achieve 30-40% reduction in ventilation (V̇E). Participants were administered Narcan® during steady-state respiratory depression. Primary endpoints included time to reversal of diminished V̇E and elevated end-tidal carbon dioxide concentration (pCO2).

Results: Narcan® restored V̇E within 2-4 min across all participants but showed delayed reversal of end-tidal pCO2 (11-17 min), with pCO2 recovery during sufentanil exposure in just 8 opioid-naïve individuals and 10 daily opioid users. Hysteresis analysis showed for V̇E-reversal onset/offset time (blood-effect-site equilibration half-life) of 0-1 min and end-tidal pCO2 2-11 min. Because of withdrawal symptoms, seven of eighteen daily opioid users participated once in the study. Study limitations included continuous opioid infusions that do not occur in real-world overdose settings.

Conclusion: A single Narcan® dose reversed moderate fentanyl- and sufentanil-induced respiratory depression, though effectiveness varied by endpoint and opioid receptor affinity. Rapid V̇E-recovery suggests clinical utility of intranasal naloxone, but delayed and sometimes incomplete recovery of end-tidal pCO2, particularly during exposure to the high-affinity opioid sufentanil, indicating reversal inefficacy and persistence of respiratory instability. Further studies are needed to address optimal naloxone doses and alternative formulations to address high-dose potent opioid threats.

Background: Professionalism is a core competency in graduate medical education, yet research examining specialty-specific professionalism perceptions between trainees and faculty remains limited, particularly regarding the influence of role and institutional culture on these perceptions. This study examined how anesthesiology trainees and attendings perceive unprofessional behavior and whether these perceptions differ based on participant characteristics.

Methods: A multi-site cross-sectional survey was conducted at five anesthesiology residency programs from February to March 2024. Participants rated degree of unprofessionalism on19 workplace vignettes depicting potentially unprofessional behaviors using a 7-point Likert scale. Vignettes were categorized into five themes: Verbal, Supervision, Quality, Time, and Engagement. Proportional odds models examined differences in ratings based on role (trainee vs. attending), adjusting for gender, race, underrepresented status, and institution.

Results: Among 369 respondents (153 trainees, 216 attendings; 35.9% response rate), perceptions varied by scenario and participant characteristics. Six vignettes were more consistently rated as unprofessional (>80% unprofessional ratings), while four showed higher variability (<50% unprofessional ratings). Significant institutional differences were observed in five vignettes (Odds ratios [ORs] <0.14 or >3.7, p < 0.0001 to 0.027). Age influenced ratings of five vignettes (ORs = 0.75, 1.68, 1.63, 1.35 and 1.31 respectively, p <0.0001 to 0.027), while gender, race and underrepresented status showed no significant differences. After adjusting for demographics, trainees and attendings differed significantly in their ratings of 10 vignettes (p <0.0001 to 0.033). Attendings rated nine scenarios as more unprofessional than trainees (ORs ranging from 0.26 to 0.50), while trainees rated only one scenario as more unprofessional than attendings (OR = 2.01).

Conclusions: Perceptions of unprofessional behavior among anesthesiology professionals vary significantly by role and institution. These findings underscore the importance of context-sensitive approaches to professionalism education that acknowledge diverse perspectives and institutional cultures while maintaining core professional standards.

Background: Dreaming during anesthesia is common and may have mental health benefits. However, systematic research on its incidence and outcomes in clinical settings remains limited. We implemented a standardized propofol-based, EEG-guided emergence bundle to facilitate a pre-emergence state conducive to dreaming, integrating it into routine care to assess adherence, dream recall, patient experience, and safety.

Methods: In this prospective quality improvement feasibility study, 474 patients undergoing elective surgeries were anesthetized according to a five-element protocol: (1) pre-induction verbal priming about dreaming; (2) propofol as emergence anesthetic; (3) EEG (SedLine) monitoring to guide emergence; (4) ≥10 minutes of minimized stimulation before emergence; and (5) immediate post-emergence interviews regarding dream recall, valence, and subjective sleep quality. In a subset of breast cancer patients (N = 106), preregistered analyses examined post-anesthesia recovery unit (PACU) outcomes.

Results: Of 452 patients interviewed, 69% reported dreaming. Among 57 patients with full adherence to all protocol elements, 93% reported dreaming. Most dreams were positive (86%), with no very negative dreams. Dreamers (M = 9.16 ± 1.57) reported higher sleep quality than non-dreamers (M = 7.65 ± 2.86; p < 0.001). The protocol was safe, with no intraoperative awareness. Recovery times, analgesic and antiemetic use did not differ between groups. Feasibility was supported by high adherence to most elements (100% for verbal priming and propofol use; ≥90% for EEG monitoring, 95% for immediate interviews), though adherence to the no-stimulation emergence period was low (14%).

Conclusions: We demonstrate the feasibility of using a standardized anesthetic protocol in real-world clinical setting to facilitate anesthesia dreaming. With full adherence, dream recall rates approached experimental studies. The protocol was safe and linked to positive patient experiences, although dream recall was unrelated to PACU outcomes. These findings align with ERAS principles and provide a foundation for exploring potential therapeutic applications of anesthesia dreaming.

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) and related advanced fibrosis are associated with poor hepatic and extrahepatic outcomes. However, the role of liver fibrosis in surgery-related mortality remains unclear. The authors aimed to assess the association between a widely used liver fibrosis marker, the Fibrosis-4 (FIB-4) score, and 30-day postoperative mortality and complications.

Methods: A multicenter historical cohort of patients underwent general anesthesia. Data were obtained from the Multicenter Perioperative Outcomes Group dataset. Exclusion criteria included known liver diseases other than MASLD, hepatic failure, and alcohol use disorder. Risk of liver fibrosis was calculated using the FIB-4 score and categorized using the MASLD accepted predefined ranges. Mixed-effects multivariable logistic regression models were built to assess the adjusted conditional odds ratio (cOR) for the primary outcome of mortality and secondary outcomes of acute kidney injury, myocardial injury, and postoperative pulmonary complications.

Results: The final cohort size for the primary outcome of mortality was 1,325,102. Compared to the low-risk FIB-4 category (1.3 or less), the inconclusive FIB-4 category (1.3 to 2.67) was associated with an adjusted cOR of 1.533-fold for mortality (99.75% CI, 1.453 to 1.616), while the elevated category (FIB-4, 2.67 or greater) was associated with an adjusted cOR of 3.765-fold (99.75% CI, 3.572 to 3.969). This association persisted with the application of age-adjusted FIB-4 cutoffs in stratification by age category. A dose-response association was also observed between FIB-4 as a continuous variable and mortality. Among secondary outcomes, elevated FIB-4 was associated with a postoperative cOR of 1.515 for acute kidney injury (99.75% CI, 1.435 to 1.598), a cOR of 1.657 for myocardial injury (99.75% CI, 1.401 to 1.960), and a cOR of 1.323 for postoperative pulmonary complications (99.75% CI, 1.280 to 1.369).

Conclusions: The FIB-4 score is associated with postoperative mortality and complications in a population without clinically apparent liver disease, and evaluation may have value in preoperative patient counseling and optimization.