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Plantar Compartment Block Improves Enhanced Recovery after Hallux Valgus Surgery: A Randomized, Comparative, Double-blind Study. 足底间室阻滞可改善拇指外翻手术后的恢复:双盲随机对比研究
IF 9.1 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/ALN.0000000000005180
Fabien Swisser, Yann Brethe, Olivier Choquet, Matthias Herteleer, Nathalie Bernard, Isabelle Laffont, Sophie Bringuier, Xavier Capdevila

Background: Walking ability is a key factor in enhanced recovery after foot ambulatory surgery. Plantar compartment block offers an analgesic alternative to popliteal sciatic nerve block (PSNB) for hallux valgus surgery. The objective of this study was to compare these two regional anesthesia strategies on patients' ability to recover a painless unaided walk.

Methods: This prospective double-blinded (patient; observing anesthesiologist) randomized study compared patients scheduled for hallux valgus surgery receiving PSNB with 1% mepivacaine, then combined plantar and peroneal nerve blocks (plantar compartment block [PCB] group) with ropivacaine 0.5% and dexamethasone, or PSNB with ropivacaine 0.5% and dexamethasone (control group). The primary outcome was the patient's ability to walk unaided 6 h after PSNB. The test was performed on a GAITRite, spatio-temporal gait analysis mat. For 3 days, the number of patient steps, pain levels, rescue analgesics, patient's experience, and adverse events were assessed.

Results: Sixty patients were included and 59 were analyzed. The number of patients walking unaided on the GAITRite mat was significantly higher in the PCB group (21 of 30, 70%) than in the control group (4 of 29, 13.8%; P < 0.001). Gait quality using the Functional Ambulation Profile score was 63 ± 13.6 in the PCB group and 49.5 ± 4.7 in the control group (P < 0.001). Median time to free ambulation at home was significantly lower in the PCB group (9 h [8.2 to 11.8]) than in the control group (33.5 h [24 to 47]; P < 0.001). Postoperative pain did not differ between the groups (β = -0.41 [-1.78 to 0.95]; P = 0.548). The number of steps on day 3, the time of first rescue analgesic, the number of patients using rescue analgesia, consumption of morphine, and patient's experience did not differ between the groups.

Conclusions: PCB decreased the time to return to unaided walking, with improved gait, compared with PSNB, improving effective analgesia and low consumption of rescue analgesics. This innovative regional anesthesia strategy enhanced recovery after surgery.

Editor’s perspective:

背景:行走能力是促进足部非卧床手术后恢复的关键因素。在足外翻手术中,足底腔阻滞是腘坐骨神经阻滞(PSNB)的一种镇痛替代方法。本研究的目的是比较这两种区域麻醉策略对患者恢复无痛自主行走能力的影响:这项前瞻性双盲(患者;观察麻醉师)随机研究比较了计划接受足底和腓肠神经阻滞(PSNB)和罗哌卡因0.5%和地塞米松阻滞(PCB组)的患者,以及计划接受足底和腓肠神经阻滞(PSNB)和罗哌卡因0.5%和地塞米松阻滞(对照组)的患者。主要结果是患者在 PSNB 术后 6 小时在无辅助情况下行走的能力。测试在 GAITRite® 时空步态分析垫上进行。在三天内,对患者的步数、疼痛程度、止痛药、患者体验和不良事件进行了评估:结果:共纳入 60 名患者,对 59 名患者进行了分析。PCB组患者在GAITRite®垫子上独立行走的次数(21/30,70%)明显高于对照组(4/29,13.8%;P结论:PCB减少了患者恢复独立行走的时间:与 PSNB 相比,PCB 缩短了恢复自主行走的时间,改善了步态,提高了镇痛效果,减少了镇痛药的消耗量。这种创新的区域麻醉策略促进了术后恢复。
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引用次数: 0
Conscientious Objection and the Anesthesiologist: An Ethical Dilemma. 良心拒绝与麻醉师:伦理困境。
IF 8.8 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/aln.0000000000005173
Raghuram Koganti,Moshe M Cohn,Steven H Resnicoff,Steven Roth
Conscientious objection is a legally protected right of medical professionals to recuse themselves from patient care activities that conflict with their personal values. Anesthesiology is different from most specialties with respect to conscientious objection in that the focus is to facilitate safe, efficient, and successful performance of procedures by others, rather than to perform the treatment in question. This could give rise to a unique, somewhat indirect ethical tension between the application of conscientious objection and potential infringement upon patient autonomy and well-being. While some situations have clear grounds and precedent for conscientious objection (e.g., abortion, or futile procedures), newer procedures, such as gender-affirming surgery and xenotransplantation, may trigger conscientious objection for complex reasons. This review discusses ethical, legal, and practical aspects of conscientious objection; challenges to anesthesia groups, departments, and healthcare organizations when conscientious objection is invoked by anesthesiologists; and strategies to help mitigate the ethical dilemmas.
依良心拒服兵役是受法律保护的医疗专业人员的一项权利,他们有权回避与其个人价值观相冲突的病人护理活动。在依良心拒服兵役方面,麻醉学与大多数专科不同,其重点是促进他人安全、高效、成功地实施手术,而不是实施相关治疗。这可能会在依良心拒服兵役与可能侵犯病人自主权和福祉之间产生一种独特的、有些间接的伦理矛盾。虽然某些情况(如堕胎或徒劳无益的手术)有明确的理由和先例可以出于良心而反对,但较新的手术,如性别确认手术和异种器官移植,可能会出于复杂的原因而引发出于良心的反对。本综述讨论了出于良心拒服兵役的伦理、法律和实践方面的问题;麻醉团体、部门和医疗机构在麻醉医师援引出于良心拒服兵役时面临的挑战;以及帮助缓解伦理困境的策略。
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引用次数: 0
Opioid-free Anesthesia on Quality of Recovery: Reply. 无阿片麻醉对康复质量的影响:回复。
IF 8.8 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/aln.0000000000005138
Maxime Léger,Maëva Campfort,Sigismond Lasocki
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引用次数: 0
Sublingual Hematoma: A Rare Anesthetic Complication. 舌下血肿:一种罕见的麻醉并发症。
IF 9.1 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/ALN.0000000000005147
Adam Warrick, Kevin Backfish, Sachin Vimal Bahadur
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引用次数: 0
Restrictive versus Decision Support Guided Fluid Therapy during Major Hepatic Resection Surgery: A Randomized Controlled Trial. 肝脏大部切除手术期间的限制性输液疗法与决策支持指导下的输液疗法:随机对照试验
IF 9.1 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/ALN.0000000000005175
Sean Coeckelenbergh, Maxim Soucy-Proulx, Philippe Van der Linden, Stéphanie Roullet, Maya Moussa, Hiromi Kato, Leila Toubal, Salima Naili, Joseph Rinehart, Tristan Grogan, Maxime Cannesson, Jacques Duranteau, Alexandre Joosten

Background: Fluid therapy during major hepatic resection aims at minimizing fluids during the dissection phase to reduce central venous pressure, retrograde liver blood flow, and venous bleeding. This strategy, however, may lead to hyperlactatemia. The Acumen assisted fluid management system uses novel decision support software, the algorithm of which helps clinicians optimize fluid therapy. The study tested the hypothesis that using this decision support system could decrease arterial lactate at the end of major hepatic resection when compared to a more restrictive fluid strategy.

Methods: This two-arm, prospective, randomized controlled, assessor- and patient-blinded superiority study included consecutive patients undergoing major liver surgery equipped with an arterial catheter linked to an uncalibrated stroke volume monitor. In the decision support group, fluid therapy was guided throughout the entire procedure using the assisted fluid management software. In the restrictive fluid group, clinicians were recommended to restrict fluid infusion to 1 to 2 ml · kg-1 · h-1 until the completion of hepatectomy. They then administered fluids based on advanced hemodynamic variables. Noradrenaline was titrated in all patients to maintain a mean arterial pressure greater than 65 mmHg. The primary outcome was arterial lactate level upon completion of surgery (i.e., skin closure).

Results: A total of 90 patients were enrolled over a 7-month period. The primary outcome was lower in the decision support group than in the restrictive group (median [quartile 1 to quartile 3], 2.5 [1.9 to 3.7] mmol · l-1vs. 4.6 [3.1 to 5.4] mmol · l-1; median difference, -2.1; 95% CI, -2.7 to -1.2; P < 0.001). Among secondary exploratory outcomes, there was no difference in blood loss (median [quartile 1 to quartile 3], 450 [300 to 600] ml vs. 500 [300 to 800] ml; P = 0.727), although central venous pressure was higher in the decision support group (mean ± SD of 7.7 ± 2.0 mmHg vs. 6.6 ± 1.1 mmHg; P < 0.002).

Conclusions: Patients managed using a clinical decision support system to guide fluid administration during major hepatic resection had a lower arterial lactate concentration at the end of surgery when compared to a more restrictive fluid strategy. Future trials are necessary to make conclusive recommendations that will change clinical practice.

Editor’s perspective:

背景:肝脏大部切除术期间的液体治疗旨在尽量减少解剖阶段的液体,以降低中心静脉压(CVP)、肝脏逆流血流和静脉出血。然而,这种策略可能会导致高乳酸血症。Acumen™ 辅助液体管理系统使用新型决策支持软件,其算法可帮助临床医生优化液体疗法。我们对以下假设进行了测试:与限制性更强的输液策略相比,使用该决策支持系统可降低肝大部切除术结束时的动脉乳酸:这项双臂、前瞻性、随机对照、评估者与患者双盲的优越性研究纳入了接受肝脏大手术的连续患者,这些患者都配备了动脉导管,导管与未经校准的每搏容量监测仪相连。在决策支持组,整个手术过程都由辅助液体管理软件指导液体治疗。在限制性输液组,建议临床医生将输液量限制在 1-2 ml.kg-1.h-1 直到完成肝切除术。然后,他们根据先进的血液动力学变量进行输液。对所有患者的去甲肾上腺素进行滴定,以维持平均动脉压大于 65mmHg。主要结果是手术完成(即皮肤闭合)时的动脉乳酸水平:结果:在 7 个月的时间里,共有 90 名患者接受了手术。决策支持组的主要结果低于限制组(中位数[Q1-Q3] 2.5[1.9-3.7]mmol.L-1 vs 4.6[3.1-5.4]mmol.L-1,中位数差异-2.1,95%CI(-2.7,-1.2),p结论:在肝脏大部切除术中,使用临床决策支持系统指导输液的患者在手术结束时的动脉乳酸浓度低于采用限制性输液策略的患者。未来有必要进行试验,以提出改变临床实践的结论性建议。
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引用次数: 0
The Many Worlds of Patient Safety in Anesthesiology. 麻醉学患者安全的多重世界。
IF 8.8 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/aln.0000000000005190
David M Gaba
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引用次数: 0
Routine Innovation in Perioperative Clinical Trials: The Best Chance to Answer Our Most Important Questions? 围手术期临床试验的常规创新:回答我们最重要问题的最佳机会?
IF 8.8 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/aln.0000000000005187
Daniel I McIsaac,Duminda N Wijeysundera,Justyna Bartoszko
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引用次数: 0
Lung Ultrasound Predicts Pulmonary Complications: Reply. 肺部超声波可预测肺部并发症:回复。
IF 8.8 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/aln.0000000000005145
Antoine Monsel,Louis Delorme,Alexandre Sitbon,Jérémy Boussier
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引用次数: 0
Dexamethasone for Cardiac Surgery: A Practice Preference-Randomized Consent Comparative Effectiveness Trial. 地塞米松用于心脏手术:实践偏好-随机同意比较效果试验》。
IF 9.1 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/ALN.0000000000005127
Paul S Myles, Jan M Dieleman, Karin E Munting, Andrew Forbes, Catherine A Martin, Julian A Smith, David McGiffin, Lieke P J Verheijen, Sophie Wallace

Background: High-dose corticosteroids have been used to attenuate the inflammatory response to cardiac surgery and cardiopulmonary bypass, but patient outcome benefits remain unclear. The primary aim was to determine whether using dexamethasone was superior to not using dexamethasone to increase the number of home days in the first 30 days after cardiac surgery. The secondary aim was to evaluate efficiency, value, and impact of the novel trial design.

Methods: This pragmatic, international trial incorporating a prerandomized consent design favoring local practice enrolled patients undergoing cardiac surgery across seven hospitals in Australia and The Netherlands. Patients were randomly assigned to dexamethasone 1 mg/kg or not (control). The primary outcome was the number of days alive and at home up to 30 days after surgery ("home days"). Secondary outcomes included prolonged mechanical ventilation (more than 48 h), sepsis, renal failure, myocardial infarction, stroke, and death.

Results: Of 2,562 patients assessed for eligibility, 1,951 were randomized (median age, 63 yr; 80% male). The median number of home days was 23.0 (interquartile range, 20.1 to 24.1) in the no dexamethasone group and 23.1 (interquartile range, 20.1 to 24.6) in the dexamethasone group (median difference, 0.1; 95% CI, -0.3 to 0.5; P = 0.66). The rates of prolonged mechanical ventilation (risk ratio, 0.72; 95% CI, 0.48 to 1.08), sepsis (risk ratio, 1.02; 95% CI, 0.57 to 1.82), renal failure (risk ratio, 0.94; 95% CI, 0.80 to 1.12), myocardial infarction (risk ratio, 1.20; 95% CI, 0.30 to 4.82), stroke (risk ratio, 1.06; 95% CI, 0.54 to 2.08), and death (risk ratio, 0.72; 95% CI, 0.22 to 2.35) were comparable between groups (all P > 0.10). Dexamethasone reduced intensive care unit stay (median, 29 h; interquartile range, 22 to 50 h vs. median, 43 h; interquartile range, 24 to 72 h; P = 0.004). The authors' novel trial design was highly efficient (89.3% enrollment).

Conclusions: Among patients undergoing cardiac surgery, high-dose dexamethasone decreased intensive care unit stay but did not increase the number of home days after surgery.

Editor’s perspective:

背景:大剂量皮质类固醇已被用于减轻心脏手术和心肺旁路术的炎症反应,但对患者疗效的益处仍不明确。我们的主要目的是确定使用地塞米松是否比不使用地塞米松更能增加心脏手术后前 30 天的居家天数。我们的次要目标是评估新试验设计的效率、价值和影响:这项务实的国际试验采用了有利于当地实践的预随机同意设计,在澳大利亚和荷兰的 7 家医院招募了接受心脏手术的患者。患者被随机分配使用地塞米松(1 毫克/千克)或不使用(对照组)。主要结果是术后 30 天内存活和在家的天数("在家天数")。次要结果包括机械通气时间延长(超过48小时)、败血症、肾功能衰竭、心肌梗死、中风和死亡:在接受资格评估的 2093 名患者中,1951 人接受了随机治疗(中位年龄为 63 岁,80% 为男性)。地塞米松组居家天数中位数为 23.0 天(IQR,20.1 至 24.1 天),无地塞米松组为 23.1 天(IQR,20.1 至 24.6 天);中位数差异为 0.1(95% CI,-0.3 至 0.5),P=0.66。延长机械通气率 RR 0.72(95% CI,0.48 至 1.08)、败血症率 RR 1.02(95% CI,0.57 至 1.82)、肾功能衰竭率 RR 0.94(95% CI,0.80 至 1.12)、心肌梗死率 RR 0.72(95% CI,0.48 至 1.08)、肾功能衰竭率 RR 1.02(95% CI,0.57 至 1.82)。12)、心肌梗死 RR1.20(95% CI,0.30 至 4.82)、中风 RR1.06(95% CI,0.54 至 2.08)和死亡 RR0.72(95% CI,0.22 至 2.35)。地塞米松缩短了重症监护室的住院时间,中位数为29(IQR,22至50)小时,而地塞米松为43(24至72)小时,P=0.004。我们新颖的试验设计效率很高(89.3%的入选率):结论:在接受心脏手术的患者中,大剂量地塞米松可缩短重症监护室的住院时间,但不会增加术后居家天数。
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引用次数: 0
Adherence to Intravenous Access Recommendations for Cesarean Delivery. 遵守剖腹产静脉通路建议。
IF 8.8 1区 医学 Q1 ANESTHESIOLOGY Pub Date : 2024-11-01 DOI: 10.1097/aln.0000000000005179
Scott M Seki,Allison Lee,Caoimhe Duffy,James Miranda,Alexandra Acker,Mark D Neuman
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引用次数: 0
期刊
Anesthesiology
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