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.
{"title":"Plantar Compartment Block Improves Enhanced Recovery after Hallux Valgus Surgery: A Randomized, Comparative, Double-blind Study.","authors":"Fabien Swisser, Yann Brethe, Olivier Choquet, Matthias Herteleer, Nathalie Bernard, Isabelle Laffont, Sophie Bringuier, Xavier Capdevila","doi":"10.1097/ALN.0000000000005180","DOIUrl":"10.1097/ALN.0000000000005180","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusions: </strong>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.</p><p><strong>Editor’s perspective: </strong></p>","PeriodicalId":7970,"journal":{"name":"Anesthesiology","volume":" ","pages":"891-903"},"PeriodicalIF":9.1,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141892686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 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.
{"title":"Conscientious Objection and the Anesthesiologist: An Ethical Dilemma.","authors":"Raghuram Koganti,Moshe M Cohn,Steven H Resnicoff,Steven Roth","doi":"10.1097/aln.0000000000005173","DOIUrl":"https://doi.org/10.1097/aln.0000000000005173","url":null,"abstract":"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.","PeriodicalId":7970,"journal":{"name":"Anesthesiology","volume":"40 1","pages":"849-858"},"PeriodicalIF":8.8,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142385274","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 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.
{"title":"Restrictive versus Decision Support Guided Fluid Therapy during Major Hepatic Resection Surgery: A Randomized Controlled Trial.","authors":"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","doi":"10.1097/ALN.0000000000005175","DOIUrl":"10.1097/ALN.0000000000005175","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Methods: </strong>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).</p><p><strong>Results: </strong>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).</p><p><strong>Conclusions: </strong>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.</p><p><strong>Editor’s perspective: </strong></p>","PeriodicalId":7970,"journal":{"name":"Anesthesiology","volume":" ","pages":"881-890"},"PeriodicalIF":9.1,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141756707","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1097/aln.0000000000005190
David M Gaba
{"title":"The Many Worlds of Patient Safety in Anesthesiology.","authors":"David M Gaba","doi":"10.1097/aln.0000000000005190","DOIUrl":"https://doi.org/10.1097/aln.0000000000005190","url":null,"abstract":"","PeriodicalId":7970,"journal":{"name":"Anesthesiology","volume":"18 1","pages":"819-821"},"PeriodicalIF":8.8,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142385207","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1097/aln.0000000000005187
Daniel I McIsaac,Duminda N Wijeysundera,Justyna Bartoszko
{"title":"Routine Innovation in Perioperative Clinical Trials: The Best Chance to Answer Our Most Important Questions?","authors":"Daniel I McIsaac,Duminda N Wijeysundera,Justyna Bartoszko","doi":"10.1097/aln.0000000000005187","DOIUrl":"https://doi.org/10.1097/aln.0000000000005187","url":null,"abstract":"","PeriodicalId":7970,"journal":{"name":"Anesthesiology","volume":"226 1","pages":"825-828"},"PeriodicalIF":8.8,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142385275","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 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.
{"title":"Dexamethasone for Cardiac Surgery: A Practice Preference-Randomized Consent Comparative Effectiveness Trial.","authors":"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","doi":"10.1097/ALN.0000000000005127","DOIUrl":"10.1097/ALN.0000000000005127","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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).</p><p><strong>Conclusions: </strong>Among patients undergoing cardiac surgery, high-dose dexamethasone decreased intensive care unit stay but did not increase the number of home days after surgery.</p><p><strong>Editor’s perspective: </strong></p>","PeriodicalId":7970,"journal":{"name":"Anesthesiology","volume":" ","pages":"859-869"},"PeriodicalIF":9.1,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141431211","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1097/aln.0000000000005179
Scott M Seki,Allison Lee,Caoimhe Duffy,James Miranda,Alexandra Acker,Mark D Neuman
{"title":"Adherence to Intravenous Access Recommendations for Cesarean Delivery.","authors":"Scott M Seki,Allison Lee,Caoimhe Duffy,James Miranda,Alexandra Acker,Mark D Neuman","doi":"10.1097/aln.0000000000005179","DOIUrl":"https://doi.org/10.1097/aln.0000000000005179","url":null,"abstract":"","PeriodicalId":7970,"journal":{"name":"Anesthesiology","volume":"206 1","pages":"1013-1015"},"PeriodicalIF":8.8,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142385147","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}