British journal of anaesthesia最新文献

Background: The EFFORT Protein trial assessed the effect of high vs usual dosing of protein in adult ICU patients with organ failure. This study provides a probabilistic interpretation and evaluates heterogeneity in treatment effects (HTE).

Methods: We analysed 60-day all-cause mortality and time to discharge alive from hospital using Bayesian models with weakly informative priors. HTE on mortality was assessed according to disease severity (Sequential Organ Failure Assessment [SOFA] score), acute kidney injury, and serum creatinine values at baseline.

Results: The absolute difference in mortality was 2.5% points (95% credible interval -6.9 to 12.4), with a 72% posterior probability of harm associated with high protein treatment. For time to discharge alive from hospital, the hazard ratio was 0.91 (95% credible interval 0.80 to 1.04) with a 92% probability of harm for the high-dose protein group compared with the usual-dose protein group. There were 97% and 95% probabilities of positive interactions between the high protein intervention and serum creatinine and SOFA score at randomisation, respectively. Specifically, there was a potentially relatively higher mortality of high protein doses with higher baseline serum creatinine or SOFA scores.

Conclusions: We found moderate to high probabilities of harm with high protein doses compared with usual protein in ICU patients for the primary and secondary outcomes. We found suggestions of heterogeneity in treatment effects with worse outcomes in participants randomised to high protein doses with renal dysfunction or acute kidney injury and greater illness severity at baseline.

Patient blood management (PBM) encompasses implementing multimodal evidence-based strategies to screen, diagnose, and properly treat anaemia and coagulopathies using goal-directed therapy while minimising bleeding. The aim of PBM is to improve clinical care and patient outcomes while managing patients with potential or ongoing critical anaemia, clinically significant bleeding, and coagulopathies. The focus of PBM is patient-centred rather than transfusion-centred. Multimodal PBM strategies are now recommended by international organisations, including the World Health Organization, as a new standard of care and a proven means to safely and effectively manage anaemia and blood loss while minimising unnecessary blood transfusion. Compared with adult PBM, paediatric PBM is currently not routinely accepted as a standard of care. This is partly because of the paucity of robust data on paediatric patient PBM. Managing paediatric bleeding and blood product transfusion presents unique challenges. Neonates, infants, children, and adolescents each have specific considerations based on age, weight, physiology, and pharmacology. This narrative review covers the latest updates for PBM in paediatric surgical populations including the benefits and principles of paediatric PBM, current expert consensus guidelines, and important universal multimodal therapeutic strategies emphasising clinical management of the anaemic, bleeding, or coagulopathic paediatric patient in the perioperative period. Practical paediatric rules for PBM in the perioperative period are highlighted, with review of specific PBM strategies including treatment of preoperative anaemia, restrictive transfusion thresholds, antifibrinolytic agents, cell salvage, standardised transfusion algorithms, and goal-directed therapy based on point-of-care and viscoelastic testing.

Background: Postoperative anxiety and depression can negatively affect surgical outcomes and patient wellbeing. This study aimed to quantify the incidence of postoperative worsening anxiety and depression symptoms and to identify preoperative predictors of these conditions.

Methods: This prospective, observational cohort study included 1168 patients undergoing surgery lasting >1 h with overnight admission at a university-affiliated quaternary referral centre. Postoperative anxiety and depression symptoms were measured using standardised, thrice-daily ecological momentary assessments (EMAs) for 30 days. Co-primary outcomes were worsening anxiety and depression symptoms, each defined as a slope >0 when EMA was modelled as a linear function of time. Multivariable logistic regression was performed to identify independent preoperative predictors of each outcome.

Results: Postoperative worsening anxiety occurred in 60 patients (5%), and postoperative worsening depression occurred in 86 patients (7%). Predictors of postoperative worsening of anxiety symptoms included preoperative Patient-Reported Outcome Measurement Information System (PROMIS) anxiety symptoms (adjusted odds ratio [aOR] 2.48, 95% credible interval [CI] 1.29-4.79, for mild symptoms; aOR 2.22, 95% CI 1.10-4.51, for moderate to severe symptoms), and preoperative pain (aOR 3.46, 95% CI 1.32-9.12). Predictors of postoperative worsening depression symptoms included preoperative PROMIS depression symptoms (aOR 2.26, 95% CI 1.24-4.14, for mild symptoms; aOR 3.79, 95% CI 2.10-6.81, for moderate to severe symptoms). Self-reported history of anxiety or depression did not independently predict either outcome.

Conclusions: Postoperative worsening anxiety and depression appear to be associated more closely with preoperative active mental health or pain symptoms rather than self-reported history of these conditions. Preoperative identification of at-risk patients will require screening for symptoms rather than simple history taking.