British journal of anaesthesia最新文献

Background: Spread of local anaesthetic solution in the paravertebral space after erector spinae plane block (ESPB) is variable. We evaluated whether paravertebral spread of local anaesthetic is affected by patient position after ESPB.

Methods: We randomised 84 patients to receive ESPB at T₇ with a mixture of 0.375% ropivacaine and radiocontrast dye (30 ml). Participants were positioned supine, prone, or lateral for 30 min after ESPB before computed tomography scanning. The primary outcome was paravertebral space local anaesthetic spread, with secondary assessments of craniocaudal spread and distribution to neural foramina, and intercostal and epidural spaces. Loss of sensation to cold was recorded.

Results: Local anaesthetic-contrast mix reached the paravertebral space, intercostal space, and neural foramina in 96.5%, 94.2%, and 77.9% of individuals, respectively. Epidural space spread occurred in 20 cases. Prone positioning consistently allowed paravertebral and intercostal spread in all patients, with more thoracic level spread compared with supine positioning (5.0 [1.9] vs 3.1 [1.7], difference [95% confidence interval, CI]: 1.9 [0.8-3.0] levels, P<0.001 for paravertebral space spread; 2.8 [1.9] vs 1.4 [1.4], difference [95% CI] levels: 1.4 [0.4-2.5], P=0.004 for neural foramina spread; 4.3 [1.3] vs 3.2 [1.5], difference [95% CI] levels: 1.0 [0.1-1.9], P=0.019 for intercostal space spread). Local anaesthetic-contrast extended to the intercostal space further in the prone than in the lateral position group (4.3 [1.3] vs 2.6 [1.5] thoracic levels, difference [95% CI]: 1.7 [0.8-2.6], P<0.001). Sensory block in ventral dermatomes was variable in all participants.

Conclusions: Prone positioning after ESPB significantly enhanced local anaesthetic-contrast spread to the paravertebral space, intercostal space, and neural foramina, suggesting that gravity plays a substantial role in spread.

Clinical trial registration: Clinical Trials.gov (NCT06142630).

Most postoperative deaths occur on general wards, often linked to complications associated with untreated changes in vital signs. Monitoring in these units is typically intermittent checks each shift or maximally every 4-6 h, which misses prolonged periods of subtle changes in physiology that can herald a critical downstream event. Continuous monitoring of vital signs is therefore intuitively necessary for patient safety. The past five decades have seen monitoring systems evolve rapidly, and today entirely wireless, wearable, and portable continuous surveillance of vital signs is possible on general wards. Introduction of this technology has the potential to modify both the sensing (afferent) and response (efferent) limbs of monitoring, and will allow earlier detection of vital signs perturbations. But this comes with challenges, including but not limited to issues with connectivity, data handling, alarm fatigue, information overload, and lack of meaningful clinical interventions. Evidence from before and after studies and retrospective propensity-matched data suggests that continuous ward monitoring decreases the risk of intensive care unit (ICU) admissions, rapid response calls, and in some instances, mortality. This review summarises the history of general ward monitoring and describes future directions, including opportunities to implement these devices using artificial intelligence, pattern detection, and user-friendly interfaces. Pragmatic, well designed and appropriately powered trials, and real-world implementation data are necessary to make continuous monitoring standard practice at every hospital bed.

Despite the numerous recent trials, systematic reviews and meta-analyses have not conclusively shown superiority of videolaryngoscopy over other techniques for tracheal intubation of children. Clinical trials have shown significant differences using various outcome measures, but the overall clinical evidence remains weak. An international group of experts is currently working on developing good clinical research practice guidelines for paediatric airway management research, with the ultimate aim of identifying a core set of outcomes to be applied to develop future robust and comparable trials.

Background: Bleeding guidelines currently recommend use of viscoelastic testing (VET) to direct haemostatic resuscitation in severe haemorrhage. However, VET-derived parameters of clot initiation, such as clotting time (CT) and activated clotting time (ACT), might not adequately reflect a clinically relevant interaction of procoagulant and anticoagulant activity, as revealed by thrombin generation assays. The aim of this study was to evaluate the ability of CT and ACT to indicate thrombin generation activity.

Methods: Citrated whole blood obtained from 13 healthy volunteers underwent a 50% crystalloid dilution (DL-50%), followed by spiking with four-factor prothrombin complex concentrate (DL-50% + 4F-PCC). Changes in thrombin generation activity were compared with the VET parameters CT and ACT derived from four commercially available viscoelastic devices (ROTEM® Delta, ClotPro®, TEG®6s, and Quantra®) and standard coagulation tests.

Results: Dilution of whole blood resulted in a marked increase in velocity index, peak height, and endogenous thrombin potential (all P<0.01), with a further substantial increase after spiking with 4F-PCC (all P<0.001). In contrast, CT and ACT were significantly prolonged in response to DL-50% on all devices (all P<0.05). Subsequent spiking of diluted blood with 4F-PCC had no impact on CT and ACT derived from VET analysers, but it restored standard coagulation tests without reaching baseline values (all P<0.01).

Conclusions: Upregulated thrombin generation parameters after PCC spiking were not displayed by CT, ACT, or standard tests. Our results do not support treatment algorithms using prolonged CT or ACT as a trigger for administration of PCC to augment thrombin generation.

Total knee arthroplasty is a life-changing surgical procedure that is associated with a high incidence of severe postoperative pain. Key to enhancing recovery after surgery is effective analgesia and early mobilisation. Innovations in motor-sparing regional anaesthesia techniques that have improved recovery include targeted surgical local infiltration analgesia, adductor canal blockade, genicular nerve blocks, and the infiltration between the popliteal artery and posterior capsule of the knee (iPACK) block. This narrative review discusses the current available motor-sparing regional anaesthetic techniques and assesses the evidence supporting each.

Background: The impact of noninvasive ventilation (NIV) managed outside the intensive care unit in patients with early acute respiratory failure remains unclear. We aimed to determine whether adding early NIV prevents the progression to severe respiratory failure.

Methods: In this multinational, randomised, open-label controlled trial, adults with mild acute respiratory failure (arterial oxygen partial pressure/fraction of inspiratory oxygen [Pao₂/FiO₂] ratio ≥200) were enrolled across 11 hospitals in Italy, Greece, and Kazakhstan. Patients were randomised to receive early NIV or usual care. Patients in the early NIV group received 2-h cycles of NIV applied every 8 h for up to 12 days. The primary outcome was the progression to severe acute respiratory failure, defined by severe hypoxaemia, severe respiratory distress, or hypercapnic acidaemia during hospitalisation.

Results: Between May 6, 2012, and July 18, 2023, we randomised 524 patients (44.8% female; median age 73 yr, interquartile range [IQR] 63-83 yr). One patient withdrew consent. Progression to severe acute respiratory failure occurred in 49/265 (18.5%) patients randomised to early NIV, compared with 73/258 (28.3%) patients receiving usual care (relative risk 0.65, 95% confidence interval 0.48-0.90, P=0.0080). Median length of hospital stay was 10 (IQR 6-16) days in the early NIV group and 9 (IQR 5-16) days in the usual care group (P=0.30). Respiratory complications, 28-day mortality, and adverse events were not different between early NIV and usual care.

Conclusions: In patients with mild acute respiratory failure treated in nonintensive care wards, early NIV reduced the progression to severe acute respiratory failure.

Clinical trial registration: NCT01572337.