British journal of anaesthesia最新文献

Ketamine, an N-methyl-D-aspartic acid receptor antagonist that was first discovered in 1962, has become established in anaesthesia providing dose-dependent anaesthetic, sedative, and analgesic effects. Ketamine, however, also acts on a wide range of other cellular targets, resulting in interesting and diverse effects on both physiological and pathological processes. Potential beneficial properties of ketamine include cardiovascular stability for patients undergoing sedation or anaesthesia, analgesia in both acute and chronic pain, bronchodilation in severe refractory asthma, anti-inflammatory properties particularly in sepsis, tumour inhibition, and antidepressant properties with marked ability to reverse suicidal ideation. The reluctance to adopt ketamine into routine practice is likely attributable in part to the stigma and negative reputation associated with its perceived side-effects and potential for abuse. This review explores the diverse properties and therapeutic potentials of ketamine being investigated across different fields whilst also identifying areas for ongoing and future research. Given the diverse range of potential benefits and promising early work, ketamine should be the focus of ongoing research in multiple different specialty areas. This includes areas relevant to anaesthesia and perioperative medicine, such as acute and chronic pain management, ICU sedation, and even tumour suppression in those undergoing surgical resection of malignancies.

Background: Telemedicine may help improve care quality and patient outcomes. Telemedicine for intraoperative decision support has not been rigorously studied.

Methods: This was a single-centre randomised clinical trial of unselected adult surgical patients. Patients were randomised to receive usual care or decision support from a telemedicine service, which provided real-time recommendations to intraoperative anaesthesia clinicians based on case reviews and physiological alerts. ORs were randomised 1:1. The co-primary outcomes were 30-day all-cause mortality, respiratory failure, acute kidney injury, and delirium in the intensive care unit, analysed by intention to treat.

Results: Between July 1, 2019, and January 31, 2023, a total of 35,302 patients were randomised to receive telemedicine support, with 36,625 receiving usual care. Telemedicine clinicians provided review in 11,812/35,302 cases, with alerts delivered to 2044/35,302 patients. Telemedicine support had no effect on any of the co-primary outcomes. Within 30 days, 630/35,302 (1.8%) patients randomised to telemedicine died within 30 days, compared with 649/36,625 (1.8%) receiving usual care (relative risk [RR]1.01, 95% confidence interval [CI] 0.87-1.16, P=0.98). Telemedicine support did not alter postoperative respiratory failure [telemedicine 1071/33,996 (3.2%) vs usual care 1130/35,236 (3.2%), RR 0.98, 95% CI 0.88-1.09, P=0.98], acute kidney injury [telemedicine 2316/33 251 (7.0%) vs usual care 2432/34,441 (7.1%); RR 0.99, 95% CI 0.92-1.06, P=0.98], or delirium [telemedicine 1264/3873 (32.6%) vs usual care 1298/4044 (32.1%), RR 1.02, 95% CI 0.94-1.10, P=0.98].

Conclusions: In this large randomised clinical trial, intraoperative telemedicine decision support using real-time alerts and case reviews had no impact on adverse postoperative outcomes.

Clinical trial registration: NCT03923699.

Background: Optimised use of kidney function information might improve cardiac risk prediction in noncardiac surgery.

Methods: In 35,815 patients from the VISION cohort study and 9219 patients from the POISE-2 trial who were ≥45 yr old and underwent nonurgent inpatient noncardiac surgery, we examined (by age and sex) the association between continuous nonlinear preoperative estimated glomerular filtration rate (eGFR) and the composite of myocardial injury after noncardiac surgery, nonfatal cardiac arrest, or death owing to a cardiac cause within 30 days after surgery. We estimated contributions of predictive information, C-statistic, and net benefit from eGFR and other common patient and surgical characteristics to large multivariable models.

Results: The primary composite occurred in 4725 (13.2%) patients in VISION and 1903 (20.6%) in POISE-2; in both studies cardiac events had a strong, graded association with lower preoperative eGFR that was attenuated by older age (P_interaction<0.001 for VISION; P_interaction=0.008 for POISE-2). For eGFR of 30 compared with 90 ml min^-1 1.73 m^-2, relative risk was 1.49 (95% confidence interval 1.26-1.78) at age 80 yr but 4.50 (2.84-7.13) at age 50 yr in female patients in VISION. This differed modestly (but not meaningfully) in men in VISION (P_interaction=0.02) but not in POISE-2 (P_interaction=0.79). eGFR contributed the most predictive information and mean net benefit of all predictors in both studies, most C-statistic in VISION, and third most C-statistic in POISE-2.

Conclusions: Continuous preoperative eGFR is among the best cardiac risk predictors in noncardiac surgery of the large set examined. Along with its interaction with age, preoperative eGFR would improve risk calculators.

Clinical trial registration: ClinicalTrials.gov NCT00512109 (VISION) and NCT01082874 (POISE-2).

Background: Physical prehabilitation can enhance patient resilience to surgical stress, but its effects are unclear in vulnerable and frail patients. We aimed to determine the effect of a structured exercise prehabilitation programme on the quality of recovery after cardiac surgery in vulnerable and frail participants.

Methods: This single-blinded, parallel-arm, superiority, randomised controlled trial recruited patients with a Clinical Frailty Scale of 4-6 undergoing cardiac surgery. Patients were randomised to either physical prehabilitation (twice weekly) or standard care (control); both arms received standard perioperative care. The primary outcome was Quality of Recovery-15 (QoR-15) score on the third day after surgery. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE), days alive and at home (DAH₃₀), and the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 metric.

Results: Of 164 randomised patients, 138 were included in the primary analysis (median age 64 [interquartile range 60-69] yr; 70% males). Compliance with the 5-week prehabilitation programme was high (82%), with no adverse exercise-induced events reported. There were no between-group differences in QoR-15 scores (median difference -3, 95% confidence interval [CI] -9 to 3), early and late MACCE, and DAH₃₀ (P=0.779). Prehabilitated patients had lower disability levels than control patients (P=0.022) at 90 days after surgery (mean difference -9%, 95% CI -17% to -2%).

Conclusions: A 5-week programme of physical prehabilitation in predominately prefrail patients was safe, but it did not enhance quality of recovery scores after surgery. Prehabilitation resulted in a clinically meaningful decrease in disability scores at 90 days after surgery.

Clinical trial registration: ChiCTR1800016098.

Prehabilitation aims to reduce the impact of major surgery by improving the physical and psychological resilience of patients. Although exercise represents one component of prehabilitation, nutritional and psychological support are also critical to its effectiveness, and any benefits are only likely to be realised if the different components are implemented together, ideally in a behaviour change framework. Implementation of prehabilitation in cardiac surgery has not been as widespread as in other types of surgery, despite many randomised controlled trials (RCTs) of single interventions in this setting. The late adoption of a prehabilitation programme in cardiac surgery represents an opportunity to ensure that it is both clinically effective and cost-effective before widespread roll-out. This was mostly not done for prehabilitation in noncardiac surgery, where programmes were implemented largely without trials of these combined interventions. The most likely chance of an effective prehabilitation programme for cardiac surgery is to combine all the efficacious and implementable single interventions together in one comprehensive evidence-based programme. This should then be tested in an adequately powered multicentre RCT in a representative cardiac surgery population.

Background: Delaying surgery after a major cardiovascular event might reduce adverse postoperative outcomes. The time interval represents a potentially modifiable risk factor but is not well studied.

Methods: This was a longitudinal retrospective population-based cohort study, linking data from Hospital Episode Statistics for NHS England and the Myocardial Ischaemia National Audit Project. Adults undergoing noncardiac, non-neurologic surgery in 2007-2018 were included. The time interval between a preoperative cardiovascular event and surgery was the main exposure. The outcomes of interest were acute coronary syndrome (ACS), acute myocardial infarction (AMI), cerebrovascular accident (CVA) within 1 year of surgery, unplanned readmission (at 30 days and 1 year), and prolonged length of stay. Multivariable logistic regression models with restricted cubic splines were used to estimate adjusted odds ratios (aORs; age, sex, socioeconomic deprivation, and comorbidities).

Results: In total, 877 430 people had a previous cardiovascular event and 20 582 717 were without an event. CVA, ACS, and AMI in the year after elective surgery were more frequent after prior cardiovascular events (adjusted hazard ratio 2.12, 95% confidence interval [CI] 2.08-2.16). Prolonged hospital stay (aOR 1.36, 95% CI 1.35-1.38) and 30-day (aOR 1.28, 95% CI 1.25-1.30) and 1-yr (aOR 1.60, 95% CI 1.58-1.62) unplanned readmission were more common after major operations in those with a prior cardiovascular event. After adjusting for the time interval between preoperative events until surgery, elective operations within 37 months were associated with an increased risk of postoperative ACS or AMI. The risk of postoperative stroke plateaued after a 20-month interval until surgery, irrespective of surgical urgency.

Conclusions: These observational data suggest increased adverse outcomes after a recent cardiovascular event can occur for up to 37 months after a major cardiovascular event.