The latest medical research on Anesthesiology
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Request AccessA Statewide Mobile Simulation Program For Improving Obstetric Skills in Rural Hospitals.
Anesthesia and AnalgesiaClosure of rural obstetric (OB) units has led to maternal care deserts, causing mothers to travel long distances for maternity care. Emergency departments (EDs) in hospitals where OB units have closed require regular training for personnel to maintain OB skills, as do rural Level-1 OB units with low volumes of maternity cases. We used a federal grant to develop an OB mobile simulation program to bring simulation-based training to rural providers. Our goal was to improve OB skills and standardize care through the framework of the Alliance for Innovation in Maternal Health (AIM) Patient Safety Bundles.
We conducted needs assessments and built a mobile simulation unit. We defined 2 groups of learners: those in Level-1 OB units and those in EDs without OB units. For Level-1 OB units, we created a train-the-trainer curriculum, to create a statewide cohort of simulation experts to implement simulations in their facilities between our visits. We gifted each Level-1 unit an OB task trainer, implemented virtual train-the-trainer simulation and task trainer workshops, and conducted post-workshop assessments. We then traveled to each Level-1 unit and helped the cohort implement in situ simulations for their staff using facility-specific resources. We conducted assessments for the cohort and the hospital staff after the simulations. For EDs, we delivered virtual didactics to improve basic OB knowledge, then traveled to ED units, implemented in situ simulations, and conducted post-simulation assessments. We chose a postpartum hemorrhage (PPH) scenario for our first round of simulations.
After train-the-trainer simulation workshops, 98% of participants surveyed agreed that workshop goals and objectives were achieved. After the task trainer workshop, 95% surveyed agreed that their knowledge of using the simulator had improved. After implementing in situ simulations in Level-1 OB units, 98.8% of the train-the-trainer cohort found that their ability to implement simulations had improved. The hospital staff participating in the simulations identified a 30% increase in ability to manage PPH. For the ED staff, postdidactic evaluations identified that 95.4% of participants reported moderate improvement in basic OB knowledge and after participation in the simulations >95% reported better skills as an ED team member when caring for pregnant patients.
These results demonstrate improved skills of hospital staff in simulated PPH in Level-1 OB units and simulated OB emergencies in EDs that no longer have OB units. Further studies are warranted to assess improvement in maternal outcomes.
Determinants and practice variability of oxygen administration during surgery in the U.S., a retrospective cohort study.
AnesthesiologyThe best approaches to supplemental oxygen administration during surgery remain unclear, which may contribute to variation in practice. We aimed to assess determinants of oxygen administration and its variability during surgery.
Using multivariable linear mixed-effects regression, we measured the associations between intraoperative fraction of inspired oxygen and patient, procedure, medical center, anesthesiologist, and in-room anesthesia provider factors in surgical cases of 120 minutes or longer in adult patients who received general anesthesia with tracheal intubation and were admitted to the hospital after surgery between January 2016 and January 2019 at 42 medical centers across the U.S. participating in the Multicenter Perioperative Outcomes Group data registry.
The sample included 367,841 cases (median [25 th, 75 th] age, 59 [47, 69] years; 51.1% women; 26.1% treated with nitrous oxide) managed by 3,836 anesthesiologists and 15,381 in-room anesthesia providers. Median (25 th, 75 th) fraction of inspired oxygen was 0.55 (0.48, 0.61), with 6.9% of cases <0.40 and 8.7% >0.90. Numerous patient and procedure factors were statistically associated with increased inspired oxygen, notably advanced ASA classification, heart disease, emergency surgery, and cardiac surgery, but most factors had little clinical significance (<1% inspired oxygen change). Overall, patient factors only explained 3.5% (95% CI, 3.5 to 3.5) of the variability in oxygen administration and procedure factors 4.4% (4.2 to 4.6). Anesthesiologist explained 7.7% (7.2 to 8.2) of the variability in oxygen administration, in-room anesthesia provider 8.1% (7.8 to 8.4), medical center 23.3% (22.4 to 24.2), and 53.0% (95% CI, 52.4 to 53.6) was unexplained.
Among adults undergoing surgery with anesthesia and tracheal intubation, supplemental oxygen administration was variable and appeared arbitrary. Most patient and procedure factors had statistical but minor clinical associations with oxygen administration. Medical center and anesthesia provider explained significantly more variability in oxygen administration than patient or procedure factors.
Effect of Remimazolam on Emergence Delirium in Children Undergoing Laparoscopic Surgery: A Double-Blinded Randomized Trial.
AnesthesiologyPreventing emergence delirium is a clinical goal for pediatric anesthesia, yet there is no consensus on its prevention. This study investigated the hypothesis that a continuous infusion or a single bolus of remimazolam can reduce the incidence of emergence delirium in children.
A hundred and twenty children aged 1-6 years old were randomly and equally allocated into three groups: group RC, which received a continuous infusion of remimazolam at 1 mg kg -1 h -1; group RB, which received a single bolus of remimazolam at 0.2 mg kg -1 at the beginning of wound closure; and group C, which received a continuous infusion of saline at 1 mL kg -1 h -1 and single bolus of saline at 0.2 mL kg -1 at the beginning of sutures. The primary outcome was the incidence of emergence delirium assessed by pediatric anesthesia emergence delirium (PAED) scale. Secondary outcomes included the number of rescues propofol administrations in the post-anesthesia care unit (PACU), recovery time, end-tidal sevoflurane concentration when maintaining BIS within the range of 40-60, and adverse events.
The incidence of emergence delirium in group RC (5%, vs. group C, risk ratio, 0.14; 95% CI, 0.04 to 0.59; P=0.001) and group RB (7.7%, vs. group C, risk ratio, 0.22; 95% CI, 0.07 to 0.71; P=0.003) was significantly lower compared with group C (32.5%). Propofol was given to 2 patients in each of groups RC and RB to treat delirium and to 10 patients in group C (group RC vs. group C, risk ratio, 0.20; 95% CI, 0.05 to 0.86; P=0.012; group RB vs. group C, risk ratio, 0.21; 95% CI, 0.05 to 0.88; P=0.014). No differences in the recovery time and adverse effects were detected.
Both continuous infusion and single bolus administration of remimazolam can effectively reduce the occurrence of emergence delirium in children.
Perspectives on sustainable practices in the use of nitrous oxide for labour analgesia: A patient and staff survey.
AnaesthesiologyNo intervention.
Assessment of the opinions of post-natal women and staff on nitrous oxide use and to investigate whether knowledge of its environmental harm would influence their choice of labour analgesia.
To evaluate the awareness and perceptions of postnatal women and staff regarding the environmental impact of nitrous oxide and if it would affect their decision to use it in the future.
One hundred postnatal women and 50 healthcare staff completed the survey. One hundred and six post-natal women were invited to complete the survey, resulting in a response rate of 94%. Knowledge of nitrous oxide's environmental impact was low. After receiving information, 46% of patients were more inclined to seek epidural or request it earlier (54%) to limit their nitrous oxide use, while 51% would choose an alternative analgesia to avoid nitrous oxide altogether. Overwhelmingly, 99% believed they had the right to know about these harmful effects when choosing an analgesic option.
Patients should be informed of the environmental impact of nitrous oxide antenatally, empowering them to make informed decision on a climate friendly analgesic option if they wish.
Experiences and perspectives of adults on using opioids for pain management in the postoperative period: A scoping review.
AnaesthesiologyOpioids play an important role in peri-operative pain management. However, opioid use is challenging for healthcare practitioners and patients because of concerns related to opioid crises, addiction and side effects.
This review aimed to identify and synthesise the existing evidence related to adults' experiences of opioid use in postoperative pain management.
All qualitative and mixed-method studies, in English, that not only used a qualitative approach that explored adults' opinions or concerns about opioids and/or opioid reduction, and adults' experience related to opioid use for postoperative pain control, including satisfaction, but also aspects of overall quality of a person's life (physical, mental and social well being).
Ten studies were included; nine were qualitative (n = 9) and one used mixed methods. The studies were primarily conducted in Europe and North America. Concerns about opioid dependence, adverse effects, stigmatisation, gender roles, trust and shared decision-making between clinicians and patients appeared repeatedly throughout the studies. The TDF analysis showed that many peri-operative factors formed people's perceptions and experiences of opioids, driven by the following eight domains: Knowledge, Emotion, Beliefs about consequences, Beliefs about capabilities, Self-confidence, Environmental Context and Resources, Social influences and Decision Processes/Goals. Adults have diverse pain management goals, which can be categorised as proactive and positive goals, such as individualised pain management care, as well as avoidance goals, aimed at sidestepping issues such as addiction and opioid-related side effects.
It is desirable to understand the complexity of adults' experiences of pain management especially with opioid use and to support adults in achieving their pain management goals by implementing an individualised approach, effective communication and patient-clinician relationships. However, there is a dearth of studies that examine patients' experiences of postoperative opioid use and their involvement in opioid usage decision-making. A summary is provided regarding adults' experiences of peri-operative opioid use, which may inform future researchers, healthcare providers and guideline development by considering these factors when improving patient care and experiences.
Cardiopulmonary exercise testing, computed tomography-derived body composition, systemic inflammation and survival after elective abdominal aortic aneurysm repair: A retrospective cohort study.
AnaesthesiologyCardio-pulmonary exercise testing (CPEX) is selectively used before intervention for abdominal aortic aneurysm (AAA). Sarcopenia, a chronic condition defined by reduced skeletal muscle function and volume, can be assessed radiologically by computed tomography (CT)-derived body composition analysis (CT-BC), and is associated with systemic inflammation.
The aim was to describe the association between CT-BC, CPEX, inflammation and survival in patients undergoing elective intervention for AAA.
Preoperative CPEX tests were recorded. CT sarcopenia score [CT-SS, range 0 to 2, calculated based on normal/low SMI (0/1) and normal/low SMD (0/1)] assessed radiological sarcopenia. Preoperative modified Glasgow Prognostic score (mGPS) was used to assess systemic inflammation.
Mean [95% confidence interval (CI) survival in the CT-SS 0 vs. CT-SS 1 vs. CT-SS 2 subgroups was 80.1 (73.6 to 86.6) months vs. 70.3 (63.5 to 77.1) months vs. 63.8 (53.4 to 74.2) months] (P = 0.01). CT-SS was not associated with CPEX results (P > 0.05). Elevated CT-SS [hazard ratio (HR) 1.83, 95% CI, 1.16 to 2.89, P < 0.01] was independently associated with increased hazard of long-term mortality; however, CPEX results were not (P > 0.05).
CPEX test results were not consistently associated with body composition and did not have significant prognostic value in patients undergoing elective treatment for AAA.
Preoperative N-Terminal Pro-B-Type Natriuretic Peptide and High-Sensitivity Cardiac Troponin T and Outcomes After Major Noncardiac Surgery: A Prospective Cohort Study.
AnesthesiologyPatients undergoing noncardiac surgery have varying risk of cardiovascular complications. This study evaluated preoperative N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T to enhance cardiovascular events prediction for major noncardiac surgery.
This prospective cohort study included adult patients with cardiovascular disease or risk factors undergoing elective major noncardiac surgery at four hospitals in China. Blood samples were collected within 30 days before surgery for N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin T measurements. The primary outcome was a composite of any cardiovascular events within 30 days after surgery. Logistic regression models were used to assess associations, and the predictive performance was evaluated primarily using area under the receiver-operating-characteristic curve (AUC) and fraction of new predictive information.
Between June 2019 and September 2021, 2833 patients were included, with 435 (15.4%) experiencing the primary outcome. In the logistic regression model that included clinical variables and both biomarkers, the odds ratio for the primary outcome was 1.68 (95% CI 1.37-2.07) when comparing the 75th percentile to the 25th percentile of N-terminal pro-B-type natriuretic peptide distribution, and 1.91 (95% CI 1.50-2.43) for high-sensitivity troponin T. Each biomarker enhanced model discrimination beyond clinical predictors, with a change in AUC of 0.028 for N-terminal pro-B-type natriuretic peptide and 0.029 for high-sensitivity cardiac troponin T, and a fraction of new information of 0.164 and 0.149, respectively. The model combining both biomarkers demonstrated the best discrimination, with a change in AUC of 0.042 and a fraction of new information of 0.219.
Preoperative N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin T both improved the prediction for cardiovascular events after noncardiac surgery in addition to clinical evaluation, with their combination providing maximal predictive information.
Gastric pressure monitoring unveils abnormal patient-ventilator interaction related to active expiration: a retrospective observational study.
AnesthesiologyPatient-ventilator dyssynchrony is frequently observed during assisted mechanical ventilation (MV). However, the effects of expiratory muscle contraction on patient-ventilator interaction are underexplored. We hypothesized that active expiration would affect patient-ventilator interaction and we tested our hypothesis in a mixed cohort of invasively ventilated patients with spontaneous breathing activity.
This is a retrospective observational study involving patients on assisted MV who had their esophageal (Pes) and gastric (Pgas) pressures monitored for clinical purposes. Active expiration was defined as Pgas rise (ΔPgas) ≥1.0 cmH2O during expiratory flow without a corresponding change in diaphragmatic pressure (Pdi). Waveforms of Pes, Pgas, Pdi, flow, and airway pressure (Paw) were analyzed to identify and characterize abnormal patient-ventilator interaction.
We identified 76 patients with Pes and Pgas recordings, of whom 58 demonstrated active expiration with a median ΔPgas of 3.4 cmH2O (IQR=2.4-5.3) observed in this subgroup. Among these 58 patients, 23 presented the following events associated with expiratory muscle activity: (1) distortions in Paw and flow that resembled ineffective efforts, (2) distortions similar to autotriggering, (3) multiple triggering, (4) prolonged ventilatory cycles with biphasic inspiratory flow, with a median % (IQR) increase in mechanical inflation time and tidal volume of 54% (44-70%) and 25% (8-35%), respectively and (5) breathing exclusively by expiratory muscle relaxation. Gastric pressure monitoring was required to identify the association of active expiration with these events. Respiratory drive, assessed by the rate of inspiratory Pes decrease, was significantly higher in patients with active expiration (median [IQR] dPes/dt: 12.7 [9.0-18.5] vs 9.2 [6.8-14.2] cmH2O/sec; p<0.05).
Active expiration can impair patient-ventilator interaction in critically ill patients. Without documenting Pgas, abnormal patient-ventilator interaction associated with expiratory muscle contraction may be mistakenly attributed to a mismatch between the patient´s inspiratory effort and mechanical inflation. This misinterpretation could potentially influence decisions regarding clinical management.
Exposure to Operative Anesthesia in Childhood and Subsequent Neurobehavioral Diagnoses: A Natural Experiment using Appendectomy.
AnesthesiologyObservational studies of anesthetic neurotoxicity may be biased because children requiring anesthesia commonly have medical conditions associated with neurobehavioral problems. This study takes advantage of a natural experiment associated with appendicitis, in order to determine if anesthesia and surgery in childhood were specifically associated with subsequent neurobehavioral outcomes.
We identified 134,388 healthy children with appendectomy and examined the incidence of subsequent externalizing or behavioral disorders (conduct, impulse control, oppositional defiant, or attention-deficit/hyperactivity disorder); or internalizing or mood/anxiety disorders (depression, anxiety, or bipolar disorder) when compared to 671,940 matched healthy controls as identified in Medicaid data between 2001-2018. For comparison, we also examined 154,887 otherwise healthy children admitted to the hospital for pneumonia, cellulitis, and gastroenteritis, of which only 8% received anesthesia, and compared them to 774,435 matched healthy controls. We also examined the difference-in-differences between matched appendectomy patients and their controls and matched medical admission patients and their controls.
Compared to controls, children with appendectomy were more likely to have subsequent behavioral disorders (the hazard ratio (HR) was 1.04 (95% CI 1.01, 1.06), P = 0.0010), and mood/anxiety disorders (HR: 1.15 (95% CI 1.13, 1.17), P < 0.0001). Relative to controls, children with medical admissions were also more likely to have subsequent behavioral (HR: 1.20 (95% CI 1.18, 1.22), P < 0.0001), and mood/anxiety (HR: 1.25 (95% CI 1.23, 1.27), P < 0.0001) disorders. Comparing the difference between matched appendectomy patients and their matched controls to the difference between matched medical patients and their matched controls, medical patients had more subsequent neurobehavioral problems than appendectomy patients.
Although there is an association between neurobehavioral diagnoses and appendectomy, this association is not specific to anesthesia exposure, and is stronger in medical admissions. Medical admissions, generally without anesthesia exposure, displayed significantly higher rates of these disorders than appendectomy-exposed patients.
Analysis of the diameter of the distal radial artery at anatomic snuffbox by ultrasonography in patients scheduled for coronary intervention.
J Vasc AccessAssessing the size of the distal radial artery (DRA) in anatomic snuffbox (AS) before coronary intervention is extremely important in the selection of suitable patients, improving the success rate of puncture and reducing the complications.
To evaluate the diameter of the DRA in AS and its influencing factors in Chinese patients scheduled for coronary intervention.
Ultrasound was used to detect the inner diameter of vessels. A total of 1182 patients were involved in the study.
In all patients, the mean inner diameters of the DRA, conventional radial artery (CRA) and ulnar artery (UA) were 2.00 ± 0.43 mm, 2.38 ± 0.51 mm and 1.99 ± 0.47 mm, respectively. The proportion of DRA diameter ⩾2.0 mm was 53% (in all patients), 64% (in males), 36% (in females), respectively. The DRA/CRA ratios were 0.85 ± 0.13 in all patients, 0.86 ± 0.13 in males and 0.84 ± 0.13 in females. The diameter of the DRA was strongly positively correlated with the diameter of the CRA (r = 0.750, p < 0.05), and weakly correlated with the body mass index (r = 0.303, p < 0.05) and the diameter of the UA (r = 0.304, p < 0.05). Multivariate regression analysis showed that female sex, age ⩾60 years, body mass index <24 kg/m2, previous CRA/DRA access and history of coronary artery disease were independent predictors of the DRA diameter <2.0 mm.
Measurement of the diameter of the DRA by ultrasonography may offer important information prior to coronary catheterization.
Application of the Estimand Framework to Anesthesia Trials.
AnesthesiologyEvents occurring after randomization, such as use of rescue medication, treatment discontinuation, or death, are common in randomized trials. These...
Overview of artificial intelligence in point-of-care ultrasound. New horizons for respiratory system diagnoses.
Anaesthesiology Intensive TherapyThroughout the past decades ultrasonography did not prove to be a procedure of choice if regarded as part of the routine bedside examination. The r...
