The latest medical research on Anesthesiology
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about anesthesiology gathered by our medical AI research bot.
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Request AccessIndividual and System Level Factors Contributing to Guideline Non-Adherent Surgical Antibiotic Prophylaxis at a Tertiary Health Care System: A Qualitative Analysis.
AnesthesiologyAntibiotics play a crucial role in preventing surgical site infections, yet adherence to Infectious Disease Society of America (IDSA) guidelines varies widely. This qualitative study aimed to explore factors influencing perioperative antibiotic administration and assess the potential impact of a clinical decision support (CDS) tool on guideline adherence.
In this qualitative study, perioperative personnel with diverse roles (surgeons, anesthesiologists, certified nurse anesthetists, trainees, and pharmacists) were interviewed using a semi-structured interview format from September 2023 through April 2024. Interviews were then analyzed for codes which were assigned to concepts using the constant comparison method for assessment of factors that were described as barriers or facilitators of guideline adherence.
After piloting with three interviews, we conducted nine sessions with a total of 17 participants: 7 attending anesthesiologists, 3 resident trainees, 2 perioperative pharmacists, 3 Certified Registered Nurse Anesthetists (CRNAs), and 2 attending surgeons. Key themes emerged: (1) Limited familiarity with Infectious Disease Society of America (IDSA) antibiotic guidelines, (2) Lack of standardization and optimization of antibiotic decision-making process, (3) Challenges with managing beta-lactam allergies, (4) Difficulty optimizing vancomycin timing, and (5) Perceived benefit of a Clinical Decision Support (CDS) tool in enhancing workflow and guideline adherence.
Non-adherence to antibiotic guidelines in the perioperative setting often results from a lack of structured workflow. Our interviews provide a foundation for developing a clinical decision support tool tailored to provider needs, aiming to improve user satisfaction and promote better adherence to perioperative antibiotic guidelines.
Radial artery haemostasis after coronary angiography: A scoping review.
J Vasc AccessNursing care in interventional cardiology is vital during perioperative stages, especially with coronary angiography. Radial artery access is now preferred, requiring proper haemostasis to prevent complications. Standardised protocols are needed for effective and economical haemostasis methods. This review aims to map the literature on haemostasis of the radial artery after coronary angiography, an area not previously reviewed.
Following the Joanna Briggs Institute methodology for scoping reviews, two reviewers independently selected studies based on eligibility criteria. Data were extracted using a specially developed tool, with disagreements resolved through discussion or a third reviewer. Data synthesis is presented in tabular form and narrative summary. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews guidelines were followed. Searches were conducted in PubMed, CINAHL Complete, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus, Opengrey, DART-Europe e-theses portal and six key interventional cardiology reference sites.
From 43 manuscripts, four haemostasis methods for the radial artery after coronary angiography were identified: manual compression (n = 5), compression bandages (n = 16), compression devices (n = 30) and haemostatic patches (n = 7). Nearly 70% (n = 30) of references focused on compression devices. Nine techniques were used to evaluate haemostasis methods, with visual inspection (34 references) and Doppler ultrasound (17 references) being the most common. Only nine haemostasis methods lacked an associated protocol.
This scoping review identifies four primary haemostasis methods post coronary angiography: manual compression, compression bandages, compression devices and haemostatic patches, with compression devices being the most frequently discussed. The variability in evaluation techniques, predominantly visual inspection and ultrasound, underscores the need for standardised guidelines. The absence of protocols for some methods further highlights the necessity for uniform standards to improve consistency and reliability in clinical practice. Standardising these methods and protocols is essential to enhance patient outcomes and advance the field.
Viscoelastic haemostatic assays to guide therapy in elective surgery: an updated systematic review and meta-analysis.
AnaesthesiaPatients undergoing major surgery frequently experience major uncontrolled bleeding. The aim of this systematic review and meta-analysis was to evaluate the clinical efficacy of using viscoelastic haemostatic assays to manage peri-operative bleeding in elective surgery.
We searched PubMed/MEDLINE and Embase databases for randomised controlled trials according to pre-determined criteria. The primary outcomes were blood product requirements; duration of stay in the operating theatre or ICU; and surgical reintervention rate.
We included 20 randomised controlled trials. The overall risk of bias was low to moderate. Twelve studies used thromboelastography-based transfusion algorithms, while eight used thromboelastometry. Viscoelastic haemostatic assay-guided therapy was associated with a statistically significant reduction in transfusion of red blood cells (standardised mean difference (95%CI) 0.16 (-0.29 to 0.02)), platelets (standardised mean difference (95%CI) -0.33 (-0.56 to -0.10)) and fresh frozen plasma (standardised mean difference (95%CI) -0.64 (-1.01 to -0.28)). There was no evidence of an effect of viscoelastic haemostatic assay-guided therapy on surgical reintervention (relative risk (95%CI) 1.09 (0.70-1.69)). Viscoelastic haemostatic assay-guided therapy was associated with lower blood loss and shorter ICU duration of stay. There was no evidence of any effect on total duration of stay and all-cause mortality.
Viscoelastic haemostatic assay-guided therapy may reduce peri-operative blood product transfusion requirements and blood loss during major elective surgery, with no discernible effect on patient-centred outcomes. The overall quality of evidence was modest.
Gastric ultrasound performance time and difficulty: a prospective observational study.
AnaesthesiaPoint-of-care gastric ultrasound is an emerging tool in peri-operative practice. However, data on the technical challenges of gastric ultrasound, which are essential for optimised training, remain scarce. We analysed gastric ultrasound examinations performed after basic training to identify factors associated with difficulty.
This was an analysis of data from a prospective observational study evaluating the potential impact of routine pre-operative gastric ultrasound on peri-operative management in adult patients undergoing elective or emergency surgery at a single centre. Before initiation, physicians received extensive structured training with at least 30 supervised gastric sonograms before independent practice. We then used regression models to identify factors associated with deviation from a predefined sonography algorithm, performance time and scan difficulty.
Seventy-three trained physicians performed 2003 ultrasound scans. Median (IQR [range]) performance time was 5 (4-6 [1-20]) min, which was achieved after 20-27 scans following structured training. Patient characteristics associated with more difficult and longer duration scans were: increase in BMI per 5 kg.m-2 (odds ratio (95%CI) 1.57 (1.35-1.83), p < 0.001 for difficulty and percentage change coefficient (95%CI) 1.03 (1.02-1.05), p < 0.001 for duration); and male sex (odds ratio (95%CI) 3.31 (2.28-4.88), p < 0.001 for difficulty and percentage change coefficient (95%CI) 1.08 (1.04-1.12), p < 0.001, for duration). Trauma surgery (odds ratio (95%CI) 3.26 (1.88-5.68), p < 0.001), ASA physical status of 3 or 4 (odds ratio (95%CI) 1.86 (1.21-2.88), p = 0.0049) and emergency surgery (odds ratio (95%CI) 1.86 (1.20-2.89), p = 0.006) were associated with deviation from the predefined sonography algorithm.
Approximately 50 scans are required to achieve a baseline performance of 5 min per gastric ultrasound. Future training programmes should focus on patients with obesity, male sex, higher ASA physical status and trauma.
Experiences and outcomes of patients participating in a perioperative shared decision-making pathway.
Anaesthesia and Intensive CareThe Complex Decision Pathway (CDP) is a novel perioperative shared decision-making pathway that was established in the Bay of Plenty, New Zealand i...
Continuous peri-operative glucose monitoring in noncardiac surgery: A systematic review.
AnaesthesiologyGlucose management is an important component of peri-operative care. The usefulness of continuous glucose monitoring (CGM) in noncardiac surgery is uncertain.
To systematically assess the glycaemic profile and clinical outcome of patients equipped with a CGM device during the peri-operative period in noncardiac surgery.
Any studies performed in the peri-operative setting using a CGM device were included. Closed-loop systems also administering insulin were excluded. Analyses were stratified according to diabetes mellitus status and covered intra-operative and postoperative data. Outcomes included glycaemic profile (normal range 3.9 to 10.0 mmol l-1), complications, adverse events, and device dysfunction.
Twenty-six studies (1016 patients) were included. Twenty-four studies were not randomised, and six used a control arm for comparison. In bariatric surgery, diabetes mellitus patients had a mean ± SD glucose of 5.6 ± 0.5 mmol l-1, with 15.4 ± 8.6% time below range, 75.3 ± 5.5% in range and 9.6 ± 6.7% above range. During major surgery, diabetes mellitus patients showed a mean glucose of 9.6 ± 1.1 mmol l-1, with 9.5 ± 9.1% of time below range, 56.3 ± 13.5% in range and 30.6 ± 13.9% above range. In comparison, nondiabetes mellitus patients had a mean glucose of 6.4 ± 0.6 mmol l-1, with 6.7 ± 8.4% time below range, 84.6 ± 15.5% in range and 11.2 ± 4.9% above range. Peri-operative complications were reported in only one comparative study and were similar in CGM and control groups. Device-related adverse events were rare and underreported. In 9.21% of cases, the devices experienced dysfunctions such as accidental removal and issues with sensors or readers.
Due to the limited number of controlled studies, the impact of CGM on postoperative glycaemic control and complications compared with point-of-care testing remains unknown. Variability in postoperative glycaemic profiles and a device dysfunction rate of 1 in 10 suggest CGM should be investigated in a targeted surgical group.
A novel cricoid pressure sensor device enhances the efficacy of oesophageal occlusion during Sellick's manoeuvre: A randomised controlled trial.
AnaesthesiologyClinical Trial Registry of India (CTRI/2021/05/033484).
To test the hypothesis of superior oesophageal occlusion during cricoid pressure when guided by the novel device as compared with conventional practice.
The primary outcome was the rate of occlusion of oesophageal opening assessed by whether a 12 CH orogastric tube could be inserted into the oesophageal entrance during videolaryngoscopy. Secondary outcomes included the magnitudes of force measured during cricoid pressure, oesophageal diameter measured ultrasonographically during cricoid pressure and intubation parameters.
Sixty-four patients completed the study. The oesophageal opening was occluded in significantly more patients in the feedback group compared with the control group (94 vs. 6%; P = 0.001). The mean ± SD force (N) applied was significantly better and consistent at all time points in the feedback group compared to the control group (22.65 ± 7.81 vs. 14.57 ± 11.13, P < 0.001). The median [IQR] anteroposterior diameter of the oesophagus during cricoid pressure was less in the feedback group compared to the control group (0.49 [0.36 to 0.56] vs. 0.57 [0.48 to 0.65], P = 0.006).
The use of the novel sensor device achieved a significantly high rate of oesophageal occlusion during application of cricoid pressure.
Co-administration of dexmedetomidine with total intravenous anaesthesia in carotid endarterectomy reduces requirements for propofol and improves haemodynamic stability: A single-centre, prospective, randomised controlled trial.
AnaesthesiologyClinicaltrials.gov identifier: NCT04662177.
To test the hypothesis that dexmedetomidine decreases the effect-site concentration of propofol required for burst-suppression in patients undergoing carotid endarterectomy.
The primary outcome was the effect-site concentration of propofol required for burst-suppression. The secondary outcomes were the requirement for vasoactive substances, neurophysiological monitoring parameters, and postoperative delirium.
The effect-site concentration of propofol required for burst suppression was 4.0 μg ml-1 [3.50 to 4.90] (median [interquartile range]) in the dexmedetomidine group compared with 6.0 μg ml-1 [5.5 to 7.3] in the control group (P < 0.001). Less norepinephrine was required in the dexmedetomidine group (total 454 μg [246 to 818] compared with 1000 μg [444 to 1326] (P = 0.015) in the control group). Dexmedetomidine did not affect intraoperative neurophysiological monitoring.
Co-administration of dexmedetomidine to total intravenous anaesthesia for carotid endarterectomy decreased the effect-site concentrations of propofol required for burst suppression by 33%. The propofol-sparing effect and peripheral alpha-agonism of dexmedetomidine may explain the reduced requirement for vasopressors.
Poor mid-term functional patency and post-operative outcomes in diabetic patients who undergo arteriovenous graft creation.
J Vasc AccessDiabetes mellitus is a leading cause of renal failure in the US and has been associated with higher mortality when compared to nondiabetic patients. This remains true despite initiation of renal replacement therapy. As such, we were interested in identifying any potential differences in access durability and postoperative outcomes in diabetic patients who receive arteriovenous fistulas versus grafts for hemodialysis.
Diabetic patients undergoing their first arteriovenous (AV) access creation surgery in the Vascular Quality Initiative from January 2011 to January 2022 were included in our study. After exclusions, the study included two groups: those receiving AV fistulas and those receiving AV grafts for hemodialysis. Demographic characteristics were summarized and compared between these two groups using chi-square analysis or unpaired t-test. After propensity score matching was conducted, the effect of procedure type on functional patency, along with secondary outcomes including wound infection were assessed using chi-square analysis.
A total of 20,159 diabetic patients who used their hemodialysis access were included in our study; 16,205 received AV fistulas while 3954 received AV grafts. Patients receiving AV grafts were more likely to be older, female, and have higher pre-operative catheter usage. After propensity score matching, patients who received AV grafts had a shorter time-to-use their conduit (50 vs 166 days, p < 0.0001), however, patients who received AV fistulas were more likely to have longer functional patency use for hemodialysis when compared to those who received AV grafts (mean survival time: 3.3 vs 2.9 years, p < 0.0001). These results were consistent between diabetics with insulin-dependent or insulin-independent diabetes.
Patients diagnosed with diabetes mellitus had an increased risk for significantly inferior clinical outcomes related to newly created AV grafts, including lower rates of mid-term functional patency and higher rates of worse post-operative outcomes when compared to diabetics who received AV fistulas.
The price of dialysis access: Implications of access type and patient-centric approaches to cost.
J Vasc AccessThis study explores out-of-pocket (OOP) costs for patients and provider reimbursement for dialysis access creation. It aims to illustrate the financial characteristics of four dialysis access modalities to consider in decision-making for clinicians, patients, and payers.
Retrospective data from the Merative™ MarketScan Commercial Claims and Encounters Databases from 2017 to 2022 was analyzed for patients who received an arteriovenous fistula (AVF), arteriovenous graft (AVG), peritoneal dialysis catheter (PDC), or percutaneous AVF (pAVF). ANOVA and Tukey HSD were used to assess cost differences among the four access modalities overall and in the context of insurance type and service site.
Database extraction resulted in 20,863 unique procedures, comprising of 15,043 AVF, 4759 AVG, 896 PDC, and 165 pAVF. Mean age was 59.2 years (±14.19) and 60.53% of the cohort was male. EPO/PPO plans were the most represented (53.06%) and most procedures were performed in the hospital outpatient department (91.99%). There were significant differences found among OOP cost and reimbursement with respect to procedure type, insurance type, and service site. Overall, pAVF had both the highest cost and reimbursement.
Patient OOP costs and provider reimbursement differ significantly based on procedure, insurance type, and service site. While pAVF creation is recognized with high reimbursements due to its complexity and the advanced technology required, it also has the highest OOP costs for patients. To help facilitate adoption of new technologies like pAVF, advocacy efforts should focus on encouraging payers to lower the OOP financial barriers for patients to receive these newer but costlier procedures.
Combined spinal-epidural vs. dural puncture epidural techniques for labour analgesia: a randomised controlled trial.
AnaesthesiaThe dural puncture epidural technique is a modification of the combined spinal-epidural technique. Data comparing the two techniques are limited. We performed this randomised study to compare the quality of labour analgesia following initiation of analgesia with the dural puncture epidural vs. the combined spinal-epidural technique.
Term parturients requesting labour epidural analgesia were allocated randomly to receive either dural puncture epidural or combined spinal-epidural. Analgesia was initiated with 2 mg intrathecal bupivacaine and 10 μg fentanyl in parturients allocated to the combined spinal-epidural group and with 20 ml ropivacaine 0.1% with 2 μg.ml-1 fentanyl in parturients allocated to the dural puncture epidural group. Analgesia was maintained using patient-controlled epidural analgesia with programmed intermittent epidural boluses. The primary outcome of the study was the quality of labour analgesia, which was defined by a composite of five components: asymmetric block after 30 min of initiation (difference in sensory level of more than two dermatomes); epidural top-up interventions; catheter adjustment; catheter replacement; and failed conversion to neuraxial anaesthesia for caesarean delivery, requiring general anaesthesia or replacement of the neuraxial block.
One hundred parturients were included in the analysis (48 combined spinal-epidural, 52 dural puncture epidural). There were no significant differences between the two groups in the primary composite outcome of quality of analgesia (33% in the combined spinal-epidural group vs. 25% in the dural puncture epidural group), risk ratio (95%CI) 0.75 (0.40-1.39); p = 0.486. Median (IQR [range]) pain scores at 15 min were significantly lower in patients allocated to the combined spinal-epidural group compared with the dural puncture epidural group (0 (0-1[0-8]) vs. 1 (0-4 [0-10]); p = 0.018).
There were no significant differences in the quality of labour analgesia following initiation of a combined spinal-epidural compared with a dural puncture epidural technique.
Neurodevelopmental Outcomes After Multiple General Anaesthetic Exposure Before Five Years Of Age - A Cohort Study.
AnesthesiologyThe GAS trial demonstrated evidence that most neurodevelopmental outcomes at 2 years and 5 years of age in infants who received a single general anaesthetic (GA) for elective inguinal herniorrhaphy were clinically equivalent when compared to infants who did not receive GA. More than 20% of the children in the trial had at least one subsequent anaesthetic exposure after their initial surgery. Using the GAS database, this study aimed to address whether multiple (2 or more) GA exposures compared to one or no GA exposure in early childhood were associated with worse neurodevelopmental outcomes at 5 years.
Children with multiple GA exposures and children with one or no GA exposure were identified from the GAS database. The primary outcome was the full-scale intelligence quotient (FSIQ) on the Wechsler Preschool and Primary Scale of Intelligence third edition (WPPSI-III) at 5 years of age. Secondary outcomes included neurocognitive tests addressing all major developmental domains and caregiver-reported questionnaires assessing emotional and behavioural problems.
Complete assessment was available from a total of 90 children in the multiple GA group and 141 children in the 0 or 1 GA group. Compared with children with a single or no GA exposure, multiply exposed children scored on average almost 6 points lower (mean: -5.8, 95% CI: -10.2 to -1.4, p= 0.011) in WPPSI-III FSIQ. They also demonstrated lower verbal and performance IQ scores and more emotional, behavioural, and executive function difficulties. However, significant residual confounding cannot be excluded from the results due to the observational nature of this study.
Multiple GA exposure before 5 years of age was associated with reduced performance in general intelligence score and some domains of neurodevelopmental assessments. The clinical significance of our results must be cautiously interpreted in light of several sources of limitations including small sample size and unadjusted residual confounding. This study illustrates the limitations of trial data sets that may not be fit for the purpose for the secondary analysis.
