Anesthesia and analgesia
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Anesthesia and analgesia · Nov 2020
Randomized Controlled TrialComparison of Pupillometry With Surgical Pleth Index Monitoring on Perioperative Opioid Consumption and Nociception During Propofol-Remifentanil Anesthesia: A Prospective Randomized Controlled Trial.
Intraoperative pupillometry monitoring is a feasible surrogate for nociception assessment, resulting in both lower intraoperative remifentanil consumption and lower peak post-operative pain.
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Anesthesia and analgesia · Nov 2020
Exposure to General Anesthesia for Cesarean Delivery and Odds of Severe Postpartum Depression Requiring Hospitalization.
This large study of 428,204 New York caesarean section records (2006-2013), including 34,356 general anaesthetics (8%), investigated the association between mode of anaesthesia and post-partum depression (PPD). Other studies have shown an association between caesarean section (emergency > elective) and PPD. (Sun 2021, Xu 2017, and others), though this is the first to look specifically at general anaesthesia as a PPD risk factor.
Guglielminotti and Li found that general anaesthesia increased the odds of severe PPD by 54% (aOR 1.54, 1.21-1.95), and suicidal ideation by a massive 91% (aOR 1.91, 1.12-3.25), though not a significant increase in anxiety or PTSD.
The researchers discuss many potential causative factors, particularly known associations between GA CS & poor pain control, and subsequent pain & PPD – while also acknowledging the obvious potential for confounders. Of note patients receiving GA were older, more often non-Caucasian, had more co-morbidities, neonatal complexity, and lower socio-economic levels – also all independently associated with PPD risk.
In order to quantify the potential confounding contribution of emergency vs elective status, the researchers employed the novel E value:
To assess the impact of emergent cesarean delivery on our results, we calculated the E value associated with the aOR for the risk of PPD and suicidality. This relatively new metric takes into consideration 2 associations: (1) that between the confounder (emergent cesarean delivery) and the outcome (PPD); and (2) the association between the confounder (emergent cesarean delivery) and the exposure (general anesthesia).
An E value of 1.7 for the unmeasured confounder emergent cesarean delivery indicates that to explain away the association between general anesthesia and depression, either: (1) emergent cesarean delivery increases the risk of depression by at least 70%; or (2) emergent cesarean delivery is at least 70% more prevalent among general anesthesia than among neuraxial anesthesia. Either association is clinically plausible.
Keep it in perspective...
We already know that general anaesthesia for CS is suboptimal: it compromises both maternal experience and safety, but it should (hopefully) only ever be a chosen mode of anaesthesia when there is a true contraindication to regional anaesthesia – even at the modestly-high 8% GA rate among this New York cohort.
Looking at it from the other end, bear in mind that the modestly-faster time-to-incision for GA over regional is also of questionable neonatal benefit.
The take-home:
Just another reason to avoid GA CS when possible – but you already knew that, right?
summary"...general anesthesia is a potentially modifiable risk factor for PPD. This finding provides further supporting evidence favoring neuraxial over general anesthesia in cesarean delivery whenever possible."
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Anesthesia and analgesia · Nov 2020
ReviewInfection Prevention Precautions for Routine Anesthesia Care During the SARS-CoV-2 Pandemic.
Many health care systems around the world continue to struggle with large numbers of SARS-CoV-2-infected patients, while others have diminishing numbers of cases following an initial surge. There will most likely be significant oscillations in numbers of cases for the foreseeable future, based on the regional epidemiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Less affected hospitals and facilities will attempt to progressively resume elective procedures and surgery. ⋯ Provision of adequate supplies of respirator masks and other respiratory protection equipment such as powered air purifying respirators (PAPRs) should be a high priority for health care facilities and for government agencies. Eye protection is also necessary because of the possibility of infection from virus coming into contact with the conjunctiva. Because SARS-CoV-2 persists on surfaces and may cause infection by contact with fomites, hand hygiene and surface cleaning are also of paramount importance.
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Anesthesia and analgesia · Nov 2020
Observational StudyReal-Time Intraoperative Determination and Reporting of Cerebral Autoregulation State Using Near-Infrared Spectroscopy.
Cerebral blood flow (CBF) is maintained over a range of blood pressures through cerebral autoregulation (CA). Blood pressure outside the range of CA, or impaired autoregulation, is associated with adverse patient outcomes. Regional oxygen saturation (rSO2) derived from near-infrared spectroscopy (NIRS) can be used as a surrogate CBF for determining CA, but existing methods require a long period of time to calculate CA metrics. We have developed a novel method to determine CA using cotrending of mean arterial pressure (MAP) with rSO2that aims to provide an indication of CA state within 1 minute. We sought to determine the performance of the cotrending method by comparing its CA metrics to data derived from transcranial Doppler (TCD) methods. ⋯ The reported cotrending method rapidly provides metrics associated with CA state for patients undergoing cardiac surgery. A major strength of the proposed method is its near real-time feedback on patient CA state, thus allowing for prompt corrective action to be taken by the clinician.
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Using the 12-item World Health Organization Disability Assessment Schedule (WHODAS-12), we measured the prevalence of disability in all eligible patients during a 4-month period who were presenting for preoperative evaluation at a US Veterans Affairs hospital. Overall disability was at least moderate in more than half of these patients (total n = 472 at Durham, NC). Two of the 6 WHODAS domains, "Getting Around" and "Participation in Society," contributed most to the overall scores-25% and 20%, respectively. Further studies are needed to determine the impact of domain-specific disabilities on postoperative outcomes and to identify potential interventions to address these vulnerabilities.