Articles: anesthesia.
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Journal of anesthesia · Feb 2025
ReviewUsing multi-level regression to determine associations and estimate causes and effects in clinical anesthesia due to patient, practitioner and hospital or health system practice variability.
In this research methods tutorial of clinical anesthesia, we will explore techniques to estimate the influence of a myriad of factors on patient outcomes. Big data that contain information on patients, treated by individual anesthesiologists and surgical teams, at different hospitals, have an inherent multi-level data structure (Fig. 1). While researchers often attempt to determine the association between patient factors and outcomes, that does not provide clinicians with the whole story. ⋯ In addition, we will explore how to estimate the influence that variability-for example, one anesthesiologist deciding to do one thing, while another takes a different approach-has on outcomes for patients, using the intra-class correlation coefficient for continuous outcomes and the median odds ratio for binary outcomes. From this tutorial, you should acquire a clearer understanding of how to perform and interpret multi-level regression modeling and estimate the influence of variable clinical practices on patient outcomes in order to answer common but complex clinical questions. Fig. 1 Infographics.
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Paediatric anaesthesia · Feb 2025
ReviewOptimizing the anesthetic care of patients with aromatic l-amino acid decarboxylase deficiency.
Aromatic l-amino acid decarboxylase (AADC) deficiency is a rare autosomal recessive disorder that results in a lack of the monoamine neurotransmitters dopamine, serotonin, norepinephrine, and epinephrine. Patients present with a wide spectrum of symptoms, including motor and autonomic dysfunction, hypotonia, and developmental delay, often before the age of one. Until recently, treatment options were limited to symptom control, but the recent approval of the first gene therapy for AADC deficiency in Europe and the UK has provided an alternative to treating symptoms for this disease. ⋯ Intraoperatively, utmost care must be taken to protect the skin, maintain body temperature, and to prepare for inotropic and/or glycemic support as needed. Postoperative intensive care management is necessary for consideration of postoperative extubation and provision of supportive care. With careful planning, preparation, and vigilance, patients with AADC deficiency can safely undergo anesthesia.
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Randomized Controlled Trial Comparative Study
Volume of intraoperative normal saline versus lactated Ringer's solution on acute kidney injury: A secondary analysis of the SOLAR trial.
Postoperative acute kidney injury (AKI) is common after non-cardiac surgery. Normal saline and lactated Ringer's solution are both used for volume replacement during surgery. Normal saline decreases renal blood flow and causes hyperchloremic acidosis whereas lactated Ringer's does not. The incidence of AKI is similar with modest volumes of each fluid. But it remains unclear whether larger volumes of normal saline provoke AKI. ⋯ While saline administration clearly causes volume-dependent hyperchloremia, we found no evidence to support the theory that large volumes of saline provoke AKI. Therefore, either fluid seems reasonable for intraoperative use.
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Auricular hematoma is a condition commonly seen in the emergency department among patients presenting with trauma to the ear. It may result in several complications such as perichondritis and cauliflower ear if not managed appropriately. ⋯ Emergency clinicians must be knowledgeable regarding the evaluation and management of auricular hematoma, including the various drainage techniques.
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The general anaesthesia or awake-regional anaesthesia in infancy (GAS) trial demonstrated evidence that most neurodevelopmental outcomes at 2 and 5 yr of age in infants who received a single general anesthetic for elective inguinal herniorrhaphy were clinically equivalent when compared to infants who did not receive general anesthesia. More than 20% of the children in the trial had at least one subsequent anesthetic exposure after their initial surgery. Using the GAS database, this study aimed to address whether multiple (two or more) general anesthetic exposures compared to one or no general anesthetic exposure in early childhood were associated with worse neurodevelopmental outcomes at 5 yr. ⋯ Multiple general anesthetic exposures before 5 yr of age were associated with reduced performance in general intelligence score and some domains of neurodevelopmental assessments. The clinical significance of this study's 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.