Combined fascia iliaca compartment block and monitored anesthesia care for geriatric patients with hip fracture: Two case reports

BACKGROUND Major hip surgery usually requires neuraxial or general anesthesia with tracheal intubation and may be supplemented with a nerve block to provide intraoperative and postoperative pain relief.CASE SUMMARY This report established that hip surgical procedures can be performed with a fascia iliaca compartment block(FICB)and monitored anesthesia care(MAC)while avoiding neuraxial or general anesthesia.This was a preliminary experience with two geriatric patients with hip fracture,American Society of Anesthesiologists status III,and with many comorbidities.Neither patient could be operated on within 48 h after admission.Both general anesthesia and neuraxial anesthesia were high-risk procedures and had contraindications.Hence,we chose nerve block combined with a small amount of sedation.Intraoperative analgesia was provided by single-injection ultrasound-guided FICB.Light intravenous sedation was added.Surgical exposure was satisfactory,and neither patient complained of any symptoms during the procedure.CONCLUSION This report showed that hip surgery for geriatric patients can be performed with FICB and MAC,although complications and contraindications are common.The anesthetic program was accompanied by stable respiratory and circulatory system responses and satisfactory analgesia while avoiding the adverse effects and problems associated with either neuraxial or general anesthesia.

Preoperative Gabapentin Dosage Relationship to Length of Stay in Post-Anesthesia Care Unit in Patients Undergoing Pelvic and Breast Surgery

Background: Gabapentin is routinely prescribed preoperatively to decrease postoperative pain intensity. It is included in the enhanced recovery after surgery (ERAS) recommendations. Objective: To analyze correlation of gabapentin dosage and post anesthesia care unit (PACU) length of stay (LOS) and cost. Study Design: A retrospective chart review of patients who underwent general anesthesia and received preoperative oral gabapentin from June 2017 to August 2017 for pelvic and breast procedures. The main outcome was correlation between PACU LOS and gabapentin dosage in the outpatients. Financial analysis was performed to assess the cost to the hospital associated with increased LOS. Results: Of the 636 patients, 405 patients received 300 mg and 231 patients received 100 mg gabapentin. Mean dosage per kg (mg/kg ± SD) was 3.12 ± 1.51 (range: 0.86 to 6.12). PACU LOS was 96 ± 77 (minutes ± SD) in patients receiving 100 mg and 120 ± 96 in patients receiving 300 mg capsule (p = 0.001). Linear regression analysis, failed to show a statistically significant correlation between per kg dosage and PACU LOS (p = 0.13). Using multiple regression analysis, we calculated the correlation coefficient to be +1.71 minutes per 1mg/kg gabapentin (95% CI: -3.75 to +7.10, p = 0.54) after adjusting for confounders. Adding 3 mg/kg to pre-op gabapentin dosage of all outpatients cost on average, an extra $9794 per month in this cohort. Conclusion: Every 1mg/kg increase in gabapentin dosage adds an estimated 7.1 minutes to PACU LOS. A 3 mg/kg increase in gabapentin adds estimated 22 additional minutes in PACU LOS. Unfortunately, increase LOS is associated with increased hospital costs.

Monitored anesthesia care and asleep-awake-asleep techniques combined with multiple monitoring for resection of gliomas in eloquent brain areas:a retrospective analysis of 225 patients

Background:Awake craniotomy(AC)has become gold standard in surgical resection of gliomas located in eloquent areas.The conscious sedation techniques in AC include both monitored anesthesia care(MAC)and asleep-awake-asleep(AAA).The choice of optimal anesthetic method depends on the preferences of the surgical team(mainly anesthesiologist and neurosurgeon).The aim of this study was to compare the difference in physiological and blood gas data,dosage of different drugs,the probability of switching to endotracheal intubation,and extent of tumor resection and dysfunction after operation between AAA and MAC anesthetic management for resection of gliomas in eloquent brain areas.Methods:Two-hundred and twenty-five patients with super-tentorial tumor located in eloquent areas underwent AC from 2009 to 2021 in Xijing Hospital.Forty-one patients underwent AAA technique,and the rest one-hundred eighty-four patients underwent MAC technique.Anesthetic management,dosage of different drugs,intraoperative complications,postoperative outcomes,adverse events,extent of resection and motor,and sensory and language dysfunction after operation were compared between MAC and AAA.Result:There was no significant difference in gender,KPS score,MMSE score,glioma grade,type,and growth site between the patients in the two groups,except the older age of patients in MAC group than that in AAA group.During the whole process of operation,there were greater pulse pressure difference(P=0.046),shorter operation time(P=0.039),less dosage of remifentanil(P=0.000),more dosage of dexmedetomidine(P=0.013),more use of antiemetics(81%,P=0.0067),lower use of vasoactive agent(45.1%,P=0.010),and lower probability of conversion to general anesthesia(GA,P=0.027)in MAC group than that in AAA group.Blood gas analysis showed that PetCO2(P=0.000),Glu concentration(P=0.000),and PaCO2(P=0.000)were higher,but SPO2(P=0.002)and PaO2(P=0.000)were lower in MAC group than that in AAA group.In the postoperative recovery stage,compared with that of AAA group,the probability of dysfunction in MAC group at 1,3,5,and 7 days after operation was lower,which were 27.8%vs 53.6%(P=0.003),31%vs 68.3%(P=0.000),28.8%vs 63.4%(P=0.000),and 25.6%vs 58.5%(P=0.000),respectively.Conclusion:Compared with AAA,it seems that MAC has more advantages in the management for resection of gliomas in eloquent brain areas,and MAC combined with multiple monitoring such as cerebral cortical mapping,neuronavigation,and ultrasonic detection is worthy of popularization for the resection of gliomas in eloquent brain areas.

Effects of General Anesthesia on the Results of Cardiac Catheterization in Pediatric Patients with Ventricular Septal Defect

Background:There is no gold standard sedation method for pediatric cardiac catheterization.In congenital heart diseases with intracardiac shunts,hemodynamic parameters are prone to change depending on the ventilation conditions and anesthetics,although few studies have examined these effects.The purpose of this study was to investigate the effects of two different sedation methods on the hemodynamic parameters.Methods:This study retrospectively evaluated consecutive patients with ventricular septal defect(VSD)below 1 year of age who underwent cardiac catheterization at Aichi Children’s Health and Medical Center,who were divided into age-and VSD diameter-matched general anesthesia(GA)and monitored anesthesia care(MAC)under the natural airway groups(n=40 each),for comparison of hemodynamic parameters.Results:In the GA group,arterial blood pH and arterial partial pressure of oxygen were significantly higher(p<0.01),whereas arterial partial pressure of carbon dioxide was significantly lower than in the MAC group(p<0.01).Mean pulmonary artery pressure(p<0.05)and systemic blood pressure(p<0.01)were lower in the GA group.Pulmonary vascular resistance index(p<0.01)and systemic vascular resistance index(p<0.01)were also significantly lower in the GA group than the MAC group.There were no significant differences in pulmonary blood flow index,systemic blood flow index,and pulmonary/systemic blood flow ratio between the two groups.Conclusions:Cardiac catheterization under GA in VSD patients results in different hemodynamic parameters compared to that under MAC.In particular,when using pulmonary artery pressure and pulmonary vascular resistance measured under GA for judgment regarding the surgical indications or perioperative management,consideration should be given to the fact that these parameters might be lower compared to those measured under MAC.

Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients-results after three years of practice

AIM To evaluate the potential benefits and risks of the use of epidural anaesthesia within an enhanced recovery protocol in this specific subpopulation.METHODS A retrospective review was conducted, including all cirrhotic patients who underwent open liver resection between January 2013 and December 2015 at Bologna University Hospital. Patients with an abnormal coagulation profile contraindicating the placement of an epidural catheter were excluded from the analysis. The control group was composed by patients refusing epidural anaesthesia. RESULTS Of the 183 cirrhotic patients undergoing open liver resections, 57 had contraindications to the placement of an epidural catheter; of the remaining 126, 86 patients received general anaesthesia and 40 combined anaesthesia. The two groups presented homogeneous characteristics. Intraoperatively the metabolic data did not differ between the two groups, whilst the epidural group had a lower mean arterial pressure(P = 0.041) and received more colloid infusions(P = 0.007). Postoperative liver and kidney function did not differ significantly.Length of mechanical ventilation(P = 0.003) and hospital stay(P = 0.032) were significantly lower in the epidural group. No complications related to the epidural catheter placement or removal was recorded.CONCLUSION The use of Epidural Anaesthesia within a fast track protocol for cirrhotic patients undergoing liver resections had a positive impact on the patient's outcomes and comfort as demonstrated by a significantly lower length of mechanical ventilation and hospital stay in the epidural group. The technique appears to be safely manageable in this fragile population even though these results need confirmation in larger studies.

Anesthesia Management for Pulmonary Cryoablation

Lung tumors represent a major health impact globally. Pulmonary cryoablation treatment as a palliative measure for patients with non-operable pulmonary lesions has gained popularity over the last decade. With increasing case load and patients medical status becoming more complex, preparation for pulmonary cryoablation requires the implementation of an enhanced perioperative anesthetic plan. Current literature as well as our institutional experience shows that this patient population presents with multiple comorbidities raising the challenge of providing anesthetic care. These procedures are done under challenging conditions with limited resources and in remote locations in the hospital. A team approach by the anesthesiologist, thoracic surgeon, and interventional radiologist is critical to the success of this treatment. The present review examines our institution’s anesthetic management of percutaneous cryoablation treatment (PCT) in the treatment of non-operable lung cancer and metastases. The objective of this article is to review the current literature guidelines and to discuss our retrospective institutional experience in anesthesia management of PCT procedures.

全麻患者术后麻醉重症监护室中新发下肢深静脉血栓的危险因素

目的筛选全麻术后转入麻醉重症监护室(AICU)的患者新发下肢深静脉血栓(DVT)的危险因素。方法回顾性收集2022年5—8月择期行全麻下手术后带气管插管转入AICU的患者192例,男105例,女87例,年龄18~85岁,BMI 18~31 kg/m^(2),ASAⅡ或Ⅲ级。收集患者基线资料、麻醉手术资料及实验室检查资料。根据入AICU 6 h内的超声结果是否有新发DVT将患者分为两组:DVT组和非DVT组。采用多因素Logistic回归分析筛选AICU中患者术后6 h内新发DVT的危险因素及其95%可信区间(CI)。结果全麻术后在AICU新发DVT的患者有64例(33.3%),均为小腿肌间静脉血栓(CMVT)。多因素Logistic回归分析结果显示,术前心律失常(OR=2.236,95%CI 1.011~4.943,P=0.047)、术前血小板计数高(OR=1.006,95%CI 1.002~1.010,P=0.007)、术前D⁃二聚体浓度高(OR=1.203,95%CI 1.046~1.383,P=0.010)、术中低血压(OR=1.010,95%CI 1.002~1.019,P=0.020)和术中应用去甲肾上腺素(OR=3.796,95%CI 1.697~8.492,P=0.001)是全麻术后AICU中患者新发DVT的危险因素;阿司匹林规律服用史(OR=0.176,95%CI 0.060~0.518,P=0.002)是其保护因素。结论术前心律失常、术前血小板计数高、术前D⁃二聚体浓度高、术中低血压及术中应用去甲肾上腺素是全麻手术后AICU患者6 h内新发DVT的危险因素。

颅脑手术患者术后低体温的危险因素分析及预测模型构建与验证

目的分析颅脑手术患者术后低体温的危险因素并构建预测模型,为临床早期筛选高危人群和干预提供参考。方法采用回顾性分析方法,选择2021年1月—2022年12月北京市某三级甲等医院的407例颅脑手术患者作为研究对象,根据时间先后按照7:3的比例分为建模组(285例)和验模组(122例)。对建模组数据依次进行单因素分析和二元Logistic回归分析,构建预测模型,并对模型进行预测效能评价;使用验模组数据对模型进行验证。结果颅脑手术患者术后低体温的发生率为40.7%,Logistic回归分析显示,术前使用咪达唑仑(OR=2.464)、手术时间<3 h(OR=3.287)、术中使用胶体液(OR=3.399)是颅脑手术患者术后低体温发生的独立危险因素,其预测模型为:Logit(p)=—2.124+0.902×术前使用咪达唑仑+1.190×手术时间<3 h+1.224×术中使用胶体液。建模组Hosmer-lemeshow(H-L)检验χ^(2)=2.634,P=0.955,受试者操作特征(receiver operating characteristic,ROC)曲线下面积为0.720;验模组H-L检验χ^(2)=13.911,P=0.084,ROC曲线下面积为0.705。结论构建的预测模型效果良好,可为医护人员筛查颅脑手术患者术后低体温的高危人群提供参考。

麻醉重症监护室是践行围术期医学的重要平台

近年来随着我国人口老龄化、疾病谱的改变和外科技术的发展,进行手术治疗的高危患者逐渐增加。而麻醉科医师传统的围麻醉期工作方式已不能满足现代医学发展的需求。麻醉学科正通过发挥自身的学科优势逐渐向围术期医学转变。麻醉重症监护室(AICU)是为围术期危重症患者提供复苏、监护和救治等麻醉医疗服务的场所,也是践行围术期医学的重要平台。本文将阐述建设发展AICU的必要性和学科优势,为手术患者围术期优质管理提供参考。

MAC技术优化日间宫腔镜手术麻醉成本的探索——基于TDABC核算模型的研究

该研究通过回顾天坛医院2021年10月-2022年9月的日间宫腔镜手术,借助估时作业成本(Timedriven Activity-based Costing,TDABC)模型计算麻醉成本,并记录围术期不良事件,评价了日间宫腔镜手术采用监测下麻醉管理(Monitored Anesthesia Care,MAC)技术消耗的麻醉成本及其安全性。717例患者完成麻醉和手术,其中466例接受了MAC麻醉,251例接受了传统的全身麻醉(General Anesthesia,GA)。MAC组平均麻醉成本为889.84元/例,明显低于GA组(1143.57元/例,P<0.0001)。MAC组围术期不良事件发生率(3.65%),与传统GA组(6.37%)相比,差异无统计学意义(P=0.0965),两组均无严重不良后果。多元回归分析显示,MAC组麻醉成本与患者年龄、手术时间和麻醉时间都有相关性(P<0.01)。MAC作为安全、有效的麻醉技术,可显著降低麻醉成本。麻醉医生可以借助TDABC模型进行成本核算,同时优化临床路径和成本控制。

改良Aldrete量表和DPART在全身麻醉术后复苏病人中的应用效果比较

目的:探讨中文版DPART量表与改良Aldrete量表对全身麻醉病人术后复苏效果的评估效果。方法:以全身麻醉术后入麻醉复苏室(PACU)接受治疗的病人为研究对象,按手术日期先后顺序分为改良Aldrete组和DPART组。改良Aldrete组105例病人采用改良Aldrete作为出室评估工具,DPART组109例病人采用DPART作为出室评估工具,比较两组病人PACU停留时间、出室时疼痛评分、镇静躁动得分、苏醒期躁动发生率、恶心呕吐评分和护士对于两种量表的可行性、实用性评价。结果:DPART组PACU停留时间长于改良Aldrete组(P<0.05),但出室时疼痛评分、恶心呕吐评分低于改良Aldrete组(P<0.05);两组出室时镇静躁动得分及苏醒期躁动发生率比较差异无统计学意义(P>0.05);DPART组量表的可行性评分低于改良Aldrete组(P<0.05),实用性评分高于改良Aldrete组(P<0.05)。结论:应用中文版DPART量表评估PACU病人,病人PACU停留时间较使用改良Aldrete量表评估延长,但病人出室时各项体征表现较好,更有利于保障全身麻醉术后病人安全转出PACU。

围术期护理超声培训需求调查和课程设计

目的调查我国围术期护理超声的临床应用和教学培训现状,以及继续教育需求。方法于2022年11月-2023年4月面向全国二级或以上医院麻醉科的医师和护士线上发放问卷调查,共收回264份有效问卷,其中医师120名,护士144名,了解其科室围术期护理超声的临床应用与培训情况。对比麻醉科医师和护士掌握床旁超声技术的差异,汇总受访者对围术期护理超声的培训建议。结果受访麻醉科医师和护士在临床使用超声、对超声技术的熟悉程度和对超声知识的熟悉程度3个方面的差异有统计学意义(P<0.001)。203位(76.9%)受访者表示麻醉科护士极少或完全不使用床旁超声。有239名(90.5%)受访者支持学习与使用围术期护理超声,并给予培训项目和每项最低学习例数建议。根据调查结果,结合中国重症护理床旁超声标准,提出围术期护理超声继续教育课程设计框架。结论现阶段围术期护理超声临床应用率低、人员培训不足,处于待开发状态,需要建设课程和进行培训实践,通过继续教育提高其临床使用率和技术水平。

麻醉复苏室护士对麻醉苏醒期风险认知和患者安全胜任力现状的影响因素分析

目的研究麻醉复苏室(Post-anesthesia care unit,PACU)护士对麻醉苏醒期风险认知和患者安全胜任力现状,并分析麻醉苏醒期风险认知和患者安全胜任力相关性的影响因素。方法采用分层多阶段聚类抽样法于2022年6月-8月抽取新疆16所综合性医院的228名PACU护士为研究对象,采用电子问卷形式,问卷由一般资料、麻醉苏醒期风险认知调查问卷和患者安全胜任力护士评价量表组成,收集PACU护士对麻醉苏醒期风险认知和患者安全胜任力情况,分析患者安全胜任力和麻醉苏醒期风险认知的相关性及影响因素。结果PACU护士麻醉苏醒期风险认知总得分为(97.34±8.06)分,患者安全胜任力护士评价量表总得分为(148.72±11.80)分。在不同医院级别、学历、职称、麻醉护理工作年限、麻醉风险应急预案和麻醉风险培训频率PACU护士的患者安全胜任力和麻醉苏醒期风险认知差异均有统计学意义(P<0.05)。Pearson相关性分析显示,PACU护士麻醉苏醒期风险认知与患者安全胜任力各维度呈正相关(P<0.05)。多元线性回归分析显示,麻醉护理工作年限、职称、麻醉风险培训频率、苏醒期风险认知总分是PACU护士患者安全胜任力的影响因素(P均<0.05)。结论PACU护士的麻醉苏醒期风险认知和患者安全胜任力处于中等偏上水平,麻醉苏醒期风险认知水平的改善有助于PACU护士提高患者安全胜任力。

床旁超声技术在围术期临床中的应用

床旁超声(POCUS)是指在床边实时利用超声来帮助患者诊断和治疗的无创操作技术,在重症医学、急诊医学和内科领域等多个医学专业中都发挥着重要作用。越来越多的临床证据表明全身POCUS可在围手术期提供快速诊断,并直接影响麻醉管理和患者的预后,促使麻醉医师在临床实践过程中增强对围手术期超声应用的重视。目前麻醉领域尚缺乏标准的超声课程,本文综述了围手术期POCUS对多个器官评估的方法,包括心脏功能、血流动力学、气管内导管的放置、肺功能、吸入风险、血管穿刺和区域神经阻滞的可视化等。旨向麻醉医师和麻醉医学生介绍和讨论关于POCUS在围手术期中的不同用途及其重要性,以提高麻醉医师对POCUS的认识和掌握程度,推动POCUS纳入围手术期医学,为持续改进围手术期患者的麻醉管理提供重要工具。

持续质量改进对麻醉恢复室全麻低体温患者复温效果的影响观察

目的探讨持续质量改进对麻醉恢复室(PACU)全麻低体温患者复温效果的影响观察。方法运用持续质量改进对低体温发生率进行原因分析并制定相关护理常规流程,全程监督反馈,进行质量改进。结果PACU全麻低体温发生率由49.83%降到了6.67%。结论持续质量改进可有效降低PACU全麻恢复期患者低体温发生率,达到医疗质量持续改进的目的。

多学科协作护理模式在脊柱侧弯矫正术后麻醉复苏室护理中的应用效果

目的探究在脊柱侧弯矫正术后麻醉复苏室护理中应用多学科协作(MDT)护理模式的效果。方法选取2023年1月至5月在核工业四一六医院行脊柱侧弯矫正术患者104例为观察对象,采用随机数字表法将其分为对照组与试验组,各52例。全部患者术后均送至麻醉复苏室接受相关护理,对照组接受常规护理干预,试验组接受MDT护理模式。比较两组术后苏醒相关指标。结果试验组患者完全苏醒时间、麻醉复苏室滞留时间、拔管时间均短于对照组,差异有统计学意义(P<0.05)。苏醒后,试验组体温高于对照组,舒张压、收缩压、心率均低于对照组,差异有统计学意义(P<0.05)。试验组躁动程度、寒战程度优于对照组,差异有统计学意义(P<0.05)。结论MDT护理模式缩短苏醒时间及麻醉复苏室滞留时间,减少躁动、寒战发生,维护患者生命体征稳定。

罗伊纽曼理念的手术室护理改善乳腺癌麻醉患者睡眠质量的研究

目的:探究在对乳腺癌麻醉患者护理时开展罗伊纽曼理念的手术室护理对患者睡眠质量改善的作用。方法:选取2022年2月至2023年12月福建厦门大学附属第一医院乳腺癌手术患者88例作为研究对象,按照奇偶数分为对照组和观察组,每组44例。对照组手术期间开展常规护理,观察组开展罗伊纽曼理念的手术室护理。对患者手术期间睡眠质量、应对行为以及心理弹性等进行比较。结果:护理前,2组患者睡眠质量比较,差异无统计学意义(P>0.05),护理后,观察组评分较对照组低,差异有统计学意义(P<0.05)。护理前,2组患者应对行为评分比较,差异无统计学意义(P>0.05),护理后,观察组各维度评分高于对照组,观察组CD-RISC量表评分均高于对照组,差异有统计学意义(P<0.05)。结论:在对乳腺癌麻醉患者护理时开展罗伊纽曼理念的手术室护理,可以提升患者在手术期间睡眠质量,改善其心理状态以及应对行为,保障护理效果。

全麻术后苏醒期患者呼气末二氧化碳分压监测的研究进展

综述呼气末二氧化碳分压监测在麻醉后苏醒室的应用,主要包括呼气末二氧化碳分压监测的优势、方法、波形分析及应用等,旨在为全麻术后苏醒期患者实施呼气末二氧化碳分压监测提供参考。

神经阻滞麻醉室护理管理质量指标体系的构建

目的构建神经阻滞麻醉室护理管理质量指标体系,为神经阻滞麻醉室护理管理质量监测与评价提供依据。方法基于“结构-过程-结果”评价模型,采用文献回顾、德尔菲法、优序图法和乘积法确立神经阻滞麻醉室护理管理质量指标体系。结果2轮函询中专家的积极系数均为100%,权威系数为0.925,肯德尔和谐系数为0.213与0.182,构建了3项一级指标、8项二级指标、59项三级指标的神经阻滞麻醉室护理管理质量评价指标。结论构建的神经阻滞麻醉室护理管理质量指标具有一定的科学性和可靠性,为评价神经阻滞麻醉室护理管理质量提供了参考依据。

不同频次唤醒护理对全身麻醉胸科腔镜手术后患者苏醒效果的影响

目的探讨不同频次的唤醒护理对全身麻醉胸科腔镜手术后带气管导管转入麻醉后监测治疗室(PACU)患者苏醒效果的影响。方法采用便利抽样法,选取全身麻醉胸科腔镜手术后带气管导管转入气管导管观察的116例患者为研究对象,探讨不同频次(试验组A每5分钟、试验组B每10分钟、对照组等待患者自然苏醒)的唤醒护理对气管导管拔管时间、拔管后苏醒时间、总苏醒时间、拔管时呛咳反应、苏醒期躁动、拔管成功率、拔管后低氧血症和平均动脉压波动发生率的影响。结果气管导管拔管时间三组比较差异有统计学意义,试验组A和试验组B显著短于对照组(均P<0.05);试验组A与试验组B差异无统计学意义(P>0.05)。拔管后苏醒时间三组比较差异有统计学意义,试验组A显著长于对照组(P<0.05)。总苏醒时间三组比较差异无统计学意义(P>0.05)。三组气管导管拔管成功率和拔管后低氧血症发生率比较,差异无统计学意义(均P>0.05)。与对照组相比,试验组A和试验组B拔管时呛咳反应、苏醒期躁动程度和拔管后平均动脉压波动发生率明显降低(均P<0.05)。结论5 min和10 min频次的唤醒护理均能有效减少全身麻醉胸科腔镜手术后患者在气管导管机械通气时间,降低拔管时呛咳反应和苏醒期躁动严重度,有利于维持拔管时血流动力学稳定,提高苏醒质量。