Daily Anesthesiology Research Analysis

INTRODUCTION: Intra-operative hypotension is common during caesarean section and may result in adverse maternal effects, such as nausea and vomiting. While oscillometric blood pressure and continuous non-invasive arterial pressure monitoring enable reactive treatment, the hypotension prediction index offers a machine learning-based approach that may allow proactive haemodynamic intervention. This study investigated whether hypotension prediction index-guided management could reduce the incidence of intra-operative hypotension compared with oscillometric and continuous non-invasive arterial pressure monitoring. METHODS: Patients scheduled for elective caesarean section under spinal anaesthesia were allocated randomly to one of three haemodynamic monitoring strategies: oscillometric blood pressure; continuous non-invasive arterial pressure; or hypotension prediction index-guided monitoring. Hypotension and hypertension were defined as mean arterial pressure < 65 mmHg and ≥ 100 mmHg, respectively. Hypotension was treated using intermittent intravenous boluses of noradrenaline. The primary outcome was the time-weighted average of hypotension. Secondary outcomes included time-weighted average hypertension and maternal adverse effects, including bradycardia, nausea and vomiting. RESULTS: Data from 171 patients were analysed. Median time-weighted average hypotension was significantly higher in patients allocated to the oscillometric and continuous non-invasive arterial pressure groups compared with the hypotension prediction index group (0.89 mmHg and 0.30 mmHg vs. 0.08 mmHg, respectively, p < 0.001). Patients allocated to the oscillometric group had a higher incidence of maternal nausea and vomiting compared with those allocated to the continuous non-invasive arterial pressure and hypotension prediction index groups (nausea: 43/59 vs. 29/55 and 30/57, respectively, p = 0.038; and vomiting: 13/59 vs. 6/55 and 3/57, respectively, p = 0.023). DISCUSSION: Hypotension prediction index-guided management during caesarean section significantly reduced intra-operative hypotension without increasing the risk of hypertension. This approach provides a proactive strategy for haemodynamic optimisation in obstetric anaesthesia. WHAT WE DID: We studied 171 people who were having a planned caesarean birth with a spinal anaesthetic. They were put into three groups, each using a different way to check blood pressure during the operation: a normal arm blood pressure cuff that checks blood pressure every few minutes; a machine that checks blood pressure all the time without a needle; and a computer system that tries to predict when blood pressure is about to drop. If a person's blood pressure fell too low, they were given medicine to raise it. WHY DID WE DO IT: Low blood pressure is common during caesarean births and can make people feel sick or vomit. Usual machines only show the problem after it has already happened. We wanted to see if a system that can warn doctors early could help stop blood pressure from dropping in the first place. WHAT WE FOUND: People using the prediction system had much less episodes of low blood pressure during their operation. People using the normal arm blood pressure cuff had the most problems with low blood pressure. People in the normal arm blood pressure cuff group also felt sick and vomited more often. This means that using a system that predicts low blood pressure can help keep blood pressure more stable and reduce sickness during caesarean birth.

INTRODUCTION: Elective caesarean section is a common and painful procedure. Uncontrolled pain following caesarean section can profoundly and negatively on a wide range of patient and healthcare-centred outcomes. The aim of this systematic review was to update existing recommendations for postoperative pain management after elective caesarean section performed under neuraxial anaesthesia. METHODS: A systematic review using the PROcedure SPEcific Postoperative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised trials evaluating the efficacy of analgesic, anaesthetic and surgical interventions were retrieved. Systematic reviews and meta-analyses of randomised controlled trials were also reviewed. Trials evaluating pain management for emergency surgical deliveries or caesarean section performed under general anaesthesia were not included. RESULTS: Sixty-one randomised controlled trials were included. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, we recommend that clinicians administer intrathecal morphine 50-100 μg or diamorphine 300 μg pre-operatively, and paracetamol, non-steroidal anti-inflammatory drugs and dexamethasone after delivery. If a neuraxial opioid is not administered, clinicians should use one of a range of recommended fascial plane blocks; alternatively, the wound should be infiltrated with local anaesthetic. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs, with opioids used for rescue. The surgical technique should include a Joel-Cohen incision. The peritoneum should not be closed. DISCUSSION: An analgesic regimen to manage pain safely and effectively after elective caesarean section based on up-to-date evidence is presented. Consideration has been given to balancing analgesic efficacy and potential adverse effects. Future research should determine the optimal dose of dexamethasone and epidural long-acting opioid, establish the most effective regional analgesic technique and develop standardised outcome sets to better compare techniques. WHAT WE DID: We looked at many good‐quality research studies to find the best ways to manage pain after a planned caesarean section. We only included studies where the caesarean was planned and done using spinal or epidural anaesthesia. In total, we reviewed 61 studies. WHY WE DID IT: A caesarean birth can be very painful, and poor pain control can make recovery harder for parents and babies. We wanted to update advice for doctors so they can give the safest and most effective pain relief after a planned caesarean section. WHAT WE FOUND: Giving a small amount of strong pain medicine into the spine during the operation helps reduce pain afterwards. After the baby is born, regular pain relief with paracetamol and anti‐inflammatory medicines works well. If spinal pain medicine is not used, doctors can use numbing injections or nerve blocks to help control pain. Strong pain medicines (opioids) should be used only if needed. Using certain surgical methods can also help reduce pain and improve recovery. These findings give clear, up‐to‐date advice to help people recover more comfortably and safely after a planned caesarean section.

AIMS: The role of electrocardiography (ECG) has been limited in the preoperative risk evaluation in noncardiac surgery due to its low prognostic value. We aimed to evaluate the utility of an AI-enabled ECG (QCG-Critical score) in predicting 30-day postoperative mortality in non-cardiac surgery and compare its performance with traditional perioperative risk-assessment tools. METHODS AND RESULTS: A retrospective cohort of 46 135 adults who underwent non-cardiac surgery at a tertiary centre between 2020 and 2021 was analysed. Preoperative ECG images acquired within 30 days before surgery were used as input to previously developed CNN-based deep-learning algorithm to generate QCG-Critical score that reflects the risk for critical illness. The primary outcome was 30-day mortality, which occurred in 0.34% of patients. Individuals with QCG-Critical scores >40 had a markedly higher mortality rate of 11.7%. The QCG-Critical score demonstrated strong predictive performance for 30-day mortality (AUROC: 0.909), outperforming the ESC surgical category (0.728) and RCRI (0.725), and was comparable to the ASA classification (0.886). The performance of QCG-Critical score remained consistent across subgroups stratified by age, sex, emergency operation, anaesthesia type, and conventional risk groups. The QCG-Critical score also demonstrated good performance for predicting 7-day mortality (AUROC: 0.933), unplanned PCI (0.857), prolonged mechanical ventilation (0.829), and presumed heart failure (0.774). CONCLUSION: The preoperative QCG-Critical score accurately predicted postoperative mortality and other adverse outcomes, outperforming conventional risk-stratification tools. The QCG-Critical score may serve as a fast, accessible, and integrable tool for perioperative risk assessments in routine surgical care.