Daily Anesthesiology Research Analysis

BACKGROUND: We evaluated whether combined general and regional anaesthesia (GA+RA) was associated with improvements in activities of daily living compared with GA alone in adult patients having major orthopaedic surgery. METHODS: This target trial emulation used data from the Japanese Diagnosis Procedure Combination system (April 1, 2016-December 31, 2023) for patients undergoing major orthopaedic surgery. The primary outcome was discharge-anchored functional change, defined as the difference in the Barthel Index scores between admission and discharge, among admissions with observed and comparable discharge Barthel Index scores. We conducted stabilised inverse probability of treatment weighting using preoperative covariates, and weighted linear regression models were fitted. Secondary outcomes included in-hospital mortality and postoperative length of stay. Missing data were handled using multiple imputations, and sensitivity analyses (inverse probability of censoring weighting, subgroup analyses, and complete case analysis) were performed. RESULTS: A total of 244 212 patients received GA+RA (peripheral nerve block: 183 564; epidural anaesthesia: 60 648) and 435 462 patients received GA alone. After propensity score weighting, GA+RA yielded a higher change in Barthel Index scores (mean difference 0.73, 95% confidence interval [CI] 0.57-0.88, P<0.001), shorter postoperative length of stay (-1.40 days, 95% CI -1.45 to -1.35, P<0.001) and lower in-hospital mortality (hazard ratio 0.85, 95% CI 0.76-0.96, P=0.006). Sensitivity analyses yielded directionally consistent findings. CONCLUSIONS: Combined general and regional anaesthesia was associated clinically with modest improvements in discharge-anchored functional change, postoperative stay and in-hospital mortality. Residual confounding and heterogeneity of regional anaesthesia techniques warrant cautious interpretation and prospective confirmation.

BACKGROUND: Conversion from epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) is a common clinical procedure in obstetric practice. However, its failure rate remains unacceptably high (15%-38% in previous reports), posing substantial risks to maternal and neonatal safety, including increased reliance on general anesthesia and associated adverse outcomes. This study aimed to evaluate the impact of preanesthetic ELA interruption on the conversion efficacy of prolonged ELA (≥ 8 h) to ESA and to explore underlying anatomical and physiological mechanisms using lumbar magnetic resonance imaging (MRI). METHODS: This integrated study comprised two complementary components: a prospective cohort study and a controlled before-after MRI study. For the prospective cohort study, 167 parturients requiring conversion from prolonged ELA (≥ 8 h) to ESA were assigned to either Group S (ELA interrupted ≥ 30 min before ESA initiation, n = 77) or Group NS (ELA continued until ESA initiation, n = 88) based on clinical practice preferences and patient-related factors. The primary outcome was the ESA failure rate; secondary outcomes included intraoperative analgesic efficacy (visceral and incision pain visual analog scale [VAS] scores), muscle relaxation quality, and maternal satisfaction. Multivariable logistic regression was used to adjust for potential confounding factors at intervention assignment. For the MRI study, 11 parturients who underwent vaginal delivery with ELA underwent lumbar MRI scans in the supine position with left uterine displacement at 2 h post-delivery (ELA active phase) and 24 h post-delivery (ELA interruption phase). Key measurements included dural sac (DS) area, epidural space (ES) area, and apparent diffusion coefficient (ADC) values of spinal ganglia at the L1-L5 levels. All MRI volumetric quantifications were performed by two experienced radiologists using a standardized segmentation protocol to improve reliability. RESULTS: In the cohort study, Group S showed a significantly lower ESA failure rate compared with Group NS (13.0% vs. 29.5%, P = 0.014). Group S also had better intraoperative pain control, muscle relaxation, and maternal satisfaction. Multivariable logistic regression adjusted for maternal weight and ELA duration confirmed that longer ELA interruption time was independently associated with reduced odds of ESA failure (OR = 0.986, 95% CI 0.977-0.996, P = 0.006). The MRI study revealed that at 2 h post-delivery, compared with 24 h post-delivery, the DS area was significantly reduced and the ES area was significantly enlarged at all lumbar levels. Epidural fluid accumulation was observed in 18.2% of parturients at 2 h. No significant differences in spinal ganglion ADC values were detected, indicating no neural edema. CONCLUSIONS: Preanesthetic interruption of ELA for ≥ 30 min significantly improves the conversion efficacy of prolonged ELA to ESA, as shown by reduced failure rates, enhanced anesthesia quality, and improved maternal outcomes. Mechanistically, ELA-related epidural space dilation, dural sac compression, and residual low-concentration local anesthetics (possibly associated with epidural fluid accumulation) may contribute to conversion failure, and these adverse changes can be relieved by preanesthetic ELA interruption. TRIAL REGISTRATION: ChiCTR2100047772 (prospective cohort study, registered in the Chinese Clinical Trial Registry on June 26, 2021; ChiCTR2200059311 (MRI study, registered in the Chinese Clinical Trial Registry on April 28, 2022).

BACKGROUND: Enhanced Recovery After Surgery (ERAS) Society guidelines provide procedure-specific, evidence-based recommendations for perioperative care. Many interventions fall within anaesthesiology, yet the extent to which they reflect cross-speciality principles remains unclear. The objective of this systematic review was to identify a universal anaesthesiological core across ERAS guidelines. METHODS: All ERAS Society guidelines were screened for eligibility. Guidelines were excluded if they had no practical anaesthesiological recommendations, had been superseded, or were not intended for standard hospital settings. A classification of 45 anaesthesiological umbrella terms was developed through pilot extraction and Delphi consensus. Two reviewers independently extracted recommendations and their strength. Methodological quality was assessed using Appraisal of Guidelines for Research and Evaluation II (AGREE II). Umbrella terms were classified as consistent (>80%), mostly consistent (60-80%), mixed (20-60%), or sparse (≤20%). RESULTS: Of 39 publications, 24 guidelines (2013-2025) were included. Anaesthesiological involvement was identifiable in 23 out of 24 guidelines. Of the 45 umbrella terms, eight were consistent, 10 mostly consistent, 16 mixed, and 11 sparse. The consistent domains were: multimodal analgesia, fasting, thromboprophylaxis, antimicrobial prophylaxis, nutrition, temperature and fluid management, and surgery-specific recommendations. The mean AGREE II score was 76%, highest for scope and purpose and clarity of presentation and lowest for stakeholder involvement. CONCLUSIONS: Despite procedural heterogeneity, a consistent anaesthesiological core is identifiable within the ERAS guidelines. Cross-guideline consistency identifies the priority domains for cross-speciality implementation, whereas recommendation strength independently indicates the confidence with which guidance transposes onto local practice; high-frequency, mixed-strength domains, notably fluid management, preoperative carbohydrate administration and preanaesthetic medication, warrant structured local appraisal. REGISTRATION: The study protocol: Open Science Framework (DOI: 10.17605/OSF.IO/CBWDT).