Anaesthesia最新文献_第8页

“Voices from the ground”: reverberations from a community of practice “来自地面的声音”：来自实践社区的回响

IF 10.7 1区医学

Anaesthesia Pub Date : 2025-02-09 DOI: 10.1111/anae.16569

Adam I. Mossenson, Karima Khalid, Patricia Livingston

{"title":"“Voices from the ground”: reverberations from a community of practice","authors":"Adam I. Mossenson, Karima Khalid, Patricia Livingston","doi":"10.1111/anae.16569","DOIUrl":"https://doi.org/10.1111/anae.16569","url":null,"abstract":"We thank Kaur et al. [1] for their thoughtful reading of our Delphi study [2]. Our findings have contributed to the development of a tool which is now embedded into the learning architecture [3] of the Vital Anaesthesia Simulation Training (VAST) Community of Practice [4]. This a globally distributed group of healthcare practitioners dedicated to offering high-quality simulation in low-resource settings. Kaur et al. raise questions about equitable partnerships in research. We believe they present a false dichotomy that we now seek to address.\u0000As highlighted in the Delphi study reflexivity statement, that work was part of a longitudinal research agenda aligned with the theoretical framework for learning within communities of practice [3]. According to this theory, community members develop skills in specific cultural and social environments through which they innovate, create new knowledge and develop a collective understanding of the practice of their community. The work of our community is situated within a nuanced definition of low-resource settings whereby resource limitations pertain less to the overall economic status of a country and more to the capacity of individuals, departments and organisations; location-specific resource availability; and logistical constraints. Low-resource settings can exist in high-income countries (HICs) (e.g. rural and remote settings). We explored simulation facilitation competencies from this perspective. We echo the belief that focusing on the dichotomy of HICs vs. low- and middle-income countries (LMICs), when not directly relevant, may foster ‘otherness’, perpetuate divisions and continue to extend destructive legacies in global health research [5].\u0000Ambimbola highlights that “The growing concerns about the imbalances in authorship are a tangible proxy for concerns about power asymmetries in the production (and benefits) of knowledge in global health” [6]. Rather than arbitrary and superficial assessment of authorship percentages, Ambimbola states that considerations should be around “who we are as authors, who we imagine we write for (i.e. gaze), and the position or standpoint from which we write (i.e. pose)” [6]. Our modified Delphi study was conducted by members of our community primarily to support reflection and performance improvement within our community. This includes simulation educators who live and work in LMICs; those practicing simulation in HICs (where the context is consistent with our definitions of low-resource settings); and those from both HICs and LMICs who conduct simulation in foreign settings.\u0000Beyond oversimplified concerns of contribution, we were surprised by the assertion by Kaur et al. that more personnel from LMICs “may have led to greater understanding of local perceptions and challenges, and ultimately more insightful results and greater","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"29 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143375656","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Ultrasound-guided neuraxial puncture: translating evidence to practice 超声引导下的轴突穿刺：将证据转化为实践

IF 10.7 1区医学

Anaesthesia Pub Date : 2025-02-05 DOI: 10.1111/anae.16558

Clístenes Crístian de Carvalho, Kariem El-Boghdadly

引用次数: 0

The role of anaesthetics in cancer outcomes: do we need more clinical trials? 麻醉在癌症预后中的作用：我们是否需要更多的临床试验？

IF 7.5 1区医学

Anaesthesia Pub Date : 2025-02-05 DOI: 10.1111/anae.16562

Eduardo Nunez-Rodriguez, Maria F. Ramirez, Juan P. Cata

引用次数: 0

Ventilatory efficiency as a predictor of 1-year mortality after non-cardiac surgery: showing clinical utility by applying decision curve analysis 通气效率作为非心脏手术后1年死亡率的预测因子：应用决策曲线分析显示临床效用

IF 10.7 1区医学

Anaesthesia Pub Date : 2025-02-05 DOI: 10.1111/anae.16554

Thomas Vetsch, Markus Huber

{"title":"Ventilatory efficiency as a predictor of 1-year mortality after non-cardiac surgery: showing clinical utility by applying decision curve analysis","authors":"Thomas Vetsch, Markus Huber","doi":"10.1111/anae.16554","DOIUrl":"https://doi.org/10.1111/anae.16554","url":null,"abstract":"The study by Arina et al. represents an innovative and commendable effort to develop a clinical prediction model to predict 1-year mortality (the primary outcome) after major non-cardiac surgery using pre-operative data [1]. We would like to highlight and elaborate on two aspects of their study related to the clinical interpretation and utility of the prediction model for decision-making.\u0000First, and with respect to clinical interpretation, the authors highlight the importance of both clinical and physiological data in predicting the primary outcome. In particular, the inclusion of data obtained from cardiopulmonary exercise testing (CPET) – reflecting objectively measured fitness – is clinically reasonable. Among the plethora of parameters derived from CPET, ventilatory efficiency (expressed by the minute ventilation (l.min-1) to carbon dioxide output (ml.kg-1.min-1)) is a frequently reported predictor of short-term postoperative mortality. It can be reported as a slope to the secondary ventilatory threshold (VE.VCO2-1 slope); as a ratio at the first ventilatory threshold (VE.VCO2-1 VT1/AT); or as a ratio at peak exercise (VE.VCO2-1 peak). Given the fact that submaximal testing may be appropriate for some patients, we recommend reporting the VE.VCO2-1 slope due to its insensitivity to ventilatory thresholds [2]. It is plausible that ventilatory efficiency could be even more relevant to predict mid- to long-term mortality compared with short-term, given its close relationship with comorbidity. The results presented by Arina et al., therefore, constitute a valuable contribution in the quest to identify novel predictors for mid- to long-term outcomes.\u0000Second, with respect to clinical utility, the authors primarily evaluate a clinical prediction model based on the multi-objective symbolic regression (MOSR) approach. Given the broad clinical readership of Anaesthesia, it would be helpful to introduce and explain this novel algorithm in more detail and, if possible, with some illustrative, practical examples. This would help avoid the introduction of another so-called ‘black-box’ medical algorithm [3]. Additionally, the suite of prediction models in the study could be combined in a so-called super learner [4].\u0000The performance of the models is evaluated with the so-called F1-score. For another performance metric – the area under the receiver operating characteristic (AUROC) – it has been emphasised that the relative gain in AUROC performance of a new or updated prediction model provides only a very limited perspective on its added clinical utility. Here, we would argue similarly, in the sense that the added benefit of the MOSR approach for clinical decision-making with respect to logistic regression or machine-learning methods can only be partly examine","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"62 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143124393","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Beyond the ‘black box’: choosing interpretable machine learning models for predicting postoperative opioid trends 超越“黑箱”：选择可解释的机器学习模型来预测术后阿片类药物的趋势

IF 7.5 1区医学

Anaesthesia Pub Date : 2025-02-02 DOI: 10.1111/anae.16553

Seshadri C. Mudumbai, James Baurley, Caitlin E. Coombes, Randall S. Stafford, Edward R. Mariano

{"title":"Beyond the ‘black box’: choosing interpretable machine learning models for predicting postoperative opioid trends","authors":"Seshadri C. Mudumbai, James Baurley, Caitlin E. Coombes, Randall S. Stafford, Edward R. Mariano","doi":"10.1111/anae.16553","DOIUrl":"10.1111/anae.16553","url":null,"abstract":"Artificial intelligence encompasses machine learning and is a popular, yet controversial, topic in healthcare. Recent guidelines from national regulatory agencies underscore the critical importance of interpretability in machine learning models used in healthcare [1]. ‘Interpretability’ means that clinicians understand the reasoning behind a model's predictions, fostering trust and enabling informed clinical decision-making [Doshi-Velez et al. preprint, https://arxiv.org/abs/1702.08608]. In response to the opioid epidemic, there has been interest in using machine learning models to predict which patients will have the highest risk of postoperative opioid dependence. To be interpretable, clinicians should be able to see which specific factors (e.g. previous opioid use, type of surgery or mental health conditions) contribute to prediction. Experts have advocated for building inherently interpretable models from the start, especially in high-stakes medical contexts, rather than retrofitting explanations onto complex models after development [2]. As machine learning algorithms become integral to peri-operative management, balancing model complexity with interpretability is crucial [3]. The objective of this study was to evaluate whether simpler, more interpretable models could match complex ones in predictive accuracy and in identifying key predictors for postoperative opioid use.Following institutional review board approval, we conducted a retrospective cohort study at a US Veterans Affairs hospital. We included adult patients who had surgery from 2015 to 2021 and had documented pre-operative and post-discharge opioid prescriptions. Patients without complete opioid prescription data were not studied.Baseline data were extracted from electronic health records and included: patient characteristics; clinical variables (such as type of surgery and duration of hospital stay); and mental health diagnoses. We assessed three outcomes, with mean daily morphine milligram equivalents (MME) as the primary outcome and variance in MME and monthly rate of change in MME as secondary outcomes; these were all measured over 12 months before surgery and post-discharge. Opioid prescriptions were converted to MME, and mental health diagnoses were identified using ICD-10 revision codes as described in previous studies [4].We developed three machine learning models to predict postoperative opioid use: lasso regression, which enhances accuracy and interpretability through variable selection and regularisation; decision tree, which predicts outcomes using interpretable decision rules inferred from data; and extreme gradient boosting (XGBoost), an ensemble method known for high predictive performance but lower interpretability [5].Analyses were performed using RStudio (version 12.0, R Foundation for Statistical Computing, Vienna, Austria) involving two scenarios: models were traine","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"80 4","pages":"451-453"},"PeriodicalIF":7.5,"publicationDate":"2025-02-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16553","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143077164","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Balancing efficiency and patient safety: lessons from the trend to outpatient lower joint arthroplasty 平衡效率和患者安全：从门诊下关节置换术趋势的教训

IF 7.5 1区医学

Anaesthesia Pub Date : 2025-02-02 DOI: 10.1111/anae.16560

Anjali A. Dixit, Jinlei Li, Seshadri Mudumbai

引用次数: 0

Confounders in anaesthesia-related depression outcomes 麻醉相关抑郁结果的混杂因素

IF 10.7 1区医学

Anaesthesia Pub Date : 2025-01-30 DOI: 10.1111/anae.16557

Chi-Jen Hsu, Mei Na Fok, James Cheng-Chung Wei

{"title":"Confounders in anaesthesia-related depression outcomes","authors":"Chi-Jen Hsu, Mei Na Fok, James Cheng-Chung Wei","doi":"10.1111/anae.16557","DOIUrl":"https://doi.org/10.1111/anae.16557","url":null,"abstract":"We read with great interest the study by Ho et al., which provides valuable insights into the long-term effects of anaesthesia choice on postoperative outcomes [1]. However, several potential confounders influencing the link between anaesthetic techniques and postoperative depression were not specifically addressed in the analysis.\u0000First, pre-existing mental health conditions, such as a history of depression or anxiety, are established risk factors for postoperative depression. These conditions may also impact the choice of anaesthesia due to concerns around peri-operative psychological stress [2]. Additionally, socio-economic status, another crucial determinant of health, could confound the relationship between anaesthesia type and depression. Patients with lower socio-economic status may have limited access to certain anaesthesia options or an increased baseline risk of depression, irrespective of surgical factors [3].\u0000Second, chronic pain and the severity of pre-operative pain are important considerations. Over half of surgical patients experience inadequate postoperative pain management. Certain pre-operative psychological interventions can mitigate acute postoperative pain scores and reduce opioid consumption [4]. Social support and living conditions, although unmeasured confounders, also play a significant role. Social isolation and limited support networks are indirectly linked to surgical outcomes through their association with depression, which is itself associated with poorer outcomes [5]. These psychosocial factors may also impact the choice of anaesthesia.\u0000Finally, reliance on ICD-10 codes for diagnosing depression may result in an underestimation of its true incidence, as mental health disorders are frequently underdiagnosed or misclassified in clinical settings. This potential underreporting could distort the observed differences between anaesthesia groups, particularly if diagnostic practices vary among contributing institutions.\u0000To strengthen future research, incorporating validated mental health assessments pre- and post-surgery, as well as collecting data on socio-economic factors and social support networks could provide a more nuanced understanding of anaesthesia's role in postoperative depression. Although the authors used propensity score matching, residual confounding from unobserved variables remains possible. Future research should include these factors to improve validity.\u0000We commend Ho et al. for their contribution and hope our discussion helps in the planning of future research, such as multicentre cohort studies that could include psychosocial factors such as social support and economic status.","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"40 1","pages":""},"PeriodicalIF":10.7,"publicationDate":"2025-01-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143056328","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Puncturing the dura: a true clinical benefit or a distraction? 刺穿硬脑膜：真正的临床益处还是分散注意力？

IF 7.5 1区医学

Anaesthesia Pub Date : 2025-01-30 DOI: 10.1111/anae.16555

Annie C. H. Fung, Anna Preston

{"title":"Puncturing the dura: a true clinical benefit or a distraction?","authors":"Annie C. H. Fung, Anna Preston","doi":"10.1111/anae.16555","DOIUrl":"10.1111/anae.16555","url":null,"abstract":"The comparison of dural puncture epidural (DPE) labour analgesia with other accepted techniques including combined spinal-epidural (CSE) and epidural alone is an interesting and debated topic. The recent paper by Zang et al. attempts to address this and concludes there were no significant differences in the quality of labour analgesia for DPE compared with the CSE technique [1]. We have concerns regarding the methodology and results of this paper and its clinical significance for DPE-related trials.First, the sample size calculation was assumed to detect a reduction in the composite primary outcome from 50% in the CSE group to 22.5% in the DPE group, based on previous calculations published by Chau et al. [2]. The most effective clinical interventions are, at most, modest in effect size [3], thus we argue that the authors used an overly optimistic prediction to calculate the minimum required sample size, which was done arbitrarily. A CSE vs. DPE would intuitively be a small effect size, thus using a small sample size would have insufficient power to evaluate this. Smaller effect sizes were most likely missed in this study due to the small sample size.Second, the primary and secondary outcomes were all focused on parameters affecting an anaesthetist's workload, except for the final secondary outcome which was the satisfaction of the mother with labour analgesia. The satisfaction scores for both CSE and DPE groups ranged from 0 to 10, which we argue is a crude and non-discriminating outcome measure. Currently, there is a lack of patient-reported outcome measure (PROM) questionnaires to capture the quality of maternity care, especially during labour [4]. Future studies investigating the quality of analgesia will need to include maternity PROMs, specifically focused on the intrapartum period. Furthermore, Zang et al. did not capture the rate of caesarean deliveries after neuraxial labour analgesia, which is a key outcome concerning the patient, obstetrician and anaesthetist. We argue that future clinical trials need to include a core outcome set for holistic and accurate measurements, which also allows for meta-analysis and homogeneity in data collection between individual trials [5].Finally, approaching the topic of labour analgesia from a holistic perspective, should we focus on the impact of an intentional dural puncture or access to labour analgesia? The clinical benefits of labour analgesia (regardless of technique) are well documented. Yet there are still disparities in access to labour analgesia, especially in socio-economically deprived parturients. A recent population-based study in Scotland found the utilisation of epidurals for labour analgesia was 22%, and women in the most deprived areas were 16% less likely to receive epidural analgesia compared with the most affluent [6]. When formulating research questions, do we aim for improving pat","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"80 5","pages":"591-592"},"PeriodicalIF":7.5,"publicationDate":"2025-01-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16555","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143056329","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Peri-operative corticosteroid supplementation guideline adherence 围手术期皮质类固醇补充指南依从性

IF 7.5 1区医学

Anaesthesia Pub Date : 2025-01-30 DOI: 10.1111/anae.16556

Lynn A. Miggelbrink, Marije Marsman, Juul van de Wetering, Wilton A. van Klei, Teus H. Kappen

{"title":"Peri-operative corticosteroid supplementation guideline adherence","authors":"Lynn A. Miggelbrink, Marije Marsman, Juul van de Wetering, Wilton A. van Klei, Teus H. Kappen","doi":"10.1111/anae.16556","DOIUrl":"10.1111/anae.16556","url":null,"abstract":"Corticosteroids are prescribed commonly to patients with autoimmune or pulmonary diseases, post-transplant and neurosurgery, as well as to patients with adrenal insufficiency [1, 2]. These patients are at risk of tertiary adrenal gland insufficiency, for which supplementation of corticosteroids during stress, such as surgery, is advised [3, 4]. The Peri-operative Replacement of Exogenous Steroids (PREdS) study performed an audit of compliance to guidelines for supplemental corticosteroids in patients with possible adrenal insufficiency in the UK [5]. A total of 21,411 adult patients undergoing surgery under the care of an anaesthetist were screened, of whom 277 (1.3%) used corticosteroids (i.e. they were considered at risk of tertiary adrenal gland insufficiency). Peri-operative prescription of supplementation was fully compliant in only 9% of the patients and 14% received none.In a retrospective cohort study, we investigated guideline adherence for such patients in our academic centre. The local clinical guideline is based on a Dutch nationwide guideline, comparable with the one used in the UK (Table 1). Patients are deemed at risk if they are using prednisolone ≥ 7.5 mg or equivalent. Supplementation dosage depends on surgical risk, so we documented compliance based on a patient's surgical procedure risk.A total of 15,246 patients undergoing elective non-cardiac surgery under general or spinal anaesthesia between January 2017 and June 2018 were included, of whom 390 were at risk of tertiary adrenal gland-insufficiency. Patients had a median (IQR [range]) age of 56 (45–69 [18–85]) y, 178 (45%) were female and 107 (27%) were scheduled for neurosurgery. On the day of surgery, 32 of 390 patients (8%) received hydrocortisone supplementation in accordance with the guidelines and 188 (48%) received another corticosteroid for an alternative reason, for example, dexamethasone for postoperative nausea or for neurosurgery. None of the remaining 170 (44%) patients received supplementation.Of the 147 patients (38%) undergoing low-risk surgery, 26 (18%) received supplementation according to the guidelines, while 38 (36%) received corticosteroids for other reasons, of whom 36 (95%) received an adequate equivalent dose. Of the 243 patients (62%) undergoing intermediate/high-risk surgery, 6 (2%) received supplemental corticosteroids according to the guidelines and 150 (62%) received corticosteroids for other reasons. Of these 150 patients, 27 (18%) received an adequate equivalent dose. On the first postoperative day, peri-operative prescription of supplementation was fully compliant in 10 (4%) of the 243 intermediate/high-risk patients.In conclusion, our hospital recorded an 8% compliance rate with the guidelines for prescribing peri-operative corticosteroid supplementation, similar to the 9% compliance rate found in the PREDs study [5]. Our study predates the Association of Anae","PeriodicalId":7742,"journal":{"name":"Anaesthesia","volume":"80 4","pages":"454-455"},"PeriodicalIF":7.5,"publicationDate":"2025-01-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16556","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143056327","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Burnout in anaesthesia: the UK and beyond 麻醉中的倦怠：英国及其他地区

IF 7.5 1区医学

Anaesthesia Pub Date : 2025-01-29 DOI: 10.1111/anae.16551

Hanlie du Plessis

引用次数: 0