BACKGROUND:Pain in trauma patients is frequent and associated with adverse physiological and psychological outcomes. Despite the recognized importance of early and effective analgesia, prehospital pain management remains insufficient in a substantial proportion of cases. Emerging evidence suggests sex-related differences in analgesic treatment, with both patient and physician sex potentially influencing therapy. This study investigates whether specific physician-patient sex pairings, alongside clinical and operational factors, are associated with the efficacy of prehospital pain management and explores how these factors interrelate to contribute to inadequate analgesia. METHODS:We conducted an observational cohort study of trauma patients treated by a Swiss physician-staffed Helicopter Emergency Medical Service between September 7, 2020, and July 24, 2025. We included patients with a Glasgow Coma Scale (GCS) ≥13, a National Advisory Committee for Aeronautics (NACA) Score 3), persistent untreated pain, and pain reduction. RESULTS:Of the 43,024 prehospital missions analyzed, 5168 met the inclusion criteria. The cohort was predominantly male (3097/5168; 59.9%); the median age was 47 [29-62] years. Extremity trauma was most common (3514/5168; 68%). In 32.2% (1663/5168; 95% confidence interval [CI], 30.9-33.3) of cases, analgesia was insufficient. While male physicians achieved greater NRS reduction (Coef. 0.20; 95% CI, 0.12-0.28), male patients reported less pain relief (Coef. -0.13; 95% CI, -0.21 to -0.05). Higher initial NRS scores (odds ratio [OR] = 1.45; 95% CI, 1.39-1.51) and omission of analgesics (OR = 5.70; 95% CI, 4.54-7.15) were associated with insufficient analgesia. The use of a combination of opioid and ketamine was associated with improved analgesia (OR = 0.69; 95% CI, 0.58-0.83). The greatest pain reduction was observed with ketamine or combination therapy. The median ΔNRS was 5 (interquartile range [IQR] 3-6) for ketamine and 5 (IQR 4-6) for combination therapy. CONCLUSIONS:In this large cohort, we found sex-related differences in patient-reported analgesia: male patients were more likely than female patients to report insufficient analgesia. Treatment by male physicians was associated with better patient-reported analgesia. Ketamine and its combination with opioids were associated with greater patient-reported NRS reduction compared to opioid monotherapy in a prehospital setting.
BACKGROUND: Postoperative delirium is a frequent and serious complication in older patients after surgery, particularly following hip fracture repair surgery, with an incidence of 10% to 55%. This study investigated whether goal-directed intraoperative blood pressure management could reduce the incidence of postoperative delirium in older patients undergoing hip fracture repair surgery. METHODS: In this single-center randomized controlled trial, 188 older patients (over 65 years) scheduled for elective hip fracture repair surgeries under spinal anesthesia were randomized to either goal-directed arterial blood pressure (ABP) group or control group. The goal-directed ABP group maintained systolic blood pressure (SBP) >80% preoperative values with continuous infusion of norepinephrine, while the control group aimed to keep SBP ≥90 mm Hg using intermittent administration of phenylephrine or ephedrine. The primary outcome was the incidence of postoperative delirium, assessed twice daily using the Confusion Assessment Method (CAM) until hospital discharge. Incidence of postoperative intensive care unit (ICU) admittance was also compared between groups. Quality of life was followed-up via telephone 3 months after surgery using the 3-level version of EuroQol Five Dimensional Questionnaire (EQ-5D-3L). RESULTS: Accumulative time spent under 80% preoperative systolic blood pressure (SBP) values was significantly shorter in goal-directed ABP group than in control group (0 [0–8] vs 12 [0–38] minutes; P < 0.001). Incidence of postoperative delirium was 26.6% (25/94) in the goal-directed ABP group and in 36.2% (34/94) in the control group, with an absolute risk reduction (ARR) of 9.6% (95% confidence interval [CI], −3.6 to 22.8), relative risk of 0.735 (95% CI, 0.478–1.130), P = .162. There was no difference in the incidence of postoperative ICU admittance or quality of life at 3 months follow-up. CONCLUSIONS: Goal-directed intraoperative blood pressure management did not significantly reduce postoperative delirium in older patients undergoing hip fracture repair surgery under spinal anesthesia.
BACKGROUND:Retrospective studies suggest that dexamethasone may provide benefits that extend beyond its antiemetic properties, including a reduction in postoperative complications. However, results from randomized controlled trials have not consistently shown there to be a reduction in composite major adverse events. This discrepancy may be due to confounding factors, measurement error, or simultaneity bias among retrospective investigations. This study used instrumental variable analysis (IVA) to help address potential sources of bias and better estimate treatment effects in patients undergoing total joint arthroplasty (TJA). METHODS:Patients who underwent primary elective TJA between 2016 and 2021 were identified using diagnosis and procedural codes. Bivariate regression, multivariable regression, and IVA were conducted. The primary end point was a 90-day composite (any versus none) of major postoperative medical complications. Secondary outcomes were infection, readmission, and death. Two distinct instruments-the frequency of dexamethasone use by surgeon and by hospital-were used to evaluate the robustness of our IVA. Patient demographics, hospital factors, and comorbidities were reported using descriptive statistics. Instrumental variable covariates were selected using the least absolute shrinkage and selection operator with 3 regularization parameter strategies. RESULTS:1525,844 TJAs performed between 2015 and 2021 were identified (976,996 knees [total knee arthroplasty {TKA}]; 548,848 hips [total hip arthroplasty {THA}]). Major postoperative medical complications were observed in 31,299 (3.43%) dexamethasone-exposed patients compared to 31,266 (4.87%) unexposed patients. Surgeon-based IVA yielded results comparable to the multivariable and bivariate analysis (local average treatment effect [LATE]: TKA: -1.20% [95% confidence interval [CI], -1.33% to -1.08%]; THA: -1.14% [95% CI, -1.30% to -0.99%]). Hospital-based IVA produced similar findings (LATE: TKA: -1.23% [95% CI, -1.38% to -1.09%]; THA: -1.18% [95% CI, -1.35% to -1.00%]). Both instruments demonstrated high F -statistics and significant Hausman tests. Secondary outcomes mirrored these results, except for mortality, which did not meet endogeneity criteria across analyses. CONCLUSIONS:The findings of this study support that dexamethasone exposure is associated with a reduction in composite major postoperative complications after TJA. The observed moderate treatment effect, in conjunction with a low baseline incidence of adverse events, may explain the inconsistent outcomes reported in previous randomized trials. Future prospective studies should incorporate composite end points and target high-risk patient populations or procedural subgroups.
BACKGROUND:Evaluation of the mitral valve during transcatheter edge-to-edge repair (TEER) for management of mitral regurgitation is commonly guided by intraprocedural interventional transesophageal echocardiography (TEE). The risk of iatrogenic mitral stenosis (MS) remains a concern, particularly in patients requiring multiple clips, since the mitral valve orifice area (MVA) is reduced. The value of conventional flow-based echocardiographic methods to rule out MS is limited by intraprocedural and general anesthesia (GA)-induced hemodynamic variability. This retrospective study introduces the novel adaptation of a 3-dimensional (3D) Orifice Area (3DOA) technique to evaluate post-TEER MVA. We evaluated the degree of agreement between MVAs derived via TEE 3DOA, TEE pressure half-time (PHT), and postprocedure transthoracic echocardiography (TTE) PHT with patients awake. METHODS:TEE and TTE images from 20 adult patients with severe mitral regurgitation undergoing a TEER (MitraClip, Abbott) procedure were retrospectively reviewed. MVAs obtained by MTEE 3DOA and TEE PHT under GA were compared to those acquired with TTE PHT with patients awake. Agreement was assessed via calculation of Bland-Altman 95% limits of agreement and Lin's concordance correlation coefficients, both with 95% confidence intervals (CIs). RESULTS:There was good agreement between TEE 3DOA-derived MVA measurements under GA and TTE PHT-derived MVA measurements in awake patients, as reflected by Bland-Altman (lower limit of agreement: -.0.45 [95% CI, -.58 to -.31] and upper limit of agreement: 0.26 [95% CI, 0.12-0.4]), and an excellent concordance correlation coefficient value (0.95 [95% CI, 0.86-0.98]). In contrast, agreement between TEE PHT-derived MVA and TTE PHT-derived MVA was weak, with much broader limits of agreement (lower limit of agreement: -1.6 [95% CI, -2.19 to -1.02] and upper limit of agreement: 1.43 [95% CI, 0.84-2.01]) and a weak concordance correlation coefficient value (0.46 [95% CI, 0.02-0.75]). CONCLUSIONS:In this retrospective cohort study, we demonstrated excellent agreement between TEE-3DOA-derived MVA under GA and TTE PHT-derived MVA in awake patients, but not between TEE versus TTE PHT. These findings warrant further validation in larger patient datasets to assess the utility of 3D echocardiographic approaches in evaluating MVA after TEER.
BACKGROUND: Adequate analgesia during general anesthesia is fundamental to minimize stress responses and optimize perioperative outcomes. Traditional monitoring based on nonspecific autonomic responses may be confounded by nonnociceptive factors. Newer nociception monitors, including the Analgesia Nociception Index (ANI) and the Nociception Level Index (NOL), offer alternative approaches, yet direct comparisons in the same patient population remain limited. METHODS: In this prospective study, 30 adult patients undergoing general anesthesia with propofol and remifentanil target-controlled infusion were monitored concurrently with ANI and NOL. Recorded values were categorized into insufficient, adequate, or excessive analgesia according to manufacturer thresholds. Agreement between monitors was evaluated. A 1-category disagreement was where monitors disagreed by one level (eg, insufficient vs adequate or adequate versus excessive). A 2-category disagreement was where they disagreed by 2 levels (eg, insufficient versus excessive). RESULTS: Across more than 38 hours of time-matched recordings, the monitors agreed in 43.7% of the monitoring time. One-category and 2-category disagreements were observed in 37.1% and 8.7% of recordings, respectively. Excessive analgesia was noted in 37.6% (ANI) and 38.1% (NOL) of surgical time. Each monitor reported “optimal analgesia” on around 31% of the time and insufficient analgesia 25% of the time. CONCLUSIONS: The modest agreement between ANI and NOL underscores discrepancies likely stemming from their different methodological approaches. These findings suggest that a multimodal strategy integrating various monitoring modalities may enhance intraoperative analgesic management.
BACKGROUND:The preoperative anesthesia consultation and risk disclosure required for informed consent can lead to negative patient expectations about their surgery, with resulting nocebo effects. Negative consequences are closely linked to patient anxiety, which further contributes to poor outcomes. Therefore, instruction in specific communication skills is essential for reducing preoperative anxiety. METHODS:Patient anxiety levels were measured before and after the preoperative anesthesia consultation using the State-Trait Anxiety Inventory (STAI-S), a numeric rating scale (NRS), and the Amsterdam Preoperative Anxiety and Information Scale (APAIS) in a single institution study. Following an initial data collection period for the control group, a single 1-hour education session on specific communication skills was offered to the Anaesthesiology Department. Patients seen by anesthesiologists who underwent this training constituted the intervention group. Central to the education was an emphasis on positive aspects, such as treatment benefit, prophylaxis, monitoring, and treatability of adverse reactions, alongside risk information. RESULTS:The preoperative consultation resulted in an anesthesia-related anxiety reduction in 85% of all patients (573 out of 673 patients). Anxiety reduction was more pronounced in the intervention group, where anesthesiologists had received the risk communication training (274 out of 306 ≈ 89.5%) compared to the control group (299 out of 367 = 81.5%), p = 0.003. Anxiety scores decreased by approximately 6% in the control and 7.5% in the intervention group. The most significant change was observed in anesthesia-related anxiety (decrease from 3.5 ± 1.6 to 3.1 ± 1.3 ≈ -11%, p = 0.016). Initial surgery-related anxiety was higher (5.0 ± 2.2) than anesthesia-related anxiety with a similar decrease post-consultation. Decrease in preoperative anxiety was most pronounced in patients with high preexisting anxiety (a drop by 4.9 in the STAI-S vs. 3.3 in the control, p = 0.033). CONCLUSION:A single session of risk communication training for anesthesiologists can significantly enhance the reduction of anesthesia-related anxiety in patients. This finding shows that evidence-based educational interventions on risk communication are feasible and effective when transferred from the study setting to clinical practice.
BACKGROUND: While ropivacaine–dexmedetomidine coadministration is widely used in surgical anesthesia, its pharmacokinetic effects in lumbar plexus blocks (LPB) remain uncharacterized. We therefore conducted a prospective randomized trial to evaluate dexmedetomidine’s modulation of ropivacaine’s pharmacokinetics and pharmacodynamics during unilateral lower limb surgery. Additionally, this study seeks to establish a dosing regimen for ropivacaine in combination with dexmedetomidine for LPB. METHODS: Patients undergoing unilateral lower limb surgery were randomly allocated to 1 of 3 groups using a random-number table. The study included a control group receiving only ropivacaine, and 2 experimental groups receiving ropivacaine combined with either 0.25 or 0.5 µg·kg −1 of dexmedetomidine, all administered perineurally. Clinical efficacy data were gathered and analyzed using statistical software to assess the pharmacodynamics of the three treatment regimens. Furthermore, data from all patients were used to develop a population pharmacokinetics model for ropivacaine, and pharmacokinetic parameters were determined. Using Bayesian estimation, we simulated ropivacaine dosing across body weights of 56 to 76 kg to identify doses where plasma concentrations exceed the toxicity threshold (4.3 ± 0.6 µg·mL −1 , mean ± standard deviation). RESULTS: A total of 46 patients were enrolled in the study. Ropivacaine pharmacokinetics were best described by a 2-compartment model, with body weight and dexmedetomidine coadministration as significant covariates. Simulations indicated that for LPB, the modeled toxic dose decreased from 4.9 to 3.0 mg·kg −1 (with 0.5 µg·kg −1 dexmedetomidine) and from 3.3 to 2.1 mg·kg −1 (without dexmedetomidine) as body weight increased from 56 to 76 kg. The inclusion of 0.5 µg·kg −1 dexmedetomidine significantly reduced the maximum concentration of ropivacaine (mean difference, 0.8 µg·mL −1 ; 95% confidence interval [CI], 0.5–1.2 µg·mL −1 ; P < .0001), increased the apparent volume of distribution (33.1 L; 95% CI, 13.4–52.8 L; P = .013), prolonged the time to maximum concentration (5 minutes; 95% CI, 1–9; P = .011), and reduced the onset time of sensory blockade (5 minutes; 95% CI, 2–6; P < .0001), while also extending the duration of sensory blockade (175 minutes; 95% CI, 55–294; P = .005). The addition of 0.25 µg·kg −1 dexmedetomidine to ropivacaine did not change outcomes compared to ropivacaine alone. CONCLUSIONS: Our research demonstrated that dexmedetomidine significantly influences the pharmacokinetics and pharmacodynamics of ropivacaine in LPB. When combining dexmedetomidine 0.5 µg·kg −1 with ropivacaine for LPB in a 66 kg adult, the maximum ropivacaine dose should not exceed 3.7 mg·kg −1 .
