American Society Of Anesthesiologists Grade Research Articles

A prospective randomized comparative study of analgesic effect of dexmedetomidine versus dexamethasone as an adjuvant to 0.75% ropivacaine in ultrasound-guided interscalene block

Abstract Background: Ultrasound (USG)-guided interscalene block (ISB) provides excellent anesthesia and analgesia for humerus surgery. Various adjuvants have been used to improve the quality of block and duration of analgesia. Aim: The aim of the study was to compare the efficacy of dexmedetomidine (DXM) and dexamethasone (DXA) as an adjuvant to 0.75% ropivacaine for interscalene brachial plexus block among patients undergoing humerus surgery. Settings and Design: The study design was a prospective randomized comparative study at a tertiary care teaching hospital. Materials and Methods: After ethical approval and CTRI registration, 52 patients of 18–60 years of age, American Society of Anesthesiology Grade I–II, scheduled for proximal and mid-shaft humerus surgery were randomly allocated in Groups A and B. Group A (n=26) received Ropivacaine 0.75% (20 ml) along with DXM 0.5 µg/ Kg and 2 ml saline (total 22 ml) and Group B (n=26) received Ropivacaine 075% along with DXA 8 mg (total 22 ml). ISB was performed with an in-plane technique using a linear probe. Duration of analgesia, block characteristics (onset, complete sensory, and motor block), and complications were recorded and compared for 24 h. Statistical Analysis: Data were statistically analyzed with Social Science Statistics. Student’s unpaired t-test and Chi-square tests were used, and all statistical tests were examined with P ≤ 0.05 level of significance. Results: The duration of analgesia in Group B was significantly longer than Group A (13 h 12 min ± 2 h 33 min–8 h 48 min ± 1 h 52 min, P < 0.00001). The groups were comparable regarding block characteristics, baseline demographics, and intraoperative hemodynamic parameters. Conclusion: DXA as an adjuvant to ropivacaine provides analgesia for longer duration compared to DXM in USG-guided ISB.

Comprehensive analysis of risk factors and pathogenetic characteristics associated with surgical site infections following craniotomy procedures.

Craniotomies are intricate neurosurgical procedures susceptible to post-operative complications, among which surgical site infections (SSIs) are particularly concerning. This study sought to elucidate the potential risk factors and pathogenetic characteristics associated with SSIs following craniotomy procedures in a clinical setting. A retrospective study was conducted from May 2020 to May 2023, examining patients subjected to elective or emergency craniotomies. The cohort underwent post-operative surveillance for SSIs, facilitating patient classification into SSI and Non-SSI groups based on infection occurrence. Data collection encapsulated demographic and clinical parameters, including American Society of Anesthesiologists (ASA) classifications, and operative factors. SSIs were diagnosed via an integrated approach combining clinical symptoms, microbiological culture findings and pertinent laboratory tests. A rigorous statistical methodology employing IBM's SPSS version 27.0 was utilised for data analysis. In a univariate analysis, significant risk factors for post-craniotomy SSIs were identified, with patients aged over 60 displaying a pronounced susceptibility. Moreover, surgeries exceeding a duration of 4 h heightened infection risks. Elevated ASA grades denoted an increased prevalence of SSIs, as did emergency procedures and higher National Nosocomial Infections Surveillance scores. Multivariate analysis pinpointed epidural/subdural drainage as a protective measure against SSIs, whereas emergency surgeries, operative times beyond 4 h and subsequent surgeries within the hospital stay amplified infection risks. Notably, coagulase-negative Staphylococcus dominated the identified pathogens at 28.09%, followed by Escherichia coli (17.98%), Klebsiella pneumoniae (10.11%) and Staphylococcus aureus (11.24%), underscoring the need for diverse prophylactic measures. SSIs following craniotomies present a multifaceted challenge influenced by a confluence of patient-related, operative and post-operative determinants. Understanding these risk factors is paramount in refining surgical protocols and post-operative care strategies to mitigate SSI incidence.

COMPARATIVE CLINICAL EVALUATION OF CAUDAL BUPIVACAINE VERSUS BUPIVACAINE PLUS TRAMADOL FOR PEDIATRIC INFRAUMBILICAL SURGERIES: A STUDY ON POSTOPERATIVE ANALGESIA

Objective: Effective post-operative pain management is crucial in pediatric patients undergoing infraumbilical surgeries. Various regional anesthesia techniques, including caudal block, have been used to provide post-operative analgesia in children. The addition of tramadol, a synthetic opioid analgesic, to bupivacaine in caudal anesthesia has shown potential benefits. This study aims to compare the clinical efficacy of single-shot caudal bupivacaine alone versus bupivacaine plus tramadol for post-operative analgesia in pediatric infra-umbilical surgeries. Methods: A prospective, randomized, double-blinded clinical study was conducted at our institute. The present study will be carried out in 60 pediatric patients of the American Society of Anesthesiologists Grades I and II between the age of 1 and 8 years, undergoing infraumbilical surgeries. These children were randomly divided into 2 groups. Group B (n=30) received caudal block with 0.25% bupivacaine (1 mL/kg) and Group BT (n=30) received caudal block with 0.25% bupivacaine (1 mL/kg) with tramadol (1 mg/kg). The variables studied were hemodynamic changes, duration of analgesia, and incidence of side effects. Pain assessment was done at 1, 2, 3, 4, 8, 12, and 24 h post-operatively using modified objective pain scale. Results: It was observed that the mean duration of analgesia in Group BT (9.05±2.21) h was significantly longer (p=0.0001) than Group B (3.78±0.94) h. Hemodynamic parameters remained comparable during intraoperative and post-operative periods. There was no incidence of nausea, vomiting, bradycardia, hypotension, pruritus, or decrease in respiratory rate in the two groups. Conclusion: In our study, we concluded that a single-shot caudal block with 0.25% bupivacaine (1 mL/kg) plus tramadol (1 mg/kg) resulted in longer duration of analgesia when compared to 0.25% bupivacaine (1 mL/kg) alone with no incidence of any side effects.

Lumbar Decompression Using the Far-Lateral Approach: Patient-Reported Outcome is Associated With the Involved Vertebral Level and Coronal Segmental Angle.

A single-centre retrospective study of prospectively collected data. Analyse factors associated with the patient-reported outcome after far lateral decompression surgery (FLDS) for lumbar nerve root compression using the far-lateral approach. To date, no studies have investigated the influence of vertebral level, coronal segmental Cobb angle, and the nature of the compressive tissue (hard or soft) on the patient-reported outcome following FLDS. Patients who had undergone FLDS between 2005 and 2020 were included. Coronal segmental angle (CSCA) was measured on preoperative, posteroanterior radiographs. The primary outcome measure was the core outcome measures index (COMI) score at two years' follow-up (2Y-FU). Patients who had undergone microsurgical decompression using a midline approach served as a comparator group. There were 148 FLDS and 463 midline approach patients. In both groups, there was a significant improvement in the COMI score from preoperative to 2Y-FU ( P <0.0001), with greater improvement in patients treated at higher vertebral levels than in those treated at L5/S1 ( P =0.014). Baseline COMI, American Society of Anesthesiologists grade, body mass index, and low back pain as the "chief complaint" all had a significant association with the two-year COMI score. The nature of compressive tissue showed no association with the COMI score at 2Y-FU. In the FLDS group, there was a statistically significant correlation between the preoperative CSCA and the change in COMI score preoperatively to 2Y-FU ( P <0.001). The association was retained in the multiple regression analysis, controlling for confounders. A one-degree increase in CSCA was associated with a 0.35-point worse COMI score at 2Y-FU ( P =0.003). Treatment of far lateral nerve root compression showed an overall good patient-reported outcome, but with less improvement with advanced CSCA. Modified approaches and techniques might be preferable for levels L5/S1.

Rhomboid intercostal subserratus plane block – the Holy Grail of post-operative analgesia in modified radical mastectomy or just another dot in the long list?

Despite the presence of numerous options for breast analgesia, our women continue to suffer the consequences of acute post-operative pain that progresses to chronic pain in up to 55% of the post-mastectomy patients a rapid surge in the use of interfacial blocks for analgesia of chest and abdominal procedures. The importance and efficacy of these blocks are because of the continuity of the interfacial planes across varied anatomical tissues. We report a series of cases of modified radical mastectomy (MRM) in five female patients with the American Society of Anesthesiology Grade II/III in whom rhomboid intercostal subserratus was used for post-operative analgesia proved to be a boon. Two were post-radiation with metastasis to axillary lymph nodes. The other three had invasive ductal carcinoma and were on chemotherapy. Rhomboid intercostal subserratus plain block is a novel block and provides pain management for patients of MRM. The analgesic efficacy may not be superior but the non-inferiority to an epidural is certainly an added advantage with safe efficacious profile fulfilling the enhanced recovery after surgery protocols following minimally invasive surgical techniques.

Comparison of outcomes between fungal and non-fungal periprosthetic joint infections in total knee arthroplasty.

Fungal periprosthetic joint infections (PJIs) are rare, but their diagnosis and treatment are highly challenging. The purpose of this study was to investigate the clinical outcomes of patients with fungal PJIs treated with two-stage exchange knee arthroplasty combined with prolonged antifungal therapy. We reviewed our institutional joint arthroplasty database and identified 41 patients diagnosed with fungal PJIs and treated with two-stage exchange arthroplasty after primary total knee arthroplasty (TKA) between January 2001 and December 2020, and compared them with those who had non-fungal PJIs during the same period. After propensity score matching based on age, sex, BMI, American Society of Anesthesiologists grade, and Charlson Comorbidity Index, 40 patients in each group were successfully matched. The surgical and antimicrobial treatment, patient demographic and clinical characteristics, recurrent infections, survival rates, and relevant risk factors that affected joint survivorship were analyzed. We defined treatment success as a well-functioning arthroplasty without any signs of a PJI, and without antimicrobial suppression, at a minimum follow-up of two years from the time of reimplantation. The fungal PJI group demonstrated a significantly worse treatment success rate at the final follow-up than the non-fungal PJI group (65.0% (26/40) vs 85.0% (34/40); p < 0.001). The mean prosthesis-free interval was longer in the fungal PJI group than in the non-fungal PJI group (6.7 weeks (SD 5.8) vs 4.1 weeks (SD 2.5); p = 0.020). The rate of survivorship free from reinfection was worse in the fungal PJI group (83.4% (95% confidence interval (CI) 64.1 to 92.9) at one year and 76.4% (95% CI 52.4 to 89.4) at two years) than in the non-fungal PJI group (97.4% (95% CI 82.7 to 99.6) at one year and 90.3% (95% CI 72.2 to 96.9) at two years), but the differences were not significant (p = 0.270). Cox proportional hazard regression analysis identified the duration of the prosthesis-free interval as a potential risk factor for failure (hazard ratio 1.128 (95% CI 1.003 to 1.268); p = 0.043). Fungal PJIs had a lower treatment success rate than non-fungal PJIs despite two-stage revision arthroplasty and appropriate antifungal treatment. Our findings highlight the need for further developments in treating fungal PJIs.

The incidence and risk factors for abnormal postoperative blood tests following primary total joint replacement.

We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na+), potassium (K+), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported. The study included 2,721 patients with a mean age of 69 years, of whom 1,266 (46.6%) were male. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥ 65 years), female sex, and ASA grade ≥ III as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dl) and packed cell volume (≤ 0.395 l/l) were noted to be significant risk factors for postoperative anaemia, and potassium (≤ 3.7 mmol/l) was noted to be a significant risk factor for AKI. The costs outweigh the benefits of ordering routine postoperative blood tests in TJR patients. Clinicians should risk-stratify their patients and have a lower threshold for ordering blood tests in patients with abnormal preoperative haemoglobin (≤ 127 g/l), blood loss > 300 ml, chronic kidney disease, ASA grade ≥ III, and clinical concern.

Longer Screws Decrease the Risk of Radiographic Pseudarthrosis Following Elective Anterior Cervical Discectomy and Fusion.

Retrospective cohort study. In patients undergoing elective anterior cervical discectomy and fusion (ACDF), we sought to determine the impact of screw length on: (1) radiographic pseudarthrosis, (2) pseudarthrosis requiring reoperation, and (3) patient-reported outcome measures (PROMs). A single-institution, retrospective cohort study was undertaken from 2010-21. The primary independent variables were: screw length (mm), screw length divided by the anterior-posterior vertebral body diameter (VB%), and the presence of any screw with VB% < 75% vs all screws with VB% ≥ 75%. Multivariable logistic regression controlled for age, BMI, gender, smoking, American Society of Anesthesiology grade, number of levels fused, and whether a corpectomy was performed. Of 406 patients undergoing ACDF, levels fused were: 1-level (39.4%), 2-level (42.9%), 3-level (16.7%), and 4-level (1.0%). Mean screw length was 14.3 ± 2.3mm, and mean VB% was 74.4 ± 11.2. A total of 293 (72.1%) had at least one screw with VB% < 75%, 113 (27.8%) had all screws with VB% ≥ 75%, and 141 (34.7%) patients had radiographic pseudarthrosis at 1-year. Patients who had any screw with VB% < 75% had a higher rate of radiographic pseudarthrosis compared to those had all screws with VB% ≥ 75% (39.6% vs 22.1%, P < .001). Multivariable logistic regression revealed that a higher VB% (OR = .97, 95%CI = .95-.99, P = .035) and having all screws with VB% ≥ 75% (OR = .51, 95%CI = .27-.95, P = .037) significantly decreased the odds of pseudarthrosis at 1-year, with no difference in reoperation or PROMs (all P > .05). Longer screws taking up ≥75% of the vertebral body protected against radiographic pseudarthrosis at 1-year. Maximizing screw length in ACDF is an easily modifiable factor directly under the surgeon's control that may mitigate the risk of pseudarthrosis.

Simultaneous single-stage urgent cardiac surgery and endovascular carotid revascularization under open-chest cardiopulmonary bypass in extremely high-risk, unstable patients

Abstract Background Patients with symptomatic/severe carotid disease (recent carotid related TIA/stroke and/or high-risk plaque) and unstable, surgery-requiring cardiac disease (multivessel coronary artery disease-CAD and/or severe valvular heart disease-VHD) constitute a major decision-making and logistics challenge. Intervention limited to cardiac-only or carotid-only pathology may significantly increase the risk of serious/fatal complications arising primarily from "the other" (untreated) condition. Purpose To assess safety and feasibility of simultaneous, neuroprotected carotid artery stenting (CAS) under open-chest extracorporeal circulation (ECC) standby combined with urgent cardiac surgery in extreme risk patients with non-ST elevation myocardial infarction –(NSTEMI)/unstable angina (UA) and/or severe VHD (NYHA III) coexisting with symptomatic (recent stroke/TIA) carotid stenosis or high-risk lesion. Methods CAS and cardiac surgery were performed (multidisciplinary neurovascular team decision) in a hybrid room, during same anaesthetic setting (absence of delay). After chest opening and ECC stand-by connection, neuroprotected CAS was performed using transfemoral or direct carotid route with an immediate switch to ECC as required. Cardiac surgery followed immediately. Patients were on acetylsalicylic acid pre-procedurally. CAS heparinization was ACT-guided and was followed by ECC large-dose heparinization (protamine reversal). Clopidogrel (300 mg) was given within 12h, if surgical drainage was decreasing. Analysis was intention to treat (ITT). Results Over 60 months, 44 patients (age 71.2y, 81.8% male) meeting inclusion criteria were enrolled (ITT group), all in American Society of Anesthesiologists grade IV. Of those, 43 underwent treatment (1 death in transportation), 35 (79.5%) were treated per-protocol. Of the remaining 8 patients 5 with severe pulmonary disease/severe obesity/severely impaired ejection fraction/seriously impaired mobility were not cleared for surgery by anaesthesia ("too-sick for surgery"), in 3 cases hybrid room was not immediately available. 100% CAS were neuroprotected and all involved plaque sequestration with micronet-covered stent. CAS procedures (n=42, one lesion severity not confirmed) were 100% technically successful. Iv. inotropics were administered routinely, need for immediate switch to ECC occurred in 4 patients. The valve procedures in this study were due to severe aortic stenosis. For further details see Table. Patients "too-sick for surgery" (11.4%) underwent total endovascular treatment. On 30-day Carotid Doppler-Duplex ultrasound no in-stent restenosis/thrombosis occurred. Conclusions This study shows that truly simultaneous CAS+cardiac surgery in extremely high-risk, heamodynamically unstable patients is feasible and safe. Stent patency at 30 days and low 30-day death/MI/stroke rate (5.7% as per protocol) suggest efficacy of this novel strategy.

Correlation of Venous Blood Sugar Measured by Lab Method and Capillary Blood Sugar Measured by Glucometer in Neurosurgical Patients Receiving Dexamethasone

Abstract Background Brain is vulnerable to extreme blood glucose levels that may occur due to multiple factors in neurosurgical patients; perioperative use of dexamethasone is the most common. Thus, frequent monitoring of blood sugar levels is advocated. This study aimed to assess correlation between venous blood sugar measured by lab method and capillary blood sugar by glucometer at various time intervals. Materials and Methods This prospective and observational study was conducted in 20 adult patients of either sex, American Society of Anesthesiologists grade I to III, scheduled to undergo brain tumor resection. The patients who were already on dexamethasone and received intraoperatively 8 mg dexamethasone were enrolled. Standard anesthesia technique and intraoperative monitoring were followed in all patients. Venous sample was withdrawn and blood sugar analyzed in laboratory, while at the same time capillary blood sugar was tested by glucometer. The sampling was done at baseline, 1 hourly after dexamethasone administration till 4 hours and then 8, 12, and 24 hours. The correlation between the two values was assessed. Results During the study, 160 venous and 160 capillary blood sugar levels were analyzed. Though capillary blood sugar levels were slightly higher than venous sugar levels, there was strong correlation between the two (Pearson correlation coefficient) with p-value less than 0.05 except at 24 hours when two values were not correlated. Conclusion Capillary blood sugar levels by glucometer have good correlation with venous sugar levels; therefore, this method may be adopted routinely for frequent blood sugar estimation as it is reliable, easy, and practical.

Effect of pre-treatment on induction of anaesthesia with etomidate: A comparison between dexmedetomidine and midazolam–fentanyl combination

Background: Because of its prompt onset of action and clearance, the use of etomidate as an anaesthetic induction agent is increasing in clinical practice. However, etomidate-induced myoclonus (EIM) remains a prevalent issue. Such myoclonic activity can be prevented by the administration of drugs that inhibit subcortical neuronal activity. Aims: This study was designed to compare the effects of pre-treatment with dexmedetomidine and fentanyl–midazolam combination on EIM as well as on attenuation of pharyngolaryngeal reflex. Materials and Methods: One hundred adult patients with the American Society of Anesthesiologists Grades 1 or 2 posted for elective surgery were enrolled and were randomly divided into two groups of 50 patients each. Group D received dexmedetomidine (1 μg/kg) in over 10 min and Group F received midazolam (0.02 mg/kg) + fentanyl (2 μg/kg) intravenously. Haemodynamic variables, incidence and severity of myoclonus were recorded. Results: The incidence of EIM was lower in Group F (26%) when compared to Group D (40%), but the difference was not statistically significant (P = 0.28). Eighteen per cent of the subjects in Group F had Grade 1 myoclonus as compared to 32% of Group D, whereas 8% of the subjects in Group F had Grade 2 myoclonus as compared to 6% of Group D. None of the patients in Group F experienced myoclonus of Grade 3, whereas 2% of the subjects had Grade 3 myoclonus. Conclusion: Administration of a combination of fentanyl and midazolam, along with dexmedetomidine as a pre-treatment, has been found to be an effective strategy for mitigating the incidence of myoclonus.

Delayed discharge from post-anesthesia care unit: A 20-case retrospective series.

To summarize the characteristics of patients with delayed discharge from the post-anesthesia care unit and to analyze the factors and outcomes of delayed discharge. Twenty cases of delayed discharge from the PACU (PACU stay >2 hours after surgery) of the main operating room in Liaocheng People's Hospital, a class A tertiary comprehensive hospital, between January 1, 2021, and December 31, 2022, among 28,084 patients who were transferred to the PACU from the operating rooms after surgery, were retrospectively analyzed. The collected data included patient characteristics, American society of anesthesiologists grade, information related to surgery and anesthesia, and outcomes. The factors for delay were assigned to 1 of 6 groups: delayed recovery from anesthesia, surgical complications, cardiovascular instability, hypoxia, inadequate analgesia, and waiting for the operating room. The incidence of delayed discharge from PACU was 0.7‰. Among 20 patients, more than half of the patients were over 65 years of age, American society of anesthesiologists grade II~III, body mass index <30 kg/m2, and urological surgery (7, 35%), liver surgery (4, 20%), thoracic surgery (4, 20%) accounted for a relatively high proportion. Nineteen (95%) patients received general anesthesia with or without peripheral nerve block. The main factors included delayed recovery from anesthesia (6, 30%), surgical complications (5, 25%), cardiovascular complications (4, 20%), hypoxia (3,15%). After discharge from the PACU, 1 (5%) died in the intensive care unit, and the other 19 (95%) patients were safely discharged from the hospital. The incidence of delayed discharge from the PACU was low, and it was more likely to occur in the elderly, during major operations, and under general anesthesia. Delayed recovery from anesthesia was the most common factor. Most patients were safely discharged from the hospital.

A call for clarity: a scoping review of predictors of poor outcome after emergency abdominal surgery for inflammatory bowel disease.

The medical management of inflammatory bowel disease (IBD) is rapidly progressing; however, many patients with the disease still require surgery. Often this is done as an emergency. Initiatives such as the National Emergency Laparotomy Audit have shown how evidence-based emergency surgery improves outcomes for the patient. The aim of this scoping review is to describe the current evidence base on risk stratification in emergency abdominal surgery for IBD. A literature search, abstract and full paper screening resulted in 17 articles representing 63 472 patients from seven countries. It is likely that age, the American Society of Anesthesiologists grade, comorbidity and organ dysfunction play a similar role in risk stratification in IBD patients as in other emergency abdominal surgery cohorts. However, the reporting of what is considered an IBD emergency is variable. Six studies include clear definitions of emergency in our study. The range of what is considered an emergency is within 12 h of admission to any time within an unplanned admission. To have data driven, evidence-based emergency surgical practice in IBD we need consistency of reporting, including the definitions of emergency and urgency. Core descriptor sets in IBD would be valuable.

INCIDENCE AND PREDICTORS OF SURGICAL SITE INFECTION IN MAJOR ABDOMINAL SURGERIES AT A TERTIARY CARE CENTER IN DELHI

Objective: Surgical site infections (SSIs) are the third commonly stated nosocomial infections, with the prevalence rate of 14–16%. In India, the prevalence of SSIs in elective surgeries ranged from 3.83% to 39% and in cases of emergency surgeries, the prevalence ranged from 12.41% to 26.4%. This study was aimed to measure the occurrence of SSIs amid subjects experiencing major abdominal surgeries at tertiary care center in Delhi and to assess the predictors related to occurrence of SSIs in these subjects. Methods: In this cross-sectional study, data were collected over a period of 1 year at the Department of Surgery, Super Specialty Hospital in New Delhi. The, from January 2017 to January 2018. All major gastrointestinal surgeries were considered. Sociodemographic details, clinical history, and surgical details were taken. Results: Out of total 626 patients, 42 (6.7%) developed SSIs. The positive predictors of SSIs in our study were male gender, American Society of Anesthesiology grade of 2 and above, wound class of two and above, longer duration of surgery, emergency surgery, open surgery, laparoscopic converted to open surgery, presence of comorbidities, presence of hypoalbuminemia, and hypoproteinemia. Conclusion: SSIs seems to be a common source of perioperative morbidity and mortality, leading to increased hospital stay and cost of treatment. Proper planning and accordingly managing such case by case scenarios can lead to decreased incidence of SSIs and help reducing burden to the health system.

COMPARATIVE STUDY BETWEEN PROPOFOL AND THIOPENTONE SODIUM IN FACILITATION OF LARYNGEAL MASK AIRWAY INSERTION

Aims: The aim of the study is to compare the conditions to facilitate the insertion of the laryngeal mask airway (LMA) with the two most commonly used agents – thiopentone and propofol, after adequate pre-medication with midazolam and fentanyl. Methods: It is prospective randomized study conducted on 70 patients of either sex, belonging to 20–60 years of age, and American Society of Anesthesiologists grades I and II who were admitted to elective minor surgeries under general anesthesia. Patients were randomly divided into 2 groups. Patients in both the groups received pre-induction doses of glycopyrrolate (0.2 mg), midazolam (0.04 mg/kg), and fentanyl (2 mcg/kg) and were induced with either propofol (2 mg/kg) or thiopentone (5 mg/kg), to facilitate insertion of LMA. The parameters were studied and were conditions for insertion, time taken, hemodynamic changes during insertion of LMA, and immediately thereafter. Results: Conditions for insertion, ease of insertion was significantly greater in propofol group when compared to thiopentone group. The difference was statistically significant (p&lt;0.05). The heart rate, systolic blood pressure, and diastolic blood pressure were compared between the 2 groups. It was observed that there was a fall in all these parameters in both groups, but it was more pronounced in the propofol group. Although this was statistically extremely significant (p&lt;0.001), it was not clinically significant. Conclusion: It was concluded that, due to better ease of insertion, lesser time taken for insertion, and better recovery profiles observed with propofol, it seemed to be slightly superior to thiopentone as an induction agent for insertion of the LMA.

Mortality After Microsurgical Treatment of Unruptured Intracranial Aneurysms in the Modern Era

The incidence of mortality after treatment of unruptured intracranial aneurysms (UIAs) has been described historically. However, many advances in microsurgical treatment have since emerged, and most available data are outdated. We analyzed the incidence of mortality after microsurgical treatment of patients with UIAs treated in the past decade. The medical records of all patients with UIAs who underwent elective treatment at our large quaternary center from January 1, 2014, to December 31, 2020, were reviewed retrospectively. We analyzed mortality at discharge and 1-year follow-up as the primary outcome using univariate to multivariable progression with P < 0.20 inclusion. During the 7-year study period, 488 patients (mean [SD] age= 58 [12] years) had UIAs treated microsurgically. Of these patients, 61 (12.5%) had a prior subarachnoid hemorrhage. One patient (0.2%) with a dolichoectatic vertebrobasilar aneurysm died while hospitalized, and 7 other patients (8 total; 1.6%) were determined to have died at 1-year follow-up (1 trauma, 2 myocardial infarction, 2 cerebrovascular accident, 1 pulmonary embolism, and 1 subdural hematoma complicated by abscess). On univariate analysis, significant risk factors for mortality at follow-up included diabetes mellitus, preoperative anticoagulant or antiplatelet use, aneurysm calcification, nonsaccular aneurysm, and higher American Society of Anesthesiologists grades (all P < 0.03). On multivariable logistic regression analysis, only nonsaccular aneurysms and higher American Society of Anesthesiologists grades were predictors of mortality. A low mortality rate is associated with recent microsurgical treatment of UIAs. However, nonsaccular aneurysms and higher American Society of Anesthesiologists grades appear to be predictors of mortality.

Carotid Endarterectomy in the Very Elderly: Short-, Medium-, and Long-Term Outcomes.

: Carotid endarterectomy (CEA) has an established effect on stroke-free survival in patients with carotid artery stenosis. Most landmark trials excluded patients ≥80 years of age due to their perceived high risk and uncertainty regarding the benefits of CEA. Despite the ongoing global increase in life expectancy, guidelines have not changed. The current study aimed to assess CEA outcomes in patients ≥80 years of age. : Data from patients ≥80 years of age, who underwent CEA between April 2016 and April 2022, were collected. Demographic information, comorbidities, surgical details, operative details, outcomes, and post-CEA survival were reviewed, and long-term data up to April 2023 were collected. : Over the 6-year study period, 258 CEA procedures were recorded, of which 70 (27.1%) were performed in patients ≥80 years of age; the mean age was 84 years (range, 80-96 years), 47 (67.1%) were males, and 69 (98.6%) were symptomatic. Twenty-three (32.9%) patients were American Society of Anesthesiologists (ASA) grade 2, and 47 (67.1%) were grade 3. The 30-day stroke and mortality rates were 4.3% and 1.4%, respectively. At 1, 3, and 5 years, the cumulative freedom-from-stroke rates were 95.7%, 92.9%, and 91.4%, respectively, and the cumulative survival rates were 94.3%, 75.7%, and 61.4%, respectively. No risk factors affected early or late stroke or early mortality rates. Patients with ASA grade 3 had significantly lower cumulative survival than those with grade 2 (HR, 5.29; 95% CI, 1.590-17.603; P<0.01). : CEA was safe and effective in average-risk, elderly patients. Higher risk patients (i.e., ASA 3) showed no increased 30-day risk for stroke or mortality but exhibited significantly worse long-term survival. Hence, careful consideration of the benefits before performing CEA is crucial.

Incidence and risk factors of postoperative pulmonary complications after oral cancer surgery with free flap reconstruction: A single center study

Postoperative pulmonary complications (PPCs) increase the risk of morbidity and mortality in patients who underwent oral cancer surgery with free flap reconstruction. The association between PPC and preoperative risk factors has been investigated; however, reports on intraoperative factors are limited. Therefore, we investigated PPC incidence and its associated preoperative and intraoperative risk factors in these patients. We retrospectively analyzed medical records of patients who underwent free flap reconstruction between 2009 and 2019. PPC was defined as presence of atelectasis, pneumonia, and respiratory failure based on radiological confirmation and clinical symptoms during hospitalization. Mortality, hospital stay, preoperative factors (including age and tumor stages), American Society of Anesthesiologists (ASA) classification, and intraoperative factors (including intraoperative fluids and medications) were recorded. PPC incidence among the 993 patients included in this study was 25.8% (256 patients). Six patients with PPCs died; death was not observed among patients without PPCs (p<0.001). Patients with PPCs had longer hospitalization than those without PPCs (30.3 vs 23.3 days; p<0.001). Tumor stage (stage I: reference; stage II [OR]: 3.3, p=0.019; stage III: 4.4, p=0.002; stage IV: 4.8, p=0.002), age (OR: 1.0; p<0.001), and ASA grade >2 (OR: 1.4; p=0.020) were independent risk factors of PPC; using labetalol was a borderline significant factor (OR: 1.4; p=0.050). The PPC incidence was 25.8% in patients undergoing oral cancer surgery with free flap reconstruction. Tumor stage, age, and ASA >2 were risk factors of developing PPC.

COVID-19 Infection Was Associated with the Functional Outcomes of Hip Fracture among Older Adults during the COVID-19 Pandemic Apex.

Background and Objectives: Hip fractures are associated with mortality and poor functional outcomes. The COVID-19 pandemic has affected patterns of care and health outcomes among fracture patients. This study aimed to determine the influence of COVID-19 infection on hip fracture recovery. Materials and Methods: We prospectively collected data on patients with hip fractures who presented at Hualien Tzu Chi Hospital between 9 March 2022 and 9 September 2022. The data included demographic information and functional scores taken before, during, and after surgery. The patients were divided into two groups: COVID-19 (+) and COVID-19 (-). Results: This study recruited 85 patients, 12 of whom (14.12%) were COVID-19 (+). No significant differences in preoperative or perioperative parameters between the two groups were observed. The postoperative Barthel index score was significantly impacted by COVID-19 infection (p = 0.001). The incidence of postoperative complications was significantly correlated with general anesthesia (p = 0.026) and the length of stay (p = 0.004) in hospital. Poor postoperative functional scores were associated with lower preoperative Barthel index scores (p < 0.001). Male sex (p = 0.049), old age (p = 0.012), a high American Society of Anesthesiologists grade (p = 0.029), and a high Charlson comorbidity index score (p = 0.028) were associated with mortality. Conclusions: Hip fracture surgeries were not unduly delayed in our hospital during the COVID-19 pandemic, but the patients' postoperative Barthel index scores were significantly influenced by COVID-19 (+). The preoperative Barthel index score may be a good predictive tool for the postoperative functional recovery of these patients.

A PROSPECTIVE RANDOMIZED INTERVENTIONAL STUDY TO DETERMINE THE INFLUENCE OF SPINAL FLEXION VERSUS EXTENSION IN THE LATERAL DECUBITUS POSITION ON THE UNILATERALITY OF SPINAL ANESTHESIA USING HYPERBARIC BUPIVACAINE FOR ELECTIVE UNILATERAL LOWER LIMB SURGERIES

Objective: A restricted sympathetic block during spinal anesthesia may minimize hemodynamic changes and advantageous in view of maintaining stable cardiovascular profile through intraoperative period. Methods: This prospective randomized interventional study was conducted on a total of 150 patients of either sex aged 20-50 years of American Society of Anesthesiologists grades 1 and 2 were randomly allocated in two groups (75 in each group).Using a 25-gauge Quincke spinal needle, 7.5 mg of 0.5% hyperbaric bupivacaine was injected over a period of 80s at L3-L4 interspace in both groups. Patients were kept in flexion or extension according to belonging groups: Group A (flexion) or Group B (extension) after drug administration for15 min of lateral decubitus position, then patients were turned to supine position. Results: Strict unilateral sensory and motor block at 15 min was noted in Group A 45 patients (60%) and 25 patients (33.33%) in Group B (p=0.002*). At 60 min, there was no significant sensory unilaterality between the groups (p=0.987). At 60 min, 30 patients (40%) in Group A and 14 patients (18.66%) in Group B had strict unilateral motor block (p=0.007*). Highest achieved sensory level on nondependent side was T10 in Group A and T8 in Group B, whereas it was T6 in Group A and T5 in Group B on dependent side. Conclusion: For unilateral spinal anesthesia, spinal flexion position provided better strict unilaterality and restricted sympathetic blockade than spinal extension position.