Anesthesia In Conjunction Research Articles

Erector spinae plane block for minimally invasive thoracic surgery: a local audit and quality improvement project

Significant postoperative pain is common after minimally invasive thoracic surgery (MITS). This can be mitigated with regional anaesthesia in conjunction with systemic multimodal analgesia. The erector spinae plane block (ESPB), a recently established interfascial block, has demonstrated effective postoperative analgesia after thoracic surgery,1 with fewer risks compared with paravertebral block (PVB). The introduction of ESP catheters for continuous infusion or intermittent bolus administration of local anaesthetic can provide further analgesia in the postoperative period,2 however, sufficient data are lacking.

Parametrial evaluation in cervical cancer by magnetic resonance imaging and clinical examination: Analysis of data from the prospective Leipzig School MMR study.

5525 Parametrial evaluation in cervical cancer by magnetic resonance imaging and clinical examination Background: In cervical cancer patients, assessment of parametrial tumor extension is important for staging and treatment planning. The 2019 cervical cancer guideline published by the Féderation Internationale de Gynécologie et d’Obstétrique (FIGO) for the first time includes recommendations for usage of magnetic resonance imaging (MRI) in this setting. However, valid data regarding the accuracy of this method, especially in patients with advanced disease, are sparce. The objective of this investigation was to compare the accuracy of parametrial assessment in cervical cancer patients using MRI and clinical examination under general anesthesia. Methods: A retrospective cohort study based on data from the prospective monocentric observational Leipzig School Mesometrial Resection study was conducted. Cervical cancer patients staged FIGO IB1 to FIGO IVA who underwent primary surgery between 1999 and 2017 were included. Data from pathological specimen of these patients was compared to the MRI findings and the results from clinical examination under general anesthesia. The gynecological oncologist had access to the MR images during clinical assessment. We calculated sensitivities, specificities, and predictive values for both examination methods. We performed logistic regression modelling to determine factors influencing the accuracy of either method. Results: 400 women were included. Pathologically proven parametrial tumor invasion was present in 165 (41%) patients. Examination under anesthesia augmented by intraoperative display of MR images exhibited a higher accuracy (83%) as compared to MRI alone (76%; McNemar’s odds ratio = 2.0, 95%CI 1.25 – 3.27, p = 0.003). While accuracy was not affected by tumor size in clinical examination, MRI was associated with a significant drop in accuracy in tumors ≥ 2.5 cm (univariable logistic regression, OR for a correct diagnosis compared to smaller tumors 0.22, p < 0.001). This association remained significant in a multivariable model. There was also a significant decrease in specificity when evaluating parametrial invasion by MRI in tumors ≥ 2.5 cm in diameter (p < 0.0001). Body mass index had no influence on performance of either method. Accuracy was significantly higher when test results were concordant (OR 7.5 and 6.0 on univariable and multivariable regression modelling, respectively, p < 0.0001 in both cases). Conclusions: Clinical evaluation of the parametrium by pelvic examination under anesthesia in conjunction with intraoperative presentation of MR images leads to more accurate staging in cervical cancer patients as compared to magnetic resonance imaging alone. Clinical examination should therefore remain an integral part of parametrial assessment in cervical cancer patients.

Comparative Study between General Anesthesia versus General Anesthesia Combined with Thoracic Epidural Analgesia on Cytokine Response in Laparoscopic Cholecystectomy Patients

Background and Objectives: The main benefits of laparoscopic surgery in comparison to open surgery involve the rapid discharge from recovery room, decreased postoperative hospital stays, reduced postoperative discomfort, easier getting back to work and faster return to ordinary daily life as well as cosmetic surgical wounds. The anesthesia type has an essential role in attenuation of the surgical stress and achievement of these advantages. We aimed to determine the outcome of giving general anesthesia in conjunction with thoracic epidural analgesia (TEA) compared to general anesthesia alone on stress response to surgery and anesthesia by investigating cytokine reaction (interleukin 6 and 8 levels), hemodynamic changes (BP, HR, RR, SPO2), and Visual Analogue Scale (VAS) scores postoperatively in patients subjected for laparoscopic cholecystectomy. Methods: This study included 40 patients aged 20 - 60 years old with American Society of Anesthesiologists physical status (ASA) I and II. They were planned for laparoscopic cholecystectomy at Aswan University Hospital from April 2017 to March 2018. They were randomly allocated into two groups. Group A (n. 20) received general anesthesia only and Group B (n. 20) received general anesthesia in conjunction with thoracic epidural analgesia using fentanyl and bupivacaine in the epidural catheter. Chi-square was applied to differentiate categorical variables, whereas comparison between continuous variables was done by using t-test. Two-tailed p ficant. Results: As regards IL-6 and IL-8 post-operative there is significant difference (p nd and 4th hr and 24th hr postoperative, with significantly increased postoperative levels of IL-6 and IL-8 in comparison to their preoperative baseline values. The largest increase in IL6 & IL8 levels was in group A (GA group). VAS score showed significant lower values in TEA group in comparison to GA group. No significant difference between groups as regard intraoperative and postoperative hemodynamic changes. Conclusion: Regional techniques including TEA attenuate and decrease cytokine reaction secondary to surgery which decreases inflammatory process and improves patient outcome and reduces pain score postoperatively.

Advantages of the Combination of Conscious Sedation Epidural Anesthesia Under Fluoroscopy Guidance in Lumbar Spine Surgery.

BackgroundWith the increase in life expectancy seen throughout the world, the prevalence of degenerative spinal pathology and surgery to treat it has increased. Spinal surgery under general anesthesia leads to various problems and complications, especially in patients with numerous medical comorbidities or elderly patients. For this reason, there is a need for safer anesthetic methods applicable to unhealthy, elderly patients undergoing spinal surgery.PurposeTo report our experience with utilizing fluoroscopy-guided epidural anesthesia in conjunction with conscious sedation in spinal surgery.Patients and MethodsWe performed a retrospective review of 111 patients at our institution that received fluoroscopy-guided epidural anesthesia for lumbar surgery from February to September 2018. Patients’ records were evaluated to evaluate patient demographics, American Society of Anesthesiology Physical Classification System (ASA) class, and pain numerical rating scores (NRS) preoperatively and throughout their recovery postoperatively. Intraoperative data including volume of epidural anesthetic used, extent of epidural spread, and inadvertent subdural injection was collected. Postoperative recovery time was also collected.ResultsThe mean age of our patients was 60 years old with a range between 31 and 83 years old. All patients experienced decreases in postoperative pain with no significant differences based on age or ASA class. There was no association between ASA class and time to recovery postoperatively. Older patients (age 70 years or greater) had a significantly longer recovery time when compared to younger patients. Recovery also was longer for patients who received higher volumes of epidural anesthesia. For every 1 mL increase of epidural anesthetic given, there was an increase in the extent of spread of 1.8 spinal levels.ConclusionWe demonstrate the safety and feasibility of utilizing conscious sedation in conjunction with fluoroscopy-guided epidural anesthesia in the lumbar spinal surgery.

Liposomal bupivacaine reduces opiate consumption after rotator cuff repair in a randomized controlled trial

Arthroscopic rotator cuff repair (ARCR) provides excellent clinical outcomes but is often associated with significant postoperative pain. The use of intraoperative anesthesia in conjunction with multimodal pharmacologicstrategies is a widely accepted approach for managing surgical pain and reducing opiate use. The purpose of this study was to determine whether using a combined field and suprascapular nerve block with liposomal bupivacaine (LB) in addition to an interscalene blockwould provide greater pain relief and a reduction in opiate consumption compared with an interscalene block alone. The study enrolled 50 patients with full-thickness rotator cuff tears undergoing primary ARCR surgery. Patients were randomized to receive intraoperative LB (n = 25) or not (n = 25) and given postoperative "pain journals" to document visual analog scale pain scores and to track their daily opioid consumption during the first 5 postoperative days. Patients in the LB group reported statistically and clinically lower pain scores during postoperative days 1 and 2 (P < .0001 and P = .03, respectively). In addition, patients in the LB group consumed significantly fewer narcotics than the control group during the 5-day period, demonstrating a 64% reduction in total narcotic consumption (P = .002). The findings of this study suggest that the addition of LB to multimodal anesthetic protocols significantly reduces the acute perioperative pain experienced following rotator cuff repair and the number of narcotic pills consumed in the first 5 days after ARCR. Furthermore, the findings provide guidelines for postoperative narcotic prescribing to reduce the quantity of opiates prescribed.

Exponential Decay Metrics of Topical Tetracaine Hydrochloride Administration Describe Corneal Anesthesia Properties Mechanistically

To identify pharmacodynamic (PD) and pharmacokinetic (PK) metrics that aid in mechanistic understanding of dosage considerations for prolonged corneal anesthesia. A rabbit model using 0.5% tetracaine hydrochloride was used to induce corneal anesthesia in conjunction with Cochet-Bonnet anesthesiometry. Metrics were derived describing PD-PK parameters of the time-dependent domain of recovery in corneal sensitivity. Curve fitting used a 1-phase exponential dissociation paradigm assuming a 1-compartment PK model. Derivation of metrics including half-life and mean ligand residence time, tau (τ), was predicted by nonlinear regression. Bioavailability was determined by area under the curve of the dose-response relationship with varying drop volumes. Maximal corneal anesthesia maintained a plateau with a recovery inflection at the approximate time of predicted corneal drug half-life. PDs of recovery of corneal anesthesia were consistent with a first-order drug elimination rate. The mean ligand residence time (tau, τ) was 41.7 minutes, and half-life was 28.89 minutes. The mean estimated corneal elimination rate constant (ke) was 0.02402 minute. Duration of corneal anesthesia ranged from 55 to 58 minutes. There was no difference in time domain PD area under the curve between drop volumes. Use of a small drop volume of a topical anesthetic (as low as 11 μL) is bioequivalent to conventional drop size and seems to optimize dosing regiments with a little effect on ke. Prolongation of corneal anesthesia may therefore be best achieved with administration of small drop volumes at time intervals corresponding to the half-life of drug decay from the corneal compartment.

Perioperative anaesthetic management of pediatric hepatoblastoma for hepatic resection

16 month old child was brought to the hospital with loose motions, vomiting and a history of failure to gain weight. Examination revealed hepatomegaly. Investigations revealed a space occupying lesion in the right lobe of the liver. She was diagnosed as a case of hepatoblastoma and was given 7 cycles of chemotherapy following which she was taken up for Right hepatectomy. Hepatic malignancies being rare in this age group and the surgery planned being extensive, the anaesthetic management was challenging. The child was taken up as a high risk case and successfully managed with the use of balanced anaesthesia in conjunction with epidural analgesia and invasive pressure monitoring.

Comment on “Accentuation of Tumor Growth Secondary to Morphine Administration: The Proneoplastic Role of Morphine besides Its Role in Pain Management”

I read with great interest the recent article by Luk et al. in a recent issue of your esteemed journal [1]. The article is highly thought provoking. Interestingly, the past few years have clearly revealed the connection between morphine administration and tumor development and progression. For instance, morphine acts on the μ-opioid receptors and increases intracellular cyclin D1 and activates G protein receptors resulting in accentuation of the mitogen-activated protein kinase (MAPK) pathway and thereby enhances angiogenesis in breast tumor cells [2]. In fact Farooqui et al. have recently demonstrated that morphine administration in breast tumor animal models activates prostaglandin E2 thereby enhancing tumor metastasis also. Similar effects are noted in prostate cancer tissue [3]. For instance, patients who undergo radical prostatectomy for prostate carcinoma and who receive opioid treatment in conjunction with general anesthesia have a 57% higher risk of tumor recurrence in comparison to patients who receive general anesthesia in conjunction with epidural anesthesia [4]. Similarly, Mathew et al. have shown that morphine administration enhances tumor growth in lung cancer models [5]. Interestingly, methylnaltrexone inhibits activation of RhoA by inhibiting transactivation of VEGF receptors [6]. As a result it attenuates morphine-induced angiogenesis and thus inhibits tumor growth. PD98059 is another new agent that inhibits the MAPK pathway and thereby decreases opioid-induced tumor cell proliferation [7]. Similarly, celecoxib attenuates opioid-induced stimulation of cyclooxygenase-2 receptors and thereby exerts antineoplastic effects [3]. These examples clearly illustrate the role of morphine in enhancing tumor angiogenesis and growth. Clearly, there is a further need to identify further such opioid receptor antagonists besides methylnaltrexone that can inhibit morphine-mediated carcinogenesis.

The effect on outcome of peribulbar anaesthesia in conjunction with general anesthesia for vitreoretinal surgery

The purpose of this study was to evaluate peri-operative outcome after vitreoretinal surgery when peribulbar anaesthesia is combined with general anaesthesia. Sixty adult patients undergoing elective primary retinal detachment surgery with scleral buckling or an encircling procedure received either peribulbar anaesthesia in conjunction with general anaesthesia or general anaesthesia alone. For peribulbar anaesthesia a single percutaneous injection of 5-7 ml of local anaesthetic solution (0.75% ropivacaine with hyaluronidase 15 iu.ml(-1)) was used. The incidence of intra-operative oculocardiac reflex and surgical bleeding interfering with the surgical field, postoperative pain and analgesia requirements, and postoperative nausea and vomiting were recorded. In the block group there was a lower incidence of oculocardiac reflex and surgical bleeding intra-operatively. Patients in the block group also had better postoperative analgesia and a lower incidence of postoperative nausea and vomiting compared with the group without a block. The use of peribulbar anaesthesia in conjunction with general anesthesia was superior to general anaesthesia alone for vitreoretinal surgery with scleral buckling.

Arthrofibrosis of the Knee

Better understanding of surgical timing, improved surgical technique, and advanced rehabilitation protocols has led to decreased incidence of motion loss after anterior cruciate ligament injury and reconstruction. However, motion loss from high-energy, multiligament injuries continues to compromise functional outcome. Prevention, consisting of control of inflammation and early motion, remains the key element in avoiding motion loss. However, certain techniques, such as manipulation under anesthesia in conjunction with arthroscopic lysis of adhesions, are reliable treatment options. Open surgical débridement is rarely necessary and should be considered only as a salvage procedure. A greater understanding of the pathogenesis of arthrofibrosis and related inflammatory mediators may result in novel therapies for treating the patient with motion loss.

Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita, using continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation

The ex utero intrapartum treatment procedure allows for the controlled management of a potentially life-threatening difficult airway in the newborn. General anesthesia has previously been reported for the management of this procedure. We report the use of continuous spinal anesthesia in conjunction with intravenous nitroglycerin for the ex utero intrapartum treatment procedure in a woman with arthrogryposis multiplex congenita, a rare syndrome characterized by rigid joints and limb contractures.

Memory priming during light anaesthesia with desflurane and remifentanil anaesthesia

Previous studies of memory priming during anaesthesia with EEG monitoring have observed implicit memory effects for words presented during light and deep anaesthesia with and without surgical stimulation. We hypothesized that memory priming occurs under each of five different combinations of anaesthesia and surgery, and no significant differences occur in memory priming among the five conditions or between the two test points such as, 12 vs 24 h after surgery. Forty gynaecological patients (aged between 28 and 66 yr, median 44.5 yr) were included in the study. They received propofol and remifentanil induction followed by desflurane and remifentanil anaesthesia in conjunction with neuromuscular blocking agents. Each patient was exposed to 60 of 120 nouns in a double-blind randomized design. These 60 nouns were divided into 5 groups of 12 words, presented under one of the five different conditions, namely, intubation, skin incision, deep anaesthesia and moderate anaesthesia (both during surgery), and light anaesthesia during the emergence phase. The depth of anaesthesia was measured using the EEG monitor, Narcotrend. No explicit memories were observed in a free recall or in a yes-no recognition test. A word-stem completion test revealed a significant implicit priming only for light anaesthesia (P < 0.01). No significant differences were detected among the five conditions. An overall implicit memory effect occurred for the second test point (P < 0.05). Our hypotheses could not be verified. Implicit memory priming occurred only under light anaesthesia, when the patients were most probably conscious. Priming effects may be enhanced after night's sleep.

Ultrarapid opiate detoxification: a review.

This review on ultrarapid detoxification examines the pharmacology, techniques, and efficacy of this potentially promising technique and contrasts it with conventional treatment modalities. The information found here is derived from experiences at the Texas Tech University, government reports, and peer reviewed journals. Incidence and prevalence of heroin use is on the rise. Social and treatment costs suggest that this problem is staggering. Approximately 400,000 patients are enrolled in or are actively seeking methadone therapy. While many of these individuals want to undergo detoxification, traditional techniques, including methadone tapering are usually unsuccessful. The withdrawal syndrome is extremely unpleasant, may be fatal, and deters patients from completing the detoxification process. Ultrarapid detoxification entails general anesthesia in conjunction with large boluses of narcotic antagonists. This combination allows the individual to completely withdraw from the opiate without suffering the discomfort of the withdrawal syndrome. Unless performed properly, this procedure can be dangerous due to the sympathetic outflow. However, with proper support, this danger can be mitigated. Ultrarapid opiate detoxification, performed under the proper circumstances, is associated with few adverse events and is relatively comfortable for patients who seek treatment for their addition.

A Hazard of an Anesthesia Delivery System in a Developing Country

A Hazard of an Anesthesia Delivery System in a Developing Country

Comparison of Two Needle Lengths in Regional Ophthalmic Anesthesia With Etidocaine and Hyaluronidase

The effect of needle length on the efficacy of regional ophthalmic anesthesia in conjunction with cataract surgery was studied in 97 patients using a two-site injection technique. The local anesthetic used was etidocaine 1.5% with hyaluronidase. In 48 patients, the anesthetic was administered inferolaterally with a 22-millimeter needle, and in the other 49 patients, with a 31-millimeter needle. Every patient had a medial injection with a 12-millimeter needle to achieve lid akinesia and to complete the globe akinesia. At 5 minutes, lid akinesia was considered better in the 22-millimeter needle group (P < .005). After one supplemental dose, when necessary, complete globe akinesia was achieved at 15 minutes significantly more often (94% vs 79%) in the 31-millimeter needle group (P < .05). Lid akinesia in the two groups was identical at that time. Eight patients in the short-needle group and three in the long-needle group experienced some pain during surgery. Throughout the study, the required intraorbital anesthetic volumes were smaller in the 31-millimeter needle group. We recommend the use of a 31-millimeter needle inferolaterally in combination with a 12-millimeter needle medially to achieve satisfactory regional anesthesia for cataract surgery.

Anesthetic management for the high-risk ophthalmic patient

A 69-year-old white female presented for corneal transplant, but her numerous medical problems placed her at unacceptably high risk for prolonged general anesthesia. Routine monitored anesthesia care measures would not have provided her or the surgeon the comfort and repose necessary, for a successful outcome. We describe anesthetic management for ophthalmic surgery, using epidural anesthesia in conjunction with retrobulbar block, in an elderly patient at high risk for general anesthesia whose intractable back and leg pain would have otherwise precluded her cooperation in maintaining a motionless operative field.

Comparative results of dominant temporal lobectomy under general or local anesthesia: Language outcome

For surgical candidates with intractable seizures of dominant temporal lobe origin, concerns are often raised regarding the potential effects of anterior temporal lobectomy (ATL) on language function. While a variety of surgical procedures exist, there are no data regarding their comparative effects on language ability. This report presents the results of a prospective controlled study, which assessed pre- and postoperative (6 months) language function in a consecutive series of 26 patients who underwent dominant hemisphere ATL. Thirteen consecutive patients received surgery under local anesthesia in conjunction with intraoperative cortical mapping of language function, and 13 subsequent consecutive patients underwent surgery under general anesthesia. A standardized battery assessed multiple aspects of language ability so that the comparative effects of language outcome could be determined. The results revealed that patients who underwent ATL under general anesthesia received significantly less lateral temporal lobe resection, exhibited more postoperative gains in various aspects of language function, were more likely to be rendered totally seizure-free, but showed a mild nontransient postoperative dysnomia. The clinical and theoretical implications of these findings are discussed.

A METHOD FOR PRODUCING CONSTANT PLASMA CONCENTRATIONS OF DRUGS: Application to Methohexitone

A delivery system in which a dilute infusion of methohexitone is continuously added to a smaller volume of more concentrated solution has been used to infuse exponentially decreasing drug concentrations at a constant rate of infusion. The constants for calculation of concentrations and infusion rate are described. It was possible to achieve and maintain the target plasma concentration required to produce anaesthesia in conjunction with nitrous oxide in oxygen. Methohexitone is the only available drug suitable for this technique, but it requires frequent opioid supplementation and is not the ideal drug for such a technique.

Intraocular Lens Surgery on a Resident's Service

Twenty-three patients had intraocular lens surgery performed by eight separate ophthalmology residents over an eighteen month period of time. Adequate technical results were achieved in 19 of the 23 cases. Three patients had visual complications directly related to the intraocular lens surgery: two with bullous keratopathy and one with cystoid macular edema. By restricting surgical indications to older patients with good vision in the fellow eye and using general anesthesia in conjunction with the operating microscope, osmotic agents, intracapsular surgery, and close operative supervision, it is hoped that results will justify continued use of intraocular lenses on our resident's service.

Mediastinoscopy vs exploratory thoracotomy: diagnosis, morbidity, mortality.

Mediastinoscopy was reviewed in a series of 36 patients suspected of having resectable carcinoma of the lung. Results of mediastinoscopy in nine cases were positive, thus eliminating the need for an exploratory thoracotomy. Of the 27 patients with negative results, six were found to have unresectable carcinoma due to mediastinal involvement beyond the reach of the mediastinoscope. The procedure is done with the patient under general anesthesia in conjunction with bronchoscopy. There was no morbidity and very little discomfort, enabling discharge from the hospital within 24 hours. In contrast, exploratory thoracotomy carried a morbidity including a 33% reduction in vital capacity and 22% reduction in total lung capacity. Mediastinoscopy, as a mode of selectivity, avoids significant operative risks, and assures preoperatively a better chance of cure for the patient with suspected carcinoma of the lung.