Anesthetic Approach Research Articles

Efficacy of regional anesthesia using ankle block in ankle and foot surgeries: a systematic review.

Ankle blocks are commonly used as surgical anesthetics and for postoperative analgesia during foot surgeries. It is chiefly an infiltration block which utilizes a localized anesthetic approach for providing surgical anaesthesia for a variety of foot procedures. Thus, in this systematic review, we focus primarily on the use, effectiveness, success and failures of regional ankle blocks in outpatient surgeries and hereby compare them with other anesthetic techniques and agents commonly used. Literature search was carried out using PubMed, Medline, Embase, Scopus and Cochrane Library for the studies existing till April 2021. Search was conducted by two independent reviewers separately keeping in view the structured format of the review. Data were thoroughly read and were extracted manually into a structured data extraction form. After going through the databases, 252 relevant articles were identified as per the search strategy. Among those 99 duplicate records were taken away. Among the remaining one hundred fifty-three records, one hundred thirty-eight records were excluded majorly going through their titles and abstracts. Next matching our inclusion criteria and going through the full texts, fifteen studies were excluded. Lastly, after excluding the reviews and case studies we included relevant 11 studies that compared the efficacy of ankle block in outpatient foot and ankle surgery in the present analysis. Seven studies used anatomic landmark guided (ALG) approach, three studies used ultrasound guided (USG) approach, while one study included both approaches. The results showed a significantly lower VAS score postoperatively at 24 hrs. It was observed that in general, immediately after surgery the VAS pain scores are low due to the continued analgesic effect provided by the ankle block. 0.25%-0.5% bupivacaine was the most common single long-acting local anesthetics used. Patient satisfaction ranged from 66%-95.8%. Major complications included block failure and consequent requirement of general anesthesia and few cases of transient nerve injuries. Therefore, this systematic review supports the fact that ankle block has advantages like excellent success rates with minimal side effects, high levels of patient satisfaction and decreased hospital expenses. Thus, it proves to be a safe and highly effective means of regional anesthesia for the majority of foot and ankle surgeries in outpatient settings.

Dexmedetomidine versus fentanyl on stress response and pain control in adult patients undergoing laparoscopic surgery

Laparoscopic procedures are widely indicated; however, the ideal approach for pain control remains debatable. This trial compared between the effects of dexmedetomidine and fentanyl infusion on stress response and pain control in patients undergoing elective laparoscopic surgeries. A prospective randomized double-blinded comparative study included 82 adult participants randomly allocated into two equal-sized groups. Group D received 1 µg/kg of intravenous (IV) dexmedetomidine over 10 min as a loading dose just before induction of anesthesia, then 0.2–0.7 µg/kg/h till 10 min before the surgery ends. Group F received 1 µg/kg of IV fentanyl as a loading dose, then 0.2–0.7 µg/kg/h. Primary objective was postoperative analgesic consumption in 24 h. Collected data were heart rate (HR), mean arterial blood pressure (MAP), blood glucose and serum cortisol levels, visual analogue score (VAS), and the perioperative analgesic consumption. Group D consumed significantly less postoperative morphine doses in 24 h (p = 0.003), and 41.5% of Group D patients did not need any postoperative morphine. Group D had better-controlled hemodynamic changes 5 min post-extubation (HR and MAP p = 0.021 and p = 0.022 respectively), showed significantly less postoperative stress response as manifested in the blood glucose and serum cortisol levels 4 h postoperatively (p = 0.006 and p = 0.001 respectively), and less VAS pain scores at early and late postoperative periods. Intraoperative IV dexmedetomidine administration as a sole analgesic agent for patients undergoing elective laparoscopic surgeries serves as a convenient anesthetic approach, since it provided a good postoperative pain control, and reduced the surgical stress response and the perioperative analgesic consumption.

Awake craniotomy with dexmedetomidine during resection of brain tumours located in eloquent regions.

An awake craniotomy (AC) is the gold standard for the resection of supra-tentorial brain tumours in eloquent areas. Intraoperative monitoring "on-demand" of essential eloquent brain functions and the increasing need to preserve higher intellectual functions during surgery requires aunique anaesthetic approach during AC. Dexmedetomidine is considered the first-choice pharmacological agent for sedation during AC. Twenty-six patients with asingle brain tumour located in areas of eloquent brain function were enrolled in this prospective study. The patients underwent AC under conscious sedation. Motor-evoked potentials and brainstem-evoked auditory potentials were measured using neurophysiological tests during surgery to assess brain potentials. Intraoperative brain relaxation was reached using amodified Bristow scale. Neuromonitoring and psychological tests were maintained until meningeal closure. All operations were carried out successfully, and no reoperations were needed. No significant impact on circulatory and respiratory parameters was observed during conscious sedation based on dexmedetomidine. Neither instrumental airway support nor conversion to general anaesthesia was necessary. Brain relaxation was good in 84% of cases. Intraoperative epileptic episodes were observed in 15% of the patients. Neuro-logical and psychological monitoring was satisfactory. Unaltered muscle force was observed postoperatively in 88% of the patients. AC performed under conscious sedation, and dexmedetomidine infusion without instrumental airway support, was safe and well-tolerated by patients with comfortable physiological sleep for most of the procedure. This approach to AC was associated with minimal risk of perioperative adverse events and may be particularly beneficial in patients with severe comorbidities.

Evaluate the quality of successful ultrasound guided supraclavicular brachial plexus block and its correlation with perfusion index ratio

Background: Ultrasound-guided supraclavicular nerve block is a popular approach for anesthesia for upper limb surgeries. Perfusion index can considered as an objective measure for peripheral perfusion that can predict peripheral block success. Early and accurate detection of peripheral block success would enable rapid corrective action this would save the operating room time and improve patient satisfaction. The main objective was to evaluate the quality of supraclavicular brachial plexus block and it’s correlation with Perfusion Index ratio. Method: It was a prospective observational study carried out over a period of 18 months from November 2018 to April 2020 in the department of anesthesia. Patients aged between 18 to 65 years. Written informed consent, 30 patients of either sex, belonging to ASA grade I and II, scheduled for elective upper limb, under supraclavicular brachial plexus block were selected for the study. Quality of block was made on the basis of 3 point scale. Result: In this study we observed that the Perfusion index was significantly higher in blocked limbed at all time points.

Anaesthesia Approach for Clival Chordoma with Craniovertebral Instability and Brainstem Compression

Anaesthesia Approach for Clival Chordoma with Craniovertebral Instability and Brainstem Compression

Advantages and issues of concern regarding approaches to peripheral nerve block for total hip arthroplasty.

In older patients with comorbidities, hip fractures are both an important and debilitating condition. Since multimodal and multidisciplinary perioperative strategies can hasten functional recovery after surgery improving clinical outcomes, the choice of the most effective and safest pathway represents a great challenge. A key point of concern is the anesthetic approach and above all the choice of the locoregional anesthesia combined with general or neuraxial anesthesia.

A retrospective comparison of dental treatment under general anesthesia versus non-pharmacological approach in patient with special health care needs

Background/purposeThe unmet dental needs are still at the highest rate in patients with special health care needs (SHCN) owing to their physical conditions, lack of cooperation, anxiety and dental fear. This study was aimed to investigate the differences in characteristics and outcomes of dental treatment between general anesthesia (GA) and non-pharmacological approach (NP) in patients with SHCN. Materials and methodsThis study reviewed the dental chart records of SHCN patients from 2005 to 2019. The dental chart records were divided into two subgroups: GA and NP groups. The demographic data, recall behavior and treatment outcomes were analyzed and compared between groups. The comparisons between groups were analyzed by Pearson's chi-squared test, Fisher's exact test and Mann–Whitney U test at a significant level of 0.05. ResultsTwo hundred and sixty-one patients aged 2.2–43.1 years with mean age 14.22 ± 8.64 years old were included. The proportion of cases treated under GA (62%) and NP (38%) was 1.6:1. General anesthesia group had significantly higher in mean ages, caries experience, definitely negative behavior and treatment needs than NP group (P < 0.001). Moreover, recall rates in GA group were significantly lower than NP group (P < 0.001) without a significant difference in regularity. New caries occurrence (P = 0.015) with faster rate (P = 0.035), and behavior changes was significantly found in GA group (P = 0.007) after 24 months of recall. ConclusionPatients with SHCN who were at older age and had high caries experience with definitely negative behavior and numerous treatment needs were more justifiably for GA. A significant new caries occurrence with faster rate tended towards SHCN patients who underwent GA.

Anaesthesia Approach for Cerebral Hemispherotomy in a Child with Hemimegaencephaly and Cortical Dysplasia with Intractable Epilepsy

Anaesthesia Approach for Cerebral Hemispherotomy in a Child with Hemimegaencephaly and Cortical Dysplasia with Intractable Epilepsy

Anesthesia for tracheal and carinal resection and reconstruction.

The aim of this review is to provide an overview of current anesthetic management of tracheal and carinal resection and reconstruction. In addition to the traditional anesthetic approach using conventional tracheal intubation after induction of general anesthesia and cross-field intubation or jet-ventilation once the airway has been surgically opened, there is a trend toward less invasive anesthetic procedures. Regional anesthetic techniques and approaches focusing on the maintenance of spontaneous respiration have emerged. Especially for cervical tracheal stenosis, laryngeal mask airways appear to be an advantageous alternative to tracheal intubation.Extracorporeal support can ensure adequate gas exchange and/or perfusion during complex resections and reconstructions without interference of airway devices with the operative field. It also serves as an effective rescue technique in case other approaches fail. The spectrum of available anesthetic techniques for major airway surgery is immense. To find the safest approach for the individual patient, comprehensive interdisciplinary planning is essential. The location and anatomic consistency of the stenosis, comorbidities, the functional status of respiratory system, as well as the planned reconstructive technique need to be considered. Until more data is available, however, a reliable evidence-based comparison of different approaches is not possible.

Comparison of three neuraxial anesthesia approaches in parturient women with obesity and pregnancy-induced hypertension who underwent cesarean section.

ObjectiveTo compare the effectiveness of different approaches of neuraxial anesthesia in parturient women with obesity and pregnancy-induced hypertension (PIH) who undergo cesarean section (CS).MethodsWe retrospectively analyzed data from 108 parturient women with obesity and PIH who underwent CS. All women were divided into the following three groups according to the neuraxial anesthesia approach: spinal anesthesia (SA), epidural anesthesia (EA), and combined spinal–epidural anesthesia (CSE). Clinical variables were compared.ResultsThe mean age of the patients was 27.3 ± 2.2 years. Women in the CSE group had a longer duration from puncture to surgery, smaller intraoperative change in mean arterial pressure, higher Apgar scores at 1 and 5 minutes, shorter surgery time, lower rates of nausea and vomiting, and lower rate of intraoperative hypotension compared with those in the SA and EA groups.ConclusionCSE takes longer to administer in parturient women with obesity and PIH who undergo CS compared with those who have SA or EA. However, CSE has several advantages over SA or EA, including a shorter surgery time, more stable intraoperative mean arterial pressure, lower rates of nausea, vomiting, and intraoperative hypotension, and better Apgar scores at 1 and 5 minutes.

Dexamethasone and postoperative analgesia in minimally invasive thoracic surgery: a retrospective cohort study

BackgroundDexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV), and recent reviews suggest a role for dexamethasone in postoperative analgesia. The aim of this study is to evaluate the efficacy of dexamethasone as an analgesic adjuvant in minimally invasive thoracic surgery. Primary outcome was morphine consumption 24 h after surgery; secondary outcomes were pain control, measured as numeric rating scale (NRS), glycemic changes, PONV, and surgical wound infection.ResultsWe performed a retrospective cohort study considering 70 patients who underwent elective lobectomy, segmentectomy, or wedge resection surgery with a mini-thoracotomy approach or video-assisted thoracoscopic surgery (VATS). All patients received the same locoregional techniques and short-acting opioids during surgery; 46 patients received dexamethasone at induction. There were no significant differences in morphine consumption at 24 h (p = 0.09) and in postoperative pain scores. Nevertheless, a higher frequency of rescue therapy (p = 0.01) and a tendency for a higher attempted-PCA pushes count were observed in patients who did not receive dexamethasone. No cases of surgical wound infections were detected, and the incidence of PONV was similar in the two groups. Postoperative glycemia was transiently higher in the dexamethasone group (p = 0.004), but the need of hypoglycemic therapy was not significantly different.ConclusionsPreoperative administration of dexamethasone did not cause a significant reduction in morphine consumption, but appears to be safe and plays a role in a multimodal anesthesia approach for patients undergoing elective minimally invasive thoracic surgery.

A retrospective case series of PENG block combined with femoral &amp; lateral cutaneous nerves block as novel regional anesthesia approach for hemiarthroplasty &amp; dynamic hip screw (DHS)

Hip fracture is a frequent trauma particularly common in elderly patients, associated with a high risk of morbidity and mortality. The innervation of the hip joint is complex, and it is challenging for the anesthesiologists to provide effective anesthesia, even analgesia. The pericapsular PENG block is a promising block aiming to block articular sensory branches of anterior capsule supplied by femoral, obturator, and accessory obturator nerves. In this case series, The PENG block combined with femoral, and lateral femoral nerves block was successfully used as regional anesthesia technique with sedation for hemiarthroplasty and dynamic hip screw surgeries. The ultrasound-guided Novel regional anesthesia approach is described, and post-operative pain scores and opioid requirements are monitored till 48 h post-operative.

Abstract 6961: Anesthetic Management During Pre-Stage II Intracardiac Hemodynamic Assessment: An Analysis of the Single Ventricle Reconstruction Trial Dataset

Background: Intracardiac hemodynamics are often obtained with cardiac catheterization prior to proceeding with Stage II palliation for infants with single ventricle anatomy. There is little data examining the hemodynamic impact of anesthetic strategy during catheterization. Methods: Data from the Pediatric Heart Network Single Ventricle Reconstruction Trial was used for analysis. In addition to anesthetic strategy, data reported from cardiac catheterization prior to Stage II palliation included mean systemic venous atrial pressure (MSVAP), end diastolic ventricular pressure (EDVP), pulmonary flow (Q p )/systemic flow (Q s ) ratio, and indexed pulmonary vascular resistance (PVRi). Indexed systemic vascular resistance (SVRi), Q p , and Q s were calculated using available hemodynamic data. Results: Of 549 subjects, pre-Stage II cardiac catheterization data following palliation with a modified Blalock-Taussig-Thomas shunt (mBTTS) or right ventricle to pulmonary artery conduit (RV2PA) was available for 390, of which 219 had adequate hemodynamic data for inclusion in analysis. Intracardiac hemodynamic comparisons were made with respect to anesthetic approach and shunt type. Moderate sedation was utilized in 90 (41%) and general anesthesia in the remaining 129 subjects. A moderate sedation strategy was associated with significantly higher Q p /Q s (1.2 [0.9, 1.6] v. 1.0 [0.7, 1.3], p&lt;0.001) and estimated SVRi (15 Wu•m 2 [11,19] v. 10 [7.8,15], p&lt;0.001), a difference consistent among both mBTTS and RV2PA subgroups. There were no differences between anesthetic groups with respect to PVRi or calculated Q s in either shunt group. Independent of shunt type, PVRi, and patient weight at catheterization, moderate sedation at catheterization was associated with a two-fold odds of a reported Q p /Q s &gt;1 (OR 2.03, 95%CI 1.13-3.63, p=0.017). Conclusions: Anesthetic strategy and alterations in SVRi represent an important consideration when evaluating hemodynamics in a shunt dependent single ventricle circulation. Future investigations may aid in understanding the relationship between anesthetic approach during catheterization and the resulting hemodynamic data employed in perioperative decision-making.

Supraclavicular vs. Infraclavicular Brachial Plexus Nerve Blocks: Clinical, Pharmacological, and Anatomical Considerations.

Peripheral nerve blocks (PNB) have become standard of care for enhanced recovery pathways after surgery. For brachial plexus delivery of anesthesia, both supraclavicular (SC) and infraclavicular (IC) approaches have been shown to require less supplemental anesthesia, are performed more rapidly, have quicker onset time, and have lower rates of complications than other approaches (axillary, interscalene, etc.). Ultrasound-guidance is commonly utilized to improve outcomes, limit the need for deep sedation or general anesthesia, and reduce procedural complications. Given the SC and IC approaches are the most common approaches for brachial plexus blocks, the differences between the two have been critically evaluated in the present manuscript. Various studies have demonstrated slight favorability towards the IC approach from the standpoint of complications and safety. Two prospective RCTs found a higher incidence of complications in the SC approach – particularly Horner syndrome. The IC method appears to support a greater block distribution as well. Overall, both SC and IC brachial plexus nerve block approaches are the most effective and safe approaches, particularly under ultrasound-guidance. Given the success of the supraclavicular and infraclavicular blocks, these techniques are an important skill set for the anesthesiologist for intraoperative anesthesia and postoperative analgesia.

Worldwide anaesthesia use during endovascular treatment for medium vessel occlusion stroke.

IntroductionThe optimal anaesthesia approach for endovascular treatment (EVT) in acute ischaemic stroke is currently unknown. In stroke due to medium vessel occlusions (MeVO), the occluded vessels are particularly small and more difficult to access, especially in restless or uncooperative patients. In these patients, general anaesthesia (GA) may be preferred by physicians to prevent complications due to patient movement. We investigated physicians’ approaches to anaesthesia during EVT for MeVO stroke.MethodsIn a worldwide, case-based, online survey, physicians’ preferred anaesthesia approach during EVT for MeVO stroke was categorized as “initial GA”, “initial GA if necessary” (depending on patient cooperation), “no initial GA, but conversion if necessary” (start with local anaesthesia or conscious sedation), and “no GA”. Preferred anaesthesia approaches were reported overall and stratified by physician and patient characteristics.ResultsA total of 366 survey participants provided 1464 responses to 4 primary MeVO EVT case-scenarios. One-third of responses (489/1464 [33%]) favoured no initial GA, but conversion if necessary. Both initial GA and initial GA if necessary were preferred in 368/1464 (25%) of responses respectively. No GA was favoured in 244/1464 (17%). Occlusion location, respondent specialization (interventional neuroradiology), higher age, and female respondent sex were significantly associated with GA preference. GA was more often used in Europe than in other parts of the world (p < 0.001).ConclusionsAnaesthesia approaches in MeVO EVT vary across world regions and patient and physician factors. Most physicians in this survey preferred to start with local anaesthesia or conscious sedation and convert to GA if necessary.

TAVI for patients with pulmonary arterial hypertension – impact of the anesthesia regime on the short-term outcome

Abstract Objectives and background Pulmonary Arterial Hypertension (PAH) has been independently associated with increased rates of postoperative heart-failure, hemodynamic instability, respiratory failure and delayed extubation. PAH has been described as a common comorbidity in patients undergoing transfemoral Transcatheter Aortic Valve Implantation (tf-TAVI). Two different anesthetic methods, general anesthesia (TAVI-GA) and conscious sedation (TAVI-S) have become established. Both must be measured by their influence on pulmonary vascular resistance, as all factors worsening PAH have to be avoided. To date, there are no practice guidelines advising the the optimal anesthetic approach for patients with PAH. Methods We included all consecutive tf-TAVI patients between 2014 and 2019 in our prospective TAVI registry. A combined endpoint covering the aspects of hemodynamic stability, ventilation and awareness was chosen as primary endpoint. 1. Freedom from catecholaminergic support, 2. Spontaneous breathing and 3. Alertness, defined as GCS &amp;gt;12 points were prerequisite for achieving. PAH was diagnosed by echocardiography immediately before the procedure. The choice for TAVI-GA or TAVI was made by the anesthesiologist. Results A total of 1390 patients were included in this analysis. PAH was diagnosed in 74% (n=1031) of the patients. As shown in Tab.1, patients with and without PAH were comparable in terms of pre-procedural comorbidities, blood gas analysis before and after their procedure and procedural data. Postprocedural, a longer stay on ICU was observed in patients with PAH. This was also seen after propensity-score marching. In terms of the primary endpoint, no difference was found between the groups. In addition, the single points catecholaminergic support, spontaneous ventilation and awareness at the time of transfers revealed no difference. Same holds true for secondary endpoints like 30-day mortality, heart failure and adverse procedural events. An analysis based on the choice of anesthesia showed a clear difference in the successful achievement of the primary endpoint. Independent of the presence of PAH, patients undergoing the procedure in TAVI-GA the primary endpoint was less often successfully documented. TAVI-GA patients were more often in need of catecholaminergic support at the end of the procedure and a reduced alertness was more often found. In patients with PAH and TAVI-GA, a longer length of ICU-stay and a higher incidence of congestive heart failure (CHF) within 30days was found. Conclusion Independent of PAH, patients undergoing tf-TAVI in TAVI-GA, were more often in need of catecholaminergic support and less often awake at the end of the procedure. General anesthesia was also more often associated with CHF but not death at 30 days. The achievement of the primary endpoint was independent of the presence of PAH. tf-TAVI can be done under sedation safely in patients with PAH. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Deutsches Herzzentrum München, Technische Universität München Table 1. Analysis with regard to PAHTable 2. Analysis with regard to Anesth

Analysis of modern anesthetic approaches in endoscopic phthisiosurgery

Objective — to analyze modern anesthetic approaches and their use in endoscopic phthisiosurgery.&#x0D; Materials and methods. During 2008—2021, we performed 133 VATS lung resections in patients with tuberculosis. The following VATS operations were performed: atypical segmentectomy — 29 (21.6 %), typical segmentectomy — 49 (36.9 %), lobectomy — 49 (36.9 %) cases, bilobectomy — 2 (1.5 %), pulmonectomy — 4 (3.1 %) observations.The number of patients diagnosed with newly diagnosed tuberculosis was 62 (46.3 %), with multidrug­resistant tuberculosis 45 (34.4 %) and extensively drug-resistant tuberculosis 26 (19 3 %). One-pulmonary ventilation, which was carried out by endobronchial intubation of the main bronchus of the contralateral lung using a double-lumen tube (DLT) in 115 (86.4 %) patients, in 15 (11.3 %) cases, endobronchial intubation was performed with a single-lumen tube (SLT) and in 3 (3.1 %) tracheal intubation.&#x0D; Results and discussion. The use of a DLT for intubation made it possible to reduce the duration of surgery by 20—25 % compared with the use of a SLT or tracheal intubation. When using a DLT, a more stable, faster and better collapse of the lungs was achieved, which in turn gave a decrease in trauma to its parenchyma due to the fact that additional instrumental actions were not required on the part of surgeons to achieve it.Intraoperative blood loss with DLT was (75.4 ± 38.7) and (112.6 ± 51.8) ml with SLT in experiments with intubation of the main bronchus of the contralateral lung and (184.3 ± 89.8) ml in tracheal intubation, largely due to visualization and comfort working conditions of the surgical team.In the recovery of costs, we adhere to restrictive infusion approaches, which allows avoiding overloading the pulmonary circulation, and therefore reducing the number of pulmonary complications. The qualitative composition of the intraoperative infusion program included crystalloid and colloidal solutions. The quantitative ratio during the intubation of DLT was 3 : 0.5, with SLT 3 : 1. The need for transfusion of blood components was only during tracheal intubation.&#x0D; Conclusions. The most important task of modern anesthesiology in endoscopic phthisiosurgery is to improve patient safety during surgery. The defining technologies of anesthetic protection in this case should be the following categories: means and methods of general anesthesia, methods of respiratory provision and technical means of their application; full intraoperative monitoring of vital functions.

The impact of inhalation anesthetics on early postoperative cognitive function and recovery characteristics in Down syndrome patients: a randomized, double \u2013 blind study

BackgroundDown syndrome (DS) is associated with intellectual disability. DS patients may be unable to cooperate and often require general anesthesia even for minor surgeries. Rapid recovery significantly contributes to fast-tracking. This prospective randomized, double - blind study investigates the impact of desflurane and sevoflurane on recovery and early postoperative cognitive function of these patients.MethodsForty-four patients undergoing dental surgery, were randomized to receive desflurane (DES-group) or sevoflurane (SEVO-group) for anesthesia maintenance. The primary outcome was postoperative cognitive function (Prudhoe Cognitive Function Test, PCFT) at 90 min and 4 h postoperatively. Secondary outcome measures were the time between volatile discontinuation and spontaneous breath, eye opening, extubation, orientation and response to commands, time to achieve an Aldrete score ≥ 9 in the Post-anesthesia Care Unit and time to fulfill discharge criteria (Post Anesthetic Discharge Scoring System, PADSS).ResultsAt 90 min, PCFT scores significantly decreased from baseline in both groups. Nevertheless, at 4 h, in DES-group there was no significant change from baseline (p = 0.163), while in SEVO-group the decrease remained significant (p < 0.001). Desflurane was also found superior regarding recovery characteristics, such as time to eye opening (p = 0.021), spatial orientation (p = 0.004), response to commands (p = 0.004). Discharge criteria were met earlier in DES-group (p = 0.018 for Aldrete score / p < 0.001 for PADSS).ConclusionsDesflurane was found superior to sevoflurane in terms of faster recovery and better preserved postoperative cognitive function in DS patients undergoing dental surgery. We suggest that desflurane, as part of a multimodal anesthetic approach, could be a useful agent to enhance early discharge from hospital of ambulatory patients with intellectual disability.Trial registrationRegistered with ClinicalTrials.gov (NCT02971254, principal investigator: E.G; November 2016).

Carbon Footprint of General, Regional, and Combined Anesthesia for Total Knee Replacements.

Health care itself contributes to climate change. Anesthesia is a "carbon hotspot," yet few data exist to compare anesthetic choices. The authors examined the carbon dioxide equivalent emissions associated with general anesthesia, spinal anesthesia, and combined (general and spinal anesthesia) during a total knee replacement. A prospective life cycle assessment of 10 patients in each of three groups undergoing knee replacements was conducted in Melbourne, Australia. The authors collected input data for anesthetic items, gases, and drugs, and electricity for patient warming and anesthetic machine. Sevoflurane or propofol was used for general anesthesia. Life cycle assessment software was used to convert inputs to their carbon footprint (in kilogram carbon dioxide equivalent emissions), with modeled international comparisons. Twenty-nine patients were studied. The carbon dioxide equivalent emissions for general anesthesia were an average 14.9 (95% CI, 9.7 to 22.5) kg carbon dioxide equivalent emissions; spinal anesthesia, 16.9 (95% CI, 13.2 to 20.5) kg carbon dioxide equivalent; and for combined anesthesia, 18.5 (95% CI, 12.5 to 27.3) kg carbon dioxide equivalent. Major sources of carbon dioxide equivalent emissions across all approaches were as follows: electricity for the patient air warmer (average at least 2.5 kg carbon dioxide equivalent [20% total]), single-use items, 3.6 (general anesthesia), 3.4 (spinal), and 4.3 (combined) kg carbon dioxide equivalent emissions, respectively (approximately 25% total). For the general anesthesia and combined groups, sevoflurane contributed an average 4.7 kg carbon dioxide equivalent (35% total) and 3.1 kg carbon dioxide equivalent (19%), respectively. For spinal and combined, washing and sterilizing reusable items contributed 4.5 kg carbon dioxide equivalent (29% total) and 4.1 kg carbon dioxide equivalent (24%) emissions, respectively. Oxygen use was important to the spinal anesthetic carbon footprint (2.8 kg carbon dioxide equivalent, 18%). Modeling showed that intercountry carbon dioxide equivalent emission variability was less than intragroup variability (minimum/maximum). All anesthetic approaches had similar carbon footprints (desflurane and nitrous oxide were not used for general anesthesia). Rather than spinal being a default low carbon approach, several choices determine the final carbon footprint: using low-flow anesthesia/total intravenous anesthesia, reducing single-use plastics, reducing oxygen flows, and collaborating with engineers to augment energy efficiency/renewable electricity.

Postoperative cognitive dysfunction after endovascular treatments for unruptured intracranial aneurysms: A pilot study.

Post operative cognitive dysfunction (POCD) has been widely observed after major surgery, particularly in elderly patients with general anesthesia (GA). However, a specific unanswered question is whether different approaches to anesthetic managements are associated with different cognitive outcomes after endovascular treatments for unruptured intracranial aneurysms (UIAs). The purpose of this study is to assess the correlation of POCD with GA versus monitored anesthesia care (MAC). We performed a pragmatic, prospective study to assess the association between different anesthetic approaches and POCD. We compared the pre- and post-procedural Montreal Cognitive Assessment (MoCA) scores in patients with normal cognition who underwent treatments of UIAs with various endovascular methods, using either GA or MAC. A total of 23 patients with UIAs were enrolled in the study. Seven (30.4%) and sixteen (69.6%) UIAs were treated without perioperative complications under GA or MAC, respectively. There was a significant decline in the post-procedural MoCA score under GA (mean difference = 1.14; 95% confidence interval = [0.42-1.87], P < 0.01). By contrast, there was no significant difference of MoCA score between pre- and post-procedure under MAC (mean difference = 0.19; 95% confidence interval = [-0.29-0.67], P = 0.59). Treating UIAs using MAC was associated with a decrease in POCD as compared to GA in patients undergoing endovascular treatments for UIAs with normal cognition. Larger randomized studies are needed to confirm these findings.