Block Anesthesia Research Articles

Effects of TTP-PECS Block Under Opioid-Sparing General Anesthesia on Postoperative Analgesia and Early Recovery Quality in Patients Undergoing Modified Radical Mastectomy.

Potent analgesics such as sufentanil and remifentanil play a pivotal role in general anesthesia, but these medications have disadvantages, including respiratory depression, nausea, vomiting, immune system suppression, and gastrointestinal function inhibition. This study aimed to evaluate the effects of the transversus thoracic muscle plane-pectoral nerves(TTP-PECS) block on postoperative analgesia, immune function and early postoperative recovery quality inpatients undergoingmodified radical mastectomy under opioid-sparing general anesthesia. A total of 100 patients scheduled for modified radical mastectomy under general anesthesia were randomly divided into the TTP-PECS block combined with opioid-sparing general anesthesia group (TO group, n=50) or the conventional general anesthesia group (GA group, n=50). The TO group underwent TTP-PECS block prior to induction, using oxycodone as the analgesic during induction instead of sufentanil, no additional continuous infusion of analgesic was performed intra-operatively. Visual analogue scale (VAS) scores at rest and during movement at different time points were recorded in both groups, and the levels of T cell subsets, natural killer (NK) cells were measured before the surgery and at 24h and 48h after the surgery. Quality of Recovery-40 (QoR-40) scores were assessed at 24h postoperatively, and the incidence of peri-operative adverse reactions was also observed in both groups. Except for 48h postoperatively, patients in the TO group had significantly lower VAS scores than those in the GA group at 2h, 6h, 12h, and 24h postoperatively at rest and during movement (P<0.05). At 24h and 48h postoperatively, the expression of CD4+ T cells and the CD4+/CD8+ ratio were significantly higher in the TO group than in the GA group (P<0.05). The QoR-40 scale, assessed at 24h postoperatively, showed that the TO group significantly outperformed the GA group in total scores as well as in sub-scores for emotional state, physical comfort, physical independence, psychological support, and pain (P<0.05). In addition, systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were lower at time points T1-T4 than at T0 in both groups (P<0.05), but the differences between the two groups were not statistically significant(P>0.05). The incidence of cough reflex during induction and postoperative nausea and vomiting were significantly lower in the TO group than in the GA group (P<0.05). There was no statistically significant difference between the two groups in the incidence of other adverse reactions (P>0.05). The combination of TTP-PECS block and oxycodone-propofol opioid-sparing general anesthesia can provide superior postoperative analgesia and reduce the incidence of postoperative nausea and vomiting. It also alleviated the suppression of cellular immune function and improves the quality of early recovery in breast cancer patients. At the same time, opioid-sparing general anesthesia is a safe strategy for modified radical mastectomy. Chinese Clinical Trial Registry; ChiCTR2200066753.

Distal paravertebral block anesthesia with a mixture of lidocaine and xylazine has a longer duration than a lidocaine block coupled with intramuscular xylazine in steers.

To determine whether the site of administration of xylazine alters its impact on lidocaine's duration of action when administered as a distal paravertebral block (DPV) in steers. 6 healthy steers were used. Unilateral DPVs were performed at L1, L2, and L4. Each steer received 2 treatments in a blinded random crossover study. The local xylazine treatment group received 6 mg of lidocaine/kg mixed with 0.02 mg of xylazine/kg as a DPV, followed by an injection of 0.9% NaCl in the cervical musculature. The systemic xylazine treatment group received 6 mg of lidocaine/kg as a DPV and 0.02 mg of xylazine/kg in the cervical musculature. Sensation was assessed by response to needle pricks along the paralumbar fossa with a 22-gauge hypodermic needle. The time of onset, duration of action, sedation score, and heart rate were compared between treatments. Data are reported as mean ± SD. This study was completed over a 2-week period in May 2023. The duration of anesthesia was significantly prolonged after DPV in steers treated with local xylazine (186.7 ± 58.7 minutes) compared to systemic xylazine (95 ± 36.3 minutes). Both treatments were associated with mild decreases in heart rate and sedation but were not significantly different between groups. The addition of xylazine to lidocaine when administered as a DPV provides a longer duration of anesthesia than when xylazine is administered at a distant site to local anesthetic solution deposition. The combination of lidocaine and xylazine when administered as a DPV prolongs the duration of action of lidocaine and is a practical, inexpensive technique.

Measurement of mandibular anatomy associated with inferior alveolar nerve block anesthesia using 3D mandible models reconstructed by CBCT.

The objective was to evaluate the anatomical relationship between the mandibular foramen and surrounding structures using CBCT and to investigate the potential causes of inferior alveolar nerve block (IANB) failure. In this retrospective study, CBCT images of 222 mandibular sides from 111 patients (55 men, 56 women; aged 18-45 years) who underwent CBCT examination at the Shenzhen University General Hospital between January 2018 and December 2020 were analyzed. Three-dimensional models were reconstructed, and measurements of angles and distances related to the mandibular foramen were performed. The presence of a bony protuberance on the medial side of the mandibular ramus was evaluated. Differences between sexes were assessed using paired t tests or Wilcoxon rank-sum tests (α = .05). The angle between the anterior-posterior line of the mandibular ramus and the line connecting the innermost point to the mandibular foramen (angle AP-IF) was significantly greater than zero (P .05), indicating the presence of a bony protuberance. The angle between the midline and the line connecting the mandibular premolar contact point to the mandibular foramen (angle F45MnLP-ML) was 49.69 ± 2.17 degrees in men and 48.19 ± 2.20 degrees in women (P .001). The distance from the occlusal plane to the mandibular foramen was 9.45 ± 3.40 mm in men and 8.28 ± 3.41 mm in women (P = .011). The presence of a bony protuberance on the medial side of the mandibular ramus may contribute to IANB failure. Adjusting the needle insertion angle and height/vertical distance according to the reported measurements may improve IANB success rates. These findings may help clinicians optimize IANB techniques and improve success rates by adjusting needle insertion angles and heights/vertical distances based on individual patient anatomy.

Minimum effective concentration 90 (EC90) of ropivacaine for Femoral nerve block: A biased-coin up-and-down sequential method study

Background and Aims: The femoral nerve (FN) is commonly blocked using ropivacaine to provide postoperative analgesia after knee surgery. However, the minimal required concentration has not yet been defined. The aim of this study was to estimate the minimal ropivacaine concentration required to achieve adequate analgesic FN block in 90% of cases (EC90). Methods: This study included 50 patients who were scheduled for knee ligament reconstruction under combined nerve block and general anaesthesia. The FN block was performed using 15 mL of ropivacaine with varying concentrations and considered adequate when associated with pain-free recovery. The sciatic, obturator, and lateral femoral cutaneous nerves were blocked to negate other knee pain generators, and their block success was confirmed. We used the biased-coin design up–down sequential method where the adequacy of an FN block altered the ropivacaine concentration used for the next block. The adequacy of the analgesic block or lack of it was analysed to calculate the analgesic EC90. The quadriceps motor power and morphine requirement were also recorded. Results: The recommended analgesic ropivacaine EC90 was 0.05% w/v. The associated quadriceps weakness and morphine requirement were minimal. Conclusion: FN block using ropivacaine 0.05% w/v may provide adequate analgesia in 90% of patients.

Effect on the size of optic nerve sheath diameter in patients undergoing surgeries under spinal anaesthesia versus peripheral nerve blocks – A randomised controlled study

Background and Aims: Post-dural puncture headache is a complication of spinal anaesthesia, theorised to be triggered by a lowering in intracranial pressure due to the cerebrospinal fluid leak through the dural puncture. Our objective was to evaluate whether there is a decrease in optic nerve sheath diameter (ONSD) with a reduction in intracranial pressure after spinal anaesthesia. Methods: Patients were randomised by a computer-generated randomisation table to receive spinal anaesthesia (Group S) or peripheral nerve block (Group P) after assessing their eligibility for the anaesthesia procedure as per the protocol. The ONSD was measured in the preoperative period and again at 4 h and 24 h after the anaesthetic, both in the supine and sitting positions, along with haemodynamic parameters. Continuous variables such as age, height, weight, mean arterial pressures, and ONSD were expressed as mean [standard deviation (SD)] [95% confidence interval (CI)] and compared using the student’s t-test. Repeated measure ANOVA and Bonferroni were used to compare intra-group parameters. Results: The mean decrease in the ONSD from a baseline mean of 3.95 (SD: 0.17) (95%CI: 3.87, 4.02) to 3.89 (SD: 0.26) (95%CI: 3.78, 4.007) mm at 4 h and 3.94 (SD: 0.12) (95%CI: 3.89, 4.0) mm at 24 h after spinal anaesthesia was statistically significant. The changes in the ONSD measurements in Group P were not statistically significant. Headache was not reported at 24 h or in the follow-up at postoperative day 5. Conclusion: Measurement of ONSD is an easy, economical method for identifying decreased intracranial pressure after spinal anaesthesia. Further research could identify cut-off values to prognosticate PDPH in high-risk individuals.

C-arm-Guided Paravertebral Block for Surgical Anesthesia in a High-Risk Cardiac Patient Undergoing Percutaneous Nephrolithotomy

C-arm-Guided Paravertebral Block for Surgical Anesthesia in a High-Risk Cardiac Patient Undergoing Percutaneous Nephrolithotomy

Efficacy and safety of perioperative analgesia in PENG block for children undergoing hip surgery with developmental dysplasia: study protocol for a randomized, double-blinded, non-inferiority trial

BackgroundSurgical intervention is critical in the treatment of hip developmental dysplasia in children. Perioperative analgesia, usually based on high opioid dosages, is frequently used in these patients. In some circumstances, regional anesthetic procedures such as caudal block and lumbar plexus block have also been used. Previous research has shown that pericapsular nerve group (PENG) block provides excellent anesthetic efficacy during open hip surgery in adults. PENG block is thought to provide a similar analgesia effect comparable to caudal block.MethodsThis study is a single-center, prospective, randomized, double-blinded, non-inferiority experiment that enrolled children aged 6 months to 7 years who were scheduled for developmental dysplasia hip surgery. Following general anesthesia and regional blocks (0.25% ropivacaine at a dose of 2.5 mg·kg−1 with epinephrine at a concentration of 1:200,000), 48 individuals will be randomly assigned to either the PENG or caudal groups. The primary outcome measure is the highest FLACC (face, legs, activity, crying, consolability) score achieved within 24 h of surgery. Secondary outcomes include intraoperative opioid consumption, analgesic dosage within 24 h of surgery, time to start rescue analgesia, number of PCA pump activations, time to remove SLIPA (streamlined liner of the pharynx airway), duration of regional block procedures, incidence of adverse events, plasma ropivacaine concentrations, and hospital stays and costs. All data will be collected by blinded investigators. The trial’s final results will be published in a peer-reviewed scientific journal.DiscussionWe expect this trial to provide some evidences that PENG block is safe and effective for perioperative analgesia in pediatric patients undergoing open hip surgery.Trial registrationChinese Clinical Trial Registry ChiCTR2100053128. Registered on November 12, 2021.

Implementing a Perioperative Ultrasound Guided Regional Anaesthesia Block Service in a District General Hospital

Implementing a Perioperative Ultrasound Guided Regional Anaesthesia Block Service in a District General Hospital

Subcutaneous Pectoral Edema After Arthroscopic Labral Repair Despite Normal Irrigation Fluid Usage and Surgery Duration.

Edema after shoulder arthroscopic surgery poses concerns due to its potential complications such as compartment syndrome, nerve damage, and respiratory issues. This study aimed to investigate the acute accumulation of subcutaneous fluid after shoulder arthroscopy. A prospective cohort study, providing Level III evidence was conducted on 50 patients undergoing arthroscopic shoulder surgery under interscalene block anaesthesia from September to December 2023. The patients were divided into two groups: rotator cuff repair (RCR, n = 29) and labral repair for shoulder instability (LR, n = 21). Subcutaneous fluid levels were measured preoperatively, postoperatively, and at discharge (24 h postsurgery) using the MoistureMeterD Compact at the neck, pectoral region, deltoid area, cubital fossa, and carpal tunnel. Data on surgery duration and irrigation fluid volume were documented. In the statistical analysis, repeated measures ANOVA and the independent-samples t-test were applied to compare parametric data, while the Friedman test and Mann-Whitney U test were used for nonparametric data. The average operation time was 29.0 ± 12.1 min for RCR and 30.0 ± 10.9 min for LR, with average irrigation fluid use of 3.8 ± 0.9 and 4.0 ± 0.7 L, respectively (both p > 0.05). There was no increase in subcutaneous edema in the neck and deltoid region in both groups. At discharge, the percentage of subcutaneous fluid increased in the cubital fossa (p = 0.04 for RCR; p < 0.001 for LR) and carpal tunnel (both p < 0.001) in oth groups, whereas pectoral edema increased only in the labral repair group (p = 0.04). Subcutaneous pectoral edema can occur following arthroscopic labral repair, and increased fluid levels in the cubital fossa and carpal tunnel were observed in both rotator cuff and labral repairs, even in the absence of prolonged surgery or excessive irrigation fluid use. These findings highlight the need for careful postoperative management of edema after shoulder arthroscopy, particularly for labral repairs, with special attention to the pectoral region, cubital fossa, and carpal tunnel to prevent potential complications. The registry is sponsored by the United States National Library of Medicine (www. gov); Registry Name: Examination of Edema After Arthroscopic Shoulder Surgery ID: NCT06014203.

Identifying Components of an Enhanced Recovery Pathway for Primary Cleft Palate Repair: A Scoping Review.

This study aims to map the existing sources of evidence on perioperative care and recovery strategies for primary cleft palate repair, to identify elements that should be included in an enhanced recovery pathway (ERP), and to identify gaps in current knowledge. Scoping review. ERPs are evidence-based, patient-centered, multimodal, perioperative care pathways designed to reduce surgical stress and improve postoperative outcomes and are increasingly being reported in the cleft lip and palate literature. PubMed, Embase, Cochrane, and Scopus databases were searched. Results were uploaded to Covidence systematic review software. Studies were included for analysis if they described strategies or elements for enhanced recovery following primary cleft palate repair. ERP elements and outcome measures were recorded and collated. Forty-seven studies were included. Frequently reported topics included anesthesia, peri-operative analgesia, and parent education. There was a dearth of evidence about peri-operative nursing care. Based on the extracted data, we propose that the following elements be included in any ERP for primary cleft palate repair: preoperative parent/caregiver education; minimization of preoperative fasting time; preoperative analgesia; local anesthetic nerve blocks; perioperative antibiotics and ondansetron; postoperative non-opioid analgesia; early postoperative oral feeding and discharge planning. The findings provide the framework to develop an institutional ERP for primary cleft palate repair. The positive contribution of consistent nursing care to enhanced recovery is obvious but under-investigated in the literature to date. The impact of ERPs on parent-reported outcomes also warrants further investigation.

The Pericapsular Nerve Group (PENG) Block on Total Hip Replacement Operation

Background: In Total Hip Replacement (THR) surgery, the term PENG block refers to the use of regional anesthesia or block anesthetic which aims to reduce pain during and after surgery. "Peng block" is an abbreviation for "Peripheral Nerve Block", which is an anesthetic procedure carried out by injecting a local anesthetic around certain nerves to numb certain areas of the body, in this case, around the hips and thighs. Case Report: A 53-year-old female patient, ASA III, was planned for left Total Hip Replacement (THR) surgery. The patient had an initial complaint of pain in the right hip since approximately 5 months ago. Patients with cardiovascular comorbidities have frequent PVCs, patients with respiratory emphysematous lung and bilateral pleural effusion, and patients also suffer from osteoarthritis. From the patient's EKG, Frequent PVC results were found and Echocardiography results showed normal heart chamber dimensions, Mild Aorta Regurgitation, Mild Tricuspid regurgitation with low probability of Pulmonary Hypertension, Normal Left Ventricle (LV) and Right Ventricle (RV) function, Normal LV diastolic Function, Ejection Fraction BP 50.5%, TAPSE 21 mm, eRAP 8 mmHg. Conclusion: Pericapsular Nerve Group (PENG) block can be an option in THR surgery, where it is expected to contribute to FN, ON, and AON anesthesia, and therefore, can provide analgesic coverage for pelvic surgery while also reducing the opioid requirements of patients with THR surgery thereby reducing the side effects of Opioids that can occur can also provide comfort to patients when starting physiotherapy Keywords: total hip replacement, peng block, anesthetic, hip

LC-MS/MS assisted pharmacokinetic and tissue distribution study of ropivacaine and 3-OH-ropivacaine on rats after plane block anesthesia.

Knowledge of drug pharmacokinetics and tissue distribution is precious for ensuring patient safety and optimizing treatments. The varied use of local anesthetics, as well as the fact that anesthetics can sometimes have low therapeutic indices and numerous adverse drug reactions, makes any novel pharmacokinetics information valuable. The present manuscript describes a pharmacokinetic study of ropivacaine carried out after plane block anesthesia on an animal model, using high sensitivity, accurate, and precise LC-MS/MS bioanalysis. Both plasmatic concentrations and tissue distribution of ropivacaine and its primary active metabolite were determined. The results showed a tissue affinity of the anesthetics, a clearance of ropivacaine mainly by hepatic metabolism, and the final, mainly renal excretion of the hydroxylated metabolite. While the results cannot simply and directly be transposed to human pharmacokinetics, they offer a valuable basis for future studies and can contribute to a better understanding of the bioavailability and toxicology of the widely used modern anesthetic.

Ultrasound guided pericapsular nerve group (PENG) block resulting in reduction of dislocated prosthetic hip.

A 78-year-old woman with a prosthetic hip dislocation underwent a pericapsular nerve group block for regional anesthesia. The hip spontaneously reduced before manual intervention, likely due to the block's analgesic and muscle-relaxing effects. Compared to other techniques, this block effectively targets hip innervation while sparing motor function. This case highlights its potential for managing hip dislocations safely, especially in patients at risk from sedation.

Anesthetic effectiveness of mental/incisive nerve block versus inferior alveolar nerve block in mandibular first and second premolars with symptomatic irreversible pulpitis: A randomized clinical trial.

This study aimed to compare the effectiveness of mental nerve block (MINB) and conventional inferior alveolar nerve block (IANB) anesthesia during endodontic treatment of mandibular first and second premolars with symptomatic irreversible pulpitis (SIP). In this randomized, double-blind, clinical trial, 120 patients undergoing endodontic treatment of mandibular premolars were randomly assigned to IANB (n=60) or MINB (n=60) using 4% articaine with 1:100,000 epinephrine hydrochloride. Pain levels were evaluated preoperatively and during cold tests, cavity preparation, and pulp extirpation using the Numerical Rating Scale (NRS). Statistical analyses included the Independent t-test, Chi-square test, and Mann-Whitney U test (α=0.05). Both groups showed a success rate of 70% for anesthesia (P = 1.000). While IANB demonstrated similar efficacy between first (71.4%) and second (68.8%) premolars (P> .05), MINB was significantly more effective for first premolars (76.9%) than second premolars (64.7%) (P< .05). MINB and IANB provide comparable pain control for mandibular premolars during endodontic procedures. However, MINB was observed to be less effective for second premolars compared to first premolars. The study suggests that, despite the comparable success rates of both anesthesia techniques, supplemental anesthesia may still be required to achieve adequate pain management for mandibular premolars.

Risk Factors for the Occurrence of Rebound Pain After Intercostal Nerves Block in Three-Port Thoracoscopic Surgery: A Case-Control Study.

Rebound pain (RP), characterised by an acute increase in pain levels, is usually observed after the effects of block anaesthesia have subsided. Severe RP can cause adverse effects, thus affecting patient prognosis. In this study, we investigated the incidence of RP and its risk factors after intercostal nerve block in three-port thoracoscopic surgery to provide a clinical basis for identifying high-risk patients and providing early intervention. A single-centre retrospective study was conducted on 475 patients who underwent three-hole thoracoscopic surgery from September 2022 to September 2023 in Jiaxing First Hospital. Data were collected and compared between patients who developed RP and those who did not. IBM SPSS Statistics 25.0 software was used for statistical analysis. Data were collected from 700 patients. After applying the exclusion criteria, 475 cases were finally included and the incidence of RP was 23.8%. The results showed that the differences in body mass index (BMI), upper and lower chest diameters, anterior and posterior chest diameters, left and right chest diameters, and gender between patients with RP and those without RP were statistically significant (p < 0.05). In addition, the proportion of female patients with RP was significantly higher. BMI (advantage ratio [OR] = 0.835, 95% confidence interval [CI]: 0.375 ~ 1.859), upper and lower chest diameters (OR = 0.916, 95% CI: 0.827 ~ 1.014), anterior and posterior chest diameters (OR = 0.765, 95% CI: 0.635 ~ 0.921), left and right chest diameters (OR = 0.612, 95% CI: 0.421 ~ 0.891), and gender (OR = 1.170, 95% CI: 0.576 ~ 2.373). The incidence of RP after three-hole thoracoscopic intercostal nerve block is high and associated with multiple risk factors. Early intervention is needed for patients at risk of RP to improve patient prognosis and satisfaction.

Exploring the impact of perioperative analgesia on postoperative chronic analgesic prescriptions in patients with lung cancer undergoing minimally invasive thoracic surgery: A retrospective observational study.

Lung cancer surgery is associated with a high incidence of chronic postsurgical pain (CPSP), which necessitates long-term analgesic prescriptions. However, while essential for managing pain, these have shown various adverse effects. Current guidelines recommend using peripheral nerve blocks over epidural anaesthesia for perioperative analgesia in minimally invasive thoracic surgery (MITS). However, the impact of perioperative analgesia on chronic analgesic prescriptions remains unclear. Therefore, this study investigated chronic analgesic prescription patterns following MITS in patients with lung cancer who received either perioperative epidural anaesthesia or nerve block. We conducted a retrospective cohort study using data from the Japanese Diagnosis Procedure Combination database. Data were extracted from patients with primary lung cancer who underwent MITS between April 2018 and March 2022. Patients were divided into two groups based on the perioperative analgesia they received: the epidural anaesthesia group and the nerve block group. We compared the proportion of analgesic prescriptions 3-6 months postoperatively between both groups using multivariable logistic regression analysis. Inverse probability of treatment weighting was used to balance the covariates between the two groups. Among the 38,719 eligible patients, 4513 (11.6%) were prescribed postoperative analgesics. We found no significant difference in the proportion of analgesic prescriptions between the epidural anaesthesia and nerve block groups (odds ratio, 1.00; 95% confidence interval, 0.99-1.01). This nationwide retrospective study suggests that the choice between perioperative epidural anaesthesia or nerve block in patients with lung cancer undergoing MITS does not influence the proportion of postoperative chronic analgesic prescriptions.

Local anaesthesia vs. brachial plexus block in trapeziometacarpal joint arthroplasty

IntroductionAn established anaesthetic procedure used during total trapeziometacarpal joint (TMCJ) arthroplasty is the brachial plexus block (BPB). It was hypothesized that local anaesthesia (LA) provides advantages in overall cost, enables intraoperative assessment of the prosthesis, and minimises the anaesthetic risk. In this study, LA to BPB was compared and outcomes, safety, and overall patient satisfaction were analyzed.Materials and methodsIn this single-center cohort study, 32 patients (34 operated thumbs) who underwent total TMCJ arthroplasty between February 2018 and July 2021 were included. Two groups were formed depending on the anaesthetic method used. One group was operated under LA, and the other under BPB. Functionality scores were assessed preoperatively and three month postoperatively. Additionally, pain was assessed on the 1st and 12th postoperative day. Data on intraoperative pain and anxiety, overall satisfaction, pain medication use, and willingness to undergo the procedure again were gathered through a retrospective telephone survey.ResultsNo significant differences between LA and BPB were found in terms of functional outcomes, pain reduction, and willingness to repeat the procedure. The analysis further showed significant differences in intraoperative anxiety (higher in the LA group; LA 1.69, SD: 2.65; BPB 0.28, SD: 0.58; measured using a numeric rating scale 0–10; p = 0.045), operation length (higher in BPB group; LA 39 min, SD: 7.46; BPB 45 min, SD: 7.02; p = 0.018) and overall setup time (higher in BPB group; LA 76 min, SD: 15.85; BPB 102 min, SD: 19.66; p < 0.001). No conversion from LA to another anaesthetic method was necessary.ConclusionThe use of LA in total TMCJ arthroplasty is a practical and reliable alternative to the well-established BPB. LA reduces the cost of the procedure, necessity of an anaesthesiology team and the duration of the patients´ hospital stay. Patients should be actively involved in selecting the anaesthetic method to optimize the operative procedure and overall outcome.

The sedation efficacy of different doses of remimazolam in elderly patients with regional nerve block anaesthesia

BackgroundRemimazolam is a benzodiazepine sedative that is indicated for induction and maintenance during general anaesthesia. Remimazolam is also used for sedation in outpatient surgery; however, most reports have focused on nonelderly patients, whereas only a few studies have reported the use of remimazolam for elderly patients when receiving regional nerve block anaesthesia.AimThe aim of this study was to evaluate the effects of different doses of remimazolam in elderly patients when specifically related to regional nerve block anaesthesia.MethodsThis study was conducted at a university hospital between February 2022 and March 2023. We included 80 patients aged 65 years or older under regional nerve block anaesthesia. After the effects of anaesthesia were determined, patients were intravenously administered different doses of the test drug, i.e. 4, 4.5, 5, 5.5, or 6 mg, which were named the R1, R2, R3, R4, and R5 groups, respectively. The primary outcome was the loss of consciousness time. The secondary outcomes included the maintenance time and the number of assisted ventilators needed. The exceptional response of patients in terms of loss of consciousness maintenance time, the mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), SpO2, and modified observers assessment of alertness/sedation (MOAA/S) scores were recorded at baseline (T0), 3 min after the injection of the test drug (T1), 6 min after the injection of the test drug (T2), 9 min after the injection of the test drug (T3), 12 min after the injection of the test drug (T4), 15 min after the injection of the test drug (T5), 18 min after the injection of the test drug (T6), 21 min after the injection of the test drug (T7), and 24 min after the injection of the test drug (T8).ResultsWe included 80 patients according to the inclusion and exclusion criteria, with 16 patients in each group. There were no significant differences in sex, age, and BMI amongst the 5 groups. The loss of consciousness time was significantly greater in the R2 group than in the R3, R4, and R5 groups (p < 0.001), and the loss of consciousness maintenance time was significantly greater in the R5 group than in the R3 group (p < 0.05). The MAP was significantly lower in the R2 and R5 groups than in the R1 group at T4 (p = 0.004) and significantly lower in the R5 group than in the R1 group at T5 (p = 0.007). The HR was significantly lower in the R5 group than in the R3 group at T3 (p = 0.004) and T4 (p = 0.007). The RR was significantly lower in the R5 group than in the R4 group at T4 (p = 0.049) and significantly greater in the R4 group than in the R2 group at T5 (p = 0.024) and T6 (p = 0.020). The RR was significantly lower in the R5 group than in the R1, R3 and R4 groups at T7 (p = 0.001). The RR was significantly greater in the R1 group than in the R2 and R5 groups at T8 (p = 0.001). The RR was significantly greater in the R4 group than in the R2 group at T8 (p = 0.001). SpO2 was significantly lower in the R3 group than in the R1 group at T3 (p = 0.003) and significantly lower in the R3 group than in the R1 and R5 groups at T4 (p = 0.002), T5 (p = 0.001), T6 (p = 0.000), and T7 (p = 0.000). The MOAA/S scores were significantly lower in the R4 and R5 groups than in the R1 and R2 groups at T1 (p = 0.000), significantly lower in the R5 group than in the R1 and R3 groups at T2 (p = 0.004), and significantly lower in the R5 group than in the R1 group at T3 (p = 0.036).ConclusionThe results indicated that doses of 5–5.5 mg remimazolam are more suitable for sedation in elderly patients, and the loss of consciousness time and depth of sedation differed according to the remimazolam dosage. Doses of 5–5.5 mg remimazolam were associated with adequate levels of sedation in elderly patients and with a decreased risk of complications, whilst haemodynamic fluctuations occurred approximately 12–15 min after the administration of remimazolam.

Intraoperative virtual reality for older patients undergoing total knee arthroplasty: study protocol for a randomized clinical trial

BackgroundIn an aging surgical patient population, preventing complications such as oversedation has taken increasing priority in perioperative care. Intraoperative use of virtual reality (VR) may decrease sedative requirements. We hypothesize that the use of immersive VR during total knee arthroplasty (TKA) will lead to decreased propofol requirements, improved patient-reported satisfaction, and reduced postoperative opioid requirements compared to active and usual care controls.MethodsThis is a single-center, randomized clinical trial of older (age > 60) patients undergoing TKA. Participants will be randomized into three groups (2:2:1): VR immersion, music, and sham VR plus usual care. All patients will receive a regional block and spinal anesthesia. Patients in the immersive VR and music groups will use patient-controlled sedation (PCS) with propofol, while those in the sham VR group will act as the standard of care control group and will receive monitored anesthesia care (MAC) with propofol infusion.Statistical analysisAnalyses will be conducted using IBM SPSS Statistics Version 25, considering a two-sided p-value < 0.05 to be statistically significant. The primary outcome is the intraoperative dose of propofol (mg kg−1 min−1). Secondary outcomes include patient satisfaction, post-anesthesia care unit (PACU) length of stay, postoperative pain scores and analgesic requirements, functional outcomes, postoperative delirium, and postoperative neurocognition.DiscussionVR used as a non-pharmacological adjunct to regional and spinal anesthesia during TKA may reduce sedative requirements while maintaining patient satisfaction. If true, this approach to minimizing sedation may impact clinical outcomes including perioperative complications and length of stay for older patients, while maintaining a high degree of patient satisfaction.Trial registrationThis trial was registered on ClinicalTrials.gov on January 29, 2021. The registration number is NCT04748549.

Investigation of Abdominoplasty Without General Anesthesia: A Scoping Review

Introduction: Abdominoplasty is a common aesthetic surgical procedure primarily performed under general anesthesia (GA). However, GA is aerosol-generating and involves extended immobilization associated with systemic complications like venous thromboembolisms (VTEs). There is increasing interest in performing abdominoplasties without GA because of potential lower complication rates and shorter postoperative recovery time. This review sought to summarize all available literature on the safety and outcomes of abdominoplasty performed without GA. Methods: A scoping review was conducted with no date limits in October 2023 encompassing Medline, Embase, Web of Science, and CINAHL. The type of anesthesia was separated into 3 categories: conscious or intravenous (IV) sedation, regional anesthetic blocks (RAB: spinal and epidural), and local anesthesia (direct local infiltration and field blocks). Results: A total of 28 studies were included. Safety data was reported for abdominoplasty alone ( n = 6), with liposuction ( n = 14), or both ( n = 1). The employed anesthesia methods were IV and local ( n = 13), RAB and local ( n = 3), IV and RAB ( n = 2), IV and RAB and local ( n = 2), and IV only ( n = 1). A total of 48 379 patients were identified, with 30 cases of VTEs reported. Two studies reported GA conversion rates between 4.8% and 6.0%. A total of 11 studies assessed abdominoplasty outcomes, highlighting high patient satisfaction and low postoperative pain. The majority of analyzed studies had a “high” or “critical” risk of bias. Conclusion: Our review provides preliminary evidence that performing abdominoplasty without GA is safe and feasible. Additional high-quality studies are necessary to further validate our findings and to develop a standardized approach.