Combined Anesthesia Research Articles

Influence of Anesthesiology Protocol on the Quality of Intraoperative Nerve Monitoring During Thyroid Surgery, One-Year Single Center Experience

Background/Objectives: Anesthesia plays a very important role in the successful management of intraoperative neuromonitoring (IONM). The aim of our study was to investigate the impact of anesthesia induction and maintenance on the quality of signals during surgeries on the thyroid and parathyroid glands using neuromonitoring. Methods: The study included 72 patients who underwent surgery with IONM for one year. All the patients were intubated using a Glidescope videolaryngoscope with a hyperangulated blade. Two different approaches were used to facilitate intubation: succinylcholine-1 mg/kg and rocuronium bromide-0.3 mg/kg. For anesthesia maintenance, total intravenous anesthesia (TIVA) or combined anesthesia was used. Patients’ body movements during operations, as well as electromyography signals from the vagus and recurrent laryngeal nerves before resection, were recorded as V1 and R1. Results: Intraoperative unwanted movements were recorded in 25% of patients. Undesired movements were more frequently recorded in the TIVA group compared to the combined anesthesia group (p < 0.001) as well as in patients who received succinylcholine compared to patients who received rocuronium bromide (p = 0.028). Type of anesthesia maintenance as well as type of muscle relaxant did not affect the quality of recorded nerve signals. (p = 0.169 and p = 0.894, respectively). Conclusions: The type of muscle relaxant used significantly affects the occurrence of undesirable movements during thyroid surgery with IONM, while the type of anesthesia maintenance did not influence either the quality of the obtained signal or the occurrence of undesirable movements.

Trends in changing the structure of anesthesia at the advanced stages of medical care in modern armed conflict

The objective was to analyze the structure of anesthesia provided to the wounded at the advanced stages of medical care in the active phase of hostilities.Materials and methods. A retrospective analysis of the medical data of anesthesia was performed. The data on the structure of anesthesia in military medical organizations of 1–3 levels in the zone of a special military operation for the period from 01.2023 to 07.2024 were analyzed.Results. In the structure of combat trauma, with the need for surgical intervention, gunshot wounds amounted to 85.2%, there was a predominance of combined (71.5%) and multiple (19.8%) wounds.The low proportion of combined general anesthesia and the lack of use of inhalation anesthesia at some stages is explained by the special conditions of care. Regional anesthesia (RA), including as part of combined anesthesia, in the structure of anesthesia at the stages of emergency specialized surgical care amounted to 34.5%, and at the stages of qualified surgical care – 25.4%. The lowest rates of RA use were at the stages of level 1, as well as at the stages of level 2 with a 100% flow of primary wounded.Conclusion. RA occupies a significant share in the structure of anesthesia at the military stages of medical evacuation; an increase in the frequency of its use is possible due to the introduction of ultrasonic navigation.

The Impact of Different Anesthetics on the Distribution and Cytotoxic Function of NK Cell Subpopulations: An In Vitro Study

Only some subpopulations of natural killer (NK) cells have cytotoxic functionality, and the effects of anesthetics on these subpopulations are unknown. This study aimed to evaluate the in vitro effects of various anesthetics, both alone and in combination, on the distribution and cytotoxic function of NK cells and their subpopulations. Peripheral blood mononuclear cells (PBMCs) from eight healthy volunteers were treated for 4 h in vitro with dexmedetomidine, remifentanil, lidocaine, propofol, sevoflurane, and combinations in clinically relevant concentrations or left untreated. Flow cytometry was used to quantify the percentage of sampled NK cells and evaluate their distribution (CD56brightCD16neg, CD56brightCD16dim, CD56dimCD16neg, CD56dimCD16bright, and CD56negCD16bright) and cytotoxicity (Granzyme B (GrzB) and perforin) of NK cell subpopulations. Although the percentage of total NK cells did not change following exposure to anesthesia, the most important cytotoxic subpopulation (CD56dimCD16bright NK cells) decreased after exposure to both propofol (−3.58%, p = 0.045) and sevoflurane (−16.10%, p = 0.008) alone, and most combinations, especially in combination with lidocaine (propofol with lidocaine (−9.66%, p = 0.002) and sevoflurane with lidocaine (−21.90%, p < 0.001)). Dexmedetomidine and remifentanil had no effect on CD56dimCD16bright NK cells. Furthermore, no anesthetic regimen or combination altered the expression of GrzB and perforin in NK cells or NK cell subpopulations. In short, propofol and sevoflurane suppressed the highly cytotoxic phenotype (CD56dimCD16bright) of NK cells, with those exposed to sevoflurane combinations showing greater reductions. Immunosuppression was intensified with the inclusion of lidocaine in the anesthetic regimen.

Effect of endoscopic ultrasound guided celiac plexus block on the palliation of pain in chronic pancreatitis (EPOCH Trial): study protocol for a randomized multicenter sham-controlled trial {1}

BackgroundCeliac plexus block has been commonly utilized for the treatment of chronic pancreatitis-associated abdominal pain. Prospective studies suggest efficacy in 30 to 50% of patients, although no randomized sham-controlled trials have been performed. The objective of this study is to assess the effect of endoscopic ultrasound (EUS)-guided celiac plexus block on abdominal pain in patients with documented chronic pancreatitis. MethodsThis is a two-arm randomized sham-controlled trial with blinded evaluators. The study will be conducted at multiple academic sites in the United States who are members of the United States Pancreatic Disease Study Group (USPG). Patients referred for EUS to exclude chronic pancreatitis as a cause of abdominal pain as well as those with established painful chronic pancreatitis undergoing EUS for another indication will be eligible. At the time of EUS with confirmation of chronic pancreatitis by standard EUS diagnostic criteria, patients will be randomized to either celiac plexus block or sham whereby an anesthetic and steroid combination will be injected into the celiac plexus or saline will be injected into the gastric lumen with the same type of needle as used for celiac plexus block, respectively. The main outcome measure will be a 50% reduction in abdominal pain using the Brief Pain Inventory Short Form (BPI-SF) at 1 month post-intervention. A number of secondary outcomes will be measured including visual analog scale (VAS), Comprehensive Pain Assessment Tool Short Form (COMPAT-SF) pain scores, and quality of life using a pancreas-specific validated measure (PANQOLI).DiscussionIn this study, the effect of celiac plexus block on abdominal pain in patients with chronic pancreatitis will be compared to a sham intervention. This randomized trial will offer a definitive assessment of the role of celiac plexus block for the treatment of abdominal pain in this setting.Trial registration {2}ClinicalTrials.gov NCT 06178315. Registered on December 21, 2023

Epidural analgesia in the perioperative period and mean arterial pressure as risk factors for postoperative complications after pancreaticoduodenectomy

Objective. To study the influence of epidural analgesia and mean arterial pressure as risk factors for the development of postoperative pancreatic fistula, delayed evacuation of gastric contents and postpancreatic bleeding after pancreaticoduodenectomy. Materials and Methods. The retrospective study included 234 patients who underwent pancreaticoduodenectomy at the National Research Center of Surgery and Transplantation named after O. O. Shalimov from January 2022 to November 2023. The surgical intervention included a standard pancreaticoduodenectomy according to the modified Child's technique. The objective was to evaluate the optimal approach to anesthesia and blood pressure management to minimize the risk of postoperative complications. Data were collected on the type of anesthesia (general anesthesia or a combination of general anesthesia and epidural analgesia), mean arterial pressure, use of vasopressors, and the incidence of postoperative complications. The analysis was performed using logistic–binomial regression to assess the risk of complications depending on the level of blood pressure and the use of epidural analgesia. Results. The combined use of epidural analgesia and general anesthesia was associated with a decrease in the incidence of clinically significant postoperative pancreatic fistula, delayed evacuation of gastric contents, and other complications. Epidural analgesia, although associated with an increased risk of hemodynamic instability, contributed to better pain control and a reduction in the incidence of postoperative complications. A decrease in mean arterial pressure by each 1 mm Hg increases the risk of postoperative pancreatic fistula by 15.8%, which confirms the importance of maintaining an adequate level of pressure to ensure optimal tissue perfusion. Despite the hypothesis of a possible negative effect of vasopressors, their use did not show a statistically significant association with the incidence of postoperative pancreatic fistula. Thus, further studies are needed to clarify the optimal parameters of patient management after pancreaticoduodenectomy.

Electrocardiogram assessment in long-eared hedgehogs (Hemiechinus auritus) following administration of anesthetics

Anesthesia in animals is a crucial requirement for conducting surgery, diagnostic imaging, and other procedures when the animal cannot be safely managed in a conscious state. The present study aimed to compare the impact of different anesthetic techniques on the electrocardiogram of hedgehogs. The animals were given three different anesthetic combinations: ketamine + xylazine, ketamine + diazepam, and ketamine + midazolam. The study measured the heart rate, duration, and amplitude of the P wave, QRS complex, and T wave through bipolar II derivations. Normal sinus rhythm was observed following induction by all anaesthetic combinations; however, the combination of ketamine and xylazine resulted in a significant decrease in heart rate. The P wave was positive with different combinations of anesthetics. The mean amplitude of the P wave in hedgehogs anesthetized using ketamine+xylazine was significantly lower than when using ketamine+diazepam and ketamine+midazolam. The QRS polarity was positive in leads I, II, and aVF after anesthesia induced by all combinations. The duration and amplitude of the QRS complexes did not differ significantly between all combinations. Hedgehogs anesthetized with ketamine+midazolam revealed the highest amplitude of the QRS (0.23 mv), while in the ketamine+diazepam anesthetized group, lowest amplitude (0.18 mv) was observed. The T wave was positive in all leads except leads III and aVR. Animals anesthetized with ketamine + xylazine had the lowest amplitude (0.117 mv) and the longest duration (0.08 s) of the T waves. The findings suggest that ketamine+midazolam is the choice combination based on ECG evaluation in hedgehogs.

A retrospective study of the safety and efficacy of peritoneal dialysis catheter placement under combined local infiltration anesthesia and monitored anesthesia care

ObjectiveGiven the lack of global consensus on anesthesia selection for peritoneal dialysis catheter (PDC) placement via open surgery, this study investigates the safety and efficacy of combining local infiltration anesthesia (LIA) with monitored anesthesia care (MAC) in patients with end-stage renal disease (ESRD).MethodsThis retrospective analysis of ESRD patients who underwent open surgical placement of PDC in the Department of Nephrology, the First Affiliated Hospital of the Army Medical University from 1 August 2020 to 31 May 2022. Patients were categorized into two groups based on anesthesia method: LIA group and LIA + MA group. MA was defined as preoperative sedation (0.2–0.7 µg/kg/h) with dexmedetomidine injection (Huidrican trade name, DEX), and intraoperative analgesia with dexrazoxane injection (Garonin trade name, DEZ) as appropriate according to the patients’ pain scores. We compared the general clinical data of the two groups of patients, the changes in blood pressure and heart rate during the whole operation, the intraoperative and postoperative pain, the total duration of the operation and the immediate postoperative complications.ResultsThe study included 123 patients (59 in the LIA + MAC group and 64 in the LIA group). The LIA + MA group exhibited lower pain scores measured by Visual Analogue Scale(VAS) during surgery (skin incision, subcutaneous adipose tissue dissection, anterior fascia, muscle traction, posterior fascia, peritoneum, and catheterization) compared to the LIA group(p<0.05). In terms of surgical incisions, to intraoperative pain scores (VRS), the LIA + MA group showed higher score level I and lower score level II compared to the LIA group (p = 0.002, 0.004, respectively). The LIA + MA group experienced lower postoperative resting pain (NRS) and VAS than the LIA group (p = 0.001,0.003, respectively). The surgical duration for the LIA + MA group was shorter than that of the LIA group (p<0.001). Preoperative systolic and diastolic blood pressures (SBP and DBP) were higher in the LIA + MA group compared to the LIA group (p<0.001,<0.001, respectively). Postoperative heart rate and DBP were lower in the LIA + MA group (p<0.001, 0.004, respectively). The LIA + MA group exhibited greater changes in heart rate, SBP, and DBP during and after surgery compared to the LIA group (p = 0.009, <0.001,<0.001, respectively). In terms of immediate postoperative complications, the proportion of patients requiring analgesics within 24 h post-surgery was significantly lower in the LIA + MA group (p = 0.031).ConclusionOpen surgery for PDC placement under LIA + MAC is both safe and effective.

Effects of Intraoperative Opioid Use and a Combined Anesthesia Protocol in Patients Undergoing Radical Cystectomy for Urothelial Carcinoma of the Bladder—A Single-Center Experience

Background: An increased intraoperative opioid dose seems to lead to worse outcomes in several types of cancer. We assessed the effect of intraoperatively administered opioids as well as the type of anesthesia on survival, recurrence rates and major perioperative outcomes in patients who underwent radical cystectomy (RC) for urothelial carcinoma of the urinary bladder. Methods: We included patients who underwent open RC at our center between 2015 and 2022. The role of the type and dosage of intraoperative opioid agents, such as remifentanil, sufentanil and morphine milligram equivalents (MME), as well as the type of anesthesia (intravenous only versus intravenous/epidural), was assessed regarding perioperative and long-term outcomes after RC. Results: A total of 508 patients with a median age of 73 years (IQR: 64–78) were included. Overall, 92 (18%) patients received intravenous anesthesia, whereas 416 (82%) received combined anesthesia. At a median follow-up of 270 days (IQR: 98–808), 108 (21%) deaths and 106 (21%) recurrences occurred. Combined anesthesia was associated with better survival (HR:0.63, 95% CI: 0.4–0.97, p = 0.037) and lower intensive care unit admission rates (OR: 0.49, 95% CI: 0.31–0.77, p = 0.002) in the univariate analysis (unadjusted). The type and dosage of intraoperative opioid agents did not affect long-term survival and recurrence rates, as well as major perioperative outcomes. Nevertheless, the findings of our study were limited by its single-center, retrospective design. Conclusion: The use of intraoperative opioids was not associated with worse outcomes in our cohort, while the use of additional epidural anesthesia seems to be beneficial in terms of overall survival and intensive care unit admissions. Nevertheless, further research is mandatory to validate the safety of opioids in patients undergoing RC.

Use of porous adhesive cement for fixation of fragments in fractures of the lower jaw

BACKGROUND:The preferred method of treating mandibular fractures is surgical, but it also has problems due to a number of complications associated with the presence of a metal structure in the surgical wound. AIM:To improve the efficiency of surgical treatment for mandibular fractures by developing and experimentally testing amethod for fixing mandibular fragments using porous adhesive cement. MATERIAL AND METHODS:The experiments were performed on 30male Agouti guinea pigs, which were divided into two groups: the main group— 20animals, the comparison group— 10guinea pigs. A mandible fracture was modeled in all animals. In the main group, the fragments were fixed with porous glue-cement “Rekost”, in the comparison group— with abone wire suture. All animals received prophylactic antibacterial therapy. All manipulations were performed under combined anesthesia. The statistical significance of the differences in the compared groups was assessed using Fisher's criterion. For all comparisons, the selected level of statistical significance was 5% (p≤0.05). RESULTS:The use of the method developed by us for fixation of bone fragments in mandible fractures allowed us to achieve a positive result in all 20laboratory animals included in the study. This was confirmed by the results of histological studies in the dynamics of observation: a reliable difference was established between the main group and the comparison group in the severity of inflammation signs on the 14th day, as well as the severity of regeneration signs. It was found that the use of porous glue-cement for fixation of mandible fragments, in contrast to bone wire suture, allows for reliable consolidation of bone fragments for the entire period of treatment (according to X-ray diagnostic data) and to stop by the 14th day (according to histological studies) signs of inflammation in the bone wound (no leukocyte infiltration and vascular congestion). In this case, the glue allows filling the fusion area with developing bone tissue by the 90th day of observation (according to histological studies) and excluding repeated surgical intervention to remove the fixing structure, since the porous adhesive cement, according to histological studies, was absorbed by the 90th day of observation, which indicates its biodegradable properties. CONCLUSION:The use of porous adhesive cement for fixation of mandibular fragments demonstrated better properties compared to bone wire suture.

Evaluation of Oral Pregabalin as a Preemptive Adjuvant for Postoperative Pain in Patients Undergoing Coronary Artery Bypass Grafting With General Anesthesia and High Thoracic Epidural: A Randomized Controlled Study.

Aim This study aimed to evaluate the effectiveness of oral pregabalin as a preventive supplement in managing postoperative pain in patients undergoing coronary artery bypass grafting (CABG) with a combination of general anesthesia and high thoracic epidural anesthesia. Material and methods This 18-month randomized controlled study at a tertiary hospital's anesthesiology department included 62 American Society of Anesthesiologists (ASA) II or III patients aged 35-75 with left ventricular ejection fraction >35%. Placebo (Group B, n = 31) or pregabalin (Group A, n = 31) was randomly allocated. Group A got 150 mg of pregabalin the night before surgery and 75 mg on postoperative days 0 and 1, whereas Group B received a placebo. Postoperative pain was evaluated using the Verbal Numerical Scale and Visual Analogue Scale, while sedation was assessed with the Ramsay Sedation Scale. Statistical analysis was performed using SPSS for Windows, Version 16.0 (Released 2007; SPSS Inc., Chicago). Results In this study, pregabalin significantly reduced postoperative pain on Day 0 and Day 1 (p < 0.001) compared to the placebo. The pregabalin group exhibited higher sedation scores on Day 0 (p < 0.001), but there were no significant differences on Day 1. Inotrope requirements were similar between both groups. Conclusions CABG patients' postoperative pain was greatly reduced by pregabalin without impacting sedation or inotrope needs. These data imply that pregabalin was a useful supplementary analgesic for CABG patients' multimodal pain treatment.

Buprenorphine with Bupivacaine 0.5% Heavy Versus Clonidine with Bupivacaine 0.5% Heavy Versus Bupivacaine 0.5% Heavy Alone in Patients Undergoing Total Abdominal Hysterectomy: A Comparative Study

Background and Aims: This research aimed to determine which of three spinal anaesthetic medication combinations—clonidine–bupivacaine, buprenorphine–bupivacaine and bupivacaine alone—is the most effective for total abdominal hysterectomy. Material and Methods: In this prospective study, approved by the Institutional Ethical Committee, 120 patients aged 35–60 years scheduled for elective total abdominal hysterectomy under spinal anaesthesia were included, following informed consent. Comprehensive pre-anaesthetic assessments, including detailed medical histories, clinical examinations and routine surgical investigations, were conducted. The study, spanning 24 months, utilised purposive sampling and a cross-sectional design. The inclusion criteria encompassed ASA I and II patients aged 35–60 years, undergoing elective total abdominal hysterectomy with a weight exceeding 45 kg, height over 150 cm, and valid informed consent. Exclusion criteria involved ASA Class III or higher, patient unwillingness for spinal anaesthesia, gross spinal deformities, bleeding diathesis, known allergy to the test drug, history of cardiac, respiratory, or central nervous system disease, hepatic or renal dysfunction and elevated intracranial pressure. Results: The onset time of sensory blockade was faster in the Bupivacaine + Buprenorphine group than in the Clonidine + Bupivacaine group, with the Bupivacaine group exhibiting the slowest onset. The Bupivacaine + Buprenorphine group had a significantly faster onset of motor block than the Clonidine + Bupivacaine and Bupivacaine groups. The total duration of motor block was shorter in both the Bupivacaine + Buprenorphine and Bupivacaine groups than in the Clonidine + Bupivacaine group. The Clonidine + Bupivacaine group showed higher incidences of bradycardia and hypotension than the other groups. The Bupivacaine + Buprenorphine group reported more side effects, including chest pain, cough, nausea and vomiting, than the other groups. Conclusion: This study found that spinal clonidine, in comparison to bupivacaine alone, gives better post-operative analgesia and sensory and motor blockage over a longer period of time.

Remimazolam in intensive care unit: Potential applications and considerations.

This manuscript explores the potential use of Remimazolam in the intensive care unit (ICU) and critical care units, considering its pharmacological characteristics, clinical applications, advantages, and comparative effectiveness over current sedatives and anesthetics. We reviewed existing PubMed and Google Scholar literature to find relevant studies on Remimazolam in ICU. We created search criteria using a combination of free text words, including Remimazolam, critical care, intensive care, sedation, anesthesia, pharmacokinetics, and pharmacodynamics. Relevant articles published in the English language were analyzed and incorporated. Remimazolam is an ultra-short-acting benzodiazepine derivative promising for sedation and anesthesia. It is a safer option for hemodynamically unstable, elderly, or liver or kidney issues. It also has comparable deep sedation properties to propofol in the ICU. Furthermore, it reduces post-procedural delirium and patient comfort and reduces the need for additional sedatives in pediatric patients. In conclusion, Remimazolam is an excellent alternative to current sedatives and anesthetics in the ICU. Its cost is comparable to that of current medications. Further research on its long-term safety in the ICU and its broader application and incorporation into routine use is necessary.

Evaluation of Anaesthetic Efficacy of Xylazine-Ketamine-Guaifenesin Combination for Relieving Dystocia in Buffaloes

Background: Dystocia in dairy animals remains major concern causing huge economical losses of farmers. Over the past years, field veterinarian relieves dystocia via maneuvering, fetotomy, modified Schaffers and cesarean methods under local or regional anaesthesia which is always stressful and painful procedure leading to excessive tissue damage. Considering the involved stress and further conception during relieving dystocia under local or regional anaesthesia is always questionable. Hence, the present study was aimed to relieve dystocia in buffalo without stress by improving gentle handling of uterus during cesarean or obstetrical method under the anaesthetic combination of xylazine-ketamine-guaifenesin under field condition. Methods: The present study was undertaken in twelve clinical cases of buffaloes with history of dystocia irrespective of age and breed and they were sedated with xylazine and subjected to obstetrical or cesarean procedure under ketamine and guaifenesin anaesthetic protocol. Result: Twelve buffaloes with average age between 3-8 years and body weight 389.66±19.56 kg reported to hospital and amongst them eight were primiparous. Among maternal dystocia, uterine torsion was most common followed by incomplete cervical dilation whereas in foetal dystocia, malpositioned foetus and emphysematous foetus was reported. Tachycardia and hypothermia were consistent findings in all animals. The alkaline phosphatase, SGPT and SGOT has been increased significantly due to muscular damage. Mean duration of general anaesthesia required for obstetrical and cesarean procedure was 35.00±0.25 min and 132.00±0.18 min, respectively. The present study was concluded that, use of ketamine-Guaifenesin combination premedicated with xylazine hydrochloride produced excellent muscle relaxation during obstetrical and cesarean procedure in buffaloes characterized by loss of abdominal muscle tone, stable respiration and minimal cardiopulmonary changes.

Xylazine-Ketamine Outperforms Diazepam-Ketamine in Rabbit Anesthesia

Background: Limited research on the effects of ketamine combinations on rabbit anesthesia underscores the need for safe and effective injectable methods. Specific Background: This study compares the efficacy and safety of two anesthetic combinations—xylazine-ketamine and diazepam-ketamine —in rabbits to address this gap. Knowledge Gap: Ketamine combinations are commonly used in rabbits, but there is limited data on their effects on analgesic properties and anesthesia duration. Aims: The study assesses the onset of righting reflex loss, analgesia duration, recumbency duration, and standing attempts in rabbits treated with XK and DK. Results: Ten healthy rabbits were administered XK (5 mg xylazine and 10 mg ketamine per kg) or DK (1 mg diazepam and 30 mg ketamine per kg) intramuscularly. The study found no significant difference in OLRR between the groups. Only XK produced significant analgesia (OA: 4.5±0.2 min, DA: 45.1±1.9 min), while DK showed no analgesic effect. DR and ATS were significantly shorter in XK (56.1±3.1 min and 7.3±0.7 min) compared to DK (121.1±7.5 min and 25.3±1.2 min). Novelty: The study compares XK and DK in rabbits, finding XK provides superior analgesia and faster recovery times, while DK is ineffective for pain management. Implications: The study indicates that XK is more effective for analgesic procedures, while DK is recommended for painful treatments with additional analgesics. Highlights: XK Provides Analgesia: Only Xylazine-Ketamine offers significant pain relief. Shorter Recovery Time: XK results in quicker recovery compared to DK. DK Needs Supplement: Diazepam-Ketamine requires additional analgesics for pain management. Keywords: Anesthesia, Xylazine-Ketamine, Diazepam-Ketamine, Rabbits, Analgesia

Intracameral Anaesthetic Mydriatic Versus Topical Mydriasis in Pediatric Cataract Surgery: A Randomized Control Study

To compare pupil dynamics after using premixed intracameral anesthetic mydriatic combination (ICAM) of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) versus topical mydriatic (TM) drops consisting of tropicamide 0.8%, phenylephrine 5%, and cyclopentolate 0.5% in pediatric cataract surgery. Randomized, masked, fellow eye-controlled trial. Tertiary eye care facility. Children ≤12 years of age with bilateral cataracts planned for surgery. One eye was randomized to receive ICAM and the other eye (control) TM drops. Commercially available ICAM that was injected at the beginning of surgery or TM 3 times at an interval of 30 minutes, 1 hour before the scheduled time of surgery. The other treatment was administered for the second eye cataract surgery. Pupil dynamics at various points of surgery were studied by a masked observer. Sixty-three patients (126 eyes) were randomized to receive ICAM in 1 eye (group 1) or TM drops (group 2). The mean age of the children in the study was 15.7 ± 24.3 months (range 3 months to 5 years). Adequate mydriasis with a single injection was achieved in 93.5% of patients in group 1 and 88.8% of patients in group 2 without additional pharmacotherapy or intervention. The mean pupillary diameter increased from 1.78 mm to 5.1 mm after injection of 1 unit of ICAM and from 1.75 mm to 6.06 mm with TM drops (P < .0001). The maximum pupillary dilation achieved was 6.06 ± 1.17 mm in group 1 and 6.75 ± 1.07 mm in group 2 (P = .004). The average change in pupillary size from injection of drug until the end of surgery was positive in group 1 (0.75 ± 0.98 mm) and negative in group 2 (-0.3348 ± 2.57 mm), ie, there was a relative miosis in group 2 toward the end of surgery (P = .001). Topical drugs achieved a larger maximum pupil size compared with ICAM. However, ICAM provided adequate and stable mydriasis without the need for augmentation compared with topical drops in children undergoing cataract surgery.

High frequency variability index in predicting postoperative pain in video/robotic-assisted thoracoscopic surgery under combined general anesthesia and peripheral nerve block: an observational study.

The high frequency variability index (HFVI)/analgesia nociception index (ANI) is purported to assess the balance between nociception and analgesia in patients under general anesthesia. This observational study investigated whether intraoperative HFVI/ANI correlates with postoperative pain in patients performed with nerve block under general anesthesia in video/robotic-assisted thoracoscopic surgery (VATS/RATS). We investigated whether maximum postoperative pain at rest and postoperative morphine consumption are associated with HFVI/ANI just before extubation, mean HFVI/ANI during anesthesia, the difference in HFVI/ANI between before and 5min after the start of surgery, and the difference in HFVI/ANI between before and 5min after the nerve block. Data obtained from 48 patients were analyzed. We found no significant association between HFVI/ANI just before extubation and postoperative Numerical Rating Scale (NRS) score. Receiver operating characteristic curve analysis revealed that moderate (NRS > 3) or severe (NRS > 7) postoperative pain could not be predicted by HFVI/ANI just before extubation. In addition, there were no associations between postoperative morphine consumption and HFVI/ANI at any time points. The present study demonstrated that it is difficult to predict the degree of postoperative pain in patients undergoing VATS/RATS under general anesthesia combined with peripheral nerve block, by using HFVI/ANI obtained at multiple time points during general anesthesia.

Application of combined anesthesia with spontaneous breathing in the surgery of intertrochanteric fracture of femur in elderly patients.

This study aims to investigate the feasibility and safety of combined anesthesia with spontaneous breathing in the operation of intertrochanteric fracture of femur in the elderly. Between January 2020 and January 2023, a total of 141 elderly patients (45 males, 96 females; mean age: 72.5±6.8 years; range, 65 to 87 years) who underwent proximal femoral nail anti-rotation (PFNA) surgery for intertrochanteric fracture of femur were included in this single-blind, prospective, randomized-controlled study. The patients were randomly divided into three groups. Group A (experimental group) was a general anesthesia with laryngeal mask airway (LMA) group preserving spontaneous breathing, Group B (control group 1) was a general anesthesia with LMA group for mechanical ventilation, and Group C (control group 2) was a tracheal intubation anesthesia group for mechanical ventilation. The differences of related indexes among the three groups were compared. The mean onset time of anesthesia (6.23±1.45 vs. 12.78±2.78 vs. 13.73±2.43 min), postoperative recovery time of consciousness (8.13±0.83 vs. 11.34±0.89 vs. 12.45±0.86 min), and postoperative complete awakening time (10.45±2.34 vs. 18.87±2.56 vs. 19.62±2.93 min) were significantly shorter in Group A than in Groups B and C (p<0.05). The duration of analgesic effect was longer in Group A than in Groups B and C (p<0.05). After anesthesia, the Ramsay Sedation Scale and Visual Analog Scale (VAS) scores were significantly lower in Group A than the other groups (p<0.05). The mean Mini-Mental State Examination (MMS) scores were significantly higher in Group A than in Groups B and C (p<0.05). Hemodynamic parameters showed that blood pressure, heart rate, cardiac output, and cardiac index (CI) levels were significantly higher in Group A than the other groups (p<0.05). Our study results indicate that combined anesthesia preserving spontaneous breathing is safe and feasible in the operation of intertrochanteric fracture of femur in the elderly, with faster anesthesia recovery than the mechanical ventilation group.

Selective opioid agonist Taphalgin® as a component of postoperative analgesia in various surgical areas: “NIKITA” observational multicenter study

Introduction. The role of peptides in antinociceptive system regulation has became a subject of interest for scientists worldwide. The first registered peptide analgesic tyrosyl-D-arginyl-phenylalanyl-glycinamide acetate which currently can be used in clinical practice was developed in Russia under the name Taphalgin® (PharmFirma “Sotex”, Russia). The effectiveness and safety of this pharmaceutical in postoperative pain management was evaluated in the all-Russia multicenter prospective observation program NICITA (Non-interventional Clinical Trial of Taphalgin ®).Aim. To analyze the effectiveness and safety of Taphalgin® in postoperative pain management in various surgical fields.Materials and methods. The observational program NICITA included 887 patients including patients with malignant tumors of various locations from 15 study centers in different Russian cities. All patients underwent surgical interventions in various anatomical areas under general, regional and combination anesthesia. The principal scheme of postoperative pain management was based on the multimodal approach which included peptide opioid agonist alongside acetaminophen, cyclooxygenase inhibitors in combination with regional anesthesia or without it. The study also included patients who underwent small-volume surgeries, and pain was managed through Taphalgin® monotherapy with subsequent switch to cyclooxygenase inhibitors. The primary endpoint of the NICITA observational program was response to therapy after the first Taphalgin® administration. Decreased pain syndrome per the numerical rating scale 15–60 min after subcutaneous injection and maintenance of analgesic effect 3 h later were considered treatment response. The secondary endpoints included mean time to analgesia start after administration of the 1st single drug dose (in min), duration of effect, types and frequency of adverse reactions including serious in the central nervous system, pulmonary system, gastrointestinal tract developed during the observational program, as well as patient and research physician satisfaction with pain management. To evaluate the significance of pain intensity change at rest and in motion in time, analysis of variance with repeat measurements was used; for pairwise comparison of two time periods, Student’s t-test for dependent samples was used. The differences were considered significant at p = 0.05.Results. Statistically significant decrease in pain intensity in the total patient group was observed 15 minutes after Taphalgin® administration; it reached its minimum 40 min after the injection (р &lt;0.05). The percentage of patients responding to analgesic therapy with Taphalgin® was 96.5 %. During administration of the drug, insignificant decrease (10–15 mmHg) in arterial blood pressure (1.7 % of cases) and vertigo (1 % of cases) were observed. In some patients, several adverse reactions were observed. Satisfaction with analgesic effect of Taphalgin® was relatively high both in patients and research physicians.Conclusion. Taphalgin® has pronounced analgesic effect and is effective for pain management after surgical interventions of various volumes and injury level. The use of this drug is associated with low rate of adverse reactions and absence of pulmonary depression characterizing opioid agonists. Therefore, Taphalgin® can be recommended for clinical use for postoperative pain management after various types of surgical interventions.

Effective Epidural Analgesia during Labor: A Feasible Method to Decrease Unnecessary Cesarean Deliveries in Thailand

Thailand has reported a high rate of cesarean delivery (45%–55%), prompting global concern about an increase in cesarean delivery rates. Fear of labor pains is one of the most common reasons pregnant women opt for cesarean delivery. Labor pain is associated with cervix dilation and fetal descent into the birth canal, which is exacerbated by ischemic pain caused by uterine contraction. Modern medical and non-medical techniques have demonstrated efficacy in reducing pain and ensuring safety during labor and delivery. Neuraxial labor analgesia is a highly effective medical pain relief method but has no effect on the rate of cesarean or assisted vaginal delivery. Medication administration for pain relief during labor, using a combination of a local anesthetic and an opioid, was observed to be transmitted across the placenta to the fetus, but had no significant effects on fetal outcomes in mothers who chose epidural analgesia. There are several techniques for administering neuraxial labor analgesia that can be customized for each pregnant woman. To achieve the most wonderful feasible labor and delivery experience, effective epidural labor analgesia is a crucial technique for reducing anxiety and suffering about labor pain. It is safe, widely used world-wide, and effective. Implementing a policy to increase public and medical providers awareness and acceptance of labor pain relief, as well as establishing a safe obstetric anesthesia service provided by obstetric anesthesiologists, could improve maternal and neonatal safety while significantly lowering the rate of unnecessary cesarean deliveries.

Assessing the Risks and Benefits of Hypotensive Anesthesia and Piezosurgical Instruments in Bimaxillary Surgery.

The challenge in bimaxillary surgery lies in significant intraoperative bleeding, prompting various strategies to minimize blood loss. Among the methods considered for controlling intraoperative bleeding, hypotensive anesthesia and the use of piezosurgical instruments (Osada, Tokyo, Japan) have been explored. However, hypotensive anesthesia may have adverse effects on cardiac function, and surgical time is likely to be prolonged when using piezosurgical instruments. This study retrospectively examined whether the combined use of hypotensive anesthesia and piezosurgical instruments reduces intraoperative bleeding and whether the combination impacts cardiac function. The combination of hypotensive anesthesia and piezosurgical instruments significantly reduced intraoperative bleeding. Furthermore, the combination was associated with a significantly higher incidence of tachycardia, particularly with the use of nicardipine. Additionally, the combination significantly lengthened the duration of the surgery and may have increased the burden on cardiac function. Landiolol was effectively employed to manage tachycardia. When selecting hypotensive anesthesia as a means to limit bleeding, proactive preparation and preventive small-dose administration of landiolol could be beneficial in managing the potential occurrence of tachycardia.