Anaesthetic Practice Research Articles

Recommendation for the practice of total intravenous anesthesia.

This Recommendation was developed by the Japanese Society of Intravenous Anesthesia Recommendation Making Working Group (JSIVA-WG) to promote the safe and effective practice of total intravenous anesthesia (TIVA), tailored to the current situation in Japan. It presents a policy validated by the members of JSIVA-WG and a review committee for practical anesthesia management. Anesthesiologists should acquire and maintain the necessary knowledge and skills to be able to administer TIVA properly. A secure venous access is critically important for TIVA. To visualize and understand the pharmacokinetics of intravenous anesthetics, use of real-time pharmacokinetic simulations is strongly recommended. Syringe pumps are essential for the infusion of intravenous anesthetics, which should be prepared according to the rules of each individual anesthesia department, particularly with regard to dilution. Syringes should be clearly labeled with content and drug concentration. Whenmanaging TIVA, particularly with the use of muscle relaxants, monitoring processed electroencephalogram (EEG) is advisable. However, the depth of sedation/anesthesia must be assessed comprehensively using various parameters, rather than simply relying on a single EEG index. TIVA should be swiftly changed to an alternative method that includes inhalation anesthesia if necessary. Use of antagonists at emergence may be associated with re-sedation risk. Casual administration of antagonists and sending patients back to surgical wards without careful observation are not acceptable.

Multimodal Analgesia and Small Opioid Prescriptions are the New Standard in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership

BackgroundThe purpose of this survey study was to assess the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS) as well as identify changes in practice made by AAHKS members over time. MethodsA survey of 37 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 3,243 practicing adult reconstruction surgeon members of AAHKS in May 2023. Results were compared to a nearly identical survey sent out to all board-certified adult reconstruction surgeon members of AAHKS 5 years previously in November 2018. ResultsThere were 527 responses (16%) to the survey. Since 2018, the mean number of opioid pills prescribed after total joint arthroplasty has declined significantly from 49 to 32 pills after total knee arthroplasty (TKA) and from 44 to 18 pills after total hip arthroplasty (THA). The use of multimodal analgesics in addition to opioids has also increased over the past 5 years from 74 to 93%. The most common medications utilized include nonsteroidal anti-inflammatories (98%), acetaminophen (80%), and gabapentinoids (32%). A majority of surgeons (78%) still use a spinal for TKA and THA. However, there has been an increase in the number of surgeons using peripheral nerve blocks for TKA from 69% in 2018 to 84% in 2023. The routine use of periarticular injection or local infiltration anesthesia in THA and TKA has also increased over the past 5 years from 80 to 86%. ConclusionsSince 2018, there has been increased adoption of multimodal analgesia and anesthesia, and improved consensus regarding the optimal regimen among surveyed arthroplasty surgeon members of AAHKS. The number of opioid pills prescribed after THA and TKA has declined significantly over the past 5 years.

Update on the Obstetric Anesthesia Practice in Flanders/Belgium: A 10-year follow-up survey and review

Background: With 75% of women receiving neuraxial anesthesia for labor and cesarean section (CS) in Flanders, Belgium, obstetric anesthesia is an essential part of perinatal care. Despite advancements in obstetric anesthesia and guidelines being updated regularly, past surveys have shown great variability among hospitals. Objective: This investigation aims to observe current obstetric anesthesia practices, compare them with previous surveys, and assess adherence to guidelines among anesthesiologists. Methods: An online questionnaire-based survey, approved by the KU Leuven Ethics Committee, was conducted focusing on three main topics: analgesia during labor, anesthesia for CS, and postoperative analgesia after CS. The survey, consisting of 127 questions, was distributed via email to the heads of anesthesia departments in 57 Flemish hospitals providing obstetric anesthesia care. Responses were anonymously analyzed. Results: For labor analgesia initiation, a conventional epidural with administration of ropivacaine 0.2% (+- sufentanil) remains the most widespread used technique, although Combined-Spinal Epidural (CSE) has gained significant popularity. Patient-controlled epidural analgesia (PCEA) in combination with continuous epidural infusion (CEI) is the preferred maintenance method, however programmed-intermittent bolus (PIEB) has found its way into standard practice. CSs are mostly done by performing CSE or single shot spinal, using hyperbaric bupivacaine 0.5% with sufentanil. Spinal-induced hypotension is treated with a combination of left lateral tilt, fluid administration and vasopressor administration, usually as a bolus. Post-CS pain is mainly treated by a combination of oral/ parenteral analgesics and neuraxial analgesia (PCEA +- CEI), with only a minority choosing regional techniques such as wound infiltration, transverse abdominal plane blocks, quadratus lumborum blocks, etc. Conclusion: Compared to previous surveys, the Flemish anesthesiologists adhere well to the latest guidelines and gold standards in obstetric anesthesia, consistently modernizing their practices. Nevertheless, with the continual introduction of novel techniques and methods, it is imperative for practitioners to maintain efforts in pursuing ongoing innovation.

Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers.

As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs. Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002). This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.

Oesophageal intubations in anaesthetic practice across Australia and New Zealand: A webAIRS analysis of 109 incidents.

Oesophageal intubations are more common than may be realised and can potentially cause significant patient harm even if promptly identified and corrected. Reports of morbidity due to unrecognised oesophageal intubation continue to present in coroner and media reports. Therefore, it would be helpful to identify mechanisms to prevent these events and implement strategies to avoid and identify incorrect endotracheal tube placement. This analysis of oesophageal intubations reported to webAIRS aims to provide an in-depth analysis of all events in which oesophageal intubation occurred. WebAIRS is a web-based, bi-national incident reporting system collecting voluntarily reported anaesthetic events across Australia and New Zealand, with more than 10,500 incidents registered. A structured search through the webAIRS database identified 109 reports of oesophageal intubation reported between July 2009 and September 2022. A common cause of oesophageal intubation was the misidentification of the larynx due to a poor laryngeal view. Desaturation directly attributed to the misplaced endotracheal tube occurred in 43% of all reports. The authors precisely defined early recognised oesophageal intubation and delayed or unrecognised oesophageal intubation. Most reports (74%) described early recognition of the misplaced intubation, of which 27% led to directly contributed to hypoxia. Cardiovascular collapse as a direct consequence of the late recognition of oesophageal intubation was described in five (18%) of these events. There was inconsistency in end-tidal carbon dioxide monitoring and interpretation of the resulting waveform. Findings show that oesophageal intubation continues to be an issue in anaesthesia. Incidents described confusion in diagnosis, human factors issues and cognitive bias. Clear diagnostic guidance and treatment strategies are required to be developed, tested and implemented.

Cesarean Section under General Anesthesia over 10 Years at Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction: The global surge in cesarean deliveries necessitates safe anesthetic practices to optimize outcomes. While the neuraxial block is the preferred method, specific conditions warrant general anesthesia. This study is aimed to determine the prevalence of cesarean sections under general anesthesia at a tertiary care center. Methods: A descriptive cross-sectional study was conducted on cesarean sections performed between April 14, 2013, and April 13, 2023, at a tertiary care center. Ethical approval was obtained from the Institutional Review Committee (Reference number: 20092023/01). Total sampling was done. Data for the past ten years were manually collected from hospital records using a self-structured proforma and analyzed using Microsoft Excel 2018 and IBM SPSS version 26. The point estimate and 95% confidence interval were calculated for the study. Results: In this study, there were 216 (2.98%) (95% CI: 2.59-3.38%) cesarean sections under general anesthesia in 10 years. Notably, among them, there were 103 (47.69%) primigravida, nullipara 130 (60.19%), 135 (62.50%) with no living children, and 161 (74.54%) without any past abortions. In most cases, 182 (84.26%) were emergency procedures and 34 (15.74%) were elective. Fetal bradycardia with distress was the primary indication observed in 121 (56.02%) cases, followed by 32 (14.81%) maternal requests. Additionally, twenty-one cases were found initially planned as cesarean sections under subarachnoid block but were converted to general anesthesia. The prevalence in this study was found within the recommended limits.Conclusions: The findings highlight that the majority of these procedures were emergency cases, predominantly due to fetal distress, with a notable proportion involving primigravida and nulliparous women.

Can the Pioneering Impact of Artificial Intelligence in Anaesthetic Practice Uphold Good Medical Practice?

The potential applications of Artificial Intelligence (AI) in anaesthesia are expansive.~However, like any technological advancement, the integration of AI in anaesthetic practice comes with both benefits and potential risks. This article seeks to set out some of the advantages and disadvantages of the use of AI technologies within the field of anaesthesia. Benefits of the application of AI in anaesthesia include an improvement in perioperative risk stratification, personalisation of anaesthetic plans, improvement in efficiency and ultimately reduce healthcare costs. However, reliance on technology may reduce clinical acumen but furthermore there are issues surrounding data quality, privacy as well as legal and ethical concerns, which require further evaluation. Whilst AI within anaesthetic practice holds immense promise, there are substantial challenges which require careful consideration and ongoing evaluation. A collaborative approach will be required from healthcare staff, developers and regulators to promote the safe, responsible, and effective application of AI in anaesthesia practice.

Cerium oxide nanoparticles (nanoceria) pretreatment attenuates cell death in the hippocampus and cognitive dysfunction due to repeated isoflurane anesthesia in newborn rats

General anesthetics exposure, particularly prolonged or repeated exposure, is a crucial cause of neurological injuries. Notably, isoflurane (ISO), used in pediatric anesthesia practice, is toxic to the developing brain. The relatively weak antioxidant system at early ages needs antioxidant support to protect the brain against anesthesia. Cerium oxide nanoparticles (CeO2-NPs, nanoceria) are nano-antioxidants and stand out due to their unique surface chemistry, high stability, and biocompatibility. Although CeO2-NPs have been shown to exhibit neuroprotective and cognitive function-facilitating effects, there are no reports on their protective effects against anesthesia-induced neurotoxicity and cognitive impairments. Herein, Wistar albino rat pups were exposed to ISO (1.5 %, 3-h) at postnatal day (P)7+P9+P11, and the protective properties of CeO2-NP pretreatment (0.5 mg/kg, intraperitoneal route) were investigated for the first time. The control group at P7+9+11 received 50 % O2 (3-h) instead of ISO. Exposure to nanoceria one-hour before ISO protected hippocampal neurons of the developing rat brain against apoptosis [determined by hematoxylin-eosin (HE) staining, immunohistochemistry (IHC) analysis with caspase-3, and immunoblotting with Bax/Bcl2, cleaved caspase-3 and PARP1] oxidative stress, and inflammation [determined by immunoblotting with 4-hydroxynonenal (4HNE), nuclear factor kappa-B (NF-κB), and tumor necrosis factor-alpha (TNF-α)]. CeO2-NP pretreatment also reduced ISO-induced learning (at P28–32) and memory (at P33) deficits evaluated by Morris Water Maze. However, memory deficits and thigmotactic behaviors were detected in the agent-control group; elimination of these harmful effects will be possible with dose studies, thus providing evidence supporting safer use. Overall, our findings support pretreatment with nanoceria application as a simple strategy that might be used for pediatric anesthesia practice to protect infants and children from ISO-induced cell death and learning and memory deficits.

Anesthesia for an infant with congenital mediastinal mass: a case report

BackgroundGiant anterior mediastinal masses in infants are one of the most challenging cases faced in pediatric anesthesia practice. They can pose unique challenges for resection such as cardiovascular collapse on induction of anesthesia and injury to surrounding structures that maybe compressed or displaced. Principles that must be followed and kept in mind during removal of giant mediastinal mass include appropriate diagnostic imaging to define mass extent, airway control during induction, a multidisciplinary team approach including cardiothoracic for sternotomy, cannulation to institute cardiopulmonary bypass, otolaryngology for rigid bronchoscopy, preservation of neurovascular structure, and complete resection whenever possible. Our patient had a mass that weighed twice his whole body weight.Case presentationHere we present a 3-month-old Middle Eastern infant weighing 3.2 kg with a large congenital teratoma who presented to the emergency room with cyanosis and respiratory distress. During his hospital course, he underwent three procedures, two of them under light-to-moderate sedation: a diagnostic computer tomography scan followed by mass content drainage by interventional radiology (Figs. 1, 2). On the third day, he had a thoracotomy with complete tumor resection under general anesthesia with the help of an epidural for pain control (Fig. 3). The resected tumor weighed 2.5 kg, which was equal to twice the patient’s total body weight (Fig. 4). After the surgery, he was extubated in the operating room and discharged home 3 days later.Fig. 1Anterior–posterior chest x-ray showing the anterior mediastinal mass (AMM)Fig. 2Cross-section computed tomography (CT) showing large anterior mediastinal mass (AMM)Fig. 3Gross anatomy of the tumor before resectionFig. 4Gross anatomy of the removed tumorConclusionAnterior mediastinal mass patients can be challenging for the anesthesiologist. They need meticulous thorough perioperative assessment to determine the extent of compression on major intramediastinal structures and to predict the complications. Planning by multidisciplinary team and discussion with the family is important. These types of cases should be preferably operated on by an experienced team in a well-equipped operation room in tertiary care institutes.

Pharmacological Insights and Clinical Applications of Ciprofol: A Narrative Review.

Ciprofol (HSK3486) is a novel intravenous anaesthetic developed as an alternative to propofol, offering a safer and more effective option in anaesthesia. It works primarily by modulating the gamma-aminobutyric acid (GABA) receptors in the central nervous system, leading to sedation and hypnosis. Ciprofol's unique pharmacological properties include a rapid onset of action, shorter duration, and reduced cardiovascular and respiratory depression compared to propofol, making it particularly suitable for outpatient and day surgery procedures.Molecular changes in ciprofol appear to be superior to those of other cibenzolines; it is more potent and has a stable hemodynamic effect. It has been used in primary surgery, inpatients and outpatients, and even for sedation of intensive care patients. The reported clinical data indicate that ciprofol is a powerful sedative that is characterised by a high-enough speed of emergence from the state of anaesthesia, which is necessary for outpatient conditions and intensive operating modes. It can be considered a new and important perspective in the technology of intravenous anaesthetics with its improved pharmacological characteristics and clinical effects. With the further accumulation of clinical data, ciprofol will undeniably become an essential agent in today's anaesthetic practice and contribute to an enhancement of healthcare efficiency by providing a more secure approach to numerous kinds of surgical interventions. The purpose of the current study is to provide a review of the pharmacology and clinical use of ciprofol, a new intravenous anaesthetic agent. Various studies demonstrate the functionality and safety profile of ciprofol, which solidifies it as a potential contender for propofol. Regarding respiratory depression, hypoxemia, and injection pain during hysteroscopy, ciprofol was shown to be a relatively safer option than propofol. Ciprofol can, therefore, be recommended for intravenous anaesthesia because of its effectiveness and safety, which has been clearly demonstrated. Randomised trials uniformly report the ability to achieve quicker onset of sedation and lower risk with the agent compared to propofol. These findings imply that ciprofol has many benefits concerning a variety of applications in patients due to a lower rate of adverse reactions and increased patient comfort.

Prilocaine vs bupivacaine in spinal anesthesia for urologic endoscopy: clinical trials & historical overview

Introduction. In the evolving landscape of anesthetic practices for short-duration urologic procedures, the quest for an anesthetic agent that balances efficacy with minimal side effects remains a significant clinical challenge.The objective was to compare the efficacy and safety of 2% hyperbaric prilocaine and 0.5% hyperbaric bupivacaine in spinal anesthesia.Materials and methods. A comparative analysis was performed in terms of onset and duration of sensory and motor block, incidence of side effects (hypotension and bradycardia), and overall patient outcomes in urologic endoscopy. The research sample was divided into two groups, each consisting of 20 patients. In one case, spinal anesthesia was performed using 2% hyperbaric prilocaine (40 mg) + fentanyl 25 mcg, in the other – 0.5% hyperbaric bupivacaine (10 mg) + fentanyl 25 mcg.Results. Prilocaine offers a faster onset of sensory and motor block and a shorter duration of sensory block compared to bupivacaine. Prilocaine also showed a quicker recovery of full motor function and had a significantly lower incidence of side effects such as hypotension and bradycardia.Conclusion. These results suggest that 2% hyperbaric prilocaine could be an alternative to 0.5% hyperbaric bupivacaine in spinal anesthesia for urologic endoscopy, especially in procedures requiring quick recovery. The promising results of prilocaine in such short-duration surgeries can also prompt a reevaluation of anesthesia protocols across various surgical interventions and lead to enhanced patient outcomes, emphasizing safety, comfort, and efficacy of surgical care.

EFFICACY OF INTRAPERITONEAL BUPIVACAINE INSTILLATION FOR POSTOPERATIVE PAIN CONTROL: A QUALITY IMPROVEMENT STUDY

Laparoscopic surgery is associated with better pain experience, reduced Length of Hospital Stay and better scar. However, the resulting postoperative pain is distinct and can be disturbing, hence the need for multimodal analgesia. The side effects of parenteral analgesics and low practice of regional anaesthesia has limited their role in multimodal analgesia. Therefore, strategies that limit the reliance on these pain control modalities will be beneficial. Our study evaluated the efficacy of intraperitoneal instillation of plain bupivacaine after laparoscopic surgeries. The double blinded randomized study enrolled 50 consenting patients who fulfilled recruitment criteria. The bupivacaine group received 20mls of 0.25% plain Bupivacaine while the saline group received 20mls normal saline instillation into the peritoneal cavity via the umbilical port of the laparoscopy device. Visual Analogue Scale (VAS) was assessed at presentation at the Post anaesthesia care unit (PACU) and at 4, 8, 12, 16, 20, 24 hours afterward. In addition, the interval between end of surgery, first request for analgesia and total analgesic requirements were recorded. The VAS at presentation was significantly lower in the Bupivacaine group compared to the saline group, however, there was no statistically significant difference at other times. In addition, there was a significant difference in time to first analgesic request in both groups. The only observed post operative complications were nausea and vomiting. Intraperitoneal Instillation of Bupivacaine is an easy, non-invasive, cheaper and safer method of pain control following laparoscopic surgery in carefully selected patients.

Pioneering Patient-Centered Surgical Care and Anesthesia Practice: Hanaoka Seishū's Contribution to Surgery During Japan's Isolationist Era.

Pioneering Patient-Centered Surgical Care and Anesthesia Practice: Hanaoka Seishū's Contribution to Surgery During Japan's Isolationist Era.

Comparison of Intravenous Ondansetron and Dexamethasone for Preventing Propofol-Induced Pain During Laparoscopic Cholecystectomy: A Double-Blind, Randomized Study.

Background Propofol is the most common induction agent used in current anesthesia practice. Patients receiving propofol injections commonly experience varying degrees of pain, creating an unpleasant anesthesia experience. Methods Seventy-two patients, aged between 18 and 70, scheduled for elective laparoscopic cholecystectomy under general anesthesia were randomized into two groups. Group D received 8 mg of dexamethasone, and Group O received 8 mg of ondansetron intravenously before induction. After five seconds, mid-arm venous occlusion was applied for one minute using a tourniquet. Propofol (0.5 mg/kg) was administered intravenously over five seconds, and patients rated the injection pain over the next 15 seconds. The primary outcome was pain intensity using the Verbal Rating Scale during propofol injection. Secondary outcomes included intraoperative hemodynamic changes and postoperative nausea and vomiting (PONV). Normally distributed variables were compared using the Student's t-test, non-normally distributed variables using the Mann-Whitney U-test, and qualitative data using the chi-square or Fisher's exact test. Statistical significance for the study was set at p < 0.05. Results In Group D, 30 out of 36 patients (83.3%) experienced no pain, while four patients (11.1%) reported mild pain, two patients (5.6%) reported moderate pain, and no patients (0.0%) reported severe pain. In contrast, in Group O, only 15 out of 36 patients (41.6%) experienced no pain, with 12 patients (33.3%) experiencing mild pain, seven patients (19.4%) experiencing moderate pain, and two patients (5.6%) experiencing severe pain. Overall, six out of 36 patients in Group D (16.7%) experienced some level of pain, compared to 21 out of 36 patients in Group O (58.3%), a statistically significant difference (p < 0.05). Regarding postoperative nausea, 16 out of 36 patients in Group Dexamethasone (44.44%) experienced nausea, whereas 23 out of 36 patients in Group Ondansetron (63.88%) reported this symptom, with the difference being statistically significant (p = 0.0372). Additionally, postoperative vomiting occurred in nine out of 36 patients in Group Dexamethasone (25%), compared to 18 out of 36 patients in Group Ondansetron (50%), with this difference also reaching statistical significance (p= 0.026). Conclusions Intravenous dexamethasone before propofol administration reduces injection pain and PONV in laparoscopic cholecystectomy more effectively as compared to ondansetron.

Antimicrobial effects of ropivacaine, levobupivacaine and bupivacaine at different temperatures

Objective: Various prior studies have shown a possible antimicrobial activity of different local anesthetic (LA) drugs. The aim of this study was to assess the antimicrobial (antibacterial or antifungal) activity of commonly used commercially available LA drugs used in regional anesthesia practice such as; ropivacaine, levobupivacaine and bupivacaine on S.aureus ATCC 6538, S. epidermidis, E.coli and Candida albicans at different temperatures. Materials and Methods: Possible antimicrobial effects of ropivacaine (1% and 0.125%), levobupivacaine (0.75% and 0.125%) and bupivacaine (0.5% and 0.125%) on S.aureus ATCC 6538, S.epidermidis, E.coli and C.albicans ATCC 10231, which were isolated from patients in the microbiology laboratory were investigated at 240C and 37C. Results: All three LA drugs showed antifungal activity at 37°C and 24°C in 3rd and 12th hours. Levobupivacaine’s (0.75%) antibacterial effect was observed at the 12th hour. Ropivacaine (1%) had relatively more antibacterial effect at the 3rd and 12th hour at 37°C rather than 24°C whereas bupivacaine had less. Conclusion: Potential clinical implications of antibacterial or antifungal effects of local anesthetics might be promising.

Comparison of the Efficacy Between Ultrasound-Guided Paravertebral Block and Erector Spinae Block for Postoperative Analgesia in Percutaneous Nephrolithotomy Using Levobupivacaine: A Prospective and Randomized Study.

Introduction Various techniques have been developed in the current era of regional anesthesia practice. With the advent of ultrasound, the visualization of needle and pleura in real time enables a better outcome with negligible adverse events. This study was designed to compare the efficacy between ultrasound-guided erector spinae plane block (ESPB) and paravertebral block (PVB) in percutaneous nephrolithotomy (PCNL) for the duration of postoperative analgesia with levobupivacaine, a local anesthetic with higher lipid solubility, making it more potent and resulting in a longer duration of action. Methods This prospective randomized single-blinded study enrolled 50 patients of ASA grades I and II, aged between 20 and 60 years, who were scheduled for PCNL under general anesthesia. Patients were divided into two groups of 25 each: group ESPB andgroup PVB, and 25 mL of 0.25% levobupivacaine was administered to both groups. They were primarily evaluated for the duration of postoperative analgesia. Total rescue analgesic requirements, hemodynamic parameters, and any adverse effects were also assessed. Results Both ESPB and PVB provided a significant duration of analgesia postoperatively. Demographic characteristics in both groups were comparable. The duration of postoperative analgesia in group ESPB was 746 ± 58.6 minutes when compared to group PVB, which is 768 ± 68.6 minutes (p = 0.08). Intravenous (IV) paracetamol was used as a rescue analgesic. The doses used were also comparable in both groups, with the visual analog score (VAS) being high after around 12 hours of surgery. The total rescue analgesic requirement was similar in both groups (group ESPB, 2.0 ± 1.6; group PVB, 2.2 ± 1.4; p = 0.51). There were no significant hemodynamic or other adverse effects in either group. Conclusion We conclude that both ESPBand PVB using isobariclevobupivacaine 0.25% as a local anesthetic are equally efficacious in providing effective postoperative analgesia in patients undergoing PCNL under generalanesthesia.

Effectiveness of Ondansetron and Metoclopramide in Management of Post-Operative Nausea and Vomiting in Laparoscopic Surgeries

Post-operative nausea and vomiting (PONV) is one of the most complicated and serious problems with anesthesia and surgical practices that may occur separately or in combination, and without prophylactic intervention. It is account for one third of patients under general anesthesia. This study aims to compare the efficacy of Ondansetron and Metoclopramide on post-operative nausea and vomiting in laparoscopic surgery. Data of four studies were integrated with a total number of 979 patients. Then, PONV in accordance to Ondansetron and Metoclopramide was analyzed and calculated. The results show that the incidence of PONV in metoclopramide patient’s group was (423/979) 43% and in ondansetron patient’s group was (404/979) 41%. There was no clear difference between the two groups. However, Ondansetron was slightly effective than metoclopramide in reducing PONV.

Beyond adverse events in anesthesiology: 'unanticipated events' and strategies for improved reporting.

Patient safety in anesthesiology has advanced significantly over the past several decades. The current process of improving care is often based on studying adverse events (AEs) and near misses. However, there is a wealth of information not captured by focusing solely on these events, potentially resulting in missed opportunities for care improvements. We review terms such as AEs and nonroutine events (NREs), and introduce the concept of unanticipated events (UEs), defined as events that deviate from intended care that may/may not have been caused by error, may/may not be preventable, and may/may not have caused injury to a patient. UEs incorporate AEs in addition to many other anesthetic events not routinely tracked, allowing for trend analysis over time and the identification of additional opportunities for quality improvement. We review both automated and self-reporting tools that currently exist to capture this often-neglected wealth of data. Finally, we discuss the responsibility of quality/safety leaders for data monitoring. Consistent reporting and monitoring for trends related to UEs could allow departments to identify risks and mitigate harm before it occurs. We review various proposed methods to expand data collection, and recommend anesthesia practices pursue UE tracking through department-specific reporting interfaces.

Comparison of the effect of lidocaine and its combination with melatonin and the Valsalva maneuver on etomidate induced injection pain

Background &amp; Objective: Etomidate is commonly used in anesthesia practice because of its rapid recovery time, low incidence of apnea, and lower incidence of allergic reactions; but pain upon injection is one of the unfavorable complications of this drug, which can cause both physical and mental discomfort to the patients. It is imperative to use appropriate means to lower the pain at the injection site of etomidate in patients undergoing anesthesia. We conducted this study to compare the effects of lidocaine, lidocaine and the Valsalva maneuver, with a combination of lidocaine, melatonin and the Valsalva maneuver on decreasing the pain of etomidate injection. Methodology: This clinical trial enrolled 135 patients. The patients were allocated into 3 groups, with one group receiving lidocaine (Group 1), the second group receiving lidocaine and the Valsalva maneuver (Group 2), and the last group receiving a combination of lidocaine, melatonin and the Valsalva maneuver. The pain resulting from injecting etomidate was evaluated based upon the Visual Analog Scale (VAS) score (with 1 being no pain and 10 the most severe imaginable pain). Data were compared and analyzed using proper statistical tests using SPSS version 23. Results: The results of this study showed that the overall pain score in all of the groups after injection of etomidate did not show any significant difference. The mean VAS score in Group 1 was 0.27 ± 0.88, in Group 2 it was 0.16 ± 0.63, and in Group 3 0.04 ± 0.2. However, the difference between the groups was statistically not significant (P = 0.32). Conclusion: The current study shows that the pain on injection of etomidate in the three groups of the study was reduced in a similar fashion; however, in the group which combined lidocaine, melatonin and the Valsalva maneuver, pain was the lowest, but the overall differences in score in the three groups were statistically not different. Keywords: Etomidate, lidocaine, melatonin, Valsalva maneuver. Citation: Nazemroaya B, Poudeh ND. Comparison of the effect of lidocaine and its combination with melatonin and the Valsalva maneuver on etomidate induced injection pain. Anaesth. pain intensive care 2024;28(5):842−849; DOI: 10.35975/apic.v28i5.2279 Received: July 27, 2024; Reviewed: September 04, 2024; Accepted: September 09, 2024

Anesthesia Management in Antenatal Care for Women With Chronic Kidney Disease: A Comprehensive Review.

Chronic kidney disease (CKD) presents significant challenges in the management of pregnant women due to its impact on renal function and cardiovascular stability. This review examines the crucial role of anesthesia management in antenatal care for women with CKD, focusing on the complexities introduced by renal dysfunction and the implications for maternal and fetal health outcomes. The review discusses the physiological changes in CKD during pregnancy, highlighting the increased risks of hypertension, proteinuria, and adverse fetal outcomes. Anesthesia considerations, including the choice of anesthesia techniques (general anesthesia, regional anesthesia), perioperative monitoring, and management of fluid and electrolyte balance, are analyzed in the context of CKD-specific challenges. Clinical outcomes and current evidence regarding anesthesia efficacy and safety in CKD patients are reviewed, emphasizing the need for tailored anesthesia protocols to ensure optimal maternal comfort and fetal safety. The review concludes by identifying research gaps and proposing future directions to enhance anesthesia practices and improve outcomes for pregnant women with CKD undergoing surgical interventions or labor management.