Level Of Anesthesia Research Articles

Effect of preoperative analgesics and cooled Lidocaine with Epinephrine on the anesthetic efficacy of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: A single-blind, randomized controlled trial

Background:Treating mandibular molars with symptomatic irreversible pulpitis poses challenges, as achieving anaesthesia in “hot teeth” is difficult. Epinephrine aids anaesthesia by reducing blood absorption through local vasoconstriction. However, when epinephrine is contraindicated, cooling the anaesthetic may provide effective vasoconstriction in cutaneous arteries and inhibit sensory nerve action potentials, enhancing anaesthetic efficacy.Aim:To evaluate the effectiveness of preoperative analgesics and cooling of 2% lidocaine solution with 1:200,000 Epinephrine on the efficacy of Inferior alveolar nerve block (IANB) during root canal treatment in patients with symptomatic irreversible pulpitis of the mandibular molars.Materials and methods:This study was conducted on 36 subjects diagnosed with symptomatic irreversible pulpitis. Participants were randomly assigned into one of three groups, each consisting of 12 patients (n=12). The subjects in Group A (Control) received Vitamin E 400 mg tablets as premedication and Local Anaesthetic injection of 2% Lignocaine at room temperature. The subjects in Group B received Piroxicam 20 mg tablets as premedication and local anaesthetic injection of 2% Lignocaine at Room Temperature. The subjects in Group C received Piroxicam 20 mg tablets as premedication and local anaesthetic injection of 2% Lignocaine at 4° Celsius. The patient’s preoperative pain levels before and after administering the analgesic, before and after the administration of local anaesthesia and intraoperative pain levels were recorded using the Heft-Parker visual analogue scale. Anaesthetic success was again evaluated after re-initiation of the endodontic treatment. The heart rates of the patients were measured using a finger pulse oximeter.Results:The patients in group C showed the highest mean difference in pain levels followed by group B and A. However, the Group A patients displayed the highest heart rates followed by Groups B and C. One-way ANOVA showed a significant differences in the pain levels (p=0.0002) and heart rates (p=0.0004) among the groups.Conclusion:This study showed that Piroxicam effectively achieved IANB in patients with symptomatic irreversible pulpitis of mandibular molars. Cooling 2% lidocaine with 1:200,000 epinephrine to 4°C significantly reduced post-injection heart rate and enhanced anesthetic success.

Unilateral Spinal Anesthesia in Hip Fracture Surgery for Geriatric Patients With High Cardiovascular Risk due to Aortic Stenosis is Safe and Effective.

Aortic stenosis is a cause of mortality or morbidity. It complicates the selection and management of anesthetic procedures. The aim of this study was to evaluate the efficacy, hemodynamic effects and postoperative outcome of unilateral spinal anesthesia in geriatric patients with hip fractures with moderate or severe aortic stenosis. A retrospective observational study was conducted on geriatric high-risk patients with cardiac conditions who underwent surgery for hip fractures under unilateral spinal anesthesia with low-dose hyperbaric bupivacaine. The study period spanned from January 2018 to December 2021. The inclusion criteria were individuals with moderate to severe aortic stenosis, as defined by the American Heart Association Criteria. Data on demographic information, cardiac pathologies, hemodynamic data, data on motor and sensory block, perioperative complications, and mortality rates at 30th and 180th days were collected. Mortality rates at the 30th day and 180th day were 8.9% (n:4) and 24.4% (n:11), respectively. T6 level was predominantly obtained level of anesthesia (44.4%). Motor and sensory block formation times averaged 7.6 and 4.8 minutes, respectively. Surgical procedures were performed mostly within 1 hour (66.7%), and complications were rare (11.1% hypotension). Initial analgesic effect showed a rapid resolution, with 64.4% of patients requiring analgesic within the first hour postoperatively. In elderly patients with moderate to severe aortic stenosis scheduled for hip fracture surgery, we posit that unilateral spinal anesthesia with ultra-low dose is safe and effective option.

Layered and Thoracic Segmental Spinal Anaesthesia in Patients with Kyphoscoliosis for Various Surgeries: A Case Series

Kyphoscoliosis involves exaggerated anterior and lateral curvatures of the spine, affecting the dorsolumbar spine. Associated multiple organ system dysfunctions cause difficulties with both general and regional anaesthetic techniques. Co-existing neuromuscular disorders, pulmonary infections, difficulties in securing the airway, postoperative pulmonary morbidities, and the need for mechanical ventilation associated with general anaesthesia make neuraxial anaesthesia the most widely used technique in these cases. Continuous neuraxial techniques in these patients offer advantages over single-shot spinal anaesthesia in achieving the desired level of anaesthesia, managing patchy blocks, extending the duration of anaesthesia, and providing postoperative analgesia, but they are technically more challenging. Single-shot spinal anaesthesia can be a simple, safer, and effective alternative for surgical procedures of shorter duration. Performing thoracic segmental spinal anaesthesia in these patients is very challenging due to the complete distortion of anatomy and possible obliteration of neuraxial spaces. Layered spinal anaesthesia involves combining multiple local anaesthetics with different baricities to produce a successful subarachnoid block. Present series is reported with successful and uneventful use of the layered and thoracic segmental spinal anaesthetic technique in patients with kyphoscoliosis for various surgeries, including laparoscopic procedures.

The Efficacy of Low-Dose Esketamine and Butorphanol in Treating Depression and Pain After Cesarean Section

Objective: To explore the efficacy of combining low-dose esketamine with butorphanol in treating depression and pain following cesarean section. Methods: 100 cases of elective cesarean section were selected and randomly assigned into two groups in a 1:1 ratio. All parturients who fulfilled the inclusion criteria received spinal anesthesia, maintaining the anesthesia level at T6. In the esketamine group, the dosage regimen comprised esketamine 0.5 mg/kg and butorphanol 10 mg, diluted with 0.9% sodium chloride injection to 100 mL. The control group received butorphanol 10 mg, diluted similarly. Analgesia in both groups commenced after cutting the umbilical cord, with a loading volume of 2 mL, a background infusion dose set to 2 mL/h, and patient-controlled analgesia at 2 mL with an effective interval time of 30 minutes. The main indicators included the maternal burnout scale (MBS) and numerical rating scale (NRS) for pain to assess postpartum depression and pain after surgery. Results: No significant differences were observed in MBS scores between the two groups on postoperative days 1 to 9 (P > 0.05). Postpartum depression was not detected in either group. Pain NRS scores at 24 and 48 hours after surgery, including incision and uterine contraction pain, showed no significant differences between the two groups (P > 0.05). Tramadol rescue was not administered to any patients in either group. Additionally, no adverse reactions requiring drug intervention occurred in either group. Conclusion: This study concluded that the combination of low-dose esketamine with butorphanol did not further optimize the analgesic effect of butorphanol but significantly improved postpartum depression after cesarean section. Further research is needed to investigate the impact of the ketamine postoperative analgesia regimen on postpartum analgesia and depression.

Pig Sedation and Anesthesia for Medical Research.

In clinical veterinary practice, proper training and expertise in anesthesia administration and monitoring are essential. Pigs are suitable experimental animals for many surgical techniques because they are similar in size to humans and have a short reproductive cycle. This makes them ideal for research concerning organ transplantation, cardiovascular surgery, and other procedures that require a large animal model. Sedation and premedication should be administered at the lowest dose to be effective with predictable results and reduced adverse effects, to ensure the safety of both the animal and the team involved in the procedure, with a fast onset and optimizing the induction and maintenance of anesthesia. The goal of induction is to achieve a safe and effective level of anesthesia that ensures patient safety and facilitates research. Most of the time, inhalation anesthesia with endotracheal intubation is the ideal choice for maintenance of anesthesia. The difficulties related to endotracheal intubation of pigs can be overcome by knowing the anatomical peculiarities. Effective analgesia tailored to the specific procedure, the pig's condition, and individual responses to medications should complete the maintenance and recovery protocols, reducing perioperative complications.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Effects of Coffee on Local Anesthesia Failure

Background: There exists a prevalent belief among patients that the use of coffee diminishes the efficacy of local anaesthetic. Caffeine is extensively utilized on a global level through the consumption of coffee, tea, and chocolate. Throughout the duration of the day. Moreover, it is conventionally perceived as a demonstration of communal benevolence, specifically within the context of Saudi Arabia. The mechanism of action of local anaesthetics involves the disruption of sodium channel influx across the neuronal membrane. Methodology: A cross-sectional epidemiological observational study was done in the city of Ha'il. The data was gathered during a two-month period spanning from July 1st, 2022 to September 1st, 2022. The sample population consisted of individuals who sought dental services within the Hail region. The present investigation had a sample size of 131 individuals, with 47.69% representing the female population and 52.31% representing the male population. However, upon conducting an assessment of patients' knowledge and opinions, it was shown that 32% of participants concurred with the notion that coffee possesses the ability to mitigate the occurrence of local anaesthetic failure. A mere 10% of individuals possessed knowledge regarding the scientific evidence that establishes a correlation between the drinking of coffee and the failure of local anaesthetics.Conclusion: Research investigations have demonstrated that caffeine can expedite the recuperation process following anesthesia, exhibiting effectiveness even when administered at elevated levels of anesthesia. Based on the sole existing evidence, it can be inferred that caffeine exhibits a capacity to counteract the effects of general anesthesia. Based on the available scientific evidence, it has been observed that caffeine has the potential to influence cognitive function by enhancing alertness. Additionally, sleep loss has been found to induce worry and anxiety. These findings partially elucidate the challenges faced by individuals who consume coffee when delivering local anesthetics. In order to mitigate the incidence of local anaesthetic failure, it is advisable for dentists to incorporate stress reduction measures into their routine practice.

Obesity exacerbates postoperative cognitive dysfunction by activating the PARP1/NAD+/SIRT1 axis through oxidative stress

The purposes of this study were to explore the impact of obesity on postoperative cognitive dysfunction (POCD) and to investigate the underlying mechanism by which obesity exacerbates POCD. In this study, fifteen-month-old male C57BL/6 J mice were fed a High-fat diet for three months to establish obesity models. Internal fixation of tibial fractures under isoflurane inhalation was performed to construct a POCD animal model. Three days after surgery, mice were subjected to the Morris water maze (MWM) experiment to evaluate their learning and memory abilities. The findings from the MWM experiment revealed that in comparison to the Ad Libitum Surgical group (ALS), mice in the High-fat Surgical group (HFS) exhibited prolonged escape latencies and reduced platform crossings. These outcomes suggest the potential exacerbating role of obesity in cognitive impairment within the POCD mouse models. Immunofluorescence (IF) findings demonstrate that obesity intensifies anesthesia and surgery-induced oxidative stress levels within the hippocampus. Compared to the Ad Libitum Control group (ALC), an elevation in PARP1 expression and a reduction in the NAD+/NADH ratio and SIRT1 expression were observed in the hippocampus of mice from the ALS. Moreover, when contrasting the HFS group with the ALS group, increased PARP1 expression along with decreased NAD+/NADH ratio and SIRT1 expression were evident. In vitro studies found that compared with the Control group (CON), oil red staining and BODIPY probe staining showed significant lipid droplet aggregation in the palmitic acid (PA) group. IF results demonstrated that HT22 cells in the PA group experienced oxidative stress and activation of the PARP1/NAD+/SIRT1 axis in contrast to the CON group. Moreover, manipulation of PARP1 expression in HT22 cells through PARP1 lentivirus-based silencing or overexpression revealed a converse relationship between PARP1 expression levels and the NAD+/NADH ratio as well as SIRT1 expression levels. This study concludes that obesity may exacerbate POCD by triggering activation of the oxidative stress-induced PARP1/NAD+/SIRT1 axis.

EEG spectral slope: A reliable indicator for continuous evaluation of consciousness levels during propofol anesthesia

The level of consciousness undergoes continuous alterations during anesthesia. Prior to the onset of propofol-induced complete unconsciousness, degraded levels of behavioral responsiveness can be observed. However, a reliable index to monitor altered consciousness levels during anesthesia has not been sufficiently investigated. In this study, we obtained 60-channel EEG data from 24 healthy participants during an ultra-slow propofol infusion protocol starting with an initial concentration of 1 μg/ml and a stepwise increase of 0.2 μg/ml in concentration. Consecutive auditory stimuli were delivered every 5 to 6 s, and the response time to the stimuli was used to assess the responsiveness levels. We calculated the spectral slope in a time-resolved manner by extracting 5-second EEG segments at each auditory stimulus and estimated their correlation with the corresponding response time. Our results demonstrated that during slow propofol infusion, the response time to external stimuli increased, while the EEG spectral slope, fitted at 15–45 Hz, became steeper, and a significant negative correlation was observed between them. Moreover, the spectral slope further steepened at deeper anesthetic levels and became flatter during anesthesia recovery. We verified these findings using an external dataset. Additionally, we found that the spectral slope of frontal electrodes over the prefrontal lobe had the best performance in predicting the response time. Overall, this study used a time-resolved analysis to suggest that the EEG spectral slope could reliably track continuously altered consciousness levels during propofol anesthesia. Furthermore, the frontal spectral slope may be a promising index for clinical monitoring of anesthesia depth.

Eras Protokollerine Uygun Olarak Radikal Sistektomi Yapılan Hastalarda Anestezi Derinliği Klinik Sonuçları Etkiler Mi?

Objective: To investigated whether low and high MAC (Minimum Aleveolar Concentration) level of anesthesia have an effect on the depth of anesthesia, clinical results paremeters in patients underwent radical cystectomy in accordance with ERAS (Enhanced Recovery After Surgery) protocols Material and Methods: Retrospective data of 41 patients underwent radical cystectomy between 2019-2022 were collected, 35 of them were included. The patients were divided in two groups: Group H (1 MAC, n:18) and Group L (0.5 MAC, n:17). All patients were prepared and managed in line with ERAS protocols. Perioperative and early postoperative parameters including depth of anesthesia which was followed by PSI (Pneumonia Severity Index) and SR (Supression Ratio), preoperative and postoperative 24th hours Mini Mental Test results, post-anesthesia care unit (PACU) unit admission and duration and complications were compared. Results: The mean age of the patients (61 and 65 years, in the Group H and L, respectively) were similar (p=0.234) in both groups. PSI was found to be significantly lower in Group H at the 60th, 120th minutes and fascia closure (p=0.004, p=0.001, and p=0.000 respectively). PSI <25 duration was significantly higher in group H (139.0±186.7 and 17.6±54.8 in group H and L, respectively, p=0.001). The duration of SR>0 was significantly higher in Group H (p=0.000). Both anesthesia (474 min) and surgery (432 min) times were significantly higher in Group H (p=0.013 and 0.029 respectivelly). Nausea and vomiting at 12 hours postoperatively was also common in Group H (p=0.008). The rest of parameters that compared were similar, including the minimental test. Conclusion: The MAC values did not significantly affect perioperative and early postoperative outcomes. While high MAC level MAC level generates a deeper anesthesia, low MAC level seems an effective alternative providig a lower inhalation anestesia agent consumption.

Pro-Con Debate: Electroencephalography-Guided Anesthesia for Reducing Postoperative Delirium.

Postoperative delirium (POD) has significant implications on morbidity, mortality, and health care expenditures. Monitoring electroencephalography (EEG) to adjust anesthetic management has gained interest as a strategy to mitigate POD. In this Pro-Con commentary article, the pro side supports the use of EEG to reduce POD, citing an empiric reduction in POD with processed EEG (pEEG)-guided general anesthesia found in several studies and recent meta-analysis. The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) trial is the exception to this, and issues with methods and achieved depths are discussed. Meanwhile, the Con side advocates that the use of EEG to reduce POD is not yet certain, citing that there is a lack of evidence that associations between anesthetic depth and POD represent causal relationships. The Con side also contends that the ideal EEG signatures to guide anesthetic titration are currently unknown, and the potential benefits of reduced anesthesia levels may be outweighed by the risks of potentially insufficient anesthetic administration. As the public health burden of POD increases, anesthesia clinicians will be tasked to consider interventions to mitigate risk such as EEG. This Pro-Con debate will provide 2 perspectives on the evidence and rationales for using EEG to mitigate POD.

Comparison of Motor Evoked Potentials Neuromonitoring Following Pre- and Postoperative Transcranial Magnetic Stimulation and Intraoperative Electrical Stimulation in Patients Undergoing Surgical Correction of Idiopathic Scoliosis.

The relationships between the results of pre- and intraoperative motor evoked potential recordings during neuromonitoring and whether idiopathic scoliosis (IS) surgical correction improves the spinal efferent transmission have not been specified in detail. This study aims to compare the results of surface-recorded electromyography (EMG), electroneurography (ENG, M, and F-waves), and especially motor evoked potential (MEP) recordings from tibialis anterior muscle (TA) bilaterally in 353 girls with right idiopathic scoliosis (types 1-3 according to Lenke classification). It has not yet been documented whether the results of MEP recordings induced by transcranial single magnetic stimulus (TMS, pre- and postoperatively) and trains of electrical stimuli (TES; intraoperatively in T0-before surgery, T1-after pedicle screws implantation, and T2-after scoliosis curvature distraction and derotation following two-rod implantation) can be compared for diagnostic verification of the improvement of spinal cord neural transmission. We attempted to determine whether the constant level of optimal anesthesia during certain surgical steps of scoliosis treatment affects the parameters of MEPs recorded during neuromonitoring procedures. No neurological deficits have been observed postoperatively. The values of amplitudes but not latencies in MEP recordings evoked with TMS in IS patients compared before and after surgery indicated a slight improvement in efferent neural transmission. The results of all neurophysiological studies in IS patients were significantly asymmetrical and recorded worse on the concave side, suggesting greater neurological motor deficits at p = 0.04. The surgeries brought significant improvement (p = 0.04) in the parameters of amplitudes of sEMG recordings; however, the consequences of abnormalities in the activity of TA motor units were still reflected. ENG study results showed the symptoms of the axonal-type injury in peroneal motor fibers improving only on the concave side at p = 0.04, in parallel with F-wave parameters, which suggests that derotation and distraction might result in restoring the proper relations of the lumbar ventral roots in the spinal central canal, resembling their decompression. There were no significant differences detected in the amplitudes or latencies of MEPs induced with TMS or TES when comparing the parameters recorded preoperatively and intraoperatively in T0. The amplitudes of TES-evoked MEPs increased gradually at p = 0.04 in the subsequent periods (T1 and T2) of observation. A reduction in MEP latency at p = 0.05 was observed only at the end of the IS surgery. Studies on the possible connections between the level of anesthesia fluctuations and the required TMS stimulus strength, as well as the MEP amplitude changes measured in T0-T2, revealed a lack of relationships. These might not be the factors influencing the efferent transmission in spinal pathways beside the surgical procedures. Pre- (TMS-evoked) and intraoperative (TES-evoked) recordings are reliable for evaluating the patient's neurological status before and during surgical scoliosis correction procedures. An increase in MEP amplitude parameters recorded on both sides after scoliosis surgery proves the immediate improvement of the total efferent spinal cord transmission. Considering comparative pre- and postoperative sEMG and ENG recordings, it can be concluded that surgeries might directly result in additional lumbar ventral root decompression. We can conclude that MEP parameter changes are determined by the surgery procedures during neuromonitoring, not the anesthesia conditions if they are kept stable, which influences a decrease in the number of false-positive neuromonitoring warnings.

The Influence of Electromyographic on Electroencephalogram-Based Monitoring: Putting the Forearm on the Forehead.

Monitoring the electroencephalogram (EEG) during general anesthesia can help to safely navigate the patient through the procedure by avoiding too deep or light anesthetic levels. In daily clinical practice, the EEG is recorded from the forehead and available neuromonitoring systems translate the EEG information into an index inversely correlating with the anesthetic level. Electrode placement on the forehead can lead to an influence of electromyographic (EMG) activity on the recorded signal in patients without neuromuscular blockade (NMB). A separation of EEG and EMG in the clinical setting is difficult because both signals share an overlapping frequency range. Previous research showed that indices decreased when EMG was absent in awake volunteers with NMB. Here, we investigated to what extent the indices changed, when EEG recorded during surgery with NMB agents was superimposed with EMG. We recorded EMG from the flexor muscles of the forearm of 18 healthy volunteers with a CONOX monitor during different activity settings, that is, during contraction using a grip strengthener and during active diversion (relaxed arm). Both the forehead and forearm muscles are striated muscles. The recorded EMG was normalized by z -scoring and added to the EEG in different amplification steps. The EEG was recorded during anesthesia with NMB. We replayed these combined EEG and EMG signals to different neuromonitoring systems, that is, bispectral index (BIS), CONOX with qCON and qNOX, and entropy module with state entropy (SE) and response entropy (RE). We used the Friedman test and a Tukey-Kramer post hoc correction for statistical analysis. The indices of all neuromonitoring systems significantly increased when the EEG was superimposed with the contraction EMG and with high EMG amplitudes, the monitors returned invalid values, representative of artifact contamination. When replaying the EEG being superimposed with "relaxed" EMG, the qCON and BIS showed significant increases, but not SE and RE. For SE and RE, we observed an increased number of invalid values. With our approach, we could show that EMG activity during contraction and resting state can influence the neuromonitoring systems. This knowledge may help to improve EEG-based patient monitoring in the future and help the anesthesiologist to use the neuromonitoring systems with more knowledge regarding their function.

The Clinical Anesthesia Effect of Remifentanil Combined with Propofol in Laparoscopic Cholecystectomy in the Elderly

Objective: To explore and analyze the effect of remifentanil combined with propofol for anesthesia in patients undergoing laparoscopic cholecystectomy, and to explore its clinical application value. Methods: A total of 64 patients who underwent laparoscopic cholecystectomy were selected and randomly divided into two groups, with 32 patients in each group. The anesthesia used in the control group was propofol combined with fentanyl, whereas the observation group was propofol combined with remifentanil and fentanyl. Medical staff routinely performed thyroidectomy on the patients after receiving anesthesia. After the treatment was completed, the researchers recorded the adverse reactions of the patients and the anesthesia effect during laparoscopic cholecystectomy and analyzed the anesthesia effect of the patients. Results: After the operation, the excellent and good rates of anesthesia in the observation group were significantly higher (P < 0.05). Pain in the observation group was significantly lower (P < 0.05). The clinical indicators after receiving anesthesia were significantly better in the observation group (P < 0.05). During the operation period, the two groups had different degrees of adverse reactions, while the incidence of adverse reactions in the observation group was relatively lower (P < 0.05). Conclusion: Patients in the observation group showed better anesthesia and lower pain levels during surgery, higher excellent and good rates of anesthesia, lower VAS scores, and better anesthesia indicators. Therefore, remifentanil-propofol combined anesthesia can be used as an effective anesthesia option in laparoscopic cholecystectomy, which improves the anesthesia effect during the operation and the postoperative pain control of patients and has clinical application value.

Bilirubin potentiates etomidate-induced sedation by enhancing GABA-induced currents after bile duct ligation

ObjectivesOur previous clinical trial showed that etomidate requirements to reach an appropriate level of anesthesia in patients with obstructive jaundice were reduced, which means that these patients are more sensitive to etomidate. However, the mechanism is still not completely clear. The present study was aimed to investigate the mechanism by which bilirubin facilitates etomidate induced sedation.MethodsA bile duct ligation (BDL) rat model was used to simulate obstructive jaundice. Anesthesia sensitivity to etomidate was determined by the time to loss of righting reflex (LORR). Intrathecal injection of bilirubin was used to test the effects of bilirubin on etomidate induced sedation. The modulating effects of bilirubin on GABA responses were studied using the whole-cell patch clamp technique.ResultsThe time to LORR induced by etomidate was significantly decreased in the BDL groups (p < 0.05), and unconjugated bilirubin in serum and cerebrospinal fluid (CSF) were markedly increased (p < 0.05). The time to LORR induced by etomidate was decreased after intrathecal injection of bilirubin (p < 0.05). A bilirubin concentration of 1.0 μM increased the GABA-induced currents of rat cortical pyramidal neurons (p < 0.05). Furthermore, 1.0 μM bilirubin enhanced GABA-induced currents modulated by etomidate (p < 0.05).ConclusionsOur results demonstrated that pathologic bilirubin in CSF could enhance etomidate induced sedation. The mechanism may be that bilirubin increase the GABA-induced currents of rat pyramidal neurons.

Perioperative sleep disorders in gynaecological daycase surgery patients and analysis of risk factors: protocol for a cross-sectional study

IntroductionSleep disorders are clinical syndromes of disturbed sleep-wake rhythms and abnormal sleep quality. They have various causes, but their main manifestations are difficulty falling asleep, sleep disruption and daytime fatigue....

Spontaneous and Visual Stimulation Evoked Firing Sequences Are Distinct Under Desflurane Anesthesia.

Recurring spike sequences are thought to underlie cortical computations and may be essential for information processing in the conscious state. How anesthesia at graded levels may influence spontaneous and stimulus-related spike sequences in visual cortex has not been fully elucidated. We recorded extracellular single-unit activity in the rat primary visual cortex in vivo during wakefulness and three levels of anesthesia produced by desflurane. The latencies of spike sequences within 0-200ms from the onset of spontaneous UP states and visual flash-evoked responses were compared. During wakefulness, spike latency patterns linked to the local field potential theta cycle were similar to stimulus-evoked patterns. Under desflurane anesthesia, spontaneous UP state sequences differed from flash-evoked sequences due to the recruitment of low-firing excitatory neurons to the UP state. Flash-evoked spike sequences showed higher reliability and longer latency when stimuli were applied during DOWN states compared to UP states. At deeper levels, desflurane altered both UP state and flash-evoked spike sequences by selectively suppressing inhibitory neuron firing. The results reveal desflurane-induced complex changes in cortical firing sequences that may influence visual information processing.

Fascial plane blocks in children-Scientifically supported or not?

Since the introduction of Fascial Plane Blocks in 2007 there has been an enormous interest and application of Fascial Plane Blocks, evidenced by substantially more than 1000 PubMed items. Despite this gigantic number of publications, also including randomized controlled trials and meta-analyses in children, there is still no clear-cut insight into how much of the purported effect is in fact due to the blockade of nerve structures and how much is merely adding the well-known analgesic and anti-inflammatory effects of the plasma levels of local anesthetics that are achieved with these techniques. Furthermore, Fascial Plane Blocks appear useful only if compared to conventional multi-modal analgesia (no block or placebo) and Fascial Plane Blocks lack the potency to provide surgical anesthesia on their own and appear only to be of value when used for minor-moderate surgery. Despite the huge literature, there has so far not emerged any clinical situations where Fascial Plane Blocks have definitively been shown to be the block of choice, being decisively more effective than other established regional blocks. Lastly, Fascial Plane Blocks may appear as virtually free of complications, but case reports are emerging that point to a real risk for causing local anesthetic systemic toxicity when using Fascial Plane Blocks. This text aims to synthesize the current knowledge base regarding the Fascial Plane Blocks that are relevant to use in the pediatric context. In summary, there does currently not exist any convincing scientific evidence for the continued support for the use of Fascial Plane Blocks in children, except for the rectus sheath block and possibly also the transmuscular quadratus lumborum block.

Predictors of Low Risk for Delirium during Anesthesia Emergence.

Processed EEG is used to monitor the level of anesthesia and it has shown the potential to predict the occurrence of delirium. While emergence trajectories of relative eeg band power identified post-hoc show promising results in predicting a risk for a delirium, they are not easily transferable into an online predictive application. In this article we describe a low-resource and easily applicable method to differentiate between patients at high risk and low risk for delirium, with patients at low risk expected to show decreasing eeg power during emergence. We included data from 169 patients (median age: 61 [49, 73]), who underwent surgery with general anesthesia, maintained either with propofol, sevoflurane, or desflurane. The data were derived from a previously published study. We chose a single frontal channel and calculated the total and spectral band power from the EEG and calculated a linear regression model to observe the parameters' change during anesthesia emergence, described as slope. The slope of total power and single band power was correlated with the occurrence of delirium. Of 169 patients, 32 (19%) showed delirium. We observed that patients whose total EEG power diminished the most during emergence were less likely to screen positive for delirium in the PACU. A positive slope in total power and band power evaluated by using a regression model was associated with a higher risk-ratio (total: RR 2.83 (95%CI: 1.46 to 5.51) alpha/beta band: RR 7.79 (95%CI: 2.24 to 27.09)) for delirium. Furthermore, a negative slope in multiple bands during emergence was specific for patients without delirium and allowed to define a test for patients at low risk. In this study we developed an easily applicable exploratory method to analyze a single frontal EEG channel and to identify patterns specific for patients at low risk for delirium.

The Choice of Anesthesia after First Failed Spinal Block and Its Impact on Maternal and Neonatal Outcomes in Cesarean Delivery: A Cross-Sectional Study

Objective: The preferred choice of anesthesia for cesarean delivery is spinal block, which has a failure rate of 0.5% to 17.0%. The present study investigated the incident rate of second choice of anesthesia following a failed block, as well as the factors influencing the anesthesiologist’s selection. Materials and Methods: A single-center, retrospective cross-sectional study was conducted using electronic medical records of parturients who had experienced a failed spinal block for cesarean deliveries between 2014 and 2019. Each rate of repeated spinal block and the conversion to general anesthesia were calculated. Factors associated with the decision-making were examined, and maternal and neonatal outcomes were reviewed. Results: Three hundred four women were recruited. The rates of repeated block and conversion to general anesthesia were 81.2% and 18.8%, respectively. Dural puncture with more than one attempt (p=0.022) and anesthesia level at the thoracic dermatome (p&lt;0.001) were associated with a lower decision to repeat the block. Maternal in the repeated block group had a higher incidence of hypotension at 59.5% (p&lt;0.001) and shivering at 16.2% (p=0.008). Neonates in the repeat block group had a lower incidence of any complications than those in the conversion to general anesthesia group at 4% versus 29.8% (p&lt;0.001). Conclusion: Following an unsuccessful spinal block for cesarean section, the repeated block was still preferred. The level of anesthesia and the spinal attempts were the significant factors in this choice. Keywords: Cesarean delivery; Conversion to general anesthesia; Failed spinal block; Maternal and neonatal outcomes; Repeat block