Anesthetic Regimen Research Articles

Electrocardiographic, clinical and haematological evaluation of propofol and xylazine-ketamine anaesthesia in Goat

Limited information is available to ascertain the quality of intravenous anaesthetic regime predominantly practised in goats for short term surgical interventions. Clinical, electrocardiographic and haematological studies were conducted on twelve female Barbari crossbred goats, aged 2–4 years to assess the anaesthetic quality of propofol and xylazine-ketamine combination. Onset, duration and recovery from anaesthesia, clinical parameters (rectal temperature, pulse and respiratory rates), electrocardiography (ECG) and oxyhemoglobin (HbO2) saturation were assessed at 0, 10, 60, 120 min and haematological parameters at 0, 60, 180 min after propofol (4 mg/kg) and xylazine (0.05 mg/kg)-ketamine (4 mg/kg) were administered intravenously. Clinical and haematological parameters except lymphocyte count decreased. With stable plane of propofol anaesthesia, ECG amplitudes and heart rate increased while ECG intervals decreased. After ketamine induction, P wave amplitude, ECG intervals increased whereas R wave amplitude, heart rate decreased. Rectal temperature and pulse rate were better maintained in goats receiving propofol anaesthesia. Xylazine-ketamine exerted subtle deviation from pre-anaesthetic cardiovascular, respiratory, haematological parameters

A longitudinal study of the association of epidural anesthesia and low-dose synthetic oxytocin regimens with breast milk supply and breastfeeding rates

Breastfeeding is known to improve maternal and child health. However, epidural anesthesia (EDA) and synthetic oxytocin (synOT) are suggested to have negative effects on breastfeeding. In this study, we aimed to determine the effects of intrapartum synOT and EDA on breast milk supply, breastfeeding rates, and maternal salivary oxytocin levels. Women were recruited during pregnancy or after birth at a single hospital. Data were collected at 3 days postpartum (T1), 1 month postpartum (T2), and 4 months postpartum (T3) on 83 low-risk primiparous women who planned to breastfeed for at least 12 weeks postpartum to avoid dropouts from early discontinuance of breastfeeding. Women with cesarean section, twin pregnancy, premature neonates, and an Apgar score of < 7 at 5 min were excluded. Participants recorded their 24-h milk supply by test weights at 3 days and 1 month postpartum. Additionally, they filled out questionnaires assessing their breastfeeding level and lactogenesis stage II initiation. Salivary oxytocin levels were obtained at 3 days postpartum. Women who delivered using EDA had lower salivary oxytocin levels (P = .055, d = .442), breast milk supply in early postpartum (P = .025, d = .520) and at 1 month postpartum (P = .036, d = .483), and breastfeeding rates at 4 months postpartum (P = .037, V = .236) than women who did not deliver using EDA. There was no association between breastfeeding and the use of intrapartum synOT. In conclusion, this study showed that women who delivered using EDA had lower breast milk supply in the early postpartum period and breastfeeding rates at 4 months postpartum. It also revealed that using synOT at low doses during labor did not affect breastfeeding. Thus, women who deliver using EDA need support for increased breast milk supply in the early postpartum period.Trial registration: UMIN000037783 (Clinical Trials Registry of University Hospital Information Network).

Comparison of Cardiac Indices Using Two Different Concentrations of Topical Adrenaline during Endoscopic Transsphenoidal Pituitary Surgery: A Prospective Randomized Observational Study.

Introduction Adrenaline-soaked wicks are often employed to decongest nasal mucosa during transsphenoidal pituitary surgeries to ensure proper hemostasis and visibility of the operating field. Considerable debate exists regarding the optimum concentration of adrenaline that strikes a balance between hemostasis as well as the hemodynamic side effects of adrenaline. This study assessed cardiac indices like cardiac output and cardiac index using a FloTrac Vigileo cardiac output monitor to compare two different concentrations of adrenaline used for topical instillation. Materials and Methods 60 adult patients undergoing transsphenoidal pituitary surgery were randomly assigned to receive cotton wicks soaked in adrenaline solution (either 1:100,000 or 1:200,000) for nasal decongestion. Following a standardized anesthetic regime, a FloTrac Vigileo cardiac output monitor was attached with the invasive arterial line for precise monitoring and recording of cardiac indices (cardiac output and cardiac index). Additionally, quality of surgical field (as reported by the operating surgeon) blood loss, incidences of adverse hemodynamic events, and rescue drug usage were recorded. Results No difference in cardiac outputs and cardiac indexes of the patients was observed during baseline to 55 minutes and at 80 minutes and onward, whereas difference rose to statistical significance at the time points of 60 minutes and 70 minutes ( p < 0.05). Other parameters like stroke volume, stroke volume variation, and hemodynamic parameters were similar. Quality of the surgical fields (as reported by the surgeon), intraoperative bleeding, incidences of adverse effects, and frequency of rescue drugs usage were similar. Conclusion Instillation of 1:100,000 dilution of adrenaline solution compared with 1:200,000 for nasal decongestion is associated with significant rise in cardiac output and cardiac index at 60 and 70 minutes of the surgery with similar blood loss and hemodynamic variables. Therefore, the lower concentration of adrenaline can be recommended for usage during transsphenoidal pituitary surgeries.

Induction of pre-hospital emergency anaesthesia i-PHEA: a national survey of UK HEMS practice

BackgroundPre-hospital emergency anaesthesia is a critical intervention undertaken by helicopter emergency medical teams. Previous studies informed current practice for induction regimes, using a standardized approach of fentanyl, ketamine and rocuronium. There may be a trend towards post-induction hypotension attributed to the induction regime used. Several new combinations of fentanyl, ketamine and rocuronium are emerging in clinical practice. There is currently no consensus on what induction regimes should be used.MethodsA semi-structured survey was distributed to the medical leads of all UK air ambulance organisations between December 2022 and February 2023. Responses that were returned within the study period were included. Exclusions included missing data, declined participation and failure to return the survey within the data collection period. The survey sought to establish provision of pre-hospital emergency anaesthesia and current induction regimes for stable, unstable and post-cardiac arrest patients. Data was extracted from Microsoft Forms into Excel. Descriptive statistics were used to analyse survey response rate, provision of PHEA and induction regimes. The survey was endorsed by the National HEMS Research and Audit Forum.Results19 air ambulance organisations responded (response rate 86%). The majority of organisations provide over 100 pre-hospital emergency anaesthetics per annum (79%, n = 15/19). A standard combination of fentanyl, ketamine and rocuronium is used as a primary induction regime in haemodynamically stable patients by 52% of services (n = 10/19). In haemodynamically compromised patients, fentanyl was omitted or pracititioner choice emphasized by 79% of services (n = 15/19). There was variability in the dose of rocuronium from 1 mg/kg to 2 mg/kg throughout services.ConclusionThere is variability in the approach to pre-hospital emergency anaesthesia. There is a growing dataset that would enable development of a registry to better understand induction regimes and the impact on patient physiology. Organisations are increasingly adopting a patient centered, practitioner choice model towards induction of anaesthesia.

Efficacy of propofol-based anesthesia against risk of brain swelling during craniotomy: A meta-analysis of randomized controlled studies

Study objectiveThis meta-analysis aimed to compare the risk of brain swelling during craniotomy between propofol-based and volatile-based anesthesia. DesignMeta-analysis of randomized controlled trials (RCTs). SettingOperating room. InterventionPropofol-based anesthesia. PatientsAdult patients undergoing craniotomy. MeasurementsDatabases, including EMBASE, MEDLINE, Google Scholar, and Cochrane Library, were searched from inception to April 2023. The primary outcome was the risk of brain swelling, while the secondary outcomes included the impact of anesthetic regimens on surgical and recovery outcomes, as well as the risk of hemodynamic instability. Main resultsOur meta-analysis of 17 RCTs showed a significantly lower risk of brain swelling (risk ratio [RR]: 0.85, p = 0.03, I2 = 21%, n = 1976) in patients receiving propofol than in those using volatile agents, without significant differences in surgical time or blood loss between the two groups. Moreover, propofol was associated with a lower intracranial pressure (ICP) (mean difference: −4.06 mmHg, p < 0.00001, I2 = 44%, n = 409) as well as a lower risk of tachycardia (RR = 0.54, p = 0.005, I2 = 0%, n = 822) and postoperative nausea/vomiting (PONV) (RR = 0.59, p = 0.002, I2 = 19%, n = 1382). There were no significant differences in other recovery outcomes (e.g., extubation time), risk of bradycardia, hypertension, or hypotension between the two groups. Subgroup analysis indicated that propofol was not associated with a reduced risk of brain swelling when compared to individual volatile agents. Stratified by craniotomy indications, propofol reduced brain swelling in elective craniotomy, but not in emergency craniotomy (e.g., traumatic brain injury), when compared to volatile anesthetics. ConclusionsBy reviewing the available evidence, our results demonstrate the beneficial effects of propofol on the risk of brain swelling, ICP, PONV, and intraoperative tachycardia. In emergency craniotomy for traumatic brain injury and subarachnoid hemorrhage, brain swelling showed no significant difference between propofol and volatile agents. Further large-scale studies are warranted for verification.

Establishment and validation of intravenous anesthesia with dexmedetomidine for pigs under assisted spontaneous breathing: A preclinical model of intensive care conditions.

Large animal models are frequently used to investigate new medical approaches. In most cases, animals are kept under general anesthesia and mandatory mechanical ventilation during the experiments. However, in some situations assisted spontaneous breathing is essential, e.g. when simulating conditions in a modern intensive care unit. Therefore, we established an anesthesia regime with dexmedetomidine and midazolam/ketamine in porcine models of assisted spontaneous breathing. The total intravenous anesthesia was used in lung healthy pigs, in pigs with oleic acid induced acute respiratory distress syndrome and in pigs with methacholine induced bronchopulmonary obstruction. We were able to maintain stable conditions of assisted spontaneous breathing without impairment of hemodynamic, respiratory or blood gas variables in lung healthy pigs and pigs with induced acute respiratory distress syndrome for a period of five hours and in pigs with induced bronchopulmonary obstruction for three hours. Total intravenous anesthesia containing dexmedetomidine enables stable conditions of assisted spontaneous breathing in healthy pigs, in pigs with induced acute respiratory distress syndrome and in pigs induced bronchopulmonary obstruction as models of intensive care unit conditions.

Total intravenous anesthesia decreases hospital stay but not incidence of postoperative pulmonary complications after lung resection surgery: a propensity score matching study

BackgroundThere is no consensus regarding the superiority of volatile or total intravenous anesthesia (TIVA) in reducing the incidence of postoperative pulmonary complications (PPCs) after lung resection surgery (LRS). Thus, the aim of this study was to investigate the different anesthetic regimens and the incidence of PPCs in patients who underwent LRS. We hypothesized that TIVA is associated with a lower incidence of PPCs than volatile anesthesia.MethodsThis was a retrospective cohort study of patients who underwent LRS at Taipei Veterans General Hospital between January 2016 and December 2020. The patients’ charts were reviewed and data on patient characteristics, perioperative features, and postoperative outcomes were extracted and analyzed. The patients were categorized into TIVA or volatile anesthesia groups and their clinical data were compared. Propensity score matching was performed to reduce potential selection bias. The primary outcome was the incidence of PPCs, whereas the secondary outcomes were the incidences of other postoperative events, such as length of hospital stay (LOS) and postoperative nausea and vomiting (PONV).ResultsA total of 392 patients each were included in the TIVA and volatile anesthesia groups. There was no statistically significant difference in the incidence of PPCs between the volatile anesthesia and TIVA groups. The TIVA group had a shorter LOS (p < 0.001) and a lower incidence of PONV than the volatile anesthesia group (4.6% in the TIVA group vs. 8.2% in the volatile anesthesia group; p = 0.041). However, there were no significant differences in reintubation, 30-day readmission, and re-operation rates between the two groups.ConclusionsThere was no significant difference between the incidence of PPCs in patients who underwent LRS under TIVA and that in patients who underwent LRS under volatile anesthesia. However, TIVA had shorter LOS and lower incidence of PONV which may be a better choice for maintenance of anesthesia in patients undergoing LRS.

Comparison of Two Anesthetic Regimens on Extubation Time and Postoperative Recovery in Children Undergoing Ambulatory Adenoidectomy: A Retrospective Study

PurposeThis aim of this study was to compare two anesthetic regimens in terms of extubation time and postoperative recovery in children undergoing ambulatory adenoidectomy. DesignA retrospective cohort study with propensity score matching. MethodsThe medical charts of 452 children aged between 3 and 8 years undergoing ambulatory adenoidectomy were retrieved for analysis, of which 438 were eligible to participate in this study. A majority (n = 327) were children exposed to a conventional propofol-pronounced general anesthetic regimen (high-dose propofol plus low-dose remifentanil, labeled as group P), while n = 111 were administered a modified remifentanil-pronounced anesthetic regimen (low-dose propofol plus high-dose remifentanil, namely group R). Propensity score matching was employed to adjust for confounders, resulting in 69 matched patients in each group. The primary endpoint of this study was extubation time. The secondary endpoints were total intraoperative fluid volume, length of stay in the postanesthesia care unit (PACU), postoperative pain rating, the incidence of emergence agitation, nausea and vomiting, as well as the level of consciousness (fully awake or waking by gentle patting) when transferred out of PACU, and any major complications (wound bleeding, reintubation, readmission, and overnight stay). FindingsNo major complications were observed in both groups. Compared to group P, group R had significantly shorter extubation time (8.2 ± 1.4 minutes vs 13.3 ± 2.4 minutes, P < .001), shorter length of stay in the PACU (14.1 ± 3.1 minutes vs 20.2 ± 3.4 minutes, P < .001), and a higher proportion of cases being fully awake when transferred out of the PACU (91% vs 46%, P < .001). Lastly, the pain rating, frequency of oropharyngeal airway usage, incidence of emergence agitation, and nausea and vomiting were comparable between the two groups (P > .05 for all). ConclusionsRemifentanil-pronounced anesthesia was superior to propofol-pronounced anesthesia in children undergoing ambulatory adenoidectomy, given that the former was associated with a faster recovery time from anesthesia without jeopardizing patient safety.

The Current Situation of Anaesthesia for Hysteroscopy in Mainland China: A National Survey.

Purpose: The need for anaesthesia or analgesia for performing hysteroscopy remains debatable. This study aimed to conduct an overview of the situation of anaesthesia for hysteroscopy in mainland China. Methods: Two questionnaires were separately designed for anaesthesiologists and gynaecologists and distributed to every medical institution that performed hysteroscopic procedures on patients with infertility in mainland China. Electronic questionnaires were distributed via WeChat, and data on anaesthesia regimen, monitoring parameters, procedure number, and other information were collected. Results: Reproductive technology is conducted by 536 institutions in mainland China. The survey received 491 responses from anaesthetists (91.6%) and 436 from gynaecologists (81.3%). In 2021, 552,225 hysteroscopies were conducted in 268 medical centres. The average percentage of hysteroscopy under anaesthesia is 63.8% in 2021, wherein 47.3% of institutions have an anaesthesia percentage of >75%. Propofol and opioid analgesics, such as fentanyl and sufentanil, were the most commonly used intravenous anaesthetics. All sedations were performed by anaesthesiologists. Monitoring parameters included pulse oxygen saturation (98.9%), electrocardiogram (91.6%) and noninvasive blood pressure (91.3%). An anaesthesiologist-to-operating room ratio of <1 was observed in 31.3% of medical institutions. Surprisingly, 52.4% of medical institutions performing hysteroscopy had no postanaesthesia care unit (PACU). Most institutions with PACU were equipped with independent oxygen sources, suction and monitors. Both rigid and flexible hysteroscopes (rigid hysteroscope, 45.1%; flexible hysteroscope, 4.5%; both types, 50.4%) were used, and the hysteroscopic diameter was ≤5 mm in 60.3% of medical centres. Conclusions: China performs a large number of hysteroscopies, and sedation is the most frequently used anesthesia regimen. However, issues such as inadequate emergency support devices, insufficient personnel and weak resuscitation management after anaesthesia, have been observed.

Comparison of the respiratory effects of commonly utilized general anaesthesia regimes in male Sprague-Dawley rats.

Background: Respiratory parameters in experimental animals are often characterised under general anaesthesia. However, anaesthesia regimes may alter the functional and mechanical properties of the respiratory system. While most anaesthesia regimes have been shown to affect the respiratory system, the effects of general anaesthesia protocols commonly used in animal models on lung function have not been systematically compared. Methods: The present study comprised 40 male Sprague-Dawley rats divided into five groups (N = 8 in each) according to anaesthesia regime applied: intravenous (iv) Na-pentobarbital, intraperitoneal (ip) ketamine-xylazine, iv propofol-fentanyl, inhaled sevoflurane, and ip urethane. All drugs were administered at commonly used doses. End-expiratory lung volume (EELV), airway resistance (Raw) and tissue mechanics were measured in addition to arterial blood gas parameters during mechanical ventilation while maintaining positive end-expiratory pressure (PEEP) values of 0, 3, and 6cm H2O. Respiratory mechanics were also measured during iv methacholine (MCh) challenges to assess bronchial responsiveness. Results: While PEEP influenced baseline respiratory mechanics, EELV and blood gas parameters (p < 0.001), no between-group differences were observed (p > 0.10). Conversely, significantly lower doses of MCh were required to achieve the same elevation in Raw under ketamine-xylazine anaesthesia compared to the other groups. Conclusion: In the most frequent rodent model of respiratory disorders, no differences in baseline respiratory mechanics or function were observed between commonly used anaesthesia regimes. Bronchial hyperresponsiveness in response to ketamine-xylazine anaesthesia should be considered when designing experiments using this regime. The findings of the present study indicate commonly used anaesthetic regimes allow fair comparison of respiratory mechanics in experimental animals undergoing any of the examined anaesthesia protocols.

Posterior fossa tumor resection in children: a case report and the role of intraoperative neurophysiologic monitoring

Introduction/Background: Surgery plays a crucial role in the surgical management of posterior fossa tumors in children, but maximizing the resection while preserving function remains challenging. Along with other tools available to the surgeon, intraoperative neuromonitoring aims at improving safety during these complex interventions. This case report highlights the role of real-time intraoperative neuromonitoring during surgery and its impact on the surgeon's decision-making process. Case report: We present the case of a 10-year-old boy with a fourth ventricle medulloblastoma, who underwent microneurosurgical resection under intraoperative neuromonitoring. The use of neurophysiological monitoring yielded relevant information during the tumor dissection of the floor of the fourth ventricle, the most crucial step of surgery, thus helping the surgeon to change tactics to minimize long-term neurological deficits. Conclusion: In combination with meticulous microneurosurgery techniques, modern anesthetic regimens, and ultrasonic aspiration, intraoperative neuromonitoring adds up to the surgeon's armamentarium for increasing safety and improving outcomes following surgery for pediatric patients bearing posterior fossa tumors.

Statins modify the response of chicks to challenges with xylazine-ketamine and carbaryl

Statins are known to affect brain function in a manner not related to their dyslipidemic effects. The purpose of the present study was to assess the behavioral response of a chick model (7-14 days old) after single treatments with the statins atorvastatin, fluvastatin or simvastatin at 100 mg/kg, orally, to a pharmacological challenge with an anesthetic regimen of xylazine (5 mg/kg)-ketamine (20 mg/kg), intramuscularly, and a toxicological challenge with the reversible cholinesterase inhibiting insecticide carbaryl (250 mg/kg, orally). Only simvastatin significantly reduced the duration of xylazine-ketamine anesthesia by 47%. Carbaryl at 250 mg/kg, orally induced signs of cholinergic poisoning (57.1 - 100%) in chicks within 3.14 min, and 57.1% death occurred within 85 min. Toxicological challenge of statin-treated chicks with carbaryl also induced signs of cholinergic poisoning, but with varying percentages of reductions compared to the control (carbaryl) group. The reductions in 4 h carbaryl-induced lethality in chicks pre-treated with atorvastatin, fluvastatin and simvastatin were 43, 57 and 29%, respectively, below that of the control value. Correspondingly, their toxicity scores decreased by 18, 18 and 11%, respectively. These data suggest that statins might modulate the functional status of the brain in a manner that affects the impact of centrally acting drugs or toxicants, and hence the behavioral outcomes in chicks. Further studies are warranted on the behavioral effects of statins after prolonged therapy.

Intraoperative Stimulation Mapping in Neurosurgery for Anesthesiologists, Part 2: The Anesthetic Considerations

AbstractIntraoperative language and sensorimotor function mapping with direct electrical stimulation allows precise identification of functionally important brain regions. Direct electrical stimulation brain mapping has become the standard of care for the resection of brain lesions near or within eloquent regions with various patient outcome benefits. Intraoperative stimulation mapping (ISM) is commonly performed in an awake patient for language and motor assessments. However, motor mapping under general anesthesia, termed asleep motor mapping, has been increasingly performed over the last two decades for lesions primarily affecting the motor areas of the brain. Both asleep-awake-asleep and monitored anesthesia care have been successfully used for awake craniotomy in modern neuroanesthesia. Each anesthetic agent exerts varying effects on the quality of ISM, especially under general anesthesia. Careful selection of an anesthetic technique is crucial for the successful performance of ISM in both awake and asleep conditions. A comprehensive search was performed on electronic databases such as PubMed, Embase, Cochrane, Scopus, Web of Science, and Google Scholar to identify articles describing anesthesia for awake craniotomy, intraoperative brain mapping, and asleep motor mapping. In the second part of this narrative review, we summarize the effects of different anesthetic regimes and agents on ISM, causes of the failure of awake craniotomy and mapping, and outline the anesthetic considerations for ISM during awake craniotomy and asleep motor mapping.

Sub-dose anesthetics combined with chloride regulators protect the brain against chronic ischemia-hypoxia injury.

Cerebral ischemia-hypoxia leads to excitotoxicity-mediated neuronal damage and cognitive dysfunction, especially in the elderly. Excessive intracellular [Cl- ]i accumulation weakens γ-aminobutyric acid (GABA) compensatory effects. Sub-anesthetic dose of propofol protected the brain against ischemia-hypoxia, which was abolished by blocking Cl- efflux transporter K+ /Cl- cotransporter 2 (KCC2). We aimed to determine whether low-dose anesthetic combined with [Cl- ]i regulators could restore the compensatory GABAergic system and improve cognitive function. Chronic cerebral hypoxia (CCH) model was established by bilateral carotid artery ligation in aged rats. Sub-dose of anesthetics (propofol and sevoflurane) with or without KCC2 agonist N-ethylmaleimide (NEM) or Na+ /K+ /Cl- cotransporter 1 (NKCC1) antagonist bumetanide (BTN) was administered systemically 30 days post-surgery. Primary rat hippocampal neuronal cultures were subjected to hypoxic injury with or without drug treatment. Memory function, hippocampal neuronal survival, GABAergic system functioning, and brain-derived neurotrophic factor (BDNF) expressions were evaluated. Sub-anesthetic dose of combined propofol (1.2 μg mL-1 ) and sevoflurane [0.7 MAC (minimum alveolar concentration)] did not aggravate the hypoxic brain injury in rats or cell damage in neuronal cultures. Adding either BTN or NEM protected against hypoxic injury, associated with improved cognitive function in vivo, less intracellular accumulation of [Cl- ]i , reduced cell death, restored GABAergic compensation, and increased BDNF expression both in vivo and in vitro. Sub-anesthetic dose of propofol and sevoflurane is a recommended anesthesia regimen in at-risk patients. Restoration of [Cl- ]i homeostasis and GABAergic could further reduce the brain damage caused by ischemia-hypoxia.

Anesthetic modulation of water diffusion: Insights from a diffusion tensor imaging study.

Diffusion tensor imaging (DTI) in animal models are essential for translational neuroscience studies. A critical step in animal studies is the use of anesthetics. Understanding the influence of specific anesthesia regimes on DTI-derived parameters, such as fractional anisotropy (FA) and mean diffusivity (MD), is imperative when comparing results between animal studies using different anesthetics. Here, the quantification of FA and MD under different anesthetic regimes, alpha-chloralose and isoflurane, is discussed. We also used a range of b-values to determine whether the anesthetic effect was b-value dependent. The first group of rats (n=6) was anesthetized with alpha-chloralose (80mg/kg), whereas the second group of rats (n=7) was anesthetized with isoflurane (1.5%). DTI was performed with b-values of 500, 1500, and 1500s/mm2, and the MD and FA were assessed individually. Anesthesia-specific differences in MD were apparent, as manifested by the higher estimated MD under isoflurane anesthesia than that under alpha-chloralose anesthesia (P<0.001). MD values increased with decreasing b-value in all regions studied, and the degree of increase when rats were anesthetized with isoflurane was more pronounced than that associated with alpha-chloralose (P<0.05). FA quantitation was also influenced by anesthesia regimens to varying extents, depending on the brain regions and b-values. In conclusion, both scanning parameters and the anesthesia regimens significantly impacted the quantification of DTI indices.

Pain experience in patients undergoing topical anesthesia alone versus topical plus intracameral anesthesia during cataract surgery.

To evaluate and compare the pain experience and discomfort during cataract surgery and over the 24 hours after surgery in patients undergoing either topical anesthesia alone or topical anesthesia plus intracameral anesthesia, provided by using a standard topical anesthesia regimen and a 0.2-mL dose of Mydrane®. Prospective study involving 100 patients who underwent cataract surgery receiving either topical anesthesia alone (group 1, n = 50) or topical anesthesia plus intracameral anesthesia (group 2, n = 50) between January 2021 and March 2022. The pain experienced by patients during and after surgery was assessed using a pain scale and a questionnaire. One hour after surgery, patients were asked to rate the intensity of discomfort they experienced throughout the procedure by pointing to a 0-100 Visual Analogue Scale (VAS). According to VAS measurements, patients who underwent surgery under topical anesthesia reported more significant pain than those who underwent surgery under topical anesthesia plus intracameral anesthesia during and over the 24 hours after surgery. (p = 0.02 and p = 0.01, respectively). Patients undergoing topical anesthesia had 2.34-fold greater odds of having pain during surgery [95% Confidence Interval (CI): 1.58-5.25, p = 0.03]. Topical anesthesia plus intracameral anesthesia lower intraoperative and postoperative pain levels, improving patient cooperation and representing a useful analgesic delivery method in cataract surgery.

Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis

BackgroundEvidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity.MethodsWe identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data.ResultsA total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2–7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53–2.24)].ConclusionsNo significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery.Trial registration10.17605/OSF.IO/3DJ6C.

Analysis of the efficacy of subclinical doses of esketamine in combination with propofol in non-intubated general anesthesia procedures - a systematic review and meta-analysis

BackgroundThe number of non-intubated general anesthesia outside the operating room is growing as the increasing demand for comfort treatment. Non-intubated general anesthesia outside the operating room requires rapid onset of anesthesia, smoothness, quick recovery, and few postoperative complications. Traditional anesthetic regimens (propofol alone or propofol and opioids/dezocine/midazolam, etc.) have severe respiratory and circulatory depression and many systemic adverse effects. In this paper, we compare the effectiveness and safety of propofol and subclinical doses of esketamine with other traditional regimens applied to non-intubated general anesthesia through a systematic review and meta-analysis.MethodsWe searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and Sinomed databases for the period from January 2000 to October 2022. We rigorously screened the literature according to predefined inclusion and exclusion criteria, while risk assessment of the studies was performed using The Cochrane Collaboration’s tool, and statistical analysis of the data was performed using RevMan 5.4 software. The main outcome indicators we evaluated were the various hemodynamic parameters and incidence of various adverse effects between the experimental and control groups after induction of anesthesia.ResultsAfter a rigorous screening process, a total of 14 papers were included in the final meta-analysis. After risk bias assessment, three of the papers were judged as low risk and the others were judged as having moderate to high risk. Forest plots were drawn for a total of 16 indicators. Meta-analysis showed statistically significant differences in HR’ WMD 3.27 (0.66, 5.87), MAP’ WMD 9.68 (6.13, 13.24), SBP’ WMD 5.42 (2.11, 8.73), DBP’ WMD 4.02 (1.15, 6.88), propofol dose’ SMD -1.39 (-2.45, -0.33), hypotension’ RR 0.30 (0.20, 0.45), bradycardia’ RR 0.33 (0.14, 0.77), hypoxemia or apnea’ RR 0.45 (0.23, 0.89), injection pain’ RR 0.28 (0.13, 0.60), intraoperative choking’ RR 0.62 (0.50, 0.77), intraoperative body movements’ RR 0.48 (0.29, 0.81) and overall incidence of adverse reactions’ RR 0.52 (0.39, 0.70).The indicators that were not statistically different were time to wake up’ WMD − 0.55 (-1.29, 0.19), nausea and vomiting 0.84’ RR (0.43, 1.67), headache and dizziness’ RR 1.57 (0.98, 2.50) and neuropsychiatric reaction’ RR 1.05 (0.28, 3.93). The funnel plot showed that the vast majority of studies fell within the funnel interval, but the symmetry was relatively poor.ConclusionIn non-intubated general anesthesia, the combination of subclinical doses of esketamine and propofol did reduce circulatory and respiratory depression, injection pain, and other adverse effects, while the incidence of esketamine’s own side effects such as neuropsychiatric reactions did not increase, and the combination of the two did not cause the occurrence of new and more serious adverse reactions, and the combination of the two was safe and effective.Trial registrationPROSPREO registration number: CRD 42022368966.

Effects of opioid-free total intravenous anesthesia on postoperative nausea and vomiting after treatments of lower extremity wounds: protocol for a randomized double-blind crossover trial

BackgroundPostoperative nausea and vomiting (PONV) are common after general anesthesia and surgery. This study aims to compare the effects of total intravenous opioid-free anesthesia (OFA) with conventional opioid-based anesthesia (OBA) on PONV in patients following treatments for wounds of lower extremities.MethodsThis randomized, double-blind, crossover trial will include a total of 72 adult patients scheduled for at least two separate surgical treatments of lower extremity wounds under general anesthesia. Patients will be randomized to 1 of 2 anesthesia sequences of OFA and OBA. Patients in sequence 1 will receive OFA in the first treatment procedure and OBA in the second procedure, while patients in sequence 2 will receive the two anesthesia regimens in the reverse order. The washout period is at least 5 days. OFA will be delivered with intravenous esketamine, lidocaine, dexmedetomidine, and propofol. OBA will be delivered with intravenous sufentanil and propofol. The primary endpoint is the incidence of PONV within the first 48 h postoperatively. The secondary endpoints are the severity of PONV, antiemetic rescue therapy, postoperative pain scores, the worst pain, need for rescue analgesia, postoperative sedation, hypotension, bradycardia, hypertension, tachycardia, hypoxemia, psychotomimetic or dissociative effects, time to extubation, and length of postanesthesia care unit stay. Patients who complete two surgical procedures with designated anesthesia regimens will be included in the final analyses.DiscussionThis crossover trial will determine whether total intravenous OFA reduces PONV in patients following treatments for lower extremity wounds. The results of this trial will also represent an important step to understand the benefits and possible risks of OFA in surgical patients.Trial registrationChinese Clinical Trial Registry (ChiCTR2200061511).

Efficacy and safety comparison of esketamine-propofol with nalbuphine-propofol for upper gastrointestinal endoscopy in children: a multi-center randomized controlled trial.

Anesthetics such as propofol, esketamine and nalbuphine are used during the upper gastrointestinal endoscopy to achieve and maintain the desired sedation level. The aim of the study was to evaluate the effectiveness and safety of propofol-nalbuphine and propofol-esketamine in children. A multi-centered study was performed at three tertiary class-A hospitals. Children between 3 and 12 years old undergoing diagnostic painless upper gastrointestinal endoscopy were included and randomly divided into esketamine or nalbuphine group to estimate the primary outcome of successful endoscope insertion. The patients were given esketamine 0.5 mg/kg and propofol 2 mg/kg intravenously in esketamine group, with nalbuphine 0.2 mg/kg and propofol 2 mg/kg in the nalbuphine group. The primary outcome was success rate for the first attempt of endoscope insertion in each group. Secondary outcomes included the safety of both anesthesia regimens and gastroenterologist's satisfaction. We used the Face, Leg, Activity, Cry and Consolability (FLACC) scale to evaluate the level of pain before and during the procedure and the Pediatric Anesthesia Emergence Delirium (PAED) scale to assess the level of agitation and delirium after awakening from anesthesia. Among 246 patients, 200 were randomly included in the final intention-to-treat analysis, with 100 patients in each group. The success rate for the first attempt of endoscope insertion in the esketamine group was higher than the nalbuphine group (97% vs. 66%; P < 0.01). The heart rate and mean arterial pressure after intraoperative administration in the esketamine group were higher than those in the nalbuphine group, while the delirium incidence during awakening was higher in esketamine group (all P < 0.05). The success rate for the first attempt of endoscope insertion of children undergoing upper gastrointestinal endoscopy in the esketamine group was higher than the nalbuphine group, propofol-related hemodynamic changes were reduced accordingly, while the incidence of esketamine-related adverse effects could be high. Chinese Clinical Trial Registry: ChiCTR2000040500.