Anesthetic Strategies Research Articles

Two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position: a systematic review

Esophageal cancer surgery is still carrying a high risk of morbidity and mortality. That is why some anesthesia strategies have tried to reduce those postoperative complications. In this systematic review performed in accordance with the PRISMA-S guidelines (PROSPERO (ID: CRD42022310385)), we aimed to investigate the safety and advantages of two-lung ventilation (TLV) over one-lung ventilation (OLV) in minimally invasive esophagectomy (MIE) in the prone position. Seven trials, with a total number of 1710 patients (765 patients with TLV versus 945 patients with OLV) were included. Postoperative mortality and morbidity rates were similar between TLV and OLV when realised for esophagectomy. Interestingly, we observed no difference in changes in intraoperative respiratory parameters, operative duration, thoraco-conversion rate, number of harvested lymph nodes, postoperative heart rate and respiratory rate between TLV and OLV. TLV brings better results in terms of intraoperative oxygen arterial pressure (PaO2) during the thoracic time, postoperative oxygenation, PaO2 on inspired fraction of oxygen (FiO2) ratio, duration of thoracic surgery, preoperative time, blood loss, temperature on postoperative day-1, and C-reactive protein dosage. Our study highlighted the safety of TLV for MIE in prone position when compared to OLV. Interestingly, we found better intra and postoperative ventilation parameters. The choice of ventilation modality did not influence clinical outcome after surgery and the quality of oncological resection. Large randomised controlled trials are needed to confirm these results.

Anesthetic considerations for endovascular treatment in stroke therapy.

The introduction of clot removement by endovascular treatment (EVT) in 2015 has improved the clinical outcome of patients with acute ischemic stroke (AIS) due to a large vessel occlusion (LVO). Anesthetic strategies during EVT vary widely between hospitals, with some departments employing local anesthesia (LA), others performing conscious sedation (CS) or general anesthesia (GA). The optimal anesthetic strategy remains debated. This review will describe the effects of anesthetic strategy on clinical and radiological outcomes and hemodynamic parameters in patients with AIS undergoing EVT. Small single-center randomized controlled trails (RCTs) found either no difference or favored GA, while large observational cohort studies favored CS or LA. RCTs using LA as separate comparator arm are still lacking and a meta-analysis of observational studies failed to show differences in functional outcome between LA vs. other anesthetic strategies. Advantages of LA were shorter door-to-groin time in patients and less intraprocedural hypotension, which are both variables that are known to impact functional outcome. The optimal anesthetic approach in patients undergoing EVT for stroke therapy is still unclear, but based on logistics and peri-procedural hemodynamics, LA may be the optimal choice. Multicenter RCTs are warranted comparing LA, CS and GS with strict blood pressure targets and use of the same anesthetic agents to minimize confounding variables.

Combined proximal or distal nerve blocks for postoperative analgesia after total knee arthroplasty: a randomised controlled trial

BackgroundMany regional anaesthetic techniques have been proposed to manage pain after total knee arthroplasty, but the best approach is unclear. We compared opioid consumption in the first 48 h between two different regional anaesthesia strategies in patients undergoing total knee arthroplasty. MethodsIn this single-centre, prospective study, we randomly allocated 90 patients to a combination of IPACK (interspace between popliteal artery and capsule of the posterior knee), triangle femoral and obturator nerve blocks (distal group), or a combination of sciatic, femoral, obturator, and lateral femoral cutaneous nerve blocks (proximal group). All patients received an opioid-sparing general anaesthesia regimen. The primary outcome was opioid consumption in the first 48 h. Secondary outcomes included opioid consumption in the first 24 h and verbal rating pain scores in the first 48 h. ResultsThere was no difference in median cumulative oral morphine equivalent consumption at 48 h between the distal and the proximal block groups (33 [18–78] mg vs 30 [22–51] mg, respectively; P=0.29). Median oral morphine equivalent consumption at 24 h was higher in the distal group compared with the proximal group (30 [13–59] vs 15 [0–18], respectively; P<0.001). Verbal rating pain scores were lower in the proximal group compared with the distal group on arrival to the postanaesthesia care unit and at 6 and 12 h. ConclusionsIn patients undergoing total knee arthroplasty under total intravenous general anaesthesia with a multimodal analgesia regimen, proximal nerve blocks resulted in improved pain scores in the first 12 h and reduced opioid consumption in the first 24 h when compared with distal nerve blocks. No difference in pain scores or opioid consumption was seen at 48 h. Clinical trial registrationNCT 04499716.

Preoperative Cryoneurolysis for Total Knee Arthroplasty: A Case Series

PurposeThe purpose of this pilot project case series is to describe the use of preoperative cryoneurolysis for 10 patients presenting for total knee arthroplasty (TKA). DesignDescriptive research design. MethodsBilling codes were used to identify 10 patients who had previously undergone TKA, preoperative cryoneurolysis and physical therapy (PT) at a Midwestern community hospital. Data collected included anesthetic management strategies, multimodal analgesic therapies, postanesthesia care unit pain scores (PACU), pain scores during physical therapy, and achievement of a range of motion during physical therapy. FindingsNine of 10 patients who received preoperative cryoneurolysis had PACU pain scores of 0 (0-10 scale) up to 90 minutes postoperatively. Pain scores immediately following cryoneurolysis therapy were reduced in all patients reporting pain greater than 0 (1-10 pain scale) before their treatment. Increased active range of motion trends were noted with reports of decreased pain scores during postoperative physical therapy sessions. ConclusionsThis pilot project case series demonstrates potential benefits of using preoperative cryoneurolysis to provide postoperative pain control and aid with physical therapy recovery following TKA.

Effects of opioid-free anesthesia on postoperative morphine consumption after bariatric surgery

Study objectivesThe objective of this study was to determine whether postoperative morphine requirement in obese patients undergoing laparoscopic bariatric surgery was reduced by opioid-free anesthesia (OFA), as compared to an anesthetic strategy using opioids (opioid balanced anesthesia (OBA)) and to investigate the differences that may exist between the use of clonidine and dexmedetomidine in the context of OFA. DesignRetrospective cohort study. SettingAcademic medical center in Lyon, France. Patients257 patients who underwent laparoscopic bariatric surgery between March 2017 and March 2019. 77 patients were included in the OBA group and 180 in the OFA group. The OFA group was subdivided in two: 90 patients received OFA with clonidine (OFAC) and 90 received OFA with dexmedetomidine (OFAD). MeasurementsProportion of patients who did not receive morphine during the first 24 postoperative hours. Main resultsDuring the first 24 postoperative hours, the proportion of patients who did not require morphine was significantly higher in the OFA (87%) than in the OBA (52%) group (OR: 6.31; 95% CI [3.38; 11.80], P < 0.001). This difference remained significant after adjustment for age, body mass index, sex, type and duration of surgery (OR: 7.99; 95% CI [4.05; 16.48], P < 0.001). A greater proportion of patients in the OFAD (93%) than in the OFAC group (81%, P = 0.026) did not receive morphine during the same period. ConclusionsOFA is associated with a lower morphine requirement than with OBA during the first 24 h after bariatric surgery. In addition, OFAD seems to be more effective than OFAC in order to reduce morphine consumption.

Optimizing Intraoperative Haemodynamics and Haemostasis to Enhance Recovery After Liver Transplantation for Cirrhosis in Adults

Cirrhosis with end stage liver disease is a leading cause of non-communicable disease related deaths in Sri Lanka. Liver transplantation remains the only curative treatment for such patients. Multi-organ dysfunction characteristic of end stage liver disease, surgical and anaesthetic factors, quality of the graft, coagulopathy and haemodynamic instability, all lead to the complexity of the perioperative care for liver transplant. Aggressive management focused particularly on maintaining intra-operative haemodynamic stability and optimizing haemostasis, directly impacts successful patient outcomes and forms the core of the anaesthetic strategy.

Pancreatic Cancer and Microenvironments: Implications of Anesthesia.

Simple SummaryPancreatic cancer is a lethal malignant neoplasm with less than 10% 5-year relative survival after the initial diagnosis. Several factors may be related to the poor prognosis of pancreatic cancer, including the rapid tumor progression, increased metastatic propensity, insignificant symptoms, shortage of early diagnostic biomarkers, and its tendency toward resistance to both chemotherapy and radiotherapy. Pancreatic neoplastic cells interact intimately with a complicated microenvironment that can foster drug resistance, metastasis, or relapse in pancreatic cancer. In addition, evidence shows that perioperative factors, including surgical manipulation, anesthetics, or analgesics, might alter the tumor microenvironment and cancer progression. This review outlines the up-to-date knowledge of anesthesia implications in the pancreatic microenvironment and provides future anesthetic strategies for improving pancreatic cancer survival. Pancreatic malignancy is a lethal neoplasm, as well as one of the leading causes of cancer-associated mortality, having a 5-year overall survival rate of less than 10%. The average life expectancy of patients with advanced pancreatic cancer does not exceed six months. Although surgical excision is a favorable modality for long-term survival of pancreatic neoplasm, metastasis is initially identified in nearly 80% of the patients by the time of diagnosis, making the development of therapeutic policy for pancreatic cancer extremely daunting. Emerging evidence shows that pancreatic neoplastic cells interact intimately with a complicated microenvironment that can foster drug resistance, metastasis, or relapse in pancreatic cancer. As a result, the necessity of gaining further insight should be focused on the pancreatic microenvironment contributing to cancer progression. Numerous evidence reveals that perioperative factors, including surgical manipulation and anesthetics (e.g., propofol, volatile anesthetics, local anesthetics, epidural anesthesia/analgesia, midazolam), analgesics (e.g., opioids, non-steroidal anti-inflammatory drugs, tramadol), and anesthetic adjuvants (such as ketamine and dexmedetomidine), might alter the tumor microenvironment and cancer progression by affecting perioperative inflammatory or immune responses during cancer surgery. Therefore, the anesthesiologist plays an important role in perioperative management and may affect surgical outcomes. However, the literature on the impact of anesthesia on the pancreatic cancer microenvironment and progression is limited. This review summarizes the current knowledge of the implications of anesthesia in the pancreatic microenvironment and provides future anesthetic strategies for improving pancreatic cancer survival rates.

The strategy of non-intubated spontaneous ventilation anesthesia for upper tracheal surgery: a retrospective case series study.

BackgroundUpper tracheal surgery is used to treat patients who with tracheal tumors or tracheal stenosis. The non-intubated spontaneous ventilation anesthesia (NSVA) may have advantages over endotracheal intubation and surgical cross-field intubation in upper tracheal surgery. This study aimed to illustrate and assess the feasibility of NSVA strategy for upper tracheal surgery.MethodsThis is a retrospective case series study in which 51 patients (from May 2015 to August 2020) who met the criteria in NSVA strategy were analyzed. Anesthesia was performed using total intravenous anesthesia (TIVA) combined with bilateral superficial cervical plexus block (CPB) or thoracic epidural anesthesia (TEA). Patients received spontaneous ventilation through laryngeal mask airway (LMA) during the surgery. Anesthesia conversion technique was applied to patients who met the anesthesia conversion criteria.ResultsIn total, 51 patients met the NSVA criteria and were included in this study. Forty-six out of 51 patients (90%) had TIVA + bilateral superficial CPB and five patients (10%) had TIVA + TEA + CPB. During the airway-opened period, 46 patients had stable spontaneous ventilation. Five patients need anesthesia conversion, two patients had high-frequency ventilation (HFV), and three patients required cross-field intubation. Postoperative complications occurred in seven (14%) patients, no reintubation was needed after surgery. The median postoperative hospital stay was 6.31±4.30 days.ConclusionsThis NSVA strategy includes criteria for patient selection, preoperative assessment, surgical technique, airway management, criteria and technique for anesthesia conversion. The NSVA strategy is a feasible procedure in upper tracheal surgery.

Comparison of the Different Anesthesia Strategies for Atrial Fibrillation Catheter Ablation: A Systematic Review and Meta-Analysis.

Background Catheter ablation has become a widely applied intervention for treating symptomatic atrial fibrillation (AF), which can be performed under general anesthesia (GA), deep sedation, or conscious sedation (CS). But the strategy of anesthesia remains controversial. Objectives This systematic review and meta-analysis aims to compare the advantages of GA/deep sedation and CS in AF catheter ablation, including procedural parameters and clinical outcomes. Methods PubMed, Embase, and the Cochrane Library were searched up to November 2021 for randomized controlled trials and observational studies that assessed the outcomes of catheter ablation under GA/deep sedation or CS. Ten studies were included in this meta-analysis after screening with the inclusion and exclusion criteria. Heterogeneity between studies was evaluated by the I2 index and the Cochran Q test, respectively; sensitivity analysis including meta-regression was performed if heterogeneity was high. Publication bias was assessed using a funnel plot and Egger' test. Results This meta-analysis found GA/deep sedation to be associated with a lower recurrence rate of AF catheter ablation (p=0.03). In terms of procedural parameters, there was no significant difference between the two groups for the procedural time (p=0.35) and the fluoroscopy time (p=0.60), while the ablation time was shorter in the GA/deep sedation group (p=0.008). The total complication rate and the incidence of serious adverse events were statistically insignificant between the two groups (p=0.07 and p=0.94). Meta-regression did not suggest any covariates as an influential factor for procedural parameters and clinical outcomes. Conclusion GA/deep sedation may reduce the risk of recurrence after AF ablation without increasing the incidence of complications. GA/deep sedation shortens the ablation duration, although there is no statistical difference in other procedural parameters between GA/deep sedation and CS.

The impact of local vs general anesthesia in patients undergoing thoracic endovascular aortic surgery

ObjectiveGeneral anesthesia (GA) is associated with inherent risks that can be avoided by the use of lesser invasive anesthetic strategies. We hypothesize that examine and compare the use of local or regional anesthesia (LRA) to that of GA in patients undergoing thoracic endovascular aortic repair (TEVAR). MethodsPatients undergoing TEVAR between 2010 and 2020 in the Vascular Quality Initiative were analyzed. Exclusion criteria included receipt of branched or physician-modified endografts and devices extending distally beyond zone 5. Patients were categorized as receiving LRA or GA. Center volume was reported by quartile according to annualized TEVAR volume, and operative outcomes were compared using appropriate frequentists tests. Univariable and multivariable regression models for anesthesia type and operative outcomes were created to compare unadjusted and adjusted rates of each outcome. Long-term survival was estimated using a Kaplan-Meier survival estimator, whereas adjusted survival analysis was performed using a Cox proportional hazards model. ResultsOf the 17,099 patients who underwent TEVAR, 7299 met the inclusion and exclusion criteria. Of these, 3.8% received LRA. There were no significant differences in the annual proportion of patients who received LRA from 2011 to 2020 (P = .49, χ2 test for trend). Only 18.8% of patients who received LRA were treated at the highest quartile volume centers. Patients who received LRA were older and more comorbid compared with those who received GA. There were no differences in in-hospital mortality (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.42-1.38; P = .44) or composite of any complication (OR, 0.79; 95% CI, 0.54-1.14; P = .22) between patients who received LRA compared with those who received GA. This also applied to patients presenting with rupture. Receipt of LRA was associated with lower odds of postoperative congestive heart failure (OR, 0.19; 95% CI, 0.01-0.89; P = .01) as well as decreased length of intensive care unit (OR, 0.54; 95% CI, 0.40-0.72; P < .01) and hospital length of stay (OR, 0.64; 95% CI, 0.46-0.84; P < .01). LRA was not associated with decreased long-term survival compared with GA (hazard ratio, 0.95; 95% CI, 0.72-1.25; P = .72). ConclusionsDespite a greater number of baseline comorbidities, patients undergoing TEVAR with LRA experienced shorter intensive care unit and postoperative lengths of stay, with similar operative outcomes and long-term survival compared with patients who received GA. Similar findings were found among the rupture cohort. LRA should be considered more frequently in select patients undergoing TEVAR.

Evolution of Anesthetic Techniques for Shoulder Surgery: A Narrative Review

Shoulder surgery has radically evolved within the last 70 years, from a marginal orthopedic sub-specialty to an area of great research and advancement; consequently, anesthetic techniques have undergone important development. In fact, a wide variety of anesthetic strategies have emerged, to provide anesthesia and post-operative analgesia: general anesthesia (GA), regional anesthesia (RA), or combined GA and RA. A literature review on online databases was carried out about the different anesthetic approaches for shoulder surgery and their evolution through the years, taking in consideration papers from 1929 to 2021. A comprehensive preoperative assessment of patients undergoing shoulder surgery allows to identify and modify potential risk factors and complications of general anesthesia. Moreover, the use of ultrasound-guided regional blocks could improve the effectiveness of these techniques and bring better postoperative outcomes. Anesthetic management for shoulder surgery has progressed drastically during the last century. More studies are needed to finally standardize anesthetic techniques for specific procedure.

Breakthrough pain during cesarean section under neuraxial anesthesia: a two-center prospective audit

Worldwide, most Cesarean sections (CS) are performed under neuraxial anesthesia. However, neuraxial anesthesia can fail and intraoperative breakthrough pain can occur. The aim of the present investigation was to evaluate the incidence of breakthrough pain in consecutive CS and to describe the potential risk factors for breakthrough pain. In a two center, prospective audit all CS performed under neuraxial anesthesia were included and the occurrence of breakthrough pain as well as all possible risk factors of breakthrough pain were recorded as well as the alternative anesthetic strategy. A total of 393 patients were enrolled in the study over 6 months, 206 in UZ Leuven and 187 in ZNA Middelheim, 295 elective CS and 98 secondary CS. Of all 393 participants, 65 experienced breakthrough pain during the CS (16.5%). Twoo significant risk factors for breakthrough pain during CS were observed: the duration of surgery (p &lt;0.001) and the epidural drug used (p=0.0032). Breakthrough pain during a CS is extremely uncomfortable for the mother. In this observational study, the incidence of breakthrough pain during CS was 16.5%. Duration of surgery and epidural drug used were both significant risk factors of breakthrough pain during CS in this audit. A pro-active policy is required in order to prevent breakthrough pain or discomfort during CS. Early identification of problematic epidural catheters for labor analgesia, adequate level of anesthetic block before surgery, and administration of a prophylactic epidural top-up if duration of surgery is prolonged as opposed to the choice of local anesthetic used, could be essential in the prevention. Further high-quality studies are needed to evaluate the many potential risk factors associated with breakthrough pain during CS.

General Anesthesia versus Sedation, Both with Hemodynamic Control, during Intraarterial Treatment for Stroke: The GASS Randomized Trial

It is speculated that the anesthetic strategy during endovascular therapy for stroke may have an impact on the outcome of the patients. The authors hypothesized that conscious sedation is associated with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anesthesia. In this single-blind, randomized trial, patients received either a standardized general anesthesia or a standardized conscious sedation. Blood pressure control was also standardized in both groups. The primary outcome measure was a modified Rankin score less than or equal to 2 (0 = no symptoms; 5 = severe disability) assessed 3 months after treatment. The main secondary outcomes were complications, mortality, reperfusion results, and National Institutes of Health Stroke Scores at days 1 and 7. Of 351 randomized patients, 345 were included in the analysis. The primary outcome occurred in 129 of 341 (38%) of the patients: 63 (36%) in the conscious sedation group and 66 (40%) in the general anesthesia group (relative risk, 0.91 [95% CI, 0.69 to 1.19]; P = 0.474). Patients in the general anesthesia group experienced more intraoperative hypo- or hypertensive episodes, while the cumulative duration was not different (mean ± SD, 36 ± 31 vs. 39 ± 25 min; P = 0.079). The time from onset and from arrival to puncture were longer in the general anesthesia group (mean difference, 19 min [i.e., -00:19] [95% CI, -0:38 to 0] and mean difference, 9 min [95% CI, -0:18 to -0:01], respectively), while the time from onset to recanalization was similar in both groups. Recanalization was more often successful in the general anesthesia group (144 of 169 [85%] vs. 131 of 174 [75%]; P = 0.021). The incidence of symptomatic intracranial hemorrhage was similar in both groups. The functional outcomes 3 months after endovascular treatment for stroke were similar with general anesthesia and sedation. Our results, therefore, suggest that clinicians can use either approach.

Comparison of Recovery Profiles of Patients Undergoing Endoscopic Lumbar Discectomy under Desflurane, Propofol, or Sevoflurane Anesthesia: A Randomized, Prospective, Clinical, Comparative Study

Background Agents like propofol, sevoflurane, and desflurane having rapid revival of psychomotor and cognitive functions translating into reliable anesthetic recovery are chosen for day care procedures. This prospective randomized comparative study was undertaken to compare the psychomotor and cognitive functions of patients undergoing discectomy under different anesthetic strategies. Methods Seventy-five adult American Society of Anesthesiologists grade I and II patients being operated for endoscopic lumbar discectomy under different anesthetic regimens were enrolled and were subjected to Trieger Dot Test (TDT), Digit Symbol Substitution Test (DSST), and Mini-Mental State Examination (MMSE) preoperatively at specified intervals postoperatively. There emergence and early recovery times, complications, and satisfaction levels were also noted. Results No difference was found in the postoperative TDT and DSST and MMSE scores among the groups at all the time points (15 minutes, 3 minutes, 1 hour, 2 hours, 3 hours, and 4 hours). TDT and DSST demonstrated a tendency to return to baseline by 2nd and 3rd hour postoperatively. Emergence and early recovery times were earlier in the inhalation groups ( p 0.005 and 0.007, respectively). Time required to attain a Modified Aldrete Score of 9, complications, and observed side effects were similar among the groups. Conclusion Patients in the three groups had similar impairments in their psychomotor and cognitive functions which recovered at comparable time periods postoperatively. Emergence and early recovery were, however, faster in the desflurane group.

Antitumor Anesthetic Strategy in the Perioperatory Period of the Oncological Patient: A Review.

The stress response triggered by the surgical aggression and the transient immunosuppression produced by anesthetic agents stimulate the inadvertent dispersion of neoplastic cells and, paradoxically, tumor progression during the perioperative period. Anesthetic agents and techniques, in relation to metastatic development, are investigated for their impact on long-term survival. Scientific evidence indicates that inhaled anesthetics and opioids benefit immunosuppression, cell proliferation, and angiogenesis, providing the ideal microenvironment for tumor progression. The likely benefit of reducing their use, or even replacing them as much as possible with anesthetic techniques that protect patients from the metastatic process, is still being investigated. The possibility of using “immunoprotective” or “antitumor” anesthetic techniques would represent a turning point in clinical practice. Through understanding of pharmacological mechanisms of anesthetics and their effects on tumor cells, new perioperative approaches emerge with the aim of halting and controlling metastatic development. Epidural anesthesia and propofol have been shown to maintain immune activity and reduce catecholaminergic and inflammatory responses, considering the protective techniques against tumor spread. The current data generate hypotheses about the influence of anesthesia on metastatic development, although prospective trials that determinate causality are necessary to make changes in clinical practice.

A Comparison of Two Peripheral Nerve Blocks Combined With General Anesthesia in Elderly Patients Undergoing Arthroplasty for Hip Fractures: A Pilot Randomized Controlled Trial.

BackgroundCombined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period.MethodsA total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate.ResultsCompared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation.ConclusionOur pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.

General Anesthesia vs. Local Anesthesia During Endovascular Treatment for Acute Large Vessel Occlusion: A Propensity Score-Matched Analysis

ObjectiveTo date, no consensus still exists on the anesthesia strategy of endovascular treatment (EVT) for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). We aimed to compare the 90-day outcomes, puncture-to-recanalization time (PRT), successful recanalization rate, and symptomatic intracranial hemorrhage (sICH) of patients undergoing general anesthesia (GA) or local anesthesia (LA) ± conscious sedation (CS) during the procedure.MethodsWe selected patients from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment (ANGEL) registry and divided them into the GA group and the LA ± CS group. The two groups underwent 1:1 matching under propensity score matching (PSM) analysis. Then, we compared the primary outcome including the 90-day modified Rankin Scale (mRS) 0–2, secondary outcome including the 90-day mRS, the 90-day mRS 0–1, the 90-day mRS 0–3, PRT, and successful recanalization rate as well as the safety outcome including sICH, any ICH, and 90-day mRS 6.ResultsAmong the 705 enrolled patients, 263 patients underwent GA and 442 patients underwent LA ± CS. After 1:1 PSM according to the baseline characteristics, each group has 216 patients. Patients with GA had the higher median 90-day mRS [3 (1–5) vs. 2 (1–4), p < 0.001], the lower 90-day mRS 0–2 rate (43.5 vs. 56.5%, p = 0.007), higher mortality (19.9 vs.10.2%, p = 0.005), and longer PRT [92 (60–140) vs. 70 (45–103) min, p < 0.001]. There were no differences in sICH and successful recanalization rate between both the groups.ConclusionIn the real-world setting, LA ± CS might provide more outcomes benefits than GA in patients with AIS-LVO during the procedure.

Change of Anesthetic Management From Open to Laparoscopic Living Donor Right Hepatectomy After Learning Curve

In our hospital, open living donor hepatectomy (OLDH) began in 1996 and laparoscopic living donor hepatectomy (LLDH) began in 2013. In this study, we focus on the change of anesthetic management from OLDH to LLDH. Under the approval of the Institutional Review Board of our hospital, medical records of the last 2 years (2011 and 2012 vs 2019 and 2020) of each OLDH and LLDH era were collected. Left hepatectomy in any period and OLDH during the LLDH era were excluded. There were 175 OLDHs and 213 LLDHs. We performed 836 cases of OLDH before 2011 and 206 cases of LLDH before 2019. Laryngeal mask airway replaced intubation in half of LLDH cases. Erector spinae plane block was performed in a quarter of LLDH cases. Lung-protective ventilation with low tidal volume and positive end-expiratory pressure were applied for LLDH. Additional peripheral venous line was decreased, and there was no central venous catheterization. Anesthesia duration time was reduced and crystalloid infusion per hour was also decreased. There was no intraoperative transfusion and there was no difference in postoperative transfusion incidence. Reoperation rate was not different. Only 1 donor in OLDH transferred to the intensive care unit after the operation because of uncontrolled hypertension. Length of hospital stay was decreased. As the surgical tactics for living liver donors become less invasive, the anesthetic strategy also becomes less invasive. In addition, new types of airway management, ventilation method, and analgesic technique have been introduced.

The Impact of Initial Surgical Management on Outcome in Patients With Severe Burns: A 9-Year Retrospective Analysis.

The aim is to investigate the prognostic value of the factors related to the initial surgical management of burn wounds in severely burned patients. A total of 189 severely burned adult patients who were admitted to our institute between January 2012 and December 2020 and met the inclusion criteria were recruited. Patients were divided into survival and nonsurvival groups. The patient data included sex, age, total burn surface area (TBSA), burn index, inhalation injury, mechanical ventilation, initial surgical management of the burn wound (including postinjury time before surgery, surgical duration, surgical area, intraoperative fluid replenishment, intraoperative blood loss, and intraoperative urine output), and duration in the burn intensive care unit (BICU). Independent samples t-tests, Mann-Whitney U-tests, and χ 2 tests were performed on these data. Those of which with statistically significant differences were subjected to univariate and multivariate Cox regression analyses to identify independent risk factors affecting the prognosis of severely burned patients. Receiver operating characteristic curves were plotted, and the area under the curve (AUC) and optimal cutoff value were calculated. Patients were divided into two groups, according to the optimal cutoff value of the independent risk factors. The TBSA, surgical area, and survival rates of the two groups during hospitalization were analyzed. The survival group (146 patients) and the nonsurvival group (43 patients) differed significantly in TBSA, burn index, inhalation injury, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, intraoperative blood loss, and duration in the BICU (P < .05). Univariate Cox regression analysis showed that TBSA, burn index, mechanical ventilation, initial surgical area, intraoperative fluid replenishment, and intraoperative blood loss were risk factors for death in severely burned patients (P < .05). Multivariate Cox regression analysis showed that the burn index and intraoperative blood loss were independent risk factors for death in severely burned patients (P < .05). When the intraoperative blood loss during the initial surgical management of burn wounds was used to predict death in 189 severely burned patients, the AUC was 0.637 (95% confidence interval: 0.545-0.730, P = .006), and the optimal cutoff for intraoperative blood loss was 750 ml. Kaplan-Meier survival analysis showed that the prognosis of the group with intraoperative blood loss ≤750 ml was better than that of the group with intraoperative blood loss >750 ml (P = .008). Meanwhile, the TBSA and surgical area in the group with intraoperative blood loss ≤750 ml were significantly lower than that of the group with intraoperative blood loss >750 ml (P < .05). The burn index and intraoperative blood loss during the initial surgical management of burn wounds are independent risk factors affecting the outcome of severely burned patients with good predictive values. During surgery, hemostatic and anesthetic strategies should be adopted to reduce bleeding, and the bleeding volume should be controlled within 750 ml to improve the outcome.

Risk Factors for General Anesthesia Conversion in Anterior Circulation Stroke Patients Undergoing Endovascular Treatment

Background and Purpose: No current consensus exists on the best anesthetic management of ischemic stroke patients undergoing mechanical thrombectomy. Both conscious sedation (CS) and general anesthesia (GA) are currently considered valid anesthetic strategies, yet patients managed under CS may require emergent conversion to GA, which has been associated with worse outcomes. The aim of this study was to analyze the conversion rate and potential risk factors for GA conversion during mechanical thrombectomy. Methods: Two-hundred and twenty-seven patients with consecutive acute anterior circulation ischemic stroke treated with mechanical thrombectomy and initiated under CS or local anesthesia were included in this retrospective analysis. Conversion rate to GA was calculated, while univariate and multivariate analysis were used to identify risk factors. Results: Twenty patients (8.8%) were switched to GA. Multivariate analysis identified procedure duration (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.00–1.02, p value 0.028), tandem stroke (OR 8.57, 95% CI 2.06–35.7, p value 0.003), Sequential Organ Failure Assessment (SOFA) (OR 1.76, 95% CI 1.19–2.61, p value 0.005), and number of pharmacological agents used (OR 5.76, 95% CI 2.49–13.3, p value <0.001) as independently associated with conversion to GA. Conclusion: In our study, tandem occlusion, longer endovascular procedures, SOFA, and number of pharmacological agents used predicted the risk of emergent conversion to GA in stroke patients undergoing endovascular treatment. Prospective studies investigating optimal CS strategies are deemed necessary.