Awake Extubation Research Articles

The effect of deep and awake extubation on emergence agitation after nasal surgery: a randomized controlled trial

BackgroundPost-anesthetic emergence agitation is common after general anesthesia and may cause adverse consequences, such as injury as well as respiratory and circulatory complications. Emergence agitation after general anesthesia occurs more frequently in nasal surgery than in other surgical procedures. This study aimed to assess the occurrence of emergence agitation in patients undergoing nasal surgery who were extubated under deep anesthesia or when fully awake.MethodsA total of 202 patients (18–60 years, American Society of Anesthesiologists classification: I–II) undergoing nasal surgery under general anesthesia were randomized 1:1 into two groups: a deep extubation group (group D) and an awake extubation group (group A). The primary outcome was the incidence of emergence agitation. The secondary outcomes included number of emergence agitations, sedation score, vital signs, and incidence of adverse events.ResultsThe incidence of emergence agitation was lower in group D than in group A (34.7% vs. 72.8%; p < 0.001). Compared to group A, patients in group D had lower Richmond Agitation-Sedation Scale scores, higher Ramsay sedation scores, fewer agitation episodes, and lower mean arterial pressure when extubated and 30 min after surgery, whereas these indicators did not differ 90 min after surgery. There was no difference in the incidence of adverse events between the two groups.ConclusionsExtubation under deep anesthesia can significantly reduce emergence agitation after nasal surgery under general anesthesia without increasing the incidence of adverse events.Trial registrationRegistered in Clinicaltrials.gov (NCT04844333) on 14/04/2021.

Postoperative throat discomfort and associated factors among surgical patients at Ethiopian Teaching Hospitals: cross-sectional study

BackgroundThroat pain and airway discomfort are the most commonly upsetting conditions for patients’ wellbeing after surgery. However, little is known about the problem and associated factors, especially in developing countries like Ethiopia. Therefore, this work determined the magnitude, severity, and associated factors of throat discomfort within 24 h after elective surgery.ResultsThe majority (63.2%, or 211) of the participants were female, with a mean age of 35.7 ± 9.7 years. The overall postoperative throat discomfort was observed in 122 (36.5%) patients, and it was severe in 20.5% of them. However, the severity level declined over time to 21.9% (21/96), 15.3% (18/118), and 5.6% (5/89), respectively, on the 1st, 6th, and 24th hours, as indicated by participants. Utilization of a larger ETT (AOR = 6.26, CI 2.13–18.43, P = 0.001), surgery lasting two or more hours (AOR = 11.20, CI 3.53–35.50, P = 0.000), awake extubation (AOR = 0.16, CI 0.05–0.43 P = 0.000), frequent episodes of hypotension (AOR = 12.85, CI 4.56–36.18, P = 0.000), and a less experienced anesthetist (AOR = 18.10, CI 6.51–50.31, P = 0.000) were significantly associated with throat discomfort.ConclusionsPost-extubation throat discomfort complaints are high (36.5%). Due attention has to be given to minimize or prevent perioperative frequent episodes of hypotension, higher ETT size utilization, blood loss, and the duration of surgery as much as possible. Postoperative throat discomfort should not be ignored. And we recommend that patient reassurance and orientation with analgesia has to be considered during the postoperative period.

Comparison of conventional awake extubation with endotracheal tube – laryngeal mask airway exchange extubation for evaluation of respiratory and hemodynamic parameters during emergence in neurosurgical patients

Background: Emergence from general anesthesia and tracheal extubation may be associated with tremendous physiological and metabolic stress in patients which could be major concern for the anesthesiologist in patients especially with neurosurgical patients. Aims and Objectives: The study was designed to find a novel method to achieving a smooth extubation in neurosurgery by compare the respiratory complications and hemodynamic stress response between conventional awake extubation of an endotracheal tube (ETT) and that following exchange extubation of ETT using a laryngeal mask airway (LMA) in craniotomy surgeries. Materials and Methods: A total of 60 patients of American Society of Anesthesiologists physical status I and II between ages 18 and 60 years undergoing neurosurgery were evaluated for respiratory events such as bucking, coughing, desaturation, and hemodynamic changes due to sympathetic stimulation such as tachycardia, hypertension, and any other complications that have occurred in any of the two extubation methods. Results: In Group A, 86.67% patients have shown significant events of bucking and coughing while desaturation events were comparable between two groups. Manipulation events, that is, chin lift and jaw thrust had to perform in 66.67% and 21.67%, respectively, in patients of Group A compared to only 03.33% patients in Group L. (P&lt;0.05). In Group A, 97.33% patients shown tachycardia compared to 30% in Group L where only 30%. Similarly, mean arterial pressure after extubation found to be significantly high in 63.33% of the patients in Group A with 63.33% as compared to13.33% of patients in Group L (P&lt;0.05). Conclusion: ETT/LMA exchange is the most effective technique for achieving the clinical endpoints of the study, that is, prevention of emergence hypertension and respiratory complications compared to awake extubation methods. The exchange of ETT with LMA in deeper plane of anesthesia significantly reduces emergence related the hemodynamic and respiratory unwonted events.

Hemodynamic Changes during Traditional Awake Extubation and Extubation Using LMA Supreme in Controlled Hypertensive Patients

Background: Anesthesia is quite remarkable and attenuation of pressor response is one of the most keenly researched subjects in the field of anaesthesiology, the reason being the non-availability of a ‘procedure/drug of choice’ for the same. Patients with arterial hypertension generally exhibit excessive pressor response to stress such as laryngoscopy, intubation, surgical incision and extubation, which can lead to arrhythmias, myocardial ischemia and cerebrovascular accidents. Exchange extubation with LMA Supreme can be used to overcome or blunt the excessive pressor response following extubation. Objective: To compare the hemodynamic changes during traditional awake extubation and extubation using LMA supreme in controlled hypertensive patients. Methods: The prospective study was carried out in the department of Anaesthesiology, Shaheed Tajuddin Ahmad Medical College Hospital, Gazipur, Bangladesh from January to December-2021. Fifty (50) patients were randomized by permuted blocks into two groups. After complete pre- anesthetic check-up and investigations. Controlled hypertensive patients with ASA (American Society of Anesthesiologists) grade II, between the age of 17 and 65 years, undergoing elective, non-oral surgery were included in the group. Hemodynamic stress response between traditional awake extubation of the endotracheal tube (ETT) and that following exchange extubation of ETT by using a laryngeal mask airway (LMA Supreme) in terms of Post Extubation Heart Rate (H.R), Systolic Blood Pressure (S.B.P), Diastolic Blood Pressure (D.B.P), Mean Arterial Pressure (MAP), to determine whether this method is easy to perform, the amount of experience needed to perform the exchange well and to calculate the time delay in extubation caused by adopting this method. Results: There was highly significant increase in pulse rate in Group A (ETT Group) as compare to LMA SupremeTM group, which was statistically significant till 15min. of extubation. Statistically ...........

Tracheal Extubation Under Deep Anesthesia Using Transnasal Humidified Rapid Insufflation Ventilatory Exchange vs. Awake Extubation: An Open-Labeled Randomized Controlled Trial.

BackgroundTracheal extubation can be associated with several complications, including desaturation, agitation, hypertension, and tachycardia. We hypothesize that the use of transnasal humidified rapid insufflation ventilator exchange (THRIVE) immediately after extubation under deep anesthesia reduces the incidence of these adverse events.MethodsOne hundred patients who underwent elective abdominal surgery under general anesthesia were randomly assigned to undergo tracheal extubation under deep anesthesia employing THRIVE (THRIVE group) or awake extubation (CONTROL group). The primary outcome was the incidence of experiencing desaturation (SpO2 < 90%) at any time during emergence from anesthesia. Secondary outcomes included variations in heart rate and blood pressure, comfort level, bucking, and agitation.ResultsThe THRIVE group showed a lower incidence of desaturation than the CONTROL group (12 vs. 54%, OR = 0.22 [95% CI, 0.10–0.49], P < 0.001). Less patients in the THRIVE group experienced a 20% (or more) increase in mean arterial pressure (4 vs. 26%, OR = 0.15 [95% CI, 0.04–0.65], P = 0.002). THRIVE patients did not suffer from agitation or bucking, while in the CONTROL group agitation and bucking occurred in 22 and 58% of the patients, respectively. Additionally, the THRIVE group showed a lower incidence of uncomfortable experience than the CONTROL group (8 vs. 36%, OR = 0.22 [95% CI, 0.08–0.61], P = 0.001).ConclusionTracheal extubation under deep anesthesia using THRIVE decreases the incidence of desaturation and adverse haemodynamic events and increases patient satisfaction. Extubation under deep anesthesia using THRIVE might be an alternative strategy in selected patient populations.

Superior laryngeal nerve block with in-line lignocaine nebulization for awake extubation response.

Background and Aims:Tracheal extubation is associated with various undesirable hemodynamic and airway responses. Various drugs are used effectively to curb these responses. But these drugs have limitations and produce side effects. Hence, the study was planned to assess the effects of superior laryngeal nerve block with inline lignocaine nebulization on awake extubation responses to suggest an alternative. The aim of this study was to assess the effect of bilateral superior laryngeal nerve block with inline lignocaine nebulization on awake extubation responses.Material and Methods:A study was conducted in 35 patients aged 18-60 years, posted for surgery less than 3 h under general anesthesia. The hemodynamic responses like heart rate, arterial blood pressure, and mean arterial pressure were recorded preoperatively and at 1, 5, and 10 min postextubation. Undesirable respiratory responses like bucking, severity of sore throat, and cough response were also assessed. Repeated measures analysis of variance followed by the Tukey HSD test was used to find the significance of hemodynamic parameters. Qualitative data were expressed as percentages.Results:Decrease in Systolic Blood Pressure, Diastolic Blood Pressure and Mean Arterial Pressure was statistically significant at 5 mins (T2) and 10 mins (T3) postextubation as compared to baseline (T0). No cough was observed postextubation in 80% patients while 20% had mild Grade 1 cough.Conclusion:Superior laryngeal nerve block with in-line lignocaine nebulization for awake extubation is effective in curbing the haemodynamic and respiratory responses of extubation.

A descriptive survey of tracheal extubation practices among Indian anaesthesiologists.

Background and Aims:This study assesses the extubation practices of anaesthesiologists and whether these practices differ from existing guidelines.Methods:The literature related to tracheal extubation was searched and a validated questionnaire was designed to assess practices of tracheal extubation. The questionnaire included techniques, manoeuvres, preparation, timing and plan of extubation. The survey link was shared with eligible participants. The responses were assessed using Statistical Package for Social Sciences (SPSS) software.Results:Of the 1264 respondents, 66.8% keep difficult airway cart ready only when difficult extubation is anticipated. Only 12.3% of respondents perform deep extubation with supraglottic airway device (SAD) exchange while 73.3% of respondents perform awake extubation with pharmacological control for preventing haemodynamic fluctuations. In the case of anticipated difficult extubation, 48.3% anaesthesiologists prefer the airway exchange catheter (AEC) exchange technique. Of all, 84.8% anaesthesiologists administer 100% oxygen before performing extubation and 81.7% continue to oxygenate during and 83.9% provide oxygen after extubation in all patients. In the case of suspected airway edema or collapse or surgical cause for airway compromise, 70% anaesthesiologists perform a leak test. The most preferred plan of extubation in patients with suspected airway collapse after surgery is direct extubation in fully awake position (54.6%). In patients with anticipated difficult extubation, 50.8% anaesthesiologists prefer to ventilate for 24 hours and reassess.Conclusion:We observed that the extubation practices vary widely among anaesthesiologists. Almost half of the anaesthesiologists were unaware of extubation guidelines.

The Need to Protect Health Care Workers Is Unchanged in the Presence of COVID-19 Pandemic Fatigue: The Probable Might Still Be Possible.

To the Editor We read with interest the article by Thiruvenkatarajan et al1 on airway management in the operating room and interventional suites in coronavirus disease 2019 (COVID-19) patients. We applaud the clarity of their review, prioritizing safety for health care workers (HCW) who perform aerosol-generating procedures. Because the COVID-19 pandemic is ongoing with no end in sight, it is expected that many people, including HCW, may experience pandemic fatigue, and adhering to guidelines for safe airway management may become increasingly challenging. Recently, a small observational study demonstrated that intubation and extubation did not generate aerosol in healthy individuals and concluded that “elective tracheal intubation should not be designated as an aerosol-generating procedure.”2 However, we share the sentiment with Thiruvenkatarajan et al1 that HCW performing airway maneuvers should be considered at high risk of contracting respiratory infections until proven otherwise by well-designed, robust randomized-control trials, especially amid the COVID-19 pandemic. In the meantime, the local guidelines should reflect the high-risk nature for infection of such procedures. Although most tracheal intubations performed in the operating rooms are controlled, the nature of intubation is unpredictable with the unanticipated difficulty being possible, not to mention the possibility of a patient coughing or bucking during airway maneuvers with suboptimal effect of a nondepolarizing muscle relaxant or the subsiding effect of depolarizing muscle relaxant in the presence of unplanned prolonged airway maneuvers. Furthermore, we agree that video laryngoscopy should be used in the first instance to protect HCW, even though this translates to trainees getting less exposure to direct laryngoscopy. As mentioned by Thiruvenkatarajan et al,1 extubation is less controlled than intubation with regard to aerosol generation and droplet dispersion. It has been shown that around 40% of patients cough at the time of extubation, but it can be as high as 70% after awake extubation.3 Deep extubation performed with oropharyngeal airway and jaw thrust in selected patients, or facemask covering the patient’s airway immediately following awake extubation, may reduce aerosol or droplet spread. It has been demonstrated that individuals with influenza produce a significantly greater volume of aerosol and higher number of particles per cough when ill compared with afterward. There was also a higher volume of particles that could reach the alveolar region of the lungs if inhaled by another person.4 Respiratory infection, including COVID-19 transmission, depends on the viral load of the patients at the time of airway maneuver, with multiple factors affecting aerosol generation, including cough velocity, mucous density, surface tension, surface properties that line the airway, and viscosity.5 One of the lessons from the COVID-19 pandemic is the recognition that intubation and facemask ventilation are high-risk events for transmission for viral respiratory pathogens, even though the risk of transmission may not entirely be due to aerosol generation.6 With the complexity and multifactorial process of pathogen transmission, one should err on the side of caution and utilize personal protective equipment (PPE) appropriate to cover droplet, contact, and aerosol precautions when intubating or extubating proven or suspected COVID-19 patients, until there is clinical evidence that intubation and extubation are not high-risk events for transmission. The standards for protecting HCW should not be set at the bare minimum. If the idea is to be resource conscious, there needs to be an effort by health care institutions to adapt reusable and sustainable solutions. Unlike prion disease, coronavirus can be effectively eliminated by normal cleaning practices. Reusable equipment can be used to preserve scarce resources while protecting the environment. We would like to reinforce the requirement that those performing airway maneuvers take proper precautions and don appropriate PPE for personal safety and disease containment and to remember that “an infected lung is potentially an infectious lung.” This is particularly true when pandemic fatigue may lead to complacency while preparing for a second surge in COVID-19 cases worldwide. Vivian H. Y. Ip, MBChB, FRCADepartment of Anesthesia and Pain MedicineUniversity of AlbertaEdmonton, Alberta, Canada[email protected] Rakesh V. Sondekoppam, MBBS, MDDepartment of AnesthesiaUniversity of Iowa HospitalIowa City, Iowa

Effectiveness and Safety of Extubation before Reversal of Neuromuscular Blockade versus Traditional Technique in Providing Smooth Extubation.

Background:Traditional extubation often leads to bucking, coughing, and undesirable hemodynamic changes. Extubation just before administering reversal could reduce force of coughing, bucking and may provide better extubation conditions.Aim of Study:The aim of the study was to assess the incidence of bucking with extubation just before administering reversal of neuromuscular blockade compared to traditional technique of awake extubation. Incidence of coughing during extubation, vomiting/regurgitation, aspiration, hemodynamic changes, postoperative bleeding, and extubation conditions were also assessed.Settings and Design:This was a prospective randomized study conducted in a tertiary care institute.Subjects and Methods:Forty patients were allocated into two equal groups. In Group E, at the end of surgery, extubation was performed and reversal was administered after extubation. In Group L, reversal was given and patients were extubated in the traditional way. Quality of extubation was assessed using extubation quality score.Statistical Tests Used:Pearson Chi-square test, Fisher's exact test, and independent sample t-test.Results:Group E showed significantly lower incidence of bucking (15% vs. 65%) and coughing (10% vs. 45%). Incidences of desaturation and regurgitation/aspiration were comparable. In Group E, 85% of patients did not cough during extubation compared to 50% in Group L. Extubation quality was significantly better in Group E. Although extubation time was significantly shorter in Group E, recovery time was comparable in both groups.Conclusion:Extubation just before reversal of neuromuscular blockade resulted in lesser incidence of bucking and coughing during extubation with lesser postoperative bleeding compared to traditional technique of awake extubation without added risks of regurgitation, aspiration, or delayed recovery.

Tracheal extubation of anesthetized pediatric patients with heart disease decreases the incidence of emergence agitation: A retrospective study.

Background:Emergence agitation for pediatric patients after general anesthesia is one of the postoperative complications. The relationship between consciousness at tracheal extubation and emergence agitation is not clear.Aim:The aim of the present study was to determine whether tracheal extubation of anesthetized pediatric patients with heart disease by propofol decreases the incidence of emergence agitation.Settings and Design:This was a retrospective case-control study conducted at a children's hospital.Materials and Methods:Pediatric patients with heart disease aged 0-14 years who underwent cardiac catheterization under general anesthesia by propofol between October 2014 and September 2018 were enrolled. The incidence of emergence agitation by anesthetized extubation was compared with that by awake extubation.Statistical Analysis Used:Logistic regression analysis was performed.Results:Anesthetized extubation was performed in 202 patients and awake extubation was performed in 56 patients. The incidence of emergence agitation was significantly lower in patients who underwent anesthetized extubation than in patients who underwent awake extubation (25.2% vs. 69.6%, P = 0.000). In logistic regression analysis, anesthetized extubation [odds ratio (OR): 0.075, 95% confidence interval (CI): 0.034-0.165, P = 0.000] and older age (OR: 0.808, 95% CI: 0.728-0.897, P = 0.000) were associated with a decreased incidence of emergence agitation, and preoperative anxiety (OR: 2.220, 95% CI: 1.060-4.660, P = 0.03) was associated with an increased incidence of emergence agitation.Conclusions:Tracheal extubation under anesthesia by propofol decreases the incidence of emergence agitation in pediatric patients with heart disease.

Assessment of Common Criteria for Awake Extubation in Infants and Young Children.

Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children. This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success. Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100). Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.

This Month in Anesthesiology.

This Month in Anesthesiology.

The Effects of Dexmedetomidine on Airway-Related Complications During Emergence from General Anesthesia in Nasal and Paranasal Surgeries

Background: Stimulation of various sites, from the nasal mucosa to the diaphragm, can evoke laryngospasm. To reduce airway reflexes, tracheal extubation should be performed by special technique or with drugs that do not depress ventilation. However, tracheal extubation during rhinoplasty may be difficult because of the aspiration of blood and the possibility of laryngospasm. Dexmedetomidine has sedative and analgesic effects, without affecting respiratory status. Objectives: To evaluate the effects of dexmedetomidine on airway-related complications during emergence from general anesthesia (GA) in nasal and paranasal surgeries. Patients and Methods: This prospective randomized clinical study was included 90 patients of both sexes, admitted for elective nasal and paranasal sinus surgery. They were randomly allocated into three groups 30 patients each, Group A: Standard awake extubation technique. Group B: fully awake “no stimulation extubation” technique. Group C: Dexmedetomidine–group, who received intravenous (I.V) dexmedetomidine 0.5-1 μg/kg bolus in 100 ml of normal saline over 10 minutes before the end of surgery by 10 minutes, The dexmedetomidine bolus was followed by 0.2 μg/kg/hr which was stopped immediately when extubation was done. Results: The following parameters were assessed between the three groups: hemodynamics, airway-related complications, extubation time. Group C: was associated with a significant increase in extubation quality compared with group A and group B regarding hemodynamics, airway-related complications, extubation time. Conclusion: This study showed that the dexmedetomidine group associated with minimal circulatory reflexes and airway-related complications further to the advantage of short extubation time compared with the “no stimulation” extubation technique.

Deep vs. Awake Extubation and LMA Removal in Terms of Airway Complications in Pediatric Patients Undergoing Anesthesia: A Systemic Review and Meta-Analysis.

The purpose of this study was to compare the incidence of airway complications between extubation under deep anesthesia (deep extubation) and extubation when fully awake (awake extubation) in pediatric patients after general anesthesia. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement standards. The review protocol was registered with the International Prospective Register of Systematic Reviews (registration number: CRD 42018090172). Electronic databases were searched, without discrimination of publication year and language, to identify all randomized controlled trials investigating airway complications following deep or awake extubation after general anesthesia. The Cochrane tool was used to assess the risk of bias of trials. Randomized trials investigating airway complications of deep extubation compared with awake extubation after general anesthesia with an endotracheal tube and laryngeal mask airway (LMA) were sought. Overall airway complications, airway obstruction, cough, desaturation, laryngospasm and breath holding were analyzed using random-effect modelling. The odds ratio was used for these incidence variables. Seventeen randomized trials were identified, and a total of 1881 pediatric patients were enrolled. The analyses indicated deep extubation reduces the risk of overall airway complications (odds ratio (OR) 0.56, 95% confidence interval (CI) 0.33–0.96, p = 0.04), cough (OR 0.30, 95% CI 0.12–0.72, p = 0.007) and desaturation (OR 0.49, 95% CI 0.25–0.95, p = 0.04) in children after general anesthesia. However, deep extubation increased the risk of airway obstruction compared with awake extubation (OR 3.38 CI 1.69–6.73, p = 0.0005). No difference was observed in the incidence of laryngospasm and breath-holding between the two groups regardless of airway device. The result of this analysis indicates that deep extubation may decrease the risk of overall airway complications including cough and desaturation but may increase airway obstruction compared with awake extubation in pediatric patients after general anesthesia. Therefore, deep extubation may be recommended in pediatric patients to minimize overall airway complications except airway obstruction and the clinicians may choose the method of extubation according to the risk of airway complications of pediatric patients.

Effect of dexmedetomidine combined with sufentanil on postoperative analgesia and stress response in laparoscopic gastrectomy

Objective To study the effect of dexmedetomidine combined with sufentanil on postoperative analgesia and stress response in laparoscopic gastrectomy. Methods 80 patients with gastric cancer who underwent laparoscopic resection from March 2014 to March 2015 in Yiwu Central Hospital were selected as the subjects.According to draw method, the patients were divided into the observation group and the control group, with 40 patients in each group.All patients were treated with laparoscopic resection, midazolam, atropine sulfate, propofol, sufentanil citrate and rocuronium were used for anesthesia.The control group was given sufentanil analgesia after operation, while the observation group was given dexmedetomidine combined with sufentanil.The awake time, extubation time, agitation rate, incidence of postoperative cognitive dysfunction (POCD), epinephrine(E), norepinephrine(NE), cortisol(Cor), oxygen saturation(SpO2), mean arterial pressure(MAP), heart rate(HR), visual analogue scale(VAS) and changes of inflammatory factors in T0(before operation), T1(at the end of surgery), T2(extubation), T3(10 min after extubation), T4(20 min after extubation) of the two groups were compared. Results There was no statistically significant differences between the two groups in awake time and extubation time(all P>0.05). The incidence rates of restlessness and POCD in the observation group were significantly lower than those in the control group(5.0% vs.25.0%, 7.5% vs.30.0%)(χ2=6.275, 6.646, all P<0.05). At T1, T2, T3 and T4, the E, NE and Cor levels in the two groups were significantly higher than those in T0(all P<0.05), the levels at T2 were the highest, then gradually declined, the rising degree and maximum values of the observation group were significantly lower than those of the control group(all P<0.05). The elevated degree of MAP in the observation group was significantly lower than that in the control group(P<0.05). At T1, T2, T3, HR in the control group significantly increased(all P<0.05), HR at T2 was the highest, at T4 droped.At T1, T2, T3 and T4, HR in the observation group all decreased, which were lower than those in the control group(all P<0.05). Postoperative 4h, 8h, 24h, the VAS scores of the observation group were significantly lower than those of the control group[(4.30±0.50)points vs.(7.07±0.98) points, (4.01±0.46) points vs.(6.28±0.90) points, (2.79±0.31) points vs.(4.27±0.60) points](t=15.924, 14.204, 13.860, all P<0.05). The levels of TNF-α, IL-6 and IL-10 in the observation group were significantly lower than those in the control group(all P<0.05). Conclusion Dexmedetomidine combined with sufentanil has significant analgesic effect in laparoscopic gastrectomy for gastric cancer.It can stabilize the hemodynamics, relieve stress reaction and regulate inflammatory factors, and is beneficial to the recovery of the patients. Key words: Dexmedetomidine; Sufentanil; Stomach neoplasms; Laparoscopes; Gastrectomy; Anesthesia and analgesia; Stress disorders, traumatic

Survey about the Extubation Practice among Anaesthesiologists in Kosovo.

BACKGROUND:Tracheal extubations may be performed before or after awakening from anaesthesia. The advantage of extubation during anaesthesia may avoid all the unpleasant effects of fully awake extubation such as severe hypertension and tachycardia, malignant dysrhythmias, myocardial ischemia laryngospasm, and cough induced high intraocular and intracranial pressure.AIM:To show the current practice of performing extubations in Kosovo, as well as the advantage and disadvantage in performing this procedure in an awake patient or inpatient in light anaesthesia.MATERIAL:This study is conducted at the Regional Hospitals and the University Clinical Center of Kosovo during the year 2015. A questionnaire is given to the anesthesiologists to collect information about the techniques used for extubation, timing and management of extubation.RESULTS:Based on this survey results that 86% of an anesthesiologist (71) extubate the patients when they are completely awake, while 14% of them (12) prefer to extubate the patients under light anaesthesia. From all anesthesiologists involved in this study, forty of them reported problems during extubation. Complications were related to airway, and they are treated by oxygenation and jaw support, but in rare cases, reintubation were performed.CONCLUSION:Complications during extubation remain important risk factor while extubation during light anaesthesia can minimise some of them.

Anesthesia management by residents does not alter the incidence of recall of tracheal extubation: a teaching hospital-based propensity score analysis

The memory of emergence from anesthesia is recognized as one type of anesthesia awareness. Apart from planed awake extubation, unintentional recall of tracheal extubation is thought to be the results of inadequate anesthesia management; therefore, the incidence can be related with the experience of anesthetists. To assess whether the incidence of recall of tracheal extubation is related to anesthetists' experience, we compared the incidence of recall of tracheal extubation between patients managed by anesthesia residents or by experienced anesthetists. This is a retrospective review of an institutional registry containing 21,606 general anesthesia cases and was conducted with the board of ethical review approval. All resident tracheal extubations were performed under anesthetists' supervision. To avoid channeling bias, propensity score analysis was used to generate a set of matched cases (resident managements) and controls (anesthetist managements), yielding 3,475 matched patient pairs. The incidence of recall of tracheal extubation was compared as primary outcomes. In the unmatched population, there was no difference in the incidences of recall of tracheal extubation between resident management and anesthetist management (6.5% vs. 7.1%, p=0.275). After propensity score matching, there was still no difference in incidences of recall of tracheal extubation (7.1% vs. 7.0%, p=0.853). In conclusion, when supervised by an anesthetist, resident extubations are no more likely to result in recall than anesthetist extubations.

Comparison between the Effects of Alfentanil, Lidocaine and Their Composition in Controlling the Hemodynamic Responses at the Time of Awake Extubation of Patients

Background and aim: Instability in the hemodynamic symptoms has been common at the time of extubation in patients and the cause to create the side effects. The aim of this research was to study the effect of injection of Alfentanil, Lidocaine and their composition in reduction of side effects arising from extubation. Materials and methods: 172 patients (20 - 40 years old) that referred to Shahid Rajaee Hospital in 2014 and had been under the orthopedic surgery, were divided randomly and by using colored cards into four equal groups (43 patients in each group). Alfentanil (5 microgram/kilogram) was injected to the first group. The second group received Lidocaine (1 milligram/ kilogram). The composition of these two drugs was injected to the third group and the normal equal volume of Saline was injected to the fourth group which was the control group. The means of systolic and diastolic blood pressure, average arterial pressure and the number of heartbeat at the time of extubation were measured and registered 1, 5, 10, 15 and 20 minutes after extubation. Also, the amount of situation of bucking after extubation was registered in the groups. Results: The demographic results were similar in all groups. The mean of systolic blood pressure and number of heartbeats in the group of Alfentanil and composition of Alfentanil-Lidocaine had significant reduction (p 0.05). The situation of bucking in three treatment groups had significant reduction in comparison with control group. Conclusion: Alfentanil and composition of it with Lidocaine both had caused reducing the systolic blood pressure and heartbeats.

Principles of total intravenous anaesthesia: practical aspects of using total intravenous anaesthesia

### Key points Advanced pharmacokinetic models for target-controlled infusion (TCI) have facilitated an increasing use of total i.v. anaesthesia (TIVA) in various clinical settings. The technical complexity and labour-intensive methodology of TIVA can deter clinicians and lead to default use of a volatile agent. In theory, any combination of i.v. hypnotic(s) and opioid(s) can be used and opioid-free techniques are described. In practice, the synergy between TCI infusions of propofol and remifentanil proves highly effective at obtunding response to noxious stimuli1 and for this article constitutes ‘ideal’ TIVA. This drug combination achieves equilibrium between adequate depth of anaesthesia and rapid recovery. Intermittent boluses of agents or manually controlled infusions may produce an inadequate effect.2 The specific indications for TIVA are given in Table 1. TIVA is applicable to nearly all types of surgery but has particular value in clinical scenarios where a stress-free awake extubation free of laryngospasm is required. TIVA confers many advantages over a conventional volatile technique, particularly a better recovery profile with reduced risk of postoperative nausea and vomiting, and can facilitate intraoperative wake-up while retaining amnesia. The use of TIVA for cases requiring a rapid intubation sequence is controversial but is safely practiced. View this table: Table 1 Specific indications for …

Anesthesia management by residents does not alter the incidence of recall of tracheal extubation: a teaching hospital-based propensity score analysis

Background and objectivesThe memory of emergence from anesthesia is recognized as one type of anesthesia awareness. Apart from planed awake extubation, unintentional recall of tracheal extubation is thought to be the results of inadequate anesthesia management; therefore, the incidence can be related with the experience of anesthetists. To assess whether the incidence of recall of tracheal extubation is related to anesthetists’ experience, we compared the incidence of recall of tracheal extubation between patients managed by anesthesia residents or by experienced anesthetists. MethodsThis is a retrospective review of an institutional registry containing 21,606 general anesthesia cases and was conducted with the board of ethical review approval. All resident tracheal extubations were performed under anesthetists’ supervision. To avoid channeling bias, propensity score analysis was used to generate a set of matched cases (resident managements) and controls (anesthetist managements), yielding 3,475 matched patient pairs. The incidence of recall of tracheal extubation was compared as primary outcomes. ResultsIn the unmatched population, there was no difference in the incidences of recall of tracheal extubation between resident management and anesthetist management (6.5% vs. 7.1%, p=0.275). After propensity score matching, there was still no difference in incidences of recall of tracheal extubation (7.1% vs. 7.0%, p=0.853). ConclusionIn conclusion, when supervised by an anesthetist, resident extubations are no more likely to result in recall than anesthetist extubations.