Balanced Anesthesia Research Articles

Protocol Study for the Evaluation of Non-Opioid Balanced General Anaesthesia in Cardiac Surgery with Cardiopulmonary Bypass: A Randomised, Controlled, Multicentric Superiority Trial (OFACAR Study).

Opioid-free anaesthesia (OFA) is general anaesthesia based on the use of several non-opioid molecules that aim to have an analgesic effect, decrease the sympathetic response, decrease hormonal stress, and decrease the inflammatory response during surgery. Although this approach to anaesthesia is regularly used in clinical practice, it remains a novel approach. The literature on this anaesthesia modality finds a number of positive effects on cardiac, respiratory, and cognitive function but no randomised study evaluated these effects during cardiac surgery where there is a high incidence of postoperative complications. The main aim of the study is to compare OFA vs. standard balanced opioid general anaesthesia on the incidence of postoperative complications and the length of stay in intensive care and hospital. OFACAR is a multicentric, randomised, controlled, superiority, single-blind, two parallel-arm clinical trial in patients undergoing cardiac surgery with cardiopulmonary bypass. We compared a balanced general anaesthesia without opioids (OFA group) vs. a balanced opioid general anaesthesia with sufentanil (control group). One hundred and sixty patients will be enrolled in each treatment group. The primary endpoint is a composite one which corresponds to the occurrence of at least one of the postoperative complications, defined according to European standards within 30 days after surgery. Recruitment started in September 2019, and data collection is expected to end in November 2024.

Cardiorespiratory Effects and Desflurane Requirement in Dogs Undergoing Ovariectomy after Administration Maropitant or Methadone.

General anesthesia for ovariectomy in dogs is based on a balanced anesthesia protocol such as using analgesics along with an inhalant agent. While opioids such as fentanyl and methadone are commonly used for their analgesic potency, other drugs can also have analgesic effects. Maropitant, an antiemetic for dogs and cats, has also been shown to exert analgesic effects, especially on visceral pain. The aim of this study was to compare the cardiorespiratory effects and analgesic properties of maropitant and methadone combined with desflurane in dogs undergoing ovariectomy. Two groups of 20 healthy mixed-breeds bitches undergoing elective ovariectomy received intravenous either maropitant at antiemetic dose of 1 mg kg-1 or methadone at the dose of 0.3 mg kg-1. Cardiorespiratory variables were collected before premedication, 10 min after sedation and during surgery. Recovery quality and postoperative pain were evaluated 15, 30, 60, 120, 240 and 360 min postoperatively. Results showed that maropitant produced analgesia and reduced the requirement of desflurane in amounts similar to those determined by methadone (5.39 ± 0.20% and 4.91 ± 0.26%, respectively) without significant difference, while maintaining heart rate, arterial blood pressure, respiratory rate and carbon dioxide end-tidal partial pressure even at a more satisfactory level. Therefore, maropitant may be recommended as an analgesic drug for abdominal surgery not only in healthy dogs but also in those with reduced cardiorespiratory compensatory capacities or at risk of hypotension, especially when combined with a sedative such as dexmedetomidine.

Blended (Combined Spinal and General) vs. General Anesthesia for Abdominal Hysterectomy: A Retrospective Study.

Adequate pain management for abdominal hysterectomy is a key factor to decrease postoperative morbidity, hospital length of stay and chronic pain. General anesthesia is still the most widely used technique for abdominal hysterectomy. The aim of this study was to assess the efficacy and safety of blended anesthesia (spinal and general anesthesia) compared to balanced general anesthesia in patients undergoing hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. We retrospectively collected data from adult ASA 1 to 3 patients scheduled for laparoscopic or mini-laparotomic hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. Exclusion criteria were age below 18 years, ASA > 3, previous chronic use of analgesics, psychiatric disorders, laparotomic surgery with an incision above the belly button and surgery extended to the upper abdomen for the presence of cancer localizations (e.g., liver, spleen or diaphragm surgery). The cohort of patients was retrospectively divided into three groups according to the anesthetic management: general anesthesia and spinal with morphine and local anesthetic (Group 1), general anesthesia and spinal with morphine (Group 2) and general anesthesia without spinal (Group 3). NRS was lower in the spinal anesthesia groups (Groups 1 and 2) than in the general anesthesia group (Group 3) for every time point but at 48 h. The addition of local anesthetics conferred a small but significant NRS decrease (p = 0.009). A higher percentage of patients in Group 3 received intraoperative sufentanil (52.2 ± 18 mcg in Group 3 vs. Group 1 31.8 ± 16.2 mcg, Group 2 44.1 ± 15.6, p < 0.001) and additional techniques for postoperative pain control (11.4% in Group 3 vs. 2.1% in Group 1 and 0.8% in Group 2, p < 0.001). Intraoperative hypotension (MAP < 65 mmHg) lasting more than 5 min was more frequent in patients receiving spinal anesthesia, especially with local anesthetics (Group 1 25.8%, Group 2 14.6%, Group 3 11.6%, p < 0.001), with the resulting increased need for vasopressors. Recovery-room discharge criteria were met earlier in the spinal anesthesia groups than in the general anesthesia group (Group 1 102 ± 44 min, Group 2 91.9 ± 46.5 min, Group 3 126 ± 90.7 min, p < 0.05). No differences were noted in postoperative mobilization or duration of ileus. Intrathecal administration of morphine with or without local anesthetic as a component of blended anesthesia is effective in improving postoperative pain control following laparoscopic or mini-laparotomic hysterectomy, in reducing intraoperative opioid consumption, in decreasing postoperative rescue analgesics consumption and the need for any additional analgesic technique. We recommend managing postoperative pain with a strategy tailored to the patient's physical status and the type of surgery, preventing and treating side effects of pain treatments.

Minimal Intubating Dose of Succinylcholine: A Comparative Study of 0.4, 0.5 and 0.6 mg/kg Dose

Muscle relaxants are integral part of modern balanced anesthesia and succinylcholine, a depolarizing drug, is in use despite its adverse effects. The excellent intubating condition, fastest onset and shortest duration of action make it an excellent choice for anesthesiologists. The conventional dose of 1.5-2 mg/kg is commonly used for obtaining relaxation for intubation. This study was conducted with much smaller dose of succinylcholine as 0.4, 0.5 and 0.6 mg/kg to evaluate the acceptable intubating dose at 60 seconds, which was unlikely to have any untoward/side effects.

Dexmedetomidine related apnea and desaturation during awake craniotomy: a case report

Dexmedetomidine (Dex) is regarded as a novel sedative agent since the drug preserves respiration and makes ‘conscious sedation’ possible. This drug is widely used for monitored anesthesia care (MAC). We report a case of apnea and desaturation in awake craniotomy surgery under MAC after loading of Dex with 1 mg/kg over 10 min and discuss possible explanations. We advocate using Dex with a lower loading dose over a prolonged duration and the up-titration of the drug according to the patient’s response particularly in those who are underweight or elderly. Meticulous judgement for possible interactions of Dex with antiepileptics, opioids and other sedative agents is essential during MAC.&#x0D; Abbreviations: BIS- Bispectral Index; Dex- Dexmedetomidine; DBS- Deep Brain Stimulation; MAC- Monitored Anesthesia Care; TCI- Targeted-Controlled Infusion&#x0D; Key words: Dexmedetomidine; Craniotomy; Apnea; Conscious sedation; Balanced anesthesia; Anticonvulsant&#x0D; Citation: Hasyizan HM, Mohd Nazaruddin WHWM, Laila AM, Zamzuri I, Zulfakar MM. Dexmedetomidine related apnea and desaturation during awake craniotomy: a case report. Anaesth. pain intensive care 2023;27(4):609−612; DOI: 10.35975/apic.v27i4.1901&#x0D; Received: May 30, 2022; Reviewed: December 28, 2022; Accepted: May 22, 2023

Congenital heterotopic gastrointestinal duplication cyst of the face: a rare case report

Gastrointestinal duplication (GDC) cysts have various synonyms; choristoma, enterocystoma, and duplication cyst. They are infrequent congenital benign lesions diagnosed mainly in children in the first decade of life, comprising approximately less than 5% of the pediatric population with a predilection for the male sex. It is exceedingly rare in the oral cavity but it is possible, particularly on the tongue, floor of the mouth, and pharynx. From 1895 until 1994, 30 cases of this lesion in the oral cavity were reported. Nowadays, none of the authors reported a GDC in the facial region. We report an exceptional case of heterotopic gastrointestinal duplication cysts (HGDC) in the facial region of a 13 -years -old male teenager who was referred to our medical department for an evaluation of a painless progressive facial asymmetry. In the first instance, the ultrasound facial soft tissue was made with a 6.5 MHz convex transducer, reporting a big anechoic image with regular borders to a 60 x 26 x 56 mm diameter with a 46cc approximate volume. Following this, a non-contrast magnetic resonance image was executed with an open Philips PanoramaⓇ machine performed at 3T, reporting a hyperintense image in T2-weighted (repetition time msec/echo time msec: 5,500/112) sagittal sequence and FLAIR-weighted (5,714/80) axial sequence; and an isointense image in T1-weighted (24/80) coronal sequence to 54 x 30 x 51 mm diameter compatible with space occupant lesion with interior walls. A complete tumor resection was achieved under balanced general anesthesia, and the specimen was sent for histological examination. Microscopic examination showed a cystic cavity lined mostly by mucous secretory gastrointestinal epithelium and other areas by stratified squamous epithelium. The cystic wall was composed of fibrous connective tissue and contains abundant gastric cells. Its deepest portion exhibits a smooth muscle layer. In summary, HGDC is an unusual congenital head and neck lesion, but it should be considered in the differential diagnosis of neonates and children. The diagnosis of gastrointestinal tract duplications may be suggested by imaging studies; however, the correct diagnosis is defined by histopathologic analysis. Due to the risk of destruction potential and malignant transformation, HGDC should be treated surgically by complete excision.

Anesthesia and Pulmonary Hypertension: A Narrative Review

Pulmonary hypertension (PH) is a complex disease of the cardiopulmonary system. Perioperative management of PH is one of the most challenging issues for the anesthetists. Morbidity and mortality are significantly high in PH patients undergoing surgery due to right heart failure, arrhythmia, atrial fibrillation, ischemia, hemodynamic unstability, hypoxia, respiratory failure, renal failure, sepsis, and stroke. In PH patients, it is important that more than one physician, including anesthesiologist, intensivist, pulmonologist, cardiologist, and surgeon, discuss the patient’s possible difficulties and complications with a multidisciplinary approach and make a decision. In order to optimize the management of PH patients, it is necessary to comprehensively evaluate the underlying cause, pathophysiology, risk factors, course, and treatment of the disease. A balanced anesthesia technique, including inhalation or intravenous agents, appropriate regional anesthesia (RA), opioids, and α-2-adrenoceptor agonists, may provide the most uniform hemodynamic profile in these patients. The basis of anesthesia management should be to prevent and treat triggering factors, provide perfusion pressures, and optimize right ventricular functions. Advanced monitoring, pulmonary vasodilator therapies, adequate anesthesia and analgesia, and appropriate ventilator settings should be performed for patients with PH. Patients with PH should be followed in the intensive care unit in the first 48–72 h postoperatively. Our review aims to focus on appropriate preoperative preparation, perioperative monitoring, anesthesia and ventilator management, pain control, preventive methods, and treatment in patients with PH in light of the literature.

Https://medcraveonline.com/JACCOA/anesthetic-and-hemodynamic-management-in-patients-with-different-approaches-for-multiple-neurological-pathologies-case-report.html

Purpose: To evaluate the impact of three different effect-site concentrations of remifentanil [1.0, 2.0 and 2.5 ng.ml-1] on cough, heart rate and systolic blood pressure during extubation after balanced anesthesia with desflurane or sevoflurane. Design: Double-blinded controlled trial. Setting: Operating room. Patients: ASA I-II adults (n=451) who underwent elective procedures. Interventions: Subjects were randomly assigned to maintain remifentanil effect-site concentrations at 1.0, 2.0 and 2.5 ng.ml-1 by a target control infusion system after receiving balanced general anesthesia with remifentanil and sevoflurane vs. desflurane. Measurements: Cough severity (using a four-point intensity scale), heart rate and systolic blood pressure were registered during eye opening, tracheal extubation and 2.5 minutes after. Main Results: Cough was significantly reduced in all groups of remifentanil at 2.0 and 2.5 ng.ml-1 during eye opening, tracheal extubation and 2.5 minutes after, when compared with 1.0 ng.ml-1 [Risk ratio (95% CI) at tracheal extubation 0.35 (0.23-0.53) and 0.33 (0.21-0.52) for desflurane; 0.50 (0.35-0.73) and 0.45 (0.30-0.73) for sevoflurane, respectively. P &lt; 0.001]. There were no significant differences on heart rate or systolic blood pressure values at these time points for any of the studied groups. Conclusion: In adult patients of elective procedures under balanced general anesthesia with sevoflurane or desflurane, maintaining a remifentanil effect-site concentration at 2.0-2.5ng.ml-1 significantly reduce the risk of cough but not hemodynamic responses during tracheal extubation.

The effects of the administration sequence and the type of hypnotics on the development of remifentanil-induced chest wall rigidity: a randomized controlled trial

BackgroundResearch on remifentanil-induced chest wall rigidity is limited. Furthermore, its incidence is unknown, and the clinical factors influencing its development remain unclear. This prospective, double-blind, randomized controlled trial aimed to investigate the effects of the administration sequence of hypnotics and remifentanil as well as the type of hypnotic administered on the development of remifentanil-induced chest wall rigidity.MethodsA total of 125 older patients aged ge 65 years, who were scheduled to undergo elective surgery under general anesthesia, were enrolled in this study. Participants were randomly assigned to one of four groups; Thio-Remi, Pro-Remi, Remi-Thio, or Remi-Pro. After confirming the loss of consciousness and achieving a target effect-site concentration of 3 ng/mL remifentanil, the development of remifentanil-induced chest wall rigidity was evaluated.ResultsThe incidence of chest wall rigidity was significantly higher in the remifentanil-hypnotic group than in the hypnotic-remifentanil (opposite sequence) group (55.0% vs. 21.7%, P < 0.001). Logistic regression analysis revealed that remifentanil-hypnotic administration was a significant predictor of the development of chest wall rigidity (crude odds ratio 4.42, 95% confidence interval 1.99; 9.81, P < 0.001).ConclusionsPretreatment with hypnotics potentially reduces the development of chest wall rigidity during the induction of balanced anesthesia with remifentanil in older patients.Trial registrationThis article was registered at WHO International Clinical Trials Registry Platform (Trial number: KCT0006542).

NEUROPHYSIOLOGY INTRAOPERATIVE MONITORING (NIOM) PADA OPERASI DEFORMITIY CORRECTION AT ADOLESENT SCOLIOSIS

The use of neurophysiological intraoperative monitoring (NIOM) during spinal orthopaedic and neurosurgical procedures provides a challenge to the attending anaesthesiologist. Since all anaesthetic agents affect synaptic function, the choice of agent will be determined by the type of surgery and the NIOM modality employed. Had been performed surgery for scoliosis correction of spinal abnormalities in children aged 15 years with using of sensory and motoric NIOM. The surgery going under general anesthesia with the installation monitor invasive arterial line and central venous pressure during surgery for hemodynamic monitoring. Drugs used during anesthesia using balanced anesthesia technique with a combination of opioids, propofol and sevoflurane as inhalation. Muscle relaxants given intermittently for operator leisure and ventilation controls. Postoperative hospitalization in ICU with the aim of assessing the function of the respiratory and neurological of the patients and pain management.

Dexmedetomidine as an Adjuvant in Peripheral Nerve Block.

Peripheral nerve block technology is important to balanced anesthesia technology. It can effectively reduce opioid usage. It is the key to enhance clinical rehabilitation as an important part of the multimodal analgesia scheme. The emergence of ultrasound technology has accelerated peripheral nerve block technology development. It can directly observe the nerve shape, surrounding tissue, and diffusion path of drugs. It can also reduce the dosage of local anesthetics by improving positioning accuracy while enhancing the block's efficacy. Dexmedetomidine is a highly selective drug α2-adrenergic receptor agonist. Dexmedetomidine has the characteristics of sedation, analgesia, anti-anxiety, inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics. Numerous studies have revealed that dexmedetomidine in peripheral nerve blocks can shorten the onset time of anesthesia and prolong the time of sensory and motor nerve blocks. Although dexmedetomidine was approved by the European Drug Administration for sedation and analgesia in 2017, it has not yet been approved by the US Food and Drug Administration (FDA). It is used as a non-label drug as an adjuvant. Therefore, the risk-benefit ratio must be evaluated when using thesedrugs as adjuvants. This review explains the pharmacology and mechanism of dexmedetomidine, the effect of dexmedetomidine on various peripheral nerve block as an adjuvant, and compare it with other types of adjuvants. We summarized and reviewed the application progress of dexmedetomidine as an adjuvant in nerve block and look forward to its future research direction.

Evaluating the efficacy and safety of simple combination of analgesics with and without low dose opioid for perioperative analgesia, hemodynamic and recovery profile in various surgeries posted under general anaesthesia: a prospective randomised controlled study

Background: Multimodal analgesia is an emerging technique.It has been consistently demonstrated to minimise opioid consumption, related side effects and vital component of enhanced recovery after surgery pathways. The current study presents use of combination of readily available medication as a part of multimodal analgesia. Balanced anaesthesia with multimodal analgesia is harmonious use of combination of agents to produce desired effects with minimal side effects of individual agents. Methods: This study was done in a tertiary health care centre, Government General Hospital, Kakinada over a duration of two months from August 2022 to September 2022. 60 adult patients of either sex of physical status ASA grade 1and 2 undergoing elective surgery under general anaesthesia were randomly allocated into Group A and Group B of 30 patients. Group 1: received Inj. Lignocaine+Inj. Paracetamol+Inj. Magnesium sulphate+Inj. Fentanyl. Group 2:received Inj. Lignocaine+Inj. Paracetamol+Inj. Magnesium sulphate+Normal saline (control group) as premedication for perioperative analgesia. Results: All patients were hemodynamically stable for first 30 minutes period of observation in Group A compared to Group B. There is clinically and statistically significant difference in the duration of analgesia in Group A compared to Group B. There is no statistically significant difference in the Numerical Rating Scale (NRS) for pain in both the groups. Conclusions: This study concluded that simple analgesia combination of multimodal analgesia regimen comprising of Inj. Lignocaine, Inj. Paracetamol and Inj. Magnesium sulphate produces safe and effective analgesia with good recovery profiles and no adverse opioid related side effects for ASA 1 and 2 patients posted under general anaesthesia.

Endocrine and metabolic monitoring for anesthesia care in orthopedic trauma surgery on the lower extremities of children: prospective comparative study

BACKGROUND: Standard anesthesia monitoring during surgery only indirectly allows us to estimate achieving an effective level of analgesia sufficient to protect the patient from surgical trauma. Recently, studies have analyzed cortisol, glucose, and lactate levels during surgery in children and adults; however, data presented remain inconsistent.&#x0D; OBJECTIVE: This study aimed to conduct a prospective comparative analysis of endocrine metabolic dynamic rates in orthopedic trauma surgery on the lower extremities of children.&#x0D; MATERIALS AND METHODS: The study included 39 children who underwent orthopedic trauma surgery. They were divided into two groups: group 1 (n=17) underwent multicomponent balanced general anesthesia, and group 2 (n=22) received combined anesthesia (multicomponent balanced general anesthesia combined with regional blockade of the sciatic and femoral nerves). The dynamics of cortisol, glucose, and lactate indicators at three stages of the perioperative period, total amount of fentanyl, and need for an inhalation anesthetic were examined.&#x0D; RESULTS: Indicators of cortisol, glucose, and lactate in mixed venous blood during surgery did not exceed the age norm in both groups. In group 1, cortisol, glucose, and lactate levels did not statistically differ at all stages of the study. In group 2, cortisol and lactate levels increased at the fifth stage (traumatic stage) of surgery, and lactate levels increased in the sixth stage (end of surgery). In intergroup comparison, the lactate level at the traumatic stage of surgery was higher in group 1 than in group 2 (p=0.048). Cortisol and glucose levels at the stages of the study did not differ significantly. The total amount of fentanyl for pain relief in group 1 was 4.1 [3.3; 5.0] g/kg, which was 8.2 times higher than that in group 2, with 0.5 [0.4; 0.53] g/kg (p 0.0001).&#x0D; CONCLUSION: Both anesthesia methods ensure stable levels of cortisol, glucose, and lactate, and adequate level of analgesia at all stages of surgery; however, the use of a conduction blockade as a component of combined anesthesia provides more pronounced antinociceptive protection and reduces surgical stress in children.

PSYCHOMOTOR RECOVERY AFTER INTRAVENOUS DEXMEDETOMIDINE INFUSION AS A PART OF BALANCED ANAESTHESIA – AN OBSERVATIONAL STUDY

Objective: The aim of the study was to determine the recovery of psychomotor function from balanced anesthesia with and without intravenous (IV) dexmedetomidine infusion as an adjunct. Methods: A prospective and observational study was conducted in a tertiary care teaching hospital for 12 months. A total of 170 patients (American Society of Anaesthesiologists 1 and 2) in the age group of 18–50 years scheduled for elective surgery under general anesthesia with an anticipated duration of &lt;3 h received either dexmedetomidine infusion (Group D) or not (Group S). Recovery of psychomotor function postoperatively was assessed with trieger dot test (TDT), digit symbol substitution test (DSST), and intraoperative fentanyl requirement in both groups. Data collected were analyzed using SPSS version 16. Results: Both groups were comparable with respect to demographic variables. Psychomotor recovery assessed by TDT showed statistically significant early recovery in Group D compared with Group S. This was seen in the number of dots missed, maximum distance of dots missed as well as in the average distance of dots missed at post-operative time intervals of 30 min, 60 min, 90 min, and 120 min. Similarly, DSST revealed early recovery at these time points. There was a significant decrease in the intraoperative fentanyl requirement in Group D compared with Group S. Conclusion: The addition of dexmedetomidine to the balanced anesthetic technique significantly hastened the psychomotor recovery.

Fast Track Liver Transplantation: Lessons learned after 10 years running a prospective cohort study with an ERAS-like protocol

Fast Tracking in Liver Transplantation has been around for the past 25 years, although no substantial advancement, in the form of a comprehensive protocol, had been readily available. Few centers had embraced this goal, so before we started our program, a little over a decade ago, we adopted most of these ideas into a comprehensive pathway that would swiftly carry our patients from the preoperative stage through a safe home discharge. From day one, we have used this Fast Track pathway and applied it prospectively to every single patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our results after 10 years. Patients and MethodsAll liver transplants performed at our center for the first 10 years since the start of the program (September 2012–September 2022) were included. Our standard protocol included balanced general anesthesia, fluid restriction, avoidance of transfusions, inferior vena cava preservation with temporary porto-caval shunt and thromboelastography. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early. Results385 transplants were performed in 367 patients (287♂/80♀) over 120 months, mean age 57.4±9.5 years, raw MELD score 15.4±8.1. Predominant etiologies were alcohol (n=217) and HCV (n=108), with hepatocellular carcinoma present in 197 (53.7%). Eighteen patients underwent combined liver-and-kidney transplants. Mean operating time was 313±66 min with cold ischemia times of 281±85 min. Fifty-nine patients (15.3%) were transfused in the OR (2.3±1.1 units of PRBC). Extubation was immediate (< 30 min) in 365 cases (94.8%). Median ICU length of stay was 12.6 h, and median post-transplant hospital stay was 4 days (2–97) with 55 patients (15.8%) discharged home by the 2nd day, 141 (40.5%) by the 3rd day and 203 (58.3%) by the 4th day, which defined our Fast-Track group. The overall thirty-day-readmission rate was (34.5%), which became significantly lower (27.6% vs 44.1%, p=0.0014) in the Fast-Track group when compared to the regular discharge group. Patient survival was 87.6% at 1 year and 79.7% at 5 years. ConclusionFast-Tracking of Liver Transplant patients is very feasible and can be applied as the standard of care.

Rate of residual neuromuscular block using single-dose rocuronium in general anesthesia for ENT surgery: a retrospective cohort study

IntroductionNMB facilitates intubating conditions in general anesthesia. However, it is associated with significant residual postoperative paralysis and morbidity.ObjectiveTo investigate the rate of underdiagnosed residual NMB based on two TOFR criteria (< 0.91 and < 1.00).MethodsWe performed a retrospective study adhering to STROBE guidelines. We included patients undergoing ENT surgery using single-dose neuromuscular block for balanced general anesthesia from June to December 2018. We collected demographic and anthropometric data, ASA score, NMBA dose, TOFR recordings at 5, 30 and 60 min and end of the surgery, anesthesia and surgery time, and administration of reversal agent. Statistical analysis included descriptive and dispersion measures statistics, curve and cross tables for residual NMB on different TOFR criteria with sub-analysis for AR, RR, and OR in patients over 65 years old.ResultsWe included 57 patients, mean age 41; 43 females and 14 males. Mean anesthetic and surgical time were 139.4 and 116.1 min, respectively. All the patients received rocuronium under a mean ponderal single-dose of 0.48 mg/kg. Residual NMB rates were 29.9 and 49.1% for a TOFR < 0.91 and < 1.00, respectively. Older adults had an OR of 6.08 for residual NMB.ConclusionsThe rate of residual NMB was 29.9 to 49.1%, depending on the criteria used (TOFR < 0.91 and < 1.00, respectively). Patients above 65 years old had an increased risk of residual NMB (6.08 OR) and clinical symptoms related to residual NMB (11.75 OR). We recommend future research aiming to provide a specific surveillance protocol for patients above 65 years old, including shorter-action NMB, early reversal, and prolonged surveillance using the TOFR criteria of < 1.00 to identify patients at risk of residual NMB readily.

Price analysis of medicines used in general anesthesia before and after the SARS-CoV-2 pandemic: a retrospective observational study

Objectives: with the emergence of the pandemic in early 2020, there was an increase in the prices of medicines used in hospital anesthetic procedures. The main objective of this study was to assess the variations in prices of anesthetics used in general anesthesia procedures between the periods prior to and after the beginning of the SARS-CoV-2 pandemic. Methods: we investigated 105 anesthesic records of exploratory laparotomies or laparoscopic procedures performed in a private hospital in southern Brazil and analyzed the prices of medicines used in two general anesthesia techniques: total intravenous anesthesia (TIVA) and balanced anesthesia with anesthetic gases. We obtained the price of anesthetic procedures from records issued in the final trimesters of 2019, 2020, and 2021 (33, 43, and 29, respectively). Results: a statistically significant difference in prices was seen between periods for both techniques. The price of TIVA in 2019 was R$ 229.30/hour, in 2020 it was R$ 472.13/hour, and in 2021 it was R$ 247.38/hour. For balanced anesthesia, this price was R$ 66.32/hour in 2019, R$ 109.97/hour in 2020, and R$ 90.30/hour in 2021. In a post hoc analysis, significant differences were observed in the hourly prices of TIVA between 2019–2020 (p=0.01) and 2020–2021 (p=0.04); for balanced anesthesia, this was seen only in the 2019–2020 period (p=0.02). Conclusion: this study demonstrated significant increases in the mean prices of general anesthesia administered via intravenous (up to 36.36%) or inhalation (up to 89.47%) routes for exploratory laparotomies performed before and after the beginning of the SARS-CoV-2 pandemic in a private hospital in southern Brazil. However, no statistical difference in the hourly prices was observed between 2019 and 2021 for both anesthetic techniques.

Effect of Quadratus Lumborum Block on Pain and Stress Response after Video Laparoscopic Surgeries: A Randomized Clinical Trial.

There are many surgical and anesthetic factors that affect pain and the endocrine-metabolic response to trauma. The ability of anesthetic agents and neuronal blockade to modify the response to surgical trauma has been widely studied in the last few years. To evaluate if the anterior quadratus lumborum block contributes to improved surgical recovery, using as parameters analgesia, pulmonary function and neuroendocrine response to trauma. We carried out a prospective, randomized, controlled, and blinded study, in which 51 patients scheduled for laparoscopic cholecystectomy. Patients were randomly selected and assigned to 2 groups. The control group received balanced general anesthesia and venous analgesia, and the intervention group was treated under general, venous analgesia and anterior quadratus lumborum block. The parameters evaluated were: demographic data, postoperative pain, respiratory muscle pressure and inflammatory response to surgical stress with the plasma dosage of IL-6 (Interleukin 6), CRP (C-Reactive protein) and cortisol. Anterior quadratus lumborum block induced the slowing of IL-6 cytokine production and a decrease in cortisol release. This effect was accompanied by the significant reduction of postoperative pain scores. Anterior quadratus lumborum block is an important strategy for analgesia in abdominal laparoscopic surgery and contributes to reducing the inflammatory response to surgical trauma with an early return of preoperative baseline physiological functions.

Effects of opioid-free propofol or remimazolam balanced anesthesia on hypoxemia incidence in patients with obesity during gastrointestinal endoscopy: A prospective, randomized clinical trial.

There are presently no consensuses on the optimal sedation strategy for obese patients during gastrointestinal endoscopy. This study aim to explore the effects of opioid-free propofol or remimazolam balanced anesthesia on hypoxemia incidence in patients with obesity. A total of 264 patients were randomized to remimazolam + esketamine group (group R) or propofol + esketamine group (group P). Anesthesia in group P was administrated by propofol, esketamine and in group R by remimazolam, esketamine. The primary outcome was incidence of hypoxemia. Secondary outcomes were the time to loss of consciousness (LoC) and to recovery and the incidence of intraoperative and postoperative adverse reactions. We found the incidence of mild hypoxemia in group R was similar to that in group P (14.2% vs. 11.5%, p = 0.396). The incidence of severe hypoxemia in group R was significantly lower than Group P (4.2% vs. 9.2%, p = 0.019). The time to LoC in group R was longer than group P [Median (interquartile range, IQR): 53 s (45 to 61) vs. 50 s (42 to 54), p = 0.001]. The time to recovery from anesthesia in group R was less than group P [Median (IQR): 48 min (41 to 58) vs. 55.5 min (46 to 67), p<0.001]. There was no significant difference in the incidence of adverse events (p > 0.05 for all). We concluded that compared with propofol combined with esketamine, remimazolam combined with esketamine can reduce the incidence of severe hypoxemia during gastrointestinal endoscopy in obese patients. Clinical Trial Registration: www.chictr.org.cn, Identifier: ChiCTR2200065575.

Effects of Erector Spinae Plane Block on Postoperative Pain and Quality of Recovery Questionnaire Scores in Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Study.

Opioid-free anesthesia with erector spinae plane block (ESPB) has the potential to decrease perioperative opioid need, thereby potentially reducing related complications. This study aimed to compare opioid-free anesthesia with ESPB and standard opioid-based balanced anesthesia in patients undergoing video-assisted thoracic surgery (VATS) in terms of postoperative opioid need (through patient control analgesia) as well as postoperative pain management, recovery quality, and opioid-related side effects. Seventy-four patients, ranging in age from 18 to 75 years, who underwent lobectomy with VATS were included in this randomized-controlled study. The opioid-free group had ESPB, and no opioid was used during anesthesia maintenance. The opioid group received standard anesthesia with opioid use. Postoperative morphine requirement, postoperative pain as measured by the visual analog scale (VAS), intraoperative vital parameters, recovery quality using the Quality of Recovery-40 (QoR-40) questionnaire, and opioid-related complications were compared between groups. The opioid-free group received a significantly lower total dose of morphine during the first 24 postoperative hours through patient-controlled analgesia (PCA) when compared to the opioid group (7.3±3.4 vs. 21.7±7.9 mg, p<0.001). In addition, the opioid-free group had significantly better postoperative pain scores and QoR-40 scores (184.3±7.5 versus 171.2±6.4, p<0.001), shorter times to mobilization (5.5±0.8 versus 8.1±1.1 hours, p<0.001), and oral intake (5.8±0.6 versus 6.4±0.6 hours, p<0.001), as well as less frequent opioid-related side effects. The findings of this study suggest that opioid-free anesthesia with ESPB represents a promising option for patients undergoing lobectomy with VATS. It has the potential to decrease postoperative opioid need, improve postoperative pain management, and reduce opioid-related unwanted consequences.