Balanced Anesthetic Technique Research Articles

Preventive Strategies in Anesthetizing a High-Risk Patient for Robotic Surgery: A Case Report

The physiologic consequences of intraabdominal insufflation and extreme positioning in robotic surgery predispose a patient with heart failure to complications. Reports on anesthetic strategies to prevent adverse events in patients with heart failure undergoing these types of surgeries are sparse. A 65-year-old male, who was a known case of heart failure with reduced ejection fraction (EF), was scheduled for robot-assisted low anterior resection for rectal adenocarcinoma. Preoperative diagnostic tools such as echocardiography, 12-lead electrocardiography, and blood tests guided preoperative risk assessment, and anesthesia-related planning and interventions. A balanced anesthetic technique using sevoflurane, atracurium, and fentanyl, with postoperative bilateral rectus sheath and subcostal block was used. In addition to standard monitors, arterial pulse pressure variation (PPV) was utilized for goal-directed fluid therapy to prevent complications. Patient tolerated surgery and anesthesia well with no report of any complication during the perioperative course. Patient was eventually discharged and scheduled for follow-up. The physiologic consequences of robotic surgery compound the already elevated risk for complications of a patient with heart failure. Anesthetic strategies to actively prevent adverse events are of paramount importance.

Anesthetic key points in a patient with a terminal ileum neuroendocrine tumor and a rare carcinoid left heart disease presented for non-cardiac surgery: case report

BackgroundCarcinoid tumors are rare neuroendocrine malignancies presenting in an increasing number in our center. The incidence of carcinoid tumors is approximatively between 2.5 and 5 cases per 100,000 people of whom about 50% develop carcinoid syndrome. Once the carcinoid syndrome has developed, a carcinoid cardiomyopathy can occur. Carcinoid heart disease (CaHD) remains a serious and rare complication associated with a significant increase in morbidity and mortality. Although carcinoid tumors have been known and studied for several years, there are still scarce data on the anesthetic management and the peri operative period.Case presentationWe describe a case of a Caucasian 44-year-old woman with an unusual presentation of left CaHD with an ileal neuroendocrine tumor and liver metastases. Our preoperative somatostatin administration protocol, limit the cardiac damage. The maintenance of stable hemodynamics, the use of balanced anesthetic technique, all along with a good understanding of the pathology, played a major role in the successful management of anesthesia. This case report allows us to introduce our decision algorithm for the management of this type of pathology in our tertiary hospital, Cliniques Universitaires Saint-Luc.ConclusionDespite the paucity of data, anesthetic management of patients with carcinoid tumor can be safely performed with effective hemodynamic monitoring and a good understanding of the pathophysiology. Knowledge and application of a clear institutional algorithm for octreotide administration and multidisciplinary consultation at a referral center are essential for the management of these patients.

Anesthesia Considerations in Patients Undergoing Spine Surgery with Evoked Potential Monitoring

Intra-operative neuromonitoring (IONM) facilitates monitoring of the functional integrity of neural structures under general anesthesia. It aids in early detection of injury and minimizes postoperative neurologic deficit. IONM may be used during spine surgery, where either the blood supply to the spinal cord could be compromised or the surgical procedures where there is manipulation of the spinal cord. Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) are used to monitor the sensory and motor tracts in the spinal cord, respectively. Preoperatively, a team of surgeons, anesthetists, and neurophysiologists must discuss about modalities of IONM to be used, expected changes, and alarm criteria. Anesthesia drugs need to be appropriately selected to facilitate IONM, as they affect the SSEP and MEP response obtained. Both total intravenous anesthesia and balanced anesthesia technique may be used, with appropriate titration of drugs. False-positive changes in evoked potentials (EPs) must be prevented by a steady anesthesia state and physiologic parameters. It is preferable to have a checklist to follow whenever changes in EP response are observed to rule out surgical, anesthetic, and monitoring-related causes for change in response. Risk–benefit must be assessed before the selection of a patient for EP monitoring as it may be rarely associated with complications such as burns, seizures, and bite injuries to lips, tongue, and endotracheal tube. Teamwork with meticulous planning, preparation, and multidisciplinary communication is essential for the safe conduct of spine surgeries with SSEP and MEP monitoring. In this review, we discuss various considerations for anesthesia management in patients with intraoperative EP monitoring.

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.

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.

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 <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.

Dexmedetomidine vs dexamethasone as adjuvants to levobupivacaine in ultrasound-guided erector spinae plane block for patients undergoing modified radical mastectomy: a randomized double-blind study

Background & Objective: Erector Spinae Plane block (ESPB) is used in patients subjected to modified radical mastectomy (MRM) as a part of balanced anesthesia technique, and to offer prolonged postoperative analgesia. Local anesthetic agents are usually combined with various adjuvants to augment the effect. We compared dexmedetomidine (Dex) versus dexamethasone as adjuvants to ESPB in patients undergoing MRM.
 Methodology: This randomized controlled study involved 90 patients subjected to MRM under general anesthesia with preoperative ESPB using 30 ml levobupivacaine 0.25%. They were randomly assigned into three equal groups according to the adjuvants used. Dex Group (n = 30) received 1 µg/kg dexmedetomidine, Dexa Group (n = 30) received 10 mg dexamethasone, and ESPB Group (n = 30) received no adjuvants. Patients were monitored for pain using VAS scores and vital signs. The primary outcome measure was total morphine consumption. The secondary outcomes were intraoperative fentanyl consumption, pain intensity, and analgesia duration.
 Results: The postoperative analgesia duration was significantly longer in the Dex group compared with the ESPB group (P = 0.029) but not in the dexamethasone group. Intraoperative fentanyl and postoperative morphine consumption were significantly lower in the Dex group than in the ESPB group. VAS scores were significantly lower in the Dex group than in the ESPB group at rest and movement. VAS scores of the Dexamethasone group were similar to that of the ESPB group at rest and movement.
 Conclusion: As an adjuvant to levobupivacaine in erector spinae plane block, dexmedetomidine reduces pain at rest and with movement, reduces intraoperative fentanyl and postoperative morphine consumption, and prolongs the analgesia duration. It is superior to dexamethasone in pain reduction and duration of analgesia.
 Key words: Analgesia; Dexamethasone; Dexmedetomidine; Erector Spinae Plane Block; Radical Mastectomy; Postoperative Pain
 Citation: Ahmed HI, Ali AR, El Emam NH, Magdy M, Gamal RM. Dexmedetomidine vs dexamethasone as adjuvants to levobupivacaine in ultrasound-guided erector spinae plane block for patients undergoing modified radical mastectomy: a randomized double-blind study. Anaesth. pain intensive care 2022;27(1):65−72.
 DOI: 10.35975/apic.v27i1.2122
 Received: Oct 08, 2022; Reviewed: Nov 10, 2022; Accepted: Nov 22, 2022

T2-weighted Imaging Hyperintensity and Transcranial Motor-evoked Potentials During Cervical Spine Surgery: Effects of Sevoflurane in 150 Consecutive Cases.

There is debate on the impact of inhalational esthetic agents on transcranial motor evoked potentials (TcMEPs) during intraoperative neuromonitoring. Current guidelines advise their avoidance, which contrasts with common clinical practice. This retrospective cohort study of 150 consecutive cervical spine surgeries at a single institution compared stimulation voltages and TcMEP amplitudes in patients who did and did not receive sevoflurane as part of a balanced anesthetic technique. Patients were divided into 3 groups stratified by the presence or absence of increased signal intensity within the cervical spinal cord on T2-weighted magnetic resonance imaging (indicative or myelopathy/spinal cord injury [SCI]) and sevoflurane use. Patients with no magnetic resonance imaging evidence of myelopathy/SCI that received sevoflurane (n=80) had the lowest stimulation voltages and largest TcMEP amplitude responses in the lower extremities compared with those with no magnetic resonance imaging evidence of myelopathy/SCI (n=30). In patients with evidence of myelopathy/SCI who did not receive sevoflurane (n=19), lower extremity TcMEP amplitudes were similar to patients with a myelopathy/SCI that received sevoflurane. Six of these 19 patients had initial low-dose sevoflurane discontinued because of concerns of low/absent baseline TcMEP amplitudes. Balanced anesthesia with 0.5 MAC sevoflurane in patients with and without radiological evidence of myelopathy/SCI allows reliable TcMEP monitoring. However, in communication with surgical and neuromonitoring teams, it may be advisable in a subset of patients to avoid or discontinue sevoflurane in favor of a propofol/opioid-based anesthetic to ensure adequate and reproducible TcMEPs.

Postoperative Analgesia in Patients Single Shot Epidural Dexamethasone to Bupivacaine Undergoing Lower Abdominal Surgeries

Background: Good postoperative analgesia helps to reduce postoperative stress response, improve patient satisfaction, and improve outcome. Epidural block with local anaesthetic with or without additives is being used for perioperative analgesia. Various additives have been used to enhance the effect of regional blocks including epidural blocks. Objective: To assess the postoperative analgesia in patients single shot epidural dexamethasone to bupivacaine undergoing lower abdominal surgeries. Methods: This was a prospective, randomized, double blind study carried out at the Dept. of Anesthesia, Sheikh Russel National Gastroliver institute and hospital, Mohakhali, Dhaka, Bangladesh from July to December 2021. One hundred (100) adults patients of ASA physical status I and II of age Group 16-65 years and undergoing routine elective lower abdominal surgery. The patients were randomized into two groups. Group A received 9ml of 0.5% bupivacaine plain with 1 ml of normal saline. Group B received 9ml of 0.5% bupivacaine plain 9 ml with 1 ml of dexamethasone (4mg). After standard balanced anaesthesia technique, patients were observed in postoperative period for pain and hemodynamic variables accordingly. Results: In our study 100 patients belonging to ASA physical status I and II undergoing lower abdominal surgery under general anaesthesia were studied. The patient’s age ranged from 16 to 65 years. Our study showed significantly longer duration of analgesia of 8 hours when dexamethasone was added to bupivacaine for single shot epidural injection compared to four and half hours when bupivacaine alone was used (p<0.001). Consumption of rescue analgesic, Tramadol, was significantly lower in dexamethasone group in 24 hours (168.32±49.72 mg in Group A and 113.72±60.57mg in Group B, p<0.001). No adverse events were noted. The both groups the lowest blood pressure was observed at ½ hours following the block and highest at 6 hours. While comparing the two groups at 6 hours the blood pressure in Group B (120.56±12.06) was significantly less than that in Group A (125.90±9.54) (p=0.024). No significant difference was observed at ½ hours, 12 hours and 24 hours after the block. Conclusion: In conclusion, the quality of analgesia it offers not only in post-operative pain but also in labour analgesia and chronic pain management. Addition of dexamethasone to bupivacaine for single shot epidural block almost doubled the duration of analgesia. Single shot epidural block using bupivacaine with addition of dexamethasone provides effective post-operative analgesia and significantly reduced the postoperative rescue analgesic requirement.

Comparative Study of Efficacy of Buprenorphine and Fentanyl on Attenuation of Hemodynamic Changes to Laryngoscopy and Intubation: A Prospective, Randomized Double-Blind Study.

Hemodynamic changes are the most common predicted response after laryngoscopy and intubation during general anesthesia. We compared the efficacy of buprenorphine with fentanyl to attenuate this stress response. One hundred and thirty patients of either sex between the age group of 18-70 years, admitted for the routine surgical procedure under general anesthesia were enrolled in this double blind, randomized, clinical study. Patients were randomly assigned into two equal groups (60 patients in each group): group F received fentanyl 2 μg/kg, and group B received buprenorphine 2.5 μg/kg; both via intravenous route. Each group received a total volume of 10 mL by adding normal saline to the total drug volume, given over 60 seconds, 5 minutes before intubation. Thereafter patients were induced using routine balanced anesthesia technique, and the hemodynamic parameters were observed at baseline (0 minute), 1, 3, and 5 minutes after the administration of the study drug and again at 1, 3, 5, 7, and 10 minutes after intubation. Continuous variables were presented as mean with an 80% confidence interval, and a t-test was applied for comparing the difference of means between two groups after we checked the normality condition. Chi-square test was applied to test the independence of attributes of categorical variables. Repeated measures two-way analysis of variance was performed to compare the outcome variables between the two groups. In both groups, mean arterial blood pressure (MAP) and heart rate (HR) were statistically insignificant up to 5 minutes after study drug, thereafter mean HR and MAP at 1, 3, 5, 7, and 10 minutes after intubation, were statistically significant between the two groups, and P value was less than 0.05. The dose of 2.5 μg/kg buprenorphine is an effective alternative to fentanyl 2 μg/kg for attenuating the hemodynamic response accompanying laryngoscopy and tracheal intubation without causing any hemodynamic adverse effect.

A Review of Sedation Agents.

The oral and maxillofacial surgery model of anesthesia delivery is the subject of some controversy. However, a long track record of patient safety provides compelling support for the dual role of the oral and maxillofacial surgeon as proceduralist and anesthetist. Among the elements critical to continued success is a clear understanding of the pharmacology of the agents used to produce sedation and general anesthesia. This review highlights 6 sedation agents used as part of a balanced anesthesia technique in oral and maxillofacial surgery.

Effect of Non-depolarizing Muscle Relaxants Rocuronium Versus Vecuronium in the Assessment of Post-Succinylcholine Complications in Surgeries Under General Anesthesia: A Randomized Double-Blind Study at a Tertiary Care Hospital.

Background and objectiveSeveral drugs have been used to prevent or attenuate succinylcholine-induced muscle fasciculations and myalgia. We designed the present study to evaluate the efficacy of rocuronium (ROC) and vecuronium (VEC) in preventing succinylcholine-induced fasciculations and postoperative myalgia (POM) in patients undergoing surgery under general anesthesia.Materials and methodsAfter obtaining written informed consent, 125 patients were randomly selected to receive either ROC 0.06 mg/kg or VEC 0.01 mg/kg, with both diluted up to 2 ml, 90 seconds before the administration of propofol followed by succinylcholine. A standardized balanced anesthetic technique was used for all patients. The intensity of fasciculations and intubating conditions were assessed using a 4-point rating scale. All patients were evaluated up to the third postoperative day for the presence of POM, the severity of which was graded on a 4-point scale.ResultsThe incidence of post-succinylcholine fasciculations during induction was nil in 74.58% of patients in the ROC group and 51.52% in the VEC group. Mild fasciculation was seen in 22.03% in the ROC group and 33.33% in the VEC group. Moderate fasciculation was seen in 3.39% and 15.15% in ROC and VEC groups respectively. When comparing both the groups, a significant decrease (p=0.015) in intraoperative fasciculation was observed in the ROC group than in the VEC group. Both drugs provided good intubating conditions without any statistical significance and with an overall intubating score of 8-9 in both groups as per Lund. On day one, 91.53% (n=54) of the ROC group and 65.15% (n=43) of the VEC group patients did not have any myalgia symptoms. Mild myalgia was observed in 8.47% (n=5) in the ROC group and 31.82% (n=21) in the VEC group, and only 1.8% had moderate myalgia in the VEC group. The results of the study showed that POM was significantly decreased in the ROC group than in the VEC group on day one (p=0.001). The incidence of POM on day two was significantly low in both groups. There was no statistical significance between the two groups based on Fisher's exact test (p=1.000). None of the patients had myalgia on day three.ConclusionOur results showed that the incidence and severity of fasciculations and POM were significantly decreased by pretreatment with ROC in contrast to that with VEC. Hence, ROC is a better option than VEC to combat succinylcholine-related complications like fasciculation and myalgia.

Anaesthesia Concern in High-Risk Cases Under-Going Ambulatory Laparoscopic Cholecystectomy

Objective:To evaluate pre-operative implications, anesthetic management and post-operative anesthetic concerns in patientswith co-morbid diseases undergoing ambulatory laparoscopic cholecystectomy under general anesthesia. Study Design and setting:Retrospective study was conducted at Rawal Institute of Health Sciences, Islamabad from 8thOct 2017 to 5th Nov 2018. Methodology:Total one hundred and twelve patients were placed in American society of Anaesthesiologist (ASA) classII, III & IV (medically optimized) on pre-operative evaluation for ambulatory laparoscopic cholecystectomy. Generalanesthesia was administered with co-induction (nalbuphine 0.1mg/kg plus midazolam 0.01mg/kg) tracheal intubationfacilitated by 0.15mg/kg cis-atracurium. Post-operatively on clinical status evaluation and Post Anesthesia Discharge score,patients were shifted to respective ward /intensive care. Statistical analysis was done by SPSS v.21. Results:Pre-operatively medical and cardiologist evaluation was taken in 34(30.35%) and 42(37.5%) cases respectivelywhereas consultant anesthesiologist reviewed all cases. In study single case was converted to open method due to mirrizisyndrome and adhesions creating difficult laparoscopic dissection in 9(8.03%) of cases. Post-operatively in single caseatrial fibrillation with fast ventricular response noted followed by sudden bradycardia, managed and sinus rhythm restored,whereas in other case of ischemic heart disease with viral respiratory infection, needed ventilatory support after 2 hoursdue to respiratory distress and weaned off after 24hrs. In the study 76(67.9%) cases were shifted post-operatively to surgical ward and 36 cases (32.1%) needed intensive care treatment. Conclusion:Laparoscopic cholecystectomy in patients with co-morbid states requires balanced anesthetic technique considering consequences of pneumoperitoneum to decrease morbidity.

AN INTRA-OPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHIC STUDY TO COMPARE THE EFFECT OF SEVOFLURANE AND ISOFLURANE ON LEFT VENTRICULAR DYSFUNCTION IN PATIENTS WITH ISCHEMIC HEART DISEASE UNDERGOING CORONARY ARTERY BYPASS GRAFTING USING CARDIOPULMONARY BYPASS

An Intra-operative Transesophageal Echocardiographic Study to Compare The Effect of Sevourane and Isourane on Left Ventricular Dysfunction In Patients With Ischemic Heart Disease Undergoing Coronary Artery Bypass Grafting Using Cardiopulmonary Bypass Context : Diastolic dysfunction has been increasingly recognized as an important cause of congestive heart failure (CHF) and resultant morbidity. About 50% patients with CHF have 'diastolic heart failure' in spite of a normal systolic function with preserved ejection fraction. The widely used volatile anesthetic agents, Isourane and Sevourane, are considered important components of balanced anesthesia technique. However their effects on left ventricular (LV) systolic and diastolic function have not been precisely dened. This study was designed to quantify and compare their effects on left ventricular function by TEE before start of CPB. Aims : To compare the effects of Isourane and Sevourane on echocardiographic LVsystolic and diastolic parameters. Settings and design : After obtaining institutional ethics committee clearance and informed consent from 60 patients operated within my study period was included . Data were collected after induction and just before going on bypass. Materials and Methods : After inducing the patients with institutional protocol one group was given isourane(Group I) and another group was given sevourane(Group S), both at 1MAC. TEE parameters measuring LVsystolic and diastolic functions were done. Statistical analysis : Data were analysed by Epi Info (TM) 7.2.2.2. Result and conclusion :Isourane was better than sevourane in comparism of systolic and diastolic dysfunction.

Total Intravenous Anaesthesia with Ketamine, Medetomidine and Midazolam as Part of a Balanced Anaesthesia Technique in Horses Undergoing Castration.

To evaluate the use of ketamine-medetomidine-midazolam total intravenous infusion as part of a balanced anaesthetic technique for surgical castration in horses. Five healthy Standardbred cross colts were premedicated with IV acepromazine (0.01–0.02 mg/kg), medetomidine (7 µg/kg) and methadone (0.1 mg/kg) and anaesthesia induced with IV ketamine (2.2 mg/kg) and midazolam (0.06 mg/kg). Horses were anaesthetised for 40 min with an IV infusion of ketamine (3 mg/kg/h), medetomidine (5 µg/kg/h) and midazolam (0.1 mg/kg/h) while routine surgical castration was performed. Cardiorespiratory variables, arterial blood gases, and anaesthetic depth were assessed at 5 to 10 min intervals. Post-anaesthesia recovery times were recorded, and the quality of the recovery period was assessed. The anaesthetic period and surgical conditions were acceptable with good muscle relaxation and no additional anaesthetic required. The median (range) time from cessation of the infusion to endotracheal tube extubation, head lift and sternal recumbency were 17.2 (7–35) min, 25 (18.9–53) min and 28.1 (23–54) min, respectively. The quality of anaesthetic recovery was good, with horses standing 31.9 (28–61) min after the infusion was ceased. During anaesthesia, physiological variables, presented as a range of median values for each time point were: heart rate 37–44 beats/min, mean arterial pressure 107–119 mmHg, respiratory rate 6–13 breaths/min, arterial partial pressure of oxygen 88–126 mmHg, arterial partial pressure of carbon dioxide 52–57 mmHg and pH 7.36–7.39. In conclusion, the co-administration of midazolam, ketamine and medetomidine as in IV infusion, when used as part of a balanced anaesthetic technique, was suitable for short term anaesthesia in horses undergoing castration.

Dissociative and analgesic properties of ketamine are independent and unaltered by sevoflurane general anesthesia.

Ketamine, an anesthetic adjunct, is routinely administered as part of a balanced general anesthetic technique. We recently showed that the acute analgesic and dissociation properties of ketamine are separable to suggest that distinct neural circuits underlie these states. We aimed to study whether this finding is robust to the substantial neural circuit alterations associated with general anesthesia. We conducted a single-site, open-label, randomized controlled, cross-over study of sevoflurane and sevoflurane-plus-ketamine (SK) general anesthesia in healthy subjects (n = 12). Before and after general anesthesia, we assessed precalibrated cuff pain intensity and nociceptive pain quality as well as dissociation using the Clinician-Administered Dissociative States Scale (CADSS). For statistical inference, we ran a variation of backward elimination repeated-measures analysis of covariance. Models with CADSS as a covariate term were used to assess whether dissociation mediated the effect of ketamine on pain intensity and quality. Sevoflurane-plus-ketamine general anesthesia was associated with a significant (P = 0.0002) pain intensity decline of 3 (SE, 0.44). There was an order effect for dissociation such that SK was associated with a significant (P = 0.0043) CADSS increase of 17.8 (3.2) when the SK treatment came first. When the pain intensity model was reanalyzed with CADSS as an additional covariate, the effect of CADSS was not significant. These results were also conserved for pain quality. Our findings suggest that the analgesic and dissociation properties of ketamine remain separable despite general anesthesia. Thus, ketamine may be used as a probe to advance our knowledge of dissociation independent pain circuits.

Literature Review for Office-Based Anesthesia

Literature Review for Office-Based Anesthesia

Thromboelastometry-based algorithm and transfusion management during orthotopic liver transplantations

Thromboelastometry-based algorithm and transfusion management during orthotopic liver transplantations

General anesthetic techniques for enhanced recovery after surgery: Current controversies.

General anesthesia technique can influence not only immediate postoperative outcomes, but also long-term outcomes beyond hospital stay (e.g., readmission after discharge from hospital). There is lack of evidence regarding superiority of total intravenous anesthesia over inhalation anesthesia with regards to postoperative outcomes even in high-risk population including cancer patients. Optimal balanced general anesthetic technique for enhance recovery after elective surgery in adults includes avoidance of routine use preoperative midazolam, avoidance of deep anesthesia, use of opioid-sparing approach, and minimization of neuromuscular blocking agents and appropriate reversal of residual paralysis. Given that the residual effects of drugs used during anesthesia can increase postoperative morbidity and delay recovery, it is prudent to use a minimal number of drug combinations, and the drugs used are shorter-acting and administered at the lowest possible dose. It is imperative that the discerning anesthesiologist consider whether each drug used is really necessary for accomplishing perioperative goals.

Effect of xenon and dexmedetomidine as adjuncts for general anesthesia on postoperative emergence delirium after elective cardiac catheterization in children: study protocol for a randomized, controlled, pilot trial

BackgroundEmergence delirium, a manifestation of acute postoperative brain dysfunction, is frequently observed after pediatric anesthesia and has been associated with the use of sevoflurane. Both xenon and dexmedetomidine possess numerous desirable properties for the anesthesia of children with congenital heart disease, including hemodynamic stability, lack of neurotoxicity, and a reduced incidence of emergence delirium. Combining both drugs has never been studied as a balanced-anesthesia technique. This combination allows the provision of anesthesia without administering anesthetic drugs against which the Food and Drug Administration (FDA) issued a warning for the use in young children.Methods/DesignIn this phase-II, mono-center, prospective, single-blinded, randomized, controlled pilot trial, we will include a total of 80 children aged 0–3 years suffering from congenital heart disease and undergoing general anesthesia for elective diagnostic and/or interventional cardiac catheterization. Patients are randomized into two study groups, receiving either a combination of xenon and dexmedetomidine or mono-anesthesia with sevoflurane for the maintenance of anesthesia.The purpose of this study is to estimate the effect size for xenon-dexmedetomidine versus sevoflurane anesthesia with respect to the incidence of emergence delirium in children. We will also describe group differences for a variety of secondary outcome parameters including peri-interventional hemodynamics, emergence characteristics, incidence of postoperative vomiting, and the feasibility of a combined xenon-dexmedetomidine anesthesia in children.DiscussionSevoflurane is the most frequently used anesthetic in young children, but has been indicated as an independent risk factor in the development of emergence delirium. Xenon and dexmedetomidine have both been associated with a reduction in the incidence of emergence delirium. Combining xenon and dexmedetomidine has never been described as a balanced-anesthesia technique in children. Our pilot study will therefore deliver important data required for future prospective clinical trials.Trial registrationEudraCT, 2018–002258-56. Registered on 20 August 2018. https://www.clinicaltrialsregister.eu.