General Anesthesia For Elective Surgery Research Articles

Standardizing the Dosage and Timing of Dexamethasone for Postoperative Nausea and Vomiting Prophylaxis at a Safety-Net Hospital System

A single dose of dexamethasone is routinely given during general anesthesia for postoperative nausea and vomiting (PONV) prophylaxis, although the exact dosage and timing of administration may vary between practitioners. The authors aimed to standardize the dosage and timing of this medication when given to adult patients undergoing general anesthesia for elective surgery. Baseline data for 7,483 preintervention cases were analyzed. The researchers attempted to use a standard dose of 8 to 10 mg induction of anesthesia, which, based on a literature review, was effective for PONV prophylaxis, had a similar safety profile as a 4 to 5 mg dose (including in diabetic patients), and may confer additional benefits such as improved prophylaxis and quality of recovery. The interventions included standardizing the medication concentration vials, altering electronic health record quick-select button options, simplifying the intraoperative charting process, and educating the anesthesia providers. The research team then tracked compliance with the standard of care for 2,167 cases after the interventions. Overall compliance with the standard of care increased from 21.2% preintervention to 53.7% postintervention. The number of patients not receiving dexamethasone was reduced from 29.7% to 19.4%. Patients receiving a compliant dose at a noncompliant time increased from 16.3% to 23.8%. Postanesthesia care unit antiemetic administration also decreased after the interventions. This study showed improvements in compliance with the dosage of medication with the interventions. However, compliance with the timing of administration remains challenging.

Intraoperative mechanical power and postoperative pulmonary complications in low-risk surgical patients: a prospective observational cohort study

BackgroundInadequate intraoperative mechanical ventilation (MV) can lead to ventilator-induced lung injury and increased risk for postoperative pulmonary complications (PPCs). Mechanical power (MP) was shown to be a valuable indicator for MV outcomes in critical care patients. The aim of this study is to assess the association between intraoperative MP in low-risk surgical patients undergoing general anesthesia and PPCs.MethodsTwo-hundred eighteen low-risk surgical patients undergoing general anesthesia for elective surgery were included in the study. Intraoperative mechanical ventilatory support parameters were collected for all patients. Postoperatively, patients were followed throughout their hospital stay and up to seven days post discharge for the occurrence of any PPCs.ResultsOut of 218 patients, 35% exhibited PPCs. The average body mass index, tidal volume per ideal body weight, peak inspiratory pressure, and MP were significantly higher in the patients with PPCs than in the patients without PPCs (30.3 ± 8.1 kg/m2 vs. 26.8 ± 4.9 kg.m2, p < 0.001; 9.1 ± 1.9 ml/kg vs. 8.6 ± 1.4 ml/kg, p = 0.02; 20 ± 4.9 cmH2O vs. 18 ± 3.7 cmH2O, p = 0.001; 12.9 ± 4.5 J/min vs. 11.1 ± 3.7 J/min, p = 0.002). A multivariable regression analysis revealed MP as the sole significant predictor for the risk of postoperative pulmonary complications [OR 1.1 (95% CI 1.0–1.2, p = 0.036].ConclusionsHigh intraoperative mechanical power is a risk factor for developing postoperative pulmonary complications. Furthermore, intraoperative mechanical power is superior to other traditional mechanical ventilation variables in identifying surgical patients who are at risk for developing postoperative pulmonary complications.Clinical trial registration NCT03551899; 24/02/2017.

A new score for airway assessment using clinical and ultrasound parameters.

Over the last few years, ultrasonography has been introduced as the fifth pillar to patient's bedside physical examination. Clinical assessments aim to screen and look for airway difficulties to predict difficult intubations, but none have demonstrated a significant predictive capacity. Recent systematic reviews have established a correlation between ultrasound imaging and difficult direct laryngoscopy. The primary objective of this study was to determine whether the utilization of ultrasonography to examine the upper airway could accurately predict difficult direct laryngoscopy. This is a prospective observational study including 102 adult patients that required general anesthesia for elective surgery. Preoperatively, clinical airway assessments were performed. Data such as Mallampati-Samsoon grade (MS), upper lip bite test (ULBT), thyromental (TMD) and sternomental distance (SMD), cervical circumference (CC) and the Arné risk index were collected. Ultrasound evaluation was taken at five different levels in two planes, parasagittal and transverse. Therefore, the following measurements were registered: distance from skin to hyoid bone (DSHB), distance from skin to thyrohyoid membrane (DSTHM), distance from skin to epiglottis (DSE), distance from skin to thyroid cartilage (DSTC) and distance from hyoid bone and thyroid cartilage (DHBTC). Patients were divided into two groups based on the difficulty to perform direct laryngoscopy, according to Cormack-Lehane (C-L) classification. Grades I and II were classified as easy laryngoscopy and grades III or IV as difficult. Logistic regression models and the Receiver Operating Characteristic (ROC) curve was employed to determine the diagnostic precision of ultrasound measurements to distinguish difficult laryngoscopy (DL). The following risk score for DL was obtained, DSTHM ≥ 1.60 cm (2 points), DSTC ≥ 0.78 cm (3 points) and gender (2 points for males). The score can range from 0 to 7 points, and showed and AUC (95% CI) of 0.84 (0.74-0.95). A score of 5 points or higher indicates a 34-fold increase in the risk of finding DL (p = 0.0010), sensitivity of 91.67, specificity of 75.56, positive predictive value of 33.33, and negative predictive value of 98.55. The use of ultrasonography combined with classic clinical screening tests are useful tools to predict difficult direct laryngoscopy.

Development and validation of a screening method for difficult tracheal intubation based on geometric simulation and computer technology

BackgroundThe anatomical characteristics of difficult airways can be analysed geometrically. This study aims to develop and validate a geometry-assisted difficult airway screening method (GADAS method) for difficult tracheal intubation.MethodsIn the GADAS method, a geometric simulated model was established based on computer graphics. According to the law of deformation of the upper airway on laryngoscopy, the expected visibility of the glottis was calculated to simulate the real visibility on laryngoscopy. Validation of the new method: Approved by the Ethics Committee of Yijishan Hospital of Wannan Medical College. Adult patients who needed tracheal intubation under general anaesthesia for elective surgery were enrolled. The data of patients were input into the computer software to calculate the expected visibility of the glottis. The results of tracheal intubation were recorded by anaesthesiologists. The primary observation outcome was the screening performance of the expected visibility of the glottis for difficult tracheal intubation.ResultsThe geometric model and software of the GADAS method were successfully developed and are available for use. We successfully observed 2068 patients, of whom 56 patients had difficult intubation. The area under the receiver operating characteristic curve of low expected glottis visibility for predicting difficult laryngoscopy was 0.96 (95% confidence interval [CI]: 0.95–0.96). The sensitivity and specificity were 89.3% (95% CI: 78.1-96.0%) and 94.3% (95% CI: 93.2%-95.3), respectively.ConclusionsIt is feasible to screen difficult-airway patients by applying computer techniques to simulate geometric changes in the upper airway.

Neuromuscular end-point predictive capability of published rocuronium pharmacokinetic/pharmacodynamic models: An observational trial

BackgroundObjective neuromuscular monitoring remains the single most reliable method to ensure optimal perioperative neuromuscular management. Nevertheless, the prediction of clinical neuromuscular endpoints by means of Pharmacokinetic (PK) and Pharmacodynamic (PD) modelling has the potential to complement monitoring and improve perioperative neuromuscular management.s Study objectiveThe present study aims to assess the performance of published Rocuronium PK/PD models in predicting intraoperative Train-of-four (TOF) ratios when benchmarked against electromyographic TOF measurements. DesignObservational trial. SettingTertiary Belgian hospital, from August 2020 up to September 2021. Patients and interventionsSeventy-four patients undergoing general anaesthesia for elective surgery requiring the administration of rocuronium and subject to continuous EMG neuromuscular monitoring were included. PK/PD-simulated TOF ratios were plotted and synchronised with their measured electromyographic counterparts and their differences analysed by means of Predictive Error derivatives (Varvel criteria). Main resultsPublished rocuronium PK/PD models overestimated clinically registered TOF ratios. The models of Wierda, Szenohradszky, Cooper, Alvarez-Gomez and McCoy showed significant predictive consistency between themselves, displaying Median Absolute Performance Errors between 38% and 41%, and intra-individual differences (Wobble) between 14 and 15%. The Kleijn model outperformed the former with a lower Median Absolute Performance Error (16%, 95%CI [0.01; 57]) and Wobble (11%, 95%CI [0.01; 34]). All models displayed considerably wide 95% confidence intervals for all performance metrics, suggesting a significantly variable performance. ConclusionsSimulated TOF ratios based on published PK/PD models do not accurately predict real intraoperative TOF ratio dynamics. Trial registrationNCT04518761 (clinicaltrials.gov), registered on 19 August 2020.

Evaluation of Endotracheal Cuff Pressure and Volume of Air for Inflation of CUFF Following Intubation After General Anaesthesia for Elective Surgery

Evaluation of Endotracheal Cuff Pressure and Volume of Air for Inflation of CUFF Following Intubation After General Anaesthesia for Elective Surgery

Comparison of preoxygenation efficiency measured by the oxygen reserve index between high-flow nasal oxygenation and facemask ventilation: a randomised controlled trial

BackgroundHigh-flow nasal oxygenation and the oxygen reserve index (ORI), which is a non-invasive and innovative modality that reflects the arterial oxygen content, are used in general anaesthesia. This study compares the preoxygenation efficiency (measured by the ORI) of high-flow nasal oxygenation and facemask ventilation during the induction process.MethodsThis single-centre, two-group, randomised controlled trial included 197 patients aged ≥ 20 years who underwent orotracheal intubation for general anaesthesia for elective surgery. The patients were randomly allocated to receive preoxygenation via facemask ventilation or high-flow nasal oxygenation. The ORI was measured and compared between both groups.ResultsThe ORI increased during preoxygenation in all patients. At 1 min of preoxygenation, the ORI was significantly higher in the high-flow nasal oxygenation group (0.34 ± 0.33) than in the facemask ventilation group (0.21 ± 0.28; P = 0.003). The highest ORI was not significantly different between the two groups (0.68 ± 0.25 in the high-flow nasal oxygenation group vs. 0.70 ± 0.28 in the facemask ventilation group; P = 0.505).ConclusionsHigh-flow nasal oxygenation results in an oxygenation status similar to that provided by facemask ventilation during the induction process of general anaesthesia; therefore, high-flow nasal oxygenation is a feasible preoxygenation method.Trial RegistrationClinicaltrials.gov (NCT04291339).

POSTOPERATIVE SORE THROAT AFTER LARYNGOSCOPY WITH MACINTOSH VERSUS VIDEOLARYNGOSCOPE BLADE

Introduction: Direct laryngoscopy guided by a Macintosh curved blade, is the standard traditional method of endotracheal intubation in patients under general anaesthesia. Post Operative Sore Throat [POST] is a common problem faced. With the advent of newer technology, various videolaryngoscopes have come into usage. To know the incidence of sore throat after Aim: intubation with the Macintosh versus videolaryngoscope. To compare the incidence of hoarseness, hemodynamic response and time taken for intubation by two methods. A prospective, randomized study was conducted on 110 patient Method: s with normal airway undergoing general anaesthesia for elective surgeries. Patients were enrolled into two groups randomly by Systemic Randomization Technique. All patients underwent thorough pre-anaesthestic evaluation with general and systemic examination. In the operation theatre, baseline vital parameters were recorded. The standard anaesthetic regimen and surgical procedures was followed. Postoperative sore throat was assessed with 10 point score at 0,6,12,24 hours post extubation. The mean incidence of sore throat at 0,6,12 and 24 hours Result: post extubation was 6.67, 5.44, 4.91 and 3.93 in the Macintosh group whereas 4.18, 3.09, 1.22 and 1.25 in the videolaryngoscope group. The mean time taken for intubation was 19.5 sec in Macintosh group and 36.6 sec in videolaryngoscope group. All patients were haemodynamically stable throughout the procedure. Conclusion: The incidence of postoperative sore throat was more with Macintosh blade whereas the time taken for intubation and the hemodynamic stability was more with the videolaryngoscope blade

Airway management during the COVID-19 pandemic: macintosh laryngoscopy vs. video laryngoscopy.

Our study aimed to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for tracheal intubation in adult patients receiving general anesthesia for elective surgery during the COVID-19 pandemic. The study included 150 patients 18-65 years old, ASA I-II (American Society of Anesthesiologists), and negative PCR tests before the operation was scheduled for elective surgery under general anesthesia. Patients were subdivided into two groups considering the intubation method: the video laryngoscopy group (Group VL, n=75) and the Macintosh laryngoscopy group (Group ML, n: 75). Demographic data, operation type, intubation comfort, and field of view, intubation times, complications were recorded. Both groups' demographic data, complications, and hemodynamic parameters were similar. In Group VL, Cormack-Lehane Scoring values were higher (p<0.001), the field of view was better (p<0.001), and the intubation was more comfortable (p<0.002). The duration for the vocal cord appearance was significantly shorter in the VL group than in the ML group (7.55±1.00 vs. 8.31±2.20 sec, p=0.008, respectively). The beginning of intubation to full ventilation of the lungs was significantly shorter in the VL group than the ML group (12.71±2.72 vs. 17.48±6.8, p<0.001, respectively). Using VL in endotracheal intubation may be more reliable in reducing intervention times and the risk of suspected transmission during the COVID-19 pandemic.

COMPARISON OF DEXMEDETOMIDINE VERSUS FENTANYL IN ATTENUATING PRESSOR RESPONSE DURING LARYNGOSCOPY AND ENDOTRACHEAL INTUBATION

Background and objectives: Laryngoscopy and intubation is associated with a sympathetic response that results in a rapid increase in blood pressure and heart rate. The mechanisms underlying these hemodynamic changes are incompletely understood. They may be caused by a reex sympathetic discharge due to stimulation of the upper respiratory tract. It has been observed that hemodynamic responses to tracheal intubation are associated with an increase in plasma catecholamine concentrations and are attenuated by β-adrenergic blockade. This study was conducted to compare the efcacy of dexmedetomidine and fentanyl for attenuation of pressor response during laryngoscopy and intubation. Materials and methods Following approval by ethical committee, 60 ASA grade I and II patients of either sex undergoing general anaesthesia for elective surgery were included in this study. Patients were randomly divided into two groups of 30 patients each. Dexmedetomidine in a dose of 1μg/kg i.v was given to Group A patients and Fentanyl 2 μg/kg i.v was given to Group B patients. Both the drugs were diluted with normal saline solution to make 10ml and were administered slow intravenous 10 min before induction. The hemodynamic parameters were recorded, demographic data was analyzed using unpaired t-test and hemodynamic variables were analyzed by using unpaired and paired t-test. Side effects were analyzed using chi square test. Result: The two groups were comparable in their demographic proles. Dexmedetomidine proved itself to be an excellent drug when given intravenously in dose of 1μg/kg to attenuate hemodynamic response to laryngoscopy and intubation. It blunted the hemodynamic response to laryngoscopy and intubation to a greater magnitude than fentanyl in a dose of 2μg/kg intravenously as a premedication. Conclusion: We conclude that fentanyl 2μg/kg i.v. given ten minutes prior to airway instrumentation shows an inconsistent response to laryngoscopy and intubation. Between the two drugs under study, the use of dexmedetomidine 1μg/kg i.v. is satisfactory and produces a more favorable hemodynamic prole while fentanyl 2μg/kg is found to be non- dependable and less effective for the attenuation of the pressor response to laryngoscopy and endotracheal intubation.

High-Flow Nasal Cannula for Apneic Oxygenation in Obese Patients for Elective Surgery: A Systematic Review and Meta-Analysis.

Obese patients desaturate rapidly during the apneic period after induction of anesthesia for elective surgery. Administration of oxygen using high-flow nasal cannulae (HFNCs) may prevent desaturation in nonobese patients compared to facemask (FM) preoxygenation. The aim of this meta-analysis was to compare the effectiveness of HFNC to FM preoxygenation techniques in reducing preintubation desaturation in obese patients undergoing elective surgery. This study protocol was registered on PROSPERO (CRD42022309391). Adult studies that compared HFNC and FM preoxygenation in obese patients requiring general anesthesia for elective surgery were included. The primary outcome was desaturation resulting in oxygen saturation of <92% from induction of anesthesia until intubation. Secondary outcomes included the lowest arterial oxygen content before intubation expressed in mm Hg, safe apnea time expressed in seconds, the lowest oxygen saturation before intubation expressed as a percentage, patient-reported discomfort, the need for rescue ventilation, and the incidence of aspiration of gastric contents during intubation. Risk of bias was assessed using the Cochrane Collaboration tool. Certainty was assessed following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Six studies including 351 participants were eligible for analysis. There was no difference in odds of oxygen desaturation <92% between HFNC and FM (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.15-1.63; P = .24). The HFNC group had a significantly longer safe apnea time (mean difference [MD], -124.20 with 95% CI, -200.47 to -47.93; P = .001). There was no difference between HFNC and FM in the lowest arterial oxygen content (MD, -23.90; 95% CI, -88.64 to 40.85; P = .47) and the lowest peripheral oxygenation saturation (MD, -0.47 with 95% CI, -5.07 to 4.12; P = .84). HFNC had a lower odd of discomfort than FM (OR, 0.13; 95% CI, 0.03-0.52; P = .004). There was no difference in the odds of aspiration of gastric contents between HFNC and FM (OR, 0.33; 95% CI, 0.01-8.21; P = .50). The risk of bias for our primary and secondary outcomes was low. The GRADE assessment for our primary outcome indicated a low level of certainty. For secondary outcomes, the GRADE assessment indicated a very low certainty for all outcomes except for patient discomfort, which was indicated as a moderate level of certainty. There may be no difference between HFNC and FM preoxygenation in preventing oxygen desaturation <92% or the lowest oxygen saturation before intubation. Preparation remains important to prevent and manage desaturation during induction of obese patients.

Tricuspid annular plane systolic excursion to predict arterial hypotension caused by general anesthesia induction.

Hypotension, which may develop after anesthesia induction, may cause ischemic stroke, myocardial damage, acute kidney injury, and postoperative mortality. Various assessments can be used to predict hypotension. We aimed to test the relationship of tricuspid annular plane systolic movement (TAPSE) with hypotension. A total of 47 patients aged 18-65 years, who were scheduled for general anesthesia for elective surgery, had ASA I-II, and had no known cardiovascular disease, were included in the study. TAPSE was calculated in an apical four-chamber view by placing an M-mode cursor along the tricuspid annulus, and measuring the longitudinal movement amount in the peak systole. TAPSE was measured 30 minutes before the surgery. The primary objective of the present study was to test the relationship between TAPSE and hypotension because of general anesthesia induction. We accepted hypotension as a decrease of 30% or more from baseline in systolic blood pressure (SBP) in the first 10 minutes following induction or a decrease in mean arterial pressure (MAP) below 60 mmHg. Statistically significant differences were detected in TAPSE values compared to the hypotension status after general anesthesia induction (P<0.001). The value of TAPSE had an optimal cut-off value of ≤2.48cm for the diagnostic yield of the development of hypotension after the general anesthesia induction. This cut-off value had a sensitivity and specificity of 90.00% and 95.83%. TAPSE predicted the development of hypotension after general anesthesia induction. Further studies are required to prove the diagnostic accuracy of TAPSE as a predictor of hypotension after general anesthesia induction.

Longitudinal assessment of behaviour in young children undergoing general anaesthesia

BackgroundExposure to general anaesthesia in children might increase the risk of long-term behavioural problems. It is unclear if any behavioural changes in the short term after anaesthesia could be associated with long-term problems. The goal of the current study was to evaluate the short-term trajectory of parent-reported behaviour measured by the Behaviour Assessment System for Children, third edition (BASC-3) amongst children aged 2.5–6 yr who underwent general anaesthesia for elective surgery. MethodsChildren who were undergoing general anaesthesia for surgery were recruited for assessment of behaviour on two occasions: preoperatively (from 1 week to 1 day before anaesthesia), and 3 months postoperatively. To assess longitudinal changes in the parent-reported behaviour measured by BASC-3, linear mixed models were built with visit number included as a categorical variable and subject-specific random intercepts. ResultsSixty-eight children (37 girls [54%]) were enrolled in the study and completed both assessments. At 3 months after anaesthesia, statistically significant improvements (decrease in T scores) in internalising problems (−2.7 [95% confidence interval −4.2 to −1.1]), anxiety (−2.5 [−4.4 to −0.5]), and somatisation (−3.0 [−5.2 to −0.9]) were found. There were no significant differences in scores between visits for other composites or scales. The pattern of results did not depend upon prior anaesthesia exposure. ConclusionsAnaesthesia for elective surgery in young children was associated with a small decrease in internalising problems but no changes in other areas of behavioural problems when assessed at 3 months postoperatively, including in children with prior exposure to anaesthesia.

Regional pleural strain measurements during mechanical ventilation using ultrasound elastography: A randomized, crossover, proof of concept physiologic study.

BackgroundMechanical ventilation is a common therapy in operating rooms and intensive care units. When ill-adapted, it can lead to ventilator-induced lung injury (VILI), which is associated with poor outcomes. Excessive regional pulmonary strain is thought to be a major mechanism responsible for VILI. Scarce bedside methods exist to measure regional pulmonary strain. We propose a novel way to measure regional pleural strain using ultrasound elastography. The objective of this study was to assess the feasibility and reliability of pleural strain measurement by ultrasound elastography and to determine if elastography parameters would correlate with varying tidal volumes.MethodsA single-blind randomized crossover proof of concept study was conducted July to October 2017 at a tertiary care referral center. Ten patients requiring general anesthesia for elective surgery were recruited. After induction, patients received tidal volumes of 6, 8, 10, and 12 mL.kg–1 in random order, while pleural ultrasound cineloops were acquired at 4 standardized locations. Ultrasound radiofrequency speckle tracking allowed computing various pleural translation, strain and shear components. We screened 6 elastography parameters (lateral translation, lateral absolute translation, lateral strain, lateral absolute strain, lateral absolute shear and Von Mises Strain) to identify those with the best dose-response with tidal volumes using linear mixed effect models. Goodness-of-fit was assessed by the coefficient of determination. Intraobserver, interobserver and test-retest reliability were calculated using intraclass correlation coefficients.ResultsAnalysis was possible in 90.7% of ultrasound cineloops. Lateral absolute shear, lateral absolute strain and Von Mises strain varied significantly with tidal volume and offered the best dose-responses and data modeling fits. Point estimates for intraobserver reliability measures were excellent for all 3 parameters (0.94, 0.94, and 0.93, respectively). Point estimates for interobserver (0.84, 0.83, and 0.77, respectively) and test-retest (0.85, 0.82, and 0.76, respectively) reliability measures were good.ConclusionStrain imaging is feasible and reproducible. Future studies will have to investigate the clinical relevance of this novel imaging modality.Clinical trial registrationwww.Clinicaltrials.gov, identifier NCT03092557.

Comparison of Laryngeal Mask Airway (Classic) and I-Gel; Ease of insertion

Background: At the time of induction during general anaesthesia the different complication can occur with endotracheal tube. Supraglottic devices are alternative of endotracheal tube and it prevents such complications. Aim: To compare the frequency of ease of insertion with lma and i-gel® during general anaesthesia. Method: 270 patients of asa class p1 &amp; p2 undergoing general anaesthesia for elective surgeries were included after taking informed consent. Patients were divided into two groups a (lma classic) &amp; b (i-gel) by using random number table. Each group comprised of 135 patients. In both groups dose of propofol was 2.5mg /kg body weight was given intravenously within 30 sec along with nalbuphine 0.1 mg /kg body weight and midazolam 0.05mg / kg body weight. The study design was quasi experimental and sampling technique was purposive non probability convenience sampling. Chi square test was used and collected data was analysed with spss version 20. Result: The ease of insertion in the lma classic group was 82% while the ease of insertion in i-gel® was 84 %. Statistically there was no significant difference of ease of insertion between two groups (p value = 0.41). Conclusion: Both devices have same level of ease of insertion. Keywords: Lma (laryngeal mask airway classic), i-gel®, general anaesthesia, ease of insertion

Efficacy and safety of intranasal ketamine compared with intranasal dexmedetomidine as a premedication before general anesthesia in pediatric patients: a systematic review and meta-analysis of randomized controlled trials.

To compare the efficacy and safety of intranasal ketamine with intranasal dexmedetomidine as a premedication in pediatric patients undergoing general anesthesia for elective surgery or other procedures. We conducted a systematic literature search in PubMed, PubMed Central, Scopus, LILACS, Google Scholar, the Cochrane Database of Systematic Reviews, and trial registries for randomized controlled trials (RCTs) comparing intranasal ketamine with intranasal dexmedetomidine as preanesthetic medication in elective surgery or other procedures in pediatric patients. We used Review Manager software version 5.4.1 for statistical analysis and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We assessed the methodological quality of the included studies with the RoB 2 risk of bias tool. All outcomes were pooled using the Mantle-Haenszel method and a random-effects model. The quality of evidence was assessed using the GRADE approach. Out of 2,445 full texts assessed, we included ten RCTs in the analysis. The efficacy outcomes did not fulfill the comparability criteria between intranasal ketamine and intranasal dexmedetomidine for sedation at parental separation (risk ratio [RR], 0.90; 95% confidence interval [CI], 0.79 to 1.04; I2 = 89%; GRADE evidence, low), mask acceptance (RR, 0.86; 95% CI, 0.66 to 1.13; I2 = 50%; GRADE evidence, low), and iv canulation (RR, 1.16; 95% CI, 0.79 to 1.69; I2 = 69%; GRADE evidence, very low). Intranasal ketamine-treated patients showed a higher incidence of nausea and vomiting (RR, 2.47; 95% CI, 1.24 to 4.91; I2 = 0; GRADE evidence, moderate). Significantly more bradycardia was observed in the intranasal dexmedetomidine group (RR, 0.16; 95% CI, 0.04 to 0.70; I2 = 40%; GRADE evidence, moderate) than in the ketamine group. The low to very low-quality evidence in this systematic review and meta-analysis of RCTs neither confirmed nor refuted comparable premedication efficacy of intranasal ketamine and dexmedetomidine in terms of parental separation, mask acceptance, and iv cannulation in a pediatric population. Clinical decision-making is likely to be influenced by differences in gastrointestinal and cardiovascular safety profiles. PROSPERO (CRD42021262516); registered 22 July 2021.

Preoperative airway ultrasound assessment in the sniffing position: a prospective observational study

BackgroundClinical airway screening tests intend to predict difficult airways, but none have a high predictive value. Recent systematic reviews correlate ultrasound with difficult laryngoscopy. This study aimed primarily to correlate ultrasound measurements of anatomical upper airway structures in the sniffing position with difficult direct laryngoscopy. The secondary aim was to observe gender-based differences. MethodsThis prospective, cross-sectional, single-center observational study included 209 patients requiring general anesthesia for elective surgery. Preoperatively, we performed six clinical airway assessments and three ultrasound measurements, which were the Distance from Skin to the Hyoid Bone (DSHB), to the Epiglottis (DSE), and to the anterior commissure of the vocal cords (DSAC) in a sniffing position. Benumof's criteria for the “best view at the first attempt” for direct laryngoscopy assessed the difficulty of laryngoscopy. ResultsThe distance from skin to the epiglottis was the best predictor of direct difficult laryngoscopy (defined as Cormack-Lehane grade ≥ 2b) with a minimum thickness cut-off at 2.70 ± 0.19 cm (sensitivity 91.3%; specificity 96.9%). The skin to the hyoid bone distance cut-off was 1.41 ± 0.30 cm with moderate correlation (sensitivity 80.4%; specificity 60.1%). No correlation was found for the distance to the anterior commissure of the vocal cords. In women compared to men, the skin to the epiglottis distance was more sensitive (92.3% vs. 90.9%) and specific (98.8% vs. 95.2%). ConclusionsDSE in the sniffing position is the most reliable parameter for preoperative airway ultrasound assessment in the Caucasian population, with higher sensitivity and specificity in women, and might be considered as an independent predictor for direct difficult laryngoscopy.

Perioperative lung ultrasonography in healthy horses undergoing general anesthesia for elective surgery.

BackgroundLung ultrasound (LUS) is poorly evaluated in horses, especially perioperatively.Objectives(1) Describe LUS findings in healthy horses before and after general anesthesia (GA), (2) evaluate if GA induces ultrasonographic changes in healthy horses, (3) suggest a LUS scoring system, (4) identify horse variables that are associated to LUS changes after anesthesia.AnimalsTwenty‐five healthy adult horses undergoing elective surgery.MethodsProspective hypothesis‐driven observational study. LUS findings were recorded before anesthesia, 5 minutes in recovery, 15 minutes, 2H, 3H, 4H, 6H, and 24H after anesthesia in 8 lung regions. Clinical data were collected perioperatively.ResultsThere was a significant increase in amount of I‐lines (10.8 ± 8.7 vs 15.28 ± 8.19), B‐lines (3.2 ± 3.5 vs 8.72 ± 4.86), and coalescent B‐lines (0.04 ± 0.2 vs 1.12 ± 1.45) after anesthesia compared to before anesthesia, and a significantly higher LUS score 2H after anesthesia (4.92 ± 8.40) compared to before anesthesia (0.9 ± 1.8; P = .02). The maximal LUS score after anesthesia was correlated to total procedure time (Pearson r = 0.4, P = .05; Spearman r = 0.44, P = .03) and was significantly higher in horses with abnormal cardiorespiratory values during anesthesia (P = .005).ConclusionsLUS changes can be induced by GA in healthy horses. This study did not investigate if and which LUS findings indicate lesions, however, this information can aid clinicians to identify pulmonary complications after anesthesia.

Factors associated with patient Satisfaction with Anaesthetic care at A Tertiary Care Hospital

Background: Patient satisfaction with Anaesthesia care is an important variable which reflects health care service provided and is quality indicator for Anaesthesia care. Postoperative anaesthesia visits are important in reducing the dissatisfaction during perioperative period. Method: This was a prospective observational Study, conducted in a tertiary care hospital. 150 patients who underwent general anaesthesia for elective surgeries were interviewed with Standardized questionnaires. Questions were related to pre-operative, intraoperative, postoperative anaesthetic care and anaesthetic related complications. Data was entered in Microsoft excel and analysed using SPSS software version 25 (IBM). Chi square test was used to assess the association between each factor &amp; the overall dissatisfaction of patient. Result: From total of 150 patients, 145(96.7%) were satisfied and 5(3.3%) were dissatisfied with overall anaesthetic care. Factors that associated with patient dissatisfaction were pain during swallowing/sore throat (42.9% p=&lt;0.0001), nausea/vomiting (33.3% p=&lt;0.001) and shivering (15.4% p=0.011). 17.3% of the patients expressed their dissatisfaction during perioperative visits, which was finally reduced to 3.3% by additional anaesthesia visits. Conclusion: overall Patient satisfaction was 96.7% which is high and acceptable. Patients dissatisfaction rate can be improved with post-operative anaesthesia visits.

Diyabetik ve Non-Diyabetik Hastalarda Total İntravenöz Anestezi ve Sevofluran Anestezisinin Rokuronyumun Klinik Etki Süresi Üzerine Olan Etkilerinin Retrospektif Olarak Karşılaştırılması: Retrospektif Gözlemsel Çalışma

Objective: Due to the decrease in nerve conduction velocity, the clinical effect of rocuronium may be prolonged in diabetic patients receiving inhalation anesthesia, and its postoperative residual muscle relaxant effect may lead to complications. We compared the effects of total intravenous anesthesia and sevoflurane anesthesia on the clinical duration of action of rocuronium in diabetic and nondiabetic patients. Material and Methods: Patients between the ages of 18-65, who underwent general anesthesia for elective surgery in the general surgery department of our hospital (0.6 mg of rocuronium was used for tracheal intubation), with Type 2 diabetes and with the American Society of Anesthesiologists Physical Condition Classification (ASA) I-II were included in the study. Non-diabetic patients (ASA I-II) of the same age were included in the study as the control group. The duration of the clinical effect of rocuronium between the time of administration of the first dose of rocuronium and the time of administration of the additional rocuronium dose (time recorded in TOFcount 2-TOFc2) was evaluated. Results: The clinical duration of action of rocuronium was longer in both diabetic groups than in nondiabetic groups (p=0.000). When the diabetic patient groups were compared, the clinical duration of action of rocuronium was longer in the diabetic sevoflurane group than in the diabetic group that received total intravenous anesthesia (p=0.012). Conclusion: It was determined that the duration of rocuronium action was longer in diabetic patients who were administered sevoflurane anesthesia than in patients who received total intravenous anesthesia and in non-diabetic patients.