Induction Of General Anesthesia Research Articles

ROLE OF THE MACHINE LEARNING–DERIVED HYPOTENSION INDEX (HPI) TO CONTAIN INTRAOPERATIVE HYPOTENSION DURING TRANSCATHETER EDGE TO EDGE REPAIR PROCEDURES

Abstract Introduction Percutaneous endovascular valvular interventions can result in profound hemodynamic instability, elevated burden of intraoperative hypotension (IOH) and related postoperative complications: ischemic stroke, acute kidney injury and increased mortality. Machine learning(ML),a branch of Artificial intelligence (AI), can analyze large volumes of data, find associations and allowing predictive rather than reactive interventions. The Hypotension Prediction Index (HPI)a ML derived algorithm,provides a unitless number from 0 to 100, that increases accordingly to the risk of developing a hypotensive event (mean arterial pressure – MAP – < 65 mmHg for more than 1 minute) in the following minutes. The aim of this study is to describe IOH in patients undergoing percutaneous valve repair under general anesthesia treated according to an HPI–based hemodynamic guidance (fig.1). Methods Eligible adult patients undergoing transcatheter valve repair procedures (MitraclipTM, TriclipTM)were included in the study. When HPI value exceeded 85,a proactive individualized treatment protocol to prevent hypotension was provided according to the following modalities (fig. 2). Primary outcome measure was TWA–MAP (time weighted average mean arterial pressure)under the threshold of 65 mmHg. Secondary outcomes were number of patients with at least one hypotensive event, number of events per patient,depth and duration of hypotensive events and area under MAP threshold of 65 mmHg (AUT–MAP < 65). Results Twenty–five consecutive patients were prospectively enrolled and treated. During an average monitoring time per patient of 187 ± 31 minutes, the global burden of hypotension, measured as TWA–MAP < 65 mmHg, was 0.12 [0.02, 0.8] mmHg. Two thirds of the patients(16/25) experienced hypotensive events, with a median number of hypotensive events of 1 [0, 3.25] per patient and about 11% of the time spent < 65 mmHg. Each event lasted 4 [1.7, 8.6] minutes with a MAP of 59 [56, 62] mmHg, leading to a total AUT–MAP < 65 mmHg of 20.3 [3.5, 142.2] mmHg x minutes. The majority of hypotensive events occurred after induction of general anesthesia, while hypotension was rare during the procedure (fig. 3). Conclusions HPI algorithm provides accurate and continuous prediction of impending IOH before its occurrence. Machine learning models,as in the case of HPI, could facilitate the physicians to treat IOH which is a potentially modifiable risk factor for major postoperative complications.

Optimizing patient outcomes: the impact of multimodal preemptive analgesia in video-assisted thoracoscopic lobectomy.

To evaluate the efficacy of a multimodal preemptive analgesia management approach, specifically incorporating ultrasound-guided thoracic paravertebral block (UG-TPVB) in conjunction with intravenous analgesia, after video-assisted thoracoscopic (VATS) lobectomy under the guidance of Enhanced Recovery After Surgery (ERAS). A total of 690 patients who underwent VATS lobectomy between October 2021 and March 2022 were divided into the UG-TPVB group (group T, n = 345) and control group (group C, n = 345). Patients in group T received UG-TPVB prior to the induction of general anaesthesia, while group C did not undergo nerve block. A comparison was conducted between the two groups regarding various indicators, including postoperative sedation, static/dynamic numeric rating scale (NRS) scores, intraoperative fentanyl consumption, duration of mechanical ventilation/anaesthesia recovery/hospitalization, postoperative complications, and other relevant factors. The static/dynamic NRS scores of group T were lower than those of group C after surgery. Intraoperative fentanyl consumption in group T (0.384 ± 0.095 mg) was lower than that in group C (0.465 ± 0.053 mg). The duration of mechanical ventilation, anaesthesia recovery, and hospitalization were significantly shorter in group T compared to group C. Patient satisfaction rate in group T (70.1%) was higher than that in group C (53.6%). All differences were statistically significant (P < 0.05). The multimodal preemptive analgesia management strategy effectively reduces postoperative pain, decreases opioid consumption, and promotes faster recovery in patients undergoing VATS lobectomy.

COMPARISON BETWEEN NEBULISATION OF MGSO4 20 MG/KGBW WITH KETAMINE 0.5 MG/KGBW ON THE INCIDENT OF POST-OPERATIVE SORE THROAT DUE TO ENDOTRACHEAL INTUBATION IN PATIENTS UNDERGOING GENERAL ANESTHESIA IN DR. HASAN SADIKIN HOSPITALS BANDUNG

Post Operative Sore Throat (POST) is a Symptoms often experienced by patients after surgery under general anesthesia and endotracheal intubation. The incidence of POST is between 21-71.8. POST causes discomfort to patients which can prolong hospital stay. In this study, a comparison was made between MgSO4 nebulization 20 mg/ KgBW and ketamine nebulization 0.5 mg/ KgBW on the incidence of POST after general anesthesia at RSUP Dr. Hasan Sadikin Bandung . This study used a double blind randomized controlled trial design. 72 elective surgery patients were randomly divided into 2 groups. Group M was given MgSO4 nebulization while group K was given ketamine nebulization. Nebulization was performed 15 minutes before induction of general anesthesia. POST monitoring was performed at 1, 4 and 24 hours after extubation using POST scoring. In this study, it was found that the incidence of POST in group M, namely the 1st hour of 13.5, the 4th hour of 10.8 and the 24th hour of 0 was lower than that in group K, namely the 1st hour of 28.5, the 4th hour of 32.5 and the 24th hour of 0. Statistical test results p0.033 showed a significant difference in group M better than group K at the 4th hour in reducing the incidence of POST. MgSO4 and ketamine have antinociceptive and anti-inflammatory effects with the mechanism of action of blocking NMDA receptors that inhibit calcium influx that avoids central sensitization. MgSO4 also has a muscle relaxing effect and reduces airway mucus secretion, thus reducing the risk of trauma during endotracheal intubation. The conclusion of this study is that MgSO4 nebulization shows a lower incidence of POST than ketamine nebulization.

Comparison between the Hemodynamic Profile with Esmolol versus Morphine as an Adjuvant Agent during Induction of Anesthesia

Background: The induction of general anesthesia is a critical phase in anesthetic practice, often associated with significant hemodynamic changes. These changes can lead to complications due to autonomic adrenergic responses. Esmolol, a beta-1 antagonist, is commonly used to blunt these responses, but its availability is limited in some settings. Morphine, a pure mu receptor antagonist, presents a potential alternative. Objective: This study aimed to compare the efficacy of intravenous esmolol versus intravenous morphine in stabilizing the hemodynamic profile during the induction of general anesthesia. Methods: This randomized controlled trial was conducted at the Department of Anesthesiology, Combined Military Hospital, from January to June 2023. After obtaining ethical approval and trial registration, 220 ASA-II patients aged 25-55 years scheduled for elective surgeries under general anesthesia were enrolled. Patients were randomized into two groups: Group E (n=110) received 1.5 mg/kg intravenous esmolol three minutes before laryngoscopy and intubation, and Group M (n=110) received 0.1 mg/kg intravenous morphine five minutes before laryngoscopy and intubation. Baseline heart rate, systolic and diastolic blood pressure, and oxygen saturation were recorded after pre-oxygenation with 100% oxygen for three minutes. Post-intubation, the same parameters were measured five minutes after intubation. Statistical analysis was performed using SPSS version 25.0, with independent samples T-tests used to compare means. A p-value of ≤0.05 was considered statistically significant. Results: The mean age was 39.41 ± 5.13 years in Group E and 39.97 ± 5.08 years in Group M (p=0.414). Mean weight was 68.14 ± 3.88 kg in Group E and 68.08 ± 3.80 kg in Group M (p=0.916). Pre-induction mean heart rate was 71.75 ± 2.33 bpm in Group E and 71.58 ± 2.35 bpm in Group M (p=0.585). Five minutes post-intubation, mean heart rate was significantly lower in Group E (80.73 ± 2.54 bpm) compared to Group M (87.62 ± 2.83 bpm) (p&lt;0.001). Mean systolic blood pressure post-intubation was 132.88 ± 4.65 mm Hg in Group E and 140.25 ± 2.39 mm Hg in Group M (p&lt;0.001). Mean diastolic blood pressure post-intubation was 77.58 ± 2.35 mm Hg in Group E and 85.33 ± 3.71 mm Hg in Group M (p&lt;0.001). Oxygen saturation remained stable in both groups. Conclusion: Intravenous esmolol is superior to intravenous morphine in blunting the hemodynamic responses to laryngoscopy and intubation, providing a more stable hemodynamic profile during the induction of general anesthesia.

Effect of lidocaine on intraoperative blood pressure variability in patients undergoing major vascular surgery

BackgroundDynamic fluctuations of arterial blood pressure known as blood pressure variability (BPV) may have short and long-term undesirable consequences. During surgical procedures blood pressure is usually measured in equal intervals allowing to assess its intraoperative variability, which significance for peri and post-operative period is still under debate. Lidocaine has positive cardiovascular effects, which may go beyond its antiarrhythmic activity. The aim of the study was to verify whether the use of intravenous lidocaine may affect intraoperative BPV in patients undergoing major vascular procedures.MethodsWe performed a post-hoc analysis of the data collected during the previous randomized clinical trial by Gajniak et al. In the original study patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive intravenous infusion of 1% lidocaine or placebo at the same infusion rate based on ideal body weight, in concomitance with general anesthesia. We analyzed systolic (SBP), diastolic (DBP) and mean arterial blood (MAP) pressure recorded in 5-minute intervals (from the first measurement before induction of general anaesthesia until the last after emergence from anaesthesia). Blood pressure variability was then calculated for SBP and MAP, and expressed as: standard deviation (SD), coefficient of variation (CV), average real variability (ARV) and coefficient of hemodynamic stability (C10%), and compared between both groups.ResultsAll calculated indexes were comparable between groups. In the lidocaine and placebo groups systolic blood pressure SD, CV, AVR and C10% were 20.17 vs. 19.28, 16.40 vs. 15.64, 14.74 vs. 14.08 and 0.45 vs. 0.45 respectively. No differences were observed regarding type of surgery, operating and anaesthetic time, administration of vasoactive agents and intravenous fluids, including blood products.ConclusionIn high-risk vascular surgery performed under general anesthesia, lidocaine infusion had no effect on arterial blood pressure variability.Trial registrationClinicalTrials.gov; NCT04691726 post-hoc analysis; date of registration 31/12/2020.

Relationship between age and remimazolam dose required for inducing loss of consciousness in older surgical patients.

Remimazolam is a new ultra-short-acting benzodiazepine for procedural sedation and general anaesthesia, characterised by rapid onset of action, quick recovery, and organ-independent metabolism. Older patients tend to sustain more treatment-emergent adverse events (TEAEs) and worse perioperative prognoses after receiving remimazolam. However, few studies have investigated the appropriate dose of remimazolam for loss of consciousness (LOC) in geriatric patients. We designed this study to provide evidence for dose references and elucidate the relationship between age and remimazolam requirement for inducing LOC during anaesthesia induction. Exactly 120 patients scheduled for general surgery under general anaesthesia were included and divided into two groups: Group A (60 patients, 18-64 years) and Group B (60 patients, ≥ 65 years). LOC, defined as a Modified Observer's Assessment of Alertness and Sedation score at 1 had been reached, emerged after all participants received a continuous infusion of remimazolam at a rate of 0.05 mg/kg/min. The remimazolam required for inducing LOC was 0.26 and 0.19 mg/kg in groups A and B, respectively, and the remimazolam dose in group B decreased by 26.9% compared to group A. According to the bivariate linear correlation analysis, remimazolam requirement was negatively correlated with age. Multivariable linear regression models and further adjustments for potential impact factors indicated that age was an independent factor for the remimazolam dose required for LOC. This study demonstrated that age was significantly and independently correlated with the remimazolam requirement for inducing LOC. To obtain haemodynamic stability during the induction of general anaesthesia, appropriately reducing the remimazolam dose is recommended for geriatric patients.

The effect on perioperative anxiety and emergence delirium of the child or parent's preference for parental accompaniment during anesthesia induction in children undergoing adenotonsillectomy surgery.

Pediatric emergence delirium (ED) occurs in the early postoperative period and is defined as a complex psychiatric disorder. Non-pharmacological methods of treatment, such as perioperative parental presence, have been the focus of many studies, but the impact on preventing ED of which parent accompanies the child during anesthesia induction has not been identified as yet. Therefore, the aim of this study was to determine whether the selection made by children undergoing adenotonsillectomy of which parent will accompany them during anesthesia induction has the effect of reducing postoperative delirium scores and incidence compared to selections made by the parents. The study included 80 children of both genders, aged 5-12 years, who underwent day-case surgery in the otorhinolaryngology clinic. The patients were separated randomly into two groups of 40. In Group 1, the children were asked to choose which of their parents would accompany them during general anesthesia induction, and in Group 2, the parents were asked to decide who would be the accompanying parent. Evaluation of postoperative delirium was made using the Pediatric Anesthesia Emergence Delirium (PAED) scale. The anxiety level of the children was evaluated with the modified Yale Preoperative Anxiety Scale (mYPAS) both in the preoperative waiting area and during the anesthesia induction. The State-Trait Anxiety Inventory (STAI) was used to evaluate the anxiety level of the parents. The mean PAED scores were similar in both groups (mean difference [95% CI]: -0.1 [-2.8 to 0.7]). The incidence of emergence delirium was also similar in both groups (risk ratio 0.9 [0.4 to 1.8]). The mean mYPAS scores during the induction of anesthesia of Group 1 was lower than that of Group 2 (mean difference [95% CI]: -8.4 [-15.2 to -1.6]). The mean mYPAS scores evaluated in the preoperative waiting area were found to be similar in the two groups (mean difference [95% CI]: -1.9 [-7.5 to 3.5]). The mean STAI anxiety scores of the parents were similar in both groups, with higher scores obtained by mothers compared to fathers, at all measurement times. The incidence or severity of ED did not decrease significantly even though lower anxiety scores were obtained during anesthesia induction in children who were allowed to make the decision of accompanying parent. Based on these findings, it can be concluded that postoperative delirium is a more complicated process that can be affected by many other variables rather than just the parent-child general interaction.

50% efficacy dose of intravenous lidocaine in supressing sufentanil-induced cough in children: a randomised controlled trial

BackgroundOpioids such as sufentanil are used as anaesthetics due to their rapid action and superior analgesic effect. However, sufentanil induces a huge cough in paediatric patients. In contrast, intravenous (IV) lidocaine suppresses opioid-induced cough in children, but its use is limited due to anaesthetists’ concern about its toxicity. Therefore, this study aimed to evaluate the effect of dose-dependent IV lidocaine on sufentanil-induced cough (SIC) in paediatric patients.MethodsA total of 188 patients aged 3–12 years scheduled for elective tonsillectomy with or without adenoidectomy were enrolled and divided into four groups depending on different dose of lidocaine: A (0 mg.kg-1), B (1 mg.kg-1), C (1.5 mg.kg-1), and D (2 mg.kg-1). The primary outcome was the SIC grade observed during the induction of general anaesthesia. The secondary outcomes were the incidence of SIC, mean arterial pressure, and heart rate at T0, T1, T2, T3, T4, and T5.ResultsThe SIC grade was significantly different between groups A and D (P = 0.04) and between groups B and D (P = 0.03). Moreover, the incidence of SIC in groups A, B, C, and D was 81%, 87%, 68%, and 64%, respectively, and the difference between groups B and C (P = 0.03) and between groups B and D (P = 0.0083) was statistically significant. No statistical differences were observed in the hemodynamic parameters between the groups. The incidence of severe cough was statistically different between group D and group A (P < 0.0001), between group D and group B (P < 0.0001), and between group D and group C (P < 0.0001) respectively.ConclusionsLidocaine suppresses SIC in a dose-dependent manner without severe adverse events. IV lidocaine can be used in paediatric patients safely and efficiently, and the median effective dose was 1.75 mg/kg.Trial registrationThis study was approved by the Institutional Review Board of Yichang Central People’s Hospital (HEC-KYJJ-2020-038-02), The trial was registered at www.chictr.org.cn (ChiCTR2100053006).

Comparison of arterial hypotension incidence during general anesthesia induction – target-controlled infusion vs. bolus injection of propofol: a randomized clinical trial

BackgroundThe incidence of arterial hypotension during induction of general anesthesia is influenced by the method of propofol administration, but there is a dearth of randomized clinical trials comparing bolus injection and target-controlled infusion in relation to arterial hypotension. This study seeks to compare the incidence of arterial hypotension between these two methods of propofol administration. MethodsThis prospective, randomized, single-center, non-blinded study included 60 patients (aged 35 to 55 years), classified as ASA physical status I or II, who were undergoing non-cardiac surgeries. They were randomly allocated using a computer to two groups based on the method of propofol administration during the induction of general anesthesia: the Target Group, receiving target-controlled infusion at 4 μg.mL−1, and the Bolus Group, receiving a bolus infusion of 2 mg.kg−1. Both groups also received midazolam 2 mg, fentanyl 3 μg.kg−1, and rocuronium 0.6 mg.kg−1. Over the first 10 minutes of anesthesia induction, Mean Arterial Pressure (MAP), Heart Rate (HR), level of Consciousness (qCON), and Suppression Rate (SR) were recorded every 2 minutes. ResultsTwenty-seven patients remained in the TCI group, while 28 were in the Bolus group. Repeated measure analysis using mixed-effects models could not reject the null hypothesis for the effect of group-time interactions in MAP (p = 0.85), HR (p = 0.49), SR (p = 0.44), or qCON (p = 0.72). The difference in means for qCON (60.2 for TCI, 50.5 for bolus, p < 0.001), MAP (90.3 for TCI, 86.2 for bolus, p < 0.006), HR (76.2 for TCI, 76.9 for bolus, p = 0.93), and SR (0.01 for TCI, 5.5 for bolus, p < 0.001), irrespective of time (whole period means), revealed some significant differences. ConclusionPatients who received propofol bolus injection exhibited a lower mean arterial pressure, a greater variation in the level of consciousness, and a higher suppression rate compared to those who received it as a target-controlled infusion. However, the interaction effect between groups and time remains inconclusive.

Effect of different positive end expiratory pressure levels on optic nerve sheath diameter in patients with or without midline shift who are undergoing supratentorial craniotomy

PurposeIn general, high levels of PEEP application is avoided in patients undergoing craniotomy to prevent a rise in ICP. But that approach would increase the risk of secondary brain injury especially in hypoxemic patients. Because the optic nerve sheath is distensible, a rise in ICP is associated with an increase in the optic nerve sheath diameter (ONSD). The cutoff value for elevated ICP assessed by ONSD is between 5.6 and 6.3 mm. We aimed to evaluate the effect of different PEEP levels on ONSD and compare the effect of different PEEP levels in patients with and without intracranial midline shift.MethodsThis prospective observational study was performed in aged 18–70 years, ASA I–III, 80 patients who were undergoing supratentorial craniotomy. After the induction of general anesthesia, the ONSD’s were measured by the linear transducer from 3 mm below the globe at PEEP values of 0–5–10 cmH2O. The ONSD were compered between patients with (n = 7) and without midline shift (n = 73) at different PEEP values.ResultsThe increases in ONSD due to increase in PEEP level were determined (p < 0.001). No difference was found in the comparison of ONSD between patients with and without midline shift in different PEEP values (p = 0.329, 0.535, 0.410 respectively). But application of 10 cmH2O PEEP in patients with a midline shift increased the mean ONSD value to 5.73 mm. This value is roughly 0.1 mm higher than the lower limit of the ONSD cutoff value.ConclusionsThe ONSD in adults undergoing supratentorial tumor craniotomy, PEEP values up to 5 cmH2O, appears not to be associated with an ICP increase; however, the ONSD exceeded the cutoff for increased ICP when a PEEP of 10 cmH2O was applied in patients with midline shift.

To Compare the Efficacy of Sub-Pecto-Interfascial Block with Erector Spinae Plane Block in Postoperative Pain Management in Patients Undergoing Cardiac Surgery

Objectives: Pain following sternotomy has always been an issue of major concern for anesthesiologists. The incidence of pain is as high as 49% at rest following coronary artery bypass grafting. We planned to utilize the sub-pecto-interfascial plane (SIP) block and erector spinae plane (ESP) block to determine its efficacy and quality of analgesia as compared to conventional intravenous analgesia. Material and Methods: After the Institutional Ethics Committee’s approval, we recruited 105 patients and randomized them into three groups. Group 1 received conventional analgesia, group 2 SIP, and group 3 ESP block. Group 2 and Group 3 received allocated blocks after induction of balanced general anesthesia under ultrasound guidance. With high-frequency linear probe (13 MHz) planes identified, a mixture of injection ropivacaine (0.375%) and dexmedetomidine (1.1 mcg/mL) was deposited. In group 2, six injections of 6 mL each at the 2nd, 4th, and 6th intercostal spaces in the bilateral parasternal region. In group 3, two injections of 20 mL of the above-mentioned mixture on each side above the transverse process of the T5 vertebra under the erector spinae muscle plane were injected. All patients were monitored throughout the procedures, and their vitals were recorded. Heart rate, systolic blood pressure, and diastolic blood pressure were noted at baseline, at skin incision, at sternotomy, and 30 min post-extubation. Patients were followed for total fentanyl consumption, pain score (numerical rating scale [NRS] score), and peak inspiratory flow rate, which were noted at extubation and 2, 4, 6, 8, 12, and 24 hours post-extubation. Levels of C-reactive protein (CRP), cortisol, and prolactin were done at baseline and 24 h after surgery. Extubation time, time of first oral intake, and total length of intensive care unit (ICU) stay were also compared between the groups. Results: Total fentanyl consumption was significantly lower (P &lt; 0.005) in group 2 and group 3 compared to group 1. Patient receiving blocks were significantly lower NRS score compared to the control group. Spirometry has shown improved results in block groups catering to early discharge from ICU. Rise in levels of CRP, cortisol, and prolactin were much higher in group 1 as compared to group 2 and group 3. Conclusion: The application of ESP and SIP blocks is far superior than conventional parenteral analgesics in terms of pain score, total opioid’s consumption, hemodynamic maintenance, spirometry efforts, and length of ICU stays.

Effect of ultrasound-guided quadratus lumborum block on neuroendocrine stress response and postoperative analgesia in paediatric patients undergoing elective open pyeloplasty - A randomised clinical trial.

Quadratus lumborum block (QLB) is a compartmental block of the anterior abdominal wall. Surgical trauma produces neuroendocrine surgical stress responses, which are modified by anaesthetic blocks. The aim of this study was to evaluate the effect of ultrasound (US)-guided QLB on analgesia and surgical neuroendocrine stress response in paediatric patients undergoing pyeloplasty. A randomised trial was conducted in 60 children aged 1-7 years undergoing elective open pyeloplasty. Patients were randomised into Group QLB [US-guided QLB with 0.5 ml/kg of 0.25% ropivacaine after induction of general anaesthesia (GA)], and Group GA, which received only GA. Perioperative haemodynamic parameters, serum cortisol, blood glucose, analgesic consumption and postoperative FLACC scores were recorded. Unpaired t-test, Wilcoxon rank-sum test or Mann-Whitney U test was used to compare variables between the two groups. Two-way analysis of variance or the Friedmann test was used to compare quantitative variables at various points within a group. A decrease in serum cortisol and blood glucose values was observed in Group QLB at 30 min after surgical incision and 24 h after surgery compared to the preoperative value and compared to Group GA (P < 0.05). The quality of analgesia assessed by the FLACC scale was significantly better in group QLB. Dose of fentanyl consumption (µg/kg) was higher in Group GA compared to Group QLB in the intraoperative and postoperative period (P < 0.05). QLB is effective as part of multimodal analgesia and attenuates the neuroendocrine stress in paediatric patients undergoing open pyeloplasty.

Super-refractory status epilepticus, rhabdomyolysis, central hyperthermia and cardiomyopathy attributable to spinal anesthesia: a case report and review of literature

BackgroundThere are only six past reports of super-refractory status epilepticus induced by spinal anesthesia. None of those patients have died. Only < 15 mg of bupivacaine was administered to all six of them and to our case. Pathophysiology ensuing such cases remains unclear.Case presentationA 27 year old gravida 2, para 1, mother at 37 weeks of gestation came to the operating theater for an elective cesarean section. She had no significant medical history other than controlled hypothyroidism and one episode of food allergy. Her current pregnancy was uneventful. Her American Society of Anesthesiologists (ASA) grade was 2. She underwent spinal anesthesia and adequate anesthesia was achieved. After 5–7 min she developed a progressive myoclonus. After delivery of a healthy baby, she developed generalized tonic clonic seizures that continued despite the induction of general anesthesia. She had rhabdomyolysis, one brief cardiac arrest and resuscitation, followed by stress cardiomyopathy and central hyperthermia. She died on day four. There were no significant macroscopic or histopathological changes in her brain that explain her super refractory status epilepticus. Heavy bupivacaine samples of the same batch used for this patient were analyzed by two specialized laboratories. National Medicines Quality Assurance Laboratory of Sri Lanka reported that samples failed to confirm United States Pharmacopeia (USP) dextrose specifications and passed other tests. Subsequently, Therapeutic Goods Administration of Australia reported that the drug passed all standard USP quality tests applied to it. Nonetheless, they have detected an unidentified impurity in the medicine.ConclusionsAfter reviewing relevant literature, we believe that direct neurotoxicity by bupivacaine is the most probable cause of super-refractory status epilepticus. Super-refractory status epilepticus would have led to her other complications and death. We discuss probable patient factors that would have made her susceptible to neurotoxicity. The impurity in the drug detected by one laboratory also would have contributed to her status epilepticus. We propose several possible mechanisms that would have led to status epilepticus and her death. We discuss the factors that shall guide investigators on future such cases. We suggest ways to minimize similar future incidents. This is an idiosyncratic reaction as well.Graphical

Relationship between preinduction electroencephalogram patterns and propofol sensitivity in adult patients.

To determine the precise induction dose, an objective assessment of individual propofol sensitivity is necessary. This study aimed to investigate whether preinduction electroencephalogram (EEG) data are useful in determining the optimal propofol dose for the induction of general anesthesia in healthy adult patients. Seventy healthy adult patients underwent total intravenous anesthesia (TIVA), and the effect-site target concentration of propofol was observed to measure each individual's propofol requirements for loss of responsiveness. We analyzed preinduction EEG data to assess its relationship with propofol requirements and conducted multiple regression analyses considering various patient-related factors. Patients with higher relative delta power (ρ = 0.47, p < 0.01) and higher absolute delta power (ρ = 0.34, p = 0.01) required a greater amount of propofol for anesthesia induction. In contrast, patients with higher relative beta power (ρ = -0.33, p < 0.01) required less propofol to achieve unresponsiveness. Multiple regression analysis revealed an independent association between relative delta power and propofol requirements. Preinduction EEG, particularly relative delta power, is associated with propofol requirements during the induction of general anesthesia. The utilization of preinduction EEG data may improve the precision of induction dose selection for individuals.

Median Effective Dose of Ciprofol Combined With Sufentanil for Inhibiting the Upper Gastrointestinal Endoscopic Placement Reaction in Elderly Patients.

Ciprofol is a new sedative anesthetic drug that can be used for gastrointestinal endoscopy and induction of general anesthesia, but the appropriate dosage for use in elderly patients has not been determined. Sufentanil is a commonly used opioid in clinical practice, and this study was designed to induce anesthesia in elderly patients using sufentanil in combination with ciprofol. However, the optimal dosage of ciprofol when it is co-administered with sufentanil has not yet been established. This study was designed to find the median effective dose (ED50) and 95% confidence interval (95% CI) of ciprofol for intravenous anesthesia when combined with sufentanil. We studied 57 patients who were scheduled to undergo a diagnostic upper gastrointestinal endoscopy. According to age, it was divided into two groups: 65∼74 years old (group A) and over 75 years old (group B). Using the modified Dixon sequence test method, intravenous bolus of 0.1μg/kg sufentanil was given 3 min before ciprofol is administered, the initial dose of ciprofol was 0.4mg/kg, the upper gastrointestinal endoscopy was placed after reaching the depth of sedation, and vital signs and adverse events were recorded at each perioperative time point (T0-T7). In the group A, when combined with 0.1 μg/kg sufentanil, the ED50 of ciprofol to inhibiting responses to insertion of upper gastrointestinal endoscopy was 0.23mg/kg, and the 95% CI was 0.09∼0.30mg/kg; in the group B, the ED50 was 0.18mg/kg, and the 95% CI was 0.13∼0.22mg/kg. The ED50 of ciprofol in combination with sufentanil (0.1μg/kg) for upper gastrointestinal endoscopy in elderly patients: 0.23mg/kg in group A and 0.18mg/kg in group B.

Motives and fluent interaction in clinical documentation: An experience-based design for a documentation tool in anesthesiology

Documentation in anesthesiology is important but documentation quality is poor and frequently delayed. Using documentation in anesthesiology, we suggest an experience-based design approach that considers users’ motives and work practices in the design of technology to provide users with the experience of achieving valued motives (activity theory) and a fluent interaction with the environment (embodiment). We conducted an ethnographic study to identify documentation work practices, the anesthesiologists’ motives for documenting, and assess documentation quality. Based on the data and with the theoretical premises of activity theory and embodiment in mind, we designed the functions and interaction of a speech-based documentation tool. Using the Wizard of Oz method in a simulated induction of general anesthesia, we showed that the tool enabled fluent interaction, addressed a motive that anesthesiologists valued, and increased the documentation quality. We demonstrated that an experience-based design can enhance documentation quality and has the potential to contribute to safety and efficiency in safety-critical domains and provide grounds for future decision support systems.

Effect of pretreatment with a small dose of esketamine on sufentanil-induced cough during anesthesia induction: a randomized controlled trial

BackgroundSufentanil-induced cough is common during the induction of anesthesia. The objective of this study was to determine whether pretreatment with a small dose of esketamine is effective in treating sufentanil-induced cough.Methods220 patients were screened, and 200 patients who had scheduled elective surgery and were between 18 and 70 years old were randomly divided into two groups. Before sufentanil was administered, esketamine group (group K) was injected with 0.15 mg/kg esketamine at 5 s, and control group (group C) was administered with the same volume. Within 1 min after sufentanil(0.4ug/kg) injection during induction, cough incidence and severity were evaluated. After sufentanil was injected, we recorded its hemodynamic changes and side effects.ResultsIn the esketamine group (group K) and control group (group C), there was an incidence of cough of 5 and 34%, respectively. The esketamine group (group K) had a significantly lower incidence and severity of cough compared to the control group (group C) immediately after sufentanil injection (P < 0.05). MAP and HR did not differ significantly between the two groups during three different times of general anesthesia induction (P > 0.05).ConclusionIn our study, we found that sufentanil-induced cough was significantly reduced by pretreatment with 0.15 mg/kg esketamine, but with no significant changes in the hemodynamic status.Trial registrationChinese Clinical Trial Registry (ChiCTR2200063821, registered date: 17/09/2022), http://www.chictr.org.cn

Enhanced recovery after surgery (ERAS) in prolapse repair: A prospective study on pre-emptive uterosacral/cervical block.

Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre-emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery. This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively. We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180). For the first time, we demonstrated the impact of pre-emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics.

Managing a difficult airway due to supraglottic masses: successful videolaryngoscopic intubation after induction of general anesthesia.

While awake, flexible bronchoscopic intubation has long been considered the gold standard for managing anticipated difficult airways, the videolaryngoscope has emerged as a viable alternative. In addition, the decision to perform awake intubation or to proceed with airway management after induction of general anesthesia should be grounded in a comprehensive assessment of risks and benefits. A 41-year old female patient was scheduled for excision of bilateral, mobile, and pedunculated masses on both aryepiglottic folds, which covered almost the entire upper part of the glottis. We conducted a comprehensive evaluation of the patient's signs and symptoms, which included neither stridor nor dyspnea in any position, along with the otolaryngologist's opinion and the findings from the laryngeal fiberscopic examination. Given the potential challenges and risks associated with awake flexible bronchoscopic intubation for this patient, we decided to proceed with gentle tracheal intubation using a videolaryngoscope under general anesthesia. In case of failed mask ventilation and tracheal intubation, we had preplanned strategies, including awakening the patient or performing an emergent tracheostomy, along with preparations to support these strategies. Ensuring that mask ventilation was maintained with ease, the patient was sequentially administered intravenous propofol, remifentanil, and rocuronium. Under sufficient depth of anesthesia, intubation using a videolaryngoscope was successfully performed without any complications. Videolaryngoscopic intubation after induction of general anesthesia can be a feasible alternative for managing difficult airways in patients with supraglottic masses. This approachshould be based on a comprehensive preoperative evaluation, adequate preparation, and preplanned strategies to address potential challenges, such as inadequate oxygenation and unsuccessful tracheal intubation.

Effect of Zusanli Acupoint Injection with Anisodamine on Postoperative Recovery Quality of Patients Undergoing Bariatric Surgery

PurposeTo evaluate the influence of anisodamine injection at the Zusanli (ST36) on early postoperative recovery quality in patients who have undergone laparoscopic sleeve gastrectomy.Materials and Methods141 patients undergoing laparoscopic sleeve gastrectomy were randomly divided into the control group (group C), the normal saline group (group S) and the anisodamine group (group A). Acupuncture point injections were administered after induction of general anesthesia. The quality of recovery-40 questionnaire (QoR-40) scores were documented preoperatively (D0) and on the 1st (D1), 3rd (D3) and 7th (D7) days postoperatively. Additional metrics included: the numerical rating scale (NRS) for pain, postoperative nausea and vomiting (PONV), assessment and analgesic consumption 24-h post-extubation and the initial postoperative times for ambulation and anal exhaust. Substance P (SP), β-endorphin (β-EP), motilin (MTL) and gastrin (GAS) were quantified at 24-h post-surgery.ResultsCompared with group C, group A demonstrated an elevation in QoR-40 scores and physical comfort dimensions during D1-3, and an increased pain scores during D1-7; group S exhibited an augmentation in QoR-40 scores and pain scores on D1 (p < 0.05). Compared with group S, group A improved QoR-40 scores on D1 and pain scores during D1-3 (p < 0.05). SP, β-EP, MTL and GAS presented significant variances among the groups 24-h post-surgery (p < 0.05). There were significant differences between the groups in NRS pain scores and PONV scores at 24-h postoperatively, dosage of dizocin on the first postoperative day, and time to first anal defecation (p < 0.05).ConclusionThe administration of anisodamine via ST36 acupoint injections has been demonstrated to facilitate the recuperation of gastrointestinal functionality, to alleviate postoperative pain and nausea, and substantially to enhance the quality of early postoperative recovery.Graphical