Hip arthroplasty is a frequently performed surgery that requires effective multimodal analgesia for optimal recovery and adherence to enhanced recovery after surgery protocols. Traditionally, spinal anesthesia with opioids has been the mainstay for postoperative pain management, but side effects have prompted increased use of peripheral nerve blocks. The fascia iliaca block (FIB) is a well-established technique recommended by PROSPECT guidelines, while the erector spinae plane block (ESPB) has recently emerged as a potential alternative. This systematic review and meta-analysis aimed to compare the efficacy of FIB and ESPB in patients undergoing hip arthroplasty. A comprehensive search of PubMed, Cochrane, and Embase identified six randomized controlled trials (RCTs) including 348 patients, evenly distributed between ESPB and FIB groups. Primary outcomes included incidence of motor block, cumulative opioid consumption, time to first rescue analgesia, and postoperative pain scores. The analysis revealed that ESPB significantly reduced the incidence of quadriceps motor block compared to FIB, with a relative risk (RR) of 0.25 (95% CI, 0.13-0.49; P<0.001). Motor block occurred in 8.7% of ESPB patients versus 38.4% of FIB patients. However, there were no statistically significant differences between groups in 24-hour cumulative opioid consumption, time to first rescue analgesia, or pain scores at rest or during movement. ESPB offers a clear advantage over FIB in preserving motor function without compromising analgesic efficacy. These findings support ESPB as a viable alternative to FIB in hip arthroplasty pain management protocols.

Predictive value of muscle tone loss and perfusion index in the success of supraclavicular brachial plexus block: a pilot study.

Mas-related G protein-coupled receptor X2 (MRGPRX2) has emerged as a mediator of mast-cell activation in acute and chronic conditions. Exogenous ligands, such as neuromuscular blocking agents (NMBAs) and fluoroquinolones (FQs), can trigger MRGPRX2-dependent activation and may augment immunoglobulin E (IgE)-mediated pathways. Although investigators have measured serum MRGPRX2 in asthma, mastocytosis, and chronic urticaria, its role in immediate hypersensitivity reactions (IHRs) to FQs or NMBAs remains unclear. We conducted this study to determine whether increased serum MRGPRX2 concentration is a risk factor for IHRs to NMBAs or FQs and whether concentration relate to reaction severity, causative agent, or serum tryptase. We studied 43 patients with a history of IHRs to NMBAs or FQs and compared them with 50 patients with IHRs to Hymenoptera venom and 40 control individuals. Participants underwent a diagnostic evaluation that included skin testing, specific IgE measurement, and basophil activation test when indicated. We measured serum MRGPRX2 by enzyme-linked immunosorbent assay. The median serum MRGPRX2 values with interquartile ranges for the drug-induced reactions group, the Hymenoptera venom-induced reactions group, and the control group were 7.50 (3.73-15.64), 7.00 (3.96-10.62), and 5.89 (2.43-9.98) ng/mL, respectively (P = 0.32). Serum MRGPRX2 concentration showed no relationship with reaction severity, specific causative agents, or serum tryptase. In this cohort, serum MRGPRX2 was not a risk factor for the investigated drug- and venom-induced IHRs. These findings do not support using serum MRGPRX2 as a predictor of reaction occurrence or severity in these settings.

Background: Interscalene brachial plexus block (ISB) remains the gold standard anesthesia method in shoulder surgery. However, risk of diaphragm paralysis is a major concern among anesthesiologists. Recent studies on anterior suprascapular nerve block (ASB) and costoclavicular brachial plexus block (CCB) have given promising results for preventing diaphragm paralysis and providing sufficient analgesia. Methods: Forty-six patients who underwent arthroscopic shoulder surgery under one of three regional anesthesia techniques, including ISB (n = 15), ASB (n = 15), and CCB (n = 16), were included in the study. Diaphragmatic excursion was measured by ultrasonography 30 min after the block. Postoperative pain was assessed with a numerical rating scale. The groups were compared in terms of diaphragm paralysis and postoperative pain status. Results: The groups were similar in basic patient and surgical characteristics as well as motor and sensory block scores. There was no difference in analgesic use between the groups. Diaphragm measurements in the ISB group were found to be significantly lower compared to the ASB and CCB groups (p &lt; 0.001). In addition, diaphragm measurements in the ASB group were found to be lower than in the CCB group (p = 0.036). When comparing diaphragm measurements between the initial and 30th min of block, significant decreases were observed in the ISB and ASB groups (p &lt; 0.001), whereas no difference was found in the CCB group. Conclusions: Postoperative pain scores and analgesic use were similar between the three blocks. In terms of diaphragm paralysis, the best blocks appeared to be CCB followed by ASB. CCB and ASB can be considered as safe and effective alternative blocks in arthroscopic shoulder surgery, particularly for patients without serious obstructive or restrictive pulmonary disease.

Objective: To compare mean duration of analgesia when 1mg Nalbuphine is added to 15mg of Bupivacaine 0.75% versus 15mg of Bupivacaine 0.75% alone in spinal anesthesia for infraumbilical surgeries. Study Design: Randomized Controlled Trial. Setting: Department of Anesthesia, Allied Hospital, Faisalabad. Periods: April 2024 to October 2024. Methods: Total 60 subjects undergoing elective infraumbilical surgery under spinal anesthesia were assigned to two groups; Group A received inj. 0.75% Bupivacaine 15mg along with inj. Nalbuphine 1mg (0.1ml) in subarachnoid space via 25 gauge Quinke type spinal needle and Group B received 0.75% bupivacaine 15mg alone in subarachnoid space using 25guage spinal needle. Analgesia duration (hours) was calculated from sensory block onset to first request of analgesia using VAS score. Analysis of data was done using SPSS.23, for statistical significance p-value ≤0.05 was taken. Results: Sensory and motor block onset in Group A vs B noted was 3.25 ± 0.41 minutes &amp; 6.36 ± 0.66 minutes vs 4.31 ± 0.39 minutes &amp; 7.90 ± 0.63 minutes (p&lt;0.001). Duration of postoperative analgesia was longer in Group A 5.77 ± 0.57 hours vs 5.03 ± 0.29 hours in Group B (p &lt; 0.001). Conclusion: These findings suggest that intrathecal Nalbuphine added to Bupivacaine can considerably prolonged the duration of analgesia versus when Bupivacaine used alone in spinal anesthesia for infraumbilical surgeries irrespective of age, gender, or comorbidity status.

Amyotrophic lateral sclerosis (ALS) confers heightened and unpredictable sensitivity to nondepolarizing neuromuscular blocking agents and a high risk of postoperative respiratory failure. Although sugammadex reliably reverses rocuronium, recurarization may occur and is likely under-recognized in ALS. We report 2 ALS patients undergoing percutaneous endoscopic gastrostomy, one of whom developed delayed recurarization after apparent reversal. Both women (67 and 68 years) presented with progressive dysphagia requiring percutaneous endoscopic gastrostomy. Case 1 had dyspnea, dysarthria, and long-standing noninvasive positive-pressure ventilation; Case 2 had bulbar signs without preoperative ventilatory support. The key perioperative concern in both cases was ventilatory failure from residual neuromuscular block. ALS had been established clinically. In Case 2, recurarization was diagnosed shortly after extubation when acute hypercapnic respiratory failure and clinical weakness followed an earlier recovery to a train-of-four (TOF) ratio of 92%. Intravenous anesthesia with propofol and remifentanil was used. Case 1 received rocuronium 10 mg (0.2 mg/kg) and was reversed with sugammadex 90 mg (2 mg/kg) at TOF count 0, achieving a TOF ratio of 98% within 3 minutes before extubation and postoperative noninvasive ventilation. Case 2 received rocuronium 30 mg (0.6 mg/kg) and sugammadex 200 mg (3.8 mg/kg) at TOF count 1, recovered to a TOF ratio of 92% at 4 minutes, but developed respiratory failure 3 minutes after extubation; mask ventilation and neostigmine 2 mg with atropine 0.25 mg were given. Case 1 recovered uneventfully and was discharged on postoperative day (POD) 6. Case 2 required intensive care unit admission, re-intubation on POD 1, and re-extubation on POD 3; she was discharged on POD 23 without new neurologic deficits. In ALS, recurarization can occur despite seemingly adequate sugammadex reversal. When rocuronium is used, sugammadex is recommended for reversal, with vigilant quantitative neuromuscular monitoring and extended post-extubation observation to detect delayed weakness.

Clinical decision making during supervised endotracheal intubations in academic emergency medicine.

Suxamethonium, a rapid-acting muscle relaxant, has been conventionally preferred during rapid sequence induction (RSI). The priming principle, which uses non-depolarising muscle relaxants, is an alternative in situations where it is contraindicated. Unfortunately, its efficacy has not been sufficiently documented in Nigerian patients. The study aimed to use atracurium and pacuronium to evaluate the efficacy of the priming principle. In this randomised controlled trial, ninety adults undergoing elective surgery under general anaesthesia were randomly allocated into three equal groups. Group A (Atracurium), Group P (Pancuronium) and Group C (control) received 0.05 mg/kg atracurium, 0.01 mg/kg pancuronium and 1 ml saline, respectively, as the priming agent. Three minutes after, anaesthesia was induced with 2 mg/kg propofol and then the intubating dose of pancuronium administered. The onset time of neuromuscular block, intubating condition and occurrence of muscle weakness during the priming interval were noted. Data were analysed using the Statistical Package for the Social Sciences version 25, and a P < 0.05 was considered statistically significant. The mean onset time in Groups A, P and C was 215.7 ± 59.9 s, 237.1 ± 76.5 s and 265.8 ± 72.0 s, respectively, P = 0.024. Post hoc analysis showed that the onset time was only significant between Groups A and C (P = 0.02). The intubating condition was comparable in all groups (P = 0.25). The incidence of muscle weakness during the priming interval was 6.67% in the priming groups. In adults, priming with atracurium but not pancuronium shortens the onset time of pancuronium. However, during RSI, where a fast onset is crucial, the shortened onset time with priming is not clinically relevant.

Neuromuscular blocking agents (NMBAs) are crucial for anesthesia, enabling intubation and optimal surgical conditions. Timely reversal of blockade is critical for safe extubation and recovery. While neostigmine, a traditional reversal agent, is effective for moderate blockade, it has limitations in reversing deep blockade and requires anticholinergics to mitigate side effects. Sugammadex, a novel agent, addresses these limitations by selectively encapsulating aminosteroid NMBAs like rocuronium, providing rapid and reliable reversal. It demonstrates significant advantages, including faster recovery and reduced postoperative complications, especially in high-risk populations such as elderly patients or those with organ dysfunction. However, challenges such as high costs and potential adverse effects, including hypersensitivity and cardiovascular events, restrict its routine use. This review explores sugammadex's pharmacological features, clinical applications, and cost-effectiveness, offering strategies to optimize its use in complex surgical scenarios while addressing current limitations.

Development and Validation of a Predictive Model for Hypoxemia in the Postanesthesia Care Unit Following Thoracoscopic Lung Surgery: A Multicenter Cohort Study.

Intubating conditions based on the time from rocuronium administration versus the train-of-four count: A randomized, prospective, clinical trial.

Background/Objectives: Rapid sequence intubation (RSI) involves nearly simultaneous administration of a rapid-acting induction agent and a neuromuscular blocking agent (NMBA) to facilitate ideal intubation conditions. The NMBAs most commonly used for RSI are succinylcholine and rocuronium, which cause paralysis for 5–15 min and 45–70 min, respectively. Awareness with paralysis can occur in patients who are given longer-acting NMBAs with delayed initiation of post-intubation sedation or insufficient sedation depth. The previous literature has associated the use of rocuronium with a significantly longer time to sedation and analgesia. However, a recent study found no difference. The purpose of this study was to assess the association between paralytic agent choice and time to initiation of analgesia and/or sedation after RSI in the emergency department (ED) of a large tertiary care hospital. Methods: This study was an institutional review board (IRB)-approved, single-center, retrospective cohort evaluation of adult patients (≥18 years of age) who received succinylcholine or rocuronium following administration of an induction agent in the ED for RSI during the study time period. The primary outcome was time to initiation of post-intubation analgesia and/or sedation. Continuous data were analyzed by using Mann–Whitney U or Student’s t-test, and categorical data were analyzed using the Chi Square test or Fisher’s Exact test. Results: A total of 400 patients were included in this study. The median time to sedation with succinylcholine was 9 min compared to 14 min with rocuronium (p &lt; 0.01). No significant differences were identified in the baseline characteristics or secondary outcomes related to induction agent choice or ED length of stay. Conclusions: The results of this study further support that the use of rocuronium for RSI is associated with a significantly longer time to sedation and/or analgesia, making emergency medicine provider awareness essential for minimizing the risks associated with inadequate post-intubation sedation.

Background: Different adjuvants have been studied to enhance the quality and extend the duration of spinal anesthesia. The use of dexmedetomidine has been increased in recent times due to its analgesic and sedative properties. Aims and Objectives: To compare the intrathecal dexmedetomidine and fentanyl in patients undergoing lower-limb surgery under spinal anesthesia. Materials and Methods: Fifty patients (aged 20–50 years) of American Society of Anesthesiologists grades I and II undergoing elective lower-limb orthopedic procedures were included in the study. In group-D (n=25), 5 μg of intrathecal dexmedetomidine with 12.5 mg of 0.5% hyperbaric bupivacaine and group-F (n=25), 25 μg of intrathecal fentanyl with 12.5 mg of 0.5% hyperbaric bupivacaine. Results: There was a statistically significant difference in both the groups. The mean time for two-segment regression and regression of sensory block to L1 was slow with intrathecal dexmedetomidine as compared to those receiving intrathecal fentanyl. Furthermore, the mean total time of sensory and motor block was 342.80 min and 381.24 min, respectively, while patients receiving intrathecal fentanyl had a shorter mean time of sensory and motor block which was 190.24 min and 219.24 min, respectively (P: 0.015). Mean time for the rescue analgesia was also higher with dexmedetomidine than the fentanyl group. Conclusion: Both intrathecal fentanyl and intrathecal dexmedetomidine are safe and effective, but intrathecal dexmedetomidine offers several advantages such as faster onset of pain relief, prolonged duration of sensory and motor blockade, and longer time before requiring additional pain medication.

Background Elderly patients undergoing lung resection are particularly susceptible to postoperative adverse respiratory events (AREs), due to age-related physiological decline and a higher incidence of residual neuromuscular blockade (RNMB). Sugammadex is a selective relaxant binding agent that enables rapid and complete reversal of aminosteroid neuromuscular blocking agents such as rocuronium, offering potential advantages over traditional acetylcholinesterase inhibitors like neostigmine. However, evidence directly comparing the impact of sugammadex versus neostigmine on clinically relevant respiratory outcomes, particularly AREs in elderly patients undergoing lung resection remains limited. Methods and analysis This is a prospective, double-blinded, randomized controlled clinical trial involving 530 elderly patients (≥65 years old) scheduled for video-assisted thoracoscopic lung surgery requiring one-lung ventilation. Patients will be 1:1 randomized to receive sugammadex or neostigmine for neuromuscular blockade reversal. The primary outcome is a composite of AREs occurring in the post-anaesthesia care unit (PACU). Secondary outcomes include time from neuromuscular to extubation, the composite of ARE and rescue measures, PACU length of stay, postoperative pulmonary and extra-pulmonary complications, unplanned intensive care unit (ICU) admission, chest drainage tube duration, hospital length of stay, and mortality. All patients will be followed up until 30 days after surgery. The primary analysis will be conducted on a modified intention-to-treat basis. Discussion This trial is designed to address a critical gap in perioperative care for elderly patients undergoing lung resection by directly comparing sugammadex and neostigmine in terms of clinically meaningful respiratory outcomes. While previous studies have primarily focused on pharmacokinetic profiles or surrogate markers such as train-of-four recovery time, evidence regarding the impact of these agents on postoperative AREs remains limited. Given the growing elderly surgical population and the high incidence of RNMB and pulmonary complications in this group, the findings of this study will offer valuable insight into optimizing neuromuscular blockade reversal strategies. Trial registration This study is registered at Chinese clinical trial registry (ChiCTR2400094005).

To characterize the performance of an electronic health record (EHR) data-based classifier of persistent moderate-to-severe acute respiratory distress syndrome (ARDS). Retrospective observational study. Six ICUs from two health systems. We included adults receiving greater than or equal to 24 hours of invasive mechanical ventilation (IMV) with a Pao2/Fio2 of less than or equal to 150 mm Hg on Fio2 greater than or equal to 0.6 in the first 72 hours of IMV. We evaluated classifier performance in two temporally and geographically distinct cohorts: a development cohort including patients in one of two academic medical or three mixed community ICUs in the first 3 months of 2021 or in 2022-2023, and a validation cohort from a different academic medical ICU in 2017. None. In both cohorts, study physicians assessed patients for clinical ARDS criteria. We retrospectively applied the EHR classifier, which required a persistent Pao2/Fio2 of less than or equal to 150 mm Hg or receipt of interventions to address severe hypoxemia (i.e., prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators) in the 24 hours after initially meeting hypoxemia criteria. We also evaluated classifier definitions that used peripheral oxygen saturation (Spo2)/Fio2 of less than or equal to 162 to indicate persistent hypoxemia. Of 924 patients in the development cohort, 504 (55%) had clinician-adjudicated ARDS. Of 90 patients in the validation cohort, 48 (53%) had clinician-adjudicated ARDS. In the development and validation cohorts, the primary EHR-based classifier identified 382 and 38 patients as having persistent moderate-to-severe ARDS, respectively (positive predictive value [PPV], 71%; 95% CI, 66-75% and PPV, 66%; 95% CI, 50-81%). When Spo2/Fio2 was used as the second hypoxemia marker more patients were classified as ARDS in both development and validation cohorts but with lower PPVs (67% and 62%, respectively.). An EHR-based classifier using readily available data had acceptable performance for identifying patients with persistent moderate-severe ARDS. This open-source tool could be used for retrospective or prospective identification of this vulnerable population for research and quality improvement initiatives.

This case report described the entire process of a 72-year-old Chinese woman undergoing resection of a giant thyroid tumor. The novelty of this case report lies in its emphasis on the crucial role of anesthetic management for giant thyroid tumors, particularly in patients with concurrent cardiac comorbidities. We present a 72-year-old Chinese female with a giant thyroid tumor caused respiratory compromise due to tracheal compression, complicated by atrial septal defect. She required general anesthesia for tumor resection. A multidisciplinary team developed critical contingency strategies: (1) awake endotracheal intubation under direct laryngoscopy, (2) a remimazolam/sufentanil combination for procedural tolerance, (3) improved tracheal catheter preparation, and (4) surgical tracheostomy readiness. Anesthesia maintenance was achieved with sevoflurane, supplemented by sufentanil and remifentanil for multimodal analgesia and vecuronium/mivacurium neuromuscular blockade. Successful tumor resection achieved complete decompression, with no postoperative complications documented during 30-day follow-up. This case demonstrates that meticulous interdisciplinary communication and structured perioperative protocols form the cornerstone of safe anesthesia practice for patients with dual pathology of airway compromise and cardiac comorbidities, providing crucial insights for managing such complex clinical scenarios.

Cervical dystonia is the most common focal dystonia, characterized by involuntary muscle contractions leading to abnormal postures and significant discomfort. Although neuromuscular blockade with botulinum toxin and other agents is the primary treatment, selective cervical denervation, which includes sternocleidomastoid (SCM) and posterior cervical muscle denervation, is a surgical option for refractory cases. The aim of this study was to evaluate the great auricular point (GAP) as a reliable intraoperative landmark for selective cervical denervation, optimizing spinal accessory nerve (SAN) preservation during SCM myotomy/denervation. A review of anatomic studies and cadaveric dissections was conducted to assess the GAP's role in guiding safe SCM myotomy and minimizing SAN injury. The anatomic relationship between the GAP, SAN, and great auricular nerve was evaluated for consistency. Subsequently, this technique, including denervation of the accessory nerve branches to SCM, was applied clinically in 5 patients. We report a modification of selective cervical denervation using the GAP technique during SCM myotomy and selective denervation. The GAP was consistently located inferior to the SAN exit site at the posterior SCM border. Shoulder motion and scapular stability were maintained in all 5 patients. The GAP provided a stable reference point for SCM myotomy, effectively preserving the SAN's trapezius branch and enhancing surgical precision. The GAP serves as a reliable intraoperative landmark for selective cervical denervation, facilitating safe SCM myotomy and minimizing iatrogenic SAN injury. In addition, this technique may minimize revisions by providing enhanced visibility and precision during SCM myotomy. Further clinical validation is warranted to confirm its broader efficacy in neurosurgical practice.

Perioperative anaphylaxis in Japan: Epidemiology, diagnosis, and challenges.

Early extubation in cardiac surgery improves recovery and outcomes. Extubation of the airway after cardiac surgery in the operating room or in the immediate postoperative period is a key component of the optimization of outcomes in cardiac surgical patients. Specific objectives of this study included measuring time to extubation with secondary outcomes of post-extubation vital signs, lung function, and esophageal motility. Exploratory parameters included ICU stay and re-intubation in 24h. In this study, we compare two groups of patients undergoing coronary bypass grafting surgery (CABG) under general anesthesia with muscle relaxation. Reversal of neuromuscular blockade randomized to group 1: neostigmine and group 2: sugammadex. A standard anesthetic protocol was followed throughout the perioperative period in each of these patients with the goal of in-operating room extubation. A two-sample t-test and/or linear model was used in the data analysis. 4 subjects were not extubated in the neostigmine group versus 1 subject in the sugammadex group. The average time to extubation in the neostigmine group was 10.4min, (STDEV: 5.9min) and sugammadex was 6min, (STDEV: 4.7min). p = 0.001 (ANOVA). Significant secondary outcome measures included patients who received sugammadex had higher heart rates at the second measurement (85.0) vs. neostigmine (79.5) p = 0.047 and higher systolic blood pressures at the second measurement point for sugammadex (111.7) vs. neostigmine (103.9) p = 0.023. 11/36 (30%) failed the Functional Dysphasia Screen in the neostigmine group versus 5/35 (14%) in the sugammadex. Subjects in the neostigmine group had an average ICU stay of 40.1 +/- 32.4h versus 35.6 +/- 15.8 in the sugammadex group. 2 patients in the neostigmine group were re-intubated and 1 patient was placed on non-invasive positive pressure ventilation vs. no airway interventions in the sugammadex group. Based on the results of this study, utilizing sugammadex for reversal of neuromuscular blockade after CABG may increase early extubation in the operating room, decrease the re-intubation rates, provide a very consistent level of muscle strength for lung function, and may improve postoperative esophageal dysmotility. ClinicalTrials.gov NCT03939923, Registration date of Feb 2, 2019.

BackgroundVariation in anesthesia practice exists regarding the use of neuromuscular blockade agents (NMBA), such as rocuronium, with a laryngeal mask airway (LMA). In hip arthroscopy, NMBAs facilitate distraction of the hip joint, reducing the required traction force. LMAs reduce intubation-related side effects and improve anesthetic efficiency but LMA use with NMBAs may be concerning due to risk for pulmonary aspiration without an endotracheal tube (ETT). This study assessed the prevalence of pulmonary aspiration and airway complications among patients undergoing hip arthroscopy using general anesthesia with LMA and low dose NMBA.MethodsPatients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at a single institution from 2014-2024 were retrospectively analyzed. General anesthesia was performed with mixed anesthetic (propofol and sevoflurane). After LMA insertion, low dose rocuronium (10-50 mg) was administered prior to hip distraction. Outcomes analyzed included pulmonary aspiration, airway complications, conversion to ETT and operative times.ResultsThis series included 1169 patients (48.8% female) with a mean age of 37.8 years (± 11.0) and BMI of 24.4 kg/m2 (± 3.9). 64.0% were ASA Class I, 34.8% Class II, and 1.2% Class III. 24 patients underwent endotracheal intubation due to pre-operative aspiration risk factors. Of the 1145 patients who underwent LMA with NMBA, no patients experienced pulmonary aspiration or anesthesia/airway complications. 21 patients (1.8%) required conversion to endotracheal intubation during the case due to poor LMA fit or ventilation leak. There was no association of ASA class with conversion from LMA to ETT. Mean airway manipulation time was 6.0 mins (± 6.4), mean procedure duration was 100.3 mins (± 48.7), and mean procedure end time to airway removal time was 5.0 minutes (± 5.0). No surgical complications related to hip distraction or traction force occurred.ConclusionGeneral anesthesia with LMA ventilation and low-dose NMBA is safe and effective for hip arthroscopy, enabling muscle relaxation for hip distraction without ETT morbidity.