Neuromuscular Blockade Research Articles

Identifying Variation in Intraoperative Management of Brain-Dead Organ Donors and Opportunities for Improvement: A Multicenter Perioperative Outcomes Group Analysis.

Intraoperative events and clinical management of deceased organ donors after brain death are poorly characterized and may consequently vary between hospitals and organ procurement organization (OPO) regions. In a multicenter cohort, we sought to estimate the incidence of hypotension and anesthetic and nonanesthetic medication use during organ recovery procedures. We used data from electronic anesthetic records generated during organ recovery procedures from brain-dead adults across a Multicenter Perioperative Outcomes Group (MPOG) cohort of 14 US hospitals and 4 OPO regions (2014-2020). Hypotension, defined as mean arterial pressure or MAP <60 mm Hg for at least 10 cumulative minutes was the primary outcome of interest. The associations between hypotension and age, sex, race, anesthesia time, OPOs, and OPO case volume were examined using multivariable mixed-effects Poisson regression analyses with robust standard error estimates. We calculated intraclass correlation coefficients (ICCs) to describe the variation between-MPOG centers and the OPO regions in the use of medications, time of the operation, and duration of the operation. We examined 1338 brain-dead adult donors, with a mean age of 42± (standard deviation [SD] 15) years; 60% (n = 801) were males and 67% (n = 891) non-Hispanic White. During the entire intraoperative monitoring period, 321 donors (24%, 95% confidence interval [CI], 22%-26%) had hypotension for a median of 13.8% [quartile1-quartile 3: 9.4%-21%] of the monitoring period and a minimum of 10 minutes to a maximum of 96 minutes [(median: 17, quartile1-quartile 3: 12-24]). The probability having hypotension in donors 35 to 64 years and 65 years and older were approximately 30% less than in donors 18 to 34 years of age (adjusted relative risk ratios, aRR, 0.68, 95% CI, 0.55-0.82, aRR, 0.63, 95% CI, 0.42-0.94, respectively). Donors received intravenous heparin (96.4%, n = 1291), neuromuscular blockers (89.5%, n = 1198), vasoactive medications (82.7%, n = 1108), crystalloids (76.2%, n = 1020), halogenated anesthetic gases (63.5%, n = 850), diuretics (43.8%, n = 587), steroids (16.7%, n = 224), and opioids (23.2%, n = 310). The largest practice heterogeneity observed between the MPOG center and OPO regions was steroids (between-center ICCs = 0.65, 95% CI, 0.62-0.75, between-region ICCs = 0.39, 95% CI, 0.27-0.63) and diuretics (between-center ICCs = 0.44, 95% CI, 0.36-0.6, between-region ICCs = 0.30, 95% CI, 0.22-0.49). Despite guidelines recommending maintenance of MAP >60 mm Hg in adult brain-dead organ donors, hypotension during recovery procedures was common. Future research is needed to clarify the relationship between intraoperative events with donation and transplantation outcomes and to identify best practices for the anesthetic management of brain-dead donors in the operating room.

Comparing the clinical features of lateral and medial approaches of costoclavicular technique versus traditional lateral sagittal technique as infraclavicular brachial plexus block methods: a randomized controlled trial

BackgroundIt is aimed to compare the block onset times and performance features of costoclavicular techniques (medial and lateral approach) versus lateral sagittal technique.MethodsPatients were randomized into three groups. For costoclavicular techniques, ultrasound probe was placed parallel to clavicle obtaining nerve cords, axillary artery and axillary vein visual from lateral-to-medial, respectively. The block needle was advanced from lateral (Group CLB) or medial (Group CMB) to perform costoclavicular block. For lateral sagittal technique (Group LSB), ultrasound probe was placed sagittal and perpendicular below the coracoid process to obtain sagittal artery image with the cords around. Total 20 ml of 0.5% bupivacaine and 10 ml of 2% lidocaine were deposited for all groups. Sensory and motor block onset times, block performance properties, complications, and patient/surgeon satisfactions were investigated.ResultsAmong 56 patients, the primary outcome, sensory block onset time was shorter in Group CLB than Group CMB and Group LSB (10 [5–15], 10 [10–20], and 15 [10–15] minutes, respectively, p < 0.05). Motor block onset was also fastest in Group CLB (15 [10–20] mins for CLB, 20 [15–20] mins for LSB, and 22.5 [15–25] mins for CMB, p = 0.004). Block performance properties did not differ between the groups. The only complication observed was vascular puncture with an incidence of 28% in Group CMB.ConclusionsLateral approach costoclavicular technique provides fastest block onset than the other techniques. Considering the success and safety profile, this technique stands as a good alternative in clinical practice.Trial registrationThis study is prospectively registered to clinicaltrials.gov on 20/02/2022 (NCT05260736).

Adverse events related to neuromuscular blocking agents: a disproportionality analysis of the FDA adverse event reporting system.

Background: Neuromuscular blocking agents (NMBAs) are primarily used during surgical procedures to facilitate endotracheal intubation and optimize surgical conditions. This study aimed to explore the adverse event signals of NMBAs, providing reference for clinical safety. Methods: This study collected reports of atracurium, cisatracurium, rocuronium, and vecuronium as primary suspect drugs in The US Food and Drug Administration Adverse Event Reporting System (FAERS) from the first quarter of 2004 to the third quarter of 2023. The adverse events (AEs) reported in the study were retrieved based on the Preferred Terms (PTs) of the Medical Dictionary for Regulatory Activities. In addition, we conducted disproportionality analysis on relevant reports using the reporting odds ratio (ROR) method and Bayesian confidence propagation neural network (BCPNN) method. A positive signal was generated when both algorithms show an association between the target drug and the AE. Results: A total of 11,518 NMBA-related AEs were reported in the FAERS database. The most AEs of rocuronium were collected. NMBA-related AEs involved 27 different system organs (SOCs), all of the four NMBAs had positive signals in "cardiac disorders," "immune system disorders," "respiratory, thoracic and mediastinal disorders" and "vascular disorders." At the PTs level, a total of 523 effective AEs signals were obtained for the four NMBAs. AEs labled in the instructions such as anaphylaxis (include anaphylactic reaction and anaphylactic shock), bronchospasm, respiratory arrest and hypotension were detected positive signals among all NMBAs. In addition, we also found some new AEs, such as ventricular fibrillation for the four NMBAs, hyperglycaemia for atracurium, kounis syndrome and stress cardiomyopathy for rocuronium, hepatocellular injury for cisatracurium, hyperkalaemia for vecuronium. To further investigated the AEs associated with serious clinical outcomes, we found that cardiac arrest and anaphylaxis were the important risk factors for death due to NMBAs. Conclusion: NMBA-related AEs have a significant potential to cause clinically severe consequences. Our study provides valuable references for the safety profile of NMBAs, and considering the limitations of the FAERS database, further clinical data are needed to validate the findings of this study.

Effect of dexmedetomidine constant rate infusion on the analgesic duration of peripheral nerve blocks in dogs: a randomized clinical study

The aim of this study was to evaluate whether a constant rate infusion of dexmedetomidine could prolong the analgesic effect of peripheral nerve blocks. Twenty client-owned dogs were enrolled and randomly divided into 2 groups. The DEX group received dexmedetomidine infusion at 1 mcg kg−1 h−1, and the NaCl group received an equivalent volume infusion of saline. Infusions were started after securing vascular access and continued for 10 min, after which intravenous (IV) methadone at 0.2 mg kg−1 and propofol to effect were administered. All animals were maintained with isoflurane in 70% oxygen. Sciatic, saphenous and obturator nerve blocks were performed using 0.1 mL kg−1 0.5% ropivacaine/block. Intraoperative fentanyl was administered if the heart rate and/or mean arterial pressure (MAP) increased > 15% from the previous measurement, and vasopressors were administered if MAP was ≤ 70 mmHg. Postoperative pain was assessed every hour using the Glasgow Composite Pain Scale (GCPS) until the first rescue analgesia administration. Postoperative rescue analgesia (methadone (0.2 mg kg−1 IV) and carprofen (2 mg kg−1 IV)) was administered if the pain score was higher than 6/24 or 5/20. Duration of analgesia was defined as the time between the nerve block procedure and initial postoperative rescue analgesia. Ambulation, proprioception, and skin sensitivity were evaluated to assess the duration of the motor and sensory block. A Student T and chi-square test were used to compare groups for duration of postoperative analgesia and intraoperative fentanyl and vasopressor use, respectively (p values ≤ 0.5 considered significant). A greater number of dogs in the NaCl group required fentanyl (5/10 p = 0.03) and vasopressors (8/10, p = 0.02) than did those in the DEX group (0/10 and 2/10, respectively). The duration of postoperative analgesia was significantly longer (604 ± 130 min) in the DEX group than in the NaCl group (400 ± 81 min, p = 0.0005).Dexmedetomidine infusion at 1 mcg kg−1 h−1 delays the time to first administration of rescue analgesia and reduces intraoperative analgesic and vasopressor requirements during Tibial Tuberosity Advancement surgery.

Understanding the Ocular Hypertension Model in Mice Induced by Dexamethasone-21-Acetate – Implications for Glaucoma Research

Purpose This study aimed to assess the effectiveness of monocular and bilateral injections of Dexamethasone-21-acetate (Dex-21-Ac) into the murine fornix twice a week as a glucocorticoid-induced ocular hypertension model and investigated potential systemic side effects. Methods Dex-21-Ac was administered twice weekly in three groups: bilateral injections, monocular injections, and a control group receiving the vehicle solution bilateral. After 21 days, enucleated eyes were examined using immunocytochemistry (ICC), and organ histology was performed. Results All groups receiving Dex-21-Ac injections had a significant increase in intraocular pressure (IOP). Monocular injections also resulted in a significant increase in IOP in the fellow eye. The Dex-21-Ac-treated groups showed a bilateral increase in IOP of approximately 8 mmHg, accompanied by elevated expression of alpha smooth muscle actin and fibronectin in the anterior chamber angle. There were no significant changes in weight progression. Hepatic steatosis was observed in all Dex-21-Ac-treated animals, and some suffered from residual neuromuscular blockade under fentanyl anesthesia. Conclusion Bilateral injections of Dex-21-Ac twice a week lead to a significant increase in daytime IOP and fibrotic changes in the trabecular meshwork. Unilateral application has a significant impact on the fellow eye. Local dexamethasone leads to notable systemic effects independent of changes in animal weight. Considering liver damage and associated influence on metabolization, hepatically eliminated injection anesthetics may lead to overdosing and are not recommended. They should be replaced by inhalation anesthesia.

Quantitative Analysis of the Effect of Neuromuscular Blockade on Motor-Evoked Potentials in Patients Undergoing Brain Tumor Removal Surgery: A Prospective, Single-Arm, Open-Label Observational Study.

Background: We aimed to elucidate the quantitative relationship between the neuromuscular blockade depth and intraoperative motor-evoked potential amplitudes. Methods: This prospective, single-arm, open-label, observational study was conducted at a single university hospital in Seoul, Korea, and included 100 adult patients aged ≥19 years undergoing brain tumor removal surgery under general anesthesia. We measured the neuromuscular blockade degree and motor-evoked potential amplitude in the deltoid, abductor pollicis brevis, tibialis anterior, and abductor hallucis muscles until dural opening. Results: The pharmacokinetic-pharmacodynamic model revealed the exposure-response relationship between the rocuronium effect-site concentration and motor-evoked potential amplitudes. The mean motor-evoked potential amplitudes decreased proportionally with increasing neuromuscular blockade depth. As the mean amplitude increased, the coefficient of variation decreased bi-exponentially. The critical ratio of the first evoked response to the train-of-four stimulation (T1)/control response (Tc) thresholds beyond which the coefficient of variation exhibited minimal change were found to be 0.63, 0.65, 0.68, and 0.63 for the deltoid, abductor pollicis brevis, tibialis anterior, and abductor hallucis muscles, respectively. Conclusions: Our results reveal that the motor-evoked potential amplitude exhibits deterioration proportional to the degree of neuromuscular blockade. In light of the observed bi-exponential decline of the coefficient of variation with the motor-evoked potential amplitude, we recommend maintaining a T1/Tc ratio higher than 0.6 for partial neuromuscular blockade.

Factors Influencing Neuromuscular Blockade Reversal Choice in the United States Before and During the COVID-19 Pandemic: Retrospective Longitudinal Analysis.

Neuromuscular blockade (NMB) agents are a critical component of balanced anesthesia. NMB reversal methods can include spontaneous reversal, sugammadex, or neostigmine and the choice of reversal strategy can depend on various factors. Unanticipated changes to clinical practice emerged due to the COVID-19 pandemic, and a better understanding of how NMB reversal trends were affected by the pandemic may help provide insight into how providers view the tradeoffs in the choice of NMB reversal agents. We aim to analyze NMB reversal agent use patterns for US adult inpatient surgeries before and after the COVID-19 outbreak to determine whether pandemic-related practice changes affected use trends. A retrospective longitudinal analysis of a large all-payer national electronic US health care database (PINC AI Healthcare Database) was conducted to identify the use patterns of NMB reversal during early, middle, and late COVID-19 (EC, MC, and LC, respectively) time periods. Factors associated with NMB reversal choices in inpatient surgeries were assessed before and after the COVID-19 pandemic reached the United States. Multivariate logistic regression assessed the impact of the pandemic on NMB reversal, accounting for patient, clinical, procedural, and site characteristics. A counterfactual framework was used to understand if patient characteristics affected how COVID-19-era patients would have been treated before the pandemic. More than 3.2 million inpatients experiencing over 3.6 million surgical procedures across 931 sites that met all inclusion criteria were identified between March 1, 2017, and December 31, 2021. NMB reversal trends showed a steady increase in reversal with sugammadex over time, with the trend from January 2018 onwards being linear with time (R2>0.99). Multivariate analysis showed that the post-COVID-19 time periods had a small but statistically significant effect on the trend, as measured by the interaction terms of the COVID-19 time periods and the time trend in NMB reversal. A slight increase in the likelihood of sugammadex reversal was observed during EC relative to the pre-COVID-19 trend (odds ratio [OR] 1.008, 95% CI 1.003-1.014; P=.003), followed by negation of that increase during MC (OR 0.992, 95% CI 0.987-0.997; P<.001), and no significant interaction identified during LC (OR 1.001, 95% CI 0.996-1.005; P=.81). Conversely, active reversal (using either sugammadex or neostigmine) did not show a significant association relative to spontaneous reversal, or a change in trend, during EC or MC (P>.05), though a slight decrease in the active reversal trend was observed during LC (OR 0.987, 95% CI 0.983-0.992; P<.001). We observed a steady increase in NMB active reversal overall, and specifically with sugammadex compared to neostigmine, during periods before and after the COVID-19 outbreak. Small, transitory alterations in the NMB reversal trends were observed during the height of the COVID-19 pandemic, though these alterations were independent of the underlying NMB reversal time trends.

Evaluation of fluid responsiveness using liver compression in dogs with experimentally induced hypovolemia.

To investigate whether liver compression (LC) could increase stroke volume (SV) by more than 15% in healthy, anesthetized dogs with hypovolemia and suggest LC as a novel method to evaluate fluid responsiveness. 6 healthy Beagles. This prospective, nonrandomized experimental study was conducted from November 2023 to February 2024. The dogs were anesthetized with isoflurane and mechanically ventilated under neuromuscular blockade. After instrumentation, the dogs underwent the following 4 experimental stages in a sequential, nonrandomized manner: stage 1, baseline; stage 2, 30% withdrawal of circulating blood volume; stage 3, 50% infusion of the collected blood; and stage 4, the remaining 50% infusion of the collected blood. At each stage, SV via pulmonary artery thermodilution and hemodynamic variables were measured before, during, and after the LC. In stage 2, LC significantly increased mean SV by 30%, from 6.9 to 9 mL/beat. Simultaneously, LC significantly increased mean arterial pressure by 11 mm Hg and mean central venous pressure by 2 mm Hg, while pulse pressure variation significantly decreased from 28% to 22%. In stages 1, 3, and 4, LC did not significantly change mean SV, mean arterial pressure, and pulse pressure variation; however, mean central venous pressure significantly increased during stage 3. This study demonstrates that LC at 22 mm Hg for 1 minute could increase SV more than 15% in anesthetized, hypovolemic dogs and LC could be used as a novel method to evaluate fluid responsiveness.

Effect of Ondansetron on Maternal Hypotension During Spinal Anesthesia With Ropivacaine for Cesarean Sections: A Randomized, Double-Blind Trial.

Ondansetron, a selective 5-hydroxytryptamine 3 (5-HT3) receptor antagonist, has been proven to be effective in the prevention of spinal-induced hypotension for elective cesarean section. A total of 138primigravida parturients scheduled for elective cesarean section were randomly assigned to three groups. Groups ONDA4 and ONDA8, respectively, received 4 and 8mgof ondansetron in 100 mL normal saline, before spinal anesthesia with 1.7 mL ropivacaine 0.75% and 15 mcg of fentanyl, whereas the CONTROL group received an equal volume of normal saline. Noninvasive blood pressure and heart rate were recorded upon arrival, before and after spinal injection, and thereafter every minute for a time period of 10 minutes along with total doses of phenylephrine (mcg) or ephedrine (mg). Time required for the spinal anesthesia to achieve a sensory and motor block at the T4 level andBromage 3 scale respectively, as well as to regress to the T7 level and a Bromage1 scale were noted. Maternal nausea/vomiting or shivering, umbilical artery pH, and neonatal Apgar score at 1 and 5 min were also recorded. There were no differences between groups in systolic, diastolic blood pressure, heart rate (p=0.355, p=0.550, p=0.474 respectively), doses of phenylephrine or ephedrine, (p=0.920, p=0.142 respectively), time for the block to reach T4 (p=0.889) and Bromage scale 3(p=0.269), or to regress to T7 (p=0.273) and Bromage scale 1 (p=0.392), the incidence of nausea/vomiting (p=0.898/p=0.365), umbilical artery pH (p=0.739), neonatal Apgar score at 1 and 5 min (p=0.936 and p=0.907 respectively). Our results showed no significant effect of two different doses of ondansetron, in preventing maternal hypotension, following spinal anesthesia with ropivacaine for cesarean section.

Reversal of neuromuscular block with neostigmine and sugammadex: a retrospective cohort study in two centers using different types of neuromuscular monitoring.

This bicentric retrospective cohort study evaluates reversal of muscle relaxation in real life achieved either by neostigmine or sugammadex in two hospitals using different types of neuromuscular monitoring (acceleromyography and kinemyography). The research question concerns compliance with recommendations. Patients who underwent an abdominal surgery under general anesthesia in the period from January 2017 through December 2020 with a neuromuscular block with rocuronium were included in the study. Data were extracted from the Centricity anesthesia information management system. In total, 2242 patients were assessed: 459 in center 1 (61 having received neostigmine and 398 sugammadex) and 1783 in center 2 (531 and 1252, respectively). Patients' characteristics differed between centers, with more high-risk patients in center 1. The mean train-of-four (TOF) ratio after supramaximal current determination (supramaximal threshold) was higher in center 1 (p < 0.001). Most patients received neostigmine while the TOF ratio was < 40% (68.6% in center 1 and 62.4% in center 2), while extubation was performed while the TOF ratio was > 90% in 61.0% in center 1 and in 32.1% in center 2 (p < 0.001). Patients received sugammadex irrespective of the number of responses to TOF before reversal, and extubation was performed while the TOF ratio was > 90% in 85.0% in center 1 and in 53.6% in center 2 (p < 0.001). No side effect was encountered. Despite guidelines for the TOF ratio before extubation, recommendations were not adequately respected and more vigilance is mandatory. The TOF test before use gave values that were 100% far apart with an underestimation with acceleromyography and an overestimation using kinemyography.

Pain during caesarean delivery in a tertiary maternity hospital: a retrospective cohort study (2022–2023)

BackgroundIntra-operative pain during Caesarean delivery (PDCD) is the leading cause of successful litigation against obstetric anaesthesiologists. PDCD may require conversion to general anaesthesia (GA). The aim of this analysis is to assess our incidence of PDCD and associated GA conversion. MethodsData were collected from electronic patient records. Data included baseline demographics, incidence of PDCD and rates of GA conversion, proportion of PDCD cases attributable to failed epidural (EA) or spinal anaesthesia (SA), and level of sensory and motor blockade in cases of PDCD. Results were audited against current standards set by the Royal College of Anaesthetists ‘rates of PDCD should be <5% for category 4, <15% for categories 2-3, and <20 % for category 1 CD ’ and that ‘rates of conversion to GA due to neuraxial complications should be <1% for category 4, <5% for categories 2-3 and <15% for category 1 patients’. ResultsDuring the 12-month study period, 2,429 patients underwent CD, of whom 52 (2.1%) experienced PDCD. The incidence of PDCD was 3.1% (41/1,309) for category 1-3 patients, while 1% (11/1,120) of category 4 patients experienced PDS. Of the 52 patients with PDCD, 17 patients required GA (33%). SA was used in 24/52 (47%) cases and EA in 28/52 (53%) cases. The median level of sensory block in patients with PDCD was located at the T4 dermatome, the median level of motor block was Bromage level 2. ConclusionsPDCD occurred in 2.1% of CD, one-third required conversion to GA. Most patients experiencing PDCD met current motor and sensory blockade criteria.

Comparison of Fentanyl With Midazolam As Adjuvants to Levobupivacaine in Spinal Anesthesia for Cesarean Sections: A Randomized Controlled Trial.

Background and objectives Spinal anesthesia stands as a cornerstone for patients undergoing lower segment cesarean section (LSCS), offering advantages like faster onset and high block density. Levobupivacaine, known for its high potency and long-acting nature, has a slower onset. The safety of intrathecal fentanyl or midazolam is evaluated as an adjuvant to levobupivacaine in parturients. This study aims to compare the duration of postoperative analgesia provided by fentanyl or midazolam added to 0.5% hyperbaric levobupivacaine in elective cesarean sections. Secondary objectives include evaluating the onset and duration of sensory and motor blockade and the incidence of nausea and vomiting. Identifying the more effective adjuvant will help optimize spinal anesthesia protocols, improve postoperative outcomes, and enhance patient comfort and recovery. Methods This study was conducted at SRM Medical College Hospital and Research Centre, Chennai, India, over six months (May 1, 2023, to October 1, 2023). A total of 90 patients undergoing elective LSCS received spinal anesthesia in a prospective randomized double-blinded controlled trial. Patients were allocated to three groups: Group A received levobupivacaine with fentanyl, Group B received levobupivacaine with midazolam, and Group C received levobupivacaine with normal saline. Block characteristics, postoperative analgesia, hemodynamic stability, and complications were assessed. Assessments were conducted at specified time points: intraoperatively, every five minutes for the first 30 minutes, every 10 minutes for the next hour, every two hours for six hours, and every four hours up to 24 hours postoperatively. Statistical analysis utilized one-way analysis of variance (ANOVA). Results Group B (levobupivacaine with midazolam) exhibited a shorter time to sensory block onset (88 seconds) compared to Groups A and C (both 145 seconds) (p < 0.001). Group A (levobupivacaine with fentanyl) showed a shorter time to maximum motor block (p = 0.045) than Groups B and C. The sensory block duration was significantly longer in Group A (127.5 minutes) compared to Group B (60 minutes) and Group C (69 minutes) (p < 0.001). Motor block duration was also prolonged in Group A (251 minutes) compared to Group B (147 minutes) and Group C (177 minutes) (p = 0.045). The first analgesic requirement was delayed in Group A (248 minutes), whereas Groups B (115 minutes) and C (90 minutes) (p < 0.001) required more frequent analgesia. Group A experienced a higher incidence of postoperative nausea and vomiting. Conclusion Midazolam accelerated sensory block onset, while fentanyl prolonged anesthesia duration without significantly affecting motor block. Fentanyl delayed the first analgesic requirement, whereas midazolam reduced postoperative nausea, vomiting, and shivering.

Peculiarities of anesthesia for caesarean section in patients with gestational diabetes mellitus

BACKGROUND: Women with gestational diabetes mellitus are at high risk of operative delivery. Meanwhile, hyperglycemia affects the metabolism of narcotic analgesics, while increasing their need. Thus, the anesthesiologist is faced with the question of what method of anesthesia to choose for a particular cesarean section. AIM: The aim of this study was to estimate the features of the perioperative period of cesarean section in patients with gestational diabetes mellitus. MATERIALS AND METHODS: This prospective, controlled, single-center study enrolled 101 patients who were delivered by planned cesarean sections from April to November 2023. Group 1 included patients with gestational diabetes mellitus on diet therapy (n = 28), group 2 comprised patients with gestational diabetes mellitus on insulin therapy (n = 29), and group 3 (control) included women with a normal pregnancy without carbohydrate metabolism disturbances (n = 44). RESULTS: The highest initial values of mean arterial pressure were in group 2 and amounted to 91.8 ± 7.0 mmHg. In group 1, the mean arterial pressure was within 89.1 ± 6.4 mmHg, and in group 3, that was 85.9 ± 9.1 mmHg, which was significant (p 0.05). The sympathetic block developed longer in patients of group 2. In group 1, the sensory block was recorded at the ThIV–ThV level after 10.1 minutes and the motor block (Bromage score 3) after 12.2 minutes compared to 7.8 and 8.6 minutes, respectively, in group 2, and 4.5 and 5.1 minutes, respectively, in group 3. In group 2, authors observed the most rapid regression of the block (79.4 minutes after the injection of local anesthetic), which required an earlier start of the transversus abdominis plane block (after 65.3 minutes). The sympathetic block regressed after 86.2 and 138.1 minutes in patients of groups 1 and 3, respectively (p 0.05), when the transversus abdominis plane block was performed. Thus, immediately after cesarean section, women with gestational diabetes mellitus (especially on insulin therapy) had a higher need for analgesics than those without gestational diabetes mellitus. CONCLUSIONS: During cesarean section under spinal anesthesia in patients with gestational diabetes mellitus, the rate of development of the sympathetic block is reduced (especially in women who received insulin therapy). At the same time, block regression in these patients occurs much faster, which requires an earlier start of postoperative anesthesia. An increased need for systemic analgesics has been demonstrated during the postoperative period in women with gestational diabetes mellitus, mainly with insulin therapy.

Adductor Canal Block Versus Femoral Nerve Block for Postoperative Pain Management in Anterior Cruciate Ligament Reconstruction: A Prospective Interventional Study.

Background A common knee joint disorder is injury to the anterior cruciate ligament (ACL), which often requires surgery. Proper pain control after the surgery facilitates fast recovery and prevents chronic pain. To provide analgesia for knee procedures, the use of opioids, non-steroidal anti-inflammatory medications, and regional techniques arecommonly employed. This study aims to evaluate the efficacy of adductor canal block (ACB) and femoral nerve block (FNB) for postoperative pain management after anterior cruciate ligament reconstructions (ACLRs). Methodology This prospective interventional study included 30 participants scheduled for patellar graft ACLR. They were assigned into groups, i.e., ACB and FNB, with 15 patients each. The evaluation occurred one day before the operation, and all surgical procedures were performed using spinal anesthesia. During the postoperative period, a 10-point visual analog scale (VAS) was utilized to quantify pain intensity at the end of the surgery and at various intervals after the surgery. Patients with a VAS score greater than 4 received either FNB or ACB using bupivacaine 0.125%. Duration of analgesia time, power of quadriceps muscle, and neurologic complications were documented. Results No statistically significant value was observed in the mean duration of analgesia between the patients in ACB (348.33 minutes) and the patients in FNB (363.06 minutes). No motor block was observed in 12 patients who received ACB, while only four patients had a motor-sparing effect among those who received FNB. No neurological adverse effects were observed in the study participants. Conclusions ACB provides an equal duration of analgesia similar to FNB, and ACB significantly spares motor strength and maintains higher quadriceps power than FNB.

Neurologic disease in the obstetric patient.

Neurologic disorders and complications during pregnancy are common, but guidelines and data are sparse. This review aims to give an overview of recent developments in neuroanesthesia and management of neuropathology during pregnancy, with the hope that these may fill the gaps in current guidelines and recommendations, as well as their implications for an anesthetic approach. Neuraxial and general anesthesia are safe in multiple sclerosis and myasthenia gravis, though neuromuscular blockade response is unpredictable and risk for exacerbation exists. Cerebral vascular pathology is common and carries a significant morbidity and mortality burden, but thrombolytic and endovascular therapies are often appropriate and safe. Instrumental vaginal delivery can minimize intracranial pressure shifts and is a viable option. Tumors and cerebral malformations require a complex multidisciplinary and anesthetic approach. While clinical trials remain sparse, larger population-based studies offer insight into the optimal approach to the parturient with neurologic disease.

Clinical effects of perineural dexmedetomidine or magnesium sulphate as adjuvants to ropivacaine in dogs undergoing tibial plateau leveling osteotomy

The study aimed to compare the quality of perioperative analgesia, the motor block duration, and the effects on main cardiovascular parameters of dexmedetomidine (1 μg/kg/nerve block) or magnesium sulphate (2 mg/kg/nerve block) as adjuvants to 0.3% ropivacaine for sciatic and saphenous nerves block in dogs undergoing tibial plateau leveling osteotomy (TPLO). Dogs randomly received perineural dexmedetomidine-ropivacaine (D group), magnesium sulphate-ropivacaine (M group), or ropivacaine (C group). Fentanyl was administered in case of intraoperative nociception. Postoperative pain was assessed using the Short Form-Glasgow Composite Measure Pain Scale (SF-GCMPS) and VAS scale. The duration of motor blockade and intra- and postoperative cardiovascular parameters were also recorded. Group M required significantly more fentanyl than D group (p = 0.04). Group M had a significantly higher SF-GCMPS score than group C at 4 (p = 0.002) and 5 h after extubation (p = 0.01), and a significantly higher VAS score than group D at 3 h after extubation (p = 0.03), and at 4 h if compared to group C (p = 0.009). No significant differences regarding the duration of motor blockade were detected between groups (p = 0.07). The heart rate was significantly lower in group D than in M and C groups intraoperatively and during the first 1.5 h post extubation. The addition of dexmedetomidine or magnesium sulphate as adjuvants to perineural ropivacaine did not improve the quality of perioperative analgesia and did not prolong the motor blockade in dogs undergoing sciatic and saphenous nerves block for TPLO surgery.

Comparison of inflammatory markers in low-pressure pneumoperitoneum with deep neuromuscular block versus standard pressure pneumoperitoneum among patients undergoing laparoscopic cholecystectomy for gallstone disease: a randomized control trial.

Low-pressure pneumoperitoneum (LPP) is an attempt to improve laparoscopic surgery. Lower pressure causes lesser inflammation and better hemodynamics. There is a lack of literature comparing inflammatory markers in LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB in laparoscopic cholecystectomy. This was a single institutional prospective randomized control trial. Participants included all patients undergoing laparoscopic cholecystectomy for symptomatic gall stone disease. Participants were divided into 2 groups group A and B. Group A-Low-pressure group in which pneumoperitoneum pressure was kept low (8-10mmHg) with deep Neuromuscular blockade (NMB) and Group B-Normal pressure group (12-14mmHg) with moderate NMB. A convenience sample size of 80 with 40 in each group was selected. Lab investigations like CBC, LFT, RFT and serum IL-1, IL-6, IL-17, TNF alpha levels were measured at base line and 24h after surgery and compared using appropriate statistical tests. Other parameters like length of hospital stay, post-operative pain score, conversion rate (low-pressure to standard pressure), and complications were also compared. Eighty participants were analysed with 40 in each group. Baseline characteristics and investigations were statistically similar. Difference (post-operative-pre-operative) of inflammatory markers were compared between both groups. Numerically there was a slightly higher rise in most of the inflammatory markers (TLC, ESR, CRP, IL-6, TNFα) in Group B compared to Group A but not statistically significant. Albumin showed significant fall (p < 0.001) in Group B compared to Group A. Post-operative pain was also significantly less (p < 0.001) in Group A compared to Group B at 6h and 24h. There were no differences in length of hospital stay and incidence of complications. There was no conversion from low-pressure to standard pressure. Laparoscopic cholecystectomy performed under low-pressure pneumoperitoneum with deep NMB may have lesser inflammation and lesser post-operative pain compared to standard pressure pneumoperitoneum with moderate NMB. Future studies with larger sample size need to be designed to support these findings.

Indicators and effectiveness of sensory and motor blocking unilateral spinal anesthesia combined with unilateral epidural analgesia

Indicators and effectiveness of sensory and motor blocking unilateral spinal anesthesia combined with unilateral epidural analgesia

Comparison of Ropivacaine with or without Fentanyl in Spinal Anaesthesia for Lower Limb Surgeries

Introduction: Spinal anaesthesia is a preferred technique used for lower limb orthopaedic surgeries. Ropivacaine with its short duration of motor blockade and provision for early ambulation along with addition of spinal additives has proven beneficial to the patient. This prospective, double-blind, randomized controlled study set out to evaluate the effects of 0.75% isobaric ropivacaine with fentanyl versus 0.75% isobaric ropivacaine during lower limb orthopaedic surgeries performed under spinal anaesthesia. Methods: The study enrolled 74 patients, aged 18-65 years of either sex, ASA PS I and II, planned for lower limb orthopaedic surgeries. Patients were randomly allocated to receive either 2.5 ml of 0.75% isobaric ropivacaine and 0.5ml of normal saline (Group R) or 2.5 ml of 0.75% isobaric ropivacaine and 0.5ml of fentanyl (25mcg) (Group RF). Results: The demographic profile, onset time of sensory block to T10 dermatome, time for complete motor blockade, maximum block height, duration of motor block, and haemodynamic parameters did not significantly differ between the two groups. Group R took 200.27 ± 21.28 minutes for the S2 dermatome segment regression, while Group RF took 284.59 ± 32.88 minutes (p-value&lt;0.001). Group RF experienced analgesia for a longer duration (335.68±22.18 min) than Group R (240.00±28.28 min) (p-value&lt;0.001). Conclusion: Fentanyl greatly extends the duration of S2 segment regression and analgesia when combined with ropivacaine; the effects on haemodynamics and motor blockade is clinically negligible and side effects are minimal.

Effect of Atracurium and Rocuronium on the State and Response Entropy during Isoflurane Anesthesia: Randomized Prospective Study

Abstract Background Several researches have inspected the impact of inhalation anesthetics, intravenous anesthetics, and muscle relaxants on spectral entropy, but many didn’t evaluate the extent of neuromuscular block. Besides, they didn’t inspect the impact of distinct degrees of neuromuscular blockade on spectral entropy under dissimilar saturations of isoflurane inhalation. Hence, this study evaluated variant degrees of minimum alveolar concentration (MAC) to estimate the isoflurane concentration, along with various level of neuromuscular blockade. Aim of this study is to evaluate the effect of muscle relaxants (atracurium and rocuronium) on entropy readings (state, response entropy and response- state difference) during isoflurane anesthesia. This is a prospective randomized study where forty patients were included and divided into two study groups; patients in Group A received atracurium, while patients in Group R received rocuronium. State and response entropy were observed under MAC 0.8% and 1% under 50% and 100% neuromuscular blockage. Results There was a positive correlation between state (SE) and response entropy (RE) at baseline, different MAC, and different train of four (TOF) for both atracurium and rocuronium. State and response entropy decreased with increasing MAC of isoflurane (p &amp;lt; 0.001), while atracurium and rocuronium at TOF 50% and 100% showed no effect on SE or RE or RE-SE (P &amp;gt; 0.05). Conclusions State and response entropy can be used effectively to evaluate depth of anesthesia at different isoflurane MAC and atracurium or rocuronium doses. Registration number: ClinicalTrials.gov Identifier: NCT 05097508, Registered 5 October 2021 - prospectively registered, http://www.ClinicalTrial.gov