Neuromuscular Blockade Research Articles

Is pericapsular nerve group block superior to other regional analgesia techniques following total hip arthroplasty? a systematic review and network meta-analysis

BackgroundA systematic review and network meta-analysis (NMA) to compare the safety and efficacy of pericapsular nerve group block (PENGB) with other regional analgesia techniques in patients undergoing total hip arthroplasty (THA).MethodsWe searched PubMed, Embase, Web of Science, and the Cochrane Library for relevant research from inception to May, 2024. Randomized controlled trials (RCTs) comparing PENGB with other regional analgesia techniques in patients undergoing THA were included. The primary outcome was resting pain scores at 6 h after surgery. The NMA was made by using Stata 15.1 software. Potential risk of bias was assessed by using CINeMA. Sensitivity and subgroup analyses were performed on the primary outcome.ResultsA total of 11 RCTs including 766 patients were eligible for inclusion. For postoperative resting and movement pain scores within 24 h analysis, PENGB + periarticular local anesthetic infiltration (PLAI) was found to be significantly more effective than other treatments and its Surface under the cumulative ranking curve (SUCRA) was the lowest. Moreover, PENGB + PLAI was ranked the best in reducing opioid consumption within 24 h and the length of hospital stay. PENGB was found to have significantly lower incidence of quadriceps motor block and postoperative nausea and vomiting (PONV).ConclusionsPENGB is more likely to reduce the incidence of quadriceps motor block and PONV in patients undergoing THA, but PENGB + PLAI is superior to other regional analgesia techniques (PLAI, PENGB, fascia iliaca compartment block, and quadratus lumborum block) in improving postoperative pain and shortening the length of hospital stay.Trial registration numberCRD42024538421.

Comparison of Low-dose Diluted Hyperbaric Bupivacaine and Standard Hyperbaric Bupivacaine in Subarachnoid Block for Ambulatory Endovenous Laser Ablation of Varicose Vein: A Randomized Controlled Trial

Abstract Background: Low-dose spinal anesthesia represents a highly coveted anesthetic technique for patients undergoing endovenous laser ablation of varicose veins in a day-care setting, given its prompt onset, reliable anesthesia, brief turnover time, and cost-effectiveness. Given that intense motor block is not required for this procedure, this trial compared the efficacy of low-dose diluted hyperbaric bupivacaine with standard hyperbaric bupivacaine in the subarachnoid block for endovenous laser ablation of varicose veins. Methodology: A prospective, randomized controlled trial at a tertiary care hospital, Tamil Nadu, South India. Sixty individuals with varicose veins requiring endovenous laser ablation surgery were split at random into two groups. Group A (n = 30) got 0.5% hyperbaric bupivacaine 10 mg (2 ml), Group B (n = 30) got diluted hyperbaric bupivacaine 5 mg (1 ml of 0.5% hyperbaric bupivacaine diluted with an equivalent volume of normal saline) intrathecally. This study evaluated the time to surgical readiness, peak sensory block level, motor block grade, sensory block level at the completion of surgery, duration of motor and sensory blocks, and timing of discharge. Results: The median peak sensory block level for Group A was T6 (T8–T6), whereas for Group B it was T8 (T10–T6), with a P = 0.03. At the conclusion of surgery, the median sensory block level was T6 (T6–T8) for Group A and T8 (T7–T10) for Group B. No patients in either group needed a rescue analgesic. The average timing of discharge for Group B was shorter (P = 0.00002). Conclusion: For patients receiving endovenous laser ablation therapy for varicose veins, subarachnoid blockade with low-dose diluted hyperbaric bupivacaine (5 mg) offers an effective anesthesia, the best recovery profile, and early hospital discharge.

Association Between Neuromuscular Blocking Agents and Outcomes of Emergency Tracheal Intubation: A Secondary Analysis of Randomized Trials

To examine the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt and severe complications during tracheal intubation of critically ill adults in an emergency department (ED) or ICU. We performed a secondary analysis of data from 2 multicenter randomized trials in critically ill adults undergoing tracheal intubation in an ED or ICU. Using a generalized linear mixed-effects model with prespecified baseline covariates, we examined the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt (primary outcome) and severe complications during tracheal intubation (secondary outcome). Among the 2,440 patients in the trial data sets, 2,339 (95.9%) were included in the current analysis; 475 patients (20.3%) received succinylcholine and 1,864 patients (79.7%) received rocuronium. Successful intubation on the first attempt occurred in 375 patients (78.9%) who received succinylcholine and 1,510 patients (81.0%) who received rocuronium (an adjusted odds ratio of 0.87; 95% CI 0.65 to 1.15). Severe complications occurred in 67 patients (14.1%) who received succinylcholine and 456 patients (24.5%) who received rocuronium (adjusted odds ratio, 0.88; 95% CI 0.62 to 1.26). Among critically ill adults undergoing tracheal intubation, the incidences of successful intubation on the first attempt and severe complications were not significantly different between patients who received succinylcholine and patients who received rocuronium.

Effect of Neuromuscular Blockade Reversal on Postoperative Gastrointestinal Motility after Laparoscopic Cholecystectomy: Neostigmine / Atropine versus Sugammadex.

To compare sugammadex with neostigmine / atropine combination for reversal of neuromuscular blocker agents in terms of postoperative gastrointestinal motility in patients who underwent laparoscopic cholecystectomy. Experimental study. Place and Duration of the Study: University of Health Sciences, Izmir Bozyaka Training and Research Hospital, Izmir, Turkiye, between December 2020 and June 2021. Seventy-two patients undergoing laparoscopic cholecystectomy were included. At the end of the surgery, patients were antagonised for neuromuscular blockers either by atropine / neostigmine or sugammadex by an anaesthesiologist who was not involved in the study. Total anaesthesia time, pneumoperitoneum time, surgery time, number of postoperative opioid dose requirements and total opioid dose administered, number of medication requirements for postoperative nausea and vomiting, postoperative hospital stay, and first gas and stool output time of all the cases were evaluated by the researcher who was unaware of the medicines used for antagonisation. There were no statistically significant differences between the two groups in terms of their effects on postoperative gastrointestinal motility (first gas and stool output time), duration of anaesthesia, duration of surgery, duration of pneumoperitoneum, the number of postoperative opioid dose requirements, the number of drug requirements for postoperative nausea / vomiting, and the postoperative hospitalisation duration of the cases. Effects of reversal agents on postoperative gastrointestinal motility are still debated. Studies on this subject in the literature are both limited in number and have been conducted with different medicine combinations in a wide variety of patient populations. The authors thought that further prospective randomised studies are needed to interpret this effect more clearly. Sugammadex, Neostigmine / atropine, Gastrointestinal motility, Laparoscopic cholecystectomy.

Minimum Local Anesthetic Dose of Ropivacaine in Cesarean Section for Real-Time Ultrasound-Guided Spinal Anesthesia Using 24-Gauge versus 26-Gauge Needles Based on Fluid Simulation Technology: A Randomized Controlled Trial.

Previous research has demonstrated that real-time ultrasound-guided (UG) spinal anesthesia requires a higher minimum local anesthetic dose (MLAD) compared to traditional methods. However, the precise MLAD of ropivacaine for UG cesarean sections remains undetermined. In this study, we ascertained the MLAD of ropivacaine for cesarean section. We also investigated the mechanism underlying the diffusion of ropivacaine within the spinal canal using fluid simulation technology. We randomly placed 60healthy parturients undergoing elective cesarean section with real-time UG spinal anesthesia into Groups I (26-gauge spinal needle) and II (24-gauge spinal needle). For the first parturient in both groups, 15 mg of ropivacaine was administered intrathecally. Based on the effective or ineffective response of the previous parturient, the dose for the subsequent parturient was increased or decreased by 1 mg. Spinal anesthesia characteristics and side effects were recorded. A computer-generated spinal canal model was developed. Leveraging fluid dynamics simulation technology, we documented the diffusion of ropivacaine in the spinal canal using 26-and 24-gauge spinal needles. The MLADs in Groups I and II were 12.728 mg (12.339-13.130 mg) and 9.795 mg (9.491-10.110 mg), respectively. No significant difference was observed in the onset times and durations of sensory or motor blocks, incidence of complications, or neonatal Apgar scores between both groups. Fluid simulation modeling indicated that the 26-gauge spinal needle achieved a higher distribution level more quickly; however, its peak drug concentration was lower compared to the 24-gauge spinal needle. For cesarean section anesthetization, the required MLAD of ropivacaine when using a real-time UG 26-gauge spinal needle is significantly greater than that with a 24-gauge needle. The spinal needle diameter influences ropivacaine's MLAD by markedly affecting its diffusion rate within the spinal canal.

Effect of Single Low-Dose Dexamethasone on Peri-operative Blood Glucose Levels

Background: Post-operative nausea and vomiting (PONV) is the second most common complaint reported after surgery with an incidence of 30%-80%. PONV is associated with numerous morbidities, hence prevention is beneficial. Dexamethasone is used as a prophylactic anti-emetic agent, however, being a corticosteroid, it could cause hyperglycaemia which is associated with a number of other adverse effects. Objectives: To study the effect of a single low-dose intravenous dexamethasone given as a prophylactic anti-emetic agent on perioperative blood glucose levels. Methods: Eighty-eight women who had elective myomectomy or hysterectomy under combined spinal-epidural (CSE) anaesthesia were randomised into two groups of 44 each. Following baseline blood glucose estimation, one group had 4 mg (1 ml) of intravenous dexamethasone 1-2 seconds after blood glucose check while the control group had 1 ml of normal saline. Blood glucose was measured every hour intra-operatively and two-hourly post-operatively till 12 hours after drug administration. Nausea, vomiting, dyspepsia, pain, motor block duration and urinary output were assessed hourly. Results: The mean maximum change in blood glucose from baseline in the dexamethasone group was statistically significantly higher than in the control group, 51.00±26.57 mg/dl vs. 35.80±25.71 mg/dl (p = 0.007) so also was the mean maximum blood glucose, 153.93±31.63 mg/dl vs. 139.52±28.95 mg/dl (p = 0.028) respectively. Conclusion: Intravenous dexamethasone at a single, low-dose (4 mg) used as a prophylaxis for nausea and vomiting is associated with significant increase in blood glucose concentration.

Comparative Efficacy of Intrathecal Hyperbaric Levobupivacaine With Fentanyl Versus Hyperbaric Bupivacaine With Fentanyl in Elective Cesarean Section.

Background In parturient posted for elective cesarean sections, a widely used local anesthetic in the subarachnoid blockade is racemic hyperbaric bupivacaine. Hyperbaric levobupivacaine, the pure S (-) isomer of bupivacaine, was introduced and has since become more widely used in India because of its short duration of motor blockade and reduced risks of neurotoxicity and cardiotoxicity. This study aimed to compare the characteristics of sensory and motor blockade and side effects of equivalent doses of hyperbaric bupivacaine and levobupivacaine with opioid additive fentanyl in order to extend the duration of analgesia during elective cesarean births. Methodology A total of 130 women classified as American Society of Anesthesiologists (ASA) class I and II who are undergoing elective cesarean sections were enrolled in this randomized, prospective, double-blind comparative study after providing written informed consent. They were randomly assigned to one of two groups: Group LF, which included 65 women, obtained 25 mcg (0.5 ml) of fentanyl and 10 mg (2 ml) of hyperbaric levobupivacaine, or Group BF, which included 65 women, received 25 mcg (0.5 ml) of fentanyl and 10 mg (2 ml) of hyperbaric bupivacaine. Pinprick, cold swab, and the Bromage scale are used to assess the characteristics of sensory and motor blockade; hemodynamic alterations and adverse effects are also observed. Results The levobupivacaine group, consisting of 65 participants aged between 21 and 29 years, exhibited fewer side effects and significantly shorter durations of sensory and motor block compared to the bupivacaine group. In both groups, hemodynamic stability is comparable. Levobupivacaine provides analgesia for a significantly shorter period compared to bupivacaine. Conclusions In cesarean procedures, intrathecal hyperbaric levobupivacaine and fentanyl can be effective alternatives to hyperbaric bupivacaine and fentanyl due to their ability to maintain hemodynamic stability while providing adequate sensory and motor blockade.

Effect of low-volume ropivacaine in ultrasound-guided superior trunk block on diaphragmatic movement in patients undergoing shoulder arthroscopy: a randomized controlled trial

ObjectivesThe incidence of hemidiaphragmatic paresis (HDP) in superior trunk block (STB) usually depends on the dose of local anesthetic. This study aimed to further evaluate the impact of a lower volume (10 mL) of the same low concentration (0.25%) ropivacaine compared to a conventional volume (15 mL), on diaphragmatic function and analgesic efficacy under a multimodal analgesia regimen for shoulder arthroscopy.MethodsPatients scheduled to undergo shoulder arthroscopy were randomized allocated to receive either 10 mL or 15 mL of 0.25% ropivacaine in the STB under ultrasound guidance prior to general anesthesia. The primary outcome was the percentage reduction in diaphragm excursion (ΔDE) between baseline and 30 min after block. Secondary outcomes included DE and diaphragm thickening fraction (DTF) before and after block, incidence of HDP, onset of sensory/motor block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity, pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, and adverse events post-surgery.ResultsCompared with 15 mL volume, 10 mL ropivacaine significantly reduced the incidence of post-block HDP (as measured by ΔDE: 39.47% vs. 64.10%; and by post-block DTF: 13.16% vs. 33.33%). There was no significant difference in onset of sensory block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity between the two groups, except that the onset of motor block was significantly slower in the 10 mL group than in the 15 mL group. Pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, or postoperative adverse events were not significantly different between the two groups.ConclusionIn shoulder arthroscopy, STB with 10 mL of ropivacaine can reduce the incidence of HDP with no significant difference in analgesic effects under a multimodal analgesia regimen compared with 15 mL.Trial registration: We registered the study at chictr.org (ChiCTR2200057543 , 14/03/2022.https://www.chictr.ogr.cn

Structure-Activity Relationship Studies Leading to the Discovery of Highly Water-Soluble and Biocompatible Acyclic Cucurbit[n]uril FY-3451 as a Universal Antagonist That Rapidly Reverses Neuromuscular Blocking Agents In Vivo.

The development of a reversal agent that can rapidly reverse clinically used nondepolarizing neuromuscular blocking agents (NMBAs) has long been a challenge. Here, we report the synthesis of a series of highly water-soluble acyclic cucurbit[n]urils (acCBs). Systematic structure-activity relationship studies reveal that introducing two propylidene units on the peripheral benzene rings not only remarkably improves the activity of the corresponding derivative acCB6 (FY 3451) in reversing the neuromuscular block of rocuronium, cisatracurium, vecuronium, and pancuronium, the four clinically used NMBAs, through stable inclusion, but also allows for high water-solubility as well as a maximum tolerated dose (2000 mg/kg on rats). In vivo experiments with rats show that, at the identical dose of 25 mg/kg, for rocuronium, vecuronium, and pancuronium, acCB6 can achieve a recovery time shorter than that of sugammadex for rocuronium and, at the dose of 100 mg/kg, realize comparably rapid reversal for cisatracurium.

Study To Assess The Onset And Duration Of Sensory And Motor Block In Both Groups (IV Dexamethasone Compared To Normal Saline) In Patients Undergoing Below Umbilical Surgeries

Study To Assess The Onset And Duration Of Sensory And Motor Block In Both Groups (IV Dexamethasone Compared To Normal Saline) In Patients Undergoing Below Umbilical Surgeries

Effectiveness of Two Models of Telerehabilitation in Improving Recovery from Subacute Upper Limb Disability after Stroke: Robotic vs. Non-Robotic.

Finding innovative digital solutions is fundamental to ensure prompt and continuous care for patients with chronic neurological disorders, whose demand for rehabilitation also in home-based settings is steadily increasing. The aim is to verify the safety and the effectiveness of two telerehabilitation (TR) models in improving recovery from subacute upper limb (UL) disability after stroke, with and without a robotic device. One hundred nineteen subjects with subacute post-stroke UL disability were assessed for eligibility. Of them, 30 patients were enrolled in the study and randomly assigned to either the Robotic Group (RG), undergoing a 20-session TR program, using a robotic device, or the Non-Robotic Group (NRG), undergoing a 20-session TR program without robotics. Clinical evaluations were measured at baseline (T0) and post-intervention (T1, 5 weeks after baseline), and included assessments of quality of life, motor skills, and clinical/functional status. The primary outcome measure was the World Health Organization Disability Assessment Schedule 2.0, evaluating the change in perceived disability. Statistical analysis shows that patients of both groups improved significantly over time in all domains analyzed (mean decrease from baseline in the WHODAS 2.0 of 6.09 ± 2.62% for the NRG, and of 0.76 ± 2.21% for the RG), with a greater improvement of patients in the NRG in motor (Fugl-Meyer Assessment Upper Extremity-motor function, Box and Block Test) and cognitive skills (Trail Making Test-A). This study highlights the potential of TR programs to transform stroke rehabilitation by enhancing accessibility and patient-centered care, promoting autonomy, improving adherence, and leading to better outcomes and quality of life for stroke survivors.

Suspected intracranial hypertension in COVID-19 patients with severe respiratory failure.

COVID-19 patients may exhibit neurological symptoms due to direct viral damage, systemic inflammatory syndrome, or treatment side effects. Mechanical ventilation in patients with severe respiratory failure often requires sedation and neuromuscular blockade, hindering thorough clinical examinations. This study aimed to investigate neurological involvement through clinical and noninvasive techniques and to detect signs of intracranial hypertension in these patients. We conducted a prospective observational study on mechanically ventilated COVID-19 adult patients admitted to our ICU, following standard of care protocols for ventilation and permissive hypercapnia. Data were collected at three time points: admission day (T1), day seven (T7), and day fourteen (T14). At each time point, patients underwent multimodal noninvasive neurological monitoring, including clinical examination, pupillary reactivity, transcranial color doppler of the middle cerebral artery (MCA), and optic nerve sheath diameter (ONSD) assessed via ultrasound (US). Head computer tomography (CT) was performed at T1 and T14. A limited subset of patients had a follow-up examination six months after ICU discharge. Seventy-nine patients were recruited; most were under deep sedation and neuromuscular blockade at T1. Pupillary size, symmetry, and reactivity were normal, as was the MCA mean velocity. However, ONSD, assessed by both US and CT, appeared enlarged, suggesting raised intracranial pressure (ICP). In a subgroup of 12 patients, increased minute ventilation was associated with a significant decrease in US-ONSD, corresponding to a drop in paCO2. At follow-up, twelve patients showed no long-term neurological sequelae, and US-ONSD was decreased in all of them. In this cohort, enlarged ONSD was detected during non-invasive neurological monitoring, suggesting a raised ICP, with hypercapnia playing a prominent role. Further studies are needed to explore ONSD behavior in other samples of mechanically ventilated, hypercapnic patients.

Low-Dose Opioid Spinal Analgesia during Cesarean Section at the Commune 1 Reference Health Center of Bamako

The need to provide maternal comfort and facilitate rapid recovery during caesarean section requires pain management. The aim of our study of low-dose morphine spinal analgesia during caesarean section was to evaluate its effectiveness during and after the operation. Methodology: We conducted a prospective, descriptive, cross-sectional study lasting 6 months from 1 July to 31 December 2023. It involved 101 Caesarean women undergoing spinal analgesia, selected by random sampling at the reference health centre in Commune I of the Bamako district. Results: The mean age of the patients was 27 ±1.51 years, with ASA I classification in 63.4%. The combination of bupivacaine 10 mg and morphine 0.1 mg was used in 68.3% of cases. The mean duration of motor block release was 2.78 ± 0.7 hours. The manifestation of pain (VAS=0) was 100% at H1 (first hour), with peaks of VAS [1,3] in 42.57% and VAS [4,6] in 6.97% at H4 (fourth hour). Arterial hypotension was found in 57% of cases. From H12 onwards, all the women were very satisfied. Conclusion: The efficacy of morphine spinal analgesia during caesarean section has been proven in all our parturients from H12 (twelfth hour). However, pain management in the first few hours must be started with a well-adapted protocol.

Comparison of Duration of Action in Spinal Anesthesia of 0.5% Bupivacaine and 0.5% Bupivacaine with Dexmedetomidine

Background: Spinal anesthesia is a common technique for surgeries below the navel, utilizing bupivacaine, a local anesthetic. Adding adjuncts like dexmedetomidine may enhance the efficacy and duration of the block.Objective: To compare the duration of action of 0.5% bupivacaine versus 0.5% bupivacaine with dexmedetomidine in spinal anesthesia.Methods: This quasi-experimental trial included 60 patients aged 20-60 years, ASA grade 1 or 2, undergoing general, plastic, orthopedic, or urological surgery at CMH Karachi. Patients were non-randomly assigned to Group B (0.5% bupivacaine, n=30) or Group BD (0.5% bupivacaine plus 5 mcg dexmedetomidine, n=30). Onset and duration of sensory and motor blocks, duration of analgesia, and adverse effects were recorded. Data were analyzed using SPSS version 25, with a p-value ≤ 0.05 considered significant.Results: Group BD showed faster onset of sensory block (7.08 ± 0.54 mins vs. 13.48 ± 0.73 mins, p < 0.001) and motor block (10.32 ± 0.91 mins vs. 17.55 ± 0.69 mins, p < 0.001). Duration of motor block was longer in Group BD (284.06 ± 5.64 mins vs. 133.93 ± 5.72 mins, p < 0.001), as was duration of analgesia (218.07 ± 4.86 mins vs. 125.36 ± 5.42 mins, p < 0.001).Conclusion: The addition of dexmedetomidine to 0.5% bupivacaine significantly enhances the onset and duration of spinal anesthesia with a comparable safety profile.

Safety and efficacy of the Tao facemask for positive pressure ventilation in morbidly obese patients

Purpose: Positive-pressure mask ventilation is an essential skill for individuals providing basic and advanced airway interventions in a variety of clinical settings. The C-E grip technique is most commonly used with standard facemasks to provide an effective seal that allows for positive pressure ventilation. The Tao mask is a novel facemask that utilises an ergonomic grip by using downwards pressure of the palm of the hand accompanied by midline jaw lift. Specifically, the technique to create a seal involves downwards pressure of the palm centred on the mask accompanied by a jaw lift with four fingers centred under the mandible. A previous comparison between the Tao and standard masks revealed superior performance across a cross-section of average patients. The purpose of this study was to evaluate the safety and effectiveness of the Tao mask compared to the standard mask in a subset of patients with morbid obesity as defined by a body mass index (BMI) greater than or equal to 40 kg/m2. Methods: This prospective crossover trial included 156 patients aged ⩾18 years at the Medical University of South Carolina who were scheduled for elective surgery under general endotracheal anaesthesia with a BMI of ⩾40 kg/m2 at the time of surgery. After the induction of general anaesthesia, but prior to the administration of a neuromuscular blocking drug (NMBD), each patient was ventilated with both the standard and Tao masks, and effectiveness was measured using both the Han and Warters scales. The process was repeated after the administration of an NMBD. Results: Data were collected and analysed from 153 individuals. The mean BMI was 50.7 ± 9.3 kg/m2. The Tao mask ventilation scores were significantly lower (more effective) than the standard mask scores on both the Han and Warters Scales before pre-NMBD ( p = 0.0002 and p < 0.001, respectively) and after post-NMBD ( p = 0.002 and p < 0.001, respectively). On the Warters Scale, it was significantly easier to ventilate with the Tao Mask pre-NMBD ( p = 0.0001). On the Han Scale, the Tao mask was significantly easier than the standard mask post-NMBD ( p = 0.03). With regard to mask sequence, the mean Warters scores were lower for the Tao mask pre-NMBD only when the standard mask was used first ( p = 0.002). Similarly, the difference in the mean Warters scores post-NBMD was significant only when the standard mask was used first ( p = 0.02). Conclusion: The Tao mask demonstrated equivalent safety and superior effectiveness in ventilating morbidly obese surgical patients despite a trial design that favoured the standard mask owing to anaesthetist experience. The use of the Tao mask may be particularly beneficial in clinical situations involving inexperienced operators or in patients for whom mask ventilation is likely to be difficult. ClinicalTrials.gov registration number: NCT03473366

Respiratory effects of prone position in COVID-19 acute respiratory distress syndrome differ according to the recruitment-to-inflation ratio: a prospective observational study

BackgroundImprovements in oxygenation and lung mechanics with prone position (PP) in patients with acute respiratory distress syndrome (ARDS) are inconstant. The objectives of the study were (i) to identify baseline variables, including the recruitment-to-inflation ratio (R/I), associated with a positive response to PP in terms of oxygenation (improvement of the ratio of arterial oxygen partial pressure over the inspired oxygen fraction (PaO2/FiO2) ≥ 20 mmHg) and lung mechanics; (ii) to evaluate whether the response to the previous PP session is associated with the response to the next session.MethodsIn this prospective, observational, single-center study in patients who underwent PP for ARDS due to COVID-19, respiratory variables were assessed just before PP and at the end of the session. Respiratory variables included mechanical ventilation settings and respiratory mechanics variables, including R/I, an estimate of the potential for lung recruitment compared to lung overinflation.ResultsIn 50 patients, 201 PP sessions lasting 19 ± 3 h were evaluated. Neuromuscular blockades were used in 116 (58%) sessions. The PaO2/FiO2 ratio increased from 109 ± 31 mmHg to 165 ± 65 mmHg, with an increase ≥ 20 mmHg in 142 (71%) sessions. In a mixed effect logistic regression, only pre-PP PaO2/FiO2 (OR 1.12 (95% CI [1.01–1.24])/every decrease of 10 mmHg, p = 0.034) in a first model and improvement in oxygenation at the previous PP session (OR 3.69 (95% CI [1.27–10.72]), p = 0.017) in a second model were associated with an improvement in oxygenation with PP. The R/I ratio (n = 156 sessions) was 0.53 (0.30–0.76), separating lower- and higher-recruiters. Whereas PaO2/FiO2 improved to the same level in both subgroups, driving pressure and respiratory system compliance improved only in higher-recruiters (from 14 ± 4 to 12 ± 4 cmH2O, p = 0.027, and from 34 ± 11 to 38 ± 13 mL/cmH2O, respectively, p = 0.014).ConclusionsA lower PaO2/FiO2 at baseline and a positive O2-response at the previous PP session are associated with a PP-induced improvement in oxygenation. In higher-recruiters, lung mechanics improved along with oxygenation. Benefits of PP could thus be greater in these patients.

Buprenorphine with Bupivacaine 0.5% Heavy Versus Clonidine with Bupivacaine 0.5% Heavy Versus Bupivacaine 0.5% Heavy Alone in Patients Undergoing Total Abdominal Hysterectomy: A Comparative Study

Background and Aims: This research aimed to determine which of three spinal anaesthetic medication combinations—clonidine–bupivacaine, buprenorphine–bupivacaine and bupivacaine alone—is the most effective for total abdominal hysterectomy. Material and Methods: In this prospective study, approved by the Institutional Ethical Committee, 120 patients aged 35–60 years scheduled for elective total abdominal hysterectomy under spinal anaesthesia were included, following informed consent. Comprehensive pre-anaesthetic assessments, including detailed medical histories, clinical examinations and routine surgical investigations, were conducted. The study, spanning 24 months, utilised purposive sampling and a cross-sectional design. The inclusion criteria encompassed ASA I and II patients aged 35–60 years, undergoing elective total abdominal hysterectomy with a weight exceeding 45 kg, height over 150 cm, and valid informed consent. Exclusion criteria involved ASA Class III or higher, patient unwillingness for spinal anaesthesia, gross spinal deformities, bleeding diathesis, known allergy to the test drug, history of cardiac, respiratory, or central nervous system disease, hepatic or renal dysfunction and elevated intracranial pressure. Results: The onset time of sensory blockade was faster in the Bupivacaine + Buprenorphine group than in the Clonidine + Bupivacaine group, with the Bupivacaine group exhibiting the slowest onset. The Bupivacaine + Buprenorphine group had a significantly faster onset of motor block than the Clonidine + Bupivacaine and Bupivacaine groups. The total duration of motor block was shorter in both the Bupivacaine + Buprenorphine and Bupivacaine groups than in the Clonidine + Bupivacaine group. The Clonidine + Bupivacaine group showed higher incidences of bradycardia and hypotension than the other groups. The Bupivacaine + Buprenorphine group reported more side effects, including chest pain, cough, nausea and vomiting, than the other groups. Conclusion: This study found that spinal clonidine, in comparison to bupivacaine alone, gives better post-operative analgesia and sensory and motor blockage over a longer period of time.

Ultrasound-Guided Lumbar Plexus-Sciatic Nerve Blocks Versus Epidurals for Orthopaedic Surgeries: A Study to Compare the Competency of Novice Anaesthesiology Residents in a High-Volume Level 1 Trauma Centre.

The relative merits of peripheral nerve blocks (PNB) over central neuraxial anaesthesia and the advantages of the above two techniques over general anaesthesia for surgical interventions of the lower limb are well established. The competency of anaesthetic trainees in a high-volume level 1 trauma centre in administering dual ultrasound and nerve stimulator-guided lumbar plexus-sciatic nerve block(DUNLuPS) vs. epidural anaesthesia (EA) was compared by reporting the adequacy of anaesthesia with the two techniques, time taken for the performance of block, time of onset of sensoryblock (TOSB), and time of onset of motor block (TOMB). This prospective, randomized, study enrolled 92 patients aged 18-80 years with lower limb fractures admitted in trauma triage and scheduled for surgery. Thepatients were randomly allocated equally into the EA group and the DUNLuPS group. A total of 20 anaesthesia trainees in the third year of residencywith clinical experience of more than 15 independent lumbar plexus-sciatic nerve blocks were included in the study.A volume of 20 ml of 0.5% ropivacaine was administered in the lumbar plexus (Shamrock technique) but the volume used for sciatic nerve (subgluteal approach) was varied so that the cumulative dose did not exceed 3 mg/kg. For each block, the onset of nerve blockade was assessed every five minutes, and the assessments continued for an additional 30 minutes after the nerve blocks were finished. Clinical characteristics and adequacy of anaesthesia were comparable, i.e., 95.65% and93.47% success in the EA (n = 46) and DUNLuPS (n = 46) groups, respectively. Performance time was significantly more in the DUNLuPS group but followed by significantly less TOSB and TOMB. The time for the first analgesic request was 351.63 ± 148.70 minutes in the DUNLuPS group and 147.60 ± 52.65 minutes in the EAgroup (p < 0.0001). Both EA and DUNLuPS provide effective and comparable intra-operative anaesthesia for orthopaedic lower limb surgeries (OLLS) when administered by residents with more than two years of experience (third year of residency)in ultrasound-guided regional nerve blocks in a high-volume level 1 trauma centre. Statistically significant differences in the block performance characteristicshad no clinical advantage as it was compensated by the faster onset time in the DUNLuPS group. Post-operative pain management was better in the DUNLuPS group, sothe practice and conduct of anaesthesia for trauma patients should focus on the establishment of "block rooms" and timely training of residents in the former so that the advantages can be extended to the patient population.

Variability in temperature control practices amongst the Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial

AimTemperature control is a complex bundled intervention; the synergistic impact of each individual component is ill defined and underreported. Resultantly, the influence of parameter optimization on temperature control’s overall neuroprotective effect remains poorly understood. To characterize variability in temperature control parameters and barriers to short pre-induction and induction times, we surveyed sites enrolling in an ongoing multicenter clinical trial. MethodsThis was a cross-sectional, survey study evaluating temperature control practices within the Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial (NCT04217551). A 23-question web-based survey (Qualtrics) was distributed to the site principal investigators by email. Respondents were asked about site practices pertaining to the use of temperature control, including the request to upload individual institutional protocols. Open-ended responses were analyzed qualitatively by categorizing responses into identified themes. To complement survey level data, records pertaining to the quality of temperature control were extracted from the ICECAP trial database. ResultsThe survey response rate was 75% (n = 51) including 23.5% (n = 12) survey respondents who uploaded institutional protocols. Most sites reported having institutional protocols for temperature control (n = 41; 80%), including 62.5% (n = 32) who had separate protocols for initiation of temperature control in the emergency department (ED). Fewer sites had protocols specific to sedation or neuromuscular blockade (NMB) management (n = 35, 68.6%). Use of NMB during temperature control induction was variable; 61.7% (n = 29) of sites induced paralysis less than 20% of the time. While most institutional protocols (n = 11, 83.3%) commented on the importance of early initiation of temperature control, this was incongruent with the largest reported barrier, which was clinical nihilism regarding the importance of early temperature control initiation (n = 30, 62.5%). Within the ICECAP trial database, 1 in 2 patients were treated with NMB however, use of NMB and time to initiation of temperature control device varied widely between sites. ConclusionAmongst ICECAP trial sites, there was significant variability in resources, methods, and barriers for early temperature control initiation. Defining and standardizing high-quality temperature control must be prioritized, as it may impact the interpretation of past and current clinical trial findings.

Effect of sugammadex with neostigmine on postoperative bowel function and on recovery of neuromuscular functions: A randomized controlled trial.

Early recovery of neuromuscular and bowel function after abdominal surgery are important clinical indicators of postoperative recovery. This study aimed to investigate the effects of sugammadex, and neostigmine added to sugammadex, on postoperative bowel function and recovery from neuromuscular blocking agents. Ninety gynecological surgery patients, aged 18 to 65 years, with American Society of Anesthesiologists of 1 to 2 were randomly assigned to 3 groups: sugammadex 2 mg/kg (Group S), sugammadex 1 m/kg with neostigmine 20 µg/kg + atropine 10 µg/kg (Group S1N), and sugammadex 1.5 mg/kg with neostigmine 20 µg/kg + atropine 10 µg/kg (Group S2N), for reversal at the end of surgery during moderate block (train-of-four [TOF] count 1-2). Propofol, remifentanil, rocuronium, and sevoflurane were used for general anesthesia, and neuromuscular function was assessed using kinemyography. The primary outcomes assessed the effects of sugammadex alone and in combination with neostigmine on the time to first flatus. The secondary outcomes included time to first defecation and recovery time; defined as the administration of reversal agent to TOF ratio 90%. Data from 90 female patients who underwent abdominal gynecological surgery were analyzed. No significant differences were found between the groups in term of the time to first flatus, defecation, or postoperative nausea and vomiting after surgery. However, significant differences were observed in the time to reach a TOF ratio 90% (P < .001) and extubation time (P = .003). The addition of neostigmine to sugammadex did not affect bowel function recovery. However, combining 20 μg/kg neostigmine with 1.5 mg/kg sugammadex or 2 mg/kg sugammadex alone antagonized moderate-depth nondepolarizing neuromuscular blockade with similar efficacy.