Postoperative Respiratory Depression Research Articles

Practice Guidelines for Monitoring Neuromuscular Blockade-Elements to Change to Increase the Quality of Anesthesiological Procedures and How to Improve the Acceleromyographic Method.

Neuromuscular blocking agents are a crucial pharmacological element of general anesthesia. Decades of observations and scientific studies have resulted in the identification of many risks associated with the uncontrolled use of neuromuscular blocking agents during general anesthesia or an incomplete reversal of neuromuscular blockade in the postoperative period. Residual relaxation and acute postoperative respiratory depression are the most serious consequences. Cyclic recommendations have been developed by anesthesiology societies from many European countries as well as from the United States and New Zealand. The newest recommendations from the American Society of Anesthesiologists and the European Society of Anesthesiology were published in 2023. These publications contain very detailed recommendations for monitoring the dosage of skeletal muscle relaxants in the different stages of anesthesia-induction, maintenance and recovery, and the postoperative period. Additionally, there are recommendations for various special situations (for example, rapid sequence induction) and patient populations (for example, those with organ failure, obesity, etc.). The guidelines also refer to pharmacological drugs for reversing the neuromuscular transmission blockade. Despite the development of several editions of recommendations for monitoring neuromuscular blockade, observational and survey data indicate that their practical implementation is very limited. The aim of this review was to present the professional, technical, and technological factors that limit the implementation of these recommendations in order to improve the implementation of the guidelines and increase the quality of anesthesiological procedures and perioperative safety.

Ketodex versus opioid based anesthesia in cleft palate

Background & objective: Cleft palate is a congenital anomaly of the palate of the infants, and it may or may not be associated with cleft lip. The only remedy is surgical repair under general anesthesia. Postoperative pain relief in cleft palate repair surgery is very important to keep the infant or child calm and pain-free. It can only be achieved by use of analgesic drugs. We compared ketodex - a combination of ketamine and dexmedetomidine, versus opioid based anesthesia in cleft palate surgery as regards postoperative respiratory depression, need for oxygenation, and the emergence agitation.
 Methodology: Fifty children, aged 6 months to 5 y, undergoing cleft palate surgery under general anesthesia, were randomly assigned to either ketodex group (Group KD) or opioids group (Group OP). Group KD received ketamine 1mg/kg loading dose followed by infusion @ 0.1 mg/kg/h, and dexmedetomidine loading dose 1 µg/kg followed by infusion @ 0.2 µg/kg/h], isoflurane anesthesia. Group OP received fentanyl in a loading dose of 2 µg/kg followed by infusion @ 0.5 µg/kg/h, followed by isoflurane anesthesia. Heart rate, mean blood pressure, emergence agitation, extubation time, FLACC score for pain, surgeons’ satisfaction, and the adverse effects were noted.
 Results: Emergence agitation score was significantly lower in Group KD compared to Group OP. FLACC score showed insignificant difference between the two groups. There was no need for opioid administration in the PACU. Three patients in Group OP desaturated and needed oxygen supply. Incidence of vomiting was significantly higher in Group OP compared to Group KD (P = 0.022).
 Conclusion: Ketodex used in opioid free anesthesia for cleft palate repair surgery in children provides adequate pain relief without respiratory depression, and is a good alternative of routine opioid based general anesthesia.
 Key words: Ketamine; Dexmedetomidine; Opioids; Anesthesia; Recovery; Cleft Palate Surgery; Pediatrics
 Citation: Mohamed MM, Abdelraof AF, Noser MA. Ketodex versus opioid based anesthesia in cleft palate. Anaesth. pain intensive care 2024;28(1):74-80; DOI: 10.35975/apic.v28i1.2239
 Received: May 31, 2023; Reviewed: June 06, 2023; Accepted: January 02, 2024

Esketamine combined with sufentanil versus sufentanil in patient-controlled intravenous analgesia: a meta-analysis.

Objective: Patient-controlled intravenous analgesia (PCIA) can alleviate pain to some extent, and several randomized controlled trials (RCTs) have examined the efficacy of esketamine-assisted sufentanil in postoperative PCIA. In this research, we conducted a meta-analysis of relevant RCTs to compare the effect and safety of esketamine-sufentanil versus sufentanil alone for postoperative PCIA. Methods: We systematically searched the Cochrane Library, PubMed, Embase, Web of Science, CNKI, and other libraries up to December 2023 to screen out RCTs examining the use of esketamine combined with sufentanil for PCIA. We analysed analgesia scores, sedation scores, adverse drug reactions and postpartum depression scores as outcome indicators. Results: This meta-analysis included 32 RCTs. The results of the meta-analysis were as follows. 1) Visual Analog Scale: The VAS scores at 6, 12, 24, and 48h were lower in the esketamine-sufentanil group than in the sufentanil alone group, and significant differences were found at all time points (p < 0.05). 2) Ramsay Sedation Scale: The sedation score of the esketamine-sufentanil group at 48h after surgery was higher than that of the sufentanil group alone [mean difference (MD) = -0.09 points, confidence interval (CI): (-0.26, -0.07), p = 0.27], but this difference was not significant (p > 0.05). 3) Safety: Compared with sufentanil alone, the incidence rates of postoperative nausea-vomiting, dizziness-headache, skin pruritus and respiratory depression were significantly lower in the esketamine-sufentanil group. 4) Postartum depression: The reduction in postpartum depression scores were significantly greater in the esketamine-sufentanil group than in the sufentanil alone group at 3days [MD = -1.35 points, CI: (-1.89, -0.81), p < 0.00001] and 7days [MD = -1.29 points, CI: (-2.42, -0.16), p = 0.03]. Conclusion: The meta-analysis showed that the use of esketamine combined with sufentanil for postoperative PCIA could improve postoperative analgesia, alleviate postpartum depression and reduce the rate of postoperative adverse reactions, but there was no significant difference in sedation.

The safety and efficacy between remimazolam and propofol in intravenous anesthesia of endoscopy operation: a systematic review and meta-analysis.

Propofol is the most widely used intravenous anesthetic in endoscopic surgery, but is associated with several adverse reactions. Public research has shown that remimazolam, a safe general anesthetic, is increasingly being used as a substitute for propofol in clinical operations. Our meta-analysis aimed to analyze whether the adverse reaction rate of remimazolam in endoscopic surgery is acceptable and whether the surgical success rate is not lower than that of propofol. This meta-analysis examined the adverse events and efficacy of remimazolam vs. propofol during endoscopic surgery. MEDLINE, Embase, ClinicalTrials.gov, and Google Scholar were comprehensively searched. Seven studies comparing remimazolam and propofol were included in our meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane manual were used to assess the quality of the results published in all included studies to ensure that our meta-analysis results are reliable and worthwhile. Compared to propofol, the use of remimazolam reduced postoperative injection pain [relative risk (RR)=0.06, 95% confidence interval (CI): 0.03-0.12, P <0.00001], postoperative hypotension (RR=0.45, 95% CI: 0.28-0.73, P =0.001), and postoperative respiratory depression (RR=0.20, 95% CI: 0.08-0.47, P =0.0002); however, it also slightly reduced the success rate of the operation [risk difference (RD)=-0.02, 95% CI: -0.04 to -0.01, P =0.0007]. There were no significant differences in the occurrence of bradycardia symptoms after the operation (RD=-0.01, 95% CI: -0.03 to 0.01, P =0.35), recovery time after the operation [standardized mean difference (SMD)=0.68, 95% CI: -0.43 to 1.80, P =0.23] or discharge time (SMD=0.17, 95% CI: -0.58 to 0.23, P =0.41). We also performed a subgroup analysis of each corresponding outcome. Our analysis showed that remimazolam may be a safer shock option than propofol for endoscopic surgery. However, further research is required to determine their utility.

Opioids and postoperative respiratory depression

Opioids and postoperative respiratory depression

Postoperative opioid-induced respiratory depression or oversedation requiring naloxone treatment in a community hospital: a case series

Background Postoperative opioid-induced respiratory depression and oversedation can lead to fatal events and increase perioperative mortality. In reports from major academic centers, naloxone administration has been used as a proxy for severe opioid overdose. Herein, we studied the incidence, clinical characteristics, and outcomes of postoperative naloxone use in a mid-size community hospital. Methods This was a retrospective review of adult patients who received naloxone within 48 postoperative hours between July 9, 2017, and May 31, 2022. Results During the study timeframe, a total of 23,362 surgical procedures were performed and a total of 19 patients received naloxone (8 in the recovery room, 11 on hospital wards), with an incidence of 8.1 [95% confidence interval 4.9–12.7] per 10,000 anesthetics. In 12 cases (63%), naloxone was indicated for oversedation, and in 7 cases (37%), for opioid-induced respiratory depression. All patients received naloxone within the first 24 postoperative hours. While all patients survived the opioid-related adverse event, 2 patients were intubated, 1 developed stress-induced cardiomyopathy, and 5 required intensive care unit admission. Conclusion The rate of early postoperative opioid-induced respiratory depression or oversedation in our community hospital was low; however, these patients often require a substantial escalation of medical management.

Incidence of postoperative opioid-induced respiratory depression episodes in patients on room air or supplemental oxygen: a post-hoc analysis of the PRODIGY trial

BackgroundSupplemental oxygen (SO) potentiates opioid-induced respiratory depression (OIRD) in experiments on healthy volunteers. Our objective was to examine the relationship between SO and OIRD in patients on surgical units.MethodsThis post-hoc analysis utilized a portion of the observational PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial dataset (202 patients, two trial sites), which involved blinded continuous pulse oximetry and capnography monitoring of postsurgical patients on surgical units. OIRD incidence was determined for patients receiving room air (RA), intermittent SO, or continuous SO. Generalized estimating equation (GEE) models, with a Poisson distribution, a log-link function and time of exposure as offset, were used to compare the incidence of OIRD when patients were receiving SO vs RA.ResultsWithin the analysis cohort, 74 patients were always on RA, 88 on intermittent and 40 on continuous SO. Compared with when on RA, when receiving SO patients had a higher risk for all OIRD episodes (incidence rate ratio [IRR] 2.7, 95% confidence interval [CI] 1.4–5.1), apnea episodes (IRR 2.8, 95% CI 1.5–5.2), and bradypnea episodes (IRR 3.0, 95% CI 1.2–7.9). Patients with high or intermediate PRODIGY scores had higher IRRs of OIRD episodes when receiving SO, compared with RA (IRR 4.5, 95% CI 2.2–9.6 and IRR 2.3, 95% CI 1.1–4.9, for high and intermediate scores, respectively).ConclusionsDespite oxygen desaturation events not differing between SO and RA, SO may clinically promote OIRD. Clinicians should be aware that postoperative patients receiving SO therapy remain at increased risk for apnea and bradypnea.Trial registrationClinicaltrials.gov: NCT02811302, registered June 23, 2016.

Considerations for Functional Nasal Surgery in the Obstructive Sleep Apnea Population.

Obstructive sleep apnea (OSA) and nasal obstruction are common in the general population and frequently treated by otolaryngologists and facial plastic surgeons. Understanding the appropriate pre-, peri-, and postoperative management of OSA patients undergoing functional nasal surgery is important. OSA patients should be appropriately counseled in the preoperative period on their increased anesthetic risk. In OSA patients who are continuous positive airway pressure (CPAP) intolerant, the role of drug-induced sleep endoscopy should be discussed with the patient, and depending on the surgeon's practice may prompt referral to a sleep specialist. Should multilevel airway surgery be indicated, it can safely be performed in most OSA patients. Surgeons should communicate with the anesthesiologist regarding an airway plan given this patient population's higher propensity for having a difficult airway. Given their increased risk of postoperative respiratory depression, extended recovery time should be given to these patients and the use of opioids as well as sedatives should be minimized. During surgery, one can consider using local nerve blocks to reduce postoperative pain and analgesic use. After surgery, clinicians can consider opioid alternatives such as nonsteroidal anti-inflammatory agents. Neuropathic agents, such as gabapentin, require further research in their indications for managing postoperative pain. CPAP is typically held for a period of time after functional rhinoplasty. The decision on when to restart CPAP should be individualized to the patient based on their comorbidities, OSA severity, and surgical maneuvers performed. More research would provide further guidance in this patient population to shape more specific recommendations regarding their perioperative and intraoperative course.

OBESITY AND ANTICIPATED DIFFICULT AIRWAY- A COMPREHENSIVE APPROACH WITH VIDEOLARYNGOSCOPY, RAMP POSITION, SEVOFLURANE AND OPIOID FREE ANAESTHESIA

Background: Anaesthetic management of obese patient can be challenging because of altered anatomy and physiology. Safe apnea period is extremely short and videolaryngoscope is believed to reduce the number of failed intubation attempts. Slow emergence with fat-soluble volatile agents may be due to delayed release from adipose stores. Use of opioids in the presence of obesity increases the occurrence of obstructive sleep apnea, hypoxia and upper airway obstruction. The aim is to provide safe airway management in obesity by reducing the number of intubation attempts and the time taken for intubation with reduced post-operative respiratory depression. Methods: 25 patients with the BMI of &gt;30kg/m2 were selected. Standard technique for induction of anaesthesia using Inj. Dexmedetomidine 1mcg/kg 10 mins before intubation with patient in RAMP position was done. HugeMed videolaryngoscope with appropriate sized blade was used and maintainance of anaesthesia with Sevoflurane and Inj. Dexmedetomidine 0.5mcg/kg/hr. Assessment consisted of number of intubation attempts, time required for intubation, visualisation of glottis, hemodynamic stress response to laryngoscopy and intubation and post-operative respiratory depression. Results: Among 25 patients, 18 patients had intubation at the first attempt, the maximum attempts taken were three in 2 patients. In majority of the patients i.e, 10, time taken for intubation was 13-15 secs. The maximum time to intubate was 18-20 secs in 2 patients. The visualisation if glottic structures assessed by Percentage Of Glottic Opening (POGO) score was 80-100% in majority of 20 patients. Most of the patients had a saturation of 96-100% post-operatively. There was a significant fall in the above hemodynamic parameters from baseline to intubation and 5mins later. The mean reduction in HR was 28.42%, SBP- 28.72%, DBP- 38.85% and MAP- 34.69%. Conclusion: This study emphasises on the use of advanced airway tools, standard intubation techniques and careful drug selection in order to prevent and minimise the risk of airway complication in obesity.

Respiratory Monitoring after Opioid-Sparing Bariatric Surgery in Patients with Obstructive Sleep Apnea (OSA)

Introduction with Aim: Postoperative respiratory depression can complicate a patient’s recovery after surgery. A predictive score (PRODIGY) was recently proposed to evaluate the risk of opioid-induced postoperative respiratory depression. For the first time, we applied this score to a cohort of patients receiving bariatric surgery, stratified by Obstructive Sleep Apnea (OSA) status. In addition, we recorded continuous postoperative capnography to evaluate respiratory depression and apnea episodes (Respiratory Events, RE). Materials and Methods: The present study was approved by our IRB and comprised continuous surveillance of respiratory variables during postoperative recovery (in PACU) after robotic bariatric surgery. We utilized continuous capnography and pulse oximetry (Capnostream 35, Medtronic Inc., and Profox Respiratory Oximetry software). Preoperative preparation included OSA evaluation for all bariatric patients, additional sleep studies for severe OSA grades, and evaluation of risk for respiratory depression (low, intermediate, or high) using the published PRODIGY score. In addition, we evaluated patients by OSA status. All patients received multimodal intraoperative non-opioid anesthesia from the same team. After surgery, all patients received continuous respiratory surveillance in PACU (average duration exceeding 140 min). Respiratory depression events were scored using a modified list of the five standard published categories. Events were measured according to analysis of continuously recorded tracing of the compiled respiratory variables by observers kept blind from the study patient’s group. Results: Of the 80 patients evaluated (18 male), 56 had obstructive sleep apnea and were using CPAP at home (OSA); 24 did not. OSA patients received CPAP via an oronasal mask or a nasal pillow pressure support immediately after arriving in PACU, utilizing their at-home settings. We encountered 115 respiratory depression events across 48 patients. The most frequent respiratory event recorded was a transient desaturation (as low as 85%), which usually lasted 20–30 sec and resolved spontaneously in 3 to 5 min; most episodes followed small boluses of IV opioid analgesia administered during recovery, on demand. All episodes resolved spontaneously without any nursing or medical intervention. OSA patients had significantly more events than non-OSA patients (1.84 (1.78–1.9) mean events vs. 0.50 (0.43–0.57) for non-OSA, p = 0.0002). The level of PRODIGY score (low, intermediate, or high), instead, was not predictive of the number of events when we treated this variable as continuous (p = 0.39) or categorical (high vs. low, p = 0.65, and intermediate vs. low, p = 0.17). Conclusions: We attribute these novel results, showing a lack of respiratory events requiring intervention, to opioid-free anesthesia, early CPAP utilization, and head-up positioning on admission to PACU. Furthermore, all these patients had light postoperative narcotic requirements. Finally, an elevated PRODIGY score in our patients did not sufficiently predict respiratory events, but OSA status alone did. Key Points Summary: We investigated the incidence of Respiratory Events (RE) in Obstructive Sleep Apnea patients after surgery (56 patients) and compared them to similar patients without OSA (24 patients). All patients received identical robotic-assisted surgery and low- or no-opiate anesthesia. Patients were pre-screened with the standard published PRODIGY scores and were monitored after PACU arrival with continuous oximetry and capnography (Capnostream 35 and Profox analysis). OSA patients showed more RE than non-OSA (1.8 vs. 0.5, p = −0.0002). However, patients with elevated PRODIGY scores did not develop more frequent RE compared to patients with low scores. We attribute these novel results to opioid-sparing anesthesia/analgesia and immediate CPAP utilization on admission to PACU.

Intraoperative lidocaine infusion as a sole analgesic agent versus morphine in laparoscopic gastric bypass surgery

BackgroundThe aim of this study was to assess the effect of intra-operative intra-venous (IV) lidocaine infusion compared to IV morphine, on the post-operative pain at rest, the intra-operative and post-operative morphine requirements, the sedation and the Modified Aldrete scores in the post-anesthesia care unit (PACU), the hemodynamic parameters; mean values of the mean blood pressure (MBP) and the heart rate (HR), the peri-operative changes in the SpO2, and the respiratory rate (RR) in laparoscopic Roux-en-y gastric bypass. Sixty patients ˃ 18 years old, with body mass index (BMI) ˃ 35 kg/m2, American Society of Anesthesiologists (ASA) physical status II or III, were randomly divided into 2 groups: the lidocaine (L) group patients received intra-operative IV lidocaine infusion, and the morphine (M) group patients received intra-operative IV morphine.ResultsThe post-operative numeric pain rating scale (NPRS) at rest was statistically significant less in group L than in group M patients, in the post-operative 90 min in the PACU. This was reflected on the post-operative morphine requirements in the PACU, as 26.6% of patients in group M required morphine with a mean total dose of 10.8 mg. The mean values of the MBP and HR recorded after intubation were comparable between patients of both groups, indicating attenuation of the stress response to endotracheal intubation by both lidocaine and morphine. However, the mean values of the MBP and HR recorded after extubation were statistically significant lower in patients of group L, indicating the attenuation of the stress response to extubation by lidocaine. Patients in group M showed statistically significant lower mean values of the MBP; before pneumoperitoneum and after 15 min from the pneumoperitoneum, this was reflected on statistically significant higher mean values of the HR. Patients in group L showed statistically significant lower mean values of the MBP and the HR; at 30 and 45 min from the pneumoperitoneum. Patients in group L showed statistically significant lower mean values of the MBP; 60 min from the pneumoperitoneum, after release of pneumoperitoneum and in the PACU. Patients of both groups showed comparable mean values of the HR after 60 min from the pneumoperitoneum, after release of the pneumoperitoneum and in the PACU. No patient in either groups developed post-operative respiratory depression in the PACU. Patients in group L showed statistically significant higher median sedation score, which was reflected on statistically but not clinically significant less Modified Aldrete score in patients of group L.ConclusionsIn morbid obese patients, the intra-operative IV lidocaine infusion offered post-operative analgesia in the PACU, on the expense of a higher sedation score, which didn’t affect the Modified Aldrete score clinically, with attenuation of the stress response to endotracheal intubation and extubation.Trial registrationsFMASU R16/2021. Registered 1st February 2021, with Clinical Trials Registry (NCT05150756) on 10/08/2021.

Prediction of postoperative respiratory depression and respiratory complications in patients on preoperative methadone.

We developed prediction models for postoperative respiratory depression and respiratory complications for 958 patients who were on methadone preoperatively. The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/min, oxygen saturation (SpO2) < 90%, or requirement of naloxone for 48h postoperatively. Secondary outcome was the composite of postoperative respiratory complications. Prediction models for postoperative respiratory depression and respiratory complications were constructed using multivariate logistic regression with preoperative and intraoperative characteristics as the predictors. For the multivariate logistic regression model for postoperative respiratory depression, surgery duration (P = 0.005), body mass index (BMI) (P = 0.008), surgery involving digestive system (P = 0.031), and American Society of Anesthesiologists (ASA) physical status ≥ 4 (P = 0.038) were statistically significant predictors. The area under the receiver operating characteristic curve (AUROC) of the model was 0.581 (0.558-0.601) [median (95% confidence interval (CI))] with fivefold cross-validation. For the model for postoperative respiratory complications, surgery duration (P = 0.001), history of hypertension (P = 0.028), surgery involving musculoskeletal system (P < 0.001), surgery involving integumental system (P = 0.034), surgery categorized to miscellaneous therapeutic procedures (P = 0.028), combined general and regional anesthesia (P = 0.033), ASA physical status 3 (P < 0.001), and ASA physical status ≥ 4 (P < 0.001) were statistically significant predictors, and AUROC of the model was 0.726 (0.712-0.737). Multivariate logistic regression models including preoperative, and intraoperative characteristics as the predictors performed poorly to predict postoperative respiratory depression, and moderately for postoperative respiratory complications. Neither model is accurate enough to be subject to clinical use.

This Month in Anesthesiology

This Month in Anesthesiology

Effects of hydromorphone-based intravenous patient-controlled analgesia with and without a low basal infusion on postoperative hypoxaemia: study protocol for a randomised controlled clinical trial

IntroductionWhen patients receive patient-controlled intravenous analgesia (PCIA), no basal infusion is always recommended, as the addition of a basal infusion increases the occurrence of postoperative opioid-induced respiratory depression. However, few...

Review of Postoperative Respiratory Depression: From Recovery Room to General Care Unit.

Contemporary evidence suggests that episodes of respiratory depression during anesthesia recovery are associated with subsequent respiratory complications in general care units.

Preventing Postoperative Respiratory Depression

Safety Tip of the Month| October 2022 Preventing Postoperative Respiratory Depression ASA Monitor October 2022, Vol. 86, 18. https://doi.org/10.1097/01.ASM.0000890052.75873.d9 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Preventing Postoperative Respiratory Depression. ASA Monitor 2022; 86:18 doi: https://doi.org/10.1097/01.ASM.0000890052.75873.d9 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: respiratory depression, opioids The Anesthesia Patient Safety Foundation (APSF) declared that “no patient shall be harmed by opioid-induced respiratory depression (OIRD)” about a decade ago (asamonitor.pub/3JCdDkf). In 2021 alone, more than 100,000 Americans died due to drug overdoses, with around 75% of those deaths due to opioids (asamonitor.pub/3f9RhZi). Postoperative OIRD continues to be a costly and potentially fatal problem (Anesth Analg 2020;131:1012-24). The following three steps are identified as critical for screening, diagnosing, monitoring, and reducing OIRD (Figure) (Anesth Analg 2020;131:1007-11). The incidence of undiagnosed obstructive sleep apnea (OSA) may be as high as 60% (Chest 2016;149:631-8). OSA is a significant predictor of postoperative respiratory complications (Sleep 2008;31:1071-8; Anesthesiology 2014;121:707-18). The Snoring, Tiredness, Observed apnea, high blood Pressure and BMI, Age, Neck circumference, Gender (STOP-Bang) questionnaire is effective in identifying adult patients with OSA at high risk of OIRD (... You do not currently have access to this content.

Transient hypoxemia after endotracheal tube extubation in a patient who received reversal of muscle relaxation using sugammadex after general anesthesia: A case report

Post-operative respiratory depression is common in patients recovering from anesthesia and can result in fatal cardiopulmonary collapse, anoxic brain injury, and mortality. We report a case of a 54-year-old morbidly obese female patient who developed transient hypoxemia after general anesthesia. The patient with obstructive sleep apnea (OSA) underwent breast excision surgery. At the end of the surgery, her muscle function was fully restored using sugammadex. However, the patient developed transient hypoxemia in the post-anesthesia care unit. The clinician should keep in mind that OSA patients are likely to develop hypoxemia due to the residual sedative effects and airway obstruction despite the recovery of muscle function after anesthesia.

Impact of opioid free Anaesthesia versus opioid Anaesthesia on the immediate postoperative oxygenation after bariatric surgery: a prospective observational study

Introduction: Opioid induced respiratory depression (OIRD) is a preventable aetiology of postoperative respiratory depression with 85% of the episodes taking place in the first 24 postoperative hours. Due to altered respiratory functional metrics and frequently coexisting comorbidities, obese patients are at a particularly higher risk for such complications. The present study aimed to assess if an opioid-free anesthesia (OFA) was associated with a reduced immediate postoperative OIRD when compared to Opiod-based anesthesia (OA). Methods: Obese patients presenting for bariatric surgery were consecutively included in a non-randomized fashion. Lung protective ventilation strategies applied in both groups. In the OA group, Sufentanil was used for intraoperative analgesia in a liberal fashion. In the OFA group, patients received a pre-induction dexmedetomidine loading, followed by a lidocaine, ketamine and dexmedetomidine bolus immediately before induction, further maintained throughout the intraoperative period. Plethysmographic saturations were obtained before induction as well as after extubation and in the Post-anesthesia care unit (PACU). Opioid requirement and Postoperative Nausea and Vomiting incidence were similarly registered. Results: Thirty-four patients were included in the OFA group, and 30 in the OA group. No significant anthropometric and comorbidity differences were found between both groups. OFA patients had significantly lower pre-induction saturations after dexmedetomidine loading. No difference was found for post-extubation saturations as well as well as pre-PACU discharge. The need for supplemental oxygen at the PACU was higher in the OA group. Opioid requirement and cumulative consumption (MEDs) were significantly higher with OA. Conclusion: OFA was not associated with significant postoperative saturation changes but led to a lower need of postoperative supplemental oxygen therapy. OA led to higher opioid rescue need. No fatal respiratory complications were registered in both groups in the immediate postoperative period.

Effects of Opioid Sparing Analgesia for Surgical Procedure of Laparoscopic Pyloromyotomy in Order to Enhance Recovery and Better Surgical Outcomes

Aim: To determine the analgesic efficacy in early post operative period with out respiratory depression and to determine surgical outcome for patients under laparoscopic pyloromyotomy.&#x0D; Methodology: This study was done at Pediatric surgery operating theatre and Post anesthesia care unit (PACU). Peoples University of Medical and Health Sciences for women (PUMHSW) Nawabshah during the period of 2010-2022. Total 103 cases were observed with n=68 male and n=35 females. Ethical approval was obtained from PUMHSW ethical review board and written informed consent was taken from subjects’ parents or guardians. Infants of both sexes with 2-4.5 kg weight, age 3-8 weeks and diagnosed cases of infantile hypertrophic pyloric stenosis (IHPS) patients confirm by ultrasound were included in this study. Patients with the age of more than 2 months, with significant co morbid conditions, required an additional procedure during the operation, and those subjects possess a contraindication to the laparoscopic approach in the opinion of either the surgeon or the anesthesiologist were excluded from this study. Postoperative pain was measured by using the Neonatal Infant Pain Scale (NIPS) at 30,60,90,120 mins after completion of surgery.&#x0D; Results: In current study 103 patients were participated with male (n=68) to female (35) ratio 1.94:1 with mean age 34.94±7.31 days. Mean weight of the patients were studied 3.08±0.59 kg. Laparoscopic surgical procedure are less painful and patients can be managed by non opioid analgesic combination of intravenous acetaminophen with local anesthetic infiltration to achieved adequate pain relief and avoidance of delayed recovery, postoperative respiratory depression.&#x0D; Conclusion: Laparoscopic pyloromyotomy is safe and effective technique without postoperative respiratory depression and apneic episodes and better surgical outcome especially when opioid sparing multimodal analgesia is given.

Postoperative respiratory depression in patients on sublingual buprenorphine: a retrospective cohort study for comparison between postoperative continuation and discontinuation of buprenorphine

BackgroundWe tested the hypothesis that patients who continued buprenorphine postoperatively experience postoperative respiratory depression less frequently than those who discontinued buprenorphine.MethodsThis is a retrospective cohort study of patients who were on buprenorphine preoperatively. The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/minute, oxygen saturation (SpO2) < 90%, or requirement of naloxone for 48 h postoperatively. The secondary outcome was the composite of postoperative respiratory complications. The associations between postoperative buprenorphine continuation and respiratory depression and respiratory complications were estimated using separate multivariable logistic regression models, including demographic, intraoperative characteristics, and preoperative buprenorphine dose as covariates.ResultsPostoperative buprenorphine continuation was not associated with postoperative respiratory depression (adjusted odds ratio (OR), 1.11, 95% confidence interval (CI), 0.61 to 1.99, P=0.72). In subanalysis stratified by the preoperative buprenorphine dose, buprenorphine continuation was not associated with postoperative respiratory depression either when preoperative buprenorphine dose was high (≥16 mg daily) or low (<16 mg daily). Postoperative buprenorphine continuation was associated with lower incidence of postoperative respiratory complications (adjusted OR, 0.43, 95% CI, 0.21 to 0.86, P=0.02).ConclusionsContinuing buprenorphine was not associated with respiratory depression, but it was associated with a lower incidence of respiratory complications.