Prolonged Extubation Time Research Articles

Safety of Small-Diameter Endotracheal Tubes in Microlaryngeal Surgery.

Microlaryngeal surgeries require unique considerations for airway management to facilitate patient safety and adequate surgical exposure. Small-diameter endotracheal tubes (ETTs) are widely used but have raised concerns regarding patient safety, including questions about the potential for barotrauma, effective ventilation, and adequate oxygenation. We hypothesize that small ETTs will prove to be safe in a variety of cases. We conducted a case series analyzing the safety of 5.0 ETTs in microlaryngeal surgeries at Washington University School of Medicine from November 2020 to November 2023. Outcome measures included intraoperative desaturations (SpO2 < 90% for >2 min), high peak inspiratory pressures (PIPs) (>40 cm H2O), and prolonged extubation times (>15 min). Univariate regression models were used to analyze associations of sociodemographic and clinical variables with these outcome measures. This study included 76 small-ETT microlaryngeal surgeries. There were 5 instances of desaturations, no reported incidents of barotrauma, and no cases in which intraoperative tube exchange was required due to issues with oxygenation or ventilation. Median PIP was 38 cm H2O, with a range of 17-78 cm H2O. 46% of patients had a PIP above 40 cm H2O. There were prolonged extubation times in 14% of procedures. No association was shown between sociodemographic and clinical variables with risk of desaturations, high PIPs, or prolonged extubation times. Our study suggests that 5.0 ETTs are safe for microlaryngeal surgery in a variety of patients. Otolaryngologists and anesthesiologists should consider this information when choosing between the multiple available options for airway management during microlaryngeal surgery. Level 4 Laryngoscope, 2024.

Effects of intraoperative low-dose esketamine on postoperative pain after vestibular schwannoma resection: A prospective randomized, double-blind, placebo-controlled study.

Esketamine may reduce acute postoperative pain in several settings. However, the effects of low-dose esketamine on postoperative pain after vestibular schwannoma (VS) resection with propofol/remifentanil total intravenous anaesthesia (TIVA) are unclear. The aim of this study is to observe the effects of intraoperative low-dose esketamine on postoperative pain after vestibular schwannoma resection. This single-centre, randomized, placebo-controlled, double-blind trial included 90 adults undergoing VS resection via the retrosigmoid approach with TIVA. The patients were randomly allocated to two groups: esketamine or control (n = 45 in each group). Patients received low-dose esketamine (0.2 mg/kg) or a similar volume of normal saline after dural closure. The primary outcome was the pain score during movement (gentle head movement) at 24 h postoperatively. Secondary outcomes included recovery time, bispectral index (BIS) values and haemodynamic profiles during the first 30 min after esketamine administration, and adverse effects. Low-dose esketamine did not reduce pain scores at rest (P > .05) or with movement (P > .05) within the first 24 h after surgery. Esketamine moderately increased BIS values for at least 30 min after administration (P < .0001) but did not affect heart rate (P = .992) or mean arterial blood pressure (P = .994). Esketamine prolonged extubation time (P = .042, 95% confidence interval: 0.08 to 4.42) and decreased the effect-site concentration of remifentanil at extubation (P = .001, 95% confidence interval: -0.53 to -0.15) but did not affect the time to resumption of spatial orientation. Postoperative nausea and vomiting rates did not differ between groups, and no hallucinations or excessive sedation was observed. Intraoperative low-dose esketamine did not significantly reduce acute pain after VS resection with propofol/remifentanil TIVA. However, BIS values increased for at least 30 min after esketamine administration.

The impact of an anesthesia residency teaching service on anesthesia-controlled time and postsurgical patient outcomes: a retrospective observational study on 15,084 surgical cases

BackgroundLimited data exists regarding the impact of anesthesia residents on operating room efficiency and patient safety outcomes. This investigation hypothesized that supervised anesthesiology residents do not increase anesthesia-controlled or prolonged extubation times compared to supervised certified registered nurse anesthetists (CRNA)/certified anesthesiologist assistants (CAA) or anesthesiologists working independently. Secondary objectives included differences in critical outcomes such as intraoperative hypotension, cardiac and pulmonary complications, acute kidney injury, and mortality.MethodsThis retrospective single-center 24-month (January 1, 2020- December 31, 2021) cohort focused on primary outcomes of anesthesia-controlled times and prolonged extubation (>15 min) with additional assessment of secondary patient outcomes in adult patients having general anesthesia with an endotracheal tube or laryngeal mask airway for elective non-cardiac surgery. The study excluded sedation, obstetric, endoscopic, ophthalmology, and non-operating room procedures. Procedures were divided into three groups: anesthesiologists working solo, anesthesiologists supervising residents, or anesthesiologists supervising CRNA/CAAs. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes.ResultsA total of 15,084 surgical cases met the inclusion criteria for this study for the three different care models: solo anesthesiologists (1,204 cases), anesthesiologist/resident pairing (3,146 cases), and anesthesiologist/CRNA/CAA (14,040 cases). Before multivariate analysis, the resident group exhibited longer anesthesia-controlled times (median, [interquartile range], 26.1 [21.7–32.0], p < 0.001), compared to CRNA/CAA (23.9 [19.7–29.5]), and attending-only surgical cases (21.0 [17.9–25.4]). After adjusting for covariates in a general linear regression model (age, BMI, ASA classification, comorbidities, arterial line insertion, surgical service, and surgical location), there were no significant differences in the anesthesia-controlled times between the provider groups. Prolonged extubation times (>15 min) were significantly less common in the anesthesiologist-only group compared to the other groups (p < 0.001). Despite these time differences, there were no clinically significant differences among the groups in postoperative pulmonary or cardiac complications, renal impairment, or the 30-day mortality rate of patients.ConclusionAnesthesia residents do not increase anesthesia-controlled operating room times or adversely affect clinically relevant patient outcomes compared to anesthesiologists working independently or supervising certified registered nurse anesthetists or certified anesthesiologist assistants.

Comparison between Bilateral Ultrasound-Guided Quadratus Lumborum Block and Sacrococcygeal Epidural in Cats Undergoing Ovariectomy.

Ultrasound-guided quadratus lumborum block (QLB) and sacrococcygeal epidural anaesthesia (ScE) have been used for neutering cats, providing effective pain relief. To compare the effects of the QLB with those of ScE in cats undergoing ovariectomies. Feral cats undergoing ovariectomy were premedicated with dexmedetomidine (20 μg kg-1) and methadone (0.2 mg kg-1) intramuscularly. Anaesthesia was induced with 2-4 mg kg-1 of propofol intravenously and maintained with isoflurane in oxygen. The cats were randomly allocated to the groups QLB (bilateral QLB with 0.4 mL kg-1 of 0.25% bupivacaine) and ScE (0.3 mL kg-1 of 0.25% bupivacaine). Hemodynamic data and analgesia rescue were collected at four intraoperative periods. The pain scale and motor block were assessed in both groups during the postoperative period. The ScE results in increased hypotension, prolonged extubation time, and higher postoperative motor block than the QLB (p < 0.05). The QLB and ScE groups required a similar number of intraoperative rescues and presented the same postoperative pain scale classification. The QLB with 0.25% bupivacaine is a potential alternative to ScE with 0.25% bupivacaine in perioperative pain management in elective cat ovariectomy. The QLB promoted less hypotension and postoperative motor block when compared with the ScE group.

Effect of Dexmedetomidine versus Propofol on Sevoflurane related Emergence Agitation in Paediatric Patients: A Randomised Clinical Study

Introduction: Postoperative Emergence Agitation (EA) is a troublesome side-effect of sevoflurane anaesthesia. Drugs like dexmedetomidine and propofol offer significant benefits in reducing the incidence and severity of sevoflurane-related postoperative EA in paediatric patients. Aim: To compare the efficacy of intravenous dexmedetomidine and propofol in reducing the incidence and severity of EA associated with sevoflurane anaesthesia in paediatric patients. Materials and Methods: A randomised clinical study was conducted on 140 patients, belonging to American Society of Anaesthesiologists Physical Status (ASA PS) classes I and II, aged between 2-6 years, undergoing infraumbilical surgery lasting more than one hour. The patients were divided into two equal groups receiving dexmedetomidine 0.3 μg/kg (Group SD) and propofol 1 mg/kg (Group SP) at the start of skin closure, administered over 10 minutes. The incidence of EA in the Post Anaesthesia Care Unit (PACU) was evaluated using the Watcha scale, and the severity of EA was assessed using the Paediatric Anaesthesia Emergence Delirium (PAED) scale. A Watcha score of 3 or 4 indicated the presence of EA, while a PAED score of ≥12 was deemed significant. Statistical analysis of the data was performed using International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) version 22.0, with an Independent sample t-test for comparing normally distributed quantitative parameters, and the Chi-square test for comparing categorical outcomes between the study groups. Results: The mean age of the patients in group SD was 4.19±0.78 years, and in group SP was 4.03±0.71 years. Both study groups were found to be comparable in terms of patient characteristics such as age, sex, weight, and duration of surgery (p-value &gt;0.05). The incidence of postoperative EA, as measured by the Watcha scale, was higher in group SP compared to group SD upon arrival and up to 30 minutes in the PACU (p-value &lt;0.001). The severity of EA, assessed using the PAED score, was greater in group SP compared to group SD at 0, 5, 10,15 and 20 minutes in the PACU (p-value &lt;0.001). Conclusion: Dexmedetomidine 0.3 μg/kg was more effective than propofol 1 mg/kg in reducing the incidence and severity of EA associated with sevoflurane anaesthesia, with minimal haemodynamic effects and no clinically relevant severe adverse effects in both the groups. The significantly prolonged extubation times observed in the propofol group did not result in significantly longer stays in the PACU.

Application of Dexmedetomidine as an Opioid Substitute in Opioid-Free Anesthesia: A Systematic Review and Meta-analysis

BACKGROUND: Opioid-based general anesthesia was previously used to alleviate perioperative pain; however, several complications associated with using anesthesia have raised several concerns. Various studies have investigated the application prospect of using opioid-free general anesthesia, such as dexmedetomidine, as an opioid substitute. OBJECTIVES: We performed a systematic review and meta-analysis to explore and highlight the safety and effectiveness of dexmedetomidine as an opioid substitute for opioid-free anesthesia. STUDY DESIGN: A systematic review and meta-analysis. SETTING: We screened for suitable clinical trials from electronic databases, including “PubMed,” “Cochrane Library,” “EMBASE,” and “Web of Science.” Eligible trials were included in this meta-analysis. METHODS: The quality of the screened randomized controlled trials (RCTs) was determined using the risk of bias assessment criteria by the Cochrane Collaboration tool. We used the “Review Manager 5.3” and “Stata 10.0” software to perform the meta-analysis. We evaluated the quality of evidence using the “Grading of Recommendations Assessment, Development, and Evaluation” approach. RESULTS: For the analysis, we included 32 RCTs encompassing 2,509 patients. In the opioid-free group, the 2-hour postoperative pain score of patients (mean difference = -0.53, 95% CI: -1.00, -0.07; P = 0.02, I2=78%) was significantly lower compared to those in the opioid-based group. In addition, several patients required rescue analgesia (risk ratio = 0.70, 95% CI: 0.58, 0.84, P &lt; 0.05, I2 = 71%) and opioids postsurgery. However, the duration of extubation and postanesthesia care unit, as well as the incidences of bradycardia, were high in patients receiving dexmedetomidine as opioid-free general anesthesia. LIMITATIONS: Subgroup analysis for different anesthesia-maintaining drugs had not been conducted. The heterogeneity did not reduce after subgroup analysis. Different doses of dexmedetomidine had not been evaluated. CONCLUSIONS: These findings indicate that opioid-free general anesthesia based on dexmedetomidine could be effective; however, prolonged extubation time and cardiovascular complications are a few risks associated with dexmedetomidine. KEY WORDS: Opioid-free anesthesia, dexmedetomidine, meta-analysis

Dexmedetomidine infusion for emergence coughing prevention in patients undergoing an endovascular interventional procedure: A randomized dose-finding trial

ObjectiveDexmedetomidine has been introduced in emergence coughing, agitation, and shivering prevention. This study aimed to investigate the optimal dose of dexmedetomidine for emergence cough prophylaxis. MethodsIn this randomized, double-blinded, and prospective trial, 356 patients scheduled for an endovascular interventional procedure were randomly assigned to 0.3 (D 0.3), 0.4 (D 0.4), 0.5 (D 0.5), and 0.6 (D 0.6) μg·kg−1·h−1 dexmedetomidine rate, or saline control (C), from anesthesia induction until the end of surgery. The primary outcomes measured were cough grade and frequency. Additionally, groups were compared according to mean arterial pressure (MAP), heart rate, agitation, shivering, postoperative nausea and vomiting (PONV), extubation time, sedation scores, and postoperative first night sleep quality (secondary outcomes). ResultsA total of 351 patients were included in the analysis. The respective incidences of D 0.3, D 0.4, and D 0.5 versus C group were: 78.6%, 68.6%, 53.4% and 42.9% vs 89.7% for cough (p = 0.002, p < 0.001, and p < 0.001 between group D 0.4, D 0.5 and D 0.6 vs C, respectively); 30%, 27.1%, 20.5%, 15.7% vs 44.1% for agitation (p = 0.04, p = 0.003, and p < 0.001 between group D 0.4, D 0.5 and D 0.6 vs C, respectively); 8.6%, 7.1%, 6.8%, 5.7% vs 22.1% for shivering (p = 0.027, p = 0.013, p = 0.01, and p = 0.01 between D 0.3, D 0.4, D 0.5 and D 0.6 vs C, respectively); and 52.9%, 57.1%, 42.5%, 44.3% vs 61.8% for poor sleep quality (p = 0.02 and p = 0.04 between group D 0.5 and D 0.6 vs C, respectively). D 0.4, D 0.5 and D 0.6 showed lower MAP during extubation, compared with the C group. Also, D 0.5 and D 0.6 presented a slight delay in extubation (3.1 and 3.3 min longer than C; p = 0.002 and p < 0.001, respectively). Meanwhile, the frequency of atropine, vasopressor administration, PONV and dizziness were similar to the control. ConclusionsBoth 0.5 and 0.6 μg·kg−1·h−1 dexmedetomidine infusion rates effectively mitigated emergence coughing with prolonged extubation time, besides sleep disturbance. D 0.4, D 0.5, and D 0.6 reduced agitation and sustained hemodynamic stability. Finally, the four doses applied were effective in shivering attenuation.

¿Cómo es la cirugía neonatal en un centro terciario de España?: revisión de los últimos 5 años

Introduction and objectivesThe results of neonatal surgery have improved in recent decades, even the most complex. Dedicated groups could help in centres with low activity. We analysed the neonatal surgery outcomes of our centre in the last 5 years. MethodsAll neonatal patients operated during the period between 2015 and 2019, were collected excluding patients with patent ductus arteriosus and extracorporeal membrane oxygenation. ResultsA total of 134 patients underwent surgery with a predominance of extracorporeal circulation (65.7%). The transposition of the great arteries (n=32) and coarctation (n=27) were the most frequent pathologies. Patients with cardiopulmonary bypass presented more surgical difficulty (10 vs. 8, P<0.001), prolonged extubation time (3 vs. 1, P<0.001) and intensive care unit length of stay (11 vs. 8, P=0.003), as well as higher mortality at 30 days and in hospital (7.9% vs. 0%, P=0.049; 10.2 vs. 0%, P=0.03). Those operated without cardiopulmonary bypass had a higher percentage of underweight patients (10.2 vs. 21.7, P=0.05) and prematurity (7.9% vs. 21.7%, P=0.03), with a predominance of palliative procedures. Overall mortality at 30 days and hospital mortality was 5.2 and 6.7% respectively, with a decrease compared with the previous period (4.8 and 11.1%). ConclusionsLow-activity national centres can obtain results comparable to other European centres due to highly cohesive multidisciplinary teams.

Comparison of Two Methods of Anesthesia Using Patient State Index: Propofol Versus Sevoflurane During Interventional Neuroradiology Procedure.

BackgroundOver the past few decades, interventional neuroradiology (INR) has been a rapidly growing and evolving area of neurosurgery. Sevoflurane and propofol are both suitable anesthetics for INR procedures. While the depth of anesthesia is widely monitored, few studies have examined the patient state index (PSI) during clinical neuroanesthesia.ObjectivesThis study aimed to investigate the differences in PSI values and in hemodynamic variables between sevoflurane anesthetic and propofol anesthetic during INR procedures.MethodsWe reviewed the medical charts of the patients who underwent embolization of a non-ruptured intracranial aneurysm by a single operator at a single university hospital from May 2013 to December 2014. Sixty-five patients were included and divided into two groups: S group (sevoflurane anesthesia, n = 33) vs. P group (propofol anesthesia, n = 32). The PSI values, hemodynamic variables, and use of hemodynamic drugs between two groups were analyzed.ResultsThere were significant differences between the PSI values obtained through different perioperative stages in the two groups (P < 0.0001). During the procedure, the PSI values were significantly lower in the P group than in the S group (P = 0.000). The P group patients had a more prolonged extubation time (P = 0.005) and more phenylephrine requirement than the S group patients (P = 0.007). More anti-hypertensive drugs were administered to the patients in the S group during extubation (P = 0.0197).ConclusionsThe PSI can be used to detect changes in anesthetics concentration and in the depth of anesthesia during INR procedures. Although the extubation was faster under sevoflurane anesthetic, propofol anesthetic showed rather smoother recovery.

Dexmedetomidine for the prevention of emergence delirium and postoperative behavioral changes in pediatric patients with sevoflurane anesthesia: a double-blind, randomized trial.

ObjectivesEmergence delirium (ED) is a common neurologic complication that can not only distress children and their families in the early postanesthetic period, but can also have adverse effects on children in the long-term. This study aimed to investigate the effects of single-dose dexmedetomidine on ED in children with sevoflurane anesthesia and to observe postoperative behavioral changes through long-term follow-up.MethodsPatients aged 2–7 years, American Society of Anesthesiologists class (ASA) I or II, scheduled for tonsillectomy with and without adenoidectomy were randomized to receive dexmedetomidine 0.5 μg/kg (Group D) or volume-matched normal saline (Group C) over 10 minutes after induction of anesthesia. The primary outcome was the incidence of ED within 30 minutes after extubation. Other outcomes were the incidence of pain, extubation time, post-anesthesia care unit (PACU) length of stay after extubation, adverse events, and the incidence of negative postoperative behavioral changes (NPOBCs).ResultsNinety children completed the study. Compared with the control group (Group C), dexmedetomidine decreased the incidence of ED (31.1% vs 53.3%; P=0.033) and pain (28.9% vs 57.8%; P=0.006), but it prolonged extubation time (P⩽0.001). PACU length of stay after extubation and the percentage of adverse events were similar between groups. The incidence of NPOBCs in Group D was significantly lower at 1 and 7 days after discharge (33.3% vs 60.0%; P=0.011% and 24.4% vs 46.7%; P=0.028, respectively) than it was in Group C, but no significant difference was found at the 30th day.ConclusionDexmedetomidine 0.5 μg/kg reduced the incidence of ED after sevoflurane anesthesia and might be used to prevent NPOBCs.Clinical trials registrationChiCTR1800016828.

Influence of magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy: A meta-analysis of randomized controlled studies.

Background:The impact of magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of magnesium sulfate on hemodynamic responses for laparoscopic cholecystectomy.Methods:We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through June 2018 for randomized controlled trials (RCTs) assessing the effect of magnesium sulfate on hemodynamic responses for laparoscopic cholecystectomy. Meta-analysis is performed using the random-effect model.Results:Four RCTs involving 208 patients are included in the meta-analysis. Overall, compared with control group in laparoscopic cholecystectomy, intravenous magnesium sulfate is associated with systolic blood pressure at 30 minutes [Std. MD = −1.34; 95% confidence interval (95% CI) = −1.86 to −0.82; P < .00001], diastolic blood pressure at 30 minutes (Std. MD = −1.40; 95% CI = −1.86 to −0.94; P < .00001), mean arterial pressure at 30 minutes (Std. MD = −1.19; 95% CI = −1.91 to −0.46; P = .001), systolic blood pressure at 10 minutes (Std. MD = −1.61; 95% CI = −2.08 to −1.13; P < .00001), diastolic blood pressure at 10 minutes (Std. MD = −1.54; 95% CI = −2.68 to −0.40; P = .008), heart rate at 30 minutes (Std. MD = −2.09; 95% CI = −2.87 to −1.32; P < .00001), but results in prolonged extubation time (Std. MD = 0.96; 95% CI = 0.18–1.74; P = .02).Conclusion:Magnesium sulfate can reduce blood pressure, but with the increase in extubation time for laparoscopic cholecystectomy.

Emergence and Recovery Characteristics of Five Common Anesthetics in Pediatric Anesthesia: a Network Meta-analysis.

Desflurane, halothane, isoflurane, propofol, and sevoflurane are widely used anesthetics in pediatric anesthesia. Adverse effect including emergence agitation, postoperative nausea and vomiting, and postoperative pain are common. Prolonged extubation time and emergency time are also troubling anesthesiologists. Previous studies have noted the characteristics of various anesthetics in pediatric anesthesia, while the results were inconclusive and conflicting. In this study, we aimed at performing a comprehensive network meta-analysis concerning the emergence and recovery characteristics of pediatric anesthetics. Relevant articles were retrieved and selected according to our inclusion criteria. Network meta-analysis was performed with a random-effect model within a Bayesian framework. ORs and corresponding 95% credible intervals were calculated by Markov chain Monte Carlo methods. Node-splitting method was used to calculate the inconsistency. Rank probabilities were assessed by the surface under the cumulative ranking curve (SUCRA). Propofol was recommended as the most efficient and safe anesthetic in pediatric anesthesia with few adverse effects. Desflurane has the highest incidence of emergence agitation and worst recovery characteristics. Halothane was regarded as an efficient anesthetic with the best recovery characteristics, while postoperative nausea and vomiting is a common adverse effect. Isoflurane was reported to be the safest concerning postoperative pain, and cases using sevoflurane in pediatric anesthesia reported the highest incidence of analgesic requirement. Our network meta-analysis demonstrated that propofol was suggested as the first choice in the clinical practice for its efficiency and safe in pediatric anesthesia.

Factors Influencing Fast Track Extubation Following Liver Transplant Surgery: A 3 Year Mayo Clinic Experience

SESSION TITLE: Critical Care SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, April 17, 2016 at 02:15 PM - 03:45 PM PURPOSE: Liver transplantation (LT) is a complex surgery with potential for a number of short term peri and post operative complications including bleeding, vascular compromise and hemodynamic instability. Most transplant centers utilize some kind of formal or informal approach to assess readiness for early extubation after LT. What is currently lacking in the literature is a risk predictor tool to determine which patients would be a candidate for rapid extubation. The goal of this study was to identify pre and intra-operative factors that could help identify factors associated with successful early extubation post LT. METHODS: Retrospective analysis of all patients who underwent LT from Jan 1st 2012 to December 31th, 2014. A total of 313 patients (including pediatric subjects) comprised the study cohort. A total of 154 patients remained intubated longer than six hours (late extubation group) and 159 patients were extubated within first 6 hours post LT surgery (early extubation group). We compared the demographics, preoperative and intraoperative clinical and laboratory markers between the two groups RESULTS: Baseline characteristics such as age, gender, MELD, MELD-Na, BMI and length of the surgery were no different between two groups (P > 0.05). On univariate analysis; coagulation parameters obtained at the end of surgery including higher INR (p= 0.03), lower platelets (p= 0.006) and lower fibrinogen (p= 0.003) were all associated with delayed extubation. Similarly intraoperative transfusion volume of RBC, platelets, FFP, autologous PRBC, cryoprecipitate, crystalloids, volume of ascitic fluid removed and low urine output were all significantly associated with delayed extubation (P <0.001). On multivariate analysis the only variable that was associated with delayed extubation was the transfusion of more than 6 units in OR (P=0.02). CONCLUSIONS: Our data suggest that several important intra-operative variables including last intraoperative coagulation labs, intraoperative transfusion requirements, lower urine output, large volume ascitic fluid removed and amount of crystalloid infused are associated with prolonged time to extubation. However on multivariate modelling only FFP transfusion of more than 6 units was associated with prolonged extubation time CLINICAL IMPLICATIONS: With identification of factors associated with early extubation in patient post liver transplant surgery, our hope is to ultimately develop risk predictor tool to determine which patients would be a candidate for rapid extubation. DISCLOSURE: The following authors have nothing to disclose: Devang Sanghavi, Kumar Sarvottam, Rahul Kashyap, Bibek Pannu, Julie Heimbach, Vivek Iyer No Product/Research Disclosure Information

Effects of Intravenous Dexmedetomidine on Emergence Agitation in Children under Sevoflurane Anesthesia: A Meta-Analysis of Randomized Controlled Trials

ObjectiveEmergence agitation (EA) is a common complication in children under sevoflurane anesthesia. The aim of this meta-analysis was to evaluate the effects of intravenous dexmedetomidine on EA in children under sevoflurane anesthesia.MethodsA comprehensive literature search was conducted to identify clinical trials that evaluated the effects of intravenous dexmedetomidine and placebo on EA in children under sevoflurane anesthesia. The search collected trials from MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Web of Science. Analysis was conducted using STATA version 12.0. Data from each trial were pooled using relative ratio (RR) for dichotomous data or weighted mean difference (WMD) for continuous data and corresponding 95% confidence interval (95% CI). Heterogeneity assessment, sensitivity analysis, and publication bias were performed.ResultsTwelve trials, in which 459 patients received dexmedetomidine and 353 patients received placebo, were included in this analysis. We found that intravenous dexmedetomidine decreased the incidences of EA (RR = 0.346, 95% CI 0.263 to 0.453, P<0.001), and postoperative pain (RR = 0.405, 95% CI 0.253 to 0.649, P<0.001). Intravenous dexmedetomidine also prolonged extubation time (WMD = 0.617, 95% CI 0.276 to 958, P<0.001), and emergence time (WMD = 0.997, 95% CI 0.392 to 1.561, P = 0.001). Further evidences are required to evaluate the incidence of postoperative nausea and vomiting (PONV). Sensitivity analysis strengthened evidences for lower incidences of EA, pain, and prolonged extubation time, and emergence time. Funnel plots did not detect any significant publication bias.ConclusionMeta-analysis demonstrated that dexmedetomidine decreased the incidence of EA in children under sevoflurane anesthesia.

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Introduction: Prolonged mechanical ventilation after cardiac surgery is associated with prolonged length of stay and increased morbidity and mortality. Shorter postoperative ventilation times are accepted as a marker of quality. We implemented quality improvement efforts and methodology to reduce postoperative MV times for cardiac surgery patients in our cardiovascular intensive care unit. Methods: Baseline time-to-extubation data was obtained from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD). An institutional unit-based data collection form was instituted to allow real-time assessment of extubation times. To inform quality improvement efforts, data was collected on demographics, surgery type, medical history, and mechanical ventilation times on all critically ill adult postoperative cardiac surgery patients for 2.5 months. Individual patient-specific times to extubation were placed in run charts. Improvement actions implemented included informal education of members of the healthcare team about prolonged extubation times, renewed focus on non-physician driven extubation protocol for weaning mechanical ventilation, and implementation time-oriented goals for extubation. Extubation-time data was analyzed in run charts to determine whether system changes had produced a change in median mechanical ventilation times. Standard run chart rules were used to determine whether a statistically significant shift in median mechanical ventilation times had occurred. Results: Baseline unit STS ACSD median postoperative mechanical ventilation time from January 2013 through March 2013 was 9.48 hours. After initiation of quality improvement efforts, run charts demonstrated a shift in median ventilation time to 4.7 hours. Conclusions: Median postoperative mechanical ventilation times for cardiac surgery patients were reduced after quality improvement efforts which included real-time data collection, informal education about mechanical ventilation times, emphasis of a non-physician driven mechanical ventilation weaning protocol, and time-oriented goals for extubation. System changes produced median extubation times lower than the STS ACSD 2012 national median postoperative ventilation time of 6.8 hours. Run chart methodology proved useful in monitoring system change during quality improvement efforts in this cardiovascular intensive care unit.

Efficacy and safety of intraoperative dexmedetomidine in pediatric posttonsillectomy pain: Peritonsillar versus intravenous administration

BackgroundAlthough being used off-label, the utility of dexmedetomidine in pediatric settings is increasing. Alpha-2 agonists have peripheral analgesic effects. This prospective, randomized, double-blind, Placebo-controlled study was designed to evaluate the safety and efficacy of dexmedetomidine single intraoperative preincisional dose in pediatric patients undergoing tonsillectomy and adenoidectomy.Patients and methodsEighty-four children (5–12 years) were randomized into three groups: DEX.IV (n = 28) received dexmedetomidine 1 μg/kg iv. infusion in 10 min, DEX.PT (n = 28) received dexmedetomidine 1 μg/kg peritonsillar infiltration, and the Placebo controls (n = 28). Assessment parameters included pain, sedation, hemodynamics, and adverse effects.ResultsIntraoperative dexmedetomidine administration resulted in a significant reduction in pain scores postoperatively in the DEX.IV and DEX.PT groups, with no significant difference between them. The time to first postoperative analgesic request was significantly prolonged in DEX.IV (583.45 ± 157.94 min, P < 0.000) and DEX.PT (537.61 ± 106.17 min, P < 0.000) groups compared with the Placebo group (119.75 ± 43.44 min). Similarly, a significantly lower paracetamol consumption during the first postoperative day was recorded in the DEX.IV (459.37 ± 114.82 mg, P < 0.000) and DEX.PT (475.38 ± 143.11 mg, P < 0.000) groups, than in the Placebo group (705.00 ± 249.27 mg), with no significant difference between DEX.IV and DEX.PT groups. Patients in the DEX.IV group exhibited significantly prolonged extubation times ((13.83 ± 3.38 min, P < 0.000) and significantly higher mean Ramsay sedation scores at 15, 30, 60, 120, and 180 min postoperative (P < 0.000), compared with DEX.PT and Placebo groups. The mean intraoperative heart rates were significantly slower in DEX.IV group during and after the intravenous infusion of dexmedetomidine and at 15th min intraoperative (p < 0.05), compared with DEX.PT and Placebo groups, with no significant differences in mean heart rates among the groups in other time points measured. Patients in DEX.PT group had a significantly higher total oral intake in first day postoperative (P < 0.000) and a significantly higher family satisfaction (p < 0.000), compared with DEX.IV and Placebo groups.ConclusionPeritonsillar infiltration or iv. dexmedetomidine similarly enhanced the postoperative analgesia after tonsillectomy in pediatric patients. However, locally applied dexmedetomidine was associated with no systemic effects, higher total oral intake in first day postoperative, and higher family satisfaction.

Meta-Analysis of Average and Variability of Time to Extubation Comparing Isoflurane with Desflurane or Isoflurane with Sevoflurane

We recently determined how to use anesthesia information management system data to model the time from end of surgery to extubation. We applied that knowledge for meta-analyses of trials comparing extubation times after maintenance with desflurane and sevoflurane. In this study, we repeated the meta-analyses to compare isoflurane with desflurane and sevoflurane. A Medline search through December 2009 was used to identify studies with (1) humans randomly assigned to isoflurane or desflurane groups without other differences (e.g., induction drugs) between groups, and (2) mean and SD reported for extubation time and/or time to follow commands. The search was repeated for random assignment to isoflurane or sevoflurane groups. We considered extubation times >15 minutes (representing 15% of cases in the anesthesia information management system data) to be prolonged. Desflurane reduced the mean extubation time by 34% and reduced the variability in extubation time by 36% relative to isoflurane. These reductions would reduce the incidence of prolonged extubation times by 95% and 97%, respectively. Sevoflurane reduced the mean extubation time by 13% and reduced the SD by 8.7% relative to isoflurane. These reductions would reduce the incidence of prolonged extubation times by 51% and 35%, respectively. The pharmacoeconomics of volatile anesthetics are highly sensitive to measurement of relatively small time differences. Therefore, surgical facilities should use these values combined with their local data (e.g., mean baseline extubation times) when making evidence-based management decisions regarding pharmaceutical purchases and usage guidelines.

Statistical Modeling of Average and Variability of Time to Extubation for Meta-Analysis Comparing Desflurane to Sevoflurane

The recovery profile of an ideal anesthetic or technique would be fast (e.g., mean of 5 min from end of surgery to extubation) with little variability (e.g., always 4-7 min). We used anesthesia information management system (AIMS) data to learn how to model the time from end of surgery to extubation. We applied that knowledge for meta-analyses of trials comparing extubation times after use of desflurane and sevoflurane. AIMS data studied were 32,792 cases performed by 95 surgeons that included tracheal intubation and extubation in the operating room (OR) and use of volatile anesthetic(s). Meta-analysis included the 29 randomized controlled trials through 2008 comparing extubation times with desflurane and sevoflurane. Percentage differences in means and standard deviations were studied using random effects meta-analysis and a Bayesian method. Times to extubation were better fit by (skewed) Weibull distributions than by (symmetric) normal distributions. Drug choice had nearly equally proportional effects on the means and standard deviations of extubation times, as shown by unchanged coefficients of variation (P > 0.10 for 26 of 29 studies) and nonsignificant pooled difference in the coefficient of variation (sevoflurane--desflurane = -1%, 95% confidence interval [CI] -3% to 1%, P = 0.22). Applying these findings, desflurane reduced the mean extubation time by 25% (95% CI 17%-32%, P < 0.0001) and standard deviation by 21% (95% CI 16%-26%). To value the intangible costs (e.g., frustrated waiting surgeons) of prolonged extubation times, we considered the 15% of AIMS cases with times >15 min. These cases averaged 4.9 min longer times from out of the OR to the start of surgery of the surgeon's next case (95% CI 2.7-7.1 min, P < 0.0001). Reduction in the means and standard deviations by 20%-25% would likely reduce incidences of these prolonged extubation times by 71%-82% (95% CI 68%-84%). Desflurane reduces the average extubation time and the variability of extubation time by 20%-25% relative to sevoflurane. The principal economic value of these end points is their reductions of direct (labor) costs of OR time. However, reductions in intangible costs of prolonged extubation are real, being associated with subsequent delays. Reductions in the average and variance of times to extubation can be interpreted and monitored in terms of corresponding expected 75% reductions in the incidences of prolonged extubation times by using desflurane relative to sevoflurane.

Use of continuous subcutaneous anesthetic infusion in cardiac surgical patients after median sternotomy

The use of opioid analgesics to control pain after median sternotomy in cardiac surgical patients is worldwide accepted and established. However, opioids have a wide range of possible side effects, concerning prolonged extubation time, gastrointestinal tract dyskinesia and urinary tract disorders mostly retention. All these may lead to a prolonged ICU stay or overall hospitalization time increase.To determine whether a continuous subcutaneous regional anesthetic infusion delivered directly to the sternotomy site would result in decreased levels of postoperative pain and opioid requirements in cardiac surgical patients undergoing median sternotomy.The continuous subcutaneous infusion (OnQ Painbuster system) was applied in 37 patients. 3 patients were exempted due to prolonged ICU stay. 29 patients underwent CABG, 5 had AVR, 1 MVR and modified Maze, 1 patient had a 3-valve repair due to endocarditis and another one had reconstruction of the left ventricle. Requirements of opioid analgesics were recorded for 96 hours after operation. Pain was assessed using the visual analog scale and the total postoperative hospital length of stay was also measured.The postoperative pain was significantly diminished (0 – 3 at VAS). The mean postoperative length of stay was 5,8 days, rather improved compared to the average stay of 6,7 days.Continuous subcutaneous infusion of ropivacaine directly at the median sternotomy significantly diminishes postoperative pain and the need for opioid analgesic use. Moreover, it seems to reduce overall postoperative length of stay for all cardiac surgical patients.

Initial Perioperative Care of the Cardiac Surgical Patient

Recently, changes in the management of cardiac patients have allowed earlier discharge from the cardiac recovery area and reduced hospital length of stay. These changes have been drien by a need to reduce the cost of cardiac surgery and imrove efficiency. This change has been both financially sucessful and safe for patients. To allow for this success, a joint effort is required between the departments of cardiac surgery and anesthesiology involving the preoperative, intraoperative and postoperative treatment of these patients. Through recogition of suitable candidates, modifications in anesthetic techique, and appropriate postoperative management, the goal of extubation within 6 hours of admission to the cardiac recovery area can be achieved. Changes in intraoperative and early postoperative management of cardiac surgical patients are discussed. Specific recovery models are reviewed with disussion of the parallel and integrated models. Methods of preicting prolonged extubation times and intensive care unit length of stay are also discussed. Initial management of the cardiac patient in the cardiac recovery area is presented with a more in-depth review of specific complications: stroke, atril fibrillation, blood loss, left ventricular dysfunction, and pulonary dysfunction.