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.

Effect of glucose-insulin-potassium on lactate levels at the end of surgery in patients undergoing cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: study protocol for a randomized controlled trial

IntroductionCytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been established as an effective treatment for peritoneal cancer (PC). However, this kind of combination therapy is associated with a high lactate level. Moreover, studies have suggested that the rate of complications early after surgery directly increased with elevated lactate levels. Glucose-insulin-potassium (GIP), a potent cardioprotective intervention, has been demonstrated to adjust blood glucose (BG) levels and reduce lactate levels. However, the insulin-glucose ratio should be adjusted according to the surgery performed. Here, we aimed to evaluate the advantages of using modified GIP during CRS/HIPEC to reduce the lactate level at the end of surgery and further reduce the incidence of early postoperative complications.Methods and analysisThe modified GIP versus conventional management during surgery study is a single-center, randomized, single-blinded outcome assessment clinical trial of 80 patients with PC who are between 18 and 64 years old and undergoing CRS/HIPEC. Participants will be randomly allocated to receive modified GIP or conventional treatment (1:1). The primary outcome will be the plasma lactate level at the end of surgery. The secondary outcomes will include the highest levels and fluctuation ranges of lactate and BG during surgery, extubation time, APACHE-II score 24 h after surgery, postoperative defecation and exhaust time, postoperative lactate clearance time, postoperative liver and kidney function, incidence of complications within 7 days after surgery, length of intensive care unit stay (LIS), length of hospital stay (LHS), and total cost of hospitalization.Ethics and disseminationThe trial protocol was approved by the Scientific Research Ethics Committee of Beijing Shijitan Hospital Affiliated with Capital Medical University, approval number sjtky11-1x-2022(118). The results will be published in international peer-reviewed journals.Trial registrationChiCTR2200057258. Registered on March 5, 2022.

Anesthetic Effects of Dexmedetomidine Combined with Nalbuphine in Patients Undergoing Laparoscopic Cholecystectomy and its Impact on Nutritional Status.

Laparoscopic cholecystectomy (LC) is a common surgical procedure for the removal of the gallbladder. Effective anesthesia is crucial for ensuring patient comfort and safety during LC. Dexmedetomidine, a selective α2-adrenergic agonist, is widely used as an adjunct to anesthesia due to its sedative and analgesic properties. Nalbuphine, a synthetic opioid analgesic, is also employed for pain management during various surgical procedures. This study aimed to determine the anesthesia effects of dexmedetomidine combined with nalbuphine on patients undergoing LC and its impact on their nutritional status. The clinical records of 100 patients who underwent LC at Wuhan No.1 Hospital between January 2021 and January 2022 were analyzed retrospectively. Forty-six patients who received intravenous dexmedetomidine (0.4 µg/kg) were assigned to the control group, while fifty-four patients who received intravenous nalbuphine (0.2 mg/kg) and dexmedetomidine (0.4 µg/kg) were assigned to the study group. The outcomes compared between the two groups included heart rate (HR), mean arterial pressure (MAP), Riker sedation-agitation scale (RSAS) scores, visual analogue scale (VAS) scores, duration of operation, awakening time from anesthesia, extubation time, adverse reactions, and nutrition-related indicators before and after surgery. There were no significant differences in MAP between the groups at the same time point (p > 0.05). However, at T1 and T3, the study group had significantly lower HR compared to the control group (p < 0.05), with no significant differences in HR at other time points (p > 0.05). The study group exhibited significantly lower RSAS scores compared to the control group (p < 0.01). No significant differences were observed between the groups in terms of duration of operation, awakening time from anesthesia, and extubation time (p > 0.05). At 6 hours post-operation, there were no significant differences in VAS scores between the groups (p > 0.05), but at 12, 24, and 48 hours post-operation, the study group had significantly lower VAS scores compared to the control group (p < 0.0001). No significant inter-group difference was observed in the total incidence of adverse reactions (p = 0.180). Additionally, one week after surgery, the study group exhibited significantly higher levels of albumin, prealbumin, transferrin, and total protein compared to the control group (p < 0.0001). Dexmedetomidine combined with nalbuphine provides a superior anesthetic effect compared to dexmedetomidine alone in patients undergoing LC. This combination effectively controls hemodynamic fluctuations during the recovery period and reduces agitation without affecting the awakening time from anesthesia. These findings suggest that this combination is beneficial and worth promoting.

Data-driven Machine Learning Models for Risk Stratification and Prediction of Emergence Delirium in Pediatric Patients Underwent Tonsillectomy/Adenotonsillectomy.

In the pediatric surgical population, Emergence Delirium (ED) poses a significant challenge. This study aims to develop and validate machine learning (ML) models to identify key features associated with ED and predict its occurrence in children undergoing tonsillectomy or adenotonsillectomy. The analysis involved data cleaning, exploratory data analysis (EDA), supervised predictive modeling, and unsupervised learning on a medical dataset (n = 423). After preliminary data cleaning, EDA encompassed plotting histograms, boxplots, pairplots, and correlation heatmaps to understand variable distributions and relationships. Four predictive models were trained including logistic regression (LR), random forest (RF), Support Vector Machine (SVM), and Gradient Boosting (XGBoost). The models were evaluated and compared using Receiver Operating Characteristic (ROC) Area Under the Curve (AUC), precision, recall, and feature importance. The RF model showed better performance and was used for the test (AUC-ROC 0.96, precision 1.00, and recall 0.92 on the validation set). K-means clustering was applied to find groups within the data. Elbow method and silhouette scores were used to determine the optimal number of clusters. The formed clusters were analyzed by aggregating features to understand the characteristics of each cluster. EDA revealed significant positive correlations between age, weight, American Society of Anesthesiologists (ASA) health score, and surgery duration with the risk of developing ED. Among the ML models, RF achieved the highest performance. Key predictive variables, based on the model's feature importance, included delirium screening scales, extubation time, and time to regain consciousness. Unsupervised K-means clustering identified 2-3 optimal clusters, which represented distinct patient subgroups: younger, healthier, low-risk individuals (cluster 0), and older patients with increasing chronic disease burden, higher delirium screening scores, and consequently higher post-operative delirium risk (clusters 1 and 2). ML techniques are valuable tools for extracting insights and making accurate predictions from healthcare data. High-performing algorithm-based models can be implemented for clinical decision support systems, facilitating early identification and intervention for ED in pediatric patients. By investigating various variables, it is possible to assess risk and implement preventive measures effectively. Furthermore, unsupervised clustering reveals distinct patient subgroups, enabling personalized perioperative management strategies and enhancing overall patient care.

The impact of diurnal variations on emergence delirium following general anesthesia and surgery in children.

Emergence delirium (ED) is a widely recognized issue that prolongs mechanical ventilation and post-anesthesia care unit (PACU) resuscitation time, consequently increasing hospital costs and mortality. Postoperative disturbance in circadian rhythms, commonly leading to sleep disorders, has been identified as a significant risk factor for ED. However, the influence of surgery timing (morning vs. afternoon) on the incidence of ED in pediatric patients undergoing general anesthesia remains unknown. Patients aged 2-6 years who were operated on under general anesthesia with a bispectral index value between 50 and 60 were categorized based on anesthesia start time into either the morning surgery group (Group M, 8:00-12:00) or the afternoon surgery group (Group A, 13:00-17:00). The primary outcome was the post-extubation incidence of ED assessed by the Cornell Assessment of Pediatric Delirium (CAPD) score. Secondary outcomes included extubation time, duration of PACU stay, and adverse postoperative events and complications. We recruited a total of 560 patients, 280 in group M and 280 in group A. Compared to Group M, Group A exhibited a significantly higher incidence of ED (p < 0.001), elevated CAPD scores (p < 0.001), and prolonged PACU stays (p < 0.001). Notably, there was no significant difference in extubation time and anesthesia-related adverse events or other postoperative complications between the groups. Our study highlights that the time of surgery significantly affects the incidence of ED, CAPD scores, and PACU stay duration in children. Further validation of these findings may guide future strategies to reduce ED.

Erector spinae plane block versus intravenous opioid for analgesia in pediatric cardiac surgery: A systematic review and meta-analysis.

The erector spinae plane block (ESPB) has recently emerged as a regional anesthesia technique for perioperative pain management in pediatric cardiac surgery. However, evidence comparing its effectiveness with intravenous (IV) opioid-based analgesia is limited. We aimed to evaluate and compare the analgesic efficacy of ESPB versus IV opioids in this setting. We systematically reviewed and meta-analyzed studies comparing ESPB with IV opioid analgesia in pediatric cardiac surgeries with midline sternotomy. Primary outcomes were intraoperative fentanyl consumption and intensive care unit (ICU) length of stay (LOS). Secondary outcomes included postoperative opioid consumption, time to first rescue analgesia, pain scores, postoperative vomiting and other complications, extubation time, and hospital LOS. Statistical analyses were performed using RStudio version 4.2.3. Five studies with 384 patients were included, with 178 receiving ESPB. ESPB significantly reduced intraoperative fentanyl use (MD -1.90 μg.kg-1; 95% CI -3.15 to -0.66 μg.kg-1; p = .003; I2 = 58%) and ICU LOS (MD -3.50 h; 95% CI -4.32 to -2.69 h; p < .0001; I2 = 0%). No significant differences were found in the remaining outcomes. Our findings suggest the ESPB might be an important adjunct to enhancing analgesia for midline sternotomies in pediatric cardiac surgery, potentially reducing intraoperative opioid requirements and ICU LOS. CRD 42024526961.

Frequency of Screening and Spontaneous Breathing Trial Techniques

The optimal screening frequency and spontaneous breathing trial (SBT) technique to liberate adults from ventilators are unknown. To compare the effects of screening frequency (once-daily screening vs more frequent screening) and SBT technique (pressure-supported SBT with a pressure support level that was >0-≤8 cm H2O and a positive end-expiratory pressure [PEEP] level that was >0-≤5 cm H2O vs T-piece SBT) on the time to successful extubation. Randomized clinical trial with a 2 × 2 factorial design including critically ill adults who were receiving invasive mechanical ventilation for at least 24 hours, who were capable of initiating spontaneous breaths or triggering ventilators, and who were receiving a fractional concentration of inspired oxygen that was 70% or less and a PEEP level of 12 cm H2O or less. Recruitment was between January 2018 and February 2022 at 23 intensive care units in North America; last follow-up occurred October 18, 2022. Participants were enrolled early to enable protocolized screening (more frequent vs once daily) to identify the earliest that patients met criteria to undergo pressure-supported or T-piece SBT lasting 30 to 120 minutes. Time to successful extubation (time when unsupported, spontaneous breathing began and was sustained for ≥48 hours after extubation). Of 797 patients (198 in the once-daily screening and pressure-supported SBT group, 204 in once-daily screening and T-piece SBT, 195 in more frequent screening and pressure-supported SBT, and 200 in more frequent screening and T-piece SBT), the mean age was 62.4 (SD, 18.4) years and 472 (59.2%) were men. There were no statistically significant differences by screening frequency (hazard ratio [HR], 0.88 [95% CI, 0.76-1.03]; P = .12) or by SBT technique (HR, 1.06 [95% CI, 0.91-1.23]; P = .45). The median time to successful extubation was 2.0 days (95% CI, 1.7-2.7) for once-daily screening and pressure-supported SBT, 3.1 days (95% CI, 2.7-4.8) for once-daily screening and T-piece SBT, 3.9 days (95% CI, 2.9-4.7) for more frequent screening and pressure-supported SBT, and 2.9 days (95% CI, 2.0-3.1) for more frequent screening and T-piece SBT. An unexpected interaction between screening frequency and SBT technique required pairwise contrasts that revealed more frequent screening (vs once-daily screening) and pressure-supported SBT increased the time to successful extubation (HR, 0.70 [95% CI, 0.50-0.96]; P = .02). Once-daily screening and pressure-supported SBT (vs T-piece SBT) did not reduce the time to successful extubation (HR, 1.30 [95% CI, 0.98-1.70]; P = .08). Among critically ill adults who received invasive mechanical ventilation for more than 24 hours, screening frequency (once-daily vs more frequent screening) and SBT technique (pressure-supported vs T-piece SBT) did not change the time to successful extubation. However, an unexpected and statistically significant interaction was identified; protocolized more frequent screening combined with pressure-supported SBTs increased the time to first successful extubation. ClinicalTrials.gov Identifiers: NCT02399267 and NCT02969226.

Comparison of Total Intravenous Anesthesia with Inhaler Anesthesia in Children Intubated with Remifentanil without Muscle Relaxant

Objective: The effects of remifentanil and muscle relaxant-free intubation as well as total intravenous anesthesia and inhaled anesthesia for tonsillectomy and/or adenoidectomy in children were compared. Materials and Methods: The study was conducted on 80 patients who were to undergo tonsillectomy and/or adenoidectomy between December 2014 and June 2015. Patients were randomized and divided into two groups. In the total intravenous anaesthesia group, 2.5 mg/kg propofol and 2 mcg/kg remifentanil were administered as induction within 90 seconds. In this group, 3 mg/kg/h propofol and 0.5 mcg/kg/min remifentanil were used for maintenance of anesthesia. In the sevoflurane group, 8% sevoflurane and 2 mcg/kg remifentanil were administered as induction within 90 seconds. In this group, 2.5% sevoflurane, 50% nitrogen protoxide and 50% oxygen were used at 6 l/min for maintenance of anesthesia. Results: Peak heart rate and systolic arterial pressure were significantly higher in Group I. Diastolic arterial pressure was significantly higher in Group T at 1 and 2 minutes after intubation and in Group 2 at 10 minutes postoperatively. Mean arterial pressure was higher in Group T at 2 minutes after intubation. In addition, Wong-Baker pain scale and agitation score were significantly higher in Group I. Spontaneous respiration and extubation time were significantly shorter in Group I. There was no difference between the groups in terms of side effects. Conclusion: Group total intravenous anaesthesia was thought to be a better choice in children because it had less impact on postoperative pain, agitation and recovery.

Enhanced Recovery after Surgery (ERAS) in Pediatric Cardiac Surgery - Status quo of implementation in Europe

ObjectivesEnhanced Recovery After Surgery (ERAS) is a multimodal care pathway to enhance recovery after surgery that is well established in various surgical disciplines. In pediatric cardiac surgery, implementation of ERAS protocols remains inconsistent. We conducted a survey of active European pediatric cardiac surgical centers to assess the current state of ERAS concepts and the current practice in perioperative pediatric cardiac care. DesignProspective, 79-item, web-based cross-sectional survey. SettingWeb-based survey endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC). ParticipantsAnesthesiologists of European pediatric cardiac surgical centers. InterventionsNone Measurements and Main resultsOut of a total of 98 centers, 50 responded. Eight responses were excluded due to incomplete survey forms or non-European location, leaving 42 responses (42,9%) for statistical analysis. Sixteen of the 42 centers (38,1%) follow an ERAS concept. Only 3 (7,1%) have formalized and detailed the ERAS concept in a written document, covering the entire perioperative period, while 13 (31%) have formalized it solely for the intraoperative period.Regarding regional and local anesthesia, 13 (31%) centers regularly practice regional anesthesia blocks, and 11 (26,2%) centers utilize wound infiltration by the surgical team. ConclusionThis European survey revealed that implementation of ERAS concepts in pediatric cardiac surgery is generally low, with considerable heterogeneity in clinical practice regarding the timing of extubation, the choice of surgical procedures triggering on-table extubation, the choice of anesthetic drugs and the use of regional anesthesia. More coordinated efforts are needed to implement ERAS concepts in pediatric cardiac surgery and harvest the benefits of ERAS concepts for the pediatric cardiac population.

Dexmedetomidine decreases cerebral hyperperfusion incidence following carotid stenting: A double-blind, randomized controlled trial.

Cerebral hyperperfusion syndrome (CHS) is a severe complication after carotid artery stenting (CAS). Dexmedetomidine (Dex) is an α2 adrenoceptor agonist with sedative, analgesic, and neuroprotective properties. This randomized, double-blind, placebo-controlled trial (ChiCTR1900024416) aims to investigate whether prophylactic low-dose Dex decreases CH-induced brain injury following CAS. After obtaining written informed consent, patients aged 18-80 who underwent CAS were enrolled between July 2019 and October 2022. Patients were randomly assigned to receive either intravenous Dex (0.1μg/kg/h, until post-operative day 3) (n= 80) or placebo (normal saline) (n= 80). The primary endpoint was the incidence of CH and CHS assessed up to the third post-operative day. The secondary endpoints included National Institute of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) scores within 30days of operation, extubation time, discharge from the hospital within 7days post-operation, length of hospital stay post-operation, and all-cause 30-day mortality. Blood samples were collected before and after surgery for lipidomics, brain-derived neurotrophic factor (BDNF), and neurofilament light chain (Nfl) measurements. Acceptability, safety, and efficacy were evaluated by Cox model and logistic model. CH occurred in 30 (37.5%) of 80 patients who received a placebo compared to 9 (11.2%) of 80 patients given Dex (prevalence: odds ratio [OR]: 0.21, 95% confidence interval [CI]: 0.088-0.467; p<0.001; incidence: hazard ratio [HR]: 0.27, 95% CI: 0.14-0.50; p<0.001). CHS was significantly higher in the placebo group (13.75%) than in the Dex group (2.5%) (prevalence: [OR]: 0.161, 95% CI: 0.024-0.626; p= 0.020; incidence: [HR]: 0.17, 95% CI: 0.06-0.52; p= 0.009). Dex significantly upregulated BDNF, decreased Nfl, and uniquely increased lysophosphatidylethanolamine. A low prophylactic dose of Dex significantly reduced the incidence of CH and CHS up to 72h after CAS. This work was funded byNational Natural Science Foundation of China(no.82271288) andtheHenan Provincial Science and Technology Research Project(nos.242300421192andJQRC2023004).

A Retrospective Multicenter Study of Operating Room Extubation and Extubation Timing following Cardiac Surgery

BackgroundIn an effort to enhance recovery after cardiac surgery, intraoperative extubation has been targeted as possibly beneficial. This multi-center cohort study aimed to assess this by evaluating the outcomes of OR extubation versus extubation within six hours of intensive care unit arrival (early ICU extubation). Furthermore, we assessed time to ICU extubation and mortality and morbidity. MethodsPatients undergoing on-pump cardiac surgery across 79 hospitals between 2011-2020 were included to 1) compare outcomes among OR extubation and early ICU extubation patients, and 2) assess time to overall ICU extubation and outcomes. ResultsThe overall study cohort comprised 163,982 patients, including 95,982 patients [ [ OR extubation : n= 2,529 (2.6%)and early ICU extubation : n= 93,453 (97.4%)] who underwent comparison of OR with early ICU extubation. Following overlap weighting, OR extubation patients had longer OR times (5.6 vs. 5.1 hours, p < 0.0001), and higher rates of reintubation (5.2% vs 2.9%, p=0.003), prolonged ventilation (3% vs 2%, p = 0.021), reoperation for bleeding (1.5% vs 0.7%, p < 0,01), pneumonia (1.9% vs. 1.1% , p < 0.006), and greater in-hospital mortality on multivariable regression (OR 1.34, p < 0.001). OR extubation patients at centers with low OR extubation rates (< 10%, N=60) had higher mortality (odds ratio 1.6, p = 0.001). Beyond 22 hours of postoperative ICU ventilation, the risk of morbidity and mortality increased significantly . ConclusionsFew cardiac surgery patients are extubated in the OR, which is associated with no clinical benefit and with increased morbidity. Cardiac surgery programs should reconsider OR extubation following cardiopulmonary bypass. Additionally, increased intubation time, in particular > 22 hours, is associated with an increase in adverse outcomes.

Effects of adding intravenous midazolam to a dual postoperative nausea and vomiting regimen in patients undergoing breast surgery: A pragmatic randomized controlled trial

Background: For high-risk patients, adding a third antiemetic drug to dual postoperative nausea and vomiting (PONV) prophylaxis is controversial. Given the established antiemetic properties of midazolam, this study compared the combination of low-dose dexamethasone-ondansetron and midazolam with high-dose dexamethasone-ondansetron. Methods: A total of 300 female patients scheduled for breast surgery were recruited and randomly assigned to two groups. The DO group received dexamethasone 8 mg and ondansetron 4 mg, whereas the DOM group received dexamethasone 4 mg, ondansetron 4 mg, and midazolam 0.04 mg/kg. The primary outcome was the incidence of PONV within 24 h. Secondary outcomes were PONV severity, antiemetic requirement, blood glucose levels, satisfaction and sedation scores, time to eye opening and extubation, pain outcome, and sore throat. Results: Primary outcome analysis included 298 patients. Incidence of PONV within the first 24 h after surgery occurred in 52 of 150 (35%) patients in the DO group and 33 of 148 (22%) patients in the DOM group (adjusted risk ratio, 0.63; 95% confidence interval, 0.45–0.88; P = 0.007). The antiemetic requirement was significantly greater in the DO group compared with the DOM group (P = 0.034). However, a significantly higher sedation level and longer time for eye-opening and extubation were observed in the DOM group (P &lt; 0.05). Conclusion: Compared to high-dose dexamethasone and ondansetron alone, midazolam combined with low-dose dexamethasone and ondansetron decreased the incidence of PONV in patients undergoing breast surgery; however, it increased the sedation level in the early postoperative period.

Effect of intravenous different drugs on the prevention of restlessness during recovery period of pediatric laparoscopic surgery: a randomized control trial.

To explored the impact of dexmedetomidine and esketamine in mitigating restlessness during the postoperative recovery phase following laparoscopic surgery in children. 102 individuals aged 1 to 7years experiencing laparoscopic surgery were randomly allocated into three groups, each accepting 1μg/kg of dexmedetomidine, 0.3mg/kg of esketamine, or saline immediately at the end of carbon dioxide pneumoperitoneum. Emergence agitation(EA) occurrence was assessed by PAED scale and 5-point agitation scale. Pain was judged using Face, Legs, Activity, Cry, and Consolability (FLACC) scale. The recovery time, extubation time, and post-anesthesia care unit (PACU) stay time were recorded for all three groups. Patients administered 1μg/kg of dexmedetomidine (8.8%) and individuals given 0.3mg/kg of esketamine (11.8%) showed lower incidences of emergence agitation compared to those receiving saline (35.5%; P = 0.009). There was no statistically significant difference in the time to discharge from the PACU among the three groups of patients (P > 0.05). The recovery time and extubation time were notably extended in the dexmedetomidine group (40.88 ± 12.95min, 42.50 ± 13.38min) when compared to the saline group (32.56 ± 13.05min, 33.29 ± 11.30min; P = 0.009, P = 0.010). Following CO2 pneumoperitoneum in pediatric laparoscopic surgeries, the intravenous administration of 1μg/kg dexmedetomidine or 0.3mg/kg esketamine effectively lowers EA occurrence without extending PACU time.

Pain and immune function in patients undergoing gastric cancer surgery following stellate ganglion block with total intravenous anesthesia.

Stellate ganglion block is a commonly used sympathetic nerve block technique that restores the balance of the sympathetic and vagal nervous systems of the body and inhibits sympathetic nerve activity. To analyze the effect of a stellate ganglion block combined with total diploma intravenous anesthesia on postoperative pain and immune function in patients undergoing laparoscopic radical gastric cancer (GC) surgery to provide a reference basis for the formulation of anesthesia protocols for radical GC surgery. This study included 112 patients who underwent laparoscopic radical surgery for GC between January 2022 and March 2024. There was no restriction on sex. The patient grouping method used was a digital random table method, and the number of cases in each group was 56. The control group was administered total intravenous anesthesia, and the observation group compounded the stellate ganglion block according to the total intravenous anesthesia protocol. Postoperative hemodynamics, pain levels, and immune indices were compared between the groups. The heart rate and mean arterial pressure in the observation group after intubation were lower than those in the control group (P < 0.05). Pain levels were compared between the two groups at 2 hours, 12 hours, 24 hours, and 48 hours after surgery (P > 0.05). The number of CD3+, CD4+, and CD4+/CD8+ cells at the end of surgery was higher in the observation group than in the control group, and the number of CD8+ cells was lower in the observation group than in the control group (P < 0.05). There were no significant differences between the two groups in terms of propofol dosage, awakening time, extubation time, or postoperative adverse reactions (P > 0.05). The application of a stellate ganglion block combined with total intravenous anesthesia had no significant effect on postoperative pain levels in patients undergoing laparoscopic radical GC surgery. However, it can safely reduce the effect of surgery on the immune function of patients and is worth applying in clinical practice.

The effect of transcutaneous electrical acupoint stimulation on postoperative awakening after general anaesthesia: a systematic review and meta-analysis.

The existing body of research concerning the impact of transcutaneous electrical acupoint stimulation (TEAS) on early postoperative recovery is marked by a lack of consensus. This meta-analysis, encompassing a systematic review of randomised controlled trials, seeks to critically assess the efficacy of TEAS in relation to awakening from general anaesthesia in the postoperative period. The inclusion criteria for this study were peer-reviewed randomised controlled trials that evaluated the influence of TEAS on the process of regaining consciousness following general anaesthesia. A comprehensive search was conducted across several reputable databases, including PubMed, Embase, the Cochrane Library, the China National Knowledge Infrastructure, the VIP Database, the SinoMed Database, and the WANFANG Medical Database. The search was not limited by date, extending from the inception of each database up to December 2023. The methodological quality and risk of bias within the included studies were appraised in accordance with the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions, version 5.1, and its associated tool for assessing risk of bias. The analysis encompassed 29 studies involving a total of 2,125 patients. Participants in the TEAS group demonstrated a significantly shorter duration to achieve eye-opening [mean difference (MD), -3.16 min; 95% confidence interval (CI), -3.93 to -2.39], endotracheal extubation (MD, -4.28 min; 95% CI, -4.79 to -3.76), and discharge from the post-anaesthesia care unit (MD, -8.04 min; 95% CI, -9.48 to -6.61) when compared to the control group receiving no or sham stimulation. Additionally, the TEAS group exhibited markedly reduced mean arterial blood pressure (MD, -9.00 mmHg; 95% CI, -10.69 to -7.32), heart rate (MD, -7.62 beats/min; 95% CI, -9.02 to -6.22), and plasma concentrations of epinephrine (standardised MD, -0.81; 95% CI, -1.04 to -0.58), norepinephrine (MD, -47.67 pg/ml; 95% CI, -62.88 to -32.46), and cortisol (MD, -110.92 nmol/L; 95% CI, -131.28 to -90.56) at the time of extubation. Furthermore, the incidence of adverse effects, including agitation and coughing, was considerably lower in the TEAS group relative to the control group (odds ratio, 0.30; 95% CI, 0.22-0.40). The findings of this study indicate that TEAS may hold promise in facilitating the return of consciousness, reducing the interval to awakening post-general anaesthesia, and enhancing the awakening process to be more tranquil and secure with a diminished likelihood of adverse events. However, caution must be exercised in interpreting these results due to the notable publication and geographical biases present among the studies under review. There is an imperative for further high-quality, low-bias research to substantiate these observations. The review protocol was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42022382017).

Opioid-free anesthesia attenuates perioperative immunosuppression by regulating macrophages polarization in gastric cancer patients treated with neoadjuvant PD-1 inhibitor.

Opioid anesthesia can modulate the impaired immune response and opioid-sparing anesthesia may preserve immune functions. This study was performed to assess the effects of opioid-free anesthesia (OFA) and opioid-based anesthesia (OA) on perioperative macrophages differentiation, cytokine changes, and perioperative complications in locally advanced GC (LAGC) patients. We used quality of recovery-15 (QoR-15) questionnaire scores and visual analog scale (VAS) scores to compare postoperative quality of recovery and pain level. In addition, the adverse reactions of patients in the two groups were compared. The perioperative serum level of inflammatory cytokines and the ratio of macrophage subtypes were detected. The OFA group had significantly longer extubation time and PACU stay, whereas the OA group had significantly higher rate of hypotension, higher doses of norepinephrine, higher PONV and dizziness rate, and delayed flatus passage time. The QoR-15 score on postoperative 24 h was significantly higher in OFA group than in OA group. At the end of or after the surgery, the OFA group had higher levels of interleukin (IL)-12, IL-1β, tumor necrosis factor (TNF)-α, CD68+CD163- macrophage rate, but lower levels of IL-10, transforming growth factor (TGF)-β, and CD68+CD163+ macrophage rate, indicating OFA attenuated perioperative immunosuppression by diminishing M2 and promoting M1 macrophage polarization. And the reversal tendency is more obvious in LAGC patients with neoadjuvant PD-1 inhibitor. The OFA may attenuate perioperative immunosuppression by diminishing M2 and promoting M1 macrophage polarization in LAGC patients with neoadjuvant PD-1 inhibitor. http://gcpgl.sysucc.org.cn, identifier 2022-FXY-001.

Goal-Directed Fluid Therapy Using Pulse Pressure Variation in Thoracic Surgery Requiring One-Lung Ventilation: A Randomized Controlled Trial.

Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung ventilation. Methods: Patients scheduled for pulmonary lobectomy using uniportal video-assisted thoracic surgery approach were randomly assigned to two groups. In the PPV group, fluid administration was guided by the pulse pressure variation parameter, while in the near-zero group, it was guided by conventional hemodynamic parameters. The primary outcome was the partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) ratio 15 min after extubation. The secondary outcomes included extubation time, the incidence of postoperative pulmonary complications in the first three postoperative days, and the length of hospital stay. Results: The PaO2/FiO2 ratio did not differ between the two groups (364.48 ± 38.06 vs. 359.21 ± 36.95; p = 0.51), although patients in the PPV group (n = 44) received a larger amount of both crystalloids (1145 ± 470.21 vs. 890 ± 459.31, p = 0.01) and colloids (162.5 ± 278.31 vs 18.18 ± 94.68, p = 0.002) compared to the near-zero group (n = 44). No differences were found in extubation time, type and number of PPCs, and length of hospital stay. Conclusions: PPV-guided fluid management in thoracic surgery requiring one-lung ventilation does not improve pulmonary gas exchange as measured by the PaO2/FiO2 ratio and does not seem to offer clinical benefits. Additionally, it results in increased fluid administration compared to fluid management based on conventional hemodynamic parameters.

Ultrasound-guided bilateral anterior quadratus lumborum block at the lateral supra-arcuate ligament in patients undergoing laparoscopic radical gastrectomy: A randomised controlled study

Objective: Ultrasound-guided bilateral anterior quadratus lumborum block at the lateral supra-arcuate ligament has recently been proposed as an effective analgesia for abdominal surgery. To test the hypothesis that this novel technique was a viable alternative approach of conventional thoracic epidural analgesia for laparoscopic radical gastrectomy. Methods: Three hundred patients scheduled for laparoscopic radical gastrectomy were randomised 1:1 into the anterior quadratus lumborum block group: receiving the novel regional analgesia, and the thoracic epidural analgesia group: receiving thoracic epidural anaesthesia. The primary endpoint was intraoperative consumption of propofol and remifentanil. Intention-to-treat analysis was performed for all variables. Results: At five and ten minutes after block, anterior quadratus lumborum block group achieved more dermatomes coverage of the sensory block with both p &lt; 0.001. Intraoperative consumption of propofol and remifentanil was comparable between two groups (1116.21 ± 199.76 versus 1166.45 ± 125.31µg, p = 0.245 and remifentanil 1.83 ± 0.41 versus 1.81 ± 0.37ng, p = 0.988). However, anterior quadratus lumborum block group was associated with less intraoperative consumption of norepinephrine and atropine, shorter time to urinary catheter removal and out-of-bed activity than the thoracic epidural anaesthesia group. No significant difference in extubation time, pain scores at rest and exercising at all time points following surgery was observed between the two groups. Conclusions: Compared with conventional thoracic epidural anaesthesia, the novel technique was an equivalent effective component of multimodal analgesic protocol for laparoscopic radical gastrectomy. There were some advantages, including shorter procedure time, more reliable dermatomal coverage, shorter duration of urinary catheterisation and earlier time of out-of-bed activity to enhance recovery after surgery. Trial registration: The study was registered in the Chinese Clinical Trial Registry on 2 November 2022 (ChiCTR2200065325).

Extravascular lung water assessment by lung ultrasound in infants following pediatric cardiac surgery.

Lung edema is a significant factor in prolonged mechanical ventilation and extubation failure after cardiac surgery. This study assessed the predictive capability of point-of-care Lung Ultrasound (LUS) for the duration of mechanical ventilation and extubation failure in infants following cardiac procedures. We conducted a prospective observational trial on infants under 1 year, excluding those with pre-existing conditions or requiring extracorporeal membrane oxygenation. LUS was performed upon intensive care unit (ICU) admission and prior to extubation attempts. B-line density was scored by two independent observers. The primary outcomes included the duration of mechanical ventilation and extubation failure, the latter defined as the need for reintubation or non-invasive ventilation within 48 h post-extubation. The study included 42 infants, with findings indicating no correlation between initial LUS scores and extubation timing. Extubation failure occurred in 21% of the patients, with higher LUS scores observed in these cases (p = 0.046). However, interobserver variability was high, impacting the reliability of LUS scores to predict extubation readiness. LUS was ineffective in determining the length of postoperative ventilation and extubation readiness, highlighting the need for further research and enhanced training in LUS interpretation.

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.