Total Anesthesia Research Articles

Comparison of the Effects of Inhalational Anesthesia with Sevoflurane and Total Intravenous Anesthesia in Open Heart Surgery

Background: The primary objective of this study was to compare sevoflurane inhalation anesthesia with total intravenous anesthesia (TIVA) in terms of its effectiveness in maintaining adequate depth of anesthesia during all open heart surgery procedures, including cardiopulmonary bypass. The study's secondary objective was to compare sevoflurane inhalation anesthesia with TIVA regarding the impact on the time of tracheal extubation and the incidence of postoperative acute kidney injury during open heart surgeries. Methods: A total of 58 patients undergoing open heart surgery were included, with 30 receiving sevoflurane inhalation anesthesia and 28 receiving TIVA. Demographic characteristics, intraoperative parameters, and postoperative outcomes were recorded and analyzed. Statistical analysis revealed no significant differences in Bispectral Index (BIS) monitor values, mean arterial pressure, body temperature, or other intraoperative parameters between the two groups. Notably, the time to tracheal extubation was significantly shorter in the Sevoflurane group compared to the TIVA group, although both groups exhibited similar rates of postoperative acute kidney injury (AKI). Results: None of the patients had complaints of intraoperative awareness. The mean arterial pressure, body temperature, and bispectral index values during and before cardiopulmonary bypass were similar between the groups. Postoperative variables such as intensive care unit stay duration, incidence of acute kidney injury, and immediate and 24-hour post-extubation visual analog scale values were similar between the groups. The tracheal extubation time was found to be statistically shorter in the sevoflurane group. Conclusion: We believe that sevoflurane inhalation anesthesia can achieve adequate depth of anesthesia during the intraoperative period in open heart surgery without increasing the rate of postoperative complications.

The Association of Body Mass Index and Early Outcomes Following Orthognathic Surgery

The existing data on the link between body mass index (BMI), operative characteristics, and surgical outcomes across orthognathic surgery are limited. The purpose was to measure the association between BMI and early postoperative outcomes in orthognathic surgery. This is a retrospective cohort study of patients (n=118) aged > 14years undergoing bimaxillary orthognathic surgery between 2015 and 2018 by a single surgeon within the Kaiser Permanente Northern California-integrated healthcare system. Patients undergoing unilateral or additional procedures, history of prior orthognathic surgery, or pre-existing pain conditions were excluded. The predictor variable was BMI measured as a continuous (kg/m2) and categorical variable (underweight/normal, overweight, obese). The primary outcome variables were additional postoperative antibiotics, increased postoperative visits, wound dehiscence, and wound infection. The secondary outcome variables were total operative and anesthesia time. The demographic covariates included age, sex, and race/ethnicity. The clinical covariates included history of obstructive sleep apnea, Mallampati score, tobacco use, American Society of Anesthesia classification, thyromental distance, history of difficult intubation, and Angle's classification. Bivariate and multivariate analyses were performed to measure the associations between BMI and the primary and secondary outcomes. Multivariable logistic regression analyses were used to measure associations between BMI and the postoperative outcomes. Statistical significance was defined as P<.05. The study sample was composed of 118 subjects with a mean age of 26.91years (standard deviation 9.43). Forty-seven percent (n=55) were male, and the mean BMI was 25.13 (standard deviation 5.19). BMI category was significantly associated with age, with increasing age associated with higher BMI category (P=.02). According to the bivariate and multivariable logistic regression analyses, controlling for age, race/ethnicity, BMI, and total operative time, increased total operative time was associated with additional postoperative antibiotics (odds ratio=1.03, 95% confidence interval: 1.01, 1.05), and increased postoperative appointments (odds ratio=1.02, 95% confidence interval: 1.01, 1.04). No significant association between BMI and other clinical or operative characteristics was seen aside from American Society of Anesthesia classification. Elevated BMI was not associated with worsened operative characteristics or postoperative outcomes. This supports the suitability of orthognathic surgery in a BMI-diverse population.

Quality of Postoperative Recovery in Total Intravenous Anesthesia between Remimazolam and Propofol for Intraoperative Neurophysiological Monitoring: A Prospective Double-Blind Randomized Controlled Trial.

This study compared the overall postoperative recovery of patients who underwent total intravenous anesthesia with remimazolam or propofol, using the Quality of Recovery-15 questionnaire (QoR-15). Seventy-two patients who underwent spine surgery with intraoperative neurophysiological monitoring (IONM) were randomly categorized into the remimazolam group (group R) or propofol group (group P). On the first postoperative day, the QoR-15 scores for groups P and R were 114 and 112, respectively, indicating no significant difference (p = 0.691). Similarly, group-time interaction effects on QoR-15 scores were not significantly different. In the post-anesthesia care unit, the pain intensity at rest was notably higher in group P than in group R (3.0 [0.0] vs. 2.8 [0.5], respectively, p = 0.009). Although the intraoperative consumption of remifentanil was higher in group R (1452.4 µg vs. 2066.8 µg, respectively, p < 0.001), the intraoperative use of vasopressors was lower in group R (1705.6 µg vs. 286.1 µg, respectively, p < 0.001) compared to group P. Group R exhibited significantly lower variability in mean blood pressure over time compared to group P. Remimazolam was viewed as a promising intravenous agent for general anesthesia, showing potential to replace propofol in spine surgery with IONM, considering both recovery quality and intraoperative hemodynamic stability.

Relationship between preinduction electroencephalogram patterns and propofol sensitivity in adult patients

PurposeTo determine the precise induction dose, an objective assessment of individual propofol sensitivity is necessary. This study aimed to investigate whether preinduction electroencephalogram (EEG) data are useful in determining the optimal propofol dose for the induction of general anesthesia in healthy adult patients.MethodsSeventy healthy adult patients underwent total intravenous anesthesia (TIVA), and the effect-site target concentration of propofol was observed to measure each individual’s propofol requirements for loss of responsiveness. We analyzed preinduction EEG data to assess its relationship with propofol requirements and conducted multiple regression analyses considering various patient-related factors.ResultsPatients with higher relative delta power (ρ = 0.47, p < 0.01) and higher absolute delta power (ρ = 0.34, p = 0.01) required a greater amount of propofol for anesthesia induction. In contrast, patients with higher relative beta power (ρ = -0.33, p < 0.01) required less propofol to achieve unresponsiveness. Multiple regression analysis revealed an independent association between relative delta power and propofol requirements.ConclusionPreinduction EEG, particularly relative delta power, is associated with propofol requirements during the induction of general anesthesia. The utilization of preinduction EEG data may improve the precision of induction dose selection for individuals.

Efficacy and safety during endoscopic retrograde cholangiopancreatography (ERCP) under total intravenous anesthesia – propofol alone versus propofol supplemented with dexketa, a comparative study in medical college, Kolkata

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure and, hence, is distressing for awake patients, requiring an adequate level of anesthesia. Recent advancements have encouraged the use of monitored anesthesia care, that allows the patient to tolerate unpleasant experiences during procedures while maintaining cardio-respiratory function. Usually, propofol-based anesthesia is given in ERCP. The main aim of this study is to compare the effect of propofol alone and propofol with ketamine and dexmedetomidine on the hemodynamics during ERCP, recovery profile, and side effects (if any). Aims and Objectives: (1) To compare efficacy in terms of hemodynamic stability and desaturation events. (2) Recovery and quality of recovery. (3) Pain score. (4) Incidence of post-operative nausea and vomiting. Materials and Methods: This is a comparative double-blinded study. Adult patients from the age group of 18–70 years belonging to the American Society of Anesthesiologists (ASA-I) and ASA-II who had undergone ERCP under total intravenous anesthesia were taken and randomly assigned to either of the two groups. Both groups received 0.01 mg/kg glycopyrrolate, 0.1 mg/kg ondansetron, 0.05 mg/kg midazolam, 50 mcg fentanyl, and 40 mg hyoscine. Group A patients received 30 mg propofol as a bolus dose and then repeated according to requirements. Group B patients received 0.5 mcg/kg dexmedetomidine as a loading dose and 0.3 mcg/kg/h as a maintenance infusion dose. 30 mg propofol was given before negotiating scope and then 1 mL (1:1) mixture of propofol and ketamine was repeated according to requirements. Total propofol consumption, hemodynamics, quality of recovery, and side effects (if any) were recorded at regular intervals. Results: The study showed significant cases in Group A had episodes of hypotension and apneic events, whereas there were very few hemodynamic instability and almost no apneic events in Group B patients. The requirement of propofol was much higher in Group A patients. Conclusion: Dexmedetomidine when used along with propofol and ketamine in ERCP patients reduced the dose requirement of propofol and maintained hemodynamic stability without causing any apneic events.

Anesthesia Considerations in Patients Undergoing Spine Surgery with Evoked Potential Monitoring

Intra-operative neuromonitoring (IONM) facilitates monitoring of the functional integrity of neural structures under general anesthesia. It aids in early detection of injury and minimizes postoperative neurologic deficit. IONM may be used during spine surgery, where either the blood supply to the spinal cord could be compromised or the surgical procedures where there is manipulation of the spinal cord. Somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) are used to monitor the sensory and motor tracts in the spinal cord, respectively. Preoperatively, a team of surgeons, anesthetists, and neurophysiologists must discuss about modalities of IONM to be used, expected changes, and alarm criteria. Anesthesia drugs need to be appropriately selected to facilitate IONM, as they affect the SSEP and MEP response obtained. Both total intravenous anesthesia and balanced anesthesia technique may be used, with appropriate titration of drugs. False-positive changes in evoked potentials (EPs) must be prevented by a steady anesthesia state and physiologic parameters. It is preferable to have a checklist to follow whenever changes in EP response are observed to rule out surgical, anesthetic, and monitoring-related causes for change in response. Risk–benefit must be assessed before the selection of a patient for EP monitoring as it may be rarely associated with complications such as burns, seizures, and bite injuries to lips, tongue, and endotracheal tube. Teamwork with meticulous planning, preparation, and multidisciplinary communication is essential for the safe conduct of spine surgeries with SSEP and MEP monitoring. In this review, we discuss various considerations for anesthesia management in patients with intraoperative EP monitoring.

Are there beneficial effects to hybrid anesthesia*?

As the COVID-19 pandemic increased the use of propofol in the intensive care unit for the management of respiratory sequelae and supply had become a major issue. Indeed, most hospitals in Japan were forced to use propofol only for induction of anesthesia with inhalational maintenance. Large amounts of propofol remain in the syringe which exacerbates the problems by increased waste. I propose that use of low dose propofol in combination with a low concentration inhaled anesthetic as an alternative and call this hybrid anesthesia. Several advantages of hybrid anesthesia are evident in the literature. Volatile anesthesia has several disadvantages such as cancer progression, emergence agitation, marked reduction in motor evoked potentials (MEP), laryngospasm with desflurane and postoperative nausea and vomiting (PONV). Volatile anesthesia exerts some beneficial actions such as myocardial protection and fast emergence with desflurane. In contrast, total intravenous anesthesia (TIVA) provides better survival in patients undergoing radical cancer surgery, reduction in emergence agitation, laryngospasm, PONV and better MEP trace Intraoperative awareness occurs more often during TIVA. When intravenous and volatile anesthesia are combined (hybrid anesthesia), the disadvantages of both methods may be offset by clear advantages. Thus, hybrid anesthesia may, therefore, be a viable anesthetic choice.

Normalized Pulse Volume as a Superior Predictor of Respiration Recovery and Quantification of Nociception Anti-nociception Balance Compared to Opioid Effect Site Concentration: A Prospective, Observational Study

Background Quantifying pain and the balance between nociception and anti-nociception (NANB) in sedated patients is challenging. Traditional opioid titration methods overlook individual differences, while existing indices like the Noxious Stimulation Response Index (NSRI) lack correlation with effect-site concentration (Ce). The Normalized Pulse Volume (NPV), used in polygraphs, has potential for pain quantification but is underexplored. This study aimed to assess NPV’s efficacy as a pain monitoring tool compared to Ce and to explore its potential in various clinical settings. Methods The study included 39 patients undergoing surgery under total intravenous anesthesia from July 2013 to May 2014. Selection criteria were an American Society of Anesthesiologists physical status classification system (ASA score) of 1 or 2 and surgeries with minimal fluid resuscitation or blood loss. Exclusion criteria were significant posture changes, massive hemorrhage, and high perfusion index variation. NPV and Ce were measured using the Masimo SET adult SpO2 sensor. Results Out of 39 patients, 9 were excluded. NPV at recovery of spontaneous respiration (RoR) was 2.62 (95% CI: 2.26–2.98) with a coefficient of variation (CoV) of 36.3%, while total Ce was 1.48 ng/ml (95% CI: 1.14–1.84) with a CoV of 62.4%. NPV showed a narrower CoV than Ce (p &lt; 0.05, 1.93*10−5), indicating less variability. NPV outperformed Ce in predicting RoR, suggesting a more accurate reflection of NANB balance. Its superiority in stable measurement underlines its potential as a reliable pain indicator. The study’s limitations include temporal differences in NPV and Ce calculations, affecting comparative analysis. Conclusion NPV demonstrates promise as an objective, reliable indicator of pain or NANB, showing a strong correlation with Ce. Its application could improve pain assessments in clinical settings, optimizing patient care and analgesic administration. Future research should integrate NPV with other vital signs for a comprehensive pain monitoring system.

Comparison of combined intravenous and inhalation anesthesia and total intravenous anesthesia in laparoscopic surgery and the identification of predictive factors influencing the delayed recovery of neurocognitive function.

Compare the anesthesia effects of combined intravenous and inhalation anesthesia (CIVIA) and total intravenous anesthesia (TIVA) in laparoscopic surgery. Furthermore, our objective is to examine the elements that contribute to the delay in postoperative recovery of neurocognitive function and anticipate the manifestation of delayed recovery by analyzing serum cytokines. The CIVIA group and the TIVA group both consisted of 130 patients who were scheduled to have elective major abdominal surgery through laparoscopy. The criteria taken into account by the observational and record-keeping study were the patients' ages, sexes, body masses, heights, and the presence or absence of any preexisting problems. Both groups also had their anesthetic depth, duration, and per-unit-of-time muscle relaxant and analgesic dosages recorded. Finally, the length of each patient's stay in the hospital as well as their overall length of stay were tracked. By using the Mini-Mental State Examination (MMSE) to measure cognitive function, we assessed the mental states of the subjects. Additionally, we wanted to identify any biomarkers that could be linked to postoperative cognitive decline or delays in neurocognitive recovery. A total of 51 participants from the CIVIA group and 53 participants from the TIVA group satisfactorily completed the necessary neuropsychological exam for identifying delayed neurocognitive recovery at the study's completion. In the initial data of the two groups, no significant discrepancies were found (p > 0.05). The CIVIA group exhibited noteworthy reductions in the quantity of administered analgesics and muscle relaxants per unit of time in comparison to the TIVA group (p < 0.05). In addition to this, the duration from the sevoflurane tank being closed to the extubation period demonstrated a significant reduction in the CIVIA group compared to the TIVA group (p < 0.05). Moreover, no statistically notable distinction was observed in terms of postoperative hospitalization duration and overall hospitalization duration among both groups (p > 0.05). According to the study, both the CIVIA group and the TIVA group had a total of 7 (13.72%) and 17 (32.07%) individuals, respectively, who met the criteria for neurocognitive delayed recovery (Odds Ratio: 0.336; 95% CI: 0.134-0.864; p = 0.026). According to the research findings, it is indicated that there is a possibility for an increased presence of IL-6 in the bloodstream within 60 min following the incision made on the skin. This occurrence subsequently leads to the prolonged restoration of neurocognitive capabilities. The CIVIA technique outperforms the TIVA method in terms of overall assessment in the setting of laparoscopic surgery. It's also important to remember that an increased blood IL-6 level during laparoscopy may operate as a separate risk factor for a delay in the restoration of neurocognitive function.

Development, Validation, and Comparison of a Novel Nociception/Anti-Nociception Monitor against Two Commercial Monitors in General Anesthesia.

In this paper, we present the development and the validation of a novel index of nociception/anti-nociception (N/AN) based on skin impedance measurement in time and frequency domain with our prototype AnspecPro device. The primary objective of the study was to compare the Anspec-PRO device with two other commercial devices (Medasense, Medstorm). This comparison was designed to be conducted under the same conditions for the three devices. This was carried out during total intravenous anesthesia (TIVA) by investigating its outcomes related to noxious stimulus. In a carefully designed clinical protocol during general anesthesia from induction until emergence, we extract data for estimating individualized causal dynamic models between drug infusion and their monitored effect variables. Specifically, these are Propofol hypnotic drug to Bispectral index of hypnosis level and Remifentanil opioid drug to each of the three aforementioned devices. When compared, statistical analysis of the regions before and during the standardized stimulus shows consistent difference between regions for all devices and for all indices. These results suggest that the proposed methodology for data extraction and processing for AnspecPro delivers the same information as the two commercial devices.

Evaluation of Surgical Conditions during Elective Endoscopic Sinus Surgery with Total Intravenous Anesthesia and Monitored Anesthesia Care

Evaluation of Surgical Conditions during Elective Endoscopic Sinus Surgery with Total Intravenous Anesthesia and Monitored Anesthesia Care

Enhanced recovery after endoscopic sinus surgery: Establishing comprehensive protocols for improvement of perioperative patient care

AbstractObjectivesEnhanced recovery after surgery (ERAS) protocols for endoscopic sinus surgery (ESS) have not been widely implemented, and a critical review of ERAS recommendations and a comprehensive analysis of the supporting literature has not been undertaken. We describe an ESS ERAS protocol including key perioperative interventions for patients undergoing ESS and assess the available evidence.Data SourcesA search was conducted of all relevant ERAS literature in otorhinolaryngology, anesthesia, and surgery using Medline (via PubMed), and Scopus. Keywords included “endoscopic sinus surgery,” “sinus surgery,” “FESS,” and “ESS” for each area of intervention. Where applicable, the authors considered high‐level evidence for recommendations devised for patient cohorts in otorhinolaryngology not undergoing ESS, as well as cohorts undergoing surgical procedures for which ERAS protocols have been extensively evaluated.MethodsStudies received grades of “low,” “moderate,” or “high” quality evidence based on the Oxford Centre for Evidence‐Based Medicine criteria. Each intervention was subsequently assigned a grade of “strong,” “weak,” or “conditional” based on the available evidence.ResultsStrong recommendations include comprehensive patient education and counseling, minimization of preoperative fasting, application of topical/local anesthetics and vasoconstrictors, use of total intravenous anesthesia, avoidance of pharyngeal packing, and use of postoperative nasal irrigation and multimodal analgesia. Conditional recommendations include antibiotic prophylaxis. Weak recommendations include perioperative venous thromboembolism prophylaxis, controlled hypotension, and use of postoperative nasal packing/dressing.ConclusionA comprehensive ERAS protocol for ESS can include a variety of high yield, evidence‐based interventions that would likely improve surgical outcomes and patient satisfaction.

Predicting the optimal concentration of remifentanil for skull pin fixation with hemodynamic and analgesia nociception index monitoring

Inadequate antinociception during skull pin fixation may cause hemodynamic instability in intracranial surgery. The optimal concentration of remifentanil to provide adequate antinociception and stable hemodynamics during skull pin fixation under analgesia nociception index monitoring is unknown. This study is to assess the 90% effective concentration of remifentanil for skull pin fixation under hemodynamic and analgesia nociception index monitoring. Twenty-six patients were enrolled for intracranial surgery, anesthesia was induced and maintained under total intravenous anesthesia using target-controlled infusion for remifentanil and propofol under analgesia nociception index and bispectral index monitoring. Skull pin fixation was performed at different effect-site concentrations of remifentanil required for Dixon's up-and-down method with a step size of 0.5 ng/ml under bispectral index 40–60. Inadequate antinociception is defined when either ANI < 30 or > 20% in hemodynamic changes from baseline (e.g. heart rate > 100 beats/min, or blood pressure > 180/100 mmHg) and the effect-site concentration of remifentanil is considered as failure. It is considered success as ANI > 30 and < 20% hemodynamic changes from baseline simultaneously. Seven pairs of failure/success were used for probit analysis. The 90% effective concentration of remifentanil for skull pin fixation with adequate antinociception and hemodynamic stability was 4.7 ng/ml.

A retrospective analysis of anesthetic techniques and their related perioperative complications in children undergoing cochlear implant surgeries – our preliminary experience at a tertiary care referral centre

: Cochlear implants serve as a favorable option for treatment of hearing loss in children. However, there is limited data regarding the type of anesthetic techniques used and its associated complications in such patients. Hence, the primary objective of this study was evaluation of postoperative nausea vomiting (PONV) with three different general anesthesia techniques in pediatric cochlear implant surgeries. The secondary objectives included assessment of intraoperative and postoperative complications: A retrospective analysis of all children less than 13 years, who underwent cochlear implant surgery at our hospital between December 2019 to February 2022 was performed. Appropriate data were noted. Nine patients each were classified into three groups (Group A, B and C) on the basis of anesthetic techniques used in our institution. Group A received inhalational agent for induction and maintenance, with no Non-Depolarizing Muscle Relaxant (NDMR), Group B patients received Total Intravenous Anesthesia with NDMR and Group C received intravenous induction and inhalational agent for maintenance with NDMR. Twenty-seven patients were included. There were no major intraoperative complications. PONV was noticed in two patients of Group A and one patient of Group C. One patient belonging to Group A developed laryngospasm and desaturation. Delayed Awakening was seen in one patient each of Group A, B and C. Overall, four complications were noted in patients of Group A, one in Group B and two in Group C. All complications were mild and were managed successfully.This preliminary study suggests that peri-operative anesthetic complications with all three anesthestic techniques were comparable and safe.

PRESS (Propofol, Remifentanil, Electricity/EEG, Setup and Setting) to Start: Introducing a Total Intravenous Anaesthesia Checklist at a Large Teaching Hospital.

Total intravenous anaesthesia (TIVA) is becoming more widely used, and as of yet there are few safety checks for the use of TIVA when compared to inhaled anaesthesia. This study aims to assess the feasibility and utility of introducing a TIVA checklist at a large teaching hospital. Methods A survey was sent out to all consultant and trainee anaesthetists at our hospital regarding their use of TIVA and errors in practice related to its use. A checklist was created based on common errors reported in the survey, errors described in NAP5 and our hospital's standard operating procedure. The checklist was introduced, andanother survey was distributed a month later to assess compliance and utility and to gain feedback. Results In the first survey, there were 39 responses. A total of 64% had seen an error with the use of TIVA. For those using TIVA 70% of the time or more, 31% had seen an error in the last three months.Twelve per cent of those who had seen errors found that the errors led to patient harm. Only 33% used a method to double-check for errors prior to commencing TIVA. In the follow-up survey, 80% of those who used the checklist had found it useful, and 30% had corrected an error while using the checklist. Eighty-seven per cent felt the checklist would prevent errors from being made. Eighty per cent of respondents said they would use the checklist in their future practice. The checklist was found to be more useful for trainees, and for those who use TIVA less often. Discussion The 'PRESS to start TIVA" checklist has been shown to be a useful tool to prevent errors and a majority of anaesthetists at our hospital plan to use it going forward. Our data suggests that anaesthetists who are less experienced with TIVA benefit more from having a checklist. There was a marked increase in the number of anaesthetists who would use a checklist in the future, compared to those who used one in the initial survey. This shows that introducing a checklist is feasible and is likely to reduce errors going forward.

Comparison of the Effectiveness of Total Intravenous Anesthesia (TIVA) vs Inhalation Techniques in Patients with Morbid Obesity at Dr. M. Djamil General Hospital, Padang, Indonesia

Introduction: Morbidly obese patients (BMI ≥ 40 kg/m²) present unique challenges in anesthesia. Total intravenous anesthesia (TIVA) and inhalation techniques have their respective advantages and disadvantages in this group of patients. This study aims to compare the effectiveness and safety of TIVA and inhalation anesthesia in morbidly obese patients at Dr. M. Djamil General Hospital Padang.&#x0D; Methods: A prospective, randomized study was conducted on 80 morbidly obese patients undergoing elective surgery. Patients were randomized to receive TIVA with propofol and remifentanil or inhalation anesthesia with sevoflurane and desflurane.&#x0D; Results: The TIVA group demonstrated faster recovery time (p = 0.02) and less postoperative opioid requirements (p = 0.01) than the inhalation group. There was no significant difference in the incidence of intraoperative or postoperative complications.&#x0D; Conclusion: TIVA is an effective and safe option for morbidly obese patients undergoing elective surgery. TIVA offers faster recovery and fewer postoperative opioid requirements than inhalation anesthesia.

Effects of opioid-free anaesthesia compared with balanced general anaesthesia on nausea and vomiting after video-assisted thoracoscopic surgery: a single-centre randomised controlled trial

ObjectivesOpioid-free anaesthesia (OFA) has emerged as a promising approach for mitigating the adverse effects associated with opioids. The objective of this study was to evaluate the impact of OFA on...

Flexible bronchoscopy insufflated and high-flow nasal oxygen pilot trial (BUFFALO protocol pilot trial)

BackgroundHypoxaemia occurs in approximately 30% of children during anaesthesia for flexible bronchoscopy. High-flow nasal oxygen (HFNO) can prolong safe apnoea time and be used in children with abnormal airways. During flexible bronchoscopy, there is limited evidence if HFNO confers advantages over current standard practice in avoiding hypoxaemia. The aim is to investigate feasibility of HFNO use during anaesthesia for flexible bronchoscopy to reduce frequency of rescue oxygenation and hypoxaemia.MethodsBUFFALO is a bi-centre, unmasked, randomised controlled, parallel group, protocol for a pilot trial comparing HFNO techniques to standard practice during anaesthesia. Children (n = 81) aged > 37 weeks to 16 years presenting for elective bronchoscopy who fulfil inclusion but not exclusion criteria will be randomised prior to the procedure to HFNO or standard care oxygenation post induction of anaesthesia. Maintenance of anaesthesia with HFNO requires total venous anaesthesia (TIVA) and with standard, either inhalational or TIVA at discretion of anaesthetist in charge of the patient. Outcomes will include the feasibility of recruitment and adherence to trial procedures, acceptability of the intervention of the protocol and completion rates of data collection methods.DiscussionFindings of this trial will determine feasibility to plan for a larger multicentre randomised clinical trial and support the feasibility of the proposed study procedures.Trial registrationBUFFALO trial was registered with Australia and New Zealand Clinical Trials Registry (TRN12621001635853) on 29 November 2021 and commenced recruitment in May 2022. https://www.anzctr.org.au/. The primary manuscript will be submitted for publication in a peer-reviewed journal.

Evaluation of Analgesic Nociceptive Index in intraoperative and postoperative pain management in general anesthesia applied with two different methods

Aim: Effectiveness of analgesic nociceptive index (ANI) monitoring in predicting both intraoperative and postoperative early pain in neurosurgery patients undergoing lumbar spinal surgery. The patients were administered general anesthesia using different anesthesia management techniques.Method: The study included a total of 60 patients with American Society of Anesthesiologist (ASA) I-III. The patients were randomly divided into two groups of 30 each using the closed envelope method. Group T received total intravenous anesthesia (TIVA) with remifentanil-propofol, while Group D with desflurane-remifentanil. Non-invasive ANI monitoring was applied to patients undergoing lumbar spinal surgery, and ANI, heart rate, systolic/diastolic arterial pressure values were recorded before and after induction, skin incision, major muscle incision, laminectomy, right-left fasciectomy, screw fixation, after extubation and during the postoperative period. Post-operative heart rate, ANI value, mean arterial pressure values, and visual analog scale (VAS) values were measured.Results: No statistically significant difference was found in terms of the demographic data of the patients. According to the groups, no statistically significant difference was found between the ANI and VAS measurements of the cases at the postoperative 5th minute (P=0.261), postop 10th minute (P=0.379), postop 15th minute (P=0.673), postop 30th minute (P=0.784) and postop 60 minute (p =0.750).Conclusions: In our study on lumbar spine surgery, we could not detect any significant relationship between ANI monitoring and VAS values in the early postoperative period. There was no difference in ANI and VAS with either anaesthetic technique. In light of the results of our study, we believe that more studies are needed on the use of ANI monitoring in the early postoperative period.

MODIFIED GENERAL ANESTHESIA FOR ELECTIVE CESAREAN SECTION

Introduction: The general anesthesia for elective caesarean section is used when there are contraindications to subarachnoid anesthesia, with a total frequency up to 20%. The medical community does not have a single unified algorithm of general anesthesia for this type of surgery. The main disadvantages of the general anaesthesia for caesarean section are a high percentage of the accidental preservation of the patient's consciousness during the operation (1:670) and a pronounced stress reaction to the surgical trauma. Purpose: To compare the «routine» technique of total intravenous anesthesia with artificial lungs ventilation for elective cesarean section and the modified general anesthesia with adjuvants addition. Materials and methods: Our study is based on an examination of 60 patients. All patients were randomly divided into 2 groups. The first group is a «routine» method of general anesthesia, the second group is modified general anesthesia with adjuvants addition. Intravenous forms of medical drugs were used as adjuvants: paracetamol (1000 mg), clonidine (100 μg), 30 minutes before surgery. Perioperative monitoring and treatment were based on the recommendations of the American Association of Anesthesiologists, the bispectral index and determination of the stress-induced substances (glucose, cortisol) blood levels were added. The newborns were evaluated with the Apgar scale and umbilical venous blood gas analysis was carried out. The two-sided Student's t-test was used for statistical data processing (p value = 0.001; Student's t-test &lt; -3.466 and &gt; 3.466). Results: There was no statistically significant difference in mean initial indicators between the two groups. The obtained results demonstrated the presence of statistically significant differences between the two groups: the mean blood pressure in a period after the trachea intubation/beginning of the surgery (t = 24.3); the mean blood pressure in a period of the newborn extraction (t = 25.5); the heart rate in a period after the trachea intubation/beginning of the surgery (t = 11.7); the heart rate in a period of the newborn extraction (t = 21.3); the bispectral index in a period after the trachea intubation/beginning of the surgery (t = 4); the bispectral index in a period of the newborn extraction (t = 8.2); assessment of newborns according to the Apgar scale at 1 minute (t = –4.5); pH of the umbilical venous blood (t = –5.44); PCO2 of the umbilical venous blood (t = 4.8); PO2 of the umbilical venous blood (t = –7.6); the blood glucose level in a period of the newborn extraction (t = 10.9); the plasma cortisol level in a period of the newborn extraction (t = 25.4). Conclusions: In view of the obtained results, modified general anesthesia with the adjuvants addition (clonidine, acetaminophen) in a period before the birth of a child during elective cesarean section has reasonable (statistically significant) advantages over the «routine» method of general anesthesia.