Is Recreational Marijuana Use Associated With Changes in the Vital Signs or Anesthetic Requirements During Intravenous Sedation?

PURPOSE

The prevalence of tetrahydrocannabinol (THC) use is increasing in the general population due to its increased availability, legality, and cultural acceptability. The purpose of the current study was to measure the association of THC use on the vital signs and anesthetic requirements during intravenous (IV) sedation procedures in recreational marijuana users.

METHODS

A retrospective cohort study was performed. A study sample was chosen from July 2018 to May 2022 based on the following inclusion criteria: patients who underwent toxicology screening due to their history of recent drug use and received IV sedation. The predictor variable of the present study is THC status grouped into THC+ and THC-. THC status was established using urine toxicology. Patients who screened positive for THC were coded THC+. Patients who screened negative for THC were coded THC-. Primary outcome variable was changes in vital signs, including mean arterial pressure (MAP), heart rate (HR), and respiratory rate (RR) during IV sedation procedures in THC+ and THC- groups. Secondary outcome variable was difference in medication (midazolam, fentanyl, propofol, and ketamine) requirements in THC+ and THC- groups. Covariates included age, gender, race, weight, duration of surgery, smoking history, and alcohol use, data on psychiatric diagnosis and psychiatric medications. Descriptive statistics and 2-sample t test were calculated. Statistical significance was set at P < .05.

RESULTS

In total, 53 patients met the inclusion criteria and were included in the study, with 27 patients in the THC+ group and 26 patients in the THC- group. There were no significant statistical differences in the MAP_%, HR_%, and RR_% at T₅, T₁₀, T₂₀, and T₃₀ between the THC+ and THC- groups. When comparing THC+ and THC- groups, in bivariate analyses, the THC+ group required, on average, higher doses of fentanyl [83.82 mcg compared to 65 mcg (P = .02)] and propofol [70 mg compared to 45.26 mg (P = .03)] during IV sedation. However, after adjusting the effect of age, gender, and weight, THC had no significant effect on midazolam (P-value = .28), fentanyl (P-value = .12), propofol (P-value = .06) and ketamine (P-value = .86) requirements.

CONCLUSIONS

These findings suggest there are no differences in vital signs or anesthetic requirements between the THC+ and THC- groups.

Event-based MPC for propofol administration in anesthesia

BACKGROUND AND OBJECTIVE

The automatic control of anesthesia is a demanding task mostly due to the presence of nonlinearities, intra- and inter-patient variability and specific clinical requirements to be meet. The traditional approach to achieve the desired depth of hypnosis level is based on knowledge and experience of the anesthesiologist. In contrast to a typical automatic control system, their actions are based on events that are related to the effect of the administrated drug. Thus, it is interesting to build a control system that will be able to mimic the behavior of the human way of actuation, simultaneously keeping the advantages of an automatic system.

METHODS

In this work, an event-based model predictive control system is proposed and analyzed. The nonlinear patient model is used to form the predictor structure and its linear part is exploited to design the predictive controller, resulting in an individualized approach. In such a scenario, the BIS is the controlled variable and the propofol infusion rate is the control variable. The event generator governs the computation of control action applying a dead-band sampling technique. The proposed control architecture has been tested in simulation considering process noise and unmeasurable disturbances. The evaluation has been made for a set of patients using nonlinear pharmacokinetic/pharmacodynamic models allowing realistic tests scenarios, including inter- and intra-patient variability. Results For the considered patients dataset the number of control signal changes has been reduced of about 55% when compared to the classical control system approach and the drug usage has been reduced of about 2%. At the same time the control performance expressed by the integrated absolute error has been degraded of about 11%.

CONCLUSIONS

The event-based MPC control system meets all the clinical requirements. The robustness analysis also demonstrates that the event-based architecture is able to satisfy the specifications in the presence of significant process noise and modelling errors related to inter- and intra-patient variability, providing a balanced solution between complexity and performance.

Comparison of Single Target-Controlled Infusion Pump-Delivered Mixed Propofol and Remifentanil with Two Target-Controlled Infusion Pumps-Delivered Propofol and Remifentanil in Patients Undergoing Breast Cancer Surgery-A Prospective Study

Total intravenous anesthesia (TIVA) with remifentanil and propofol (RP) is considered to be an ideal type of general anesthesia (GA) for pediatric and adult patients undergoing medical procedures. However, delivery of an RP mixture by target-controlled infusion (TCI) for GA in surgical procedures has not been described. We investigated the merit of this approach for breast cancer surgery. Eighty-four patients (n = 42 per group) were randomly allocated to propofol and remifentanil either delivered by separate TCI pumps (S group) or in an RP mixture by a single TCI pump (M group). Dosages were adjusted based on the bispectral index (BIS) and the analgesia nociception index (ANI). The primary outcomes were adequate anesthesia (BIS 40-60 and ANI 50-70, respectively), acceptable hemodynamic fluctuations (<30% of baseline) with less frequent TCI pump adjustments, bolus injections of anesthetics, and total consumption of anesthetics during the procedure. The secondary endpoints included time of emergence from anesthesia, patient satisfaction, postoperative pain, rescue with opioids, and adverse events. The characteristics of patients, hemodynamic parameters, BIS and ANI scores, duration of surgery, anesthesia, and emergence were not significantly different between groups. The adjustment frequency of TCI was significantly higher in the S group (3 (range 0-6) vs. 2 (0-6) times; p = 0.005). The total dosage of anesthetics, pain rating, patient satisfaction, need for opioids postoperatively, and incidence of adverse events were not significantly different. We have demonstrated that this RP mixture provided adequate hypnotic and analgesic effects under BIS and ANI monitoring in patients undergoing breast cancer surgery within 1 h.

Safety and efficacy of etomidate in combination with oxycodone in painless gastroscopic procedures in the elderly: A prospective randomized controlled trial study

OBJECTIVE

Etomidate is often combined in rapid succession during induction of anesthesia. However, the effect of pretreatment with oxycodone on recovery of cognitive function and adverse effects has rarely been studied. We conducted a prospective randomized controlled trial to compare etomidate alone with etomidate combined with oxycodone in elderly patients undergoing painless gastroscopy.

METHODS

Hundred elderly patients undergoing painless gastroscopy were divided into a control and an observation group, with 50 cases in each group. The age, gender, height, weight, body mass index and American Society of Anesthesiologists physical status (I/II) of patients in both groups were recorded. The recovery of cognitive function was compared in both groups using the Neurobehavioral Cognitive Status Examination. Adverse events, including somatic motor reactions, hypotension, bradycardia, myocardial tremor, nausea and vomiting, and injection pain, were also recorded in both groups. Moreover, heart rate, peripheral capillary oxygen saturation, systolic blood pressure, and diastolic blood pressure were evaluated in the 2 groups at different time points.

RESULTS

A total of 100 patients were enrolled in this study. The demographic characteristics in the 2 groups were not significantly different (P > .05). Regarding the recovery of cognitive functions, more subjects in the observation group passed the memory, arithmetic and orientation test than in the control group (P < .05). Fewer adverse events such as dynamic body reactions, cardiac tremor, nausea and vomiting, and injection pain occurred in the observation group than in the control group (P < .05). During anesthesia and after awakening, the results of peripheral capillary oxygen saturation, systolic blood pressure and diastolic blood pressure were better in the observation group than in the control group (P < .05).

CONCLUSION

Etomidate in combination with oxycodone for painless gastroscopic operation in the elderly is a safe and effective anesthetic strategy.

The utility of the perfusion index as an indicator of anesthetic depth for repeated propofol sedation in children: An observational study

BACKGROUND

Children receiving proton therapy require repeated sedation. In this study, we aimed to investigate the utility of the perfusion index (PI) for evaluating consciousness level during repeated propofol sedation.

METHODS

In this prospective observational study, children aged from birth to 19 years old scheduled for proton therapy under repeated propofol sedation were enrolled. The primary outcome was the equivalence of PI values 5 min after anesthesia induction on consecutive sedation. Total consumption of propofol during sedation, time to reach the University of Michigan sedation scale (UMSS) score 1 after end of proton therapy, and duration of post-anesthesia care unit (PACU) stay were recorded.

RESULTS

The PI values measured 5 min after induction of anesthesia were not equivalent to each other in consecutive sedation except for the second versus third (1st vs. 2nd: 97.5% CI: -1.34, 0.91; p = 0.206, 0.034; 2nd vs. 3rd: 97.5% CI: -0.87, 0.94; p = 0.023, 0.036 3rd vs. 4th: 97.5% CI: -2.08, -0.26; p < 0.99, <0.001; 4th vs. 5th: 97.5% CI: 0.21, 2.28; p < 0.001, >0.99; respectively). In consecutive sedation, there was not a significantly different difference in the time to reach UMSS score 1 (p > 0.99, all) for total consumption of propofol, time to reach UMSS score 1 after the end of proton therapy, and duration of PACU stay.

CONCLUSIONS

During repeated propofol sedation in children, PI was insufficient to be used as an indicator of consciousness level assessment. However, we suggest that the information related to repeated sedation provided by this study may be helpful in clinical practice.

[Specialty of cognitive impairments in geriatric patients in urological practice.]

Purpose of the study - to assess the level of cognitive disorders in gerontological patients of the urological profile, depending on the use of sedation in the intraoperative period. A prospective cohort study was performed on 60 gerontological patients diagnosed with BPH II-III stages. Two groups were formed: conscious patients and patients using sedation. Operation - bipolar transurethral enucleation of the prostate (BTUEP). Determination of the depth of sedation with propofol was carried out according to the Ramsey sedation scale in the BIS-monitoring mode. Registration of cognitive status was carried out on the basis of the Montreal Cognitive Function Scale and the Hamilton Depression Scale. The level of cognitive functions of patients in both study groups before surgical treatment indicated the presence of mild impairments according to the Montreal Cognitive Function Scale and the Hamilton Depression Scale. In the group using sedation in patients, a statistically significant decrease (p<0,005) in the score for three items of the Hamilton depression scale was determined in comparison with the group with preserved consciousness in patients: average insomnia (χ2=5,07), working capacity and activity (χ2=4,17), mental anxiety (χ2=4,43). Anesthesia, including spinal anesthesia and sedation controlled by BIS-monitoring, in gerontological patients during BTUEP provides a positive effect on the cognitive functions of patients and reduces the manifestations of depressive symptoms according to the results of clinical interviews using the Montreal Cognitive Assessment Scale and the Hamilton Depression Scale.

Anesthetic Preferences for Cardiac Anesthesia: A Survey of the Society of Cardiovascular Anesthesiologists

BACKGROUND

Volatile anesthetics have been historically preferred for cardiac anesthesia, but the evidence for their superiority to intravenous agents is mixed. We conducted a survey to better understand the current state of practice and the rationale behind provider preferences for anesthesia for cardiac surgery with cardiopulmonary bypass. We hypothesized that anesthetic preference would vary considerably among surveyed providers without a clear majority, as would the rationale behind those preferences.

METHODS

Email invitations were sent to members of the Society of Cardiovascular Anesthesiologists, who were asked to identify the anesthetics or sedatives they typically prefer to administer during induction, prebypass, bypass, postbypass, and postoperative periods and why they prefer those agents. Members' beliefs regarding the importance of anesthetics on postoperative outcomes were also assessed.

RESULTS

Invitations were sent on 2 separate dates to 3328 and 3274 members, of whom 689 (21%) responded. The median (interquartile range [IQR]) respondent age was 45 (37-56) years, 79% were men, and 75% were fellowship trained. The most frequently chosen drug for induction was propofol (80%). Isoflurane was the most frequently selected primary agent for the prebypass (57%), bypass (62%), and postbypass periods (50%). Sevoflurane was the second most frequently selected (30%; 17%, and 24%, respectively). Propofol was the third most frequently selected agent for the bypass (14%) and postbypass periods (17%). Ease of use was the most frequently selected reason for administering isoflurane and sevoflurane for each period. During bypass, the second most frequently selected rationale for using isoflurane and sevoflurane was institutional practice. A total of 76% responded that the perfusionist typically delivers the bypass anesthetic. Ischemic preconditioning, organ protection, and postoperative cognitive function were infrequently selected as rationales for preferring the volatile anesthetics. Most respondents (73%) think that anesthetics have organ-protective properties, especially isoflurane (74%) and sevoflurane (59%), and 72% believed that anesthetic choice contributes to patient outcome. The median (IQR) agreement (0 = strongly disagree to 100 = strongly agree) was 72 (63-85) for the statement that "inhaled anesthetics are an optimal maintenance anesthetic for cardiac surgery."

CONCLUSIONS

In a survey of cardiac anesthesiologists, a majority of respondents indicated that they prefer volatile anesthetics for maintenance of anesthesia, that anesthetic selection impacts patient outcomes, and that volatile anesthetics have organ-protective properties. The members' rationales for preferring these agents possibly reflect that practical considerations, such as ease of use, effectiveness, and institutional practice, also influence anesthetic selection during cardiac surgery in addition to considerations such as organ protection.

A 67-Year-Old Woman With Fluctuating Hypertension and Hypotension After Elective Surgery

CASE PRESENTATION

A 67-year-old woman with hypertension, type 2 diabetes mellitus, and hypothyroidism presented for an elective blepharoplasty. She underwent monitored anesthesia care with propofol and dexmedetomidine. No inhaled gases or neuromuscular blockade were administered during the procedure.

Improved Individualized Patient-Oriented Depth-of-Hypnosis Measurement Based on Bispectral Index

Total intravenous anesthesia is an anesthesiologic technique where all substances are injected intravenously. The main task of the anesthesiologist is to assess the depth of anesthesia, or, more specifically, the depth of hypnosis (DoH), and accordingly adjust the dose of intravenous anesthetic agents. However, it is not possible to directly measure the anesthetic agent concentrations or the DoH, so the anesthesiologist must rely on various vital signs and EEG-based measurements, such as the bispectral (BIS) index. The ability to better measure DoH is directly applicable in clinical practice-it improves the anesthesiologist's assessment of the patient state regarding anesthetic agent concentrations and, consequently, the effects, as well as provides the basis for closed-loop control algorithms. This article introduces a novel structure for modeling DoH, which employs a residual dynamic model. The improved model can take into account the patient's individual sensitivity to the anesthetic agent, which is not the case when using the available population-data-based models. The improved model was tested using real clinical data. The results show that the predictions of the BIS-index trajectory were improved considerably. The proposed model thus seems to provide a good basis for a more patient-oriented individualized assessment of DoH, which should lead to better administration methods that will relieve the anesthesiologist's workload and will benefit the patient by providing improved safety, individualized treatment, and, thus, alleviation of possible adverse effects during and after surgery.

Differential dosing of oxycodone in combination with propofol in diagnostic painless gastroscopy in elderly patients: A prospective randomized controlled trial

OBJECTIVE

The aim of this study is to investigate the safety and efficacy of different doses of oxycodone in combination with propofol during painless gastroscopy.

METHODS

120 patients underwent painless gastroscopy under general anesthesia. According to the different doses of oxycodone, patients were divided into 4 groups, group A (oxycodone 0.025 mg/kg + propofol), group B (oxycodone 0.05 mg/kg + propofol) and group C (oxycodone 0.1 mg/kg + propofol), control group (propofol alone), with 30 cases in each group. The general characteristics of all patients were then evaluated. Mean arterial pressure (MAP), heart rate (HR) and peripheral capillary oxygen saturation (SpO2) were recorded at different time points, including the time before anesthesia (T0), failure of the lash reflex (T1), successful placement of the mirror (T2), removal of the mirror (T3) and waking up (T4). The intraoperative propofol dosage and the operative time of gastroscopy were recorded. The occurrence of adverse effects in the 4 groups was also compared.

RESULTS

General characteristics, gastroscopy operative time and SpO2 did not differ significantly between the 4 groups (P > .05). However, group C had the lowest amount of propofol during gastroscopy (P < .05). At T1, groups A, B, and C had a faster HR than the control group (P < .05). At T2, groups A, B, and C had a lower MAP than the control group (P < .05). Groups B and C had fewer adverse effects than groups A and the control group (P < .05). Importantly, groups B and C had a shorter recovery time than groups A and the control group (P < .05), but no statistically significant differences were found between groups B and C.

CONCLUSION

0.05 mg/kg oxycodone in combination with propofol can be used safely and effectively for painless gastroscopy, with the advantages of a low propofol dose, maintenance of hemodynamic stability and few adverse effects.

Apremilast-induced increases in acute ethanol intoxication and decreases in ethanol drinking in mice involve PKA phosphorylation of GABAA β3 subunits

We previously showed that apremilast, an FDA-approved PDE4 inhibitor, selectively alters behavioral responses to ethanol and certain GABAergic drugs in a PKA-dependent manner in C57BL6/J mice. Here, we investigated if PKA phosphorylation of β3 GABAA receptor subunits is involved in apremilast regulation of ethanol, propofol, or diazepam responses. Apremilast prolonged rotarod ataxia and loss of the righting reflex by ethanol and propofol in wild-type mice, but not in β3-S408A/S409A knock-in mice. In contrast, apremilast hastened recovery from the ataxic and sedative effects of diazepam in both genotypes. These findings suggest that apremilast modulation of ethanol and propofol behaviors in wild-type mice is mediated by β3 subunit phosphorylation, whereas its actions on diazepam responses involve a different mechanism. The PKA inhibitor H-89 prevented apremilast modulation of ethanol-induced ataxia. Apremilast sensitized wild-type males to ethanol-induced ataxia and decreased acute functional tolerance (AFT) in females but had no effect in β3-S408A/S409A mice of either sex. These results could not be attributed to genotype differences in blood ethanol clearance. There were also no baseline genotype differences in ethanol consumption and preference in two different voluntary drinking procedures. However, the ability of apremilast to reduce ethanol consumption was diminished in β3-S408A/S409A mice. Our results provide strong evidence that PKA-dependent phosphorylation of β3 GABAA receptor subunits is an important mechanism by which apremilast increases acute sensitivity to alcohol, decreases AFT, and decreases ethanol drinking.

Decreased Electroencephalographic Alpha Power During Anesthesia Induction Is Associated With EEG Discontinuity in Human Infants

BACKGROUND

Electroencephalogram (EEG) discontinuity can occur at high concentrations of anesthetic drugs, reflecting suppression of electrocortical activity. This EEG pattern has been reported in children and reflects a deep state of anesthesia. Isoelectric events on the EEG, a more extreme degree of voltage suppression, have been shown to be associated with worse long-term neurologic outcomes in neonates undergoing cardiac surgery. However, the clinical significance of EEG discontinuities during pediatric anesthesia for noncardiac surgery is not yet known and merits further research. In this study, we assessed the incidence of EEG discontinuity during anesthesia induction in neurologically normal infants and the clinical factors associated with its development. We hypothesized that EEG discontinuity would be associated with sevoflurane-induced alpha (8-12 Hz) power during the period of anesthesia induction in infants.

METHODS

We prospectively recorded 26 channels of EEG during anesthesia induction in an observational cohort of 54 infants (median age, 7.6 months; interquartile range [IQR] [4.9-9.8 months]). We identified EEG discontinuity, defined as voltage amplitude <25 microvolts for >2 seconds, and assessed its association with sevoflurane-induced alpha power using spectral analysis and multivariable logistic regression adjusting for clinically important variables.

RESULTS

EEG discontinuity was observed in 20 of 54 subjects (37%), with a total of 25 discrete events. Sevoflurane-induced alpha power in the posterior regions of the head (eg, parietal or occipital regions) was significantly lower in the EEG discontinuity group (midline parietal channel on the electroencephalogram, International 10-20 System [Pz]; 8.3 vs 11.2 decibels [dBs]; P = .004), and this association remained after multivariable adjustment (adjusted odds ratio [aOR] = 0.51 per dB increase in alpha power [95% CI, 0.30-0.89]; P = .02). There were no differences in the baseline (unanesthetized) EEG between groups in alpha power or power in any other frequency band.

CONCLUSIONS

We demonstrate that EEG discontinuity is common during anesthesia induction and is related to the level of sevoflurane-induced posterior alpha power, a putative marker of cortical-thalamic circuit development in the first year of life. This association persisted even after adjusting for age and propofol coadministration. The fact that this difference was only observed during anesthesia and not in the baseline EEG suggests that otherwise hidden brain circuit properties are unmasked by general anesthesia. These neurophysiologic markers observed during anesthesia may be useful in identifying patients who may have a greater chance of developing discontinuity.

Propofol Waste Reduction in the Operating Room

Propofol is the most wasted intravenous medication used in anesthesia in the operating room (OR). Propofol, a sedative anxiolytic, is used as a continuous infusion in sedation procedures or monitored anesthesia care. Inherent to these infusions is unpredictability in determining the amount of medication needed for the duration of a procedure. This project implemented customized propofol preparation charts consistent with the literature to aid the administering professional in determining the approximate milliliter requirement for the duration of a procedure. The preintervention steps consisted of voluntary data collection among anonymous anesthesia professionals in the OR regarding infusion characteristics. Patient weight, a commonly used infusion rate, and the duration of procedure were used in the calculation within customized charts. Postintervention data collection was conducted in the same manner to capture the impact of the charts. Data were measured simultaneously at a local healthcare system's main hospital and separate surgery center site, and waste reduction from baseline data was found to be 49% and 60%, respectively. This project was conducted over a 4-month period and translates to a potential yearly savings of greater than $15,000 for the healthcare system. Waste reduction led to savings for anesthesia departments and healthcare organizations.

Fractal Properties of Heart Rate Dynamics: A New Biomarker for Anesthesia-Biphasic Changes in General Anesthesia and Decrease in Spinal Anesthesia

Processed electroencephalogram (EEG) has been considered a useful tool for measuring the depth of anesthesia (DOA). However, because of its inability to detect the activities of the brain stem and spinal cord responsible for most of the vital signs, a new biomarker for measuring the multidimensional activities of the central nervous system under anesthesia is required. Detrended fluctuation analysis (DFA) is a new technique for detecting the scaling properties of nonstationary heart rate (HR) behavior. This study investigated the changes in fractal properties of heart rate variability (HRV), a nonlinear analysis, under intravenous propofol, inhalational desflurane, and spinal anesthesia. We compared the DFA method with traditional spectral analysis to evaluate its potential as an alternative biomarker under different levels of anesthesia. Eighty patients receiving elective procedures were randomly allocated different anesthesia. HRV was measured with spectral analysis and DFA short-term (4-11 beats) scaling exponent (DFAα1). An increase in DFAα1 followed by a decrease at higher concentrations during propofol or desflurane anesthesia is observed. Spinal anesthesia decreased the DFAα1 and low-/high-frequency ratio (LF/HF ratio). DFAα1 of HRV is a sensitive and specific method for distinguishing changes from baseline to anesthesia state. The DFAα1 provides a potential real-time biomarker to measure HRV as one of the multiple dimensions of the DOA.

Effects of midazolam co-induction to general anesthesia: A randomized clinical trial

BACKGROUND

This study aimed to determine the potential advantages of midazolam co-induction with general anesthesia (GA) over the use of propofol alone.

METHODS

We conducted a randomized, placebo-controlled, single-blinded clinical trial of 102 patients, aged 18 to 65, American Society of Anesthesiologists II and III, who underwent elective laparoscopic gallbladder surgery. Patients were randomly divided into 3 groups: the placebo group (C) received 1 mL of 0.9% saline intravenously and the test groups received intravenous midazolam at doses of 0.03 mg/kg (M1) or 0.06 mg/kg (M2) before induction of GA. We assessed effects of midazolam co-induction on arterial pressure and heart rate (HR) in the early stage of GA prior to surgical incision and effects on perioperative and postoperative glycemia and cortisol levels. Systolic/mean/diastolic (SAP/MAP/DAP) arterial pressure and HR were measured 4 times (preoperative, on the third, sixth and ninth minute after atracurium administration). Cortisol was measured on 3 occasions (preoperatively, 60 minutes after surgical incision, and the following morning) and glucose on 4 occasions (preoperatively, 15 and 60 minutes after incision, and the following morning). We also assessed the incidence of postoperative anxiety, postoperative nausea and vomiting (PONV), and propofol requirement for induction.

RESULTS

SAP/MAP/DAP were significantly higher in M2 immediately after induction compared to the other study groups (P = .002/.004/.013). Midazolam co-induction led to a significant reduction in postoperative anxiety (P = .03), reduced cortisol concentration 60 minutes after surgical incision (P < .001) and propofol requirements (P < .001).

CONCLUSION SUBSECTIONS

Midazolam co-induction prevented a marked decline in SAP/MAP/DAP immediately after induction of GA, led to reduced postoperative anxiety and cortisol response to surgery, and reduced propofol requirements for induction.

Postoperative hypotonia in a patient with stiff person syndrome: a case report and literature review

PURPOSE

Stiff person syndrome (SPS), an autoimmune disease that manifests with episodic muscle rigidity and spasms, has anesthetic considerations because postoperative hypotonia may occur. This hypotonia has been linked to muscle relaxants and volatile anesthetics and may persist in spite of neostigmine administration and train-of-four (TOF) monitoring suggesting full reversal. We present a patient with SPS who experienced hypotonia following total intravenous anesthesia (TIVA), which was promptly reversed with sugammadex. These observations are considered in light of the relevant medical literature.

CLINICAL FEATURES

A 46-yr-old female patient with SPS underwent breast lumpectomy and sentinel node biopsy. Anesthesia consisted of TIVA (propofol/remifentanil) with adjunctive administration of rocuronium 20 mg to obtain adequate intubating conditions. Despite return of the TOF ratio to 100% within 30 min, hypotonia was clinically evident at conclusion of surgery two hours later. Sugammadex 250 mg reversed residual muscle relaxation permitting uneventful extubation. A literature review identified six instances of postoperative hypotonia (TIVA, n = 3; volatile anesthetics, n = 3) in spite of neostigmine administration (n = 2) and TOF monitoring suggesting full reversal (n = 4).

CONCLUSIONS

Patients with SPS may show hypotonia regardless of general anesthetic technique (TIVA vs inhalational anesthesia), which can persist despite recovery of the TOF ratio and may be more effectively reversed by a chelating agent than with an anticholinesterase. If general anesthesia is required, we suggest a cautious approach to administering muscle relaxants including using the smallest dose necessary, considering the importance of clinical assessment of muscle strength recovery in addition to TOF monitoring, and discussing postoperative ventilation risk with the patient prior to surgery.

Comparison of regional cerebral oxygen saturation during one-lung ventilation under desflurane or propofol anesthesia: A randomized trial

BACKGROUND

During one-lung ventilation (OLV), deterioration of pulmonary oxygenation reduces arterial oxygen saturation and cerebral oxygen saturation (rSO2). However, oxidative stress during OLV causes lung injury, so the fraction of inspiratory oxygen (FiO2) should be kept as low as possible. We investigated the changes in rSO2 under propofol or desflurane anesthesia while percutaneous oxygen saturation (SpO2) was kept as low as possible during OLV.

METHODS

Thirty-six patients scheduled for thoracic surgery under OLV in the lateral decubitus position were randomly assigned to propofol (n = 19) or desflurane (n = 17) anesthesia. FiO2 was set to 0.4 at the start of surgery under two-lung ventilation (measurement point: T3) and then adjusted to maintain an SpO2 of 92% to 94% after the initiation of OLV. The primary outcome was the difference in the absolute value of the decrease in rSO2 from T3 to 30 minutes after the initiation of OLV (T5), which was analyzed by an analysis of covariance adjusted for the rSO2 value at T3.

RESULTS

The mean rSO2 values were 61.5% ± 5.1% at T3 and 57.1% ± 5.3% at T5 in the propofol group and 62.2% ± 6.0% at T3 and 58.6% ± 5.3% at T5 in the desflurane group. The difference in the absolute value of decrease between groups (propofol group - desflurane group) was 0.95 (95% confidence interval, [-0.32, 2.2]; P = .152).

CONCLUSIONS

Both propofol and desflurane anesthesia maintain comparable cerebral oxygenation and can be used safely, even when the SpO2 is kept as low as possible during OLV.

Effect of Parecoxib Sodium Combined with Dexmedetomidine on Analgesia and Postoperative Pain of Patients Undergoing Hysteromyomectomy

Background

Propofol combined with remifentanil is the most common anesthesia method in laparoscopic hysteromyomectomy. However, whether the combination of the two is helpful to patients undergoing hysteromyomectomy still requires unclear.

Objective

To determine the effect of parecoxib sodium combined with dexmedetomidine on analgesia and postoperative pain of patients undergoing hysteromyomectomy.

Methods

Altogether, 72 patients receiving hysteromyomectomy in our hospital from February 2017 to March 2019 were enrolled. Among them, 35 patients treated with parecoxib sodium were assigned to the control group, while the rest 37 patients treated with parecoxib sodium combined with dexmedetomidine were assigned to the research group. The following items of the two groups were evaluated: visual analog scale (VAS) score, mechanical pain threshold (MPT), Riker sedation-agitation scale (RSAS) score, and expression of serum cortisol and melatonin.

Results

At 12 and 24 h after operation, the VAS score of the research group was lower than that of the control group (P < 0.05), and at 6, 12, and 24 h after operation, the MPT of the research group was notably higher than that of the control group (P < 0.05). In addition, at 10 min after extubation, the research group got notably lower RSAS score than the control group (P < 0.05). Before extubation and at 20 min after extubation, the research group showed notably higher melatonin expression and notably lower serum cortisol expression than the control group (both P < 0.05).

Conclusion

Parecoxib sodium combined with dexmedetomidine can effectively control the postoperative pain of patients undergoing hysteromyomectomy, reduce the incidence of agitation, and effectively control serum cortisol and melatonin in them.

Anesthesia Management for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Surgery on Short-Term Patient Outcomes

The aim of this retrospective study was to understand the impact of anesthesia management for the patients under cytoreductive surgery and hyperthermic intraperitoneal chemotherapy surgery (CRS+HIPEC). The perioperative electronic medical records of 833 CRS+HIPEC surgical cases from two hospitals were analyzed to study the characteristics of shortterm patient outcomes in hospitals for CRS+HIPEC. Older age, higher American Society of Anesthesiologists (ASA) score, male gender, longer anesthesia time, higher Peritoneal Cancer Index (PCI), and higher intraoperative blood loss predict the prolonged hospital stay for patients. Older age, higher ASA score, longer anesthesia time, higher PCI, higher intraoperative fluid administration, lower intraoperative propofol dosage, higher intraoperative blood loss, and failed extubation predict the prolonged intensive care unit stay. Older age, male gender, longer anesthesia time, higher ASA score, higher PCI, higher intraoperative opioid dosage, and higher intraoperative blood loss predict the higher degree postoperative complications. We also observed that implementation of enhanced recovery after surgery protocols may improve patient outcomes for CRS+HIPEC. These results need further confirmation from future prospective randomized studies.

[The Pierre Robin sequence from an anesthesiologic perspective : Presentation of the procedure based on a retrospective analysis at a university hospital]

INTRODUCTION

As part of surgical interventions in pediatric patients, children with craniofacial malformations and syndromes are presented in the field of oral and maxillofacial surgery, anesthesia and also in all other clinical disciplines. In particular, the Pierre Robin sequence in the clinical context leads to a situation albeit a rare one, which should be given high attention in preoperative, intraoperative and postoperative care.

MATERIAL AND METHODS

In a retrospective analysis from 1993 to 2020 in the Department of Oral and Maxillofacial Surgery at the University Hospital Halle (Saale), a total of 54 patients were identified with syndromic changes and a need for surgical treatment. During this period, 12 patients with a Pierre Robin sequence were genetically confirmed, who received a total of 20 surgical interventions under general anesthesia at different times. Statistical analysis was performed using SPSS 17.0.

RESULTS

In 12 patients with a Pierre Robin sequence, 20 surgical procedures were performed with the patient under general anesthesia. The youngest patients had an average age of 6 months, the oldest 16 years at the time of the operation. The average age was 5.7 years. In addition to the genetic component, all children were assigned to the ASA I classification. The surgical indication was initially an isolated cleft palate in all patients, followed by further interventions such as dental restorations, corrective surgery in the area of the palate or ear nose throat (ENT) examinations. Drug induction of general anesthesia was weight-adapted using propofol 1%, fentanyl or remifentanil and rocuronium. In our study, out of 18 orotracheal intubations, only 2 patients had to be intubated by video laryngoscopy. One patient required nasal intubation and another was fitted with a laryngeal mask. The success rate of conventional intubation was 89.5%. Postoperatively, one infant had recurrent drops in saturation, so that reintubation was necessary.

Can intravenous lidocaine definitely attenuate propofol requirement and improve outcomes among colonoscopic patients under intravenous sedation?: A double-blinded, randomized controlled trial

BACKGROUND

Propofol-sparing effect of lidocaine has not been fully elucidated because propofol is usually mixed with many medications in anesthetic practice. Therefore, the study aimed to verify the additive effect of intravenous lidocaine to propofol without other sedative medications and control the depth of anesthesia using the bispectral index (BIS) during colonoscopy in a prospective, randomized, double-blinded controlled trial.

METHODS

Sixty-eight patients scheduled and undergoing colonoscopy were randomly allocated to receive intravenous lidocaine (1.5 mg/kg then 4 mg/kg/h) (Group L) or a similar volume of normal saline (Group C) with propofol administration guided by BIS monitoring. The primary outcome was total propofol requirements between group comparisons. The secondary outcomes included the number of hypoxemic periods, hemodynamic changes, duration in returning of BIS > 85, sedation scores, pain scores, postoperative opioid requirement, and patient satisfaction between group comparisons.

RESULTS

Intravenous lidocaine showed significantly reduced total propofol use (151.76 ± 50.78 mg vs 242.06 ± 50.86 mg, Group L vs Group C, respectively, P < .001). Duration in returning to BIS > 85, sedation scores, and patient satisfaction scores were significantly superior in Group L (P < .05). The number of hypoxemic episodes, changes of hemodynamic response, pain scores, and postoperative opioid requirement were similar in both groups. No adverse effects were detected in both groups.

CONCLUSION

Intravenous lidocaine produced a definitely effective reduced propofol requirement without other sedative agents and improved outcomes including patient satisfaction, duration in returning to BIS > 85, and sedation score during colonoscopy without adverse effects.

Retrospective observational study of the effects of residual neuromuscular blockade and sugammadex on motor-evoked potential monitoring during spine surgery in Japan

Given neuromuscular blockade (NMB) can affect the amplitude and detection success rate of motor-evoked potentials (MEP), sugammadex may be administered intraoperatively. We evaluated the factors affecting the degree of residual NMB (i.e., the train-of-four [TOF] ratio) and the relationship between TOF ratio and MEP detection success rate in Japanese patients undergoing spine surgery. This single-center retrospective observational study included adults who underwent spine surgery under propofol/remifentanil anesthesia, received rocuronium for intubation, and underwent myogenic MEP monitoring after transcranial stimulation. TOF ratios were assessed using electromyography. Sugammadex was administered after finishing the MEP setting and the TOF ratio was ≤0.7. To identify factors affecting the TOF ratio, TOF ratio and MEP detection success rate were simultaneously measured after finishing the MEP setting; to compare the time from intubation to the start of MEP monitoring after NMB recovery between sugammadex and spontaneous recovery groups, multivariable analyses were performed. Of 373 cases analyzed, sugammadex was administered to 221 (59.2%) cases. Age, blood pressure, hepatic impairment, and rocuronium dose were the main factors affecting the TOF ratio. Patients with higher TOF ratios (≥0.75) had higher MEP detection success rates. The time from intubation to the start of MEP monitoring after NMB recovery was significantly shorter in patients administered sugammadex versus patients without sugammadex (P < .0001). The MEP detection success rate was higher in patients with a TOF ratio of ≥0.75. Sugammadex shortened the time from intubation to the start of MEP monitoring after NMB recovery.

Propofol-based total intravenous anesthesia is associated with better survival than desflurane anesthesia in limb-salvage surgery for osteosarcoma: A retrospective analysis

Previous studies have demonstrated that anesthetic techniques can affect the outcomes of cancer surgery. We investigated the association between anesthetic techniques and patient outcomes after elective limb-salvage surgery for osteosarcoma (OS). This was a retrospective cohort study of patients who underwent elective limb-salvage surgery for OS between January 2007 and December 2018. Patients were grouped according to the administration of propofol-based total intravenous anesthesia (TIVA) or desflurane (DES) anesthesia. Kaplan-Meier analysis was performed, and survival curves were constructed from the date of surgery to death. Univariate and multivariate Cox regression models were applied to compare the hazard ratios (HRs) for death after propensity matching. Subgroup analyses were done for postoperative recurrence, metastasis, and tumor-node-metastasis (TNM) staging. A total of 30 patients (17 deaths, 56.7%) who received DES anesthesia and 26 (4 deaths, 15.4%) who received TIVA were eligible for analysis. After propensity matching, 22 patients were included in each group. In the matched analysis, patients who received TIVA had better survival with a HR of 0.30 (95% confidence interval [CI], 0.11-0.81; P = .018). Subgroup analyses also showed significantly better survival in the presence of postoperative metastasis (HR, 0.24; 95% CI, 0.06-0.87; P = .030) and with TNM stage II to III (HR, 0.26; 95% CI, 0.09-0.73; P = .011) in the matched TIVA group. In addition, patients administered with TIVA had lower risks of postoperative recurrence and metastasis than those administered with DES anesthesia in the matched analyses. Propofol-based TIVA was associated with better survival in patients who underwent elective limb-salvage surgery for OS than DES anesthesia. Prospective studies are needed to assess the effects of TIVA on oncological outcomes in patients with OS.

Virtual reality immersion compared to monitored anesthesia care for hand surgery: A randomized controlled trial

Introduction

Common anesthesia practice for hand surgery combines a preoperative regional anesthetic and intraoperative monitored anesthesia care (MAC). Despite adequate regional anesthesia, patients may receive doses of intraoperative sedatives which can result in oversedation and potentially avoidable complications. VR could prove to be a valuable tool for patients and providers by distracting the mind from processing noxious stimuli resulting in minimized sedative use and reduced risk of oversedation without negatively impacting patient satisfaction. Our hypothesis was that intraoperative VR use reduces sedative dosing during elective hand surgery without detracting from patient satisfaction as compared to a usual care control.

Methods

Forty adults undergoing hand surgery were randomized to receive either intraoperative VR in addition to MAC, or usual MAC. Patients in both groups received preoperative regional anesthesia at provider discretion. Intraoperatively, the VR group viewed programming of their choice via a head-mounted display. The primary outcome was intraoperative propofol dose per hour (mg · hr^-1). Secondary outcomes included patient reported pain and anxiety, overall satisfaction, functional outcome, and post anesthesia care unit (PACU) length of stay (LOS).

Results

Of the 40 enrolled patients, 34 completed the perioperative portion of the trial. VR group patients received significantly less propofol per hour than the control group (Mean (±SD): 125.3 (±296.0) vs 750.6 (±334.6) mg · hr^-1, p<0.001). There were no significant differences between groups in patient reported overall satisfaction, (0–100 scale, Median (IQR) 92 (77–100) vs 100 (100–100), VR vs control, p = 0.087). There were no significant differences between groups in PACU pain scores, perioperative opioid analgesic dose, or in postoperative functional outcome. PACU LOS was significantly decreased in the VR group (53.0 (43.0–72.0) vs 75.0 (57.5–89.0) min, p = 0.018).

Conclusion

VR immersion during hand surgery led to significant reductions in intraoperative propofol dose and PACU LOS without negatively impacting key patient reported outcomes.

Influence of body fatness on propofol requirements for loss of consciousness in target-controlled infusion: A STROBE-compliant study

This prospective observational study evaluated the effects of body fat on the pharmacologic effect of propofol. Hundred patients aged 18 to 75 years who were scheduled to undergo orthopedic surgery under regional block were enrolled. All participants underwent bioelectrical impedance analysis and were allocated into 2 groups: the high and normal adiposity group, according to percent body fat. Following successful regional block, propofol was incrementally infused until loss of consciousness (LOC) with a target-controlled infusion pump. The effect-site concentration of propofol at LOC and the total infused dose of propofol per total body weight until LOC were recorded. At the end of the surgery, the infusion of propofol was stopped. The elapsed time to recovery of consciousness (ROC) and the effect-site concentration at ROC were recorded. These pharmacologic data were compared between 2 groups. The effect-site concentration of propofol at LOC (µg/mL) was significantly lower in the high adiposity group than in the normal group in both sexes (3.5 ± 0.4 vs 3.9 ± 0.6; P = .020 in males, and 3.4 [interquartile range: 2.9-3.5] vs 3.8 [interquartile range: 3.3-3.9]; P = .006 in females). Total dose per total body weight until LOC (mg/kg) were also significantly lower in the high adiposity group than in the normal group. There was no significant difference in the data related to ROC. The pharmacologic effects of propofol may be affected by the composition of body components. The concentration of propofol using a target-controlled infusion system may be diminished in patients with a high proportion of body fat.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) as unique technique for airway management during operative hysteroscopy under general anesthesia: a registered feasibility pilot cohort study

OBJECTIVE

The term THRIVE refers to the delivery of 100% heated and humidified oxygen via a nasal cannula to maintain viable gas exchange during prolonged apnea. There are no reports of its application for Operative Hysteroscopy (OH) under general anesthesia (GA). The aim of the study is to investigate the success rate of THRIVE as unique airway management technique in this setting. The results will support the development of a randomized controlled trial (RCT) to demonstrate the non-inferiority of THRIVE compared to traditional techniques.

PATIENTS AND METHODS

Twenty consecutive ASA I-II women presenting for OH were enrolled. Standard anesthesia, as well as transcutaneous carbon dioxide (tcCO2) monitoring, was performed. After preoxygenation with 30 L∙min-1, GA was induced with propofol and fentanyl, then oxygen flow was increased to 70 L∙min-1 and anesthesia maintained with propofol infusion. The primary outcome was success rate of THRIVE defined as SpO2 > 94%, tcCO2 < 60 mmHg and no need for rescue airway intervention.

RESULTS

Mean age was 47 ± 12 years. Mean duration of the procedure was 25 ± 9 minutes, and the success rate of the technique was 100%. Median SpO2 during the procedure was 100 (IQR 99-100) %. Mean maximum tcCO2 level was 51 ± 7 mmHg while mean tcCO2 level during the procedure was 45 ± 7 mmHg. At the end of the procedure, mean tcCO2 was 44 ± 5 mmHg.

CONCLUSIONS

THRIVE allowed adequate gas exchange during OH under GA, without additional rescue airway interventions. The application of THRIVE in this setting may allow minimal airway manipulation and optimal comfort for the patient with low failure rate. We calculated the sample size for the planned non-inferiority RCT investigating the effectiveness of THRIVE versus laryngeal mask ventilation in OH: 82 is the minimal number of patients per group to test a non-inferiority limit of 10%.

ED50 and ED95 of Propofol Combined with Different Doses of Intravenous Lidocaine for First-Trimester Uterine Aspiration: A Prospective Dose-Finding Study Using Up-and-Down Sequential Allocation Method

Purpose

This study aimed to test the effect of different doses of intravenous lidocaine on the median effective dose (ED50) and 95% effective dose (ED95) of propofol-induction dose and identify the optimal dose.

Patients and Methods

Patients undergoing first-trimester uterine aspiration were screened and randomly enrolled into the following groups: saline (L₀), 0.5 mg/kg lidocaine (L_0.5), 1.0 mg/kg lidocaine (L_1.0), and 1.5 mg/kg lidocaine (L_1.5). Anesthesia was induced with 1.0 µg/kg fentanyl. Prepared lidocaine or saline solution was injected later according to allocation, followed by propofol. The dose of propofol for each patient was determined using the up-and-down sequential study design. The primary end point was the ED50 and ED95 of the propofol-induction dose. The total propofol doses, awakening time, and adverse events were recorded.

Results

The ED50 (95% confidence interval) of propofol was significantly lower in groups L_1.0 and L_1.5 than group L₀ (1.6 [1.5–1.7] mg/kg and 1.8 [1.6–1.9] mg/kg, versus 2.4 [2.3–2.5] mg/kg, respectively; p<0.001). There was no significant difference in ED50 between groups L_1.0 and L_1.5 (p>0.05). However, surprisingly, the ED50 was significantly higher in group L_0.5 than L₀ (2.8 [2.6–3.0] mg/kg vs 2.4 [2.3–2.5] mg/kg; p<0.05). The total doses of propofol in groups L_1.0 and L_1.5 were lower than those in groups L₀ and L_0.5 (p<0.05). The systolic blood pressure (SBP) decline after anesthesia induction in group L_0.5 was greater than that in group L₀ (p<0.01). The incidence of respiratory depression in group L_0.5 was greater than that in groups L₀ and L_1.0 (p<0.05).

Conclusion

In patients who underwent first-trimester uterine aspiration, intravenous lidocaine 1.0 mg/kg prior to propofol injection significantly reduced the ED50 of propofol induction dose without severe side effects, equivalent to the effect of 1.5 mg/kg dose. We recommend 1.0 mg/kg as the optimal dose.

Etomidate-induced myoclonus correlates with the dysfunction of astrocytes and glutamate transporters in the neocortex of Sprague-Dawley rats

OBJECTIVE

Etomidate-induced myoclonus is common in clinical anesthesia. Propofol and lidocaine, as other sedative hypnotic and anticonvulsant drugs, rarely induce myoclonus. The mechanism of the myoclonus remains unclear.

MATERIALS AND METHODS

Eighty-four adult male Sprague-Dawley (SD) rats anesthetized intravenously with etomidate, propofol, or lidocaine plus etomidate were observed of the behavioral changes at 0, 1, 2, 3, 4 and 5 min after anesthesia. Five minutes later, glutamate levels were measured in the cerebrospinal fluid (CSF), neocortex and hippocampus. The mRNAs and proteins expression of EAAT1, EAAT2, and GFAP in the neocortex and hippocampus were analyzed by quantitative real-time polymerase chain reaction (qRT-PCR), Western blot and immunofluorescence staining.

RESULTS

Etomidate increased the mean behavioral scores at different time points and the neocortical glutamate level compared with the propofol (p=0.0283) and the lidocaine plus etomidate group (p=0.0035); The correlation analysis revealed a strong correlation between the mean behavioral score and the neocortical glutamate content (Spearman's r=0.6638, p=0.0027). No significant difference was found in the EAAT1, EAAT2, or GFAP mRNAs in the neocortex and hippocampus among three groups; etomidate decreased EAAT1 (p=0.0416 and p=0.0127) and EAAT2 (p=0.0363 and p=0.0109) proteins but increased the GFAP (p=0.0145 and p=0.0149) protein in the neocortex compared to the propofol and lidocaine plus etomidate group. Furthermore, etomidate activated GFAP-positive cells in the neocortex, but conversely inhibited proteins of EAATs in motor cortex.

CONCLUSIONS

Etomidate-induced myoclonus is associated with neocortical glutamate accumulation. Suppression of the astrogliosis in neocortex and promoting extracellular glutamate uptake by regulating glutamate transporters (EAATs) in the motor cortex may be the therapeutic target for prevention of etomidate-induced myoclonus.

Effect of low-dose lidocaine on MEPs in patients undergoing intracranial tumor resection with propofol anesthesia: A randomized controlled trial

OBJECTIVE

To investigate the effect of low-dose lidocaine on motor evoked potentials (MEPs) in patients undergoing intracranial tumor resection with propofol anesthesia.

METHODS

Forty patients who underwent intracranial tumor resection and required MEP monitoring were selected. They were randomly divided into the lidocaine group (group L, n = 20) and the control group (group C, n = 20) by computer-generated randomization. All patients were given propofol anesthesia under the guidance of the bispectral index. In group L, 1 mg/kg of lidocaine was injected intravenously during anesthesia induction. Then, lidocaine was continuously pumped at a speed of 1 mg/kg/h until the operation started. Group C was given an equal volume of normal saline. Heart rate (HR), mean artery pressure (MAP), and bispectral index were recorded before anesthesia induction (T0), 2 minutes after tracheal intubation (T1), and 35 minutes (T2), and 50 minutes (T3) after anesthesia induction. The amplitude and latency of MEP at T2 and T3, the total dosage of propofol after anesthesia induction, and adverse events before T3 were recorded.

RESULTS

Compared with those in group C, HR and MAP were significantly decreased at T1 in group L. No significant differences were observed in HR and MAP at T0, T2, and T3 between group L and group C. The total dosage of propofol and the incidence of adverse events were significantly lower in group L than in group C before T3. There were no significant differences in the amplitude and latency of MEP between the 2 groups at each time point.

CONCLUSIONS

Low-dose lidocaine has no obvious effect on MEP in patients undergoing intracranial tumor resection. However, it increased hemodynamic stability, reduced propofol use, and decreased the incidence of adverse events.

The impact of alfentanil supplementation on the sedation of bronchoscopy: A meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of alfentanil supplementation for the sedation of bronchoscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of alfentanil supplementation on the sedation during bronchoscopy.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through December 2019 for randomized controlled trials (RCTs) assessing the effect of alfentanil supplementation versus placebo for the sedation during bronchoscopy. This meta-analysis is performed using the random-effect model.

RESULTS

Five RCTs are included in the meta-analysis. Overall, compared with control group for bronchoscopy, alfentanyl supplementation is associated with significantly reduced coughing scores (Std. MD = -0.55; 95% CI = -0.96 to -0.14; P = 0.009) and dose of propofol (Std. MD = -0.34; 95% CI = -0.64 to -0.04; P = 0.03), but reveals the increase in hypoxemia (RR = 1.56; 95% CI = 1.17 to 2.08; P = 0.002).

CONCLUSIONS

Alfentanyl supplementation benefits to reduce coughing scores and dose of propofol for bronchoscopy, but increases the incidence of hypoxemia. The use of alfentanyl supplementation for bronchoscopy should be with caution.

Carbon footprint of inhalational and total intravenous anaesthesia for paediatric anaesthesia: a modelling study

BACKGROUND

Tackling the climate emergency is now a key target for the healthcare sector. Avoiding inhalational anaesthesia is often cited as an important element of reducing anaesthesia-related emissions. However, evidence supporting this is based on adult practice. The aim of this study was to identify the difference in carbon footprint of inhalational and i.v. anaesthesia when used in children.

METHODS

We used mathematical simulation models to compare general anaesthetic techniques in children weighing 5-50 kg for TIVA, i.v. induction then inhalational maintenance, inhalational induction then i.v. maintenance, and inhalational induction and maintenance. We simulated inhalational induction with sevoflurane alone, and co-induction with sevoflurane and nitrous oxide, and both remifentanil-propofol and propofol-only i.v. anaesthesia. For each technique, we drew on previously published life-cycle data to calculate carbon dioxide equivalents for anaesthetic durations up to 480 min.

RESULTS

TIVA with propofol and remifentanil had a smaller carbon footprint over a typical anaesthetic duration of 60 min (1.26 kg carbon dioxide equivalents [CO₂e] for a 20 kg child) than i.v. induction followed by inhalational maintenance (2.58 kg CO₂e) or inhalational induction and maintenance (2.98 kg CO₂e). Inhalational induction followed by i.v. maintenance only had a lower carbon footprint than inhalational induction and maintenance when used in longer procedures (>77 min for children 5-20 kg; >105 min for children 30-50 kg).

CONCLUSIONS

In a simulation study, i.v. anaesthesia had climate benefits in paediatric anaesthesia. However, when used after inhalational induction, benefits were only achieved in longer procedures. These findings provide evidence-based guidance for reducing the environmental impact of paediatric anaesthesia, but these will require confirmation using real-world data.

Propofol doses differ in total intravenous anaesthesia (TIVA) for cancer and no cancer surgery - observational cohort study

OBJECTIVE

Propofol (2,6-diisopropylphenol) is a broadly used anaesthetic in total intravenous anaesthesia (TIVA) that might alter course of disease in patients who underwent oncology surgery. High inter-individual variability of the propofol dose needed for the same level of consciousness during surgical tumour removal is influenced by many factors.

PATIENTS AND METHODS

This is a retrospective observational cohort study of prospectively collected patients data over 20 month's period. The main endpoint of the study was to compare propofol consumption needed for cancer and no cancer surgical interventions. The secondary endpoints were to find out whether there is a difference in recovery time between the two groups of patients and to reveal potential correlations between propofol consumption and age, duration of anaesthesia, body weight and Charlson co-morbidity index (CCI) in cancer and no cancer surgery.

RESULTS

There were 103 patients with cancer (mean age 59.3 yr ± 10.7) and 109 patients operated due to other reasons (mean age 47.6 yr ± 17.52). Female sex predominated in both groups (70.9% in cancer and 67.9% in no cancer patients). They differed regarding CCI, 4.48 (±2.1) in cancer in contrast to 1.49 (±1.83) in no cancer patients, and anaesthesia time, 92.67 minutes ± 46.15 vs. 75.24 ± 37.28, respectively (p = 0.0012). Propofol induction dose did not differ significantly between the two groups (p = 0.193), while total propofol consumption was 85.86 mcg/kgBW/min (± 25.98) in cancer and 95.77 (± 31.48) in no cancer patients (p = 0.01). Propofol consumption negatively correlated with duration of anaesthesia and body weight in cancer group. However, in no cancer patients there was very strong negative association with age, duration of anaesthesia and CCI, and significant but weaker negative association with body weight. The time to awakening did not differ significantly between the groups (p = 0.219).

CONCLUSIONS

Propofol dose differed in cancer comparing to no cancer patients under general anaesthesia. There was no need for dose adjustment regarding the age and sex in patients with cancer in contrast to no cancer surgery.

Effect of ciprofol on induction and maintenance of general anesthesia in patients undergoing kidney transplantation

OBJECTIVE

This study aims at evaluating the effects of ciprofol on the induction and maintenance of general anesthesia in patients undergoing kidney transplantation.

PATIENTS AND METHODS

This prospective, randomized, single-blind study enrolled 120 patients aged 18-65 years who underwent general anesthesia for kidney transplantation. The patients were randomized into a ciprofol group (group C) and a propofol group (group P). Anesthesia induction: group C had injected IV with ciprofol 0.4 mg/kg, group P had injected IV with propofol 2.0 mg/kg, while both groups had injected IV with sufentanil 0.4-0.5 μg/kg and cisatracurium 0.2 mg/kg. Anesthesia maintenance: ciprofol was injected IV with 0.8-2.4 mg•kg-1•h-1 in group C, propofol was injected IV with 4-12 mg•kg-1•h-1 in group P, while remifentanil was injected IV with 8-15 μg•kg-1•h-1 and cisatracurium was injected IV with 0.1-0.2mg•kg-1•h-1, with the bispectral index (BIS) maintained at 40-60 during the operation.

RESULTS

The success rate of sedation in both groups was 100%. Compared with the P group, in group C the time of disappearance of the eyelash reflex and a decline in the BIS to 60 was shorter (p<0.001); the time of awakening was prolonged (p<0.001); the number of sedative drugs administered was reduced (p<0.001); MAP fluctuated less five mins after transplantation (p<0.01); the incidence of injection pain during induction was reduced (p<0.001) and intraoperative hypotension was decreased(p<0.01).

CONCLUSIONS

Ciprofol is safe and effective for anesthesia induction and maintenance in kidney transplantation and its sedative effect is better than that of propofol.

Anesthesia Overdose Versus Rapid Cooling for Euthanasia of Adult Zebrafish

The rapid increase in zebrafish use needs to be accompanied by research into the refinement of procedures. The European (EU) Directive lists three possible euthanasia methods for fish: anesthetic overdose, electrical stunning, and concussion. However, for small fish such as zebrafish, concussion and electrical stunning are difficult to perform, leaving anesthetic overdose as the most used method. Our aim was to test the efficacy and side effects of anesthesia overdose using different anesthetics and the rapid cooling method to euthanize adult zebrafish. Adult mixed-sex AB zebrafish were randomly assigned to: 250 mg/L MS222; 20 mg/L propofol +100 mg/L lidocaine; 6 mg/L etomidate; 50 mg/L clove oil; and rapid cooling (water at 2°C-4°C). Two minutes after opercular movement ceased, animals were transferred into clean water for 20 min and recovery assessed, or decapitated and used for biochemical analysis of the gills, muscle, liver, and brain; for the histological analysis of the gills and muscle; or for the assessment of cortisol levels. No animal recovered; rapid cooling was the quickest and etomidate overdose was the slowest method to cease the opercular movements. There were no major differences between euthanasia methods regarding the biochemical or histological data. Cortisol levels were higher in the rapid cooling group, but only when compared with the propofol/lidocaine group. The use of a physical method of euthanasia, such as rapid cooling, is essential when chemicals, such as anesthetics, may interfere with postmortem analyses. Although anesthetic overdose can be used without major effects on the analyses conducted in this work, rapid cooling can be another option with the advantage of being simple to administer, easily available, affordable, and very quick; this decreases the potential duration of suffering, being more humane. Therefore, a change in EU legislation should be considered to include additional humane options for euthanasia, such as rapid cooling, for zebrafish and other small tropical fish.

A modified PID-based control scheme for depth-of-hypnosis control: Design and experimental results

BACKGROUND AND OBJECTIVE

Many methodologies have been proposed for the control of total intravenous anesthesia in general surgery, as this yields a reduced stress for the anesthesiologist and an increased safety for the patient. The objective of this work is to design a PID-based control system for the regulation of the depth of hypnosis by propofol and remifentanil coadministration that takes into account the clinical practice.

METHODS

With respect to a standard PID control system, additional functionalities have been implemented in order to consider specific requirements related to the clinical practice. In particular, suitable boluses are determined and used in the induction phase and a nonzero baseline infusion is used in the maintenance phase when the predicted effect-site concentration drops below a safety threshold.

RESULTS

The modified controller has been experimentally assessed on a group of 10 patients receiving general anesthesia for elective plastic surgery. The control system has been able to induce and maintain adequate anesthesia without any manual intervention from the anesthesiologist.

CONCLUSIONS

Results confirm the effectiveness of the overall design approach and, in particular, highlight that the new version of the control system, with respect to a standard PID controller, provides significant advantages from a clinical standpoint.

Effect of ketorolac tromethamine combined with dezocine prior administration on hemodynamics and postoperative analgesia in patients undergoing laparoscopic hernia repair

OBJECTIVE

To observe the effect of Ketorolac tromethamine combined with dezocine prior administration on hemodynamics and postoperative sedation in patients undergoing laparoscopic hernia repair.

METHODS

100 male patients aged 60 to 80 years old, a line to elective laparoscopic inguinal hernia repair, were randomly divided into four groups: control group (Group A) and dezocine group (Group B), ketorolac tromethamine group (Group C), ketorolac tromethamine combined with dezocine group (Group D). Patients were administrated with 0.1 mg/kg dezocine in Group B, 0.5 mg/kg ketorolac in Group C, 0.1 mg/kg dezocine, and 0.5 mg/kg ketorolac in Group D, and with an equal dose of normal saline in group A. The heart rate (HR) and mean arterial pressure (MAP) of patients in 4 groups were recorded at each time point as follows, T0 (enter the operating room), T1 (before skin resection), 10 min after pneumoperitoneum (T2), mesh placement (T3), and laryngeal mask extraction (T4). Operation time, awakening time (time from drug withdrawal to consciousness recovery), the dosage of propofol, sufentanil, remifentanil, and intraoperative vasoactive drug dosage were recorded to compare. Visual analog scale score and sedation Ramsay score were evaluated 1, 6, 12, and 24 hours after extubation.

RESULTS

There was no significant difference in operation time, anesthesia recovery time, sufentanil dosage, and vasoactive drugs among all groups. The amount of propofol in Group B and D was less than that in Group A and C (P < .05), and there was no difference between Group B and D, A and C (P > .05). The amount of remifentanil in Group B, C, and D was less than that in Group A (P < .05), and Group D was less than B and C (P < .05). After extubation, HR and MAP were significantly higher than before (P < .05). Compared with T0, HR and MAP increased in each group at T4, but MAP and HR in Group D increased the least (P < .05). There were significant differences between Group B, C, D, and A, MAP and HR fluctuated little during extubation (P < .05), but there was a significant difference between Group D and B, C (P < .05). Visual analog scale scores of Group B, C, and D were lower than those of A at 1, 6, and 12 hours after surgery (P < .05), and there was a significant difference between Group D, and B, C (P < .05). Ramsay scores in Group B and D were higher than those in A and C at 1 and 6 hours after the operation (P < .05). There was no difference in the incidence of adverse reactions among groups.

CONCLUSION

The prophylactic use of ketorolac tromethamine and dezocine before laparoscopic inguinal hernia repair can reduce hemodynamic disorder during anesthesia recovery, increase postoperative sedative and analgesic effects.

Long-term oncological outcomes after oral cancer surgery using propofol-based total intravenous anesthesia versus sevoflurane-based inhalation anesthesia: A retrospective cohort study

Background

Previous studies have shown that the anesthetic technique may influence long-term outcomes after cancer surgery. However, the association between the anesthetic technique and long-term oncological outcomes after oral cancer surgery remains unclear. Therefore, we conducted this study to address this gap.

Methods

We reviewed the electronic medical records of patients who underwent elective oral cancer surgery between January 2014 and December 2015. The patients were grouped based on the anesthesia maintenance: either propofol or sevoflurane. Propensity score matching in a 1:1 ratio was performed to deal with the potential confounding effects of baseline characteristics. Univariate and multivariate Cox regression analyses were performed to compare hazard ratios (HRs) and identify the risk factors for death and recurrence. Survival analysis was performed using the Kaplan–Meier method, and survival curves were constructed from the date of surgery to death.

Results

In total, 1347 patients were eligible for analysis, with 343 and 1004 patients in the propofol and sevoflurane groups, respectively. After propensity score matching, 302 patients remained in each group. Kaplan–Meier survival curves demonstrated the 5-year overall and recurrence-free survival rates of 59.3% and 56.0% and 62.7% and 56.5% in the propofol and sevoflurane groups, respectively. There was no significant difference in overall survival or recurrence-free survival between the groups. The multivariate Cox analysis verified this conclusion with HRs of 1.10 and 1.11 for overall survival and recurrence-free survival, respectively, in the sevoflurane group. Older age, advanced tumor-node-metastasis (TNM) stage, and American Society of Anesthesiologists class III were associated with poor overall survival. Patients with advanced TNM stage and poorly differentiated squamous cell carcinoma had a higher recurrence risk than their counterparts.

Conclusion

The overall and recurrence-free survival rates were similar between propofol-based intravenous anesthesia and sevoflurane volatile anesthesia in patients who underwent oral cancer surgery.

Asleep DBS under ketamine sedation: Proof of concept

BACKGROUND

Deep brain stimulation (DBS) is commonly and safely performed for selective Parkinson's disease patients. Many centers perform DBS lead positioning exclusively under local anesthesia, to optimize brain microelectrode recordings (MER) and testing of stimulation-related therapeutic and side effects. These measures enable physiological identification of the DBS borders and subdomains based on electrophysiological properties like firing rates and patterns, intra-operative evaluation of therapeutic window, and improvement of lead placement accuracy. Nevertheless, due to the challenges of awake surgery, some centers use sedation or general anesthesia, despite the distortion of discharge properties and interference with clinical testing, resulting in potential impact on surgical outcomes. Thus, there is a need for a novel anesthesia regimen that enables sedation without compromising intra-operative monitoring.

OBJECTIVE

This open-label study investigates the use of low-dose ketamine for conscious sedation during microelectrode recordings and lead positioning in subthalamic nucleus (STN) DBS for Parkinson's disease patients.

METHODS

Three anesthetic regimens were retrospectively compared in 38 surgeries (74 MER trajectories, 5962 recording sites) across three DBS centers: 1) Interleaved propofol-ketamine (PK), 2) Interleaved propofol-awake (PA), and 3) Fully awake (AA).

RESULTS

All anesthesia regimens achieved satisfactory MER. Detection of STN borders and subdomains by expert electrophysiologist was similar between the groups. Electrophysiological signature of the STN under ketamine was not inferior to either control group. All patients completed stimulation testing.

CONCLUSIONS

This study supports a low-dose ketamine anesthesia regimen for DBS which allows microelectrode recordings and stimulation testing that are not inferior to those conducted under awake and propofol-awake regimens and may optimize patient experience. A prospective double-blind study that would also compare patients' satisfaction level and clinical outcome should be performed to confirm these findings.

Determination of the minimum alveolar concentration of isoflurane in donkeys

OBJECTIVE

To determine the minimum alveolar concentration (MAC) of isoflurane in donkeys and characterize recovery from anesthesia.

ANIMALS

7 healthy castrated male adult donkeys.

PROCEDURES

Anesthesia was induced with propofol and maintained under mechanical ventilation with 1.3% isoflurane end-tidal concentration (ETiso). The MAC of isoflurane was determined after a 60-minute propofol washout period using the bracketing method. A continuous noxious electrical stimulation was applied to the oral mucosa for 1 minute or until the donkey moved. The ETiso was increased or decreased by 10% depending on the response, and MAC was defined as the average of 2 ETiso values allowing and preventing movement in response to stimulation. Arterial blood gases were measured during anesthesia and the recovery period. Unassisted recovery was timed, and a quality score was assigned from 1 (very poor) to 5 (excellent).

RESULTS

The mean dose of propofol required for induction was 3.0 ± 0.6 mg/kg. The MAC of isoflurane was 1.44 ± 0.13%. One donkey was excluded from the study because it was still responsive when stimulated at ETiso of 2.8%. Immediately after extubation, the median (range) partial pressure of oxygen in the arterial blood was 63 (minimum to maximum, 46 to 72) mm Hg and 3 donkeys were hypoxemic (partial pressure of arterial oxygen < 60 mm Hg). The median time to standing was 13 (7 to 38) minutes, while the recovery score was 3 (2 to 5).

CLINICAL RELEVANCE

The MAC of isoflurane in donkeys is similar to that reported in other species. Oxygen support should be provided to donkeys during recovery from isoflurane anesthesia to prevent hypoxemia.

Impact of ketamine versus fentanyl continuous infusion on opioid use in patients admitted to a surgical-trauma intensive care unit

OBJECTIVE

Ketamine has been shown to decrease opioid utilization as an adjunct, but limited evidence is available on ketamine as a primary analgesic strategy.

DESIGN

A retrospective chart review.

PATIENTS AND PARTICIPANTS

Mechanically ventilated adult patients (≥18 years) in the surgery-trauma intensive care unit (STICU) with continuous infusion ketamine or fentanyl with concomitant propofol for at least 12 hours were screened for inclusion. The final analysis included 22 patients in the ketamine/propofol (KP) group and 24 patients in the fentanyl/propofol (FP) group.

INTERVENTIONS

Patients in the STICU received KP or FP continuous infusions.

MAIN OUTCOME MEASURES

The primary outcome compared opioid requirements between both groups during mechanical ventilation.

RESULTS

The median opioid requirement during mechanical ventilation was significantly higher in the FP group compared to the KP group (median 1,392 milligrams of morphine equivalents (MMEs) [interquartile range (IQR) 709.5-2,292] versus 206.3 MME [IQR 87-510], p < 0.001). After extubation, there was no difference in opioid utilization. Patients in the KP group spent less time at goal Critical Care Pain Observation Tool compared to the FP group (median 77.6 percent, IQR [71.9-85.2] versus 88.9 percent, IQR [76.9-97.4], p = 0.003). The proportions of patients developing adverse effects were not significantly different between the two groups.

CONCLUSIONS

Among critically ill mechanically ventilated patients in the STICU, continuous ketamine resulted in signifi-cantly less opioids during mechanical ventilation. Further studies with a larger sample size are needed to assess the ap-propriate dosing strategy for ketamine to produce adequate analgesia when used as a primary analgesic in mechanically ventilated patients.

[Effect of dexamethasone combined with oxybuprocaine hydrochloride gel on prevention of postoperative sore throat after nasal endoscopy]

OBJECTIVE

To explore the effectiveness and feasibility of dexamethasone combined with oxybuprocaine hydrochloride gel on the prevention of postoperative sore throat after nasal endoscopy.

METHODS

In the study, 60 patients with American Society of Anesthesiologist (ASA) physical statuses Ⅰ to Ⅱ, aged 18 to 72 years, scheduled for elective nasal endoscope surgery under general anesthesia requiring endotracheal intubation were randomly divided into dexamethasone combined with oxybuprocaine hydrochloride gel group (G group, n=30) and control group (C group, n=30). The patients in the G group received dexamethasone 0.1 mg/kg before induction and the oxybuprocaine gel was applied to the endotracheal catheter cuff and the front end within 15 cm. The patients in the C group received the same dose of saline and the saline was applied to the endotracheal catheter cuff and the front end within 15 cm. Then, all the patients in the two groups received the same induction and anesthesia maintainance. The operation time, anesthesia time, emergence time, extubation time and departure time were recorded. The intraoperative infusion volume, blood loss volume, propofol, remifentanil, rocuronium dosage were also recorded. The adverse reactions such as intraoperative hypotension, bradycardia and postoperative agitation were recorded. The postoperative sore throat score was recorded at the end of operation and 4 h, 8 h, 12 h, and 24 h after operation.

RESULTS

Compared with the C group, the emergence time [(8.4±3.9) min vs. (10.8±4.7) min], extubation time [(8.8±3.7) min vs. (11.9±4.8) min], and departure time [(20.0±5.3) min vs. (23.0±5.8) min] were significantly shorter, and the propofol dosage [(11.8±1.8) mg/kg vs. (15.9±4.6) mg/kg], remifentanil dosage [(10.9±4.7) μg/kg vs. (14.1±3.6) μg/kg] were significantly less in the G group, and there was no difference of rocuronium dosage in the two groups. Compared with the C group the incidence of intraoperative hypotension [10%(3/30) vs. 30%(9/30)], bradycardia [16.7%(5/30) vs. 20%(6/30)] and postoperative agitation [6.7%(2/30) vs. 23.3%(7/30)] were significantly lower in the C group. The postoperative sore throat score at the end of operation, 4 h, 8 h, 12 h and 24 h after operation in the G group were significantly lower than in the C group respectively [0 (0, 1) vs. 1 (1, 2), 0 (0, 0) vs. 1 (1, 2), 0 (0, 0) vs. 1 (1, 2), 0 (0, 0) vs. 1 (0.75, 1), 0 (0, 0) vs. 1 (0, 1)].

CONCLUSION

Dexamethasone combined with oxybuprocaine hydrochloride gel was effective and feasible on the prevention of postoperative sore throat after nasal endoscopy.

Effect of Sedation Anesthesia With Intravenous Propofol on Transrectal Ultrasound-Guided Prostate Biopsy Outcomes

BACKGROUND

Sedation anesthesia during transrectal ultrasound (TRUS)-guided prostate biopsy is known to decrease patient pain and anxiety, but little is known whether it affects the procedure's prostate cancer detection and complication rates. This study aimed to determine the effect of sedation anesthesia with intravenous (IV) propofol on TRUS-guided prostate biopsy outcomes.

METHODS

A retrospective analysis of 2,119 patients who underwent TRUS-guided prostate biopsy between November 2009 and February 2019 was undertaken. The patients were divided into two groups: patients who underwent sedation anesthesia with IV propofol and patients who underwent local anesthesia with intrarectal lidocaine gel instillation. Cancer detection and complication rates were compared between the two groups. Univariate and multivariate binary logistic regression and multinomial logistic regression analyses were conducted to investigate the effects of sedation anesthesia with IV propofol on prostate cancer detection and complication rates.

RESULTS

The cancer detection rate of patients in the sedation group was 34.0%, whereas it was 29.2% in the local group (P = 0.024). Multivariate logistic regression analysis regarding factors associated with cancer detection rate after TRUS-guided prostate biopsy in patients with prostate specific antigen (PSA) < 10 showed that IV propofol usage, age, PSA density and core length were significant factors. Multivariate logistic regression analysis regarding factors associated with complications (voiding dysfunction, bleeding and infection) showed that IV propofol usage, age and prostate size were significant factors for voiding dysfunction.

CONCLUSION

Sedation anesthesia with IV propofol during TRUS-guided prostate biopsy was associated with a higher cancer detection rate than local anesthesia with intrarectal lidocaine gel instillation. Cancer detection rate could be an important factor to consider when selecting for the optimal anesthesia for TRUS-guided prostate biopsy.