Comparison of different ratios of propofol-ketamine admixture in rapid-sequence induction of anesthesia for emergency laparotomy: a randomized controlled trial

BACKGROUND

We aimed to compare the hemodynamic effect of two ratios of propofol and ketamine (ketofol), namely 1:1 and 1:3 ratios, in rapid-sequence induction of anesthesia for emergency laparotomy.

METHODS

This randomized controlled study included adult patients undergoing emergency laparotomy under general anesthesia. The patients were randomized to receive either ketofol ratio of 1:1 (n = 37) or ketofol ratio of 1:3 (n = 37). Hypotension (mean arterial pressure < 70 mmHg) was managed by 5-mcg norepinephrine. The primary outcome was total norepinephrine requirements during the postinduction period. Secondary outcomes included the incidence of postinduction hypotension, and the intubation condition (excellent, good, or poor).

RESULTS

Thirty-seven patients in the ketofol-1:1 and 35 patients in the ketofol 1:3 group were analyzed. The total norepinephrine requirement was less in the ketofol-1:1 group than in the ketofol-1:3 group, P-values: 0.043. The incidence of postinduction hypotension was less in the ketofol-1:1 group (4 [12%]) than in ketofol-1:3 group (12 [35%]), P-value 0.022. All the included patients had excellent intubation condition.

CONCLUSION

In patients undergoing emergency laparotomy, the use of ketofol in 1:1 ratio for rapid-sequence induction of anesthesia was associated with less incidence of postinduction hypotension and vasopressor consumption in comparison to the 1:3 ratio with comparable intubation conditions.

CLINICAL TRIAL REGISTRATION

NCT05166330. URL: https://clinicaltrials.gov/ct2/show/NCT05166330 .

Postoperative nausea and vomiting after artificial joint replacement surgery: comparison between remimazolam and sevoflurane, a propensity score analysis

PURPOSE

Remimazolam, a newly synthesized ultrashort-acting benzodiazepine, has not been previously compared with sevoflurane with regard to postoperative nausea and vomiting (PONV). The aim of this study is to investigate the incidence of PONV between remimazolam and sevoflurane among patients undergoing artificial joint replacement surgery.

METHODS

We conducted a retrospective analysis of the electronic medical records of patients who underwent artificial joint replacement surgery at Kobe City Medical Center General Hospital from 2020 to 2022, with a focus on comparing the incidence of PONV among those who received sevoflurane versus remimazolam anesthesia. To control for confounding factors, we employed a propensity score-matching technique to pair patients who received sevoflurane anesthesia with those who received remimazolam anesthesia.

RESULTS

The records of 292 patients receiving general anesthesia for artificial joint replacement surgery were collected and categorized into group sevoflurane (n = 241) or group remimazolam (n = 51). Before propensity score matching, age and ASA-PS exhibited significant differences between two groups. There was no significant difference in the incidence of PONV between them (p = 0.461). After matching, there were 51 patients in each group. However, there is no significant difference in the incidence of PONV between the two matched cohorts (p = 0.243).

CONCLUSIONS

This study demonstrated that there was no difference in the prevalence of PONV between remimazolam and sevoflurane anesthesia in patients undergoing artificial joint replacement surgery.

Modified Manual Chest Compression for Prevention and Treatment of Respiratory Depression in Patients Under Deep Sedation During Upper Gastrointestinal Endoscopy: Two Randomized Controlled Trials

BACKGROUND

We aimed to determine the preventive and therapeutic efficacy of modified manual chest compression (MMCC), a novel noninvasive and device-independent method, in reducing oxygen desaturation events in patients undergoing upper gastrointestinal endoscopy under deep sedation.

METHODS

A total of 584 outpatients who underwent deep sedation during upper gastrointestinal endoscopy were enrolled. In the preventive cohort, 440 patients were randomized to the MMCC group (patients received MMCC when their eyelash reflex disappeared, M1 group) or control group (C1 group). In the therapeutic cohort, 144 patients with oxygen desaturation of a Sp o2 < 95% were randomized to MMCC group (patients who subsequently received MMCC, M2 group) or the conventional treatment group (C2 group). The primary outcomes were the incidence of desaturation episodes with an Sp o2 < 95% for the preventive cohort and the time spent below 95% Sp o2 for the therapeutic cohort. Secondary outcomes included the incidence of gastroscopy withdrawal and diaphragmatic pause.

RESULTS

In the preventive cohort, MMCC reduced the incidence of desaturation episodes <95% (14.4% vs 26.1%; RR, 0.549; 95% confidence interval [CI], 0.37-0.815; P = .002), gastroscopy withdrawal (0% vs 2.29%; P = .008), and diaphragmatic pause at 30 seconds after propofol injection (74.5% vs 88.1%; RR, 0.846; 95% CI, 0.772-0.928; P < .001). In the therapeutic cohort, patients who received MMCC had a significantly shorter time spent below 95% Sp o2 (40 [20-69] seconds vs 91 [33-152] seconds, median difference [95% CI], -39 [-57 to -16] seconds, P < .001), a lower incidence of gastroscopy withdrawal (0% vs 10.4%, P = .018), and more enhanced diaphragmatic movement at 30 seconds after Sp o2 <95% (1.11 [0.93-1.4] cm vs 1.03 [0.7-1.24] cm; median difference [95% confidence interval], 0.16 [0.02-0.32] cm; P = .015).

CONCLUSIONS

MMCC may exert preventive and therapeutic effects against oxygen desaturation events during upper gastrointestinal endoscopy.

Propofol-based intravenous anesthesia is associated with improved survival outcomes after major cancer surgery: a nationwide cohort study in South Korea

BACKGROUND

The optimal anesthetic technique for cancer surgery remains a controversial issue. This study aimed to examine whether propofol-based total intravenous anesthesia (TIVA) was associated with survival outcomes after major cancer surgery in South Korea and compare its effectiveness with that of inhalation anesthesia.

METHODS

This nationwide population-based cohort study included adult patients who were admitted to the hospital and underwent major cancer surgery between January 1, 2016, and December 31, 2020. The major cancers included lung, gastric, colorectal, esophageal, small bowel, liver, pancreatic, and bile duct or gallbladder cancers.

RESULTS

A total of 253,003 patients who underwent major cancer surgery were included in the analysis. After propensity score (PS) matching, 115,370 patients (57,685 in each group) were included in the final analysis. In the PS-matched cohort, the TIVA group showed 9% (hazard ratio [HR]: 0.91, 95% CI [0.85, 0.98], P = 0.018) and 7% (HR: 0.93, 95% CI [0.89, 0.96], P < 0.001) lower 90-day and one-year mortality rates, respectively, than the inhalation group. In subgroup analyses, the TIVA group showed lower 90-day mortality than the inhalation group in the gastric (HR: 0.86, 95% CI [0.72, 0.97], P = 0.033), colorectal (HR: 0.64, 95% CI [0.56, 0.73], P < 0.001), and pancreatic (HR: 0.76, 95% CI [0.57, 0.94], P = 0.038) cancer surgery groups.

CONCLUSIONS

Propofol-based TIVA is associated with better survival outcomes after major cancer surgeries. Moreover, propofol-based TIVA was beneficial in patients who underwent gastric, colorectal, and pancreatic cancer surgeries.

Remimazolam: a randomized controlled study of its suitability for insertion of a supraglottic airway

PURPOSE

Loss of motor response to thrusting the jaw forward is a useful indicator for uncomplicated insertion of a supraglottic airway. The aim of this study was to assess the suitability of remimazolam for insertion of a supraglottic airway assessed by loss of response to jaw thrusting.

METHODS

Seventy patients, who were scheduled for elective surgeries under general anesthesia, were allocated randomly to one of two groups. In one group (remimazolam group), remimazolam was infused 12 mg kg-1 h-1 (50 mg maximum), and in the other (propofol group), propofol was infused at 120 mg kg-1 h-1 (500 mg maximum). Once the eyelash reflex disappeared, response to jaw thrusting was assessed. Primary outcome measure was the proportion of patients with loss of response to jaw thrusting before reaching the maximum dose of the test drug. We planned an interim analysis (of one time) after 40 patients, using the Pocock adjustment method.

RESULTS

From the interim analysis results, the study was stopped after recruitment of 40 patients. Loss of response to jaw thrusting was observed in all of 21 patients (100%) in the propofol group, and in 9 of 19 patients (47%) in the remimazolam group. There was a significant difference in the proportion between the groups (P = 0.0001, 95% CI for difference 30-75%).

CONCLUSION

Remimazolam frequently does not inhibit response to jaw thrusting, and thus remimazolam is not a suitable induction agent for uncomplicated insertion of a supraglottic airway unless either a neuromuscular blocking agent or an opioid is co-administered.

Efficacy of intraoperative thoracoscopic intercostal nerve blocks in nonintubated and intubated video-assisted thoracic surgery: A randomized study

BACKGROUND

The efficacy of thoracoscopic intercostal nerve blocks (TINBs) for noxious stimulation from video-assisted thoracic surgery (VATS) remains unclear. The efficacy of TINBs may also be different between nonintubated VATS (NIVATS) and intubated VATS (IVATS). We aim to compare the efficacy of TINBs on analgesia and sedation for NIVATS and IVATs intraoperatively.

METHODS

Sixty patients randomized to the NIVATS or IVATS group (30 each) received target-controlled propofol and remifentanil infusions, with bispectral index (BIS) maintained at 40-60, and multilevel (T3-T8) TINBs before surgical manipulations. Intraoperative monitoring data, including pulse oximetry, mean arterial pressure (MAP), heart rate, BIS, density spectral arrays (DSAs), and propofol and remifentanil effect-site concentration (Ce) at different time points. A two way ANOVA with post hoc analysis was applied to analyze the differences and interactions of groups and time points.

RESULTS

In both groups, DSA monitoring revealed burst suppression and α dropout immediately after the TINBs. The Ce of the propofol infusion had to be reduced within 5 min post-TINBs in both NIVATS (p < 0.001) and IVATS (p = 0.252) groups. The Ce of remifentanil infusion was significantly reduced after TINBs in both groups (p < 0.001), and was significantly lower in NIVATS (p < 0.001) without group interactions.

CONCLUSION

The surgeon-performed intraoperative multilevel TINBs allow reduced anesthetic and analgesic requirement for VATS. With lower requirement of remifentanil infusion, NIVATS presents a significantly higher risk of hypotension after TINBs. DSA is beneficial for providing real-time data that facilitate the preemptive management, especially for NIVATS.

Effect of Anesthesia Induction on Cardiac Hemodynamics in Patients Undergoing Durable Left Ventricular Assist Device Implantation: The EACH-LVAD Study

Right ventricular (RV) dysfunction is common after left ventricular assist device (LVAD) implantation leading to clinical right heart failure (RHF) associated with worsened survival and quality of life. It is likely that intraoperative events such as anesthesia induction play a role in the development or unmasking of RV dysfunction in addition to known effects from hemodynamic changes that occur after LVAD implantation. The EACH-LVAD Study is a prospective, single-center, single-arm, observational cohort study of adult patients with advanced heart failure undergoing durable LVAD implantation with standard anesthesia induction. Intraoperative RV hemodynamics via central venous pressure, mean pulmonary artery pressure, pulmonary artery pulsatility index, and vasoactive-inotropic score (a simple weighted summation of standardized drug doses) and echocardiographic parameters (RV fractional area change, RV area in diastole, RV basal diameter, septum position, RV function, tricuspid regurgitation) were measured and compared at prespecified timepoints, including postinduction. Postoperative clinical RHF was determined based on published definitions. Forty-two patients receiving a first-time LVAD were included between September 2017 and March 2019. Propofol-based induction was used in 31 patients and etomidate-based induction in eight patients. A significant increase in central venous pressure (CVP; p < 0.001), mean pulmonary artery pressure (mPAP; p < 0.001), and vasoactive inotropic score (VIS; p < 0.001) with associated decrease in pulmonary artery pulsatility index (PAPi; p < 0.001) was observed. Right ventricular function worsened throughout. Right heart failure occurred in 70% of patients. Propofol-based induction was not associated with a higher risk of RHF (relative risk [RR], 1.01 [95% confidence interval {CI}, 0.64-1.61]). The EACH-LVAD study demonstrates an effect of anesthesia induction on worsened RV hemodynamics and echocardiographic changes which may have an effect on the development of RHF.

Comparison of Procedural Sedation With Propofol and Dexmedetomidine During Transcatheter Aortic Valve Replacement Using the Transfemoral Approach

OBJECTIVES

Although procedural sedation is an established method of anesthesia for transcatheter aortic valve replacement (TAVR), reliable evidence to guide the choice of a suitable sedative agent remains scarce. Accordingly, this trial aimed to compare the effect of procedural sedation with dexmedetomidine versus propofol on postoperative neurocognitive and related clinical outcomes in patients undergoing TAVR.

DESIGN

Prospective, randomized, double-blind clinical trial.

SETTING

The study was conducted at the University Medical Centre Ljubljana, Slovenia.

PARTICIPANTS

The study enrolled 78 patients who underwent TAVR under procedural sedation between January 2019 and June 2021. Seventy-one patients randomized into the propofol group (n = 34) and dexmedetomidine group (n = 37) were included in the final analysis.

INTERVENTIONS

Patients in the propofol group received sedation with propofol (continuous intravenous infusion of 0.5-2.5 mg/kg/h), whereas patients in the dexmedetomidine group received sedation with dexmedetomidine (loading dose of 0.5 µg/kg over 10 minutes followed by continuous intravenous infusion of 0.2-1.0 µg/kg/h).

MEASUREMENTS AND MAIN RESULTS

Minimental state examination (MMSE) was performed before and 48 hours after TAVR. There was no statistically significant difference in MMSE scores between groups before TAVR (p = 0.253), but the MMSE after the procedure revealed a significantly lower incidence of delayed neurocognitive recovery (p = 0.005) and thus better cognitive outcomes in the dexmedetomidine group (p = 0.022).

CONCLUSIONS

Compared with propofol, procedural sedation with dexmedetomidine in TAVR was associated with a significantly lower incidence of delayed neurocognitive recovery.

The art of chasing numbers in titration of anaesthetic dose

There is no difference in between-patient variability of concentrations when comparing propofol and sevoflurane titrated to a bispectral index of 40-60. There is about a 300% variation in hypnotic concentration between the bottom 5% and top 5% of the population. Anaesthesia titration cannot be based solely on measured or estimated drug concentrations.

Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial

STUDY OBJECTIVE

To determine if a nasal positive airway pressure (nasal CPAP) mask would decrease the number of hypoxemic events in obese and obstructive sleep apnea patients undergoing colonoscopy.

DESIGN

Single-center prospective randomized controlled trial.

SETTING

Tertiary academic center.

PATIENTS

We enrolled 109 patients with diagnosis of obesity and/or obstructive sleep apnea scheduled to undergo colonoscopy under propofol general anesthesia without planned tracheal intubation.

INTERVENTION

Patients were randomly allocated (1:1 ratio) to receive supplementary oxygen at a flow of 10 L/min, either through a nasal CPAP or a simple facemask.

MEASUREMENTS

The primary endpoint was the difference in the mean percentage of time spent with oxygen saturation below 90% between the two groups. Secondary outcomes included the need for airway maneuvers/interventions, average SpO2 during the case, duration and severity of oxygen desaturation, incidence and duration of procedural interruptions, and satisfaction and tolerance scores.

MAIN RESULTS

54 were allocated to the simple face mask and 55 to the nasal CPAP mask arms, respectively. A total of 6 patients experienced a hypoxemic event. Among these patients, the difference in the percentage of time spent with oxygen saturation below 90% was not clinically relevant (p = 1.0). However, patients in the nasal CPAP group required less chin lift (20% vs. 42.6%; p = 0.01) and oral cannula insertion (12.7% vs.29.6%; p = 0.03). The percentage of patients with at least one airway maneuver was higher in the simple face mask arm (68.5% vs. 41.8%; p = 0.005). Patient tolerance to device score was lower in the nasal CPAP group (8.85 vs. 9.56; p = 0.003).

CONCLUSIONS

A nasal CPAP did not prevent hypoxemia and should not be used routinely for colonoscopy in obese or OSA patients if a simple face mask is an alternative therapy. However, potential advantages of its use include fewer airway maneuvers or interventions, which may be desirable in certain clinical settings.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT05175573.

Drug-drug interaction study of ciprofol and sodium divalproex: Pharmacokinetics, pharmacodynamics, and safety in healthy Chinese subjects

Ciprofol (also known as HSK3486) is a promising intravenous anesthetic candidate derived from propofol and independently developed by Haisco Pharmaceutical Group Co., Ltd. (Chengdu, China). Compared with propofol, ciprofol has the potential to reduce the dose required and the associated risks. Ciprofol is extensively metabolized in vivo, and its interaction with other concurrently administered drugs during clinical application is worthy of attention. Therefore, an open-label, two-stage sequential study was performed in healthy subjects who received either a single administration of ciprofol injection or ciprofol injection after oral administration of sodium divalproex. The aim of the study was to evaluate the effects of sodium divalproex on ciprofol with respect to pharmacokinetics, pharmacodynamics, and safety, thus providing a basis for the rational clinical use of ciprofol and sodium divalproex.

Efficacy and Safety of Ciprofol Sedation in ICU Patients Undergoing Mechanical Ventilation: A Multicenter, Single-Blind, Randomized, Noninferiority Trial

OBJECTIVES

To determine the effectiveness and safety of ciprofol for sedating patients in ICUs who required mechanical ventilation (MV).

DESIGN

A multicenter, single-blind, randomized, noninferiority trial.

SETTING

Twenty-one centers across China from December 2020 to June 2021.

PATIENTS

A total of 135 ICU patients 18 to 80 years old with endotracheal intubation and undergoing MV, who were expected to require sedation for 6-24 hours.

INTERVENTIONS

One hundred thirty-five ICU patients were randomly allocated into ciprofol ( n = 90) and propofol ( n = 45) groups in a 2:1 ratio. Ciprofol or propofol were IV infused at loading doses of 0.1 mg/kg or 0.5 mg/kg, respectively, over 4 minutes ± 30 seconds depending on the physical condition of each patient. Ciprofol or propofol were then immediately administered at an initial maintenance dose of 0.3 mg/kg/hr or 1.5 mg/kg/hr, to achieve the target sedation range of Richmond Agitation-Sedation Scale (+1 to -2). Besides, continuous IV remifentanil analgesia was administered (loading dose: 0.5-1 μg/kg, maintenance dose: 0.02-0.15 μg/kg/min).

MEASUREMENTS AND MAIN RESULTS

Of the 135 patients enrolled, 129 completed the study. The primary endpoint-sedation success rates of ciprofol and propofol groups were 97.7% versus 97.8% in the full analysis set (FAS) and were both 100% in per-protocol set (PPS). The noninferiority margin was set as 8% and confirmed with a lower limit of two-sided 95% CI for the inter-group difference of -5.98% and -4.32% in the FAS and PPS groups. Patients who received ciprofol had a longer recovery time ( p = 0.003), but there were no differences in the remaining secondary endpoints (all p > 0.05). The occurrence rates of treatment-emergent adverse events (TEAEs) or drug-related TEAEs were not significantly different between the groups (all p > 0.05).

CONCLUSIONS

Ciprofol was well tolerated, with a noninferior sedation profile to propofol in Chinese ICU patients undergoing MV for a period of 6-24 hours.

Performance of the SEDLine Monitor: Age Dependency and Time Delay

BACKGROUND

Devices monitoring the hypnotic component of general anesthesia can help to guide anesthetic management. The main purposes of these devices are the titration of anesthesia dose. While anesthesia at low doses can result in awareness with intraoperative memory formation, excessive administration of anesthetics may be associated with an increased risk of postoperative neurocognitive disorder. We have previously shown for various indices that they are significantly influenced by the patient's age and that the monitors have a significant time delay. Here, we evaluated the influence of patient's age and time delay on the patient state index (PSI) of the SEDLine monitor.

METHODS

To analyze the influence of the patient's age, we replayed 2 minutes of electroencephalography (EEG) of 141 patients (19-88 years, ASA I-IV) undergoing general anesthesia maintained with desflurane, sevoflurane, or propofol to the SEDLine monitor. We extracted the PSI as well as the spectral edge frequency (SEF) and performed a linear regression analysis. For evaluation of the time delay, we replayed 5 minutes of EEG of stable episodes of adequate anesthesia (PSI between 25 and 50) or light sedation/wake (PSI >70) in different orders to the SEDLine to simulate sudden changes between the states. Time delays were defined as the required time span of the monitor to reach the stable target index.

RESULTS

PSI and SEF increased significantly with the patient's age. These findings did not depend on the administered anesthetic. The evaluation of the correlation between SEF and PSI showed a strong correlation with Spearman's correlation coefficient of ρ = 0.86 (0.82; 0.89). The time delays depended on the type of transition. We found a median time delay of 54 (Min: 46; Max: 61) seconds for the important transition between adequate anesthesia and awake and 55 (Min: 50; Max: 67) seconds in the other direction.

CONCLUSIONS

With our analyses, we show that the indices presented on the SEDLine display, the PSI and the SEF, increase with age for patients under general anesthesia. Additionally, a delay of the PSI to react to sudden neurophysiologic changes due to dose of the maintenance anesthetic is of a time course that is clinically significant. These factors should be considered when navigating anesthesia relying on only the proprietary index for the SEDLine monitor.

Clinical validation of an adapted Eleveld Model for high-dose propofol treatments for depression

Repeated administration of high doses of propofol to patients with treatment-resistant depression (TRD) has been shown to produce antidepressant effects in small clinical trials. These effects can be elicited when the patient's EEG burst-suppression ratio (BSR) is maintained at 70-90% for 15 min in repeated treatments. This deep anesthesia domain lies beyond the range of current propofol pharmacokinetic/pharmacodynamic (PK/PD) models. In this study, we adapt the Eleveld model for use at deep anesthesia levels with a BSR endpoint, with the goal of aiding the estimation of the dosage of propofol needed to achieve 70-90% BSR for 15 min. We test the ability of the adapted model to predict BSR for these treatments. Twenty participants underwent 6-9 treatments of high doses of propofol (5-9 of which were included in this analysis) for a total of 115 treatments. To adapt the Eleveld model for this endpoint, we optimized the model parameters Ke0, γ and Ce50. These parameters were then used in the adapted model to estimate second-by-second BSR for each treatment. Estimated BSR was compared with observed BSR for each treatment of each participant. Median absolute performance error (MdAPE) between the estimated and observed BSR (25th-75th percentile) was 6.63 (3.79-12.96) % points and 8.51 (4.32-16.74) % between the estimated and observed treatment duration. This predictive performance is statistically significantly better at predicting BSR compared with the standard Eleveld model at deep anesthesia levels. Our adapted Eleveld model provides a useful tool to aid dosing propofol for high-dose anesthetic treatments for depression.

Variability of predicted propofol concentrations and measured sevoflurane concentrations during general anaesthesia: a single-centre retrospective cohort study

BACKGROUND

Variability is high in predicted propofol concentrations during clinical anaesthesia titrated by target-controlled infusion (TCI) to maintain a processed EEG parameter (bispectral index [BIS]) within a specified range. We have shown that the potential for improving the pharmacokinetic model is minimal. The drug titration paradox revealed that titration challenges the classical relationship between drug dose and effect in both individuals and the population. We hypothesised that dynamic factors during surgery beyond the static genetic, epigenetic, and other factors such as age, height, and weight affect the necessary dose. We compared the variability of measured end-tidal sevoflurane concentrations with predicted effect-site propofol concentrations when titrated to a BIS range of 40-60, with the hypothesis that the variability in measured sevoflurane concentrations would not be less than the variability in estimated propofol concentrations.

METHODS

Clinical data from 2280 surgical procedures >1 h in duration were included in the analysis. Anaesthesia with sevoflurane or propofol was based on an institutional protocol. The titration performance for both drugs was assessed by comparing BIS values 30 min after skin incision. The variability of the required concentrations at the same time point was calculated and compared.

RESULTS

The achieved 30-min post-incision BIS ranges were not significantly different for sevoflurane or propofol TCI (30 [99% CI: 28-33] and 31 [99% CI: 27-36], respectively). The variability of sevoflurane concentrations was not significantly different from measured predicted propofol concentrations during BIS-guided anaesthesia (normalized concentration range of 0.89 [99% CI: 0.78-0.99] and 0.93 [99% CI 0.87-1.02).

CONCLUSIONS

Improvements in prediction accuracy of pharmacokinetic models beyond that of those already in clinical use are unlikely to reduce variability in target anaesthetic concentrations across patients in clinical practice.

Total intravenous anesthesia for geriatric hip fracture with severe systemic disease

PURPOSE

Our study aimed to determine the impact of a novel technique of anesthesia administration on the clinical outcomes and complications in geriatric patients with severe systemic disease undergoing hip surgery.

METHODS

We retrospectively identified patients aged > 65 years with severe systemic disease that was a constant of life [American Society of Anesthesiologists (ASA) IV] who underwent surgery for hip fracture between January 2018 and January 2020. The patients were divided into two groups: Group I [fascia iliaca compartment block plus propofol-based total intravenous anesthesia (FICB + TIVA)] and Group II [general anesthesia (GA)]. The primary outcomes were 30-day and 1-year mortality. The secondary outcomes included length of hospital stay, length of intensive care unit (ICU) stay, postoperative morbidity, Visual Analog Scale score, and consumption of analgesics.

RESULTS

There was no significant difference in the 30-day mortality (5 vs. 3.8%, p = 0.85) and 1-year mortality (15 vs. 12%, p = 0.73) between the groups. Group I had significantly lower ICU requirements (p = 0.01) and shorter lengths of ICU stay (p < 0.001) and hospital stay (p < 0.001). Moreover, a smaller proportion of patients in Group I required postoperative morphine or oral opiates.

CONCLUSION

Geriatric patients who underwent hip surgery under FICB + TIVA required fewer ICU admissions, shorter lengths of ICU and hospital stay, and had lesser postoperative opioid consumption than those who were under GA. Hence, we recommend the novel FICB + TIVA technique for hip fracture surgery in geriatric patients with poor general health status and high surgical risks (ASA IV).

Paralysis Versus Non-Paralysis Anesthesia for Operative Laryngoscopy: A Randomized Controlled Trial

OBJECTIVE

To compare outcomes between two standard-of-care anesthesia regimens for operative laryngoscopy: general anesthesia with a neuromuscular blocking agent (NMBA) versus remifentanil and propofol (non-NMBA).

METHODS

This was a prospective, single-blinded, randomized controlled trial at a tertiary care center. Patients were randomized to either anesthesia using rocuronium (NMBA) or with remifentanil/propofol infusion alone (non-NMBA). Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected.

RESULTS

Sixty-one patients who underwent suspension laryngoscopy from 2020 to 2022 were included (25 female, 36 male, ranging 20-81 years). Thirty patients were enrolled in the NMBA arm and 31 patients in the non-NMBA arm. Heart rate and mean arterial pressure were higher in the NMBA (p < 0.01). Patients in the non-NMBA group were more likely to require vasopressors (p = 0.04, RR = 3.08 [0.86-11.05]). Surgeons were more frequently satisfied with conditions in the NMBA group (86.7%) compared to the non-NMBA group (58.1%, p < 0.01). Procedures were more likely to be paused due to movement in the non-NMBA group (45.1%) compared to the NMBA group (16.6%, p < 0.03, RR = 2.26 [1.02-4.99]). Patients in the non-NMBA group were more likely to endorse myalgia the week after surgery (44%) compared to the NMBA group (8.3%, p < 0.01) and reported higher average pain levels on a 0-10 pain scale (3.7) compared to the paralysis group (2.0).

CONCLUSIONS

Anesthesia with rocuronium was associated with better intraoperative conditions and postoperative pain compared to anesthesia with remifentanil/propofol. Remifentanil/propofol were associated with lower blood pressure and suppression of laryngoscopy-associated tachycardia.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:2654-2664, 2023.

Remimazolam vs Etomidate: Haemodynamic Effects in Hypertensive Elderly Patients Undergoing Non-Cardiac Surgery

Background

Remimazolam tosilate (RT) is a novel ultrashort-acting γ-aminobutyric acid subtype A (GABAA) agonist, with several advantages including rapid induction and recovery, stable haemodynamics, and mild respiratory inhibition. However, studies have not been conducted to explore the haemodynamic effects of RT in elderly hypertensive subjects undergoing non-cardiac surgery. Therefore, we sought to compare the effects of anaesthesia induction using different doses of RT and etomidate on the haemodynamics of this group of patients.

Methods

Patients were recruited into this single-center, prospective, randomized, double-blind trial from October 2022 to June 2023. A total of 150 hypertensive elderly undergoing non-cardiac surgery were randomly assigned into 0.2 mg/kg RT group (Group RL), 0.3 mg/kg RT group (Group RH) and 0.3 mg/kg etomidate group (Group E). The primary outcome of the study was haemodynamic changes (mean arterial pressure fluctuation value -∆MAP and heart rate fluctuation value -∆HR) observed during anaesthesia induction. Secondary outcomes included incidence of adverse cardiovascular events and adverse drug reactions (injection pain and myoclonus), cumulative doses of vasoactive drugs and vital signs at different time points.

Results

Patients in Group E and Group RL had significantly lower haemodynamic fluctuations (∆MAP), lower incidence of hypotension and cumulative dose of ephedrine than subjects in Group RH. Patients in groups RL and RH had significantly lower incidence of injection pain and myoclonus compared with patients in group E. The results showed no statistically significant differences in ∆HR, hypertension, bradycardia, tachycardia, and time to loss of eye-opening reflex and start of intubation, and vital signs at different time points among the three groups.

Conclusion

Use of low-dose RT (0.2 mg/kg) for induction of non-cardiac surgical anaesthesia in elderly hypertensive patients is more effective in maintaining haemodynamic stability and has fewer adverse effects compared with etomidate.

Efficacy and Safety of Different Doses of Remimazolam Tosilate Applied in Upper Gastrointestinal Endoscopy: A Prospective Randomized Controlled Double-Blind Trial

Background

Remimazolam is a novel benzodiazepine narcotic. When used for gastrointestinal endoscopy or bronchoscopy, it provides adequate sedation and rapid recovery. However, studies on the optimal initial loading dose of remimazolam remain inadequate. Therefore, we conducted a randomized controlled clinical trial to investigate the efficacy and safety of different doses of remimazolam applied in upper gastrointestinal endoscopy.

Methods

A total of 218 patients scheduled for upper gastrointestinal endoscopy were included in our trial and divided into experimental and control groups: the experimental groups were the remimazolam groups (R1 of 0.2 mg/kg, R2 of 0.3 mg/kg, and R3 of 0.4 mg/kg), and the control group was the propofol group. Following a single injection of trial drugs during the induction period, operational requirements were evaluated based on MOAA/S scores. When the sedation was successfully achieved, safety was evaluated based on the incidence of various intraoperative and postoperative adverse events.

Results

The success rates of intraoperative sedation were 82% in group R1, 98% in group R2, 96% in group R3, and 100% in group P. The incidence of hypotension was lower in the remimazolam groups than in the propofol group (16%), 4% in group R1, 6% in group R2, and 6% in group R3. The incidence of postoperative vertigo was significantly higher, and sedation recovery time was prolonged in high-concentration remimazolam group.

Conclusion

Satisfactory efficacy can be obtained with higher concentrations of remimazolam tosilate in patients undergoing upper gastrointestinal endoscopy with ASA grade I or II. However, as the dose is progressively increased, the incidence of adverse reactions by remimazolam tosilate are also significantly increased, such as vertigo and prolonged sedation recovery time.

Trial Registration

The trial was registered prior to enrollment at the Chinese Clinical Trial Registry (ChiCTR 2000032067).

Effect of esketamine on inflammatory factors in opioid-free anesthesia based on quadratus lumborum block: A randomized trial

BACKGROUND

As strong analgesics, opioids provide the analgesic component of general anesthesia, but they have bidirectional effects on the immune system, promoting the production of pro-inflammatory factors. The idea of opioid-free anesthesia is to replace the analgesic effect of opioids in the treatment of acute pain with comparably effective drugs that do not affect the immune system and thereby decrease the production of inflammatory factors. Therefore, this study aims to observe the effect of opioid-free esketamine anesthesia based on quadratus lumborum block on inflammatory factors in patients undergoing lower abdominal or pelvic surgery.

METHODS

A total of 122 patients who underwent lower abdominal or pelvic surgery in our hospital from March 2021 to June 2022 were selected and divided into the esketamine (E) group (n = 62) and control (C) group (n = 60) according to the random number table method. According to the surgical field, the 2 groups underwent unilateral/bilateral quadratus lumborum block in the supine position under ultrasound guidance. In addition, both groups received a target controlled infusion of propofol 3 to 3.5 μg/mL and intravenous rocuronium 0.8 mg/kg. Group E was given opioid-free anesthesia, group C was given opioid-based anesthesia. A 3 to 5 laryngeal mask was inserted according to body weight, and rocuronium 0.5 mg/kg was added intermittently. The levels of interleukin-6 (IL-6), interleukin-8 (IL-8), C-reactive protein (CRP), procalcitonin, tumor necrosis factor-α (TNF-α), numeric rating scales, dosage of propofol, dexmedetomidine and rocuronium, as well as the numeric rating scales score and analgesic complications were monitored in the 2 groups.

RESULTS

There was no significant differences in general outcomes between the 2 groups (P > .05). The blood pressure in group E was higher than in group C at T1 (P < .05). The levels of IL-6, TNF-α, CRP and IL-8 in group E were significantly lower than in group C at T1, T2, T3, and T4 (P < .05). The levels of IL-6, TNF-α, procalcitonin, CRP and IL-8 in the 2 groups at T1, T2, T3, and T4 were significantly higher than at T0 (P < .05).

CONCLUSION

Opioid-free esketamine anesthesia based on quadratus lumborum block achieved perfect postoperative analgesia with little effect on inflammatory factors in patients undergoing lower abdominal or pelvic surgery.