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Wang W, Zhou H, Sun A, Xiao J, Dong J, Xu H. Determination of the Median Effective Dose of Dexmedetomidine for the Prevention of Emergence Agitation in Geriatric Patients Undergoing Major Open Surgery With General Anesthesia: A Prospective, Double-Blinded, Dose-Response Trial. Dose Response 2021; 19:15593258211037153. [PMID: 34471401 PMCID: PMC8404654 DOI: 10.1177/15593258211037153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/04/2021] [Accepted: 07/09/2021] [Indexed: 12/03/2022] Open
Abstract
Dexmedetomidine can effectively decrease the incidences of emergence agitation (EA) in adult patients, but there are major side effects related to increased dose of dexmedetomidine. The purpose of this study was to determine the median effective dose of dexmedetomidine in the prevention of EA among geriatric patients undergoing major open surgery with general anesthesia. A total of 50 geriatric patients were enrolled in this study. Dexmedetomidine 0.5 μg·kg−1·h−1 continuous intravenous infusion was administered to the first patient. The next dose was increased or decreased by .05 depending on the response of the previous patient, according to the Dixon up-and-down method. An “effective” or “ineffective” response was determined based on the Riker sedation-agitation score (RSAS), we defined “effective” as RSAS<5, and “ineffective” as RSAS≥5. The ED50 of dexmedetomidine in prevention of EA was .30 μg·kg−1·h−1 (95% CI, .27–.33) and the predicted ED95 was .42 μg·kg−1·h−1 (95% CI, .38–.51). The incidence of bradycardia was significantly increased in the group without EA compared to the group with EA (57.1% vs 13.6%, P = .002). The ED50 of dexmedetomidine in prevention of EA was .30 μg·kg−1·h−1 (95% CI, .27–.33) and the predicted ED95 was .42 μg·kg−1·h−1 (95% CI, .38–.51). Bradycardia was the main complication.
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Affiliation(s)
- WeiBing Wang
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - Hui Zhou
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - AiJiao Sun
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - JinBo Xiao
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - JingChong Dong
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - Huang Xu
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
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Emergence agitation after intraoperative neurolytic celiac plexus block with alcohol: a case report. BMC Anesthesiol 2021; 21:204. [PMID: 34399699 PMCID: PMC8365901 DOI: 10.1186/s12871-021-01426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/06/2021] [Indexed: 11/25/2022] Open
Abstract
Background Emergence agitation after general anesthesia may cause several undesirable events in the clinic during patient anesthesia recovery, and acute alcohol intoxication, while rare in surgery, is one of the risk factors. Case presentation A 66-year-old male patient was found to have pancreatic tail neoplasm upon computed tomography (CT) examination. The surgeon planned to resect the pancreatic tail under general anesthesia. However, the surgeon found extensive tumor metastasis in the abdominal cavity, and thus performed a neurolytic celiac plexus block (NCPB) with 40 ml 95% ethyl alcohol and finished the surgery in approximately 1 h. Twenty minutes later, the patient was extubated and developed significant emergence agitation in the postoperative care unit, characterized by restlessness, uncontrollable movements, confusion and disorientation. The patient was flushed and febrile with an alcohol smell in his breath and was unable to follow commands. Patient symptoms were suspected to be due to acute alcohol intoxication. Thus, the patient was given 40 mg of propofol intravenously. Following treatment, the patient recovered with less confusion and disorientation after approximately 10 min. After treatment with propofol twice more, he regained consciousness, was calm and cooperative, had no pain, and could obey instructions approximately 1 h and 40 min following the last treatment. Following this treatment, the patient was transferred to the inpatient ward and felt well. Conclusions It is paramount to correctly identify the underlying cause of emergence agitation in order to successfully manage patient symptoms, since treatment plans vary between different etiological causes. Emergence agitation may be due to acute alcohol intoxication after intraoperative use of alcohol.
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Xing J, Wu R, Liang L, Fang H, Chen L, Luo C. Comparison of the Analgesic Effects of Intravenous Infusion of Dexmedetomidine Versus Bilateral Superficial Cervical Plexus Block After Thyroidectomy: A Randomized Controlled Trial. Clin J Pain 2021; 37:623-628. [PMID: 34155159 DOI: 10.1097/ajp.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/04/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Dexmedetomidine (DEX) is widely used in clinical practice because of its safety and effectiveness. Superficial cervical plexus block (SCPB) can reduce pain in thyroid surgery. The objective of this study was to investigated whether intravenous DEX has an equivalent analgesic effect and patients' satisfaction to SCPB for thyroid surgery. MATERIALS AND METHODS Ninety patients who had been scheduled for thyroidectomy under general anesthesia with endotracheal intubation were randomly divided into 3 groups. Group D: DEX was administered intravenously at an initial dose of 1 µg/kg over 10 minutes; then induction and endotracheal intubation performed, and then a continuous intravenous infusion of DEX was administered at a rate of 0.4 μg/kg/h until 30 minutes before the end of surgery. Group B: ultrasound-guided bilateral SCPB was performed, with 10 mL of 0.375% ropivacaine injected on each side. Group C: intravenous saline was administered at the same rate and dose as in group D. Patients' perioperative status, visual analog scale scores, complications and patients' satisfaction were recorded. RESULTS The pain at rest at 1 hour after extubation and the movement-evoked pain within 24 hours after extubation were significantly lower in groups D and B than in group C. Patients' satisfaction was significantly higher in groups D and B than in group C. There was no difference in pain at rest, movement-evoked pain and patients' satisfaction between group D and B. CONCLUSIONS Perioperative intravenous infusion of DEX can effectively reduce wound pain after thyroidectomy, and the analgesic effect is equivalent to that of bilateral SCPB.
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Affiliation(s)
- Jibin Xing
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Ranliang Wu
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Ling Liang
- Department of Anesthesiology, The People's Hospital of Gaoming, Foshan, China
| | - Hongyi Fang
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Liubing Chen
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Chenfang Luo
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
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Braga A, Abelha F. Inadequate emergence after anesthesia for elective cancer surgery: a single-center cohort study. Braz J Anesthesiol 2021; 72:500-505. [PMID: 34229029 PMCID: PMC9373546 DOI: 10.1016/j.bjane.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 06/02/2021] [Accepted: 06/20/2021] [Indexed: 11/15/2022] Open
Abstract
Background Inadequate emergence after anesthesia (IEA) is a common phenomenon in adult patients undergoing anesthesia. The aim of this study was to evaluate the incidence and determinants of IEA for elective cancer surgery, and to study its influence on the quality of recovery. Methods In this observational, prospective study, 148 patients scheduled for elective cancer surgery were included. IEA was considered for patients having emergence delirium or hypoactive emergence applying The Richmond Agitation and Sedation Scale (RASS) 10 minutes after admission at PACU. Postoperative Quality of Recovery Scale (PQRS) was used at baseline and after surgery at minutes 15 (T15) and 40 (T40), and days 1 (D1) and 3 (D3). Results Of the 148 patients, 48 (32%) had IEA. Complete recovery at PQRS was less frequent in patients with IEA on physiological domain at T15 and D1, and activities of daily living domain at D3. Patients with IEA recovered more frequently in emotive domain at T15, T40, and D3. Determinants of IEA were age, risk of surgery, congestive heart disease, cerebrovascular disease, ASA physical status, RCRI score, and duration of anesthesia. IEA patients had more frequently postoperative delirium and stayed for longer at PACU and at the hospital. Conclusion IEA was a common phenomenon after anesthesia for elective curative surgery for cancer. Patients with IEA were older and had more comorbidities and a higher surgical risk. Patients with IEA had a less frequent complete recovery on the PD and in AD domains, and a more frequent complete recovery on the ED.
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Affiliation(s)
- André Braga
- Centro Hospitalar de São João, Departamento de Anestesiologia, Porto, Portugal.
| | - Fernando Abelha
- Centro Hospitalar de São João, Departamento de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Departamento Cirúrgico, Unidade de Anestesiologia e Cuidados Perioperatórios, Porto, Portugal
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Wei B, Feng Y, Chen W, Ren D, Xiao D, Chen B. Risk factors for emergence agitation in adults after general anesthesia: A systematic review and meta-analysis. Acta Anaesthesiol Scand 2021; 65:719-729. [PMID: 33370461 DOI: 10.1111/aas.13774] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 12/12/2020] [Accepted: 12/15/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Emergence agitation (EA) is an adverse post-operative complication that increases the risk for injury, self-extubation, hemorrhages, and prolonged hospitalization. This meta-analysis aims to define the risk factors for adult EA after general anesthesia and provide recommendations for clinical practice. METHODS Embase, PubMed, Medline, and the Cochrane Library databases were comprehensive retrieved. Observational studies that reported the risk factors for adult EA were enrolled. Review Manager 5.4 was used to analyze the extracted data. RESULTS Eighteen observational studies involving 16, 678 adult patients were enrolled in this study. Eighteen pre-operative and nineteen intraoperative factors with unadjusted data, and five pre-operative and five intraoperative factors with adjusted data were meta-analyzed separately. Among them, seven factors (age, male, smoking, history of substance misuse, inhalational anesthesia, urinary catheter, complain of pain, or need analgesic drug use in post-anesthetic care unit) were the risk factors no matter meta-analyzed by unadjusted data or adjusted data. Intraoperative use of benzodiazepines was the risk factor when meta-analyzed by adjusted data, but not unadjusted data. Moreover, age and inhalational anesthesia were not the risk factors when omitted one study for sensitivity analysis, and history of substance misuse could not do sensitivity analysis. CONCLUSION Based on this meta-analysis, male, smoking, urinary catheter, and post-operative pain are the risk factors, while age, inhalational anesthesia, history of substance misuse, and intraoperative use of benzodiazepines are the possible risk factors for adult EA. EDITORIAL COMMENT This systematic review and meta-analysis identify risk factors associated with the occurrence of agitation during emergence from general anesthesia. As might be expected, the strongest factors are generally things which are irritating or painful for patients, but cannot necessarily be avoided.
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Affiliation(s)
- Bing Wei
- Department of Anesthesia The People's Hospital of Kaizhou District Chongqing China
| | - Yan Feng
- Department of Anesthesia The People's Hospital of Kaizhou District Chongqing China
| | - Wenjuan Chen
- Department of Anesthesia The People's Hospital of Kaizhou District Chongqing China
| | - Dapeng Ren
- Department of Anesthesia The People's Hospital of Kaizhou District Chongqing China
| | - Daishun Xiao
- Department of Anesthesia The People's Hospital of Kaizhou District Chongqing China
| | - Bing Chen
- Department of Anesthesia The Second Affiliated Hospital of Chongqing Medical University Chongqing China
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Gutman DA, Hassid M, Jeanes Z, Redding AT, Romeo D. Prophylactic Physostigmine for Extreme and Refractory Adult Emergence Delirium, Aimed at Increasing Patient Safety and Reducing Health Care Workplace Violence: A Case Report. A A Pract 2021; 14:e01205. [PMID: 32784327 DOI: 10.1213/xaa.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Emergence delirium is a well-known phenomenon that may be encountered after general anesthesia. A common approach to this issue is to risk stratify patients preoperatively and treat them postoperatively if emergence delirium occurs. We present the case of a patient with Barrett esophagus and a history of severe and refractory emergence delirium, who was successfully treated prophylactically with physostigmine, resulting in decreased risk of harm to the patient, trauma to the perioperative staff, and a safer and more positive recovery.
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Affiliation(s)
- David A Gutman
- From the Department of Anesthesia, Medical University of South Carolina, Charleston, South Carolina
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Mansouri MT, García PS. Repetitive Anodal Transcranial Direct Current Stimulation Hastens Isoflurane-Induced Emergence and Recovery and Enhances Memory in Healthy Rats. Anesth Analg 2021; 132:1347-1358. [PMID: 33591114 DOI: 10.1213/ane.0000000000005379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Attaining a rapid and smooth return to consciousness after general anesthesia is a goal for clinical anesthesiologists. This study aimed to investigate the effects of repeated anodal transcranial direct current stimulation (atDCS) on emergence and recovery from isoflurane anesthesia in rats. METHODS Four days after surgery for atDCS socket implantation, rats received either sham stimulation or repetitive anodal direct electrical current of 0.2 mA intensity applied to the right motor cortex for 20 minutes/d for 10 consecutive days. Isoflurane potency and emergence and recovery from a 2-hour isoflurane challenge were evaluated 24 hours after the last atDCS session. Cognitive performance on novel object recognition and spontaneous alternation Y-maze tests were measured 48 hours after the last atDCS session. Locomotor activity was assessed via automated counting of electric infrared beam crossings. RESULTS Data are expressed as mean ± standard error of mean (SEM). Isoflurane potency was not affected by atDCS (sham: 1.69% ± 0.06%, transcranial direct current stimulation [tDCS]: 1.73% ± 0.11%, mean difference [MD]: 0.045, 95% confidence interval [CI]: -0.22 to 0.30; P = .72). However, the time to appearance of emergence behavioral marker (eg, return of righting reflex) was hastened in rats receiving atDCS (sham: 486 ± 31 seconds, tDCS: 330 ± 45 seconds, MD: 157, 95% CI: 30-284; P = .008). Similarly, time to acknowledgment of adhesive tape ("sticky dot" applied while anesthetized) was also decreased in atDCS-treated rats as compared to sham (sham: 1374 ± 179 seconds, tDCS: 908 ± 151 seconds, MD: 466, 95% CI: 73-858; P = .015), indicating a faster recovery of isoflurane anesthesia. Rats treated with atDCS spent more time exploring the novel object and environment when compared to sham without affecting activity cycles, indicating visual and working memory can be enhanced by atDCS. CONCLUSIONS Taken together, our findings suggest that atDCS over cortical areas might hasten recovery from isoflurane anesthesia and could potentially be used as a preventative strategy for disruptions in higher order functions related to sedation/anesthesia.
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Affiliation(s)
- Mohammad Taghi Mansouri
- From the Neuroanesthesia Laboratory, Atlanta VA Medical Center, Emory University, Atlanta, Georgia
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
| | - Paul S García
- From the Neuroanesthesia Laboratory, Atlanta VA Medical Center, Emory University, Atlanta, Georgia
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
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58
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Tolly B, Waly A, Peterson G, Erbes CR, Prielipp RC, Apostolidou I. Adult Emergence Agitation: A Veteran-Focused Narrative Review. Anesth Analg 2021; 132:353-364. [PMID: 33177329 DOI: 10.1213/ane.0000000000005211] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Emergence agitation (EA) is a self-limited state of psychomotor excitement during awakening from general anesthesia. EA is confined to the emergence period as consciousness is restored, which sharply distinguishes it from other postoperative delirium states. Sporadic episodes of EA may become violent with the potential for harm to both patients and caregivers, but the long-term consequences of such events are not fully understood. Current literature on EA in adults is limited to small-scale studies with inconsistent nomenclature, variable time periods that define emergence, a host of different surgical populations, and conflicting diagnostic criteria. Therefore, true incidence rates and risk factors are unknown. In adult noncardiac surgery, the incidence of EA is approximately 19%. Limited data suggest that young adults undergoing otolaryngology operations with volatile anesthetic maintenance may be at the highest risk for EA. Currently suggested EA mechanisms are theoretical but might reflect underblunted sympathetic activation in response to various internal (eg, flashbacks or anxiety) or external (eg, surgical pain) stimuli as consciousness returns. Supplemental dexmedetomidine and ketamine may be utilized for EA prevention. Compared to the civilian population, military veterans may be more vulnerable to EA due to high rates of posttraumatic stress disorder (PTSD) manifesting as violent flashbacks; however, confirmatory data are limited. Nonetheless, expert military medical providers suggest that use of patient-centered rapport tactics, PTSD trigger identification and avoidance, and grounding measures may alleviate hyperactive emergence phenomena. Future research is needed to better characterize EA in veterans and validate prophylactic measures to optimize care for these patients. This narrative review provides readers with an important framework to distinguish EA from delirium. Furthermore, we summarize current knowledge of EA risk factors, mechanisms, and adult management strategies and specifically revisit them in the context of veteran perioperative health. The anesthesiology care team is ideally positioned to further explore EA and develop effective prevention and treatment protocols.
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Affiliation(s)
- Brian Tolly
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Amr Waly
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Garrett Peterson
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Christopher R Erbes
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Richard C Prielipp
- Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Ioanna Apostolidou
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota
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Wu J, Gao S, Zhang S, Yu Y, Liu S, Zhang Z, Mei W. Perioperative risk factors for recovery room delirium after elective non-cardiovascular surgery under general anaesthesia. Perioper Med (Lond) 2021; 10:3. [PMID: 33531068 PMCID: PMC7856719 DOI: 10.1186/s13741-020-00174-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/28/2020] [Indexed: 12/31/2022] Open
Abstract
Background Although postoperative delirium is a frequent complication of surgery, little is known about risk factors for delirium occurring in the post-anaesthesia care unit (PACU). The aim of this study was to determine pre- and intraoperative risk factors for the development of recovery room delirium (RRD) in patients undergoing elective non-cardiovascular surgery. Methods RRD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected perioperative data in 228 patients undergoing elective non-cardiovascular surgery under general anaesthesia and performed univariate and multivariate logistic regression to identify risk factors related to RRD. PACU and postoperative events were recorded to assess the outcome of RRD. Results Fifty-seven patients (25%) developed RRD. On multivariate analysis, maintenance of anaesthesia with inhalation anaesthetic agents (OR = 6.294, 95% CI 1.4–28.8, corrected p = 0.03), malignant primary disease (OR = 3.464, 95% CI = 1.396–8.592, corrected p = 0.018), American Society of Anaesthesiologists Physical Status (ASA-PS) III–V (OR = 3.389, 95% CI = 1.401–8.201, corrected p = 0.018), elevated serum total or direct bilirubin (OR = 2.535, 95% CI = 1.006–6.388, corrected p = 0.049), and invasive surgery (OR = 2.431, 95% CI = 1.103–5.357, corrected p = 0.035) were identified as independent risk factors for RRD. RRD was associated with higher healthcare costs (31,428 yuan [17,872–43,674] versus 16,555 yuan [12,618–27,788], corrected p = 0.002), a longer median hospital stay (17 days [12–23.5] versus 11 days [9–17], corrected p = 0.002), and a longer postoperative stay (11 days [7–15] versus 7 days [5–10], corrected p = 0.002]). Conclusions Identifying patients at high odds for RRD preoperatively would enable the formation of more timely postoperative delirium management programmes.
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Affiliation(s)
- Jiayi Wu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shaojie Gao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shuang Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Yao Yu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Shangkun Liu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Zhiguo Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, 430030, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China.
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Berna P, Quesnel C, Assouad J, Bagan P, Etienne H, Fourdrain A, Le Guen M, Leone M, Lorne E, Nguyen YNL, Pages PB, Roz H, Garnier M. Guidelines on enhanced recovery after pulmonary lobectomy. Anaesth Crit Care Pain Med 2021; 40:100791. [PMID: 33451912 DOI: 10.1016/j.accpm.2020.100791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.
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Affiliation(s)
- Pascal Berna
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Christophe Quesnel
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France
| | - Jalal Assouad
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Patrick Bagan
- Department of Thoracic and Vascular Surgery, Victor Dupouy Hospital, 95100 Argenteuil, France
| | - Harry Etienne
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Morgan Le Guen
- D,partement d'Anesth,sie, H"pital Foch, Universit, Versailles Saint Quentin, 92150 Suresnes, France; INRA UMR 892 VIM, 78350 Jouy-en-Josas, France
| | - Marc Leone
- Aix Marseille Universit, - Assistance Publique H"pitaux de Marseille - Service d'Anesth,sie et de R,animation - H"pital Nord - 13005 Marseille, France
| | - Emmanuel Lorne
- Departement d'Anesth,sie-R,animation, Clinique du Mill,naire, 34000 Montpellier, France
| | - Y N-Lan Nguyen
- Anaesthesiology and Critical Care Department, APHP Centre, Paris University, 75000 Paris, France
| | - Pierre-Benoit Pages
- Department of Thoracic Surgery, Dijon Burgundy University Hospital, 21000 Dijon, France; INSERM UMR 1231, Dijon Burgundy University Hospital, University of Burgundy, 21000 Dijon, France
| | - Hadrien Roz
- Unit, d'Anesth,sie R,animation Thoracique, H"pital Haut Leveque, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marc Garnier
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France.
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Choi JJ, Kim K, Park HY, Chang YJ, Lee KC, Kim KY, Kwak HJ. CONSORT the effect of a bolus dose of dexmedetomidine on postoperative pain, agitation, and quality of recovery after laparoscopic cholecystectomy. Medicine (Baltimore) 2021; 100:e24353. [PMID: 33546069 PMCID: PMC7837825 DOI: 10.1097/md.0000000000024353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/22/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The perioperative administration of dexmedetomidine may improve the quality of recovery (QoR) after major abdominal and spinal surgeries. We evaluated the effect of an intraoperative bolus of dexmedetomidine on postoperative pain, emergence agitation, and the QoR after laparoscopic cholecystectomy. METHODS Patients undergoing elective laparoscopic cholecystectomy were randomized to receive dexmedetomidine 0.5 μg/kg 5 minutes after anesthesia induction (dexmedetomidine group, n = 45) or normal saline (control group, n = 45). The primary outcome was the QoR at the first postoperative day using a 40-item scoring system (QoR-40). Secondary outcomes included intraoperative hemodynamic parameters, postoperative agitation, pain, and nausea and vomiting. RESULTS The heart rate and the mean blood pressure were significantly lower in the dexmedetomidine group than in the control group (P < .001 and .007, respectively). During extubation, emergence agitation was significantly lower in the dexmedetomidine group than in the control group (23% vs 64%, P < .001). The median pain scores in the post-anesthetic care unit were significantly lower in the dexmedetomidine group than in the control group (4 [2-7] vs 5 [4-7], P = .034). The incidence of postoperative agitation, pain, and nausea and vomiting was not different between the groups. On the first postoperative day, recovery profile was similar between the groups. However, the scores on the emotional state and physical comfort dimensions were significantly higher in the dexmedetomidine group than in the control group (P = .038 and .040, respectively). CONCLUSIONS A bolus dose of dexmedetomidine after anesthesia induction may improve intraoperative hemodynamics, emergence agitation, and immediate postoperative analgesia. However, it does not affect overall QoR-40 score after laparoscopic cholecystectomy.
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Affiliation(s)
- Jung Ju Choi
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon
| | - Kyungmi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hee Yeon Park
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon
| | - Young Jin Chang
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon
| | - Kyung Cheon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon
| | - Kwan Yeong Kim
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon
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Fischer ND, Epple S, Wittenmeier E, Betz U, Haferkamp A, Jäger W. [Implementation of Enhanced Recovery after Surgery (ERAS®) protocol in radical cystectomy at the University Medical Center Mainz]. Urologe A 2021; 60:169-177. [PMID: 33432371 DOI: 10.1007/s00120-020-01430-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In surgical fields there has been a perceivable paradigm shift during the last decade concerning patient pre- and rehabilitation. Current literature suggests close interdisciplinary collaboration after complex procedures such as radical cystectomy in order to optimize perioperative patient care for the benefit of "fast-track" surgery. OBJECTIVES To compose a catalogue of standardized measures after radical cystectomy based on guidelines set by the ERAS®-Society. RESULTS The protocol commences with preoperative education in order to improve the physical and psychological condition of the patient. Crucial aspects in peri- and postoperative patient care are gentle surgical technique, adequate pain management, early mobilization and oral food intake, early removal of drains and foreign material and a seamless return to normal, daily life. CONCLUSIONS Prospective data analysis will be the next step in order to establish the effectiveness of the protocol especially regarding postoperative complications and median duration of hospital stay.
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Affiliation(s)
- N D Fischer
- Klinik und Poliklinik für Urologie und Kinderurologie der Universitätsmedizin, Johannes-Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
| | - S Epple
- Klinik und Poliklinik für Urologie und Kinderurologie der Universitätsmedizin, Johannes-Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - E Wittenmeier
- Klinik für Anästhesiologie und Intensivmedizin der Universitätsmedizin, Johannes-Gutenberg-Universität Mainz, Mainz, Deutschland
| | - U Betz
- Institut für Physikalische Therapie, Prävention und Rehabilitation der Universitätsmedizin, Johannes-Gutenberg-Universität Mainz, Mainz, Deutschland
| | - A Haferkamp
- Klinik und Poliklinik für Urologie und Kinderurologie der Universitätsmedizin, Johannes-Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - W Jäger
- Klinik und Poliklinik für Urologie und Kinderurologie der Universitätsmedizin, Johannes-Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
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Zierau M, Li D, Lapointe AP, Ip KI, McKinney AM, Thompson A, Puglia MP, Vlisides PE. Cortical Oscillations and Connectivity During Postoperative Recovery. J Neurosurg Anesthesiol 2021; 33:87-91. [PMID: 31436606 PMCID: PMC7031022 DOI: 10.1097/ana.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this study was to test whether postoperative electroencephalographic (EEG) biomarkers, parietal alpha power and frontal-parietal connectivity, were associated with measures of clinical recovery in adult surgical patients. METHODS This is a secondary analysis of a prospective cohort study that analyzed intraoperative connectivity patterns in adult surgical patients (N=53). Wireless, whole-scalp EEG data were collected in the postanesthesia care unit and assessed for relevance to clinical and neurocognitive recovery. Parietal alpha power and frontal-parietal connectivity (estimated by weighted phase lag index) were tested for associations with postanesthesia care unit discharge readiness and University of Michigan Sedation Scale scores upon postoperative admission. Bivariable correlation and regression models were constructed to test for unadjusted associations, then multivariable regression models were constructed to adjust for confounding. RESULTS Postoperative EEG patterns were characterized by a predominance of alpha parietal power and frontal-parietal connectivity. Neither relative parietal alpha power (% alpha, -0.25; 95% confidence interval [CI], -1.41 to 0.90; P=0.657) nor alpha frontal-parietal connectivity (weighted phase lag index, -82; 95% CI, -237 to 73; P=0.287) were associated with time until postanesthesia discharge criteria were met. Furthermore, neither alpha power (-0.03; 95% CI, -0.07 to 0.01; P=0.206) nor alpha frontal-parietal connectivity (-4.2; 95% CI, -11 to 2.6; P=0.226) were associated with sedation scores upon initial assessment. CONCLUSIONS In a pragmatic study investigating clinically relevant endpoints of postoperative recovery, we found no correlation with surrogate measures of brain neurodynamics. These data contribute to the overall impetus of developing anesthetic-invariant and generalizable markers of brain recovery.
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Affiliation(s)
| | - Duan Li
- Department of Anesthesiology
- Center for Consciousness Science
| | - Andrew P Lapointe
- Department of Radiology, University of Calgary Cummings School of Medicine, Calgary, AB, Canada
| | - Ka I Ip
- Department of Psychology, University of Michigan, Ann Arbor, MI
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Kim H, Park SS, Shim J. Differences in midazolam premedication effects on recovery after short-duration ambulatory anesthesia with propofol or sevoflurane for gynecologic surgery in young patients: A randomized controlled trial. Medicine (Baltimore) 2020; 99:e23194. [PMID: 33217829 PMCID: PMC7676561 DOI: 10.1097/md.0000000000023194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anxiolytic premedication requires careful consideration owing to potential side effects including delayed recovery after ambulatory anesthesia. We aimed to compare the effect of midazolam on recovery profiles postoperatively, depending on whether propofol or sevoflurane was the primary anesthetic. METHODS We enrolled 226 patients (age, 18-50 years) undergoing ambulatory gynecologic laparoscopic surgery. Patients were categorized into propofol without midazolam (P), propofol with midazolam (MP), sevoflurane without midazolam (S), and sevoflurane with midazolam (MS) groups. As premedication, placebo or 0.02 mg/kg intravenous midazolam was used. The primary outcome was the difference in the time from anesthetic discontinuation to eye opening in response to verbal command. Secondary outcomes included postoperative nausea and pain occurrence and time to reach the discharge score. RESULTS The time from anesthetic discontinuation to eye opening was longer in the MP group (n = 49) than in the P group (n = 50; P < .001) but was not significantly different between the MS (n = 50) and S groups (n = 49; P = .1). Midazolam premedication did not significantly affect postoperative nausea in the MP group compared with that in the P group (P = .3) but had a nausea prevention effect in the MS group compared with that in the S group (P < .001). The time to reach the discharge score was similar in all patients regardless of midazolam administration. CONCLUSION In the recovery from short-duration ambulatory gynecologic surgery in young patients, intravenous midazolam premedication showed positive effects on postoperative nausea without affecting the time from anesthetic discontinuation to eye opening with sevoflurane-based anesthesia but prolonged the time from anesthetic discontinuation to eye opening with propofol-based anesthesia. Because this difference between the propofol groups is not clinically significant, the results support midazolam premedication in young women. Further studies assessing larger populations are needed.
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Zhu L, Jiang R, Kong X, Wang X, Pei L, Deng Q, Li X. Effects of various catheter fix sites on catheter-associated lower urinary tract symptoms. Exp Ther Med 2020; 21:47. [PMID: 33273975 DOI: 10.3892/etm.2020.9478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/17/2020] [Indexed: 11/05/2022] Open
Abstract
The present study aimed to compare the effects of various catheter fix sites on catheter-associated lower urinary tract symptoms (CALUTS) in 450 patients who underwent surgical removal of upper urinary calculi 24 h earlier. All patients had 16 French Foley catheters inserted and the balloons were filled. In group A, the catheters were fixed on the top one-third of the thigh. In group B, the catheters were fixed on the abdominal wall. Patients in whom the catheters were neither fixed on the thigh nor abdominal wall were designated as controls. There were 150 patients in each group. CALUTS, such as frequency, urgency, burning during micturition, odynuria, bladder pain and other symptoms, including urethral discharge, a red and swollen external urethral orifice, catheter traction or blockage and catheter-associated discomfort were recorded. Patients in group A compared with the control group had a significantly lower incidence of frequency, urgency, odynuria, urethral discharge, catheter traction and catheter-associated discomfort (P<0.05). Patients in group B were observed to have a significantly lower incidence of urgency, urethral discharge, catheter traction and catheter-associated discomfort compared with the control group (P<0.05), but a higher incidence of odynuria, urethral pain, urethral discharge and a red and swollen external urethral orifice compared with group A (P<0.05). An additional catheter fixation site for bedridden patients was necessary and an additional fix site on the thigh was preferred to the abdominal wall, which may further reduce catheter-associated lower urinary tract symptoms.
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Affiliation(s)
- Likun Zhu
- Department of Urology Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Sichuan Clinical Medical Research Center for Nephropathy, Luzhou, Sichuan 646000, P.R. China
| | - Rui Jiang
- Department of Urology Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Sichuan Clinical Medical Research Center for Nephropathy, Luzhou, Sichuan 646000, P.R. China
| | - Xiangjun Kong
- Department of Urology Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Sichuan Clinical Medical Research Center for Nephropathy, Luzhou, Sichuan 646000, P.R. China
| | - Xinwei Wang
- Department of Urology Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Sichuan Clinical Medical Research Center for Nephropathy, Luzhou, Sichuan 646000, P.R. China
| | - Lijun Pei
- Department of Urology Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Sichuan Clinical Medical Research Center for Nephropathy, Luzhou, Sichuan 646000, P.R. China
| | - Qingfu Deng
- Department of Urology Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Sichuan Clinical Medical Research Center for Nephropathy, Luzhou, Sichuan 646000, P.R. China
| | - Xu Li
- Department of Urology Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China.,Sichuan Clinical Medical Research Center for Nephropathy, Luzhou, Sichuan 646000, P.R. China
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Ye C, Zhang Y, Luo S, Cao Y, Gao F, Wang E. Correlation of Serum BACE1 With Emergence Delirium in Postoperative Patients: A Preliminary Study. Front Aging Neurosci 2020; 12:555594. [PMID: 33192455 PMCID: PMC7655534 DOI: 10.3389/fnagi.2020.555594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/28/2020] [Indexed: 11/24/2022] Open
Abstract
Background: The mechanism underlying delirium, a common acute fluctuating mental state, may be related to the activation of a neuroinflammatory response. In this study, we attempted to investigate whether plasma inflammatory response markers, vascular and cerebrovascular injury-related markers, and neurodegeneration-associated markers were associated with emergence delirium (ED). Methods: Patients aged 50 years or above who underwent elective laparoscopic surgery under general anesthesia were included in this study. Delirium was assessed postoperatively with the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scale. Plasma samples were collected from ED patients and non-ED patients to test concentrations of inflammation markers, including interleukin 6 (IL-6), chitinase 3-like 1 (CHI3L1), S100 calcium-binding protein B (S100B), lipoprotein-associated phospholipase-A2 (Lp-PLA2), and macrophage migration inhibitory factor (MIF); vascular and cerebrovascular injury-related markers, including intercellular cell adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule (VCAM-1); and neurodegeneration-associated markers, including alpha-synuclein (α-Syn) and β-secretase 1 (BACE1). Binary logistic regression analysis was performed to analyze the relationship between biomarkers and ED, and receiver operating characteristic (ROC) curves were used to analyze the diagnostic value of biomarkers. Results: A total of 104 patients were included in this study, with an average age of 63.69 ± 7.21. IL-6 (OR = 2.73, 95% CI: 1.66–6.44, P = 0.022), S100B (OR = 4.74, 95% CI: 1.88–11.95, P = 0.001), and BACE1 (OR = 6.54, 95% CI: 2.57–16.65, P < 0.000) were independent biological indicators for the occurrence of ED.CHI3L1, Lp-PLA2, MIF, ICAM-1, VCAM-1, and α-Syn were unrelated to ED. Plasma BACE1 level had a possible diagnostic value for ED [area under curve (AUC) = 0.75, 95% CI: 0.66–0.85], whereas plasma IL-6 (AUC = 0.62, 95% CI: 0.51–0.73) and S100B (AUC = 0.65, 95% CI: 0.54–0.76) levels had little diagnostic value for distinguishing ED vs. non-ED. Conclusion: Higher levels of systemic inflammation marker IL-6, cerebral inflammation marker S100B, and neurodegeneration-associated marker BACE1 are related to ED. Plasma BACE1 may be a potential diagnostic biomarker for ED.
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Affiliation(s)
- Chunyan Ye
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha, China
| | - Yanrong Zhang
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha, China
| | - Sumei Luo
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha, China
| | - Yanan Cao
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha, China
| | - Feng Gao
- Institute on Aging and Brain Disorders, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - E Wang
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, China
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Comparison of Rhinoplasty Patients Informed With Standard Verbal Information in Preoperative Period and Rhinoplasty Patients Informed and Treated With Visual Information Through Catalog in Terms of the Development of Agitation, Edema and Ecchymose in the Postoperative Period. J Craniofac Surg 2020; 31:816-820. [PMID: 32049912 DOI: 10.1097/scs.0000000000006206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIM In this study, we aimed to compare the effects of standard verbal information in the preoperative period and the information by visual expression and physical applications in the development of agitation, edema and ecchymosis in the postoperative period. MATERIALS AND METHODS The study was carried out in 60 ASA I-II patients who were going to undergo open rhinoplasty by plastic surgery. In the Preoperative Anesthetic Assessment the patients were divided into two groups as the patients given standard verbal information (Group S; n = 30) and those informed with a catalog which contains visuals (Group V; n = 30) In the preoperative period, anxiety levels of the patients were evaluated. Standard anesthesia induction was performed in both groups after standard monitoring. Patients were monitored in the post-anesthesia care unit and ward. Patient's extubation quality, presence of postoperative agitation and periorbital edema and ecchymosis at the 6th, 12th, 18th, and 24th hours were evaluated. RESULTS No significant difference was found between the groups in terms of intraoperative and postoperative MAP, HR, extubation quality, presence of recovery agitation, postoperative pain, development edema and ecchymosis (P > 0.05). Significant positive correlation was found between post-extubation MAP and edema scores at the 16th and 24th hours postoperatively and between the post-anesthesia care unit entry MAP and ecchymosis at the 24th postoperative hours independently of the groups (r = 0.27; P = 0.038, r = 0.302; P = 0.019, r = 0.345; P = 0.007, respectively). RESULT In our study, it was concluded that detailed visual information and physical application in the preoperative period among rhinoplasty patients had no effect on the incidence of postoperative agitation, development of edema and ecchymosis.
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Kang X, Lin K, Tang H, Tang X, Bao F, Gan S, Zhu S. Risk Factors for Emergence Agitation in Adults Undergoing Thoracoscopic Lung Surgery: A Case-Control Study of 1,950 Patients. J Cardiothorac Vasc Anesth 2020; 34:2403-2409. [DOI: 10.1053/j.jvca.2020.02.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 12/31/2022]
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Ballesteros JJ, Briscoe JB, Ishizawa Y. Neural signatures of α2-Adrenergic agonist-induced unconsciousness and awakening by antagonist. eLife 2020; 9:57670. [PMID: 32857037 PMCID: PMC7455241 DOI: 10.7554/elife.57670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/09/2020] [Indexed: 12/29/2022] Open
Abstract
How the brain dynamics change during anesthetic-induced altered states of consciousness is not completely understood. The α2-adrenergic agonists are unique. They generate unconsciousness selectively through α2-adrenergic receptors and related circuits. We studied intracortical neuronal dynamics during transitions of loss of consciousness (LOC) with the α2-adrenergic agonist dexmedetomidine and return of consciousness (ROC) in a functionally interconnecting somatosensory and ventral premotor network in non-human primates. LOC, ROC and full task performance recovery were all associated with distinct neural changes. The early recovery demonstrated characteristic intermediate dynamics distinguished by sustained high spindle activities. Awakening by the α2-adrenergic antagonist completely eliminated this intermediate state and instantaneously restored awake dynamics and the top task performance while the anesthetic was still being infused. The results suggest that instantaneous functional recovery is possible following anesthetic-induced unconsciousness and the intermediate recovery state is not a necessary path for the brain recovery.
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Affiliation(s)
- Jesus Javier Ballesteros
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Jessica Blair Briscoe
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Yumiko Ishizawa
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
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Xu H, Li X, Yang B, Shen Z, Li W, Zhou Y, Jiang J, Chen X, Gu Y, Pei Z, Li J. Effects of preconditioning by nasal splint and mouth breathing on emergence delirium after functional endoscopic sinus surgery in Chinese adults: a study protocol for a randomised controlled trial. BMJ Open 2020; 10:e033803. [PMID: 32847900 PMCID: PMC7451479 DOI: 10.1136/bmjopen-2019-033803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Emergence delirium (ED) is a common adverse manifestation after general anaesthesia and may result in undesirable consequences. Its causes and mechanisms are diverse and complex, and it is still unavoidable in clinical work. There is a high incidence of ED after otorhinolaryngology surgery, which may result from the sudden loss of functional senses and discomfort of surgical organs. This study aims to test a non-invasive, non-drug treatment modality of nose clamping and mouth-breathing training before surgery to reduce ED. METHODS AND ANALYSIS This prospective randomised controlled trial (RCT) will include 200 patients who undergo functional endoscopic sinus surgery (FESS) at Shanghai General Hospital, China. Study participants will be randomly assigned in two groups with a 1:1 ratio. The pretreatment group (P-group) will receive an intervention by nasal splint and mouth-breathing training before surgery, while the control group (C-group) will not receive any intervention; following which both groups will undergo FESS under general anaesthesia in accordance with the same anaesthesia scheme. After surgery, we will perform a single-blinded assessment of ED occurrence with stratification. IBM SPSS Statistics V.20 statistical software will be used for statistical analyses. A X2 test will be used to compare the two groups, and t-tests will determine the statistical significance of continuous variables. ETHICS AND DISSEMINATION This RCT was designed in accordance with the principles of the Declaration of Helsinki and has been approved by the Ethics Committee of Shanghai General Hospital, ID: 2019KY039.We expect to release the original data in February 2022 on the ResMan original data sharing platform (IPD sharing platform) of the China clinical trial registry, which can be viewed at the following website:http://www.medresman.org.cn/pub/cn/proj/projectshow.aspx?proj=6293. TRIAL REGISTRATION NUMBER ChiCTR1900024925.
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Affiliation(s)
- Hongjiao Xu
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
| | - Xiang Li
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
| | - Bin Yang
- Department of Anaesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Zhenyuan Shen
- Medical department, Mellon community health service center, Shanghai, China
| | - Weiwen Li
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
| | - Yachun Zhou
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
| | - Jihong Jiang
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
| | - Xia Chen
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
| | - Yuyu Gu
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
| | - Zhi Pei
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
| | - Jinbao Li
- Department of Anaesthesiology, Shanghai Jiaotong University First People's Hospital, Shanghai, China
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Patel SR, Ballesteros JJ, Ahmed OJ, Huang P, Briscoe J, Eskandar EN, Ishizawa Y. Dynamics of recovery from anaesthesia-induced unconsciousness across primate neocortex. Brain 2020; 143:833-843. [PMID: 32049333 DOI: 10.1093/brain/awaa017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 10/07/2019] [Accepted: 12/08/2019] [Indexed: 12/11/2022] Open
Abstract
How the brain recovers from general anaesthesia is poorly understood. Neurocognitive problems during anaesthesia recovery are associated with an increase in morbidity and mortality in patients. We studied intracortical neuronal dynamics during transitions from propofol-induced unconsciousness into consciousness by directly recording local field potentials and single neuron activity in a functionally and anatomically interconnecting somatosensory (S1, S2) and ventral premotor (PMv) network in primates. Macaque monkeys were trained for a behavioural task designed to determine trial-by-trial alertness and neuronal response to tactile and auditory stimulation. We found that neuronal dynamics were dissociated between S1 and higher-order PMv prior to return of consciousness. The return of consciousness was distinguishable by a distinctive return of interregionally coherent beta oscillations and disruption of the slow-delta oscillations. Clustering analysis demonstrated that these state transitions between wakefulness and unconsciousness were rapid and unstable. In contrast, return of pre-anaesthetic task performance was observed with a gradual increase in the coherent beta oscillations. We also found that recovery end points significantly varied intra-individually across sessions, as compared to a rather consistent loss of consciousness time. Recovery of single neuron multisensory responses appeared to be associated with the time of full performance recovery rather than the length of recovery time. Similar to loss of consciousness, return of consciousness was identified with an abrupt shift of dynamics and the regions were dissociated temporarily during the transition. However, the actual dynamics change during return of consciousness is not simply an inverse of loss of consciousness, suggesting a unique process.
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Affiliation(s)
- Shaun R Patel
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Jesus J Ballesteros
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Omar J Ahmed
- Departments of Psychology, Neuroscience and Biomedical Engineering, University of Michigan, Ann Arbor MI, USA
| | - Pamela Huang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco CA, USA
| | - Jessica Briscoe
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Emad N Eskandar
- Departments of Neurological Surgery, Neuroscience, Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx NY, USA
| | - Yumiko Ishizawa
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
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Hampton CE, Riebold TW, Mandsager RE. Recovery characteristics of dogs following anesthesia induced with tiletamine-zolazepam, alfaxalone, ketamine-diazepam, or propofol and maintained with isoflurane. J Am Vet Med Assoc 2020; 254:1421-1426. [PMID: 31149881 DOI: 10.2460/javma.254.12.1421] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare characteristics of recovery from isoflurane anesthesia in healthy nonpremedicated dogs after anesthetic induction by IV administration of tiletamine-zolazepam with those observed after induction by IV administration of alfaxalone, ketamine-diazepam, or propofol. DESIGN Prospective, randomized crossover study. ANIMALS 6 healthy adult hounds. PROCEDURES Each dog underwent the 4 treatments in random order with a ≥ 7-day washout period between anesthetic episodes. Anesthesia was induced by IV administration of the assigned induction drug or combination (each to effect in 25% increments of calculated dose) and maintained with isoflurane in oxygen for 60 minutes. Cardiorespiratory variables and end-tidal isoflurane concentration (ETISO) were measured just before isoflurane administration was discontinued. Dogs were observed and video recorded during recovery. Recovery characteristics were retrospectively scored from recordings by 3 raters. Interrater and intrarater reliability of scoring was assessed by intraclass correlation coefficient calculation. Linear and mixed ANOVAs were used to compare extubation times, recovery scores, and body temperature among treatments. RESULTS Most cardiorespiratory variables, body temperature, ETISO, and time to extubation did not differ between tiletamine-zolazepam and other induction treatments. Recovery scores were lower (indicating better recovery characteristics) with propofol or alfaxalone than with tiletamine-zolazepam but did not differ between tiletamine-zolazepam and ketamine-diazepam treatments. Anesthetic episode number and ETISO had no effect on extubation time or recovery score. Intrarater and interrater correlations for recovery scores were excellent. CONCLUSIONS AND CLINICAL RELEVANCE Recovery of healthy dogs from anesthesia with isoflurane after induction with tiletamine-zolazepam was uncomplicated and had characteristics comparable to those observed following induction with ketamine-diazepam. However, recovery characteristics were improved when anesthesia was induced with propofol or alfaxalone.
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Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, McDonagh DL, Gan TJ, McEvoy MD, Miller TE. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesth Analg 2020; 130:1572-1590. [PMID: 32022748 DOI: 10.1213/ane.0000000000004641] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.
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Affiliation(s)
- Christopher G Hughes
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, and Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Huang J, Qi H, Lv K, Chen X, Zhuang Y, Yang L. Emergence Delirium in Elderly Patients as a Potential Predictor of Subsequent Postoperative Delirium: A Descriptive Correlational Study. J Perianesth Nurs 2020; 35:478-483. [PMID: 32576504 DOI: 10.1016/j.jopan.2019.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/30/2019] [Accepted: 11/25/2019] [Indexed: 10/24/2022]
Abstract
PURPOSE This study aimed to investigate the incidence of emergence delirium (ED) in elderly patients under general anesthesia and to determine the correlation between ED and delirium at five subsequent postoperative days. DESIGN This research is a descriptive correlational study. METHODS A total of 168 aged patients undergoing elective general anesthesia were recruited from a comprehensive tertiary teaching hospital with 2,400 beds in Southern China from April 2018 to September 2018. The Nursing Delirium Screening Scale was used to assess delirium at 30 and 60 minutes after extubation or on discharge from the postanesthesia care unit. Patients were assessed for delirium at postoperative days one through five using the same method. Patients' demographic information, including cognitive function, were collected. FINDINGS Among the 168 aged patients, 58 suffered from ED (34.5%), including the 79.3% for the 46 patients who experienced postoperative delirium (POD). A positive correlation existed between ED and POD (χ2 = 111.744; P < .01). Logistic regression analysis included seven variables: age, preoperative Mini-Mental State Examination score, underlying diseases, American Society of Anesthesiologists grade, surgery duration, postoperative complications, and the presence of ED. Age and ED were concluded to be independent predictive factors of POD. CONCLUSIONS ED in the first hour after tracheal tube removal is a predictor of delirium at five subsequent postoperative days. Accurate and timely assessment of recovery period can effectively guide the treatment and rehabilitation of POD and maximize prevention of adverse consequences.
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Affiliation(s)
- Jingying Huang
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Haiou Qi
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, PR China.
| | - Kai Lv
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Xiangping Chen
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Yiyu Zhuang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Lili Yang
- Nursing Education Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
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Zhang Y, He ST, Nie B, Li XY, Wang DX. Emergence delirium is associated with increased postoperative delirium in elderly: a prospective observational study. J Anesth 2020; 34:675-687. [PMID: 32507939 PMCID: PMC7511467 DOI: 10.1007/s00540-020-02805-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
Background The clinical significance of emergence delirium remains unclear. The purpose of this study was to investigate the association between emergence delirium and postoperative delirium in elderly after general anesthesia and surgery. Methods This prospective observational study was done in a tertiary hospital in Beijing, China. Elderly patients (65–90 years) who underwent major noncardiac surgery under general anesthesia and admitted to the postanesthesia care unit (PACU) after surgery were enrolled. Emergence delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit during PACU stay. Postoperative delirium was assessed with the Confusion Assessment Method during the first 5 postoperative days. The association between emergence delirium and postoperative delirium was analyzed with a multivariable logistic regression model. Results A total of 942 patients were enrolled and 915 completed the study. Emergence delirium developed in 37.0% (339/915) of patients during PACU stay; and postoperative delirium developed in 11.4% (104/915) of patients within the first 5 postoperative days. After adjusted confounding factors, the occurrence of emergence delirium is independently associated with an increased risk of postoperative delirium (OR 1.717, 95% CI 1.078–2.735, P = 0.023). Patients with emergence delirium stayed longer in PACU and hospital after surgery, and developed more non-delirium complications within 30 days. Conclusions Emergence delirium in elderly admitted to the PACU after general anesthesia and major surgery is independently associated with an increased risk of postoperative delirium. Patients with emergence delirium had worse perioperative outcomes. Chinese Clinical Trial Registry (chictr.org.cn) ChiCTR-OOC-17012734 Electronic supplementary material The online version of this article (10.1007/s00540-020-02805-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yan Zhang
- Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China
| | - Shu-Ting He
- Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China
| | - Bin Nie
- Departments of Anesthesiology, Fujian Provincial Cancer Hospital, Fuzhou, Fujian, China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China. .,Department of Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA.
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Mondal S, Sankova S, Lee K, Sorensen E, Kaczorowski D, Mazzeffi M. Intraoperative and Early Postoperative Management of Patients Undergoing Minimally Invasive Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2020; 35:616-630. [PMID: 32505605 DOI: 10.1053/j.jvca.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Susan Sankova
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Khang Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Erik Sorensen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - David Kaczorowski
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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Abstract
Background
Catheter-related bladder discomfort occurs because of involuntary contractions of the bladder smooth muscle after urinary catheterization. Magnesium is associated with smooth muscle relaxation. This study hypothesized that among patients having transurethral resection of bladder tumor, magnesium will reduce the incidence of postoperative moderate-to-severe catheter-related bladder discomfort.
Methods
In this double-blind, randomized study, patients were randomly allocated to the magnesium group (n = 60) or the control group (n = 60). In magnesium group, a 50 mg/kg loading dose of intravenous magnesium sulfate was administered for 15 min, followed by an intravenous infusion of 15 mg · kg−1 · h−1 during the intraoperative period. Patients in the control group similarly received normal saline. The primary outcome was the incidence of catheter-related bladder discomfort above a moderate grade at 0 h postoperatively. None, mild, moderate, and severe catheter-related bladder discomfort at 1, 2, and 6 h postoperatively, patient satisfaction, and magnesium-related adverse effects were also assessed.
Results
The incidence of catheter-related bladder discomfort above a moderate grade at 0 h postoperatively was significantly lower in the magnesium group than in the control group (13 [22%] vs. 46 [77%]; P < 0.001; relative risk = 0.283; 95% CI, 0.171 to 0.467; absolute risk reduction = 0.55; number needed to treat = 2); similar results were observed for catheter-related bladder discomfort above a moderate grade at 1 and 2 h postoperatively (5 [8%] vs. 17 [28%]; P = 0.005; relative risk = 0.294; 95% CI, 0.116 to 0.746; and 1 [2%] vs. 14 [23%]; P < 0.001; relative risk = 0.071; 95% CI, 0.010 to 0.526, respectively). Patient satisfaction on a scale from 1 to 7 was significantly higher in the magnesium group than in the control group (5.1 ± 0.8 vs. 3.5 ± 1.0; P < 0.001; 95% CI, 1.281 to 1.919). Magnesium-related adverse effects were not significantly different between groups.
Conclusions
Magnesium reduced the incidence of catheter-related bladder discomfort above a moderate grade and increased patient satisfaction among patients having transurethral resection of bladder tumor.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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Assefa S, Sahile WA. Assessment of Magnitude and Associated Factors of Emergence Delirium in the Post Anesthesia Care Unit at Tikur Anbesa Specialized Hospital, Ethiopia. Ethiop J Health Sci 2020; 29:597-604. [PMID: 31666781 PMCID: PMC6813265 DOI: 10.4314/ejhs.v29i5.10] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Emergence delirium (ED) is known as an acute agitation and confusion occurring during or immediately following emergence from general anesthesia, in the Operation Room or post anesthesia care unit (PACU). ED results in significant morbidity and complications resulting in longer hospital stays. We studied the magnitude and risk factors of ED in the general surgical population. Methods An institution-based prospective cross-sectional study was conducted on patients who underwent surgical procedure at Tikur Anbessa Specialized Hospital, Ethiopia, from March 6 – May 1, 2017. Data was collected using patient interview and chart review. Patients with Richmond Agitation Sedation Scale ≥+1 at any time were considered to have emergence delirium/agitation. Categorical data was analyzed using the fishers exact test. Continuous data was analyzed using student t-test. Independent variables were analyzed using binary logistic regression. P-value of <0.05 was considered as cutoff point to test for statistically significance. Result The overall magnitude of Emergence Delirium in this study was 31.7%. Older age (CI=4.266 – 12.095, P=0.001), substance abuse (OR =4.6, CI=1.962 – 10.863, P=0.001), preoperative anxiety (OR= 2.4, CI=1.140 – 5.244, P=0.02), benzodiazepine premedication (OR= 8, CI=2.788 – 23.21, P=0.001), excessive blood loss (OR=3.38, CI=1.789 – 6.412, P=0.001), postoperative pain (OR=3.37, CI=2.015 – 6.934, P=0.001) and longer PACU stay (CI=18.645 – 26.766, P=0.001) were positively associated with Emergence Delirium. Conclusion The magnitude of emergence delirium is high and it is associated with older age, substance abuse, premedication with benzodiazepine, excessive blood loss postoperative pain and longer PACU stay.
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Affiliation(s)
- Solomon Assefa
- Addis Ababa University, School of Medicine, Department of Anesthesia, Addis Ababa, Ethiopia
| | - Wosenyeleh A Sahile
- Addis Ababa University, School of Medicine, Department of Anesthesia, Addis Ababa, Ethiopia
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Lee SJ, Sung TY. Emergence agitation: current knowledge and unresolved questions. Korean J Anesthesiol 2020; 73:471-485. [PMID: 32209961 PMCID: PMC7714637 DOI: 10.4097/kja.20097] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
Emergence agitation (EA), also referred to as emergence delirium, can have clinically significant consequences. The mechanism of EA remains unclear. The proposed risk factors of EA include age, male sex, type of surgery, emergency operation, use of inhalational anesthetics with low blood-gas partition coefficients, long duration of surgery, anticholinergics, premedication with benzodiazepines, voiding urgency, postoperative pain, and the presence of invasive devices. If preoperative or intraoperative objective monitoring could predict the occurrence of agitation during emergence, this would help to reduce its adverse consequences. Several tools are available for assessing EA. However, there are no standardized clinical research practice guidelines and its incidence varies considerably with the assessment tool or definition used. Total intravenous anesthesia, propofol, μ-opioid agonists, N-methyl-D-aspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia, parent-present induction, and preoperative education for surgery may help in preventing of EA. However, it is difficult to identify patients at high risk and apply preventive measures in various clinical situations. The risk factors and outcomes of preventive strategies vary with the methodologies of studies and patients assessed.This review discusses important outcomes of research on EA and directions for future research.
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Affiliation(s)
- Seok-Jin Lee
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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Jo JY, Jung KW, Kim HJ, Park SU, Park H, Ku S, Choi SS. Effect of Total Intravenous Anesthesia vs Volatile Induction With Maintenance Anesthesia on Emergence Agitation After Nasal Surgery: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2020; 145:117-123. [PMID: 30489620 DOI: 10.1001/jamaoto.2018.3097] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Emergence agitation is common after nasal surgery under general anesthesia and may lead to serious consequences for the patient, including an increased risk of injury, pain, hemorrhage, and self-extubation. Despite decades of research, studies on the incidence, risk factors, and prevention of emergence agitation in adult patients are ongoing, and opinions differ on the different effects of inhalation and intravenous anesthesia. Objective To investigate the effect of anesthetic method on the occurrence of emergence agitation after nasal surgery. Design, Setting, and Participants This prospective, randomized, single-blind, clinical trial included 80 patients undergoing open rhinoplasty, septoplasty, turbinoplasty, endoscopic sinus surgery, and functional endoscopic sinus surgery under general anesthesia who were randomized to receive total intravenous anesthesia (TIVA) with remifentanil hydrochloride and propofol (n = 40) or volatile induction and maintenance of anesthesia (VIMA) with sevoflurane and nitrous oxide (n = 40) in Asan Medical Center, a tertiary referral center in Seoul, Republic of Korea. Data were collected from August 24 through October 14, 2016, and analyzed from October 26, 2016, through September 14, 2017. Main Outcomes and Measures The occurrence of emergence agitation defined by the following 2 individual criteria: a Richmond Agitation-Sedation Scale score of at least 1 and a Riker Sedation-Agitation Scale score of at least 5 immediately after extubation. Results Among the 80 patients included in the analysis (68.8% men [n = 55]; mean [SD] age, 41.6 [17.9] years), emergence agitation measured by the Richmond Agitation Sedation Scale occurred in 8 of 40 patients (20.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 17.5 (95% CI, 3.6-31.4). Emergence agitation measured by the Riker Sedation-Agitation Scale score occurred in 10 of 40 patients (25.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 22.5 (95% CI, 7.3-37.7). Conclusions and Relevance The occurrence of emergence agitation after nasal surgery under general anesthesia can be significantly reduced by using TIVA rather than VIMA. Trial Registration CRIS identifier: KCT0002145.
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Affiliation(s)
- Jun-Young Jo
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyeo-Woon Jung
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Se-Ung Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hanwool Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungwoo Ku
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Muller MD, Capp AM, Hill J, Hoffer A, Otworth JR, McQuillan PM, Bonavia AS. Anesthetic Management of Elderly Patients With Down Syndrome: A Case Report. J Perianesth Nurs 2020; 35:243-249. [PMID: 31959506 DOI: 10.1016/j.jopan.2019.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/01/2019] [Accepted: 10/06/2019] [Indexed: 10/25/2022]
Abstract
In 1930, the life expectancy of patients with Down syndrome was about 10 years; today, their life expectancy is more than 60 years. With aging, there is an increased need for anesthesia and surgery. There is, however, no published information regarding the anesthetic management of older adults with Down syndrome. In this report, we described the anesthetic management of a 50-year-old woman with Down syndrome undergoing major cervical spine surgery. Components of the anesthetic that we thought would be difficult such as intravenous line placement and endotracheal intubation were accomplished without difficulty. Despite our best efforts, our patient nevertheless experienced both emergence delirium and postoperative vomiting. We advocate that physicians, advanced practice providers, and registered nurses be aware of the unique perianesthesia needs of older patients with Down syndrome.
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Affiliation(s)
- Matthew D Muller
- Master of Science in Anesthesia Program, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH.
| | - Angela M Capp
- Master of Science in Anesthesia Program, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - James Hill
- Master of Science in Anesthesia Program, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Alan Hoffer
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - Patrick M McQuillan
- Department of Anesthesiology and Perioperative Medicine, Penn State University College of Medicine, Hershey, PA
| | - Anthony S Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State University College of Medicine, Hershey, PA
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Elaziz RAEA, Shaban S, Elaziz SA. Effects of Lidocaine Infusion on Quality of Recovery and Agitation after Functional Endoscopic Sinus Surgery: Randomized Controlled Study. OPEN JOURNAL OF ANESTHESIOLOGY 2020; 10:435-448. [DOI: 10.4236/ojanes.2020.1012038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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A COMPARISON OF THE EFFECTS OF GENERAL ANESTHESIA VERSUS SPINAL ANESTHESIA ON CATHETER-RELATED BLADDER DISCOMFORT AFTER HoLEP: A PROSPECTIVE TRIAL. JOURNAL OF MEN'S HEALTH 2020. [DOI: 10.15586/jomh.v16isp1.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
General anesthesia has been unequivocally linked to abnormal development of the central nervous system, leading to neurocognitive impairments in laboratory models. In vitro and in vivo studies have consistently shown that exposure to GABA agonists (eg, volatile anesthetics, midazolam, and propofol) or NMDA antagonists (eg, ketamine, isoflurane, and nitrous oxide) produces dose dependent and developmental age dependent effects on various neuronal transmission systems. Exposure to these drugs increases neuronal cell death in juvenile animals including rats, mice, and non-human primates. The possibility of anesthetic induced neurotoxicity occurring in children has led to concerns about the safety of pediatric anesthesia. A spectrum of behavioral changes has been documented after general anesthetic exposure in young children, including emergence delirium, which may be evidence of toxicity. Most clinical studies are retrospective; specifics about medications or monitoring are unavailable and many of the outcomes may not be sensitive to detect small neurocognitive deficits. Some of these retrospective studies have shown an association between anesthesia exposure at a young age and neurocognitive deficits, but others have not. Practitioners and families should be reassured that although general anesthetics have the potential to induce neurotoxicity, very little clinical evidence exists to support this.
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Affiliation(s)
- Mary Ellen McCann
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sulpicio G Soriano
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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Makarem J, Larijani AH, Eslami B, Jafarzadeh A, Karvandian K, Mireskandari SM. Risk factors of inadequate emergence following general anesthesia with an emphasis on patients with substance dependence history. Korean J Anesthesiol 2019; 73:302-310. [PMID: 31612693 PMCID: PMC7403114 DOI: 10.4097/kja.19214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 10/13/2019] [Indexed: 12/13/2022] Open
Abstract
Background This study aims to define the incidence and risk factors of both emergence agitation and hypoactive emergence in adult patients and substance-dependent patients following general anesthesia to elaborate on the risk factors and precise management of them. Methods The study recruited 1,136 adult patients who received elective surgeries under general anesthesia for this prospective observational study. Inadequate emergence was determined according to the Richmond Agitation-Sedation Scale (RASS). Emergence agitation was defined as a RASS ≥ +1 point, and hypoactive emergence was defined as a RASS ≤ –2 points. Subgroup analyses were then conducted on patients with substance dependence. Results Inadequate emergence in the post-anesthesia care unit (PACU) occurred in 20.3% of patients, including 13.9% with emergence agitation and 6.4% with hypoactive emergence. Ninety-five patients had a history of substance dependence. Compared to divorced patients, never-married and presently married patients, who underwent gynecological and thoracic surgeries, had a lower risk of agitation. Neurologic disorders, intraoperative blood loss, intraoperative morphine, and PACU analgesic drug administration were associated with increased agitation risk. Hypertension and psychological disorders, intraoperative opioids, and PACU Foley catheter fixation were associated with increased hypoactive emergence risk. Substance-dependent patients had higher risk for agitation (21.1%, P = 0.019) and hypoactive emergence (10.5%, P = 0.044). Conclusions Inadequate emergence in PACU following general anesthesia is a significant problem correlated with several perioperative factors. Patients with a history of substance dependence appear to be more at risk of inadequate emergence than the general population.
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Affiliation(s)
- Jalil Makarem
- Department of Anesthesia and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Babak Eslami
- Department of Anesthesia and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Afshin Jafarzadeh
- Department of Anesthesia and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Kasra Karvandian
- Department of Anesthesia and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
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Wiinholdt D, Eriksen SAN, Harms LB, Dahl JB, Meyhoff CS. Inadequate emergence after non-cardiac surgery-A prospective observational study in 1000 patients. Acta Anaesthesiol Scand 2019; 63:1137-1142. [PMID: 31241184 DOI: 10.1111/aas.13420] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 05/07/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The post-anaesthetic phase is most often uncomplicated, but patients may experience inadequate emergence (IE) characterized by unrest, restlessness, aggressiveness or in contrast sedation or lack of initiative. This may increase length of stay (LOS) and post-operative complications. The aim of this study was to investigate frequency, risk factors and consequences of IE. METHODS We conducted an observational cohort study including 1000 orthopaedic and abdominal surgical patients, screened with the Nursing Delirium Screening Scale (Nu-DESC) before induction of anaesthesia, at arrival at the post-operative care unit, and just before discharge from PACU. IE was defined as a Nu-DESC score ≥2 after surgery. Predictors included surgical procedure, type and duration of anaesthesia, age, ASA-score, sex and post-operative pain. Data were analysed during adjusted logistic regression and Wilcoxon rank sum test, the primary outcome being LOS. RESULTS IE occurred in 103 of 1000 patients (10.3%, 95% CI 8.6-12.3%). LOS was median 2 vs 1 day in patients with and without IE, mean difference was 1.3 (SD 6.2) days (P = 0.036). Thirty-day mortality was 2.9 vs 1.0% (P = 0.92) and admission to ICU 1.0 vs 0.9% (P = 0.66) in patients with and without IE. Significant associations to IE were found for inhalational anaesthetics (OR 2.65; 95% CI: 1.57-4.46), duration of anaesthesia ≥2 hours (OR 1.98; 95% CI: 1.14-3.44) and ASA-score ≥3 (OR 2.74; 95% CI: 1.64-4.57). CONCLUSION One of 10 patients had IE as defined by the Nu-DESC score, which was significantly associated with increased LOS. Longer duration of anaesthesia, inhalational anaesthesia and ASA ≥3 were significantly associated to this.
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Affiliation(s)
- Dorthe Wiinholdt
- Research Unit of Clinical Nursing Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
| | - Sine A. N. Eriksen
- Department of Anaesthesia and Intensive Care Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
| | - Lisa B. Harms
- Department of Anaesthesia and Intensive Care Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
| | - Jøergen B. Dahl
- Department of Anaesthesia and Intensive Care Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
| | - Christian S. Meyhoff
- Department of Anaesthesia and Intensive Care Bispebjerg and Frederiksberg Hospital, University of Copenhagen Copenhagen Denmark
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Labaste F, Ferré F, Combelles H, Rey V, Foissac J, Senechal A, Conil J, Minville V. Validation of a visual analogue scale for the evaluation of the postoperative anxiety: A prospective observational study. Nurs Open 2019; 6:1323-1330. [PMID: 31660159 PMCID: PMC6805714 DOI: 10.1002/nop2.330] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 04/18/2019] [Accepted: 05/21/2019] [Indexed: 11/11/2022] Open
Abstract
AIM Anxiety affects the perception of pain during the postoperative period. A simple evaluation scale could improve the management of this component. The objective of this study was to evaluate the reproducibility and the consistency of a visual analogue scale for anxiety compared with the reference method, the State-Trait Anxiety Inventory (STAI). DESIGN Observational, prospective, monocentric study of 500 patients in the post-anaesthetist care unit. Anxiety was evaluated using both the visual analogue scale for anxiety and the STAI in perioperative patients. Consistency between the visual analogue scale for anxiety and the STAI, detection thresholds and factors predicting anxiety were researched. RESULTS A correlation was found between the visual analogue scale for anxiety and the STAI. There was also a correlation between pain and anxiety. Analysis of receiver operating characteristic (ROC) curves showed a visual analogue scale for anxiety threshold of 34/100 allowing the identification of patients with or without anxiety. Predictive factors for anxiety are female gender, use of benzodiazepine in premedication, emergency surgery and significant pain in the post-anaesthetist care unit. In summary, visual analogue scale for anxiety is a useful tool for detecting the anxiety component of postoperative pain. It could be used in association with covariates of interest to improve anxiety management during the postoperative period.
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Affiliation(s)
- François Labaste
- Department of Anesthesiology and Intensive CareUniversity Hospital of ToulouseToulouseFrance
- Institut des Maladies Métaboliques et Cardiovasculaires, INSERM U1048Université de Toulouse, UPSToulouseFrance
| | - Fabrice Ferré
- Department of Anesthesiology and Intensive CareUniversity Hospital of ToulouseToulouseFrance
| | - Hélène Combelles
- Department of Anesthesiology and Intensive CareUniversity Hospital of ToulouseToulouseFrance
| | - Valentin Rey
- Department of Anesthesiology and Intensive CareUniversity Hospital of ToulouseToulouseFrance
| | - Jean‐Christophe Foissac
- Department of Anesthesiology and Intensive CareUniversity Hospital of ToulouseToulouseFrance
| | - Anne Senechal
- Department of Anesthesiology and Intensive CareUniversity Hospital of ToulouseToulouseFrance
| | - Jean‐Marie Conil
- Department of Anesthesiology and Intensive CareUniversity Hospital of ToulouseToulouseFrance
| | - Vincent Minville
- Department of Anesthesiology and Intensive CareUniversity Hospital of ToulouseToulouseFrance
- Institut des Maladies Métaboliques et Cardiovasculaires, INSERM U1048Université de Toulouse, UPSToulouseFrance
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Lai Y, Wang X, Zhou K, Su J, Che G. The Feasibility and Safety of No Placement of Urinary Catheter Following Lung Cancer Surgery: A Retrospective Cohort Study With 2,495 Cases. J INVEST SURG 2019; 34:568-574. [PMID: 31533485 DOI: 10.1080/08941939.2019.1663377] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yutian Lai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Xin Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Kun Zhou
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Jianhuan Su
- Rehabilitation Department, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
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91
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Fei S, Xia H, Chen X, Pang D, Xu X. Magnesium sulfate reduces the rocuronium dose needed for satisfactory double lumen tube placement conditions in patients with myasthenia gravis. BMC Anesthesiol 2019; 19:170. [PMID: 31472669 PMCID: PMC6717642 DOI: 10.1186/s12871-019-0841-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/26/2019] [Indexed: 12/04/2022] Open
Abstract
Background Using a minimum dose of neuromuscular blockade (NMB) to achieve intubation condition is one of the goals in anaesthesia management of patients with myasthenia gravis (MG) for thoracoscopic (VATS) thymectomy. However, tracheal intubation with double lumen tube (DLT) could be challenging if intubation condition is not optimal. This double-blind randomised controlled study was designed to investigate whether magnesium sulfate would reduce the rocuronium dose needed for DLT intubation and improve the DLT placement condition for patients with MG who were scheduled for video-assisted thoracoscopic (VATS) thymectomy. Methods Recruited patients were randomly assigned to receive magnesium sulfate 60 mg.kg− 1 or normal saline (control) prior to the administration of NMB. Titrating dose of rocuronium was administered to achieve train of four (TOF) ratio less than 10% before DLT intubation. The primary outcome was the rocuronium dose required to achieve TOF ratio less than 10%. The secondary outcome was intubation condition for DLT placement. Results Twenty-three patients had received magnesium sulfate and 22 patients had received normal saline before rocuronium administration. The required rocuronium dose [mean (standard deviation)] were 0.10 (0.05) mg.kg− 1 and 0.28(0.17) mg.kg− 1 in patients who had magnesium sulfate and normal saline respectively(P < 0.0001). With a similar depth of neuromuscular blockade and depth of anaesthesia, 100% of patients in the magnesium sulfate group and 72.7% of patients in the control group showed excellent intubation condition (P = 0.027) respectively. The patients in both groups had similar emergence characteristics. Conclusions Magnesium sulfate is associated with a decrease in rocuronium requirement for an optimal DLT intubation condition in patients with MG for VATS thymectomy. Trial registration Clinical Trial Registry of China (http://www.chictr.org.cn) identifier: ChiCTR-1800017696, retrospectively registered on August 10, 2018.
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Affiliation(s)
- Shoujun Fei
- Department of Anaesthesiology, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Hengfu Xia
- Department of Anaesthesiology, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Xiaowei Chen
- Department of Anaesthesiology, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Dazhi Pang
- Department of Thoracic surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Xuebing Xu
- Department of Anaesthesiology, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China.
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Zhang J, Yu Y, Miao S, Liu L, Gan S, Kang X, Zhu S. Effects of peri-operative intravenous administration of dexmedetomidine on emergence agitation after general anesthesia in adults: a meta-analysis of randomized controlled trials. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:2853-2864. [PMID: 31496661 PMCID: PMC6700396 DOI: 10.2147/dddt.s207016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/01/2019] [Indexed: 01/25/2023]
Abstract
Objective The aim of the current meta-analysis was to assess the effect of dexmedetomidine on emergence agitation (EA) and the recovery outcomes after general anesthesia in adults. Methods We searched the PubMed, the Cochrane Central Register of Controlled Trials, Embase, Web of Science and clinicaltrials.gov for relevant randomized controlled trials (RCTs) investigating the effects of dexmedetomidine on the EA in adults after general anesthesia compared with placebo. The primary outcome was the incidence of EA. Secondary outcomes included other recovery outcomes after general anesthesia. Results Twelve RCTs (842 participants) met the eligibility criteria. A conventional random-effects meta-analysis demonstrated that peri-operative intravenous dexmedetomidine could be effective for the prevention of EA [risk ratio (RR) 0.49, Trial Sequential Analysis (TSA)-adjusted 95% confidence interval (CI) 0.35–0.68, P<0.00001]. In addition, the TSA indicated that the meta-analysis for the incidence of EA reached the required information size (370). Lower number of patients receiving dexmedetomidine required analgesia (P=0.0009). Extubation time was longer (P=0.03) and hypotension (P=0.03) was more common with dexmedetomidine. Moreover, no difference was found in the other outcomes. Conclusion Dexmedetomidine was shown to effectively decrease the incidence of EA and to reduce postoperative analgesic requirements. Yet, other recovery outcomes including extubation time, length of PACU stay, postoperative residual sedation, hypotension, bradycardia as well as postoperative nausea and vomiting provided no data that could be used to form final conclusions.
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Affiliation(s)
- Jian Zhang
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yang Yu
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Shuai Miao
- Department of Anesthesiology, The Affiliated Hospital, Xuzhou Medical University, Xuzhou, China
| | - Lu Liu
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Shuyuan Gan
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Xianhui Kang
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Shengmei Zhu
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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93
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Kim JC, Kim J, Kwak H, Ahn SW. Premedication with dexmedetomidine to reduce emergence agitation: a randomized controlled trial. BMC Anesthesiol 2019; 19:144. [PMID: 31391001 PMCID: PMC6686469 DOI: 10.1186/s12871-019-0816-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/29/2019] [Indexed: 12/19/2022] Open
Abstract
Background Nasal bone fracture is the most common type of facial fracture, and the high incidence of severe emergence agitation occurring after closed reduction of the nasal bone fracture can be challenging to manage. The purpose of this trial was to evaluate whether pre-operative administration of dexmedetomidine is effective in reducing the incidence and severity of emergence agitation in adults undergoing closed reduction of nasal bone fractures. Methods In this randomized controlled trial, 90 patients who were scheduled to undergo closed reduction of a nasal bone fracture were prospectively included and were randomly assigned to either the control group (n = 45; 0.9% saline infusion) or the dexmedetomidine group (n = 45; 1 μ/kg over 10 min, pre-operatively). The primary endpoint was Aono’s four-point scale scores after anesthesia. The recovery time and numeric rating scale score were assessed as secondary endpoints. Results Aono’s four-point scale scores were lower in the dexmedetomidine group than in the control group (median: 1 [1] vs. 1 [1, 2], 95% confidence interval of difference: 0.01 to 0.02, P = 0.02). The number, severity, and duration of agitation episodes were significantly lower in the dexmedetomidine group than in the control group. Furthermore, the number of patients exhibiting intraoperative movement was lower in the dexmedetomidine group. Conclusions Pre-operative administration of dexmedetomidine demonstrated several significant benefits, such as a lower incidence of emergence agitation, reduced agitation severity, and a shorter duration of agitation. Additionally, we observed more stable maintenance of intraoperative anesthesia with less movement during the surgery. Trial registration Identifier: KCT0000585 (registration date: 12–19- 2012).
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Affiliation(s)
- Jong Chan Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - Jihee Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - Hayeon Kwak
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - So Woon Ahn
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea.
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Mansouri MT, Fidler JA, Meng QC, Eckenhoff RG, García PS. Sex effects on behavioral markers of emergence from propofol and isoflurane anesthesia in rats. Behav Brain Res 2019; 367:59-67. [PMID: 30898682 DOI: 10.1016/j.bbr.2019.03.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 01/18/2023]
Abstract
Clinical studies have demonstrated sex-related differences in recovery from surgical anesthesia. This study aimed to characterize the emergence pattern following two anesthesia regimens in both sexes of rats. We considered six different markers of emergence from anesthesia: sigh, eye blinking, forelimb movement, mastication, neck extension, and recovery of the righting reflex (RORR). Spontaneous motor activity 24 h after the anesthesia induction was also examined. Our results showed that the rank order of the emergence latency after intraperitoneal propofol, PRO, exposure was forelimb movement < sigh < blink < mastication < neck extension < RORR, while after inhaled isoflurane, ISO, anesthesia the sequence was changed as sigh < blink < mastication < forelimb movement < neck extension < RORR in both male and female rats. Moreover, the latency to emergence after PRO in female rats was significantly higher than male rats, although following ISO there was no difference between the sexes (P < 0.001; P > 0.05, respectively). Open-field testing revealed no difference in PRO and ISO spontaneous locomotor activity due to drug administration (P > 0.05). These two anesthetics presented different emergence sequences. Although clinical data suggests that females arouse faster than males from anesthesia with propofol, our intraperitoneal technique in a rodent model had the opposite effect. Pharmacokinetic analysis demonstrated increased absorption of injected propofol for the female rats in our study, emphasizing the role of sexual dimorphism in drug distribution in rodents. Despite these pharmacokinetic differences, the pharmacodynamic effects of the drugs were remarkably consistent among both sexes through emergence.
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Affiliation(s)
- Mohammed Taghi Mansouri
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory University, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA; Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Jonathan A Fidler
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory University, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Qing Cheng Meng
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul S García
- Neuroanesthesia Laboratory, Atlanta VA Medical Center/Emory University, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA; Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA.
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Choi H, Jung SH, Hong JM, Joo YH, Kim Y, Hong SH. Effects of Bilateral Infraorbital and Infratrochlear Nerve Block on Emergence Agitation after Septorhinoplasty: A Randomized Controlled Trial. J Clin Med 2019; 8:jcm8060769. [PMID: 31151239 PMCID: PMC6616642 DOI: 10.3390/jcm8060769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 11/16/2022] Open
Abstract
Emergence agitation is common after septorhinoplasty, and postoperative pain is the main risk factor for this condition. Infraorbital and infratrochlear nerve block have been reported to facilitate pain management in patients after nasal procedures. The effect of peripheral nerve block on the incidence of emergence agitation has not been evaluated. Sixty-six patients that were scheduled for septorhinoplasty were assigned to receive bilateral infraorbital and infratrochlear nerve block with either 8 mL of 0.5% ropivacaine (Block group) or isotonic saline (Sham Block group). The incidence of emergence agitation was evaluated using the Riker sedation-agitation scale. Analgesic consumption, hemodynamic parameters, postoperative pain scores, adverse events, and patient satisfaction with analgesia were evaluated. The incidence of emergence agitation was lower in the Block group than in the Sham Block group (6 (20.0%) versus 20 (62.5%), p = 0.002). The mean intraoperative remifentanil consumption was lower in the Block group than in the Sham Block group (0.074 ± 0.014 μg/kg/min. versus 0.093 ± 0.019 μg/kg/min., respectively, p < 0.0001), as was the proportion of patients that needed postoperative tramadol administration and median postoperative pain score at 0–2 h after surgery (9 (30.0%) versus 21 (65.6%), p = 0.011; 3.0 (2.0–4.0) versus 4.0 (3.0–4.0), p < 0.0001, respectively). Hemodynamic parameters and the incidence of adverse events were similar between the two groups. The median patient satisfaction score with respect to analgesia was higher in the Block group than in the Sham Block group (3.5 (3.0–4.0) versus 3.0 (3.0–4.0), respectively, p = 0.034). The preoperative bilateral infraorbital and infratrochlear nerve block decreased the incidence of emergence agitation after septorhinoplasty.
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Affiliation(s)
- Hoon Choi
- Deparment of Anesthesia and Pain Medicine, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea.
| | - Seung Ho Jung
- Department of Anesthesia and Pain Medicine, College of Medicine, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
| | - Jin Myung Hong
- Department of Plastic Surgery, Dream Medical Group, 848, Nonhyeon-ro, Gannam-gu, Seoul 06022, Korea.
| | - Young Ho Joo
- Department of Otorhinolaryngology-Head & Neck Surgery, College of Medicine, Korea University, 73, Goryeodae-ro, Seongbuk-gu, Seoul 02841, Korea.
| | - Youme Kim
- Deparment of Anesthesia and Pain Medicine, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea.
| | - Sang Hyun Hong
- Deparment of Anesthesia and Pain Medicine, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea.
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Park JY, Hong JH, Yu J, Kim DH, Koh GH, Lee SA, Hwang JH, Kong YG, Kim YK. Effect of Ketorolac on the Prevention of Postoperative Catheter-Related Bladder Discomfort in Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized, Double-Blinded, Placebo-Controlled Study. J Clin Med 2019; 8:jcm8060759. [PMID: 31146434 PMCID: PMC6616938 DOI: 10.3390/jcm8060759] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 05/17/2019] [Accepted: 05/27/2019] [Indexed: 11/16/2022] Open
Abstract
Urinary catheterization can cause catheter-related bladder discomfort (CRBD). Ketorolac is widely used for pain control. Therefore, we evaluated the effect of ketorolac on the prevention of CRBD in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP). All patients were randomly allocated to the ketorolac group or the control group. The primary outcome was CRBD above a moderate grade at 0 h postoperatively. CRBD above a moderate grade at 1, 2, and 6 h was also assessed. Postoperative pain, opioid requirement, ketorolac-related complications, patient satisfaction, and hospitalization duration were also assessed. The incidence of CRBD above a moderate grade at 0 h postoperatively was significantly lower in the ketorolac group (21.5% vs. 50.8%, p = 0.001) as were those at 1, 2, and 6 h. Pain scores at 0 and 1 h and opioid requirement over 24 h were significantly lower in the ketorolac group, while patient satisfaction scores were significantly higher in the ketorolac group. Ketorolac-related complications and hospitalization duration were not significantly different between the two groups. This study shows ketorolac can reduce postoperative CRBD above a moderate grade and increase patient satisfaction in patients undergoing RALP, suggesting it is a useful option to prevent postoperative CRBD.
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Affiliation(s)
- Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Gi-Ho Koh
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, Korea.
| | - Sang-A Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Yu-Gyeong Kong
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07247, Korea.
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
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Rizk SN, Samir EM. Use of ketofol to control emergence agitation in children undergoing adenotonsillectomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sherry N. Rizk
- Kasr Al Aini Hospital, Department of Anesthesia and Intensive Care, Faculty of Medicine, Cairo University, Egypt
| | - Enas M. Samir
- Kasr Al Aini Hospital, Department of Anesthesia and Intensive Care, Faculty of Medicine, Cairo University, Egypt
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Emergence delirium following sevoflurane anesthesia in adults: prospective observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31076155 PMCID: PMC9391875 DOI: 10.1016/j.bjane.2018.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background and objectives Emergence delirium after general anesthesia with sevoflurane has not been frequently reported in adults compared to children. This study aimed to determine the incidence of emergence delirium in adult patients who had anesthesia with sevoflurane as the volatile agent and the probable risk factors associated with its occurrence. Design & methods A prospective observational study was conducted in adult patients who had non-neurological procedures and no existing neurological or psychiatric conditions, under general anesthesia. Demographic data such as age, gender, ethnicity and clinical data including ASA physical status, surgical status, intubation attempts, duration of surgery, intraoperative hypotension, drugs used, postoperative pain, rescue analgesia and presence of catheters were recorded. Emergence delirium intensity was measured using the Nursing Delirium Scale (NuDESC). Results The incidence of emergence delirium was 11.8%. The factors significantly associated with emergence delirium included elderly age (>65) (p = 0.04), emergency surgery (p = 0.04), African ethnicity (p = 0.01), longer duration of surgery (p = 0.007) and number of intubation attempts (p = 0.001). Factors such as gender, alcohol and illicit drug use, and surgical specialty did not influence the occurrence of emergence delirium. Conclusions The incidence of emergence delirium in adults after general anesthesia using sevoflurane is significant and has not been adequately reported. Modifiable risk factors need to be addressed to further reduce its incidence.
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Ramroop R, Hariharan S, Chen D. Delirium do despertar após anestesia com sevoflurano em adultos: estudo observacional prospectivo. Braz J Anesthesiol 2019; 69:233-241. [DOI: 10.1016/j.bjan.2018.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 11/23/2018] [Accepted: 12/03/2018] [Indexed: 01/11/2023] Open
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Zhang GF, Guo J, Qiu LL, Li SM, Zheng M, Xia JY, Yang JJ. Effects of dezocine for the prevention of postoperative catheter-related bladder discomfort: a prospective randomized trial. Drug Des Devel Ther 2019; 13:1281-1288. [PMID: 31114164 PMCID: PMC6497880 DOI: 10.2147/dddt.s199897] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 03/05/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose: To evaluate the effects of dezocine on the prevention of postoperative catheter-related bladder discomfort (CRBD). Patients and methods: Ninety-six adult patients undergoing abdominal surgery with urinary catheterization under general anesthesia were randomized into dezocine and control (flurbiprofen) groups. The postoperative CRBD, pain score, sedation score and adverse effects were evaluated at 0, 1, 2 and 6 hrs after tracheal extubation. Results: The primary outcome showed a lower incidence of CRBD at 1 hr post-extubation in the dezocine group (29.17%) than the control group (58.33%, P<0.01). The incidences at 0 and 2 hrs post-extubation and the overall incidence were also lower in the dezocine group than the control group (all P<0.05). The severity of CRBD at 0, 1, 2 and 6 hrs and the pain, sedation score and other adverse effects were comparable between the two groups (P>0.05); however, the overall severity of CRBD was decreased in the dezocine group compared with the control group (P<0.05). Conclusion: Intraoperative dezocine reduces the incidence and severity of postoperative CRBD without clinically relevant adverse effects.
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Affiliation(s)
- Guang-Fen Zhang
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Jie Guo
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Li-Li Qiu
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Shu-Ming Li
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Man Zheng
- Department of Anesthesiology, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Jiang-Yan Xia
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Jian-Jun Yang
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
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