Chronic postsurgical pain following gastrointestinal surgery - A scoping review

BACKGROUND

Chronic postsurgical pain (CPSP) has a great impact on quality of life and socioeconomic status. The mechanisms behind CPSP remain poorly understood, however type of surgical intervention seems to play a role. Gastrointestinal surgeries are common procedures, yet research in CPSP following gastrointestinal surgery is limited. The objective of this scoping review was to map the current literature on CPSP following gastrointestinal surgery, identifying how CPSP have been investigated, and which evidence gaps exist.

METHODS

This scoping review followed a pre-published protocol and PRISMA-ScR guidelines. A search was carried out in Medline, Embase, CINAHL, Cochrane Central, Clinicaltrials.Gov, and Google Scholar. Eligible studies were original studies involving adults, undergoing gastrointestinal surgery, who had a pain assessment ≥30 days postoperatively. A two-phase screening process and data charting were done by two independent reviewers.

RESULTS

A total of 53 studies were included, published between 2001 and 2024, predominantly across Europe and Asia. The range of CPSP prevalence reported was 3.3%-46.1%. Only half the studies clearly defined CPSP, and the timing and manner of pain assessment varied considerably. Twenty-seven studies assessed risk factors for developing CPSP: preoperative pain and acute postoperative pain were consistently significant.

CONCLUSIONS

There was a wide consensus on CPSPs' negative impact on quality of life. CPSP following gastrointestinal surgery is prevalent and significantly impacts quality of life. Standardized definitions and methodologies to improve the comparability and reliability of the findings across studies are needed. Future research should focus on CPSP following specific surgical procedures to develop tailored prevention and treatment strategies.

Influence of hydrocortisone infusion method on the clinical outcome of patients with septic shock: A systematic review and meta-analysis

Background

The effect of the modality of hydrocortisone administration on clinical outcomes in patients with septic shock remains uncertain. This systematic review and meta-analysis evaluate the impact of intermittent bolus and continuous infusion of hydrocortisone on these outcomes.

Methods

We searched the PubMed, Embase databases, and Cochrane Library for randomized controlled trials (RCTs) and cohort studies published from inception to January 1, 2023. We included studies involving adult patients with septic shock. All authors reported our primary outcome of short-term mortality and clearly compared the clinically relevant secondary outcomes (ICU length of stay, hospital length of stay, vasopressor-free days, hyperglycemia, hypernatremia, and ICU-acquired weakness [ICUAW]) of intermittent bolus and continuous infusion of hydrocortisone. Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). The PROSPERO registration number is CRD42023392160.

Results

Seven studies, including 554 patients, were included. The primary outcome of this meta-analysis showed no statistically significant difference in the short-term mortality between intermittent bolus and continuous infusion groups (OR=1.21, 95% CI: 0.84 to 1.73; P=0.31; Chi2 =9.06; I 2=34%). Secondary outcomes showed no statistically significant difference in the ICU length of stay (MD=-0.15, 95% CI: -2.31 to 2.02; P=0.89; Chi2 =0.95; I 2=0%), hospital length of stay (MD=0.63, 95% CI: -4.24 to 5.50; P=0.80; Chi2 =0.61; I 2=0%), vasopressor-free days (MD=-1.18, 95% CI: -2.43 to 0.06; P=0.06; Chi2 =2.48; I 2=60%), hyperglycemia (OR=1.27, 95% CI: 0.80 to 2.02; P=0.31; Chi2 =5.23; I 2=43%), hypernatremia (OR=0.93, 95% CI: 0.44 to 1.96; P=0.85; Chi2 =0.37; I 2=0%), or ICUAW (OR=0.83, 95% CI: 0.36 to 1.94; P=0.67; Chi2 =0.90; I 2=0%) between the two groups.

Conclusions

This meta-analysis indicated no significant difference in short-term mortality between intermittent bolus or continuous hydrocortisone infusion in patients with septic shock. Additionally, the hydrocortisone infusion method was not associated with ICU length of stay, hospital length of stay, vasopressor-free days, hyperglycemia, hypernatremia, or ICUAW.

Application of a novel gastro-laryngeal mask in upper gastrointestinal endoscopy surgery: A pilot randomized clinical trial

BACKGROUND

The Gastro-Laryngeal Mask (Jcerity Endoscoper™ Airway) is a new airway management technique utilized in patients undergoing upper gastrointestinal endoscopy surgery under general anesthesia, but evidence of its effectiveness and safety is scarce.

OBJECTIVE

To assess the success rate of insertion, cardiovascular response, airway pressure, time taken for placement, nausea or vomiting, pharyngodynia, and other complications of using the new type of back-open gastroscopy laryngeal mask.

METHODS

We screened 1401 patients; 105 were ineligible, and 40 declined to participate. Participants were randomly allocated into the Jcerity Endoscoper™ Airway (JEA) group and the endotracheal tube (ET) group. Among them, 1266 patients were randomly assigned to receive endotracheal intubation (n = 633) or JEA (n = 633).

RESULTS

Compared with the ET group, the JEA group had a significantly shorter insertion time and less cardiovascular response during insertion. The time taken for extubation after anesthesia and residence time in PACU in the JEA group was shorter than in the ET group. Especially, the incidence of pharyngodynia in the JEA group was lower than that in the ET group. The satisfaction of endoscopists with the JEA reached 99.4%.

CONCLUSIONS

This study showed that the back-open JEA can not only provide a safe and effective airway guarantee for patients but also provide convenience for gastroenterologists to carry out endoscopic operations.

TRIAL REGISTRATION

The trial was registered before patient enrollment at the Chinese Clinical Trial Registry Center (ChiCTR2100046864, principal investigator: Yunqi Lv, date of registration: 2021-05-29). The study was conducted in the painless diagnosis and treatment center of the First Affiliated Hospital of Zhengzhou University from June 2021 to October 2023 (Date of enrolment of the first research participant:2021-06-01).

Evaluation of Point-of-care Ultrasound of Airway to Predict Difficult Laryngoscopy and Intubation in Intensive Care Unit Patients

Background

To evaluate the role of ultrasound (US) in the assessment of the airway and to determine whether US has the potential to serve as effective, noninvasive and less time-consuming method for the diagnosis of difficult intubation in ICU patients.

Patients and methods

This cross-sectional study was carried in 152 critically ill patients who underwent intubation in the ICU from December 2022 to April 2024. Prior to intubation thyromental height (TMH) and hyomental distance ratio (HMD-R) was measured using a scale and distance from skin to hyoid bone (SHB) and distance from skin to thyrohyoid membrane (STM) was measured using a US. Direct laryngoscopy was performed using a Macintosh blade, and the Cormack-Lehane (CL) grade was noted without external laryngeal manipulation. The laryngoscopy was classified as easy (CL Grade I and II) or difficult (CL Grade III and IV). The number of attempts at intubation, need for alternative difficult intubation approaches or inability to secure the airway was also noted.

Results

The incidence of difficult airway was 17.76%. The success rate for first-attempt intubation was 96.7%. Based on the receiver operating characteristic (ROC) curve analysis cut-off value of 1.97 cm [95% confidence interval (CI), 0.949-0.996, area under the curve (AUC), 0.972] for anterior soft tissue thickness from the skin to thyrohyoid membrane distinguished the difficult intubation group from the easy intubation group, with a sensitivity of 96.3% and specificity of 86.4%. For the hyoid bone level, a cut-off value of 0.905 cm (95% CI, 0.706-0.887, AUC, 0.797) had a sensitivity of 74.1% and specificity of 74.4%. Anterior soft tissue thickness from the skin to thyrohyoid membrane was a better predictor of a difficult airway. There was a significant correlation between clinical airway assessments and US airway assessments.

Conclusion

Point-of-care US can serve as an independent tool for assessing the airway in intensive care unit (ICU) patients, with anterior soft tissue thickness from skin to thyrohyoid membrane being a superior predictor. Combined models of sonographic and clinical tests could enhance the diagnostic value for identifying difficult intubation cases in ICU patients.

How to cite this article

Mallick S, Das S, Pradhan S, Kar S. Evaluation of Point-of-care Ultrasound of Airway to Predict Difficult Laryngoscopy and Intubation in Intensive Care Unit Patients. Indian J Crit Care Med 2025;29(1):14-20.

"Subarachnoid block in active burn injury": A case report of anesthetic challenges and considerations

Anesthetists pose different challenges in burn cases associated with polytrauma. Here, we present a case of a 35-year-old male electrician with an electric burn and a fall from height who sustained major chest trauma (hemothorax, pneumothorax, emphysema, and multiple rib fracture, and bilateral femur fracture). The collocated burn over the spinal region posed the challenge to administering a subarachnoid block, which was overcome with a paramedian approach anesthesia. The surgical outcome was good, and the patient was stable post-surgery. The paramedian approach provides an excellent alternative to the midline approach for spinal anesthesia. It should be considered in burn patients where it is impossible for the patient to flex, where the intervertebral space is very low, or when there is a burn present over the spinal region. Ultimately, early therapy and mobility goals, two essential components of burn care and rehabilitation, can be achieved with the use of paramedian regional anesthesia.

Evaluation of ultrasound measured tongue thickness, tongue thickness-thyromental distance ratio, and skin-to-epiglottis distance in predicting unanticipated difficult laryngoscopy

Background and Aims

The contemporary literature review suggests upper airway ultrasound can help us to diagnose an unanticipated difficult airway before laryngoscopy. The primary objective of this study was to compare ultrasonography (USG) and clinical airway indices across easy and difficult laryngoscopy groups.

Material and Methods

This prospective observational study included 258 patients scheduled to undergo surgery under general anesthesia with endotracheal intubation. Ultrasonographic upper airway parameters, viz., tongue thickness (TT), skin-to-epiglottis distance (DSE), and tongue thickness to thyromental distance ratio (TT/TMD) were measured. Patients were identified as easy or difficult laryngoscopy groups based on their Cormack Lehane (CL) grading.

Results

Out of 258 patients, 20 (7.75%) had difficult laryngoscopy, and 238 (92%) had easy laryngoscopy. The USG measured TT mean, and median values were 6.16 ± 0.39 [6.10] cm in difficult and 5.41 ± 0.36 [5.40] cm in easy laryngoscopy groups. The USG measured mean and median value of DSE were 2.75 ± 0.09 [2.74] in difficult and 2.27 ± 0.23 [2.27] in easy laryngoscopy groups. The ratio of TT/TMD with mean and median values of 0.98 ± 0.07 [0.99] in difficult and 0.84 ± 0.13 [0.82] in easy laryngoscopy. Using the inputs, the diagnostic accuracy of the ultrasound-measured significant variables was calculated in terms of their area under the curve using the receiver operating characteristic curve.

Conclusions

This study revealed a relationship between sonographic measurements like TT, DSE, and TT/TMD ratio for easy and difficult laryngoscopy identification. Including these sonographic parameters and their cut-off values may enhance our ability to predict an unanticipated difficult laryngoscopy.

Effects of esketamine on postoperative pain and inflammatory factors in children undergoing tonsillectomy and adenoidectomy

BACKGROUND

This study aimed to observe the effect of esketamine on postoperative pain and inflammatory factors in children undergoing tonsillectomy and adenoidectomy.

METHODS

Eighty children scheduled for tonsillectomy and adenoidectomy were randomly divided into two groups using a random number table: an esketamine group (S-ketamine group, N.=40) and a control group (control group, N.=40). The primary outcome was the postoperative pain score, measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) pain scale score. Secondary outcomes include the emergence agitation score (Pediatric Anesthesia Emergence Delirium [PAED]), the operation time, recovery time, postanesthesia care unit (PACU) stay time, adverse reactions within 48 h after operation, and the plasma C-reactive protein (CRP) and interleukin-6 (IL-6) concentrations.

RESULTS

At T1, T2, T3, T4, and T5, the FLACC pain scores of the S-ketamine group were significantly lower than those of the control group (15 min: 2.4±0.7 vs. 3.4±0.8, P<0.01; 1 h: 1.7±0.6 vs. 2.2±0.7, P<0.01; 6 h: 1.5±0.6 vs. 2.0±0.5, P<0.01; 12 h: 1.5±0.6 vs. 1.8±0.7, P<0.05; 24 h: 1.4±0.6 vs. 1.7±0.6, P<0.05). The PAED scores at T1 and T2 in the S-ketamine group were significantly lower than those in the control group (15 min: 4.0±0.9 vs. 6.4±1.3, P<0.01; 1 h: 1.7±0.6 vs. 2.1±0.5, P<0.01). Compared with T0, the plasma CRP and IL-6 concentrations at T3 in the two groups were significantly increased (P<0.01), but the increase in the S-ketamine group was significantly smaller than that in the control group at T3 (IL-6: 111.8±19.2 vs. 145.8±22.5, P<0.01; CRP: 1.2±0.5 vs. 1.5±0.5, P<0.01). The other outcomes were similar between the two groups.

CONCLUSIONS

Esketamine used in pediatric tonsillectomy and adenoidectomy can effectively reduce postoperative FLACC, PAED score, and levels of inflammatory factors without increasing adverse reactions.

Effect of acetate- and lactate-containing intravenous fluid on acid-base status, electrolytes and plasma lactate concentration in dehydrated cats

OBJECTIVES

Acetate (ACE) and lactate (LAC)-containing balanced resuscitation fluids are commonly used for fluid therapy in cats. These fluids can influence acid-base and electrolyte status. This prospective randomised study compared two balanced crystalloid solutions regarding their effect on acid-base status, electrolytes and LAC concentrations in dehydrated cats after intravenous fluid therapy.

METHODS

A total of 100 client-owned cats presenting to the emergency service with dehydration ⩾5% due to diarrhoea, vomiting or anorexia were included in this study. They were randomised to receive either ACE- (Sterofundin ISO; B Braun Vet Care) or LAC-containing (Ringer-Laktat nach Hartmann; B. Braun Vet Care) fluids for rehydration. Exclusion criteria were age <6 months, severe electrolyte abnormalities, severely increased creatinine or bolus therapy, and decompensated heart disease and liver diseases. Vital parameters were assessed and venous blood gas analysis was performed before and after fluid therapy. Data were analysed using the Mann-Whitney U-test and the Wilcoxon matched-pairs signed-rank test. The significance level was set at P ⩽0.05.

RESULTS

Post-rehydration pH normalised, and bicarbonate and base excess increased in both groups. Anion gap and LAC and potassium concentrations decreased in both groups. No difference in electrolyte, acid-base status and LAC was observed between cats receiving ACE and cats receiving LAC.

CONCLUSIONS AND RELEVANCE

Both fluids have similar effects on dehydrated cats' acid-base status and electrolyte and LAC concentrations. No significant differences in values were found between ACE- and LAC-containing resuscitation fluids. Blood LAC concentration decreased in both groups.

Psychometric evaluation of patient-reported experience measures for peri-anesthesia care: A systematic review based on COSMIN guidelines

BACKGROUND

Patient Reported Experience Measures (PREM) have become a critical component in assessing healthcare quality from the patient's perspective. Accurate and reproducible assessment tools are essential for generating robust and reliable results for evaluating peri-anesthesia patient experiences, identifying associated factors, and assessing the impact of healthcare interventions. However, there is currently no systematic review that consolidates all existing peri-anesthesia PREMs and evaluates their psychometric properties.

OBJECTIVE

To identify and assess the psychometric properties of PREMs for peri-anesthesia patients.

DESIGN

Systematic review of measurement properties following the COSMIN guidelines.

METHODS

Systematic searches were conducted in China National Knowledge Infrastructure, Wanfang, PubMed, Embase, Web of Science, CINAHL, and PsycINFO databases from January 1, 1993, to April 15, 2024. Studies reporting on the development and/or validation of any PREMs for use in the peri-anesthesia period were considered eligible. The measurement properties extracted included data on the item development process, content validity, structural validity, internal consistency, cross-cultural validity, reliability, hypothesis testing and responsiveness. For the same PREM across different studies, reliability coefficients were analyzed using a meta-analysis. The quality assessment, rating of measurement properties, synthesis, and modified grading of the evidence were carried out following the COSMIN methodology for systematic reviews.

RESULTS

A total of 26 studies encompassing 16 PREMs were included. Among them, the Patient Satisfaction with Perioperative Anesthetic Care questionnaire (PSPACq), Perception of Quality in Anesthesia (PQA), Sindhvananda General Anesthesia Satisfaction questionnaire, and Daycare Anesthesia Satisfaction (DAS) demonstrated moderate to high-quality evidence of adequate content validity and internal consistency, resulting in strong recommendations. Five PREMs exhibited high-quality evidence of inadequate structural validity and internal consistency, receiving a "not recommended" status. The remaining PREMs were weakly recommended.

CONCLUSIONS

This systematic review identified PSPACq and PQA as effective tools for assessing peri-anesthesia experiences in surgical patients, suitable for both research and clinical use. Future studies should focus on thoroughly evaluating the measurement properties of these two PREMs, as many aspects remain underexplored. A high risk of bias was noted in other PREMs, particularly in content validity, structural validity, and reliability, which increases uncertainty in the evidence base.

REGISTRATION

This study's protocol has been registered at PROSPERO under the registration number CRD42024537900.

Combined thoracic segmental spinal anesthesia and erector spinae plane block in high-risk patients undergoing thoracoscopic surgery: A case series

Thoracoscopic surgery in high-risk patients with severe respiratory disease is associated with a high morbidity and mortality rate. Though general anesthesia is the first-line anesthetic strategy for thoracoscopic surgeries, it poses a significant risk. When the hazards of general anesthesia outweigh the benefits of the procedure, there is a moral quandary over whether thoracoscopy should still be the option for patients with severe respiratory disorders. Thoracic segmental spinal anesthesia in combination with erector spinae block may emerge as an excellent alternative to general anesthesia in terms of analgesic efficacy, patient recovery profile, and minimal complication rates if administered by experienced hands. Unfortunately, there is paucity of literature exploring the impact of regional techniques and their outcomes on these patients. In this case series, we aim to emphasize that combined thoracic segmental spinal anesthesia and erector spinae plane block are a safe and effective alternative to general anesthesia in thoracoscopic surgeries.

A Double-Blind Randomized Controlled Trial Comparing Intrathecal 0.5% Isobaric Levobupivacaine With Fentanyl to 0.5% Isobaric Ropivacaine With Fentanyl for Elective Cesarean Section

Background This study was planned to compare the onset and duration of action and the levels of sensory and motor blocks of 0.5% isobaric levobupivacaine with fentanyl to 0.5% isobaric ropivacaine with fentanyl addition in subarachnoid block in elective cesarean cases. Materials and methods This hospital-based randomized interventional controlled study was conducted in a tertiary care facility in Jaipur. Sixty women who planned for elective lower-segment cesarean section, with more than 37 weeks of gestational period during the study period, were included in our study. These women were randomly divided into two study groups, using sealed opaque envelopes, and double blinding was ensured. In group L, women received 0.5% isobaric levobupivacaine with fentanyl, and in group R, 0.5% isobaric ropivacaine with fentanyl was given. Results The mean time for sensory and motor block onset was significantly lower in group L than in group R (p<0.05). The mean time for two-segment regression for sensory block was significantly higher in group L than in group R (p<0.05). The mean duration of total motor blockade (B0) was significantly higher in group L compared to group R. The differences in the mean duration of total motor blockade were statistically significant (p<0.05). The mean change in mean arterial pressure (MAP) in group L was significantly higher than in group R (p<0.05). Conclusion This study provides valuable insights into the comparative effects of 0.5% isobaric levobupivacaine with fentanyl and 0.5% isobaric ropivacaine with fentanyl for spinal anesthesia in cesarean sections. Both anesthetic agents were well-tolerated, with no severe complications or side effects observed in either group. While levobupivacaine offers an early onset of action, ropivacaine demonstrates a more favorable hemodynamic profile with an early regression of motor block. Ropivacaine may be a suitable alternative to levobupivacaine for spinal anesthesia in cesarean sections, particularly in patients with unstable hemodynamics. Further research is necessary to investigate the long-term effects of these agents and to optimize their use in different patient populations.

Estimating the usefulness of inferior vena cava collapsibility index and caval aorta index to predict hypotension after spinal anaesthesia in adult patients undergoing elective surgery in a tertiary care hospital

Background and Aims

Post-spinal anaesthesia hypotension (PSAH) can occur in 25-75% of patients. The preload or volume status of a patient is an important contributor to PSAH, and coloading with fluids is advocated to prevent PSAH. Instead of blind volume loading, prediction of volume status using inferior vena cava (IVC) collapsibility index (IVCCI) and caval aorta index (IVC: Ao index) may be used to guide fluid administration.

Material and Methods

In our study, we used ultrasound in the immediate pre-operative period to calculate IVCCI and IVC: Ao index in patients scheduled for elective surgery in the supine position, under spinal anaesthesia. Spinal anaesthesia was given in the lateral position with 0.5% hyperbaric bupivacaine. Patients were placed supine thereafter, sensory blockade level was ascertained, and blood pressure (BP) was measured every 2 min for 30 min. Episodes of hypotension were treated with fluids or vasopressors as per the discretion of the treating anaesthesiologist. In the study, 73 patients were screened, out of which 69 were included.

Results

Totally, 23 participants out of 69 developed PSAH. The receiver operating characteristic (ROC) curve was made and the area under the curve analysis was done on our collected data. We found that IVC: Ao index has better sensitivity (0.696 for IVC: Ao index ≤0.810) and specificity (0.717 for IVC: Ao index ≤0.810) than IVCCI (sensitivity 0.522 and specificity 0.630 for IVCCI ≥33.32%) to predict PSAH.

Conclusion

IVC: Ao index is a better predictor of PSAH than IVCCI. Thus, it may be used to predict volume status and guide in coloading with fluids during spinal anaesthesia.

The Role of Intravenous Anesthetics for Neuro: Protection or Toxicity?

The primary intravenous anesthetics employed in clinical practice encompass dexmedetomidine (Dex), propofol, ketamine, etomidate, midazolam, and remimazolam. Apart from their established sedative, analgesic, and anxiolytic properties, an increasing body of research has uncovered neuroprotective effects of intravenous anesthetics in various animal and cellular models, as well as in clinical studies. However, there also exists conflicting evidence pointing to the potential neurotoxic effects of these intravenous anesthetics. The role of intravenous anesthetics for neuro on both sides of protection or toxicity has been rarely summarized. Considering the mentioned above, this work aims to offer a comprehensive understanding of the underlying mechanisms involved both in the central nerve system (CNS) and the peripheral nerve system (PNS) and provide valuable insights into the potential safety and risk associated with the clinical use of intravenous anesthetics.

Poor correlation of venous lactate with systemic oxygen saturation in the paediatric cardiac ICU: a pilot study

INTRODUCTION

Cardiac intensive care providers require a comprehensive understanding of cardiac output and oxygen delivery. The estimation of cardiac output in clinical practice often relies on thermodilution and the Fick principle. Central venous saturation and lactate levels are commonly used indicators for cardiac output assessment. However, the relationship between venous lactate levels and venous oxygen saturation in paediatric cardiac intensive care patients remains unclear.

METHODS

This is a single-centre retrospective pilot study aimed to investigate the correlation between venous lactate and venous oxygen saturation in paediatric patients. Data collected included venous saturation, heart rate, mean arterial blood pressure, arterial saturation by pulse oximetry, cerebral and renal near-infra-red spectroscopy values, and the presence of a functionally univentricular heart. Statistical analyses included Bayesian Pearson correlation and regression analyses.

RESULTS

A total of 203 data points from 37 unique patients were included in the analysis. There was no significant correlation between serum lactate and venous saturation (correlation coefficient = -0.01; Bayes factor 10 = 0.06). Serum lactate also did not correlate with other haemodynamic metrics. Venous saturation showed correlations with arterial saturation and cerebral and renal near-infra-red spectroscopy. Regression analysis revealed that parallel circulation, arterial saturation, and cerebral near-infra-red spectroscopy were predictive of venous saturation. The following equation resulted from the regression analysis: 68.0 - (12.7 x parallel circulation) - (0.8 x arterial saturation) + (0.3 x cerebral near-infra-red spectroscopy). This model had a Bayes factor 10 of 0.03 and adjusted R-squared was 0.29.

CONCLUSION

In paediatric cardiac intensive care patients, there is no significant correlation between venous lactate and venous saturation, suggesting that lactate may not be a reliable marker for assessing the adequacy of oxygen delivery in this population. Only a weak correlation could be identified once the venous saturation was 70% or lower. Additional research is needed to explore alternative markers for monitoring oxygen delivery in critically ill paediatric patients.

Evaluation of three different drugs administered through intraligamentary route for reduction of intraoperative pain of symptomatic irreversible pulpitis in mandibular molars - A randomized triple-blind single-center clinical study

Introduction

Managing intraoperative pain while initiating root canal treatment necessitates the use of supplementary injection techniques.

Aim

The study sought to assess and compare the anesthetic efficacy of 0.5% bupivacaine and 50 mg/ml tramadol hydrochloride versus 2% lignocaine administered as supplemental intraligamentary injection as an adjuvant to an inferior alveolar nerve block (IANB) for mandibular molars with symptomatic irreversible pulpitis (SIP) and normal apical tissues during access cavity preparation.

Materials and Methods

Two hundred and two individuals with mandibular molars diagnosed with SIP with normal apical tissues and exhibiting moderate-to-intense pain were given 2 ml of IANB containing 2% lignocaine and 1:80,000 epinephrine. The Visual Analog Scale (VAS) was used to record intraoperative discomfort. Individuals who scored more than 5 on the VAS were deemed to need further anesthesia. The intraligamentary medication was given to 99 of these patients after they were randomly assigned to 3 groups (2% lignocaine, 0.5% bupivacaine, and 50 mg/ml tramadol). VAS score was again recorded. If the patient reported no pain during the opening of the access, it was deemed a success. The post hoc Tukey's test, paired t-test, and one-way analysis of variance were the statistical methods used to examine the data.

Results

Maximum reduction in pain was in bupivacaine followed by lignocaine and tramadol (P < 0.05). Subgroup analysis using post hoc Tukey's honestly significant difference test showed a maximum difference between bupivacaine and tramadol (1.273, P > 0.05) (95% confidence interval [CI]), followed by lignocaine and bupivacaine (-1.182, P < 0.05) (95% CI) and lignocaine and tramadol (0.091, P > 0.05) (95% CI).

Conclusion

Bupivacaine was most effective in reduction of intraoperative pain when used as an intraligamentary drug during access cavity preparation followed by lignocaine. Tramadol was the least successful drug for achieving effective pulpal anesthesia.

Maternal health and obstetric complications of genetic neuromuscular disorders in pregnancy: A systematic review

BACKGROUND

Genetic neuromuscular disorders affect muscle function and control by the nervous system, presenting significant clinical challenges, particularly during pregnancy.

OBJECTIVES

To systematically review the literature on the obstetric outcomes and complications in women with genetic neuromuscular disorders.

SEARCH STRATEGY

We searched PubMed/Medline, Scopus, and CINAHL Ultimate from inception till June 2024 using terms like "pregnancy", "genetic neuromuscular disorder", "myotonic dystrophy", "maternal health" etc. SELECTION CRITERIA: Pregnant women with genetic neuromuscular disorders.

DATA COLLECTION AND ANALYSIS

Screening, selection, and data extraction were performed independently by two reviewers.

MAIN RESULTS

A total of 28 studies from 1978 to 2023 examined pregnancy outcomes in women with genetic neuromuscular disorders. The disorders included myotonic dystrophy, spinal muscular atrophy (SMA), Charcot-Marie-Tooth disease (CMT), and others. Common complications were polyhydramnios, preterm labor, miscarriages, and cesarean sections. Myotonic dystrophy type 1 (DM1) showed higher neonatal risks than type 2 (DM2). Women with SMA faced exacerbated muscle weakness, while CMT and limb-girdle muscular dystrophy were associated with preterm labor and cesarean deliveries. Pompe disease exacerbated symptoms, and GNE myopathy showed similar pregnancy outcomes to the general population. Non-dystrophic myotonias had higher fetal distress and postpartum complications.

CONCLUSIONS

Women with genetic neuromuscular disorders face increased pregnancy complications, including preterm labor, cesarean sections, and disease symptom exacerbation. Multidisciplinary care between neurologists and obstetricians is essential in managing these high-risk pregnancies effectively, ensuring better maternal and neonatal outcomes. Further research is needed to develop standardized care protocols and improve clinical management.

Wilms tumor and associated predisposing syndromes and conditions

ABSTRACT

Wilms tumor, also known as nephroblastoma, is relatively rare but is the most common renal malignancy in children, accounting for about 5% of all childhood malignancies and 90% of all childhood renal malignancies. Advances in the understanding of the underlying cause and pathophysiology of Wilms tumor have significantly improved the prognosis and survival rates for children with Wilms tumor, but cases may occur sporadically and certain affected patients face higher rates of relapse and morbidity. The most common clinical presentation involves the identification of an abdominal mass or swelling without other signs or symptoms. The nonspecific nature of symptoms that can present can delay timely diagnosis and treatment. Numerous predisposing syndromes are associated with an increased risk for the development of Wilms tumor. Clinicians who recognize these syndromes and other conditions and understand the increased risk can provide the appropriate level of anticipatory guidance and use the optimal screening plan.

Drugs in Development to Manage Acute Pain

Acute pain, defined as short-term pain arising from injury or other noxious stimuli, affects patient outcomes, quality of life, and healthcare costs. Safe, effective treatment of acute pain is essential in preventing increased morbidity, mortality, and the transition to chronic pain. In this review, we explore some of the latest therapeutic agents, formulations, combinations, and administration routes of drugs emerging in clinical practice in the USA for the treatment of acute pain. These agents include VX-548 (Suzetrigine), Cebranopadol, AAT-076, Combogesic intravenous (IV), sublingual ketamine, XG004 (naproxen/pregabalin conjugate), and HTX-011 (Zynrelef). We analyze the pharmacodynamics, pharmacokinetics, development status, and clinical implications of these drugs, emphasizing the importance of finding an agent that provides both a strong safety profile and effective relief from acute pain. Our findings show promise but also highlight the need for further large-scale research to allow these drugs to be utilized in a clinical context for patients experiencing acute pain.

The impact of spinal versus general anesthesia on the variability of surgical times: a systematic review and meta-analysis

BACKGROUND

With spinal anesthesia, when cases are taking longer than usual, there may be behavioural tendencies for surgical teams to work more quickly. We conducted a systematic review with meta-analysis to examine standard deviations of surgical times for single-dose spinal anesthetics versus general anesthesia. We compared ratios of mean surgical times as a secondary endpoint.

METHODS

We included randomized trials of humans where general or spinal anesthesia was used for one category of surgical procedure (e.g., hip arthroplasty) and the article reported the means and standard deviations of operative durations. We used statistical methods suitable for surgical times following log-normal distributions. We used generalized confidence intervals to calculate point estimates of ratios and standard errors for each study, followed by pooling among studies using DerSimonian and Laird random-effects meta-analysis with Knapp-Hartung adjustment.

RESULTS

Among the 77 included studies, 96% were of high quality for our endpoint (i.e., had a low risk of bias), as no (0%) study focused on comparing variability of surgical times and none had surgical time as the primary endpoint. Spinal anesthesia was associated with 6.6% smaller standard deviations than general anesthesia (95% confidence interval, 15.8% smaller to 1.9% larger, P = 0.13). By meta-regression, there was no significant association of the ratios of standard deviations with study quality (P = 0.39), year of publication (P = 0.76), or categories of procedures (all five P ≥ 0.28). Spinal anesthesia was associated with 1.1% smaller means than general anesthesia (95% confidence interval, 3.7% smaller to 1.5% larger, P = 0.42). There were no significant associations between the ratios of means and study quality (P = 0.47), year of publication (P = 0.95), or categories of procedures (all five, P ≥ 0.63).

CONCLUSIONS

The results of this systematic review and meta-analysis show with high confidence that the effect of choosing spinal anesthesia on variability in surgical time, if present, is sufficiently small to have no substantive direct economic effect. The same conclusion applies to mean surgical time. Therefore, although anesthetic choice has a clinical (biological) impact and affects anesthesia times, the direct effects on surgical times and workflow are minimal at most. Anesthetic choice does not influence operating theatre productivity via changes to surgical times. The impact of spinal anesthetic effects is limited to nonoperative times (e.g., reducing anesthesia-controlled times by using a block room before the patient enters the operating room).

STUDY REGISTRATION

PROSPERO ( CRD42023461952 ); first submitted 8 September 2023.

Low dose ondansetron with dexamethasone for prophylaxis of postoperative nausea and vomiting following laparoscopic cholecystectomy-A randomized double-blind study

Background and Aims

Ondansetron and dexamethasone combination is effective for prophylaxis against postoperative nausea and vomiting (PONV). Ondansetron, when compared to dexamethasone, is known to cause more adverse effects and is relatively expensive. The present study evaluated the efficacy of standard dose and low dose ondansetron, i.e. 100 μg/kg and 50 μg/kg, respectively, with dexamethasone 8 mg for PONV prophylaxis in laparoscopic cholecystectomy (LC).

Material and Methods

After the approval from the Institutional Ethics Committee-Human Research [IEC-HR] and prospective CTRI registration, this randomized, double-blind interventional study was conducted following informed consent from each participant. Patients aged 18-65 years of either sex, with ASA physical status I or II, undergoing LC under general anesthesia, were included and divided into groups C and L. Patients in groups C and L received 100 μg and 50 μg of ondansetron, respectively, in combination with 8 mg dexamethasone. The incidence of PONV in first 6 hrs, PONV score, rescue antiemetic consumption, rescue analgesia, and hemodynamic parameters were recorded.

Results

A total of 110 patients were included with 55 in each group. Incidence of PONV in the first 6 hours was found to be higher in 1-2 hour- and 2-3-hour time intervals in group L; but was significant only at 1-2-hour time interval (P < 0.05). Proportion of patients needing rescue antiemetic in the first 6 hours was higher in group L but was not statistically significant.

Conclusion

We observed that 50 μg/kg combination of ondansetron was associated with higher incidence of post operative nausea in the immediate postoperative period than 100 μg/kg dose; however, no significant difference was observed in incidence of post-operative vomiting between two doses following LC.

Factors Associated With Decision to Use and Dosing of Sugammadex in Children: A Retrospective Cross-Sectional Observational Study

BACKGROUND

Sugammadex was initially approved for reversal of neuromuscular blockade in adults in the United States in 2015. Limited data suggest sugammadex is widely used in pediatric anesthesia practice however the factors influencing use are not known. We explore patient, surgical, and institutional factors associated with the decision to use sugammadex versus neostigmine or no reversal, and the decision to use 2 mg/kg vs 4 mg/kg dosing.

METHODS

Using data from the Multicenter Perioperative Outcomes Group (MPOG) database, an EHR-derived registry, we conducted a retrospective cross-sectional study. Eligible cases were performed between January 1, 2016 and December 31, 2020, for children 0 to 17 years at US hospitals. Cases involved general anesthesia with endotracheal intubation and administration of rocuronium or vecuronium. Using generalized linear mixed models with institution and anesthesiologist-specific random intercepts, we measured the importance of a variety of patient, clinician, institution, anesthetic, and surgical risk factors in the decision to use sugammadex versus neostigmine, and the decision to use a 2 mg/kg vs 4 mg/kg dose. We then used intraclass correlation statistics to evaluate the proportion of variance contributed by institution and anesthesiologist specifically.

RESULTS

There were 97,654 eligible anesthetics across 30 institutions. Of these 47.1% received sugammadex, 43.1% received neostigmine, and 9.8% received no reversal agent. Variability in the choice to use sugammadex was attributable primarily to institution (40.4%) and attending anesthesiologist (27.1%). Factors associated with sugammadex use (compared to neostigmine) include time from first institutional use of sugammadex (odds ratio [OR], 1.08, 95% confidence interval [CI], 1.08-1.09, per month, P < .001), younger patient age groups (0-27 days OR, 2.59 [2.00-3.34], P < .001; 28 days-1 year OR, 2.72 [2.16-3.43], P < .001 vs 12-17 years), increased American Society of Anesthesiologists [ASA] physical status (ASA III: OR, 1.32 [1.23-1.42], P < .001 ASA IV OR, 1.71 [1.46-2.00], P < .001 vs ASA I), neuromuscular disease (OR, 1.14 (1.04-1.26], P = .006), cardiac surgery (OR, 1.76 [1.40-2.22], P < .001), dose of neuromuscular blockade within the hour before reversal (>2 ED95s/kg OR, 4.58 (4.14-5.07], P < .001 vs none), and shorter case duration (case duration <60 minutes OR, 2.06 [1.75-2.43], P < .001 vs >300 minutes).

CONCLUSIONS

Variation in sugammadex use was primarily explained by institution and attending anesthesiologist. Patient factors associated with the decision to use sugammadex included younger age, higher doses of neuromuscular blocking agents, and increased medical complexity.

Anterior quadratus lumborum blocks for postoperative pain treatment following intra-abdominal surgery: A systematic review with meta-analyses and trial sequential analyses

BACKGROUND

The anterior quadratus lumborum (QL) block may be used for postoperative pain management for intra-abdominal surgeries, but the evidence is uncertain. We aimed to investigate the benefit and harm of the anterior QL block compared to placebo/no block for intra-abdominal surgery.

METHODS

We searched Medline, Embase, and CENTRAL for randomized controlled trials investigating anterior QL block for postoperative pain management for adult patients undergoing any intra-abdominal surgery. The two co-primary outcomes were cumulative 24-h opioid consumption and serious adverse events. We performed meta-analysis, trial sequential analysis (TSA), assessed the risk of bias, and present the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Thirty-five trials randomizing 2418 patients were included in the meta-analyses. Anterior QL block may reduce cumulative 24-h intravenous opioid consumption compared to placebo/no block (MD -10.42 mg, 96.7% CI -14.83 to -6.01, TSA-adjusted CI -17.03 to -3.82, p < .01). Two trials reported on SAEs. Anterior QL block may have little to no effect on the number of serious adverse events compared to placebo (RR 1.49, 96.7% CI 0.19 to 11.47, p = .68), but the evidence is very uncertain. All trial results were assessed as being high risk of bias.

CONCLUSIONS

The anterior QL block may reduce cumulative 24-h opioid consumption. Reported serious adverse events were few and the anterior QL block may have little to no effect on the number of SAEs, but the evidence was very uncertain.

Common error traps in anesthesia for neonatal surgical emergencies

Neonatal surgical emergencies are challenging, often high-risk procedures for the pediatric anesthesiologist. Though each emergency presents different anesthetic challenges, several error traps exist that are common to all procedures in this patient population. These error traps include errors in surgical timing, airway management, maintenance of normothermia and normoglycemia, and recognition of pharmacologic and physiologic differences. In this narrative review, we will discuss each error trap to aid the clinician in recognizing, planning for, and mitigating adverse events.

Efficacy and safety of the Valsalva maneuver in relieving venipuncture pain in children and adults: A systematic review and meta-analysis

Venipuncture is a common invasive clinical procedure, and pain management during puncture has been of interest to healthcare professionals. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of the Valsalva maneuver (VM) for the relief of venipuncture pain in children and adults. PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, VIP database, and CBM were searched from inception to December 2023 for all available randomized controlled trials (RCTs) that evaluated the impact of VM on venipuncture. Two reviewers independently performed study selection, data extraction, and risk of bias assessment. Continuous variables were analyzed by mean differences (MD) or standardized mean differences (SMD), whereas dichotomous variables were analyzed by risk ratios (RR). A total of 22 studies involving 1740 participants were included. The pooled results showed that VM relieved pain intensity during venipuncture in children (SMD = -0.89, 95% CI = -1.47 to -0.30, p = 0.003) and adults (SMD = -1.11, 95% CI = -1.46 to -0.77, p < 0.00001), reduced anxiety intensity (SMD = -1.07, 95% CI = -1.68 to -0.47, p = 0.0005), and shortened puncture time (MD = -13.52, 95% CI = -21.14 to -5.90, p = 0.0005). There was no significant difference in the success rate of venous cannulation, MAP, HR, or incidence of adverse events in subjects who performed VM compared to controls. VM was an effective and safe method of pain management that reduced pain intensity during venipuncture in children and adults without significant adverse effects. The results of this meta-analysis need to be further validated by more rigorous and larger RCTs.

The effect of replacing dental needles between subsequent inferior alveolar nerve blocks on pain and trismus - a double blinded, randomised split-mouth study

Background

Inferior alveolar Nerve Blocks are widely used in dental practice for achieving anaesthesia in the mandibular teeth. It is widely accepted that in order for this type of injection to be effective, the needle needs to penetrate a substantial depth of soft tissues as well as make contact with bone. This routinely leads to both blunting and barbing of the needle tip suggesting that a needle change is preferable for any subsequent injection as this will result in less tissue damage and pain for patient's. The study aimed to verify whether a change in needle affected measures of pain and trismus.

Material and Methods

This was a prospective, single center, double blinded (both clinician and participant), randomized, split-mouth study conducted in a large dental hospital and teaching facility. Participants were screened for factors that might alter their head pain sensation and participated in 2 clinical visits. In the first visit 2 needle insertions either with/without needle change were performed without anaesthetic as per an IANB injection. A survey instrument was used to capture several dimensions of pain both immediately after the visit as well as 48-72 hours later. This method was repeated on a second visit on the opposite mandibular quadrant after a washout period of at least 2 weeks. Paired t-Test's were performed at the 2 time points.

Results

Significance was only demonstrated in one of 10 sensory and 12 emotional pain descriptors during one of the 2 time points of measurement. Similarly, VAS mean pain scores and a measure of trismus were not affected by needle change.

Conclusions

This study was able to demonstrate that a change in needle between subsequent IANB's does not affect self-reported measures of pain nor trismus. Key words:Nerve block, dental injection, dental anaesthesia, pain, trismus.

Amyloid beta-induced mitochondrial dysfunction and endothelial permeability in cerebral microvascular endothelial cells: The protective role of dexmedetomidine

Postoperative cognitive dysfunction (POCD) is a common complication in patients who undergo anesthesia in different types of surgeries. Emerging evidence implicates elevated beta-amyloid (Aβ) in the pathogenesis of POCD. Meanwhile, Dexmedetomidine (DEX) has recently shown promise in reducing POCD incidence. This study aimed to elucidate the role of Aβ in inducing endothelial permeability in cerebral microvascular endothelial cells and the underlying mechanisms and testing the effects of DEX. We demonstrated that Aβ1-42, the prevalent Aβ form related to POCD, is cytotoxic to HBMECs, increasing transendothelial permeability and inducing mitochondrial dysfunction, as evidenced by elevated mitochondrial reactive oxygen species (ROS) and decreased ATP production and mitochondrial membrane potential. Furthermore, Aβ1-42 was shown to inhibit Sirt3, exacerbating mitochondrial dysfunction. Conversely, DEX was found to prevent Aβ1-42-induced mitochondrial dysfunction and permeability increases and preserved tight junction proteins in HBMECs.These findings suggest that DEX, as a Sirt3 activator, may offer a pharmacological strategy to mitigate Aβ1-42-related cerebral microvascular endothelial cell dysfunction and preserve cognitive function post-surgery.

Opioid-free anaesthesia and postoperative quality of recovery: a systematic review and meta-analysis with trial sequential analysis

BACKGROUND

There is still debate over whether opioid-free anaesthesia (OFA) can improve the patient-reported quality of recovery (QoR).

METHODS

A search was conducted across Pubmed, Cochrane Library, and EMBASE until June 2024 for randomized controlled trials comparing the impact of OFA and opioid-based anaesthesia (OBA) on QoR in adult patients undergoing general anaesthesia. The primary outcome was the quality of recovery measured with the QoR scale. The secondary outcomes were the five dimensions of the QoR scale.

RESULTS

The analysis included 15 studies, and showed that compared with OBA, OFA improved the global QoR score at postoperative 24 h (SMD 0.87; 95% CI, 0.48-1.27; I2: 92%; low-level evidence). Among them, 10 studies revealed a greater QoR-40 score at postoperative 24 h in the OFA than in the OBA (MD 6.59; 95% CI, 2.84-10.34; I2: 93%; moderate-level evidence), which exceeded the minimal clinically important difference of 6.3. Conversely, the synthetic data of 4 studies did not reveal an improvement in the global QoR-15 score at postoperative 24 h (MD 9.94; 95% CI, -0.15 to 12.35; I2: 97%; low-level evidence). Regarding different domains of scale, OFA had positive effects on physical comfort (SMD 0.75; 95% CI, 0.25-1.25; I2: 93%; moderate-level evidence) and pain (SMD 0.59; 95% CI, 0.15-1.03; I2: 91%; moderate-level evidence).

CONCLUSIONS

The meta-analysis indicate OFA can improve the quality of recovery at postoperative 24 h, particularly in terms of enhancing physical comfort and reducing pain. However, due to significant heterogeneity and moderate-to-low level of evidence, the external validity of OFA for improving postoperative recovery remains to be further validated.

REGISTRATION

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database on December 07, 2023 (CRD42023486235).

Effects of post rib plating tube thoracostomy output on the need for thoracic re-intervention: Does the volume matter?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) has been demonstrated to improve early clinical outcomes. Tube thoracostomy (TT) is commonly performed with SSRF, however there is a paucity of data regarding when removal of TT following SSRF should occur. This study aimed to compare patients undergoing thoracic reinterventions (reintubation, reinsertion of TT/pigtail, or video-assisted thoracic surgery) to those not following SSRF+TT, hypothesizing increased TT output prior to removal would be associated with thoracic reintervention.

METHODS

We performed a single center retrospective (2018-2023) analysis of blunt trauma patients ≥ 18 years-old undergoing SSRF+TT. The primary outcome was thoracic reinterventions. Patients undergoing thoracic reintervention ((+)thoracic reinterventions) after TT removal were compared to those who did not ((-)thoracic reintervention). Secondary outcomes included TT duration and outputs prior to removal.

RESULTS

From 133 blunt trauma patients undergoing SSRF+TT, 23 (17.3 %) required thoracic reinterventions. Both groups were of comparable age. The (+)thoracic reintervention group had an increased injury severity score (median: 29 vs. 17, p = 0.035) and TT duration (median: 4 vs. 3 days, p < 0.001) following SSRF. However, there were no differences in median TT outputs between both cohorts post-SSRF day 1 (165 mL vs. 160 mL, p = 0.88) as well as within 24 h (60 mL vs. 70 mL, p = 0.93) prior to TT removal.

CONCLUSION

This study demonstrated over 17 % of SSRF+TT patients required a thoracic reintervention. There was no association between thoracic reintervention and the TT output prior to removal. Future studies are needed to confirm these findings, which suggest no absolute threshold for TT output should be utilized regarding when to pull TT following SSRF.

The clinical application of transcutaneous carbon dioxide monitoring during rigid bronchoscopy or microlaryngeal surgery in children

STUDY OBJECTIVE

During rigid bronchoscopies and microlaryngeal surgery (MLS) in children, there is currently no reliable method for managing ventilation strategies based on carbon dioxide (CO2) levels. This study aimed to investigate the effects of the clinical implementation of transcutaneous CO2 (tcPCO2) monitoring during rigid bronchoscopies or MLS.

DESIGN

Prospective observational study.

SETTING

Operating theatre of a tertiary pediatric hospital, from January 2019 to March 2021.

PATIENTS

Children with an age < 18 years, undergoing rigid bronchoscopy or MLS, were eligible for inclusion. Children with tracheostomy and/or skin conditions limiting tcPCO2 monitoring were excluded.

INTERVENTIONS

TcPCO2 monitoring was performed in two groups; blinded before clinical implementation (control group) and visible for ventilation management after clinical implementation (tcPCO2 group).

MEASUREMENTS

The total tcPCO2 load outside of the normal range (35-48 mm Hg) was calculated as the area under the curve (AUC) and compared between the groups. Anesthesiologists in the tcPCO2 group received a questionnaire after each procedure.

MAIN RESULTS

A total of 120 patients were included. No significant differences were found between the two groups in the AUC during the procedure (19,202 (7,863-44,944) vs 17,737 (9,800-47,566) mm Hg · s, P = 0.84) or between different ventilation strategies. The maximal tcPCO2 level was 69.2 (62.1-81.2) mm Hg in the control group and 71.1 (62.8-80.8) mm Hg, (P = 0.85) in the tcPCO2 group. Spontaneous breathing was associated with lower tcPCO2 levels. The general satisfaction score of tcPCO2 monitoring rated by the anesthesiologist was 8.19 (0.96).

CONCLUSIONS

TcPCO2 levels reached approximately twice the upper limit of the normal range during rigid bronchoscopy and MLS. Availability of tcPCO2 monitoring did not affect these high levels, despite adjustments in strategy. However, tcPCO2 monitoring provides valuable insight in CO2 load and applied ventilation strategies.

Anaesthetic management of a large multi-nodular goitre with dynamic bilateral carotid artery compression

Dynamic carotid compression arising from a change in patient position is a rare complication of goitre, with the potential for cerebral ischaemia and infarction. In this report, a 37-year-old woman presented with a multi-nodular goitre with clinical features concerning for transient cerebral ischaemia. The anaesthetic management and neurological monitoring used to mitigate the risk of cerebral ischaemia during thyroidectomy is described and the literature surrounding this rare complication is explored.

Our Experience of Managing Central Airway Tumors: Anesthesia Perspectives

ABSTRACT

Adult patients with central airway tumors commonly present with dyspnea on exertion. These patients may remain asymptomatic until more than half of the airway diameter is obliterated. Anesthesia for debulking a central airway tumor is challenging. Anesthetic management should include a strategy for oxygenation and ventilation, a plan for the same if tumor bleeding aggravates airway obstruction and a plan to deal with acute emergencies like pneumothorax and cardiac arrest. Patients with airway tumors occupying < 50% airway diameter and comfortable during routine activities can be managed using relaxant anesthesia and rigid bronchoscopy for debulking. Airway tumors with >75% airway lumen compromise are the sickest and may present in respiratory failure. We found that in these patients, maintaining spontaneous ventilation, avoidance of general anesthesia, and muscle relaxation are the keys to management. General anesthesia and muscle relaxants decreases / abolishes negative intrapleural pressure, which may result in dynamic hyperinflation and pneumothorax in presence of airway obstruction. In this subset, we routinely use i-gel (sizes 4 and 5) as an airway conduit for debulking. We prefer i-gel® (Intersurgical Ltd, UK) over rigid bronchoscopy as it requires less sedation. To allow this, it is prudent to ensure excellent airway anesthesia prior to i-gel placement using airway blocks, topical anesthetics, and titrated doses of sedation. We manage 20-30 cases of central airway tumors for debulking or stenting every year and share our experience of managing four cases depicting a spectrum of airway and review the literature on anesthetic management of central airway tumors.

A Novel Implant Design for Cemented Endoprosthesis Stems to Reduce the Risk of Bone Cement Implantation Syndrome

BACKGROUND

 Bone cement implantation syndrome (BCIS) is a life-threatening risk of cemented stems. There are limited methods to prevent BCIS and few published studies. A survey of the Musculoskeletal Tumor Society (MSTS) surgeons was conducted to evaluate their experiences with BCIS. A novel stem designed to reduce intramedullary pressure during insertion was evaluated.

METHODS

 A survey was distributed to MSTS members, and data was collected. The novel stem featured a hollow longitudinal channel, an entry hole at the tip, and an egress hole at the collar for cement to flow from the intramedullary canal during insertion. Bending stiffness was compared using finite element analysis to a standard solid stem. Stems were cemented into cadaveric femurs. Specimens were loaded with 8000 N tensile force and then maximally torqued until failure. Intramedullary pressures were measured for novel and standard stems cemented into sawbones.

RESULTS

 In 107 survey responses, 58% (n = 63) experienced severe BCIS, and 83% (n = 52) of those had ≥1 death from BCIS complications. Many surgeons avoid cementing long stems, and 78% (n = 14) report concern for BCIS as the reason. Seventy-nine percent (n = 84) use an average of 4.75 different methods to reduce BCIS risk. The novel stem demonstrated 2.8% reduced bending stiffness. When cemented into cadaveric bone, both stem designs achieved 8000 N of tensile force, and there was no significant difference in torque failure (140.6 Nm in the novel stem; 128 Nm in the standard stem). The average peak pressure was significantly lower for the novel stem (77 psi vs. 151 psi).

CONCLUSIONS

 The majority of surgeons have concerns regarding BCIS based on their experience and use multiple methods to reduce risk. A novel stem can reduce the intramedullary insertion pressure by approximately half and possibly reduce the risk of BCIS. Testing demonstrates similar stiffness and stability compared to standard solid stems.

A Qualitative analysis of parturients' experience of spinal anesthesia and postoperative complaints

Background

Cesarean deliveries have increased globally, with regional anesthesia being the preferred technique. Despite the advantages of the procedure, parturients experience apprehension regarding pain, mobility, and complications. The postoperative period following cesarean delivery can also be challenging. However, there is limited qualitative research exploring parturients' experiences with regional anesthesia for cesarean delivery and postoperative recovery.

Methods

A qualitative study using in-depth interviews was conducted with 12 primiparous parturients who underwent cesarean delivery under regional anesthesia. Interviews explored knowledge, perceptions, and experiences regarding regional anesthesia, cesarean delivery, and postoperative recovery. Data were analyzed using thematic analysis.

Results

Parturients in the study reported experiencing pregnancy-related complications necessitated for opting cesarean delivery instead of vaginal delivery. The study revealed substantial knowledge gaps among parturients regarding cesarean section (CS) and anesthesia. Their decision for CS was driven by prioritizing fetal safety over personal comfort. Parturients did not have many concerns about anesthesia and were focusing mainly on neonatal wellbeing. They had limited recollection of the anesthesia experience but vividly remembered the delivery process and postoperative pain. A strong desire for recovery to provide neonatal care was expressed. Despite challenges, parturients reported overall satisfaction with the CS experience and willingness to recommend it when medically indicated.

Conclusion

The study highlights the need for comprehensive education on regional anesthesia, postoperative care, and coping strategies for parturients undergoing cesarean delivery. It emphasizes judicious use of cesarean delivery based on medical necessity while ensuring optimal maternal and neonatal outcomes. Further qualitative research with larger samples is recommended.

Impact of dextrose supplementation on intraoperative blood glucose levels in pediatric patients undergoing major surgeries under general anesthesia with caudal analgesia

Background and Aims

In children undergoing surgery, the stress responses of surgery can result in blood glucose elevation consequent to release of cortisol and catecholamines. The use of a regional block could attenuate the stress responses and lower the blood glucose levels. We compared the blood glucose values at specified time points during surgery with and without additional dextrose to evaluate the need for glucose supplementation as our primary outcome. Intraoperative hemodynamics and the need for any intervention for correction of blood sugars were noted secondarily.

Material and Methods

Children aged between 6 months and 8 years undergoing elective major surgery were randomized to group D (received 1% dextrose in Ringer's lactate) or group P (received only Ringer's lactate). Blood sugars were measured half hourly for 2 h following intubation, and data was analyzed using Student's t-test and Chi-square test.

Results

Demographic variables and the duration of surgery were comparable. The baseline blood glucose value was lower in group D. Analysis of covariates test for a comparison of adjusted mean blood glucose (MBG) showed the values at 30, 60, and 90 min to be comparable. However, toward the end of surgery, the MBG value was significantly higher in group D (P = 0.019). Heart rate and mean arterial pressure were comparable at the same points of measurement.

Conclusion

Dextrose supplementation is not needed for children receiving caudal analgesia for major surgeries of 2-3 h duration and may raise blood sugars at the end of surgery.

A Systematic Review and Meta-Analysis of Prophylactic Vasopressors for the Prevention of Peri-Intubation Hypotension

BACKGROUND/OBJECTIVES

Peri-intubation hypotension is a known complication of endotracheal intubation. In the hospital setting, peri-intubation hypotension has been shown to increase hospital mortality and length of stay. The use of prophylactic vasopressors at the time of sedation induction to prevent peri-intubation hypotension has been raised. This systematic review and meta-analysis aims to review the safety and efficacy of this practice.

METHODS

The study was fully registered with PROSPERO on 13 October 2022, and screening for eligibility was initiated on 20 September 2024. Randomized controlled trials, along with retrospective or prospective cohort studies, were included in the search. The terms "peri-intubation hypotension", "vasopressors", "intubation", and "anesthesia induced hypotension" were used to search the title/summary in PubMed, Cochrane Library, and Google Scholar databases. An assessment of bias for each study was conducted using the Newcastle-Ottawa Quality Assessment Scale. The primary outcome was the rate of hypotension peri-intubation. Any complications secondary to hypotension or vasopressors were the secondary outcome.

RESULTS

We identified 13 studies, which were all randomized controlled studies, to include in the final analysis. The risk ratio for preventing peri-intubation hypotension was 1.6 (95% CI, 1.2-2.14) with the use of prophylactic phenylephrine while giving propofol versus no prophylactic vasopressors and 1.28 (95% CI 1.03-1.60) with the use of ephedrine.

CONCLUSIONS

These findings suggest that in patients undergoing intubation in the operating room with propofol, prophylactic vasopressors given with induction for intubation decrease the odds of hypotension.

Comparison of 1% chloroprocaine hydrochloride versus hyperbaric bupivacaine spinal in patients undergoing anorectal surgery in an ambulatory surgery center: a double-blind randomized clinical trial

BACKGROUND

Preservative-free chloroprocaine is a promising spinal anesthetic for ambulatory surgeries, offering a short duration of action and minimal side effects, which promote faster recovery and discharge. Thus, this study aimed to compare chloroprocaine hydrochloride to the widely used bupivacaine as a spinal anesthetic in ambulatory anorectal surgeries. We hypothesized that chloroprocaine will lead to quicker recovery and discharge, supporting its use in the ambulatory surgical setting.

METHODS

In this double-blind randomized controlled trial, 110 patients were randomized to 1% chloroprocaine or 0.75% bupivacaine treatment groups. Due to the inability to place a spinal anesthetic, five patients were excluded (one in chloroprocaine and four in bupivacaine groups). The co-primary endpoints were recovery time (defined as the time of motor and sensory function return), and time discharge criteria were met. The secondary endpoint was the onset of transient neurological symptoms (TNS).

RESULTS

The chloroprocaine group had a significantly shorter time to meet discharge criteria (191.4±6.6 min) than the bupivacaine group (230.9±9.4 min; p=<0.001). There were no significant differences between interventions for recovery time. No TNS were recorded within 24 hours after the procedure for both groups.

CONCLUSION

Our study demonstrated a significantly reduced time to meeting discharge criteria with chloroprocaine compared with bupivacaine without an increased risk of TNS. Our results support the use of chloroprocaine for spinal anesthesia in ambulatory anorectal surgeries.

TRIAL REGISTRATION NUMBER

NCT03324984.

Non-adrenergic vasopressors for vasodilatory shock or perioperative vasoplegia: a meta-analysis of randomized controlled trials

BACKGROUND

Excessive exposure to adrenergic vasopressors may be harmful. Non-adrenergic vasopressors may spare adrenergic agents and potentially improve outcomes. We aimed to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of non-adrenergic vasopressors in adult patients receiving vasopressor therapy for vasodilatory shock or perioperative vasoplegia.

METHODS

We searched PubMed, Embase, and Cochrane Library for RCTs comparing non-adrenergic vasopressors with adrenergic vasopressors alone or placebo in critically ill or perioperative patients. Each eligible study was categorized into septic shock, cardiac surgery, or non-cardiac surgery. Non-adrenergic vasopressors included vasopressin, terlipressin, selepressin, angiotensin II, methylene blue, and hydroxocobalamin. The primary outcome was mortality at longest follow-up. We conducted a random-effects meta-analysis. We registered the protocol in PROSPERO International Prospective Register of Systematic Reviews (CRD42024505039).

RESULTS

Among 51 eligible RCTs totaling 5715 patients, the predominant population was septic shock in 30 studies, cardiac surgery in 11 studies, and non-cardiac surgery in 10 studies. Cochrane risk-of-bias tool for randomized trials version 2 identified 17 studies as low risk of bias. In septic shock, mortality was significantly lower in the non-adrenergic group (960/2232 [43%] vs. 898/1890 [48%]; risk ratio [RR], 0.92; 95% confidence interval [95% CI], 0.86-0.97; P = 0.03; I2 = 0%), with none of the individual non-adrenergic vasopressors showing significant survival benefits. No significant mortality difference was observed in patients undergoing cardiac surgery (34/410 [8.3%] vs. 47/412 [11%]; RR, 0.82; 95% CI, 0.55-1.22; P = 0.32; I2 = 12%) or those undergoing non-cardiac surgery (9/388 [2.3%] vs. 18/383 [4.7%]; RR, 0.66; 95% CI, 0.31-1.41; P = 0.28; I2 = 0%).

CONCLUSIONS

Administration of non-adrenergic vasopressors was significantly associated with reduced mortality in patients with septic shock. However, no single agent achieved statistical significance in separate analyses. Although the pooled effects of non-adrenergic vasopressors on survival did not reach statistical significance in patients undergoing cardiac or non-cardiac surgery, the confidence intervals included the possibility of both no effect and a clinically important benefit from non-adrenergic agents. These findings justify the conduct of further RCTs comparing non-adrenergic vasopressors to usual care based on noradrenaline alone.

Regional nerve block in postoperative analgesia after cesarean section: A narrative review

Of all obstetric operations, cesarean section is one of the most common. The impact of postoperative pain on physical and mental health in women cannot be ignored. Moreover, effective postoperative analgesia is essential in women who have given birth. Traditional systemic analgesic methods (intravenous analgesia, oral analgesics, etc) are often accompanied by adverse reactions that are positively correlated with the drug dosage. Regional nerve block is an analgesic and anesthetic technique that temporarily blocks nerve conduction by injecting local anesthetics around the nerve roots, nerve trunks, nerve plexus, ganglia, or surgical area, thereby alleviating or eliminating pain. Currently, the regional block techniques used for postoperative analgesia following cesarean section include paravertebral nerve block, transversus abdominis plane block, rectus sheath block, quadratus lumborum block, ilioinguinal-iliohypogastric nerve block, erector spinae block, wound infiltration analgesia, and intraperitoneal infusion of local anesthetics. These regional block techniques hold great promise for providing effective postoperative analgesia after cesarean section, each with unique advantages. Moreover, regional blocks have a unique place in multimodal analgesia protocols following cesarean section and are increasingly used in clinical practice for analgesia after cesarean section. This review provides an overview of the regional nerve block techniques used for postoperative analgesia following cesarean section, discusses their benefits and drawbacks, and provides a reference for choosing postoperative pain management following cesarean delivery, offering a hopeful outlook for improved patient care.

Chronic kidney disease and aging: dissecting the p53/p21 pathway as a therapeutic target

Chronic kidney diseases (CKD) are a group of multi-factorial disorders that markedly impair kidney functions with progressive renal deterioration. Aging contributes to age-specific phenotypes in kidneys, which undergo several structural and functional alterations, such as a decline in regenerative capacity and increased fibrosis, inflammation, and tubular atrophy, all predisposing them to disease and increasing their susceptibility to injury while impeding their recovery. A central feature of these age-related processes is the activation of the p53/p21 pathway signaling. The pathway is a key player in cellular senescence, apoptosis, and cell cycle regulation, which are all key to maintaining the health of the kidney. P53 is a transcription factor and a tumor suppressor protein that responds to cell stress and damage. Persistent activation of cell p53 can lead to the expression of p21, an inhibitor of the cell cycle known as a cyclin-dependent kinase. This causes cells to cease dividing and leads to senescence, where cells can no longer increase. The accumulation of senescent cells in the aging kidney impairs kidney function by altering the microenvironment. As the number of senescent cells increases, the capacity of the kidney to recover from injury decreases, accelerating the progression of end-stage renal disease. This article review extensively explores the relationship between the p53/p21 pathway and cellular senescence within an aging kidney and the emerging therapeutic strategies that target it to overcome the impacts of cellular senescence on CKD.

Management of ERCP-Related Perforations: A Single-Center Experience

Background/Objectives: Perforations represent rare but serious complications in ERCP. Although several therapeutic algorithms have been proposed to properly address these potentially life-threatening events, there is still no clear consensus on their management. We conducted a single-center retrospective study in order to assess the incidence of ERCP-related perforations and their management, as well as clinical outcomes. Methods: The hospital's electronic database was searched in order to identify all the patients who developed ERCP-related perforations in the period 1 October 2018-30 June 2023. Perforations were classified according to the Stapfer classification. Conservative management included frequent abdominal examinations, the monitoring of vital signs, white blood cell count, complete bowel rest, nasogastric tube placement, and the administration of intravenous fluids and antibiotics. Endoscopic management included biliary stent placement and/or closing observed defects with clips. Results: We recorded eight (1.29%) cases of ERCP-related perforations out of the 619 procedures conducted. We observed six (75%) Stapfer type II and two (25%) type IV perforations. In all but one patient (87.5%), the indication for ERCP was bile duct stones. Seven patients (87.5%) were subjected to sphincterotomy (87.5%) and three (37.5%) to "pre-cuts". All but one patient was treated conservatively (87.5%), with two of them-in which type II perforations were recognized intraprocedurally-also receiving endoscopic treatment with stent placement. On the day of ERCP, one patient with a type II perforation was operated on; suturing of the duodenum followed by duodenal exclusion was applied. Management was successful in all the patients, with a mean hospitalization time of 16.6 ± 4.78 days. Conclusions: Conservative and endoscopic management appear to be associated with good outcomes in Stapfer type II perforations. Nevertheless, an individual multidisciplinary approach involving endoscopists and a hepatobiliary surgeon is essential in order to properly guide the treatment.

Effects of fluid therapy with ringer's vs. ringer lactate solution on acid-base balance and serum electrolytes in patients undergoing coronary artery bypass graft surgery

Introduction

Preventing acid-base and electrolyte disturbance is crucial in coronary artery bypass graft (CABG) surgery, since any of these conditions can affect outcome. The type of crystalloid solution used during and after the surgery can affect these disturbances.

Methods

In this study, 90 patients who candidates for CABG surgery were randomly allocated to either ringer's lactate (RL) or ringer's group. In order to provide essential blood volume before and after the start of CPB fluid administration with either ringer's or RL solution was started during operation and continued for 18 hours after the patient was transferred to ICU. ABG, serum electrolytes and Lactate level were measured before and at the end of CPB, upon arrival to the ICU, and 6, 12 and 18 hours after ICU admission and compared between the two groups.

Results

Blood PH level was significantly different between the two groups upon arrival to ICU, 6 and 18 hours after ICU admission (P<0.05) which was clinically closer to the normal range in the RL group. Serum bicarbonate level showed a significantly difference between the two groups (P<0.05). There were no significantly differences between the two groups in terms of lactate level, serum electrolytes, blood loss, intake and output of fluids and blood products transfusion.

Conclusion

In this study, ringer's lactate solution creates a more favorable acid-base balance without a significant increase in blood lactate level which is attributed to the buffering effect of existing lactate, and can be used as an appropriate alternative to ringer's solution during and after CABG.

How to undertake peripheral intravenous cannulation

RATIONALE AND KEY POINTS

Peripheral intravenous (IV) cannulation in adults is one of the most commonly performed healthcare procedures. It involves the insertion of a small tube into a vein using a needle, enabling the administration of fluids, blood products and nutrition, and the collection of blood samples. Healthcare professionals performing this procedure must undergo training to be able to undertake it effectively and safely. • Knowledge of vein anatomy and understanding the risks and benefits of the procedure supports safe practice, reduces errors, costs and infection risk, and improves the overall patient experience. • To provide holistic care, nurses should understand the indications for peripheral IV cannulation, which can be a short-term intervention for administering medicines, fluids and blood products, and for parenteral nutrition • Various pharmacological interventions and psychological techniques can be used to alleviate or minimise the pain and anxiety experienced by some patients during cannulation. • Following the successful insertion of a peripheral IV cannula, nurses must provide ongoing care to preserve the cannula's patency and safeguard the patient. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when undertaking peripheral IV cannulation. • How you could use this information to educate nursing students or your colleagues on the appropriate and safe methods for undertaking peripheral IV cannulation.

Pain Management in Open Abdominal Aortic Aneurysm Repair: Potential Alternatives to Epidural Anesthesia

Despite significant advances in endovascular techniques, open abdominal aortic aneurysm (AAA) repair continues to play an important role in vascular surgery. Many studies have described the advantages of epidural anesthesia combined with general anesthesia over general anesthesia alone as an analgesic method for open AAA repair. Several recent guidelines have recommended epidural anesthesia as the first option for pain management in open AAA repair. However, AAA repair requires perioperative anticoagulation, and bleeding complications are an inevitable concern. In the past 2 decades, new methods of analgesia, represented by ultrasound-guided nerve blocks, have been developed and become popular in major abdominal surgery. These analgesic methods may address the concern of bleeding complications associated with epidural anesthesia in open AAA repair. Although the efficacy and safety of ultrasound-guided nerve blocks, continuous local wound infiltration, and intravenous administration of lidocaine in open AAA repair have been evaluated in several studies, few studies have evaluated the efficacy of continuous nerve blocks compared with epidural anesthesia. In this article, the authors present a narrative review of pain management techniques used in open AAA repair, focusing on pain management techniques other than epidural anesthesia. Research gaps and the need for further studies on this topic are also discussed.

Comparison of I-gel and Baska mask in elective surgery: a meta-analysis

OBJECTIVE

The supraglottic airway device is a viable alternative to tracheal intubation for elective surgery. To conduct a comparative analysis of the advantages and disadvantages associated with use of the Baska mask and I-gel across various dimensions.

DESIGN

A comprehensive search was conducted across PubMed, Embase, Cochrane Library, Web of Science, and other relevant databases to identify randomised controlled trials (RCTs) involving patients who used the Baska mask and I-gel.

MAIN RESULTS

Twelve studies were identified for comparison of clinical indices. The Baska mask device demonstrated general feasibility in oropharyngeal leak pressure at insertion time and 30 min post-insertion, as well as in the assessment of dysphonia. However, the I-gel had superior efficacy in reducing sore throat compared with the Baska mask.

CONCLUSIONS

Based on current evidence, the Baska mask demonstrates superior intraoperative performance compared with I-gel; however, it is associated with a higher incidence of a sore throat post-extubation. Nevertheless, the overall quality of existing studies is suboptimal, underscoring the need for additional high-quality RCTs to substantiate these findings.