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Lee HC, Wu BG, Chen BC, Luk HN, Qu JZ. Structured Routine Use of Styletubation for Oro-Tracheal Intubation in Obese Patients Undergoing Bariatric Surgeries-A Case Series Report. Healthcare (Basel) 2024; 12:1404. [PMID: 39057547 PMCID: PMC11276324 DOI: 10.3390/healthcare12141404] [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: 06/10/2024] [Revised: 07/07/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
The aim of this case series report is to provide a new topical view of styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese populations with potentially difficult airway complications. The safety and effectiveness of VLs have been repeatedly studied, and the superiority of VLs has then been observed in and advocated for routine use. In this article, among our vast use experiences with styletubation (more than 54,998 patients since 2016) for first-line routine tracheal intubation, we present the unique experience to apply the styletubation technique in obese patients undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique itself to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve is steep, but competency can be enhanced if technical pitfalls can be avoided. We, therefore, propose that the styletubation technique can be feasibly and routinely applied as a first-line airway modality in obese patients undergoing bariatric surgery.
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Affiliation(s)
- Hsiang-Chen Lee
- Department of Anesthesia, Hualien Tzuchi Hospital, Hualien 97002, Taiwan;
| | - Bor-Gang Wu
- Department of Surgery, Hualien Tzu-Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu-Chi University, Hualien 97002, Taiwan;
| | - Bo-Cheng Chen
- Department of Otolaryngology, Hualien Tzu Chi Hospital, No. 707, Sec. 3, Chung-Yang Road, Hualien 97002, Taiwan;
| | - Hsiang-Ning Luk
- Department of Anesthesia, Hualien Tzuchi Hospital, Hualien 97002, Taiwan;
- Laboratory of Bio-Math, Department of Financial Engineering, Providence University, 200, Sec. 7, Taiwan Boulevard, Shalu Dist., Taichung City 43301, Taiwan
| | - Jason Zhensheng Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA;
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Studer AS, Atlas H, Belliveau M, Sleiman A, Deffain A, Garneau PY, Pescarus R, Denis R. Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center. BMC Surg 2024; 24:204. [PMID: 38982419 PMCID: PMC11232187 DOI: 10.1186/s12893-024-02461-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 05/20/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described. METHODS A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes. RESULTS Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization. CONCLUSIONS Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.
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Affiliation(s)
- Anne-Sophie Studer
- Department of bariatric, robotic and minimally invasive surgery, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec, H4J 1C5, Canada.
| | - Henri Atlas
- Department of bariatric, robotic and minimally invasive surgery, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec, H4J 1C5, Canada
| | - Marc Belliveau
- Department of anesthesiology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec, H4J 1C5, Canada
| | - Amir Sleiman
- Department of bariatric, robotic and minimally invasive surgery, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec, H4J 1C5, Canada
| | - Alexis Deffain
- Department of bariatric, robotic and minimally invasive surgery, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec, H4J 1C5, Canada
| | - Pierre Y Garneau
- Department of bariatric, robotic and minimally invasive surgery, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec, H4J 1C5, Canada
| | - Radu Pescarus
- Department of bariatric, robotic and minimally invasive surgery, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec, H4J 1C5, Canada
| | - Ronald Denis
- Department of bariatric, robotic and minimally invasive surgery, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec, H4J 1C5, Canada
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Huang X, Cai J, Lv Z, Zhou Z, Zhou X, Zhao Q, Sun J, Chen L. Postoperative pain after different doses of remifentanil infusion during anaesthesia: a meta-analysis. BMC Anesthesiol 2024; 24:25. [PMID: 38218762 PMCID: PMC10790271 DOI: 10.1186/s12871-023-02388-3] [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] [Received: 02/03/2023] [Accepted: 12/17/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND This meta-analysis aimed to explore the correlation between the different doses of remifentanil-based anaesthesia and postoperative pain in randomised trials. METHODS The electronic databases including PubMed, Cochrane, clinical trial registries, and Google Scholar were searched up to November 2022 for randomised controlled trials (RCTs) that assessed the dose dependent efficacy of remifentanil for postoperative pain intensity and hyperalgesia. RESULTS 31 studies involving 2019 patients were included for analysis. Compared with the high remifentanil dose administration, patients in low doses showed less postoperative pain intensity at 1-2 h (weighted mean differences (WMD): 0.60, 95% CI, 0.05 to 1.15), 3-8 h (WMD: 0.38, 95% CI, 0.00 to 0.75), 24 h (WMD: 0.26, 95% CI, 0.04 to 0.48) and 48 h (WMD: 0.32, 95% CI, 0.09 to 0.55). Remifentanil-free regimen failed to decrease the pain score at 24 h (WMD: 0.10, 95% CI, -0.10 to 0.30) and 48 h (WMD: 0.15, 95% CI, -0.22 to 0.52) in comparison with remifentanil-based anaesthesia. After excluding trials with high heterogeneity, the dose of the remifentanil regimen was closely correlated with the postoperative pain score (P=0.03). In addition, the dose of the remifentanil regimen was not associated with the incidence of postoperative nausea and vomiting (PONV) (P=0.37). CONCLUSIONS Our meta-analysis reveals that the low dose of remifentanil infusion is recommendable for general anaesthesia maintenance. No evidence suggests that remifentanil-free regimen has superiority in reducing postoperative pain. Moreover, remifentanil doesn't have a dose dependent effect in initiating PONV. TRIAL REGISTRATION The protocol of present study was registered with PROSPERO (CRD42022378360).
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Affiliation(s)
- Xinyi Huang
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Jinxia Cai
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Zhu Lv
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Zijun Zhou
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Xiaotian Zhou
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Qimin Zhao
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China
| | - Jiehao Sun
- Department of Anaesthesiology, 1st affiliated hospital, Wenzhou Medical University, Ouhai District, Wenzhou, Zhejiang, China.
| | - Long Chen
- Centre for Rehabilitation Medicine, Department of Anaesthesiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China.
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Alotaibi N, Althaqafi M, Alharbi A, Thallaj A, Ahmad A, Aldohayan A, Bamehriz F, Eldawlatly A. The impact of moderate versus deep neuromuscular blockade on the recovery characteristics following laparoscopic sleeve gastrectomy: A randomized double blind clinical trial. Saudi J Anaesth 2024; 18:6-11. [PMID: 38313732 PMCID: PMC10833021 DOI: 10.4103/sja.sja_104_23] [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: 02/10/2023] [Revised: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 02/06/2024] Open
Abstract
Background Anesthesia with deep neuromuscular block for laparoscopic surgery may result in less postoperative pain with lower intra-abdominal pressure. However, the results in the existing literature are controversial. This study aimed to evaluate the effect of deep versus moderate neuromuscular block (NMB) on the postoperative recovery characteristics after laparoscopic sleeve gastrectomy (LSG) for weight loss surgery. Methods This is parallel-group, randomized clinical trial. The study was conducted at a tertiary care center. Patients undergoing LSG were included. Patients were randomly assigned to either deep (post-tetanic count 1-2) or moderate (train-of-four 1-2) NMB group. The primary outcomes were numeric rating scale scores of the postoperative pain at rest and postoperative shoulder pain. The secondary outcomes were the length of hospital stay (LOS) and postoperative complications. The statistics were performed using StatsDirect statistical software (Version 2.7.9). Results Two groups were identified: Group D (deep NMB), 29 patients, and Group M (moderate NMB), 28 patients. The BMI mean values for groups D and M were 44 and 45 kg/m2 respectively (P > 0.05). The mean durations of surgery for were 46.7 min and 44.1 min for groups M and D, respectively (P > 0.05). The mean train-of-four (TOF) counts were 0.3 and 0 for groups M and D, respectively (P < 0.05). The mean times from giving reversal agent to tracheal extubation (minutes) were 6.5 and 6.58 min for groups M and D, respectively (P > 0.05). In the recovery room, the means of pain scores were 3 and 4 for groups M and D, respectively (P > 0.05). Upon admission to the surgical ward, the median values of the pain score were non-significant (P > 0.05) (95% CI: 0.4-0.7). The opioid consumption in the recovery room was non-significant between both groups (P > 0.05) (95% CI: 0.3-0.6). Postoperative shoulder pain was non-significant between both groups (P > 0.05) (95% CI: 0.4-0.7). The median values of surgeon opinion of both groups were non-significant (P > 0.05). Regarding the LOS, the mean values of groups D and M were 1.20 and 1.21 days, respectively (P > 0.05). Conclusions There was no significant difference between moderate and deep NMB techniques in terms of duration of the surgical procedure, postoperative pain, shoulder pain, and length of hospital stay. Further studies on a larger sample size are required to investigate the long-term recovery characteristics of patients with obesity undergoing LSG.
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Affiliation(s)
- Narjes Alotaibi
- Unaizah College of Medicine and Medical Sciences, Qassim University, Riyadh, Saudi Arabia
| | - Mahmoud Althaqafi
- Cardiac Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah Alharbi
- Consultant Anesthetist, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Ahmed Thallaj
- Anesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Ahmad
- Anesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Aldohayan
- Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Bamehriz
- Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Koninckx PR, Saridogan E, Gomel V. Postoperative adhesions: are we close to finding a solution? Facts Views Vis Obgyn 2023; 15:287-289. [PMID: 38128087 PMCID: PMC10832650 DOI: 10.52054/fvvo.15.4.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
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Zhang Y, Ma D, Lang B, Zang C, Sun Z, Ren S, Chen H. Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies. Medicine (Baltimore) 2023; 102:e35126. [PMID: 37746991 PMCID: PMC10519493 DOI: 10.1097/md.0000000000035126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Research on opioid-free anesthesia has increased in recent years; however, it has never been determined whether it is more beneficial than opioid anesthesia. This meta-analysis was primarily used to assess the effect of opioid-free anesthesia compared with opioid anesthesia on the incidence of postoperative nausea and vomiting. METHODS We searched the electronic databases of PubMed, the Cochrane Library, Web of Science and Embase from 2014 to 2022 to identify relevant articles and extract relevant data. The incidence of postoperative nausea and vomiting, time to extubation, pain score at 24 hours postoperatively, and time to first postoperative rescue analgesia were compared between patients receiving opioid-free anesthesia and those receiving standard opioid anesthesia. Differences in the incidence of postoperative nausea and vomiting were evaluated using risk ratios (95% confidence interval [CI]). The significance of the differences was assessed using mean differences and 95% CI. The heterogeneity of the subject trials was evaluated using the I2 test. Statistical analysis was performed using the RevMan 5.4 software. RESULTS Fourteen randomized controlled trials, including 1354 participants, were evaluated in the meta-analysis. As seen in the forest plot, the OFA group had a lower risk of postoperative nausea and vomiting than the control group (risk ratios = 0.41, 95% CI: 0.33-0.51, P < .00001; n = 1354), and the meta-analysis also found that the OFA group had lower postoperative analgesia scores at 24 hours (P < .000001), but time to extubation (P = .14) and first postoperative resuscitation analgesia time (P < .54) were not significantly different. CONCLUSIONS Opioid-free anesthesia reduces the incidence of postoperative nausea and vomiting while providing adequate analgesia without interfering with postoperative awakening.
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Affiliation(s)
- Yanan Zhang
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Dandan Ma
- Department of Anesthesiology, Yidu Central Hospital Affiliated to Weifang Medical University, Weifang, China
| | - Bao Lang
- Department of Anesthesiology, Weifang People’s Hospital, Weifang, China
| | - Chuanbo Zang
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Zenggang Sun
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Shengjie Ren
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Huayong Chen
- Department of Anesthesiology, Yidu Central Hospital Affiliated to Weifang Medical University, Weifang, China
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Wu BG, Luk HN, Qu JZ, Shikani A. Styletubation in Bariatric Surgery: A Case Report. Healthcare (Basel) 2023; 11:2256. [PMID: 37628454 PMCID: PMC10454672 DOI: 10.3390/healthcare11162256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/27/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Direct laryngoscopes and videolaryngoscopes are the dominant endotracheal intubation tools. The styletubation technique (using a video-assisted intubating stylet) has shown its advantages in terms of short intubation time, high success rate, less required stimulation, and operator satisfaction. The learning curve can be steep but is easily overcome if technical pitfalls are avoided. Conditions that make styletubation challenging include secretions/blood, short/stiff neck, restricted mouth opening and cervical spine mobility, anatomical abnormalities over head and neck regions, obesity, etc. In this clinical report, we present the effectiveness and efficiency of the routine use of the styletubation for tracheal intubation in a super-super-obese patient (BMI 103 kg/m2) undergoing bariatric surgery with laparoscopic sleeve gastrectomy.
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Affiliation(s)
- Bor-Gang Wu
- Department of Surgery, Hualien Tzu-Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu-Chi University, Hualien 970, Taiwan;
| | - Hsiang-Ning Luk
- Department of Anesthesia, Hualien Tzu-Chi Hospital, Hualien 970, Taiwan
- Bio-Math Laboratory, Department of Financial Engineering, Providence University, Taichung 433719, Taiwan
| | - Jason Zhensheng Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Alan Shikani
- Division of Otolaryngology—Head and Neck Surgery, LifeBridge Sinai Hospital, Baltimore, MD 21040, USA;
- Division of Otolaryngology—Head and Neck Surgery, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA
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Kappelhoff N, Mohr Y, Teufel F, Walther A. ["Are opioid-free anesthesia (OFA) and volatile anesthetics really the only ways? A critical comment"]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01297-x. [PMID: 37368023 DOI: 10.1007/s00101-023-01297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Nils Kappelhoff
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland.
| | - Yannik Mohr
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
| | - Frank Teufel
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
| | - Andreas Walther
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
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Ioannidis O, Ramirez JM, Ubieto JM, Feo CV, Arroyo A, Kocián P, Sánchez-Guillén L, Bellosta AP, Whitley A, Enguita AB, Teresa M, Anestiadou E. The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care. J Clin Med 2023; 12:4185. [PMID: 37445224 DOI: 10.3390/jcm12134185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 07/15/2023] Open
Abstract
Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.
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Affiliation(s)
- Orestis Ioannidis
- Fourth Department of Surgery, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", 57010 Thessaloniki, Greece
| | - Jose M Ramirez
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Surgery, Faculty of Medicine, University of Zaragoza, 50009 Zaragoza, Spain
| | - Javier Martínez Ubieto
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009 Zaragoza, Spain
| | - Carlo V Feo
- Department of Surgery, Azienda Unità Sanitaria Locale Ferrara-University of Ferrara, 44121 Ferrara, Italy
| | - Antonio Arroyo
- Department of Surgery, Universidad Miguel Hernández Elche, Hospital General Universitario Elche, 03203 Elche, Spain
| | - Petr Kocián
- Department of Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, 150 06 Prague, Czech Republic
| | - Luis Sánchez-Guillén
- Department of Surgery, Universidad Miguel Hernández Elche, Hospital General Universitario Elche, 03203 Elche, Spain
| | - Ana Pascual Bellosta
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
- Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, 50009 Zaragoza, Spain
| | - Adam Whitley
- Department of Surgery, University Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | | | - Marta Teresa
- Institute for Health Research Aragón, 50009 Zaragoza, Spain
| | - Elissavet Anestiadou
- Fourth Department of Surgery, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", 57010 Thessaloniki, Greece
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Ulbing S, Infanger L, Fleischmann E, Prager G, Hamp T. The Performance of Opioid-Free Anesthesia for Bariatric Surgery in Clinical Practice. Obes Surg 2023:10.1007/s11695-023-06584-5. [PMID: 37106268 DOI: 10.1007/s11695-023-06584-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Opioid-free anesthesia (OFA) is an alternative to conventional opioid-based anesthesia (OBA) in patients undergoing bariatric surgery. Several small studies and a meta-analysis have suggested advantages of OFA for bariatric surgery, but current evidence is still contradictory, and a universally accepted concept has not yet been established. The purpose of this study was to determine whether patients undergoing bariatric surgery experience less postoperative pain and better postoperative recovery when anesthetized with an OFA regimen than with an OBA regimen. MATERIALS AND METHODS This prospective observational cohort study, conducted between October 2020 and July 2021, compared patients receiving OFA with patients receiving OBA. Patients were visited 24 and 48 h after the surgical procedure and asked about their postoperative pain using the visual analogue scale (VAS). Additionally, the quality of recovery-40 questionnaire (QoR-40) and the postoperative opioid requirements were recorded. RESULTS Ninety-nine patients were included and analyzed in this study (OFA: N = 50; OBA: N = 49). The OFA cohort exhibited less postoperative pain than the OBA cohort within 24 h (VAS median [interquartile range (IQR)]: 2.2 [1-4.4] vs. 4.1 [2-6.5]; P ≤ 0.001) and 48 h (VAS median [IQR]: 1.9 [0.4-4.1] vs. 3.1 [1.4-5.8]; P ≤ 0.001) postoperatively. Additionally, the OFA cohort had higher QoR-40 scores and required less opioid therapy postoperatively. CONCLUSION Based on our results the use of OFA for bariatric surgery results in less pain, reduced opioid requirements, and improved postoperative recovery-adding additional evidence regarding the use of OFA in everyday clinical practice.
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Affiliation(s)
- Stefan Ulbing
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Lukas Infanger
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gerhard Prager
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Thomas Hamp
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Wang M, Li S, Jiang H, Yu W, Hu D, Duan S, Tang J, Li Y. Systematic Evaluation of Neuromuscular Reversal Agents in Obese Patients After General Anesthesia for Bariatric Surgery. Bariatr Surg Pract Patient Care 2023. [DOI: 10.1089/bari.2022.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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Short-Term Patient Outcomes After Implementation of Robotic-Assisted Radical Prostatectomy Under Opioid Free Anesthesia at an Ambulatory Surgery Center. J Perianesth Nurs 2023; 38:488-492. [PMID: 36599789 DOI: 10.1016/j.jopan.2022.09.007] [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: 06/30/2022] [Revised: 09/05/2022] [Accepted: 09/09/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Opioid free anesthesia (OFA) is associated with decreased risk of PONV and need for rescue analgesia, making it ideal for patients anticipating same-day discharge. The purpose of this project was to describe the perioperative care and short-term outcomes for patients undergoing robotic-assisted radical prostatectomy (RARP) under OFA at an ambulatory surgical center (ASC). DESIGN A retrospective descriptive design was used to examine the perioperative care and short-term outcomes of patients undergoing RARP under OFA at an ASC. METHODS The records of all sequential patients undergoing RARP over an 18-month period were reviewed. Data collected included patient comorbidities, surgical procedures, medications administered, verbal numeric rating scale (VNRS) for pain scores, times to oral intake, ambulation, and discharge, patient disposition, and unplanned return to the ER or hospital within 30 days. FINDINGS Data were extracted from 54 sequential records. Median VNRS scores were zero throughout PACU stay. Fifty-three patients (98.1%) were successfully discharged home, with an average postoperative stay of 250.8 (SD 35.0) minutes. There were no complaints of post-discharge nausea and vomiting or intractable pain at 72 hours after surgery. One patient was transferred to the hospital and two patients returned to the emergency room within 30 days. CONCLUSIONS Although generalizability is limited, these results suggest that carefully selected patients can be discharged home after RARP under a balanced OFA technique. Innovative practices are needed to address the current backlog of patients needing non-emergent surgery. Discharge home avoids the increase in resource consumption and infection risk associated with hospital admission.
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Liu S, He B, Deng L, Li Q, Wang X. Does deep neuromuscular blockade provide improved perioperative outcomes in adult patients? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2023; 18:e0282790. [PMID: 36893114 PMCID: PMC9997990 DOI: 10.1371/journal.pone.0282790] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 02/17/2023] [Indexed: 03/10/2023] Open
Abstract
Deep neuromuscular blockade provides better surgical workspace conditions in laparoscopic surgery, but it is still not clear whether it improves perioperative outcomes, not to mention its role in other types of surgeries. We performed this systematic review and meta-analysis of randomized controlled trials to investigate whether deep neuromuscular blockade versus other more superficial levels of neuromuscular blockade provides improved perioperative outcomes in adult patients in all types of surgeries. Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception to June 25, 2022. Forty studies (3271 participants) were included. Deep neuromuscular blockade was associated with an increased rate of acceptable surgical condition (relative risk [RR]: 1.19, 95% confidence interval [CI]: [1.11, 1.27]), increased surgical condition score (MD: 0.52, 95% CI: [0.37, 0.67]), decreased rate of intraoperative movement (RR: 0.19, 95% CI: [0.10, 0.33]), fewer additional measures to improve the surgical condition (RR: 0.63, 95% CI: [0.43, 0.94]), and decreased pain score at 24 h (MD: -0.42, 95% CI: [-0.74, -0.10]). There was no significant difference in the intraoperative blood loss (MD: -22.80, 95% CI: [-48.83, 3.24]), duration of surgery (MD: -0.05, 95% CI: [-2.05, 1.95]), pain score at 48 h (MD: -0.49, 95% CI: [-1.03, 0.05]), or length of stay (MD: -0.05, 95% CI: [-0.19, 0.08]). These indicate that deep neuromuscular blockade improves surgical conditions and prevents intraoperative movement, and there is no sufficient evidence that deep neuromuscular blockade is associated with intraoperative blood loss, duration of surgery, complications, postoperative pain, and length of stay. More high-quality randomized controlled trials are needed, and more attention should be given to complications and the physiological mechanism behind deep neuromuscular blockade and postoperative outcomes.
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Affiliation(s)
- Siyuan Liu
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Bin He
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Lei Deng
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Qiyan Li
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Xiong Wang
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
- * E-mail:
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Marinari G, Foletto M, Nagliati C, Navarra G, Borrelli V, Bruni V, Fantola G, Moroni R, Tritapepe L, Monzani R, Sanna D, Carron M, Cataldo R. Enhanced recovery after bariatric surgery: an Italian consensus statement. Surg Endosc 2022; 36:7171-7186. [PMID: 35953683 PMCID: PMC9485178 DOI: 10.1007/s00464-022-09498-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/31/2021] [Indexed: 12/03/2022]
Abstract
Background Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS. Methods To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus. Results Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items). Conclusions ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.
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Affiliation(s)
- Giuseppe Marinari
- Bariatric Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mirto Foletto
- Bariatric Surgery Unit, Azienda Ospedale Università Padova, Padua, Italy
| | - Carlo Nagliati
- Department of Surgery, San Giovanni di Dio Hospital, Gorizia, Italy
| | - Giuseppe Navarra
- Department of Human Pathology, University of Messina, Messina, Italy
| | | | - Vincenzo Bruni
- Bariatric Surgery Unit, Campus Bio Medico University of Rome, Rome, Italy
| | - Giovanni Fantola
- Bariatric Surgery Unit, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Roberto Moroni
- Bariatric Surgery Unit, Policlinico Sassarese, Sassari, Italy
| | - Luigi Tritapepe
- Department of Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberta Monzani
- Department of Anesthesia and Intensive Care Units, Humanitas Research Hospital, Humanitas University Milan, Rozzano, Milan, Italy
| | - Daniela Sanna
- Emergency Department, Section of Anesthesiology and Intensive Care, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Michele Carron
- Department of Medicine-DIMED, Section of Anesthesiology and Intensive Care, University of Padua, Via V. Gallucci, 13, 35121, Padua, Italy.
| | - Rita Cataldo
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio Medico University of Rome, Rome, Italy
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Malo-Manso A, Ramírez-Aliaga M, Sepúlveda-Haro E, Díaz-Crespo J, Escalona-Belmonte JJ, Guerrero-Orriach JL. Opioid-free anesthesia for open radical cystectomy in morbid obesity. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:433-436. [PMID: 35869004 DOI: 10.1016/j.redare.2021.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/03/2021] [Indexed: 06/15/2023]
Abstract
Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.
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Affiliation(s)
- A Malo-Manso
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Biomédica de Málaga, Málaga, Spain.
| | - M Ramírez-Aliaga
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - E Sepúlveda-Haro
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - J Díaz-Crespo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - J J Escalona-Belmonte
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - J L Guerrero-Orriach
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Biomédica de Málaga, Málaga, Spain; Departamento de Pediatría y Farmacología, Universidad de Málaga, Málaga, Spain
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Medical disease and ambulatory surgery, new insights in patient selection based on medical disease. Curr Opin Anaesthesiol 2022; 35:385-391. [PMID: 35671030 DOI: 10.1097/aco.0000000000001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Improvements in perioperative care contributed to enlarge the eligibility criteria for day case surgery and more and more patients with comorbidities may be concerned. However, underlying medical diseases may influence postoperative outcomes, and therefore, must be considered when selecting patients to undergo ambulatory surgery. RECENT FINDINGS To limit postoperative complications, rigid patient selection criteria are often applied in ambulatory surgery. In practice, however, most of these criteria predict the occurrence of treatable perioperative adverse events but not the need for unanticipated admission or readmission. SUMMARY The underlying medical diseases should not be considered as sole criteria but they should rather be regarded as a dynamic process, which includes the surgical procedure as well as the experience and expertise of the perioperative setting.
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Ke F, Shen Z, Wu C, Zhang L, Dong R. The effects of moderate neuromuscular blockade combined with transverse abdominal plane block on surgical space conditions during laparoscopic colorectal surgery: a randomized clinical study. BMC Anesthesiol 2022; 22:94. [PMID: 35379189 PMCID: PMC8978431 DOI: 10.1186/s12871-022-01623-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/21/2022] [Indexed: 11/19/2022] Open
Abstract
Background Deep neuromuscular blockade may be beneficial on surgical space conditions during laparoscopic surgery. The effects of moderate neuromuscular blockade combined with transverse abdominal plane block (TAPB) on surgical space conditions during laparoscopic surgery have not been described. This work investigated whether the above combination is associated with similar surgical space conditions to those of deep neuromuscular blockade. Methods Eighty patients undergoing elective laparoscopic surgery for colorectal cancer were randomly divided into two groups. The intervention group was treated with moderate neuromuscular blockade (train-of-four (TOF) count between 1 and 3) combined with TAPB (M group), while the control group was treated with deep neuromuscular blockade (D group), with a TOF count of 0 and a post-tetanic count (PTC) ≥1. Both groups received the same anesthesia management. The distance between the sacral promontory and the umbilical skin during the operation was compared between the two groups. The surgeon scored the surgical space conditions according to a five-point ordinal scale. Patients’ pain scores were evaluated 8 h after the operation. Results The distance from the sacral promontory to the umbilical skin after pneumoperitoneum was similar between the D group and M group (16.03 ± 2.17 cm versus 16.37 ± 2.78 cm; P = 0.544). The 95% confidence intervals of the difference in the distance from the sacral promontory to the umbilical skin between the two groups were − 1.45–0.77 cm. According to the preset non-inferior standard of 1.5 cm, (− 1.45, ∞) completely fell within (− 1.50, ∞), and the non-inferior effect test was qualified. No significant difference was found in the surgical rating score between the two groups. The dosage of rocuronium in the group D was significantly higher than that in the group M (P < 0.01). The M group had significantly lower pain scores than the D group 8 h after the operation (P < 0.05). Conclusions Moderate neuromuscular blockade combined with TAPB applied to laparoscopic colorectal cancer surgery can provide surgical space conditions similar to those of deep neuromuscular blockade. In addition, it reduces the use of muscle relaxants, relieves postoperative pain within 4 h after operation, and shorten the extubation time and stay in PACU when neostigmine was used as muscle relaxant antagonist. Trial registration chictr.org.cn (ChiCTR2000034621), registered on July 12, 2020.
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Affiliation(s)
- Fang Ke
- Department of Anesthesiology, Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200025, P.R. China
| | - Zijin Shen
- Department of Anesthesiology, Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200025, P.R. China
| | - Cheng Wu
- Department of Health Statistics, Naval Medical University, Shanghai, 200433, China
| | - Lin Zhang
- Department of Anesthesiology, Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200025, P.R. China
| | - Rong Dong
- Department of Anesthesiology, Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200025, P.R. China.
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Tejedor A, Bijelic L, Deiros C, Pujol E, Bassas E, Fernanz J, Bernat MJ. Feasibility and effectiveness of opioid-free anesthesia in cytoreductive surgery with or without heated intraperitoneal chemotherapy. J Surg Oncol 2022; 125:1277-1284. [PMID: 35218579 DOI: 10.1002/jso.26833] [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: 11/16/2021] [Revised: 01/17/2022] [Accepted: 02/16/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Opioid-free anesthesia (OFA) provides analgesia minimizing opioids. OFA has not been evaluated in cytoreductive surgery (CRS) with or without heated intraperitoneal chemotherapy. We aim to evaluate OFA feasibility and effectiveness in CRS. METHODS Retrospective cohort study of adult patients (84) undergoing CRS in a tertiary center from May 2020 until June 2021. Predefined protocols for either opioid-based anesthesia (OBA) or OFA were followed. RESULTS OFA protocol patients (41) had better mean pain scores (1 ± 0.8 vs. 2 ± 1; p = 0.00) despite the avoidance of intravenous and epidural fentanyl intraoperatively (220 ± 104 and 194 ± 73 µg, respectively, in OBA vs. 0; p = 0.00). Postoperative epidural levobupivacaine was also lower in the OFA group (575 ± 192 vs. 706 ± 346 mg; p = 0.034) despite the lack of epidural fentanyl without difference in duration (4.3 ± 1.2 vs. 4 ± 1.2 days; p = 0.22). Morphine consumption was very low (4.1 ± 10 vs. 1.7 ± 5 mg; p = 0.16). Intraoperative hypertensive events and postoperative nausea and vomiting (PONV) were higher for OBA (43) (30.2% vs. 7.3%; p = 0.01% and 69.8% vs. 34.1%; p = 0.001, respectively). Postoperative epidural fentanyl was independently associated with PONV (p = 0.004). There was no difference in total complications or length of stay. CONCLUSION OFA is feasible, safe, and offers optimal pain control while minimizing the use of opioids in CRS.
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Affiliation(s)
- Ana Tejedor
- Department of Anesthesiology, Hospital Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Lana Bijelic
- Peritoneal Surface Malignancies Unit, Department of Surgery, Hospital Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Carmen Deiros
- Department of Anesthesiology, Hospital Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Elisenda Pujol
- Department of Anesthesiology, Hospital Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Eva Bassas
- Department of Anesthesiology, Hospital Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Jesús Fernanz
- Department of Anesthesiology, Hospital Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Maria José Bernat
- Department of Anesthesiology, Hospital Sant Joan Despí Moisès Broggi, Barcelona, Spain
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Salem AE, El-Mawy MG, Al-Kholy AF. Multimodal, non-opioid based analgesia for women presented for laparoscopic hysterectomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2031547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Ahmed E. Salem
- Department of Anesthesiology & ICU, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed G. El-Mawy
- Department of Anesthesiology & ICU, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Adel F. Al-Kholy
- Department of Medical Biochemistry, Faculty of Medicine, Benha University, Benha, Egypt
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20
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Stenberg E, Dos Reis Falcão LF, O'Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg 2022; 46:729-751. [PMID: 34984504 PMCID: PMC8885505 DOI: 10.1007/s00268-021-06394-9] [Citation(s) in RCA: 139] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 02/08/2023]
Abstract
Background This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol. Methods A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations. Results The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries. Conclusion A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.
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Affiliation(s)
- Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | | | - Mary O'Kane
- Dietetic Department, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Ronald Liem
- Department of Surgery, Groene Hart Hospital, Gouda, Netherlands.,Dutch Obesity Clinic, The Hague, Netherlands
| | - Dimitri J Pournaras
- Department of Upper GI and Bariatric/Metabolic Surgery, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, UK
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland.,Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anupama Wadhwa
- Department of Anesthesiology, Outcomes Research Institute, Cleveland Clinic, University of Texas Southwestern, Dallas, USA
| | - Ulf O Gustafsson
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
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Malo-Manso A, Ramírez-Aliaga M, Sepúlveda-Haro E, Díaz-Crespo J, Escalona-Belmonte JJ, Guerrero-Orriach JL. Opioid-free anesthesia for open radical cystectomy in morbid obesity. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00134-1. [PMID: 34565571 DOI: 10.1016/j.redar.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 10/20/2022]
Abstract
Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.
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Affiliation(s)
- A Malo-Manso
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, Málaga, España.
| | - M Ramírez-Aliaga
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, Málaga, España
| | - E Sepúlveda-Haro
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - J Díaz-Crespo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - J J Escalona-Belmonte
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, Málaga, España
| | - J L Guerrero-Orriach
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, Málaga, España; Departamento de Pediatría y Farmacología, Universidad de Málaga, Málaga, España
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Hung KC, Chang YJ, Chen IW, Chang YP, Chiu SF, Sun CK. Efficacy of intraoperative intravenous lidocaine for postoperative analgesia following bariatric surgery: a meta-analysis of randomized controlled studies. Surg Obes Relat Dis 2021; 18:135-147. [PMID: 34565683 DOI: 10.1016/j.soard.2021.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/09/2021] [Accepted: 08/14/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The impact of intravenous lidocaine in adults undergoing laparoscopic bariatric surgeries (LBS) remains unclear. OBJECTIVES This study aimed at investigating the effect of intravenous lidocaine on postoperative opioid consumption and recovery following LBS. SETTING Meta-analysis. METHODS We searched databases including MEDLINE, Embase, Google Scholar, and the Cochrane Library for randomized controlled trials that evaluated the use of intravenous lidocaine compared to placebo only prior to May 2021. The primary outcome was 24-hour postoperative opioid consumption, while secondary outcomes included pain score, quality of recovery (QOR)-40 score, length of hospital stay (LOS), and postoperative nausea/vomiting (PONV). RESULTS Seven trials (496 participants) were included. Intraoperative intravenous lidocaine significantly reduced 24-hour equivalent morphine consumption (mean difference [MD]: -11.97 mg; 95% confidence interval [CI]: -23.12 to -.83), pain score at 1 to 3 hours (MD: -.77; 95% CI: -1.5 to -.04), and LOS (MD: -8.93 hr; 95% CI: -13.41 to -4.44) without positive impact on 24-hour pain score and PONV. There was also an increase in time to first opioid requirement (MD: 20.23 min; 95% CI: 11.76-28.7) and QOR-40 score (MD: 24.38; 95% CI: 5.57-43.18). However, sensitivity analysis demonstrated evidence supporting the beneficial effect of lidocaine only for time to first opioid requirement and QOR-40. The associations of intraoperative intravenous lidocaine with reductions in morphine consumption, pain score at 1 to 3 hours, and LOS after LBS were also weak. CONCLUSION Intraoperative intravenous lidocaine during LBS prolonged time to first opioid requirement and improved quality of recovery postoperatively without 24-hour pain or nausea/vomiting benefits. Due to the small number of trials, larger studies are warranted to verify our findings.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; General Education Center, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan city, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yang-Pei Chang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Fu Chiu
- Department of Oral and Maxillofacial Surgery, Chi Mei Hospital, Liouying, Tainan City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan; College of Medicine, I-Shou University, Kaohsiung City, Taiwan.
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Effect of Deep versus Moderate Neuromuscular Blockade on Quantitatively Assessed Postoperative Atelectasis Using Computed Tomography in Thoracic Surgery; a Randomized Double-Blind Controlled Trial. J Clin Med 2021; 10:jcm10153228. [PMID: 34362011 PMCID: PMC8347355 DOI: 10.3390/jcm10153228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/11/2022] Open
Abstract
Background: postoperative atelectasis is a significant clinical problem during thoracic surgery with one-lung ventilation. Intraoperative deep neuromuscular blockade can improve surgical conditions, but an increased risk of residual paralysis may aggravate postoperative atelectasis. Every patient was verified to have full reversal before extubation. We compared the effect of deep versus moderate neuromuscular blockade on postoperative atelectasis quantitatively using chest computed tomography. Methods: patients undergoing thoracic surgery were randomly allocated to two groups: moderate neuromuscular blockade during surgery (group M) and deep neuromuscular blockade during surgery (group D). The primary outcome was the proportion and the volume of postoperative atelectasis measured by chest computed tomography on postoperative day 2. The mean values of the repeatedly measured intraoperative dynamic lung compliance during surgery were also compared. Result: the proportion of postoperative atelectasis did not differ between the groups (1.32 [0.47–3.20]% in group M and 1.41 [0.24–3.07]% in group D, p = 0.690). The actual atelectasis volume was 38.2 (12.8–61.4) mL in group M and 31.9 (7.84–75.0) mL in group D (p = 0.954). Some factors described in the lung protective ventilation were not taken into account and might explain the atelectasis in both groups. The mean lung compliance during one-lung ventilation was higher in group D (26.6% in group D vs. 24.1% in group M, p = 0.026). Conclusions: intraoperative deep neuromuscular blockade did not affect postoperative atelectasis when compared with moderate neuromuscular blockade if full reversal was verified.
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Richebé P, Bousette N, Fortier LP. A narrative review on the potential benefits and limitations of deep neuromuscular blockade. Anaesth Crit Care Pain Med 2021; 40:100915. [PMID: 34174460 DOI: 10.1016/j.accpm.2021.100915] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neuromuscular blockade was shown to improve surgical conditions. However, the risk of residual neuromuscular blockade upon extubation prevents anaesthesiologists from maintaining complete paralysis. For this reason, deep NMB is still underused in anaesthesia. This review focused on answering six questions revolving around the use of deep NMB versus moderate NMB. METHODS This was a non-exhaustive narrative review based on 6 selected relevant questions: does deep NMB 1) improve surgical conditions? 2) reduce surgical complications? 3) facilitate a reduction in intraoperative pneumoperitoneum pressure (PnP)? 4) does a reduction in intraoperative PnP impact clinical outcomes? 5) does the combination of deep NMB and lower PnP improve respiratory parameters? 6) improve OR efficiency or readmission rates? RESULTS This review highlights some of the key studies that have demonstrated potential benefits of deep NMB, but it also included reports showing no benefit, highlighting that the evidence is not unequivocal. Deep NMB does in fact improve surgical conditions, but whether this improvement translates into improved clinical outcomes is far from concluded. Indeed, there is an increased risk or residual curarisation, especially if patients are not monitored and reversed appropriately. The most important benefit of deep NMB may be the prevention of unacceptable surgical working conditions. The other potential major benefits are the reduction in PnP and reduction in pain. Deep NMB must be used with appropriate monitoring. CONCLUSION Deep NMB was associated with an improvement in surgical conditions, reduction in PnP, pain, and complications; but further research is needed to definitively prove this relationship.
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Affiliation(s)
- Philippe Richebé
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montréal, Montréal, QC, Canada.
| | - Nicolas Bousette
- Merck Canada Inc., 16750 Trans Canada Hwy, Kirkland, QC, H9H 4M7, Canada
| | - Louis-Philippe Fortier
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montréal, Montréal, QC, Canada
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Baek SY, Kim JW, Kim TW, Han W, Lee DE, Ryu KH, Park SG, Jeong CY, Park DH. Opioid-free anesthesia with a mixture of dexmedetomidine, ketamine, and lidocaine in one syringe for surgery in obese patients. J Int Med Res 2021; 48:300060520967830. [PMID: 33115311 PMCID: PMC7607789 DOI: 10.1177/0300060520967830] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Recently, there has been a trend toward minimizing opioid use in obese patients to prevent opioid-related postoperative complications. Moreover, the use of opioid-free anesthesia has received growing interest. This case series reports the use of simple opioid-free anesthesia consisting of a mixture of dexmedetomidine, ketamine, and lidocaine in an obese male patient undergoing laparoscopic bariatric surgery and an obese pregnant woman undergoing cesarean section. These cases indicate that opioid-free anesthesia can be safely administered to obese patients and provides effective pain control without any postoperative adverse outcomes.
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Affiliation(s)
- Seung Youp Baek
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Jae Won Kim
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Tae Woo Kim
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Woong Han
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Da Eun Lee
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Keon Hee Ryu
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Sun Gyoo Park
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Chang Young Jeong
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Dong Ho Park
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
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Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery. Anesthesiology 2021; 134:541-551. [PMID: 33630043 DOI: 10.1097/aln.0000000000003725] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil. METHODS Patients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting. RESULTS The study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay. CONCLUSIONS This trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia. EDITOR’S PERSPECTIVE
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Horrow JC, Li W, Blobner M, Lombard J, Speek M, DeAngelis M, Herring WJ. Actual versus ideal body weight dosing of sugammadex in morbidly obese patients offers faster reversal of rocuronium- or vecuronium-induced deep or moderate neuromuscular block: a randomized clinical trial. BMC Anesthesiol 2021; 21:62. [PMID: 33639839 PMCID: PMC7913453 DOI: 10.1186/s12871-021-01278-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/11/2021] [Indexed: 12/05/2022] Open
Abstract
Background This randomized, double-blind trial evaluated sugammadex-mediated recovery time from rocuronium- or vecuronium-induced moderate (M-) or deep (D-) neuromuscular block in morbidly obese adults dosed by actual (ABW) or ideal body weight (IBW). Methods Adults with BMI ≥40 kg/m2 were randomized to 1 of 5 groups: M-neuromuscular block, sugammadex 2 mg/kg ABW; M-neuromuscular block, sugammadex 2 mg/kg IBW; M-neuromuscular block, neostigmine 5 mg, and glycopyrrolate 1 mg; D-neuromuscular block, sugammadex 4 mg/kg ABW; or D-neuromuscular block, sugammadex 4 mg/kg IBW. Supramaximal train of four (TOF) stimulation of the ulnar nerve (TOF-watch SX®) monitored recovery. Primary endpoint was time to TOF ratio ≥ 0.9 for ABW and IBW groups pooled across neuromuscular blocking agent (NMBA)/blocking depth, analyzed by log-rank test stratified for agent and depth. Prespecified safety outcomes included treatment-emergent bradycardia, tachycardia, and other arrhythmias, and adjudicated hypersensitivity and anaphylaxis. Results Of 207 patients randomized, 188 received treatment (28% male, BMI 47 ± 5.1 kg/m2, age 48 ± 13 years). Recovery was 1.5 min faster with ABW vs IBW dosing. The sugammadex 2 mg/kg groups recovered 9-fold faster [time 0.11-fold, 95% CI 0.08 to 0.14] than the neostigmine group. ABW (5.3%) and IBW (2.7%) groups had similar incidences of recovery time > 10 min (95% CI of difference: − 4.8 to 11.0%); 84% for neostigmine group. Re-curarization occurred in one patient each in the 2 mg/kg IBW and neostigmine groups. Prespecified safety outcomes occurred with similar incidences. Conclusions ABW-based sugammadex dosing yields faster reversal without re-curarization, supporting ABW-based sugammadex dosing in the morbidly obese, irrespective of the depth of neuromuscular block or NMBA used. Trial registration Registered on November 17, 2017, at ClinicalTrials.gov under number NCT03346070. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01278-w.
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Affiliation(s)
- Jay C Horrow
- Department of Clinical Research, Merck & Co., Inc., 2000 Galloping Hill Rd, UG-4C-13, Kenilworth, NJ, 07033, USA.,Present address: Anesthesiology & Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wen Li
- Department of Clinical Research, Merck & Co., Inc., 2000 Galloping Hill Rd, UG-4C-13, Kenilworth, NJ, 07033, USA
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Munich, Germany
| | - John Lombard
- Department of Clinical Research, Merck & Co., Inc., 2000 Galloping Hill Rd, UG-4C-13, Kenilworth, NJ, 07033, USA
| | - Marcel Speek
- Department of Clinical Research, Merck & Co., Inc., 2000 Galloping Hill Rd, UG-4C-13, Kenilworth, NJ, 07033, USA
| | - Matthew DeAngelis
- Department of Clinical Research, Merck & Co., Inc., 2000 Galloping Hill Rd, UG-4C-13, Kenilworth, NJ, 07033, USA
| | - W Joseph Herring
- Department of Clinical Research, Merck & Co., Inc., 2000 Galloping Hill Rd, UG-4C-13, Kenilworth, NJ, 07033, USA.
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Marton Filho MA, Alves RL, do Nascimento P, Tarquinio GDS, Mega PF, Pinheiro Módolo NS. Effects of pneumoperitoneum on kidney injury biomarkers: A randomized clinical trial. PLoS One 2021; 16:e0247088. [PMID: 33606739 PMCID: PMC7895340 DOI: 10.1371/journal.pone.0247088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/29/2021] [Indexed: 01/22/2023] Open
Abstract
Background Increased intra-abdominal pressure causes hemodynamic changes that may affect renal biomarkers. Methods This randomized, single-blind, single-center clinical trial recruited patients undergoing laparoscopic cholecystectomy at a tertiary care center in Brazil. They were randomly allocated to a standard intra-abdominal pressure group (P10-12, 10–12 mm Hg) and a low intra-abdominal pressure group (P6-8, 6–8 mm Hg). The primary outcome was the change in neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C levels measured at the beginning of the procedure (T0), at the end of the procedure (T1), and 24 hours after the procedure (T2). P-values < 0.05 were considered statistically significant. Results In total, 64 patients completed the study—33 were given standard pressure and 31 were given low pressure. There was no significant difference in the biomarker between the groups (P = 0.580), but there was a significant difference between the time points with elevation at T1 (P < 0.001). Similar to NGAL, cystatin C had an elevation at T1 in both groups (P = 0.021), but no difference was found when comparing the groups. Conclusions In laparoscopic cholecystectomy, pneumoperitoneum increases NGAL and cystatin C levels intraoperatively, and the use of low-pressure pneumoperitoneum does not change the course of these biomarkers.
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Affiliation(s)
- Marcos Antonio Marton Filho
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
- Centro Universitário Estácio de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil
- * E-mail:
| | - Rodrigo Leal Alves
- Department of Anesthesiology, São Rafael Hospital and Federal University of Bahia, Salvador, Brazil
| | - Paulo do Nascimento
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | | | - Paulo Ferreira Mega
- School of Medicine, Pontifícia Universidade Católica de Campinas (PUC-CAMPINAS), Campinas, São Paulo, Brazil
| | - Norma Sueli Pinheiro Módolo
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
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Lessons from the Analysis of a Retrospective Cohort of Patients Who Underwent Large Open Abdominal Surgery Under Total Intravenous Opioid-Free Anesthesia. Drugs Real World Outcomes 2020; 8:85-93. [PMID: 33231842 PMCID: PMC7984139 DOI: 10.1007/s40801-020-00218-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/01/2022] Open
Abstract
Background Opioid-free anesthesia (OFA) is a new method of anesthesia based on a paradigm shift. Under general anesthesia, the physiology and/or the pathophysiological variations clinically observed are more a reflection of a systemic reaction to the stress (surgical and anesthesia stresses) than a true reflection of pain. Objective To report the results of a large monocenter, retrospective, non-interventional observational study of all consecutive patients who received a total intravenous (IV)-OFA protocol for the surgical management of major open abdominal and urological surgery. Patients and Methods We retrospectively extracted the anesthesia files of 311 consecutive patients (regional anesthesia excluded). No opioids were administered to any of these patients during the surgery. IV morphine administered in the recovery room was the primary endpoint of the study. The secondary endpoints included the amount of opioid required during the first two postoperative days, as well as the maximum pain intensity. Results Only very small doses of IV morphine were administered. The mean total morphine titration was 2 mg (1.9 ± 2.9 mg), corresponding to control of the maximal level of pain to 2.1 ± 2.6 as evaluated with a numerical scale in the postoperative care unit. Similarly, we observed a very low level of morphine consumption during the first two postoperative days. Conclusions These results highlight the safety and the feasibility of our total IV-OFA protocol, thus confirming this new paradigm. Under general anesthesia, the cardiovascular and inflammatory response to the stress could be reliably managed through a multimodal approach without a need for opioids. In the postoperative period, very low doses of opioids were required. Electronic supplementary material The online version of this article (10.1007/s40801-020-00218-3) contains supplementary material, which is available to authorized users.
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Mulier H, De Frene B, Benmeridja L, Vanhoorebeeck F, Denis B, Casaer B, Rogge FJ, Leleu K, Mulier J. Impact of opioid-free anesthesia on complications after deep inferior epigastric perforator flap surgery: A retrospective cohort study. J Plast Reconstr Aesthet Surg 2020; 74:504-511. [PMID: 33268289 DOI: 10.1016/j.bjps.2020.09.004] [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: 01/04/2020] [Revised: 05/06/2020] [Accepted: 09/27/2020] [Indexed: 11/16/2022]
Abstract
This study measured the number of complications after deep inferior epigastric perforator (DIEP) flap reconstruction performed under opioid-free anesthesia (OFA) combined with goal-directed fluid therapy or opioid anesthesia with liberal fluid therapy (OA). This retrospective cohort study consisted of 204 patients who underwent DIEP flap reconstruction at AZSint Jan Brugge between April 2014 and March 2019. Primary outcomes were complications, according to the Clavien-Dindo classification and the length of hospital stay (LOS). The secondary outcomes were flap failure, postoperative nausea and vomiting (PONV), postoperative pain, postoperative opioid consumption, and postoperative skin flap temperature. OFA included a combination of dexmedetomidine, lidocaine, and ketamine without any opioid administered pre- or intraoperatively. OA included a combination of sufentanil and remifentanil. OFA patients received strict goal-directed fluid therapy, whereas OA patients received liberal fluids to maintain perfusion pressure. All patients except 7 (TIVA with remifentanil) received inhalation anesthesia combined with an infusion of propofol. Of the 204 patients, 55 received OFA and 149 received OA. There were no differences in major complications, but fewer minor complications in the OFA group (17.9% vs. 51.4% and P < 0.001). Flap failure occurred in three patients of the OA group. Six patients developed flap thrombosis (five OA patients and one OFA patient). OFA was associated with fewer postoperative opioids, shorter LOS, less PONV, and less pain. In patients without previous nausea, the PONV incidence was higher in the OA group than in the OFA group (12.7% vs. 43.6% and P < 0.001). Patients with previous nausea more frequently required postoperative opioids and had a nausea rate of 60.87%.
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Affiliation(s)
- Harold Mulier
- KU Leuven - University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Bob De Frene
- Department of Plastic and Reconstructive Surgery, AZSint Jan AV Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Lara Benmeridja
- Department of Plastic and Reconstructive Surgery, AZSint Jan AV Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium; Department of Plastic and Reconstructive Surgery, Ghent University Hospital, B-9000 Ghent, Belgium
| | - Florian Vanhoorebeeck
- Department of Anesthesiology, Intensive Care and Reanimation, AZSint Jan Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Bruno Denis
- Department of Anesthesiology, Intensive Care and Reanimation, AZSint Jan Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium; Department of Anesthesiology and Acute Pain Service, Cliniques Universitaires Saint Luc, University Catholic of Louvain, av Hippocrate 10, B-1200 Brussels, Belgium
| | - Bob Casaer
- Department of Plastic and Reconstructive Surgery, AZSint Jan AV Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Fabrice Jacques Rogge
- Department of Plastic and Reconstructive Surgery, AZSint Jan AV Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Kris Leleu
- Department of Anesthesiology, Intensive Care and Reanimation, AZSint Jan Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium
| | - Jan Mulier
- KU Leuven - University of Leuven, Herestraat 49, B-3000 Leuven, Belgium; Department of Anesthesiology, Intensive Care and Reanimation, AZSint Jan Brugge-Oostende, Campus Brugge, Ruddershove 10, B-8000 Brugge, Belgium; UGhent - University of Ghent, B-9000 Ghent, Belgium.
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Abstract
PURPOSE OF REVIEW This review was conducted to gain insight into the history, present and future of bariatric and/or metabolic surgery and endoscopic treatments of obesity. The challenges that have been overcome, the challenges we still face and our recommendations for the future are discussed. RECENT FINDINGS Over the last few decades, a number of treatment strategies have emerged for the treatment of obesity. Both endoscopic and surgical options are available and they lead to significant weight loss and comorbidity reduction. However, to remain a credible treatment alternative to the obesity pandemic, we need to perform these procedures in much larger numbers than we currently do. Even though significant gains have been made in reducing the morbidity and mortality of surgical interventions, there is further room for improvement, especially when it comes to long-term issues. Due to its impact on almost every single organ system in the human body, bariatric surgery has attracted the attention of academics from a variety of medical disciplines. This has led to a rapidly enlarging body of high-quality scientific literature, supporting its wider use and cost-effectiveness. CONCLUSION Despite the advances made in bariatric surgery, the criteria determining suitability of patients for bariatric surgery in most parts of the world are still based on a consensus agreed upon in the USA in 1991. There is a need to formulate some new consensus and guidelines that would allow for a significant expansion of the pool of patients that can be offered these procedures.
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Affiliation(s)
- Edo O Aarts
- Praeclarum, Obesity Treatment, Oosterbeek, The Netherlands.
| | - Kamal Mahawar
- Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, UK.
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK.
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Lee HY, Jung KT. Advantages and pitfalls of clinical application of sugammadex. Anesth Pain Med (Seoul) 2020; 15:259-268. [PMID: 33329823 PMCID: PMC7713848 DOI: 10.17085/apm.19099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 12/18/2022] Open
Abstract
Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.
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Affiliation(s)
- Hyung Young Lee
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
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Carron M, Ieppariello G, Linassi F, Navalesi P. Ketamine and Magnesium: a Successful Combination for Bariatric Surgery. Obes Surg 2020; 30:4612-4614. [PMID: 32440776 DOI: 10.1007/s11695-020-04717-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Michele Carron
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy.
| | - Giovanna Ieppariello
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - Federico Linassi
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
| | - Paolo Navalesi
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Via V. Gallucci, 13, 35121, Padova, Italy
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Han J, Ryu JH, Koo BW, Nam SW, Cho SI, Oh AY. Effects of Sugammadex on Post-Operative Pulmonary Complications in Laparoscopic Gastrectomy: A Retrospective Cohort Study. J Clin Med 2020; 9:E1232. [PMID: 32344750 PMCID: PMC7230613 DOI: 10.3390/jcm9041232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/23/2020] [Indexed: 12/23/2022] Open
Abstract
The use of sugammadex can reduce post-operative residual neuromuscular blockade, which is known to increase the risk of post-operative respiratory events. However, its effect on post-operative pulmonary complications is not obvious. This study was performed to evaluate the effects of sugammadex on post-operative pulmonary complications in patients undergoing laparoscopic gastrectomy between 2013 and 2017. We performed propensity score matching to correct for selection bias. Post-operative pulmonary complications (i.e., pneumonia, respiratory failure, pleural effusion, atelectasis, pneumothorax, and aspiration pneumonitis) were evaluated from the radiological and laboratory findings. We also evaluated admission to the intensive care unit after surgery, re-admission or an emergency room visit within 30 days after discharge, length of hospital stay, re-operation, and mortality within 90 days post-operatively as secondary outcomes. In the initial cohort of 3802 patients, 541 patients were excluded, and 1232 patients were analyzed after propensity score matching. In the matched cohort, pleural effusion was significantly reduced in the sugammadex group compared to the neostigmine group (neostigmine 23.4% vs. sugammadex 18%, p = 0.02). Other pulmonary complications and secondary outcomes were not significantly different between the groups. In comparison to neostigmine, the use of sugammadex was associated with a lower incidence of post-operative pleural effusion in laparoscopic gastrectomy.
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Affiliation(s)
- Jiwon Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea; (J.H.); (J.-H.R.); (B.-W.K.); (S.W.N.); (S.-I.C.)
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea; (J.H.); (J.-H.R.); (B.-W.K.); (S.W.N.); (S.-I.C.)
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, 103, Daehak-ro, Jongno-gu, Seoul 03080, Korea
| | - Bon-Wook Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea; (J.H.); (J.-H.R.); (B.-W.K.); (S.W.N.); (S.-I.C.)
| | - Sun Woo Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea; (J.H.); (J.-H.R.); (B.-W.K.); (S.W.N.); (S.-I.C.)
| | - Sang-Il Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea; (J.H.); (J.-H.R.); (B.-W.K.); (S.W.N.); (S.-I.C.)
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea; (J.H.); (J.-H.R.); (B.-W.K.); (S.W.N.); (S.-I.C.)
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, 103, Daehak-ro, Jongno-gu, Seoul 03080, Korea
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Alternate airway strategies for the patient with morbid obesity. Int Anesthesiol Clin 2020; 58:1-8. [PMID: 32271196 DOI: 10.1097/aia.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Onoe K, Ogata H, Ishimoto D, Kaneko T, Ueki R, Kariya N, Tatara T, Hirose M. No effect of intraoperative rocuronium doses on 30-day postoperative complications after sugammadex reversal in patients undergoing gastrointestinal surgery. J Clin Anesth 2019; 61:109662. [PMID: 31759814 DOI: 10.1016/j.jclinane.2019.109662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/21/2019] [Accepted: 11/16/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Ken Onoe
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroki Ogata
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Daisuke Ishimoto
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Takahiko Kaneko
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Ryusuke Ueki
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Nobutaka Kariya
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tsuneo Tatara
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
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Beloeil H. Opioid-free anesthesia. Best Pract Res Clin Anaesthesiol 2019; 33:353-360. [DOI: 10.1016/j.bpa.2019.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/06/2019] [Accepted: 09/18/2019] [Indexed: 12/18/2022]
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Coskun AK, Eskin MB. Opioid usage at bariatric patients. Surg Obes Relat Dis 2019; 15:1422-1423. [PMID: 31253507 DOI: 10.1016/j.soard.2019.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/09/2019] [Accepted: 05/11/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Ali Kagan Coskun
- Department of General Surgery, University of Health Science, Gulhane School of Medicine, Ankara, Turkey
| | - Mehmet Burak Eskin
- Department of Anesthesia and Reanimation, University of Health Science, Gulhane School of Medicine, Ankara, Turkey
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de Sousa GC, Cruz FF, Heil LB, Sobrinho CJS, Saddy F, Knibel FP, Pereira JB, Schultz MJ, Pelosi P, Gama de Abreu M, Silva PL, Rocco PRM. Intraoperative immunomodulatory effects of sevoflurane versus total intravenous anesthesia with propofol in bariatric surgery (the OBESITA trial): study protocol for a randomized controlled pilot trial. Trials 2019; 20:300. [PMID: 31138279 PMCID: PMC6540380 DOI: 10.1186/s13063-019-3399-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background Obesity is associated with a chronic systemic inflammatory process. Volatile or intravenous anesthetic agents may modulate immune function, and may do so differentially in obesity. However, no study has evaluated whether these potential immunomodulatory effects differ according to type of anesthesia in obese patients undergoing laparoscopic bariatric surgery. Methods/design The OBESITA trial is a prospective, nonblinded, single-center, randomized, controlled clinical pilot trial. The trial will include 48 patients with a body mass index ≥ 35 kg/m2, scheduled for laparoscopic bariatric surgery using sleeve or a Roux-en-Y gastric bypass technique, who will be allocated 1:1 to undergo general inhalational anesthesia with sevoflurane or total intravenous anesthesia (TIVA) with propofol. The primary endpoint is the difference in plasma interleukin (IL)-6 levels when comparing the two anesthetic agents. Blood samples will be collected prior to anesthesia induction (baseline), immediately after anesthetic induction, and before endotracheal extubation. Levels of other proinflammatory and anti-inflammatory cytokines, neutrophil chemotaxis, macrophage differentiation, phagocytosis, and occurrence of intraoperative and postoperative complications will also be evaluated. Discussion To our knowledge, this is the first randomized clinical trial designed to compare the effects of two different anesthetics on immunomodulation in obese patients undergoing laparoscopic bariatric surgery. Our hypothesis is that anesthesia with sevoflurane will result in a weaker proinflammatory response compared to anesthesia with propofol, with lower circulating levels of IL-6 and other proinflammatory mediators, and increased macrophage differentiation into the M2 phenotype in adipose tissue. Trial registration Registro Brasileiro de Ensaios Clínicos, RBR-77kfj5. Registered on 25 July 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3399-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giselle Carvalho de Sousa
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil.,Department of Anesthesiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernanda Ferreira Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil
| | - Luciana Boavista Heil
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil
| | | | - Felipe Saddy
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil.,Institute D'Or of Research and Teaching, Rio de Janeiro, Brazil
| | | | | | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G1-014, Ilha do Fundão, Rio de Janeiro, 21941-902, Brazil.
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