Intraoperative magnesium supplementation improves gynecology major surgery perioperative outcome

Effects of intra-operative magnesium sulfate infusion on orthognathic surgery: A prospective and randomized controlled trial

Purpose

To comprehensively understand the effects of intra-operative infusion of magnesium sulfate on patients who underwent orthognathic surgery, including remifentanil consumption, postoperative pain, postoperative nausea and vomiting (PONV), inflammatory response, and serum magnesium levels.

Methods

Seventy-five adult patients undergoing orthognathic surgery under general balanced anesthesia were randomly divided into two groups. One group (Group M) received 50 mg/kg of magnesium sulfate in 20 mL 0.9 % saline after intubation, followed by a continuous infusion at a rate of 15 mg/kg/h until 30 min before the anticipated end of surgery. The other group (Group C) received an equal volume of isotonic saline as a placebo. (Clinical trial registration number: chiCTR2100045981).

Results

The primary outcome was remifentanil consumption. The secondary outcomes included the pain score assessed using the verbal numerical rating scale (VNRS) and PONV assessed using a Likert scale. Remifentanil comsumption in Group M was lower than Group C (mean ± SD: 0.146 ± 0.04 μg/kg/min vs. 0.173 ± 0.04 μg/kg/min, P = 0.003). At 2 h after surgery, patients in Group C suffered more severe PONV than those in Group M (median [interquartile range, IQR]: 1 [3] vs. 1 [0], mean rank: 31.45 vs. 42.71, P = 0.040). At post-anesthesia care unit (PACU), postoperative pain in Group C was severe than Group M (3 [1] vs. 3 [0], mean rank: 31.45 vs. 42.71, P = 0.013). Changes in haemodynamics and surgical field scores did not differ between the groups (all P > 0.05). The levels of cytokines (IL-4, IL-6, IL-8, IL-10, TNF-a, and MIP-1β) were not significantly different between the groups after surgery (all P > 0.05). Postoperative serum magnesium levels in Group C were lower than those in Group M (0.74 ± 0.07 mmol/L vs. 0.91 ± 0.08 mmol/L, P = 0.000) and the preoperative level (0.74 ± 0.07 mmol/L vs. 0.83 ± 0.06 mmol/L, P = 0.219).

Conclusions

In orthognathic surgery, magnesium sulfate administration can reduce remifentanil requirement and relieve PONV and postoperative pain in the early postoperative phase.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery)

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

Difficult tracheal extubation due to endotracheal tube malfunction: A challenge during the COVID-19 pandemic

Tracheal extubation is an aerosol-generating medical procedure. Difficult tracheal extubation is a serious complication that increases the risk of respiratory aerosol and pathogen spread, especially during the COVID-19 pandemic. The management of difficult extubation is potentially even more challenging during the pandemic. We report two cases of difficult extubation due to endotracheal tube cuff malfunction during the COVID-19 pandemic. Special airway maneuvers and infection control measures were employed to successfully manage the unexpected dilemma. This case series highlights the risk of COVID-19 virus transmission during difficult extubation. This report describes the preventive and reactive management of difficult extubation.