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Xiang JH, Wei P, Zhang YJ, Li LL, Li X, Wang J, Xie J, Zhong Y, Gao H, Yuan L, Chen WT, Song JG. Safety of prone emergence from general endotracheal anesthesia in patients undergoing ERCP: a randomized controlled trial. Surg Endosc 2023; 37:7493-7501. [PMID: 37415015 DOI: 10.1007/s00464-023-10187-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/30/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Conventional supine emergence and prone extubation from general endotracheal anesthesia (GEA) are associated with extubation-related adverse events (ERAEs). Given the minimally invasive nature of endoscopic retrograde cholangiopancreatography (ERCP) as well as the improved ventilation/perfusion matching and easier airway opening in the prone position, we aimed to assess the safety of prone emergence and extubation in patients undergoing ERCP under GEA. METHODS Totally, 242 eligible patients were recruited and randomized into the supine extubation group (n = 121; supine group) and the prone extubation group (n = 121; prone group). The primary endpoint was the incidence of ERAEs during emergence, including hemodynamic fluctuations, coughing, stridor, and hypoxemia requiring airway maneuvers. The secondary endpoints included the incidence of monitoring disconnections, extubation time, recovery time, room exit time, and post-procedure sore throat. RESULTS The incidence of ERAEs was significantly lower in the prone group compared with the supine group (8.3% vs 34.7%, OR = 0.17, 95% CI 0.18-0.56; P < 0.001). Moreover, the prone group demonstrated no monitoring disconnections, shorter extubation time and room exit time, faster recovery, and, lower frequency and milder sore throat after the procedure. CONCLUSIONS For patients undergoing ERCP under GEA, compared with supine, prone emergence, and extubation had remarkably lower rates of EAREs and better recovery, and can maintain continuous monitoring and improve efficiency.
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Affiliation(s)
- Jin-Hui Xiang
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Pan Wei
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Yu-Jiao Zhang
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Li-Li Li
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Xing Li
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Jian Wang
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Jian Xie
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Yong Zhong
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Hao Gao
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Lan Yuan
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China
| | - Wen-Ting Chen
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China.
- Acupuncture and Anesthesia Research Institute, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Jian-Gang Song
- Department of Anesthesiology, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, No. 528 Zhangheng Road, Shanghai, 201203, China.
- Acupuncture and Anesthesia Research Institute, Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
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Azimaraghi O, Bilal M, Amornyotin S, Arain M, Behrends M, Berzin TM, Buxbaum JL, Choice C, Fassbender P, Sawhney MS, Sundar E, Wongtangman K, Leslie K, Eikermann M. Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography. Br J Anaesth 2023; 130:763-772. [PMID: 37062671 DOI: 10.1016/j.bja.2023.03.012] [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: 10/29/2022] [Revised: 02/26/2023] [Accepted: 03/08/2023] [Indexed: 04/18/2023] Open
Abstract
Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intubation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be considered depending on the nature and severity of the patient's underlying disease, comorbidities, and procedural risks. An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical recommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for ERCP. An individual risk-benefit analysis that takes into account provider and institutional experience, patient comorbidities, and procedural risks is also needed.
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Affiliation(s)
- Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Somchai Amornyotin
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mustafa Arain
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Matthias Behrends
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Tyler M Berzin
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - James L Buxbaum
- Department of Internal Medicine, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Curtis Choice
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Philipp Fassbender
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA; Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eswar Sundar
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA; Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kate Leslie
- Monash University, Melbourne, VIC, Australia; Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
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Ozden MG, Bakan N, Kocoglu H. The effect of extubation in prone position on emergence and recovery in lumbar spinal surgery. J Neurosurg Sci 2023; 67:185-190. [PMID: 32536118 DOI: 10.23736/s0390-5616.20.05007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Extubation of patients in supine position after prone operations may lead to unwanted effects on hemodynamic and respiratory parameters during emergence and recovery period. We aimed to observe the effects of prone position on emergence and recovery periods after prone surgery. METHODS This randomized controlled trial was studied with sixty patients extubated either in prone position (30 patients) or in supine position (30 patients) after lumbar spinal surgery in tertiary educational hospitals. Heart rate, non-invasive arterial blood pressure, peripheral oxygen saturation and Bispectral Index values were measured, and recorded in all patients during operation, at the time an anesthetic agent was discontinued, before and after extubation. The number of the mouth suctioning, Aldrete recovery score, and Ricker agitation score were recorded together with the severity of cough during emergence and recovery. Incidents such as nausea, vomiting, respiratory failure, uncontrolled airway, and decreased saturation were also recorded. RESULTS Heart rate and mean arterial pressure values were significantly lower in the prone group during emergence and recovery period compared with the supine group (P<0.05). Aldrete Recovery Scores were higher in the prone group (P<0.001). The number of the mouth suctioning and the cough severity were lower in the prone group (P<0.001). CONCLUSIONS Extubation in the prone position provides a more comfortable emergence and recovery periods by less altering the hemodynamic and respiratory status with better recovery profile.
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Affiliation(s)
- Mesure G Ozden
- Anesthesiology and Reanimation Clinic, Goztepe Education and Research Hospital, Istanbul Medeniyet University, Istanbul, Türkiye -
| | - Nurten Bakan
- Anesthesiology and Reanimation Clinic, Sancaktepe Education and Research Hospital, Sancaktepe, Türkiye
| | - Hasan Kocoglu
- Anesthesiology and Reanimation Clinic, Goztepe Education and Research Hospital, Istanbul Medeniyet University, Istanbul, Türkiye
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Zhang J, Cheng Z, Tian Y, Weng L, Zhang Y, Yang X, Schäfer MKE, Guo Q, Huang C. Cerebral Tissue Oxygen Saturation Correlates with Emergence from Propofol-Remifentanil Anesthesia: An Observational Cohort Study. J Clin Med 2022; 11:jcm11164878. [PMID: 36013112 PMCID: PMC9410034 DOI: 10.3390/jcm11164878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/01/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Anesthesia emergence is accompanied by changes in cerebral circulation. It is unknown whether cerebral tissue oxygen saturation (SctO2) could be an indicator of emergence. Changes in SctO2, bispectral index (BIS), mean arterial pressure (MAP), and heart rate (HR) were evaluated during the emergence from propofol-remifentanil anesthesia. At the time of cessation of anesthetic delivery, SctO2, BIS, MAP, and HR values were recorded as baseline. The changes of these parameters from the baseline were recorded as Δ SctO2, Δ BIS, Δ MAP, and Δ HR. The behavioral signs (body movement, coughing, or eye opening) and response to commands (indicating regaining of consciousness) were used to define emergence states. Prediction probability (Pk) was used to examine the accuracy of SctO2, BIS, MAP, and HR as indicators of emergence. SctO2 showed an abrupt and distinctive increase when appearing behavioral signs. BIS, MAP, and HR, also increased but with a large inter-individual variability. Pk value of Δ SctO2 was 0.97 to predict the appearance behavioral signs from 2 min before that, which was much higher than the Pk values of Δ BIS (0.81), Δ MAP (0.71) and Δ HR (0.87). The regaining of consciousness was associated with a further increase in the SctO2 value.
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Affiliation(s)
- Jianxi Zhang
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha 410008, China
| | - Zhigang Cheng
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha 410008, China
| | - Ying Tian
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha 410008, China
| | - Lili Weng
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha 410008, China
| | - Yiying Zhang
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha 410008, China
| | - Xin Yang
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha 410008, China
| | - Michael K. E. Schäfer
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, 55122 Mainz, Germany
- Focus Program Translational Neurosciences (FTN), Research Center of Immunotherapy, Johannes Gutenberg-University Mainz, 55122 Mainz, Germany
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha 410008, China
| | - Changsheng Huang
- Department of Anesthesiology, Xiangya Hospital Central South University, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha 410008, China
- Correspondence: ; Tel./Fax: +86-731-84327413
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Han J, Hu Y, Liu S, Hu Z, Liu W, Wang H. Volume-controlled ventilation versus pressure-controlled ventilation during spine surgery in the prone position: A meta-analysis. Ann Med Surg (Lond) 2022; 78:103878. [PMID: 35734701 PMCID: PMC9207057 DOI: 10.1016/j.amsu.2022.103878] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/21/2022] [Accepted: 05/22/2022] [Indexed: 02/08/2023] Open
Abstract
Background Many studies have investigated a comparison of the potency and safety of PCV versus VCV modes in spinal surgery in prone position. However, controversy about the maximal benefits of which ventilation modes remains. The main purpose of this meta-analysis was to investigate which one is the optimal ventilation for surgery patients undergoing spine surgery in prone position between the two ventilation modes as PCV and VCV. Methods We conducted a comprehensive search of PubMed, Embase, Web of Science, the Cochrane Library, and Google Scholar for potentially eligible articles. The continuous outcomes were analyzed using the mean difference and the associated 95% confidence interval. Meta-analysis was performed using Review Manager 5.4 software. Results Our meta-analysis included 8 RCTs involving a total of 454 patients between 2012 and 2020. The results demonstrated that IOB, Ppeak and CVP for VCV are significantly superior to PCV in spinal surgery in prone position. And PCV had higher Cdyn and PaO2/FiO2 than VCV. But there was no significant difference between PCV and VCV in terms of POB, Hb, HCT, HR and MAP. Conclusions The PCV mode displayed a more satisfying effect than VCV mode. Compared to VCV mode in same preset of tidal volume, the patients with PCV mode in prone position demonstrated less IOB, lower Ppeak and CVP, and higher PaO2/FiO2 in spinal surgery. However, there is no obvious difference between PCV and VCV in terms of hemodynamics variables (HR and MAP). The PCV mode displayed a more satisfying effect than VCV mode. Compared to VCV mode, the patients with PCV mode in prone position demonstrated less IOB, lower Ppeak and CVP, and higher PaO2/FiO2 in spinal surgery. There is no obvious difference between PCV and VCV in terms of hemodynamics variables.
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Affiliation(s)
- Jun Han
- Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, Liaoning, China
- Department of Spine Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning, China
- Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Yunxiang Hu
- Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, Liaoning, China
- Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Sanmao Liu
- Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, Liaoning, China
- Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Zhenxin Hu
- Department of Spine Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning, China
- Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Wenzhong Liu
- Department of Joint Surgery, Gaomi People's Hospital, Gaomi, 261500, Shandong, China
| | - Hong Wang
- Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, Liaoning, China
- Corresponding author. Department of Spine Surgery, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116021, China.
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El-Sayed AA, Arafa SK, El-Demerdash AM. Pressure-controlled ventilation could decrease intraoperative blood loss and improve airway pressure measures during lumbar discectomy in the prone position: A comparison with volume-controlled ventilation mode. J Anaesthesiol Clin Pharmacol 2019; 35:468-474. [PMID: 31920229 PMCID: PMC6939555 DOI: 10.4103/joacp.joacp_288_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Prone positioning may induce alterations of hemodynamic and airway pressure parameters that may affect intraoperative (IO) blood loss. Pressure-controlled ventilation (PCV) may modify these alterations. To observe the relation between ventilation mode and hemodynamic, airway pressure changes, and blood loss during lumbar discectomy performed in the prone position. Material and Methods Volume-controlled ventilation (VCV) patients were using tidal volume (TV) of 8-10 ml/Kg, but for pressure-controlled ventilation (PCV) patients peak inspiratory pressure (PIP) was adjusted to provide the same TV according to ideal body weight. Respiratory and hemodynamic parameters were recorded in supine (T1), on turning to prone (T2), and on returning to the supine position (T3). Primary outcome included amount of IO blood loss; Secondary outcome included need for blood transfusion, IO hemodynamics, and airway pressure changes. Results IO blood loss and central venous pressure (CVP) were significantly higher with VCV than PCV patients. Heart rate and blood pressure were significantly reduced in the prone position with little impact of ventilation mode. Prone positioning resulted in significant increase of P-peak and non-significant decrease of P-mean pressure with VCV, while with PCV resulted in a significantly increased airway pressures. P-peak pressure was significantly lower with PCV in supine and prone positions than VCV. P-mean pressure was significantly lower in supine but significantly higher in the prone position with PCV than VCV. Conclusions Prone positioning and VCV were associated with increased CVP and IO blood loss, while PCV could lessen these effects and significantly improve airway pressures.
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Affiliation(s)
- Amir Abouzkry El-Sayed
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, Aswan University, Aswan, Egypt
| | - Sherif Kamal Arafa
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, Aswan University, Aswan, Egypt
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Savitha KS, Dhanpal R, Vikram MS. Hemodynamic Responses at Intubation, Change of Position, and Skin Incision: A Comparison of Multimodal Analgesia with Conventional Analgesic Regime. Anesth Essays Res 2017; 11:314-320. [PMID: 28663613 PMCID: PMC5490111 DOI: 10.4103/0259-1162.194556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Lumbar spine surgery is associated with hemodynamic variations at intubation, change of position, and skin incision. A balanced anesthesia with multimodal analgesia (MMA) is necessary to attenuate these changes. Aim: To assess the relative effectiveness of preemptive MMA compared with the conventional analgesic regime in suppressing the hemodynamic response to endotracheal intubation, prone positioning, and skin incision. Settings and Design: A randomized, prospective study involving 42 patients belonging to the American Society of Anesthesiologists Physical Status 1 and II scheduled to undergo elective lumbar spine surgery were allocated into two groups of 21 each. Materials and Methods: Forty-two patients were randomly allocated into Groups A and B. Group A (study group) received diclofenac, paracetamol, clonidine, and bupivacaine with adrenaline skin infiltration and Group B (control group) injection paracetamol and saline with adrenaline skin infiltration. Statistical Analysis Used: Hemodynamic parameters (heart rate [HR], systolic blood pressure [SBP], diastolic blood pressure [DBP], and mean arterial pressure [MAP]) between the groups following intubation, prone position, and skin incision were noted and compared using repeated measure analysis of variance. One sample t-test was used to compare the standard mean concentration with the means of the study and control groups. P < 5% being considered statistically significant. Results: In the study group, HR, SBP, DBP, and MAP were lower at intubation and change of position as compared to the control group and were statistically significant. Conclusion: Preemptive MMA with balanced anesthesia is effective in attenuating the hemodynamic responses to multiple noxious stimuli during lumbar spine surgery.
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Affiliation(s)
| | - Radhika Dhanpal
- Department of Anaesthesia, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - M S Vikram
- Department of Anaesthesia, St. John's Medical College Hospital, Bengaluru, Karnataka, India
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