Technological advances in perioperative monitoring: Current concepts and clinical perspectives

Brief History of Opioids in Perioperative and Periprocedural Medicine to Inform the Future

Background: Opioids and derivatives of opium had been used as analgesics for thousands of years before the introduction of inhalational anesthetic agents. Once these early volatile agents were in widespread use, opioids were used as part of anesthetic care for premedication, as intraoperative adjuncts to general anesthesia, and for the management of postoperative pain. Evidence of growing dependence on opioids in the perioperative and periprocedural patient is supported by the ongoing research to develop synthetic opioids and to customize the pharmacokinetics and pharmacodynamics to achieve specific therapeutic goals. Methods: We explore the history of opioid use in perioperative care as a means of future management in light of new persistent opioid abuse. Results: As the opium chemical structure has been modified, newer nonopioid analgesics have been approved and brought into clinical practice. Opioid-sparing and opioid-free anesthetic techniques are not only a possibility, but a reality. Conclusion: Continuing research in neurobiology and addiction genetics will ultimately lead to a pharmacogenetic approach to patients at risk for new persistent opioid abuse.

Anesthesiologists in the Ether: Technology and Telemedicine in Anesthesiology

A new frontier in veterinary anesthesia telehealth has begun. With the adoption of electronic anesthetic records and video, phone, and chat consultations, an anesthesiologist can be integrated into the care team of any patient, anywhere in the world. This article reviews the benefits of adopting an electronic anesthetic record system, and the ways that practitioners can incorporate a virtual anesthesiologist into their care team.

Prolonged Intraoperative Cardiac Arrest in a Young Patient with Successful Precordial Thump

Cardiac arrest during surgery is rare but is one of the most dreaded complications. Precordial thump (PT) had been used for a long time, but in the present day it has become obsolete. In regard to the witnessed onset of asystole, there is insufficient evidence to recommend for or against the use of the PT. This case report is of a 17-year-old male who presented to hospital with a congenital haemangioma on the right calf. He had no other significant medical conditions and was on no other medications. The patient history, clinical examination, and investigations were normal. He had undergone an operation 3 weeks previously where a section of his haemangioma was excised, and an appointment was made for excision of the remaining haemangioma. Anaesthesia induction and endotracheal intubation were smooth and uneventful. Following lifting and exsanguination of the patient’s leg by Esmarch bandage, he developed ventricular fibrillation and arrested with asystole. Cardiopulmonary resuscitation was performed, with no good response, for approximately 50 minutes. Lastly, a PT was performed, and the patient’s heart rate immediately returned. The operation was postponed. Postresuscitation care was conducted in an intensive care unit. The patient was later discharged without complications.

Prolonged Intraoperative Cardiac Arrest in a Young Patient with Successful Precordial Thump

Cardiac arrest during surgery is rare but is one of the most dreaded complications. Precordial thump (PT) had been used for a long time, but in the present day it has become obsolete. In regard to the witnessed onset of asystole, there is insufficient evidence to recommend for or against the use of the PT. This case report is of a 17-year-old male who presented to hospital with a congenital haemangioma on the right calf. He had no other significant medical conditions and was on no other medications. The patient history, clinical examination, and investigations were normal. He had undergone an operation 3 weeks previously where a section of his haemangioma was excised, and an appointment was made for excision of the remaining haemangioma. Anaesthesia induction and endotracheal intubation were smooth and uneventful. Following lifting and exsanguination of the patient’s leg by Esmarch bandage, he developed ventricular fibrillation and arrested with asystole. Cardiopulmonary resuscitation was performed, with no good response, for approximately 50 minutes. Lastly, a PT was performed, and the patient’s heart rate immediately returned. The operation was postponed. Postresuscitation care was conducted in an intensive care unit. The patient was later discharged without complications.

Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery

BACKGROUND

Intraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017.

METHODS

The meeting featured a modified Delphi process in which groups addressed various aspects of perioperative arterial pressure.

RESULTS

Three consensus statements on intraoperative blood pressure were established. 1) Intraoperative mean arterial pressures below 60-70 mm Hg are associated with myocardial injury, acute kidney injury, and death. Injury is a function of hypotension severity and duration. 2) For adult non-cardiac surgical patients, there is insufficient evidence to recommend a general upper limit of arterial pressure at which therapy should be initiated, although pressures above 160 mm Hg have been associated with myocardial injury and infarction. 3) During cardiac surgery, intraoperative systolic arterial pressure above 140 mm Hg is associated with increased 30 day mortality. Injury is a function of arterial pressure severity and duration.

CONCLUSIONS

There is increasing evidence that even brief durations of systolic arterial pressure <100 mm Hg and mean arterial pressure <60-70 mm Hg are harmful during non-cardiac surgery.

Cost-effectiveness of anesthesia maintained with sevoflurane or propofol with and without additional monitoring: a prospective, randomized controlled trial

Background

We compared cost-effectiveness of anesthesia maintained with sevoflurane or propofol with and without additional monitoring, in the clinical setting of ear-nose-throat surgery.

Methods

One hundred twenty adult patients were randomized to four groups. In groups SEVO and SEVO+ anesthesia was maintained with sevoflurane, in group SEVO+ with additional bispectral index (BIS) and train-of-four (TOF) monitoring. In groups PROP and PROP+ anesthesia was maintained with propofol, in group PROP+ with additional BIS and TOF monitoring.

Results

Total cost of anesthesia per hour was greater in group SEVO+ compared to SEVO [€ 19.95(8.53) vs. 12.15(5.32), p <  0.001], and in group PROP+ compared to PROP (€ 22.11(8.08) vs. 13.23(4.23), p <  0.001]. Time to extubation was shorter in group SEVO+ compared to SEVO [11.1(4.7) vs. 14.5(3.9) min, p = 0.002], and in PROP+ compared to PROP [12.6(5.4) vs. 15.2(4.7) min, p <  0.001]. Postoperatively, arterial blood pressure returned to its initial values sooner in groups SEVO+ and PROP+.

Conclusions

Our study demonstrated that the use of BIS and TOF monitoring decreased the total cost of anesthesia drugs and hastened postoperative recovery. However, in our circumstances, these were associated with higher disposables costs. Detailed cost analysis and further investigations are needed to identify patient populations who would benefit most from additional monitoring.

Trial registration

ClinicalTrials.gov, NCT02920749. Retrospectively registered (date of registration September 2016).

Joint consensus on abdominal robotic surgery and anesthesia from a task force of the SIAARTI and SIC

Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures. A joint task force of Italian surgeons, anesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence. Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organization, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge. The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.