Pharmacokinetics of lidocaine after bilateral ESP block

INTRODUCTION

Erector spinae plane (ESP) block is an emerging interfascial block with a wide range of indications for perioperative analgesia and chronic pain treatment. Recent studies have focused their attention on mechanisms of action of ESP block. However, the pharmacokinetics of drugs injected in ESP is, as of now, uninvestigated. The aim of this brief report is to investigate the pharmacokinetics of lidocaine in a series of 10 patients.

METHODS

We are reporting a case series of 10 patients undergoing bilateral ESP block for multilevel lumbar spine surgery.ESP was performed with 3.5 mg/kg of lidocaine based on ideal body weight. Lidocaine concentration was dosed at 5, 15, 30 min and at 1, 2 and 3 hours.

RESULTS

T_max was 5 min for all the patients. C_max ranged from 1.2 to 3.8 mg/L (mean: 2.59 mg/L). AUC_0-3 was high (76%, on average) suggesting an almost complete bioavailability. Age had a negative correlation with T½ of lidocaine.

CONCLUSIONS

Lidocaine pharmacokinetic after ESP block is well-described by a two-compartment model with a rapid and extensive rate of absorption. Nevertheless, its peak concentrations never exceeded the accepted toxicity limit. Elimination half-life was slightly prolonged, probably due to the advanced age of some patients.

Effect of dexmedetomidine on hemodynamic responses to tracheal intubation: A meta-analysis with meta-regression and trial sequential analysis

STUDY OBJECTIVE

An uncontrolled adrenergic response during tracheal intubation may lead to life-threatening complications. Dexmedetomidine binds to α2-receptors and may attenuate this response. The primary aim of our meta-analysis is to investigate dexmedetomidine efficacy in attenuating sympathetic response to tracheal intubation, compared with placebo or no dexmedetomidine, in terms of heart rate and blood pressure at intubation.

DESIGN

Meta-analysis with meta-regression and trial sequential analysis.

SETTING

Systematic search from inception until December 1, 2020 in the following databases: Pubmed, Scopus, the Cochrane Central Register of Controlled Trials, EMBASE and Google Scholar.

INTERVENTIONS

All randomized controlled trials investigating intravenous dexmedetomidine as premedication in adult patients undergoing tracheal intubation were included in our study. Studies were included without any language or publication date restriction. A trial sequential analysis and a post-hoc meta-regression were performed on the main outcomes.

MEASUREMENTS

Hemodynamic parameters and heart rate at tracheal intubation, dose of anesthetic needed for induction of anesthesia, total anesthetic requirement throughout the operative procedure, postoperative pain and percentage of patients requiring analgesics at 24 postoperative hours, postoperative nausea and vomiting, intraoperative and postoperative bradycardia, hypotension, dizziness, shivering and/or respiratory depression.

MAIN RESULTS

Ninety-nine included studies randomized 6833 patients. During laryngoscopy, all hemodynamic parameters were significantly greater in the no dexmedetomidine group. In particular, in the dexmedetomidine group, systolic blood pressure differed by -21.8 mm Hg (95% CI -26.6 to -17.1, p-value < 0.001, I² 97%), mean arterial pressure by -12.8 mm Hg (95% CI -15.6 to -10.0, p-value < 0.001, I² 98%), and heart rate by -16.9 bpm (95% CI -19.8 to -13.9, p-value < 0.001, I² 98%).

CONCLUSIONS

Patients receiving premedication with dexmedetomidine for tracheal intubation, compared with no dexmedetomidine, have a lower blood pressure and heart rate, however, the risk of bradycardia and hypotension is relevant and its use during daily practice should be cautiously evaluated for each patient.

Predictors of deep-vein thrombosis in subarachnoid hemorrhage: a retrospective analysis

BACKGROUND

Subarachnoid hemorrhage is a severe subtype of hemorrhagic stroke, and deep-vein thrombosis is a frequent complication detected in these patients. In addition to other well-established risk factors, the early activation of coagulation systems present in patients with subarachnoid hemorrhage could potentially play a role in the incidence of deep-vein thrombosis. This study aims to identify possible predictors for deep-vein thrombosis related to subarachnoid hemorrhage.

METHODS

We conducted a retrospective cohort study on patients with a diagnosis of subarachnoid hemorrhage who presented to our institution between 1 January 2014 and 1 August 2018. We reviewed electronic medical records and analyzed several parameters such as Fisher scale, World Federation of Neurosurgical Surgeons scale, aneurysm site, surgical or endovascular treatment, decompressive craniectomy, vasospasm, infection (meningitis and pneumonia), presence of motor deficit, length of stay in the ICU, length of hospital stay, number of days under ventilator support, d-dimer at hospitalization, and the time to thromboprophylaxis (days).

RESULTS

The univariate analysis showed that intraparenchymal cerebral hemorrhage, d-dimer at hospitalization, the time to thromboprophylaxis, motor deficit, and aneurysm located at the internal carotid artery were statistically significant factors. Intraparenchymal cerebral hemorrhage (OR 2,78 95%CI 1.07-7.12), motor deficit (OR 3.46; 95%CI 1.37-9.31), and d-dimer at hospitalization (OR 1.002 95% CI 1.001-1.003) were demonstrated as independent risk factors for deep-vein thrombosis. Length of hospital stay was also found to be significantly longer in patients who developed deep-vein thrombosis (p value 0.018).

CONCLUSION

Elevated d-dimer level at the time of hospitalization, motor deficit, and the presence of an intraparenchymal hemorrhage are independent risk factors for deep-vein thrombosis. Patients with DVT also had a significantly longer hospital stay. Even though further studies are needed, patients with elevated d-dimer at hospitalization and intraparenchymal cerebral hemorrhage may benefit from a more aggressive screening strategy for deep-vein thrombosis.

Single-shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta-analysis

BACKGROUND

Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach.

METHODS

We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials.

RESULTS

A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (-1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (-1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV.

CONCLUSIONS

RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

Opioid-free anesthesia in oncologic surgery: the rules of the game

BACKGROUND

Opioids are frequently used in the postoperative period due to their analgesic properties. While these drugs reduce nociceptive somatic, visceral, and neuropathic pain, they may also lead to undesirable effects such as respiratory depression, urinary retention, nausea and vomiting, constipation, itching, opioid-induced hyperalgesia, tolerance, addiction, and immune system disorders. Anesthesiologists are in the critical position of finding balance between using opioids when they are necessary and implementing opioid-sparing strategies to avoid the known harmful effects. This article aims to give an overview of opioid-free anesthesia.

MAIN BODY

This paper presents an overview of opioid-free anesthesia and opioid-sparing anesthetic techniques. Pharmacological and non-pharmacological strategies are discussed, highlighting the possible advantages and drawbacks of each approach.

CONCLUSIONS

Choosing the best anesthetic protocol for a patient undergoing cancer surgery is not an easy task and the available literature provides no definitive answers. In our opinion, opioid-sparing strategies should always be implemented in routine practice and opioid-free anesthesia should be considered whenever possible. Non-pharmacological strategies such as patient education, while generally underrepresented in scientific literature, may warrant consideration in clinical practice.

Inappropriate Citation of Retracted Articles in Anesthesiology and Intensive Care Medicine Publications

BACKGROUND

Retracted articles represent research withdrawn from the existing body of literature after publication. Research articles may be retracted for several reasons ranging from honest errors to intentional misconduct. They should not be used as reliable sources, and it is unclear why they are cited occasionally by other articles. This study hypothesized that several mechanisms may contribute to citing retracted literature and aimed to analyze the characteristics of articles citing retracted literature in anesthesiology and critical care.

METHODS

Using the Retraction Watch database, we retrieved retracted articles on anesthesiology and intensive care medicine up to August 16, 2021, and identified the papers citing these retracted articles. A survey designed to investigate the reasons for citing these articles was sent to the corresponding authors of the citing papers.

RESULTS

We identified 478 retracted articles, 220 (46%) of which were cited at least once. We contacted 1297 corresponding authors of the papers that cited these articles, 417 (30%) of whom responded to our survey and were included in the final analysis. The median number of authors in the analyzed articles was five, and the median elapsed time from retraction to citation was 3 yr. Most of the corresponding authors (372, 89%) were unaware of the retracted status of the cited article, mainly because of inadequate notification of the retraction status in journals and/or databases and the use of stored copies.

CONCLUSIONS

The corresponding authors were generally unaware of the retraction of the cited article, usually because of inadequate identification of the retracted status in journals and/or web databases and the use of stored copies. Awareness of this phenomenon and rigorous control of the cited references before submitting a paper are of fundamental importance in research.

The Impact of New Treatments on Short- and MID-Term Outcomes in Bilateral Lung Transplant: A Propensity Score Study

Background: Despite many efforts to improve organ preservation and recipient survival, overall lung transplant (LT) mortality is still high. We aimed to investigate the impact of ‘prophylactic’ veno-arterial extracorporeal membrane oxygenation (VA ECMO) and tacrolimus on 72-h primary graft dysfunction (PGD) and 30-day acute cellular rejection, respectively. Methods: All consecutive LT patients admitted to the Intensive Care Unit of the Padua University Hospital (February, 2016–2022) were screened. Only adult patients undergoing first bilateral LT and not requiring cardio-pulmonary bypass, invasive mechanical ventilation, and/or ECMO before LT, were included. A propensity score weighting analysis was employed to account for the non-random allocation of the subjects to different treatments. Results: A total of 128 LT recipients were enrolled. Compared to the ‘off-pump’-group (n.47, 37%), ‘prophylactic’ VA ECMO (n.51,40%) recorded similar 72-h PGD values, perioperative blood products and lower acute kidney dysfunction. Compared with cyclosporine (n.86, 67%), tacrolimus (n.42, 33%) recorded a lower risk of 30-day cellular rejection, kidney dysfunction, and bacteria isolation. Conclusions: ‘Prophylactic’ VA ECMO recorded 72-h PGD values comparable to the ‘off-pump’-group; while tacrolimus showed a lower incidence of 30-day acute cellular rejection.

Noninvasive respiratory support after extubation: a systematic review and network meta-analysis

BACKGROUND

The effect of noninvasive respiratory support (NRS), including high-flow nasal oxygen, bi-level positive airway pressure and continuous positive airway pressure (noninvasive ventilation (NIV)), for preventing and treating post-extubation respiratory failure is still unclear. Our objective was to assess the effects of NRS on post-extubation respiratory failure, defined as re-intubation secondary to post-extubation respiratory failure (primary outcome). Secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), discomfort, intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), and time to re-intubation. Subgroup analyses considered "prophylactic" versus "therapeutic" NRS application and subpopulations (high-risk, low-risk, post-surgical and hypoxaemic patients).

METHODS

We undertook a systematic review and network meta-analysis (Research Registry: reviewregistry1435). PubMed, Embase, CENTRAL, Scopus and Web of Science were searched (from inception until 22 June 2022). Randomised controlled trials (RCTs) investigating the use of NRS after extubation in ICU adult patients were included.

RESULTS

32 RCTs entered the quantitative analysis (5063 patients). Compared with conventional oxygen therapy, NRS overall reduced re-intubations and VAP (moderate certainty). NIV decreased hospital mortality (moderate certainty), and hospital and ICU LOS (low and very low certainty, respectively), and increased discomfort (moderate certainty). Prophylactic NRS did not prevent extubation failure in low-risk or hypoxaemic patients.

CONCLUSION

Prophylactic NRS may reduce the rate of post-extubation respiratory failure in ICU patients.

General Anesthesia Compared to Spinal Anesthesia for Patients Undergoing Lumbar Vertebral Surgery: A Meta-Analysis of Randomized Controlled Trials

Vertebral lumbar surgery can be performed under both general anesthesia (GA) and spinal anesthesia. A clear benefit from spinal anesthesia (SA) remains unproven. The aim of our meta-analysis was to compare the early analgesic efficacy and recovery after SA and GA in adult patients undergoing vertebral lumbar surgery. A systematic investigation with the following criteria was performed: adult patients undergoing vertebral lumbar surgery (P); single-shot SA (I); GA care with or without wound infiltration (C); analgesic efficacy measured as postoperative pain, intraoperative hypotension, bradycardia, length of surgery, blood loss, postoperative side effects (such as postoperative nausea/vomiting and urinary retention), overall patient and surgeon satisfaction, and length of hospital stay (O); and randomized controlled trials (S). The search was performed in Pubmed, the Cochrane Central Register of Controlled Trials, and Google Scholar up to 1 November 2020. Eleven studies were found upon this search. SA in vertebral lumbar surgery decreases postoperative pain and the analgesic requirement in the post anesthesia care unit. It is associated with a reduced incidence of postoperative nausea and vomiting and a higher patient satisfaction. It has no effect on urinary retention, intraoperative bradycardia, or hypotension. SA should be considered as a viable and efficient anesthetic technique in vertebral lumbar surgery.

Risk Factors for General Anesthesia Conversion in Anterior Circulation Stroke Patients Undergoing Endovascular Treatment

BACKGROUND AND PURPOSE

No current consensus exists on the best anesthetic management of ischemic stroke patients undergoing mechanical thrombectomy. Both conscious sedation (CS) and general anesthesia (GA) are currently considered valid anesthetic strategies, yet patients managed under CS may require emergent conversion to GA, which has been associated with worse outcomes. The aim of this study was to analyze the conversion rate and potential risk factors for GA conversion during mechanical thrombectomy.

METHODS

Two-hundred and twenty-seven patients with consecutive acute anterior circulation ischemic stroke treated with mechanical thrombectomy and initiated under CS or local anesthesia were included in this retrospective analysis. Conversion rate to GA was calculated, while univariate and multivariate analysis were used to identify risk factors.

RESULTS

Twenty patients (8.8%) were switched to GA. Multivariate analysis identified procedure duration (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.00-1.02, p value 0.028), tandem stroke (OR 8.57, 95% CI 2.06-35.7, p value 0.003), Sequential Organ Failure Assessment (SOFA) (OR 1.76, 95% CI 1.19-2.61, p value 0.005), and number of pharmacological agents used (OR 5.76, 95% CI 2.49-13.3, p value <0.001) as independently associated with conversion to GA.

CONCLUSION

In our study, tandem occlusion, longer endovascular procedures, SOFA, and number of pharmacological agents used predicted the risk of emergent conversion to GA in stroke patients undergoing endovascular treatment. Prospective studies investigating optimal CS strategies are deemed necessary.

General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis

PURPOSE

Endovascular treatment for stroke patients usually requires anesthesia care, with no current consensus on the best anesthetic management strategy. Several randomized controlled trials and meta-analyses have attempted to address this. In 2022, additional evidence from three new trials was published: the GASS trial, the CANVAS II trial, and preliminary results from the AMETIS trial, prompting the execution of this updated systematic review and meta-analysis. The primary objective of this study was to evaluate the effects of general anesthesia and conscious sedation on functional outcomes measured with the modified Rankin scale (mRS) at three months.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials investigating conscious sedation and general anesthesia in endovascular treatment. The following databases were examined: PubMed, Scopus, Embase, and the Cochrane Database of Randomized Controlled Trials and Systematic Reviews. The Risk of Bias 2 tool was used to assess bias. In addition, trial sequence analysis was performed on the primary outcome to estimate if the cumulative effect is significant enough to be unaffected by further studies.

RESULTS

Nine randomized controlled trials were identified, including 1,342 patients undergoing endovascular treatment for stroke. No significant differences were detected between general anesthesia and conscious sedation with regards to mRS, functional independence (mRS, 0-2), procedure duration, onset to reperfusion, mortality, hospital length of stay, and intensive care unit length of stay. Patients treated under general anesthesia may have more frequent successful reperfusion, though the time from groin to reperfusion was slightly longer. Trial sequential analysis showed that additional trials are unlikely to show marked differences in mean mRS at three months.

CONCLUSIONS

In this updated systematic review and meta-analysis, the choice of anesthetic strategy for endovascular treatment of stroke patients did not significantly impact functional outcome as measured with the mRS at three months. Patients managed with general anesthesia may have more frequent successful reperfusion.

TRIAL REGISTRATION

PROSPERO (CRD42022319368); registered 19 April 2022.

Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis

BACKGROUND

Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective.

OBJECTIVES

To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected.

DESIGN

Systematic review with network meta-analysis (PROSPERO:CRD42021250651).

DATA SOURCE

PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021).

ELIGIBILITY CRITERIA

All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction.

RESULTS

Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40).

CONCLUSION

All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone.

TRIAL REGISTRATION

PROSPERO (CRD4202125065).

Optimizing post anesthesia care unit admission after elective craniotomy for brain tumors: a cohort study

BACKGROUND

Postoperative admission to intensive care unit (ICU) after craniotomy for brain tumor was the routine in the past years. However, there is little evidence supporting this dogma and doubts have been casted by many authors in the last years. Our aim was to identify risk factors for ICU admission after elective brain tumor surgery in order to propose an individualized admission to ICU tailored on patient needs.

METHODS

We conducted a retrospective cohort study including all patients undergoing elective surgery for brain tumor in a neurosurgical post anesthesia care unit of a university hospital over a period of 6 years. In order to identify and validate risk factors for ICU admission, we split the final cohort of patients in a training cohort (two/third of the cohort) and the validation cohort (one/third of the cohort) using a random sequence. Using univariate and multivariate logistic regression, we created a scoring system in the training cohort and tested it with the validation cohort. Moreover, we perform a sensitivity analysis on the overall population.

RESULTS

A total of 420 patients were eligible for this study. ASA-PS, tumor volume, and surgery length entered the scoring system. Sensitivity analysis on the overall population for the scoring system had an AUC of 0.774 (95% CI 0.668-0.880, the best threshold at 12.5) CONCLUSIONS: We created a tool based on ASA-PS, length of surgery, and tumor volume to evaluate the risk for ICU admission after supratentorial tumor resection. Prospective studies are deemed necessary to validate our tool.

Trial Sequential Analysis explained using a post-hoc analysis of meta-analyses published in Korean Journal of Anesthesiology

Background

Trial sequential analysis (TSA) is a recent cumulative meta-analysis method used to weigh type I and II errors and to estimate when the effect is large enough to be unaffected by further studies. The aim of this study was to illustrate possible TSA scenarios and their significance using meta-analyses published in the Korean Journal of Anesthesiology (KJA) as working material.

Methods

We performed a systematic medical literature search for meta-analyses published in the KJA. TSA was performed on each main outcome, estimating the required sample size on the calculated effect size for the intervention, considering a type I error of 5% and a power of 90% or 99%.

Results

Six meta-analyses with a total of ten main outcomes were included in the analysis. Seven TSAs confirmed the results of the meta-analyses. However, only three of them reached the required sample size. In the two TSAs, the cumulative z-lines were not statistically significant. One TSA boundary for effect was reached with the 90% analysis, but not with the 99% analysis.

Conclusions

In TSA, a meta-analysis pooled effect may be established to assess if the cumulative sample size is large enough. TSA can be used to add strength to the conclusions of meta-analyses; however, pre-registration of the TSA protocol is of paramount importance. This study could be useful to better understand the use of TSA as an additional statistical tool to improve meta-analysis quality.

Reliability of Third Ventricle Assessment by Transcranial Ultrasound: A Computational Model of the Effect of Insonation Angle

INTRODUCTION

Transcranial sonography (TCS) is a bedside examination which is currently used in multiple neurocritical care settings. Third ventricle ultrasound is usually a simple technique, though a large insonation angle could lead to an overestimation of third ventricular diameter. The aim of this study was to use a mathematical model to evaluate the impact of probe inclination on the false positive rate when using TCS to evaluate third ventricle enlargement.

METHODS

Using R software, we simulated a pool of 100,000 fictitious patients with a normal third ventricle size (diameter from 0 to 9 mm) in daily follow-up for ventricle enlargement for 30 consecutive days using TCS. Each day, a different, random insonation angle (α) was generated and a corresponding measured diameter calculated as: measured diameter=real diameter/cos α. If the measured diameter was >9.0 mm, the simulation registered a "misdiagnosis" episode and the simulation loop was interrupted; otherwise, the simulation continued to its thirtieth iteration.

RESULTS

Of the 100,000 "patient" simulations, 30,905 (30.9%) had an erroneous TCS diagnosis of ventricular enlargement. Angles of insonation >35 degrees contributed to 79.3% of the total misdiagnoses of ventricular enlargement (false positive rate, 3.71%), whereas misdiagnosis was rare when the insonation angle was ≤15 degrees (1.30% of the total misdiagnoses; false positive rate, 0.06%).

CONCLUSION

Using probe inclinations <15 degrees, erroneous diagnosis of third ventricular enlargement was rare. Our results suggest that TCS has a low rate of false positives when the angle of insonation is minimized.

Ultrasound as a Useful Tool in Hydrocephalus Management During Pregnancy: A Case Report

A 38-year-old pregnant woman in her 24th week of gestation was admitted to our neurosurgical intensive care unit with a 5-cm cerebellar hemangioblastoma and acute hydrocephalus. Initial management included the placement of an external ventricular drain to prevent neurological deterioration. Five days after the initial diagnosis, the patient successfully underwent a neurosurgical intervention to remove the lesion. Transcranial ultrasound was used to determine the optimal ventricular drain level and facilitate weaning, bypassing the need for cerebral computed tomography and cerebral magnetic resonance imaging, which would have otherwise been necessary in postoperative follow-up.

Preoperative Dexmedetomidine and intraoperative bradycardia in laparoscopic cholecystectomy: meta-analysis with trial sequential analysis

Background

While laparoscopic surgical procedures have various advantages over traditional open techniques, artificial pneumoperitoneum is associated with severe bradycardia and cardiac arrest. Dexmedetomidine, an imidazole derivative that selectively binds to α²-receptors and has sedative and analgesic properties, can cause hypotension and bradycardia. Our primary aim was to assess the association between dexmedetomidine use and intraoperative bradycardia during laparoscopic cholecystectomy.

Methods

We performed a systematic review with a meta-analysis and trial sequential analysis using the following PICOS: adult patients undergoing endotracheal intubation for laparoscopic cholecystectomy (P); intravenous dexmedetomidine before tracheal intubation (I); no intervention or placebo administration (C); intraoperative bradycardia (primary outcome), intraoperative hypotension, hemodynamics at intubation (systolic blood pressure, mean arterial pressure, heart rate), dose needed for induction of anesthesia, total anesthesia requirements (both hypnotics and opioids) throughout the procedure, and percentage of patients requiring postoperative analgesics and experiencing postoperative nausea and vomiting and/or shivering (O); randomized controlled trials (S).

Results

Fifteen studies were included in the meta-analysis (980 patients). Compared to patients that did not receive dexmedetomidine, those who did had a higher risk of developing intraoperative bradycardia (RR: 2.81, 95% CI [1.34, 5.91]) and hypotension (1.66 [0.92, 2.98]); however, they required a lower dose of intraoperative anesthetics and had a lower incidence of postoperative nausea and vomiting. In the trial sequential analysis for bradycardia, the cumulative z-score crossed the monitoring boundary for harm at the tenth trial.

Conclusions

Patients undergoing laparoscopic cholecystectomy who receive dexmedetomidine during tracheal intubation are more likely to develop intraoperative bradycardia and hypotension.

A practical guide to patient position and complication management in neurosurgery: a systematic qualitative review

PURPOSE

Adequate patient positioning is of paramount importance in neurosurgery. Complications related to the position are common and make up for more than 16% of the claims towards anaesthesiologists and neurosurgeons. This paper aims to provide the anaesthesiologist with a practical guide to avoid common pitfalls related to the patient positioning process.

METHOD

We performed a systematic review of the medical literature for the identification, screening, and inclusion of articles. The bibliographic search was conducted on June 1st, 2021 by two of the authors. In this review, we included articles indexed by MEDLINE, Cochrane Library, or Google Scholar.

RESULTS

We retrieved a total of 5706 unique papers from our initial search. However, after the initial screening, 5363 papers were removed is not related to our research leaving a total of 343 papers. We examined the full text of all the 343 articles including 68 of them in the final qualitative analysis.

DISCUSSION

In this review we examine the most common neurosurgical positions: supine, sitting, lateral, park-bench, prone, jack-knife, and knee-chest. For each of them, the proper positioning and related complications are described. Particular attention is given to the prevention and management of these complications, providing a practical guide for clinicians.

Inattentional blindness in anesthesiology: A gorilla is worth one thousand words

INTRODUCTION

People are not able to anticipate unexpected events. Inattentional blindness is demonstrated to happen not only in naïve observers engaged in an unfamiliar task but also in field experts with years of training. Anaesthesia is the perfect example of a discipline which requires a high level of attention and our aim was to evaluate if inattentional blindness can affect anesthesiologists during their daily activities.

MATERIALS AND METHODS

An online survey was distributed on Facebook between May 1, 2021 and May 31, 2021. The survey consisted of five simulated cases with questions investigating the anesthetic management of day-case surgeries. Each case had an introduction, a chest radiography, an electrocardiogram, preoperative blood testing and the last case had a gorilla embedded in the chest radiography.

RESULTS

In total 699 respondents from 17 different countries were finally included in the analysis. The main outcome was to assess the incidence of inattentional blindness. Only 34 (4.9%) respondents were able to spot the gorilla. No differences were found between anesthesiologists or residents, private or public hospitals, or between medical doctors with different experience.

DISCUSSION

Our findings assess that inattentional blindness is common in anesthesia, and ever-growing attention is deemed necessary to improve patient safety; to achieve this objective several strategies should be adopted such as an increased use of standardized protocols, promoting automation based strategies to reduce human error when performing repetitive tasks and discouraging evaluation of multiple consecutive patients in the same work shifts independently of the associated complexity.

Enhancing study quality assessment: an in-depth review of risk of bias tools for meta-analysis-a comprehensive guide for anesthesiologists

BACKGROUND

Yearly, a multitude of randomized controlled trials are published, overwhelming clinicians with conflicting information; this data saturation leads to confusion and hinders clinicians' everyday decision-making. Hence, it is crucial to assess the quality and reliability of the evidence in order to consolidate it. Through this synthesis, clinicians can guarantee that their decisions are informed by solid evidence. Meta-analysis, a statistical technique, can effectively combine data from multiple studies to furnish accurate and dependable evidence for clinical practice and policy decisions. Nonetheless, the reliability of the obtained results depends on the use of high-quality evidence.

MAIN BODY

Risk of bias is an assessment mandatory while performing a meta-analysis and is used to have an overview of the quality of the studies from which data are extracted. Several tools have been developed and are used to perform the risk of bias assessment. In this statistical round, we will provide an overview of the most used tools for both the randomized (Cochrane Risk of Bias 2 and Jadad) and the nonrandomized (Risk Of Bias In Non-randomized Studies and Newcastle-Ottawa Scale) clinical trials.

CONCLUSION

We provided an overview of the most used risk of bias tools used in meta-analysis.