Anesthesia and pain medicine最新文献

Electromyography (EMG)-based neuromuscular monitoring has emerged as a pivotal advancement in anesthesia, offering enhanced precision and reliability in assessing neuromuscular blockade. This review describes the physiological foundations of EMG, the methodologies for quantifying compound muscle action potential, and the comparative utility of EMG over traditional acceleromyography. Clinical applications across various muscle sites-specifically the adductor pollicis, first dorsal interosseous, and abductor digiti minimi-are explored, emphasizing inter-muscle variability and its implications for dosing of reversal agents. EMG-based monitoring is associated with reduced calibration time, improved stability against signal drift, and superior prevention of residual neuromuscular blockade. However, EMG monitoring presents unique challenges, including signal artifacts and device-specific variations in response thresholds. Recent comparative studies have demonstrated the importance of understanding device-specific characteristics to optimize clinical interpretations. Collectively, this evidence supports the use of EMG as a standard modality for perioperative neuromuscular management. Its accurate and reproducible signals, combined with broad clinical compatibility, present a compelling case for widespread adoption in routine anesthetic practice.

Obesity and sleep apnea contribute to significant challenges in ambulatory surgical centers which include airway management and perioperative recovery. This narrative review was written following a literature review of articles available on ScienceDirect, PubMed, and Google Scholar from 2009 to 2024. This article highlights that obesity-related anatomical changes, such as increased neck circumference (NC) and reduced cervical extension, may complicate airway management. Successful ambulatory surgery for these high-risk patients depends on detailed attention throughout the perioperative period. Advanced airway techniques, along with continuous pulse oximetry and capnography, are vital for safe care. The use of continuous positive airway pressure or bilevel positive airway pressure in the perioperative phase is particularly beneficial in preventing respiratory complications. A systematic, multidisciplinary approach emphasizing preoperative screening, risk stratification, and standardized protocols is crucial for optimizing results.

Aging adversely impacts thermoregulatory function, thereby increasing the risk of intraoperative hypothermia. Age-associated alterations-including diminished thermal perception, impaired autonomic responsiveness, reduced thermogenic capacity due to sarcopenia, and decreased cardiovascular adaptability, exacerbate the vulnerability to hypothermia. Concomitant comorbidities and polypharmacy further compromise thermal homeostasis in geriatric patients. Anesthetic agents compound this risk by lowering the thresholds for vasoconstriction and shivering and attenuating the magnitude of thermal responses. Consequently, geriatric populations are predisposed to significant perioperative temperature decline, particularly in cooler operating room (OR) environments. Intraoperative hypothermia is associated with an increased incidence of adverse outcomes, including increased cardiac events, surgical site infections, coagulopathy, protracted pharmacodynamic effects, extended recovery, and hospitalization duration. Although recent investigations suggest a diminished incidence of hypothermia due to minimally invasive surgical techniques and enhanced temperature management protocols, the intrinsic susceptibility of the aged thermoregulatory system persists. Effective temperature management requires precise core temperature monitoring and maintains appropriate OR temperatures. Furthermore, the implementation of multimodal warming strategies, including passive insulation, active warming modalities, warming of intravenous fluids, and prewarming before anesthesia induction, is critical. Therefore, a comprehensive and proactive thermal management approach is essential in mitigating hypothermia-related risks and optimizing perioperative outcomes in the geriatric patients.

Background: Anesthetic management in pregnant women with congenital heart disease is complex due to physiological changes during pregnancy and the specific hemodynamic challenges posed by different cardiac anomalies. A multidisciplinary approach is essential to optimize maternal and fetal outcomes. Pregnancy induces significant cardiovascular changes to meet the increased metabolic demands of the mother and growing fetus. Cardiovascular changes may aggravate the underlying pathology during pregnancy, leading to hemodynamic instability.

Case: A 27-year-old pregnant woman presented with severe pulmonary stenosis after pulmonary valve balloon dilatation for an elective cesarean section using a combined spinal-epidural technique (CSE) and milrinone nebulization to avoid right ventricular dysfunction.

Conclusions: CSE reduces the stress response to surgery, minimizes myocardial depression associated with anesthetic drugs, and improves postoperative pain control. Techniques such as milrinone nebulization may help lessen the hemodynamic perturbations associated with auto-transfusion post-delivery.

Background: Bronchospasm is a rare but potentially life-threatening complication during anesthesia that requires prompt recognition and management. Traditional auscultation plays a key role but is limited in objective interpretation and continuous monitoring.

Case: We report a case of intraoperative bronchospasm during laparoscopic surgery, detected early through real-time acoustic visualization using a digitalized esophageal stethoscope. The visualization of lung sounds facilitated the rapid identification of expiratory wheezing and abnormal spectrogram patterns characteristic of bronchospasm. Immediate intervention with a bronchodilator resolved the condition without further complications.

Conclusions: This case demonstrates the utility of visual stethoscopes in enhancing perioperative respiratory management. Real-time visualization and quantification of lung sounds offer anesthesiologists a valuable tool for early diagnosis and collaborative decision-making during critical respiratory events.

Background: Intravenous (IV) fluid therapy is essential and widely used; however, it is associated with high error rates, largely due to human factors, necessitating constant and careful monitoring by medical staff. Gravity-based systems are prone to errors, whereas electronic pumps, though more accurate, are limited by size, cost, and complexity. In this study, the impact of single-drop weight measurement and real-time light source monitoring on the accuracy of gravity-based infusion systems was evaluated.

Methods: Gravity-based IV sets with IV infusion flow regulators (IIFRs) from three manufacturers were tested using 1,000 ml of 0.9% saline. The drops per min and the drop weight were recorded using a pulse oximeter, which served as a light source. The flow rates from the pulse oximeter group (PO) were compared with those from the manufacturer's drop volume (C) and the IIFR groups. The mean absolute percentage error (MAPE) of predicted versus actual volumes was analyzed along with correlations between the residual volume and drop rate.

Results: The PO group values were statistically closer to those of the actual measurements than the C and IIFR groups values (P < 0.05), demonstrating higher accuracy and lower MAPE, except at 300 ml/h when than those of the C group, independent of residual volume. The residual volume strongly correlated with the drop rate (r > 0.9).

Conclusions: Real-time drop measurements using light sources combined with single-drop weight assessment improve the accuracy of these systems. Integrating pulse oximeters into IV sets may enhance clinical precision and reduce provider workload.

Scapular or shoulder blade surgeries are uncommon in routine anesthesia practice. Most undisplaced injuries are managed conservatively; therefore, the literature on appropriate anesthetic management plans for scapular surgeries is sparse. This bone is well-protected by the surrounding muscles and tissues, and any surgery is associated with significant tissue exploration and excessive postoperative pain. The complicated innervation of the structures surrounding this bone makes pain management extremely challenging. However, recent advances in ultrasound-guided nerve blocks and cadaveric studies have been helpful in identifying target nerves to provide analgesia or even surgical anesthesia, if planned carefully. Literature searches in PubMed, Embase, and Google Scholar resulted in only a handful of articles, mainly case reports and series, in addition to being inaccessible because of the need for subscription charges. We aimed to gather as much information as possible to cover all possible regional blocks that can be performed for scapular surgeries and compile them concisely in a single article.