Indian Journal of Anaesthesia最新文献

Background and aims: With the evolution of liver transplant anaesthesia, judicious intraoperative fluid management has been widely recommended. However, existing literature on a weight-based restricted fluid strategy is limited. Our institution follows a weight-based, restrictive fluid approach with maintenance therapy at 4 ml/kg/h (2 ml/kg/h crystalloids + 2 ml/kg/h 4% albumin solution) and goal-directed fluid boluses (4 ml/kg 4% albumin solution).

Methods: This retrospective study analysed 106 adult living donor liver transplant recipients managed with a protocolised restrictive fluid strategy and compared them with 148 historical controls who received conventional fluid therapy. The primary outcomes were early extubation (extubated on table or within 6 hours post-operatively) and incidence of post-operative acute kidney injury (AKI) on post-operative days (POD) 1 and 3. Secondary outcomes included intra-operative blood transfusion requirement, vasopressor use, and vascular complication rate. Data were analysed using statistical package for the social sciences version 22 and Epi Info version 7.2.1.

Results: The restrictive group received significantly lower total fluid volumes (3284 ± 833 ml vs. 3979 ± 1524 ml; P < 0.001), had higher on-table extubation rates (83% vs. 71.3%; P = 0.031), and experienced zero AKI by POD3 compared to 13.6% in the conventional group (P < 0.001). Serum creatinine was lower on POD1 and POD3 in the restrictive group. Vasopressin use was higher (P < 0.001) in the cases, while noradrenaline and blood transfusion requirements were comparable between the groups.

Conclusion: Our protocolised weight-based restrictive fluid regimen was associated with improved pulmonary outcomes without increased renal dysfunction. However, prospective studies with larger cohorts are required to validate our findings.

Background and aims: Intra-operative hypotension (IOH) adversely affects renal graft and recipient outcomes. The Hypotension Prediction Index (HPI), a machine learning-based algorithm, predicts IOH. This study compared HPI- versus pulse pressure variation (PPV)-guided haemodynamic management in kidney transplantation, hypothesising that HPI guidance would reduce intra-operative hypotension.

Methods: In this single-centre randomised controlled trial, 82 patients with end-stage renal disease (ESRD) undergoing live-related kidney transplantation under general anaesthesia were randomised to HPI-guided (n = 41) or PPV-guided (n = 41) haemodynamic management. The primary outcome was the time-weighted average area under the threshold (TWA-AUT) of mean arterial pressure (MAP) <65 mmHg. Secondary outcomes included absolute area under the threshold (AUT), the number and total duration of hypotensive episodes per patient, and the proportion of patients with MAP <50 mmHg. Delayed graft function, serum creatinine on post-operative day 3, hospital stay, and 90-day mortality were also compared.

Results: The results were analysed for 82 patients. The median [interquartile range (IQR)] TWA-AUT <65 mmHg was 0.10 mmHg [0.04-0.17] in the HPI group and 0.16 mmHg [0.06-0.32] in the PPV group, with a median difference of -0.05 mmHg [95% confidence interval (CI): -0.18 to 0.01; P = 0.09]. The median AUT was 24.8 mmHg·min in the HPI group and 43.3 mmHg × min in the PPV group (P = 0.10). Hypotensive events occurred in 47% of patients in the HPI group versus 61% in the PPV group (P = 0.16). No significant differences were observed in the secondary outcomes between the groups.

Conclusion: HPI-guided haemodynamic management did not significantly reduce the time-weighted average of intra-operative hypotension during renal transplant surgery compared to PPV-guided haemodynamic management.

Background and aims: Postoperative delirium remains a major concern among adult patients undergoing surgery. Intranasal insulin is believed to reduce postoperative delirium in adults. However, its efficacy and safety profile remain unclear. The primary objective was to examine the effects of intranasal insulin on the incidence of postoperative delirium. Secondary outcomes include serum concentration of Tissue Necrosis Factor-alpha (TNF-α), Interleukin-6 (IL-6), C-Reactive Protein (CRP), haemostasis model assessment - insulin (HOMA-IR), and serum glucose.

Methods: All randomised controlled trials (RCTs) were searched in the databases of CENTRAL, EMBASE, and MEDLINE until January 2025. Case reports, case series, letters to the editor, and conference abstracts were excluded. We used Revman Version 5.4 to calculate the fixed-effects and random-effects models to report the primary and secondary outcomes by using the odds ratio (OR) and mean difference (MD), respectively, with a 95% confidence interval (CI). This review included a Grading of Recommendations Assessment, Development and Evaluation analysis on the quality of evidence for all measured outcomes.

Results: Seven studies with a total of 739 patients were included in this systematic review. In comparison to intranasal saline, intranasal insulin significantly reduced the incidence of postoperative delirium among adults undergoing surgery (OR: 0.37, 95% CI: 0.22, 0.63). Its administration was also associated with a statistical decrease in the serum concentration of TNF-α (MD: -3.10, 95% CI: -4.42, -1.78), serum concentration of IL-6 (MD: -3.86, 95% CI: -5.92, -1.80), and serum concentration of CRP (MD: -1.71, 95% CI: -3.38, -0.04). However, no statistical differences were observed in the HOMA-IR and serum glucose.

Conclusions: This meta-analysis highlighted the promising application of intranasal insulin in reducing the incidence of postoperative delirium, serum concentration of TNF-α, IL-6, and CRP in adult patients undergoing surgery. However, a high degree of heterogeneity and limited sample size warrant future adequately powered studies to confirm our findings.

Background and aims: Postoperative pain is common after spine surgeries. Studies involving lumbar surgeries noted that erector spinae plane block (ESPB) decreased postoperative pain and opioid consumption. Studies evaluating ESPB for cervical and thoracic spine surgeries are lacking. The primary objective was to compare intraoperative opioid consumption and postoperative pain in patients receiving local anaesthetic (LA)-ESPB versus saline-ESPB for all level spine surgeries.

Methods: This randomised controlled study comparing LA-ESPB versus saline-ESPB was conducted over 27 months after patient consent, ethics approval, and trial registration in patients undergoing cervical, thoracic, and lumbar spine surgeries. Randomisation was done using a computer-generated random number table, and allocation was performed centrally for concealment. Anaesthesiologists, patients, outcome assessors, and data analysts were blinded to interventions. Bilateral ESPB was performed after administration of GA in the prone position at the midpoint of the planned surgical incision level. A maximum of 40 mL of solution, either bupivacaine 0.25% or saline, was used for ESPB. Pain was assessed using a numerical rating scale (NRS) score. Secondary outcomes were rescue analgesia requirements, sleep, satisfaction, adverse events, chronic pain, and return to work.

Results: Data were analysed for 198 patients (LA-ESPB = 98, saline-ESPB = 100). There was no difference between the groups for primary and secondary outcomes. The intraoperative and postoperative opioid consumption was similar (P = 0.052 and 0.164, respectively). There was no difference in immediate postoperative NRS score (P = 0.880), at 24 h (P = 0.509), and at 48 h (P = 0.270). Rescue analgesia requirements, sleep, satisfaction, adverse events, chronic pain, and return to work were similar.

Conclusions: We did not observe differences in postoperative pain and perioperative analgesia consumption between LA-ESPB and saline-ESPB groups in patients undergoing all-level spine surgeries.

Fascial plane blocks are integral components of multimodal analgesia, and ultrasound guidance improves the precision and safety. Simulation-based training is a promising approach to improvise procedural performance. However, evidence suggesting translation to patient-level outcomes is limited. This scoping review aimed to explore the available evidence on the impact of simulation based training for fascial plane blocks, mapping outcomes to the Kirkpatrick (KP) evaluation framework. A systematic search was conducted per PRISMA-ScR guidelines from standard databases. Eligible studies involved physicians, residents, or certified registered nurses from anaesthesiology and emergency medicine undergoing simulation-based fascial plane block training. Data were extracted on study characteristics, training modalities and duration, block type, assessment tools, feedback from participants, and outcomes. Fourteen pre-/post-interventional studies involving 458 participants were included. Most interventions combined didactic sessions, video demonstrations, and simulation-based training using commercial or custom models. Transversus abdominis plane, serratus anterior plane, erector spinae plane, and fascia iliaca compartment blocks were studied. Outcomes assessment predominately targeted lower KP levels, focussing on learners' confidence, knowledge, or improved performance in the simulated or clinical environment, immediate post-training. Long-term follow-up was limited, with most evaluations conducted within 3 months of training. Patient-centred outcomes such as complication, infection rate, or patient satisfaction were rarely assessed. Future research should employ validated assessment tools, isolate the impact of simulation from other modalities, and evaluate higher KP levels, including patient outcomes and system-level changes, to establish its true clinical value.