Indian Journal of Anaesthesia最新文献

Background and aims: Post-spinal hypotension (PSH) is a common complication of neuraxial anaesthesia in high risk cesarean delivery (CD). This systematic review and network meta-analysis evaluate the comparative efficacy and safety of prophylactic intravenous infusions of norepinephrine, phenylephrine, and ephedrine to prevent PSH in this population.

Methods: Randomised controlled trials comparing intravenous prophylactic norepinephrine, phenylephrine, and ephedrine in high risk CD and reporting maternal or fetal outcomes were considered. Two reviewers screened studies, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 tool. A frequentist network meta-analysis was carried out. Heterogeneity was inspected with I² and Q statistics, and treatment ranking was estimated by P-scores. Sensitivity and subgroup analyses were performed to examine clinical modifiers such as preeclampsia and bolus versus infusion strategies.

Results: Eighteen trials involving 3331 participants were included. Administration of vasopressors reduced the incidence of PSH compared with placebo or no treatment [odds ratios (OR): 1.5; 95% confidence interval (CI) 1.12, 1.67; I²: 10.5%]. Norepinephrine and phenylephrine were superior to ephedrine. There was greater cardiac stability and less bradycardia and nausea with norepinephrine. In preeclamptic and in infusion treated patients, vasopressors were more effective, yet the advantage of norepinephrine was not consistently statistically significant. Neonatal outcomes such as APGAR scores and umbilical artery pH did not differ significantly between agents (OR: 1.1; 95% CI: 0.8, 1.5; P = 0.15).

Conclusion: Both norepinephrine and phenylephrine are effective for the prevention of PSH in high-risk cesarean delivery receiving neuraxial anaesthesia, with norepinephrine offering more favourable maternal safety and tolerability. These findings justify the use of norepinephrine and phenylephrine over ephedrine in this patient population.

Quadratus lumborum blocks extend abdominal wall analgesia by engaging thoracoabdominal and lumbar pathways, yet outcome variability persists because fascial continuities, neural trajectories, and sonographic-anatomic correlations are emerging. This narrative review synthesises foundational anatomy, cross-sectional relationships, and ultrasound correlations to explain injectate spread and to guide precise techniques. Drawing on cadaveric dissections, radiologic studies, and live sonoanatomy, we map the three-dimensional interplay of muscles, fascial planes, and nerves across the T12-L1 transition. These insights clarify why anterior/transmuscular approaches more reliably reach paravertebral and lumbar plexus corridors, whereas superficial or lateral techniques chiefly provide somatic flank coverage. We also dispel common misconceptions propagated by oversimplified schematics. Framing the quadratus lumborum block within a continuous fascial network-linking thoracolumbar, transversalis, psoas, and endothoracic fascia-supports more accurate target selection, rational volume planning, and improved safety. The review offers a practical framework for matching block variants to surgical indication, enhancing reproducibility, and achieving more predictable, opioid-sparing analgesia clinically.

Background and aims: Laparoscopic sleeve gastrectomy (LSG) is effective for treating obesity but frequently causes significant postoperative pain. This meta-analysis evaluated the efficacy and safety of the external oblique intercostal plane block (EOIB) in reducing pain, opioid use, and adverse effects after LSG.

Methods: This PROSPERO-registered review (CRD420251072075) searched seven major databases for comparative studies of EOIB versus placebo or other analgesic techniques in adults undergoing LSG. Primary outcomes were pain scores at rest and movement at 6, 12, and 24 h. Secondary outcomes included cumulative opioid consumption in Morphine Milligram Equivalents (MME) in the first 24 h, time to first rescue analgesia, complications or side effects like incidence of postoperative nausea and vomiting (PONV), and block related adverse events. Pooled effect sizes were calculated using a random effects model, with heterogeneity assessed via I².

Results: Four randomised controlled trials (n = 265, 2024-2025) met inclusion criteria. EOIB significantly reduced pain at rest at 6 h [standardised mean difference (SMD) -0.69, I² = 0%], 12 h (SMD -0.56, I² = 59%), and 24 h (SMD -0.66, I² = 82%), with a pooled effect across all time points (SMD -0.62, I² = 63%). Pain at movement was significantly reduced overall (SMD -0.45, I² = 74%), with a notable effect at 12 h (SMD -0.59, I² = 76%). EOIB decreased 24 h opioid consumption by an average SMD of -1.65 (I² = 93%) and lowered the proportion of patients needing rescue analgesics by 41% [risk ratio (RR) 0.59, I² = 0%]. No significant differences were observed for time to first rescue analgesia (SMD 0.57, I² = 93%) or PONV (RR 0.85, I² = 37%). No block-related complications were reported.

Conclusion: This meta-analysis suggests that EOIB is a promising analgesic technique for patients undergoing LSG. It effectively reduces early postoperative pain and overall opioid consumption in the first 24 h. While no block-related complications were reported, larger, multicenter trials are necessary to confirm its efficacy, establish a definitive safety profile, and determine its role in multimodal pain management for bariatric surgery.

Background and aims: There is limited comparative data on sensory-motor block dynamics following single-point drug delivery between ultrasound guided supraclavicular brachial plexus block and costoclavicular brachial plexus block. This study aimed to compare the efficacy of sensory-motor blockade after single-point subfascial injections at these two anatomical locations.

Methods: Following institutional ethics approval, 50 patients undergoing upper limb surgery at or below the elbow were randomised to receive a single-point injection of 20 mL of a 1:1 mixture of 2% lignocaine (with 1:200,000 epinephrine) and 0.5% bupivacaine in either the supraclavicular fossa (Gp-SC) or the costoclavicular space (Gp-CC). A blinded observer assessed the sensory-motor function of the musculocutaneous, median, ulnar, and radial nerves by using a 3-point scale. Scores were combined into a total composite score (TCS), assessed every 5 minutes for up to 40 minutes or until a TCS of 0 was achieved. Continuous variables were analysed using an unpaired Student's t-test; categorical data were analysed using the Chi-square test.

Results: Gp-CC had significantly lower TCS values than Gp-SC at all intervals except 5 minutes. Complete sensory-motor blockade at 40 minutes was more frequent in Gp-CC (92%) versus Gp-SC (60%, P < 0.001). Incomplete blockade was largely due to sparing of the ulnar (4% vs 36%, P = 0.004), median (8% vs 36%, P = 0.019), and radial nerves (0% vs 20%, P = 0.025).

Conclusion: A single-point subfascial injection of local anaesthetic at the costoclavicular space produces a more complete sensory-motor blockade of all four major terminal nerves of the brachial plexus than at the supraclavicular fossa.

Background and aims: Post-caesarean pain significantly impacts maternal recovery. The erector spinae plane (ESP) and quadratus lumborum block (QLB) are regional analgesic techniques used for postoperative pain management; however, their comparative effectiveness remains uncertain. The objective was to compare the efficacy of ESP and QLB regarding post-caesarean pain intensity, opioid consumption, time to first analgesic request, and the incidence of nausea and vomiting.

Methods: A systematic review and meta-analysis of randomised controlled trials comparing ESP and QLB in women undergoing caesarean section was conducted according to PRISMA guidelines (PROSPERO ID: CRD42024612438). The electronic databases PubMed, Embase, Cochrane Library, and Scopus were searched. Effect sizes were estimated using a random-effects model, and trial sequential analysis (TSA) was performed to assess the robustness of the evidence.

Results: Six studies involving a total of 466 patients were included. No significant differences were observed between ESP and QLB in postoperative pain scores measured by the Numeric Rating Scale at 12 hours [mean difference (MD): 0.10; 95% confidence interval (CI): -0.14, 0.35; P = 0.40] and 24 hours (MD: -0.34; 95% CI: -0.74, 0.07; P = 0.10). The time to the first analgesic request was significantly longer in the QLB group (MD: 1.40 hours; 95% CI: 0.42, 2.38; P = 0.005). Opioid consumption within the first 24 hours was comparable between the two techniques (P = 0.93), as was the incidence of nausea and vomiting (P = 0.50). TSA did not confirm firm evidence for differences in opioid consumption, pain intensity at 24 hours, or time to first rescue analgesia, and the results remained inconclusive.

Conclusion: ESP and QLB provide comparable analgesia, though current evidence remains inconclusive. Larger multicentre trials are warranted to confirm these findings.

Background and aims: Physical injuries during anaesthesia, while seemingly minor compared to other complications, can cause significant patient suffering and medico-legal consequences. This study aimed to determine the incidence and risk factors of physical injuries during anaesthesia in a large tertiary hospital to identify areas for improvement in patient safety.

Methods: A retrospective analysis of prospectively collected data in a high-volume tertiary hospital performing 25,000 surgeries annually was conducted from 2014-2019. All physical injury incidents during anaesthesia were categorised into six groups: airway injuries, eye injuries, non-regional nerve injuries, regional nerve injuries, pressure injuries, and vascular injuries. Risk factors and outcomes were analysed using Chi-square tests, with P < 0.05 considered significant.

Results: Among 161,645 anaesthetics, 246 physical injuries were reported (0.15% incidence). Pressure injuries were most common (36%), followed by airway injuries (35%), nerve injuries (14%), vascular injuries (12%), and eye injuries (3%). Physical injuries were twice as likely in patients with American Society of Anaesthesiologists Physical Status (ASA PS) ≥3 (0.28% vs 0.11%, P < 0.001) and four times more likely during after-hours procedures (0.53% vs 0.13%, P < 0.001). Overall, 60.3% required specialist review, 12.9% had temporary disabilities, and 0.73% had permanent disabilities. 31% of injuries were deemed preventable.

Conclusion: Physical injuries during anaesthesia occur in 15 per 10,000 cases, with higher ASA PS and after-hours procedures being significant risk factors. These findings support implementing enhanced protective protocols for high-risk patients and procedures to improve perioperative safety.

Background and aims: The use of supraglottic airway devices (SGADs) is still controversial in paediatric otorhinolaryngological surgeries. We conducted this review and analysis to compare SGADs to endotracheal tubes (ETTs) regarding the feasibility of their use in children.

Methods: Randomised controlled trials (RCTs) that compared SGADs versus ETTs in patients ≤18 years undergoing adenotonsillectomy surgery under general anaesthesia were searched from PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Embase till November 2024 and re-examined on 31 August 2025. The primary outcome measure was conversion from SGAD to ETT, and other outcomes included comparison of perioperative respiratory adverse events, laryngospasm, and surgical time.

Results: Six trials (n = 750) were included in the analysis. The failure rate of SGAD was 6.5% [95% confidence interval (CI): 2.2, 0.9%, P = 0.001]. The odds ratio of developing [perioperative respiratory adverse event (PRAE) with SGAD was significantly less than the ETT odds ratio (OR) 0.55 (95% CI: 0.36, 0.82, P = 0.004)]. There was a statistically similar incidence of laryngospasm with OR 0.84 (95% CI: 0.39, 1.81). No difference was found in the operating times with a mean difference of 0.82 mins (95% CI: -2.08, 3.72). The level of evidence was graded as moderate to low.

Conclusion: SGADs are a feasible alternative to ETT in paediatric adenotonsillectomy with an anticipated failure rate of 6.5%. Larger and more rigorous RCTs are needed to establish the safety of these airway devices in terms of PRAE and efficacy in terms of duration of surgery in comparison to ETTs.

Background and aims: Patients undergoing oesophagectomies are at risk of intraoperative hypothermia. The study aims to determine the incidence of hypothermia during oesophagectomy surgeries.

Methods: This observational bidirectional study evaluated 266 adult patients (175 retrospective and 91 prospective) undergoing elective oesophagectomy at a tertiary care centre between 2019 and 2022. Intraoperative core temperature was monitored hourly using a nasopharyngeal probe. Postoperative complications were recorded until discharge. Logistic regression analysis assessed the association between the incidence of hypothermia and perioperative variables. Those factors found significant in the simple logistic regression were then subjected to multiple logistic regression. A goodness-of-fit and sensitivity analysis was performed.

Results: The incidence of intraoperative hypothermia (core temperature <36°C) was 90.6% [95% confidence interval (CI): 87, 94]. Nearly 60% of patients were found to be hypothermic before the surgery began. The incidence of clinically significant hypothermia (CSH) (core temperature <35°C) was 32.3% (95% CI: 30, 40). The perioperative factors significantly and independently associated with intraoperative hypothermia were preoperative significant weight loss [odds ratio (OR): 2.03, 95% CI: 1.17, 3.52, P = 0.012] and intraoperative requirement of vasopressors (OR: 2.76, 95% CI: 1.10, 6.93, P = 0.030). We found no association between intraoperative hypothermia and postoperative complications.

Conclusion: The study recorded a high incidence of intraoperative hypothermia during oesophagectomy surgeries. Hypothermia began in the preoperative period for nearly two-thirds of patients. Factors associated with CSH included preoperative significant weight loss and the intraoperative need for vasopressors. No significant association was found with postoperative complications and discharge.

Background and aims: The sniffing position is required for direct laryngoscopy to align the oropharyngeal-laryngeal axis in the line of sight. However, videolaryngoscope (VL)-guided intubation may not need a sniffing position. This meta-analysis compared intubation using VL in the sniffing position versus ramped or head-elevated positions.

Methods: This prospective systematic review and meta-analysis included randomised controlled trials comparing VL in a ramped or head-elevated position with the sniffing position in adult patients undergoing endotracheal intubation. The primary outcome was time for intubation. The secondary outcomes included the first attempt success and the glottic view during intubation. Trial sequential analysis (TSA) was conducted for the primary outcome.

Results: This review adhered to the PRISMA 2020 guidelines. Four studies were included, with 341 patients (173 in the ramped and 168 in the sniffing position). The pooled data showed that intubation time was comparable in the ramped as well as in the sniffing position [standard mean difference: -0.74; 95% confidence interval (CI): -1.59, 0.11; P = 0.089; I ² = 92.4%; prediction interval = -3.59, 2.11]. Similarly, no significant difference in first attempt success rate between the two groups [risk ratio (RR): 1.03; 95% CI: 0.95, 1.12; P = 0.368; I ² = 33.1%]. The comparison of the good glottic view showed a pooled RR of 1.14; 95% CI: 0.61, 2.12; and P = 0.461. TSA showed an adequate sample for the primary outcome.

Conclusion: The current meta-analysis suggests that during VL, the intubation time, first-attempt success, and glottic view were comparable in both ramped and sniffing positions. However, high heterogeneity makes the results less robust.