Journal of Anaesthesiology, Clinical Pharmacology最新文献

Chronic thromboembolic pulmonary hypertension (CTEPH) is caused due to the total or partial occlusion of the pulmonary vasculature due to organized thrombus, leading to severe pulmonary hypertension and eventually right heart failure, which makes anesthetic management very challenging. Pulmonary endarterectomy (PTE) is the treatment of choice for patients with operable CTEPH. The objective of the present review is to examine the preoperative evaluation, anesthesia technique, and postoperative management in the intensive care unit (ICU) of patients with CTEPH after PTE. We identified published journal articles in the last 25 years from PubMed and Google Scholar databases with the keywords "chronic thromboembolic pulmonary hypertension,"" anesthetic management of pulmonary thrombo-endarterectomy," and "perioperative management of CTEPH." One hundred fifty-three articles were reviewed, out of which 30 articles were retrieved finally. Based on the articles reviewed, we inferred that a balanced anesthesia technique should be carefully chosen to avoid hemodynamic collapse. Transesophageal echocardiography (TEE) is used to assess biventricular function, peak pulmonary artery pressure, the severity of tricuspid regurgitation, location and extent of thrombus, and guide pulmonary artery catheter insertion. Deep hypothermic circulatory arrest (DHCA) is utilized to perform a complete endarterectomy into segmental and subsegmental arterial branches. This narrative review article highlights the role of anesthesiologists in preoperative evaluation, intraoperative TEE guidance, anesthetic management, and postoperative management of complications such as reperfusion pulmonary edema, residual pulmonary hypertension, intrapulmonary hemorrhage, and the consequences of DHCA in patients with CTEPH undergoing surgical PTE. Future research is required to study the effects of DHCA and free radical injuryon postoperative complications and its prevention.

Background and aims: This study compared the dual sub-sartorial block (DSB), which allegedly includes all pain generators of the anterior and posterior compartments of the knee joint, to the routinely used single sub-sartorial bock (SSB), in terms of analgesic efficacy and preservation of motor strength after unilateral total knee arthroplasty (TKA).

Material and methods: Sixty patients aged 18-80 years and ASA grade I-III undergoing unilateral TKA were randomised to two groups postoperatively to receive DSB or SSB. Patients in group DSB received distal femoral triangle block (15 ml) + proximal adductor canal block (20 ml), while group SSB received only proximal adductor canal block (20 ml). Primarily, the changes in pain intensity and pain control in terms of static and dynamic visual analogue score (VAS) with the duration of analgesia and cumulative dose requirement of rescue analgesic in the first 24 hours postoperatively were studied. Secondary outcomes were the postoperative degree of motor blockade, the ability of early ambulation, patient satisfaction and complications. Statistical analysis was done using the student t-test and Chi-square test using MedCalc version 12.4.3.0.

Result: At all time intervals, the static and dynamic VAS scores were lower in the patients with the DSB group (P < 0.001) with longer duration of postoperative analgesia (14.96 ± 5.05 vs 6.03 ± 1.73 hours, P < 0.0001) and less requirement of total parenteral analgesic (1.06 ± 0.37 vs 2 ± 0.52, P < 0.0001) in first 24 hours postoperatively. A shorter time was required to finish the Timed Up and Go test for patients belonging to the DSB group (53.48 ± 4.06 vs 66.16 ± 6.23 seconds, P < 0.0001) in comparison to group SSB.

Conclusion: DSB provided better pain control with a longer duration of analgesia and required fewer doses of parenteral analgesics in the first 24 hours postoperatively after TKA, as opposed to SSB. Neither block had incidences of motor weakness and other complications.

Background and aims: Neck pain resulting from various cervical spine disorders ranks second among the leading cause of musculoskeletal disorders. This prospective study was conducted to compare the efficacy of suprascapular nerve block (SSNB) using a local anaesthetic and two different doses of dexamethasone in patients with cervical radicular pain.

Material and methods: Forty participants were randomised into Group I (n = 20), in which patients received a SSNB with 6 ml of a drug solution comprising 0.25% bupivacaine (4 ml) and 8 mg of dexamethasone (2 ml), and Group II (n = 20), in which patients received SSNB with 6 ml of a drug solution comprising 0.25% bupivacaine (4 ml), 4 mg of dexamethasone (1 ml), and normal saline (1 ml). Patients were followed for a period of six months. The numeric rating scale (NRS), patient global impression of change (PGIC), need for repeat injections, and side effects were compared between the two groups.

Results: NRS and PGIC scores were found to be comparable between the two groups at all time intervals (P > 0.05). There was no significant difference amongst the two groups in terms of the number of repeat injections (P > 0.05). None of the patients reported any serious side effects.

Conclusions: A SSNB with a local anaesthetic and either 8 mg or 4 mg of dexamethasone is an equally effective technique for managing patients with cervical radicular pain. Hence, a SSNB with 4 mg of dexamethasone can be utilised to reduce the steroid dose without compromising the efficacy and safety of the treatment in patients with cervical radicular pain.

Background and aims: Intravenous magnesium sulfate is known to reduce hemodynamic response of laryngoscopy and intubation. However, it is associated with some systemic side effects. We compared the efficacy of nebulized and intravenous magnesium sulfate pretreatment on attenuation of hemodynamic response during tracheal intubation.

Material and methods: Sixty-six American Society of Anesthesiologists classification I-II patients aged 18-65 were randomly assigned to two groups: Group IV, which received 30 mg/kg of intravenous magnesium sulfate, and Group IN, which received the same dose via nebulization. Intubation was performed by an experienced anesthesiologist who was blinded to group allocation. The primary outcomes were heart rate (HR) and mean arterial pressure (MAP) during laryngoscopy and intubation. Secondary outcomes included propofol consumption for anesthesia induction, time to achieve a train-of-four (TOF) ratio of 0 after vecuronium administration, and any adverse effects.

Results: Both groups showed similar attenuation of hemodynamic responses during laryngoscopy and intubation (HR: P =0.139, MAP: P =0.40). Propofol consumption (mg) was comparable between the groups (113.64 in Group IN vs. 113.79 in Group IV, P = 0.629). However, the time (seconds) to achieve a TOF ratio of 0 was significantly shorter in Group IV compared to Group IN (228.33 vs. 247.09, P = 0.035).

Conclusion: Nebulized magnesium sulfate was as effective as intravenous magnesium sulfate in reducing hemodynamic changes during intubation, offering a noninvasive alternative for managing this response.

Background and aims: Both dexmedetomidine and midazolam-ketamine are known for their minimal respiratory depressant effects. While many studies have documented the use of dexmedetomidine in providing conscious sedation during awake fiberoptic-guided nasal intubation (AFNI), the use of midazolam-ketamine combination for this procedure has not been reported. The aim of this study was to compare the efficacy of dexmedetomidine with midazolam-ketamine combination for AFNI in patients with difficult airways undergoing oromaxillofacial surgery.

Material and methods: This study involved 60 patients undergoing oromaxillofacial surgery. They were randomized to receive either dexmedetomidine (1 μg/kg) (group D) or a combination of midazolam (0.02 mg/kg) and ketamine (0.5 mg/kg) (group MK) for sedation during awake fiberoptic nasotracheal intubation. Both groups received topical local anesthesia during the procedure using the spray-as-you-go technique. The primary outcome measured was cough score during intubation. Secondary outcomes included overall intubation, post-intubation, and sedation scores. Incidences of side effects such as hypoxemia and bradycardia were also measured.

Results: The cough score (group D: 1.33 ± 0.61, group MK: 1.3 ± 0.53; P = 0.822), overall intubation score, and post-intubation score were comparable between the two groups. Patients receiving dexmedetomidine were significantly more sedated than patients receiving midazolam-ketamine. Patients receiving dexmedetomidine had significantly lower heart rates and blood pressure than patients receiving midazolam-ketamine. Four patients in group D had hypoxemia, while no patient in group MK developed hypoxemia.

Conclusions: Both dexmedetomidine and midazolam-ketamine combinations were equally effective for sedation during AFNI in patients with difficult airways scheduled for orofacial maxillary surgery. Patients receiving dexmedetomidine were more sedated, but the incidence of side effects was similar in both groups.

Supraglottic airway devices (SADs) have a great application as an alternative to tracheal intubation, prompting a paradigm shift in routine anesthetic practice. However, its usage in neuroanesthesia is limited and debatable, considering the clinical challenges and complexity of neurosurgical procedures. Even though literature evidence exits regarding successful airway management with SADs in neurosurgery, there is no clear-cut evidence or consensus among anesthesiologists. Articles were searched in PubMed and Google Scholar by using the keywords "Supraglottic airway" AND "Laryngeal Mask" OR "LMA" AND "Craniotomy" over the past 30 years. In addition, a manual search was performed (with additional keywords "neurosurgery," spine surgery," "I-gel," "ILMA," "awake craniotomy," "radiology," "electroconvulsive therapy," and "magnetic resonance imaging") to retrieve additional articles. The primary goal of this narrative review is to determine the applicability of SADs in various neurosurgical settings. According to the review, SADs play an important role as a rescue device during intraoperative emergencies such as accidental tracheal extubation (supine, lateral, and prone positions with head fixed on cranial pins), sudden airway loss due to seizure during awake craniotomy, postoperative airway loss following trans-nasal pituitary surgeries, and macroglossia. SADs can be used successfully for short-duration minimally invasive elective procedures such as cranioplasty, burr hole evacuation of subdural collection, battery implantation for deep brain stimulation, vario-guided biopsies, and minimally invasive spine surgeries. Furthermore, SADs serve a significant function in blunting extubation responses, thereby preventing cerebral edema and tumor bed hemorrhage. Only a few studies have supported the use of SADs in long-duration major intracranial tumour surgeries, making its use controversial in major surgeries where intracranial pressure control is the key. The SADs also have clinical utility in various non-operating room neuroanesthesia procedures.