Journal of Anesthesia最新文献

Background: Studies show that the two peak heights of electroencephalographic bicoherence (pBIC-high, pBIC-low) decrease after incision and are restored by fentanyl administration. We investigated whether pBICs are good indicators for adequacy of analgesia during surgery.

Methods: After local ethical committee approval, we enrolled 50 patients (27-65 years, ASA-PS I or II) who were scheduled elective surgery. Besides standard anesthesia monitors, to assess pBICs, we used a BIS monitor and freeware Bispectrum Analyzer for A2000. Fentanyl 5 µg/kg was completely administered before incision, and anesthesia was maintained with sevoflurane. After skin incision, when the peak of pBIC-high or pBIC-low decreased by 10% in absolute value (named LT10-high and LT10-low groups in order) or when either peak decreased to below 20% (BL20-high and BL20-low groups), an additional 1 g/kg of fentanyl was administered to examine its effect on the peak that showed a decrease.

Results: The mean values and standard deviation for pBIC-high 5 min before fentanyl administration, at the time of fentanyl administration, and 5 min after fentanyl administration for LT10-high group were 39.8% (10.9%), 26.9% (10.5%), and 35.7% (12.5%). And those for pBIC-low for LT10-low group were 39.5% (6.0%), 26.8% (6.4%) and 35.0% (7.0%). Those for pBIC-high for BL20-high group were 26.3% (5.6%), 16.5% (2.6%), and 25.7% (7.0%). And those for pBIC-low for BL20-low group were 26.7% (4.8%), 17.4% (1.8%) and 26.9% (5.7%), respectively. Meanwhile, at these trigger points, hemodynamic parameters didn't show significant changes.

Conclusion: Superior to standard anesthesia monitoring, pBICs are better indicators of analgesia during surgery.

Trial registry: Clinical trial Number and registry URL: UMIN ID: UMIN000042843 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno  = R000048907.

Background: Ketamine and fentanyl are commonly used for sedation and induction of anesthesia in critically ill patients. This study aimed to compare the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock.

Methods: This randomized controlled trial included mechanically ventilated adults with septic shock receiving sedation. Patients were randomized to receive either 1 mg/kg ketamine bolus or 1 mcg/kg fentanyl bolus. Cardiac output (CO), stroke volume (SV), heart rate (HR), and mean arterial pressure (MAP) were measured at the baseline, 3, 6, 10, and 15 min after the intervention. Delta CO was calculated as the change in CO at each time point in relation to baseline measurement. The primary outcome was delta CO 6 min after administration of the study drug. Other outcomes included CO, SV, HR, and MAP.

Results: Eighty-six patients were analyzed. The median (quartiles) delta CO 6 min after drug injection was 71(37, 116)% in the ketamine group versus - 31(- 43, - 12)% in the fentanyl group, P value < 0.001. The CO, SV, HR, and MAP increased in the ketamine group and decreased in the fentanyl group in relation to the baseline reading; and all were higher in the ketamine group than the fentanyl group.

Conclusion: In patients with septic shock, ketamine bolus was associated with higher CO and SV compared to fentanyl bolus.

Clinical trial registration: Date of registration: 24/07/2023.

Clinicaltrials: gov Identifier: NCT05957302. URL: https://clinicaltrials.gov/study/NCT05957302 .

Airway management in children poses unique challenges due to the different anatomy, physiology, and pathophysiology across the pediatric age span. The recently published joint European Society of Anaesthesiology and Intensive Care-British Journal of Anaesthesia (ESAIC-BJA) neonatal and infant airway management guidelines provide recommendations and suggestions to support clinicians in deciding the best strategy. These guidelines represent a framework with the most recent and up-to-date evidence, from the initial assessment to the management of normal and difficult airways up to the extubation phase. However, such guidelines have intrinsic limitations due to the lack of supporting evidence in various fields of airway management. Pediatric institutions should adopt guidelines after careful internal review according to the local circumstances, including caseload, equipment and expertise. The current narrative review focused on providing references and practical tips on pediatric airway management, which is still not completely elucidated. Moreover, the authors put particular emphasis on the influence of human factors on the overall success of tracheal intubation, the incidence of complications, and the outcomes for patients.

Purpose: Following esophagectomy, annually several thousand patients in the United States (US) reach a stable post-esophagectomy status. Such patients may require general anesthesia (GA) for elective procedures, but no generally accepted guidelines exist for the induction of GA in post-esophagectomy patients.

Methods: A national survey describing a post-esophagectomy patient was emailed to 23,524 attending anesthesiologists who were members of the American Society of Anesthesiologists. The survey included 3 demographic and 12 anesthetic management questions. Responses were further stratified by gender, years in practice and frequency of exposure to the patient population of interest.

Results: A total of 744 (3.2%) respondents completed the survey. The respondent demographic characteristics closely reflected recent US anesthesiology workforce analyses. Endotracheal tube was the preferred method of airway management for 648 (87.1%), 419 (64.7%) used a rapid sequence induction, and 504 (67.7%) elected a reverse Trendelenburg position, with the latter two choices being favored among anesthesiologists with routine (vs. rarely/never) exposure to post-esophagectomy patients (76.6% vs. 58.4%; p < 0.001; and 73.6% vs. 63.9%; p = 0.021, respectively). Across survey participants, induction of GA was highly variable with differential effects of gender, years in practice and exposure frequency to post-esophagectomy patients.

Conclusions: US attending anesthesiologists' approach to induction of GA in a patient with a history of successful esophagectomy was not uniform. The majority of responses reflected a concern for aspiration in such a patient. Considering surgical and non-surgical upper gastrointestinal changes, establishment of practice guidance to optimize perioperative care is an unmet need.

The global COVID-19 pandemic highlighted significant existing supply-demand imbalances in anesthesia workforce, particularly impacting non-operating room anesthesia. Despite documented risks and mortality rates associated with pediatric procedural sedation and analgesia (PPSA) outside the operating room (OR), there is a pressing need for improvements in safety infrastructure. Comparative analysis with international practices reveals that anesthesiologists' involvement is associated with fewer adverse events and improved outcomes. However, lower reimbursement rate for sedation and anesthesia workforce shortage, and decentralized health resources are contributing factors to limit their participation in PPSA outside the OR in Japan. Enhancing the involvement of anesthesiologists through the public health frameworks such as "high-risk approach" and "population approach" can contribute to improvement of the safety and quality of PPSA. By tackling these challenges and implementing effective solutions, anesthesiologists can play a key role in ensuring safer and more effective PPSA outside the OR. Future challenges include enhancing training, addressing reduced clinical exposure due to work style reform, and developing effective educational systems. Research on improved educational approaches and fundamental outcome indices is crucial for improving PPSA practices outside the OR.

Purpose: Intravenous lidocaine is a non-opioid analgesic adjunct for perioperative pain relief. The aim of our study was to explore whether concurrent administration of intravenous lidocaine prolongs the duration of sensory block during total knee replacement (TKR) under spinal anaesthesia.

Methods: This prospective randomized double blind controlled trial was conducted on 28 patients (14 in lidocaine group and 14 in the control group) undergoing unilateral TKR under spinal anesthesia. In the lidocaine group, intravenous lidocaine 1.5 mg·kg^-1 followed by an infusion of 1.5 mg·kg^-1·h^-1 was administered intraoperatively after spinal anesthesia. The primary outcome was the duration of sensory block of spinal anesthesia. Secondary outcomes included onset time of sensory and motor block, duration of motor block, time to first postoperative analgesic, postoperative visual analog scale (VAS) scores and postoperative analgesia requirement in 24 h after surgery.

Results: The duration of sensory and motor block was longer in the lidocaine group (Mean ± SD; 112.50 ± 5.80 min versus 78.21 ± 9.12 min; p < 0.001 and 237.14 ± 9.14 min versus 215.00 ± 10.12 min; p < 0.001, respectively). Time to requirement of first rescue analgesia was 184.29 ± 9.38 min in the lidocaine group and 127.14 ± 23.35 min in the control group (p < 0.001). VAS scores were lower in the lidocaine group at 4, 8, 12 and 24 h after surgery (p < 0.00001, p < 0.00001, p < 0.00006, p = 0.032, respectively). Requirement of additional analgesia in the first 24 h was higher in the control group. There were no clinical signs to suggest lidocaine toxicity in any patient.

Conclusion: During unilateral TKR under spinal anaesthesia, concurrent use of intravenous lidocaine prolonged sensory block and reduced postoperative analgesic requirements.

Purpose: To investigate the efficacy of penehyclidine (PHC) for preventing postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG) under general anesthesia.

Materials and methods: In this prospective study, 219 patients who were scheduled to undergo LSG were randomly assigned to three cohorts: the control cohort (received normal saline), the infusion cohort (administered 0.25 mg of PHC intravenously followed by an additional 0.25 mg through an intravenous analgesia pump for 48 h after LSG), and the bolus cohort (received a single intravenous dose of 0.5 mg of PHC). The study outcomes included the incidence of PONV within the first 48 h postoperatively, the severity and intensity of PONV, side effects and postoperative recovery outcomes. Univariate and multivariate logistic analyses were performed to identify independent risk factors associated with PONV.

Results: Compared with the control cohort, both the infusion and bolus cohorts presented considerably lower incidences of PONV (61.64% vs. 12.33% vs. 38.36%, P < 0.05), as well as significantly decreased PONV severities (P < 0.05) and intensities (P < 0.05). There were no significant differences in side effects and postoperative recovery outcomes among the three cohorts, with the exception of dry mouthand the administration of rescue antiemetic therapy (P < 0.05). Additionally, the Apfel risk score and PHC intervention were identified as independent risk factors associated with PONV incidence following LSG (P < 0.05).

Results: PHC effectively prevented PONV occurrence and reduced its severity in LSG patients without decreasing postoperative recovery outcomes, particularly in the infusion cohort.

Background: The radial artery is commonly selected for arterial puncture and cannulation, but radial nerve palsy may occur. To minimize possible damage to the nerve, needle puncture should be made within the margin of safety (between the wrist to the distal end of the radial artery and the radial nerve running in parallel). In adults, the margin of safety for radial artery puncture is approximately 6.8 cm from the wrist in men and approximately 5.4 cm in women, but the margin of safety is not known in children of different age groups.

Methods: Using an ultrasound device, we measured the margin of safety in 100 anesthetized patients aged 0 months to 15 yr. Polynomial quadratic regression models were made, and the lower limit of the prediction interval was regarded as the margin of safety. These results were then compared with the results obtained in adults.

Results: The margin of safety became wider as a child grows older, and the height, weight, and age were all suitable explanatory variables to predict the margin of safety, providing fairly a constant predicted margin of safety from a few millimeters in neonates to approximately 4 cm in adolescents (much narrower than in adults).

Conclusions: In children and adolescents, the margin of safety for radial artery puncture is much narrower than in adults, and these findings support the recommendation to use ultrasound guidance during radial artery puncture in children and adolescents, to minimize the risk of associated complications.

Clinical trial registration: jRCT1032230243.