Journal of Anesthesia最新文献

Purpose: Postspinal hypotension (PSH) during cesarean section (CS) often causes maternal intraoperative nausea and vomiting (IONV) and fetal acidosis. Phenylephrine (PE) and norepinephrine (NE) are commonly used for management; however, the optimal agent and method (bolus vs. infusion) remains uncertain. This review assessed bolus and infusion of PE and NE for IONV and PSH during CS.

Methods: Systematic searches of MEDLINE, Embase, CENTRAL, and unpublished studies identified randomized controlled trials (RCTs) on PE and NE administration during CS under spinal anesthesia. Primary outcomes included IONV and PSH, whereas secondary outcomes encompassed Apgar scores, umbilical artery pH, rescue vasopressor bolus requirements, and adverse events. A random-effects meta-analysis and the Confidence in Network Meta-Analysis tool were utilized.

Results: Among 74 RCTs (7798 patients), NE and PE infusion reduced IONV compared with PE bolus (risk ratio [RR]: 0.47; 95% confidence interval [CI] 0.34-0.66; RR: 0.54; 95% CI 0.42-0.69, high confidence). Similarly, these approaches reduced PSH (NE infusion: RR: 0.25; 95% CI 0.21-0.31, high confidence; PE infusion: RR: 0.29; 95% CI 0.24-0.34, moderate confidence). Rescue vasopressor bolus requirements showed a similar trend. Apgar scores and umbilical artery pH were comparable across all groups. Adverse event varied, with bradycardia more common with PE, tachycardia with boluses, and dizziness with PE bolus. Hypertension was more frequent with infusions. In prophylactic studies, hypotension trends persisted, but no differences were observed in IONV.

Conclusion: Prophylactic continuous infusion appears to be a favorable strategy for managing PSH and IONV during CS. No significant difference was observed between PE and NE infusions in preventing PSH and IONV.

Purpose: Postoperative pain control following adenotonsillectomy in the pediatric population poses a great challenge to care providers. Multi-modal pain management regimes including NSAIDs such as intraoperative ketorolac usage has been purposed for many years. However, the effectiveness of ketorolac to reduce post-tonsillectomy pain and opioid-related side effects is controversial. The study was to evaluate the opioid-sparing effect of an intraoperative intravenous single dose of ketorolac in children undergoing adenotonsillectomy. We also assessed the effectiveness of perioperative ketorolac on alleviating the common adverse effects of opioid usage.

Methods: With IRB approval, a total of 142 pediatric patients aged between 3 and 12 years undergoing elective adenotonsillectomy were randomized to receive either placebo or 0.5 mg/kg ketorolac intraoperatively with other pain management remaining the same. The primary outcomes were postoperative pain scores and postoperative rescue pain medication usage. Common postoperative anesthesia-related complications such as nausea, vomiting and postoperative rebleeding were assessed.

Results: We found that ketorolac usage decreased the overall postoperative pain scores significantly (Max FLACC score 4.3 ± 2.6 for ketorolac vs. 5.9 ± 3.0 for placebo). However, intraoperative single-dose ketorolac administration did not reduce postoperative rescue opioid usage, nor decrease the rates of postoperative nausea and vomiting. We did not observe significant postoperative bleeding or other complications associated with ketorolac usage.

Conclusions: While intraoperative ketorolac usage reduces the overall postoperative pain score, it does not decrease the postoperative opioid consumption in our current practice regime. Ketorolac may be a good multi-modal pain management adjunct without increased postoperative complications such as rebleeding.

Perioperative euglycaemic diabetic ketoacidosis (EuDKA) is a rare but life-threatening complication associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). It is characterised by ketonaemia, acidosis, and normal serum glucose. Whilst guidelines advise withholding SGLT2i prior to elective surgery, limited guidance exists for emergency procedures. This systematic review aimed to describe EuDKA cases following emergency surgery, identify patient characteristics, and examine contributing risk factors. A search of electronic databases up to April 2024 identified 30 cases from 21 publications. In most cases, EuDKA onset occurred within three days postoperatively (range: intraoperative to 10 days). Reported risk factors included inadequate SGLT2i withholding time, poor glycaemic control, morbid obesity, major surgery, intercurrent illness, suboptimal intraoperative diabetes management, and delayed gastrointestinal absorption. Morbidity was significant: ten patients required intensive care, two required intubation and ventilation, two received dialysis, and one underwent exploratory laparotomy. No deaths were reported. Due to atypical biochemical findings and non-specific symptoms, EuDKA remains under-recognised. Clinicians are advised to maintain a high index of suspicion, ensure appropriate perioperative insulin management, conduct vigilant laboratory monitoring, and provide patient education to reduce the risk in emergency surgical settings.

Purpose: We investigated the incidence and predictors of moderate-to-severe movement-evoked pain (MEP) following gastrointestinal and hepatobiliary surgery and compare the findings for postoperative day one (POD1; Study A) and those for postoperative day three (POD3; Study B).

Methods: We retrospectively enrolled 1698 adult patients who underwent gastrointestinal or hepatobiliary surgery under general anesthesia. Postoperative MEP and resting pain were evaluated using an 11-point numerical rating scale (NRS), with moderate-to-severe pain defined as a score of ≥ 4. Information on perioperative variables was obtained from medical records, and binary logistic regression was performed to identify possible predictors.

Results: On POD1, 54.4% (867/1595) of the patients reported moderate-to-severe MEP (Study A). Among those with moderate-to-severe MEP on either POD1 or postoperative day two, 63.1% (311/493) continued to experience moderate-to-severe MEP on POD3 (Study B). Risk factors of moderate-to-severe MEP on POD1 included young age (OR: 1.33, 95% CI 1.08-1.64), male gender (OR: 1.47, 95% CI 1.20-1.81) and preoperative pain (OR: 1.47, 95% CI 1.16-1.88), while epidural analgesia (OR: 0.61, 95% CI 0.50-0.75) was protective. Until POD3, overweight (OR: 1.65, 95% CI 1.03-2.65) and larger incision size (OR: 1.62, 95% CI 1.07-2.45) were identified as risk factors, while postoperative acetaminophen (APAP) alone (OR: 0.33, 95% CI 0.12-0.91) and APAP combined with non-steroidal anti-inflammatory drugs (OR: 0.26, 95% CI 0.09-0.71) were protective.

Conclusion: More than a half of the patients with moderate-to-severe MEP on POD1 or POD2 continued to experience it on POD3. Distinct predictors for moderate-to-severe MEP on POD1 and POD3 were identified.

Background: We compared the effect of three levels of end-expiratory pressure on the incidence of gastric insufflation during face-mask ventilation in patients with obesity.

Methods: This randomized controlled trial included adult obese patients undergoing elective non-cardiac surgery under general anesthesia with neuromuscular blockade. Patients were randomized to receive either zero-end-expiratory pressure (ZEEP group), 4-cmH₂O positive end-expiratory pressure (PEEP) (low-PEEP group), or 8-cmH₂O PEEP (high-PEEP group) during volume-controlled mask ventilation. Gastric antral cross-sectional area (CSA) was assessed using ultrasonography before induction of anesthesia and after intubation. The percentage of change (delta) in the CSA was calculated and gastric insufflation was considered significant when the delta CSA was > 30%. The primary outcome was the incidence of gastric insufflation. Secondary outcomes were antral CSA before induction of anesthesia and after intubation in addition to ventilatory variables (end-tidal CO₂, peak airway pressure, and tidal volume) during face-mask ventilation.

Results: We analyzed data from 160 patients. The antral CSA increased after intubation in all groups. The incidence of gastric insufflation was higher in the high-PEEP group (32/54[59%]) than that in the ZEEP group (6/52[12%]) and low-PEEP group (15/54[28%]). Delta CSA, antral CSA after intubation, and incidence of gastric insufflation were not significantly different between the ZEEP and low-PEEP groups. Ventilatory variables were comparable between the groups.

Conclusion: In obese paralyzed patients, gastric insufflation can occur during face-mask ventilation whatever the level of end-expiratory pressure; however, the use of ZEEP or 4-cmH₂O PEEP was associated with lower incidence of gastric insufflation compared to 8-cmH₂O PEEP.

Clinical trial registration: Clinical trial registration at clinicaltrials.gov NCT05979129. https://classic.

Clinicaltrials: gov/ct2/show/NCT05979129.

Purpose: Nitrous oxide (N₂O) reportedly lessens postoperative pain and neuropathic pain by counteracting N-methyl-D-aspartate (NMDA) receptors. Surgeries such as postoperative lumbar posterior intervertebral fusion (PLIF) can induce severe pain, including neuropathic pain-like symptoms. Here, we investigated the impact of intraoperatively administered N₂O on postoperative pain and other symptoms following PLIF.

Methods: During PLIF surgery, the patients received either N2O 60% or air, with the inhaled oxygen concentration set at 0.4. For postoperative pain management, patients were administered fentanyl (4 µg/kg), acetaminophen, and flurbiprofen during surgery. Additionally, an intravenous patient-controlled analgesia device delivering fentanyl was connected. Postsurgical pain and other symptoms were evaluated based on the numerical rating scale (NRS), amount of fentanyl used, rate of adjuvant analgesic use, and numbness.

Results: Eighty patients were randomly assigned to either the control (air) group (n = 34) or the N₂O group (n = 39). No differences in patient background, postoperative low back pain NRS (air: 3.5 (2-6.25) vs N₂O: 4 (2-6) at 24 h, median (interquartile range), P = 0.655), or pain and numbness in the lower limbs were detected between groups. No differences in fentanyl use at 48 h (air: 330 (165-525) µg, N₂O: 225 (120-390) µg; P = 0.15). At 1 month after surgery, the two groups exhibited similar low back pain, lower limb pain, and numbness symptoms.

Conclusions: Intraoperative administration of N₂O did not improve acute or subacute postoperative nociceptive or neuropathic pain after PLIF and did not decrease the use of postoperative analgesics.