Pub Date : 2024-10-30DOI: 10.1016/j.jclinane.2024.111672
D.P. Obert , P.O. Sepúlveda , V. Adriazola , F. Zurita , J. Brouse , G. Schneider , M. Kreuzer
Elderly patients are prone to develop postoperative neurocognitive deficits potentially precipitated by inadequate anesthetic management. To investigate the potential of EEG-guided individualized anesthetic titration we evaluated the effect of the patient's age on the spectral composition of the EEG during slow propofol induction.
Twenty-six young (<65 years) and 25 old (≥65 years) patients received propofol until loss of responsiveness (LOR). After LOR, we switched from a flow rate-based to a target-controlled infusion mode keeping the calculated effect-site concentration at LOR stable. We recorded a frontal EEG and calculated the power spectral density (PSD) and the band powers. For the comparison of the spectral composition of old and young patients, we used an effect size, the area under the receiver operating characteristic curve.
The older patients received significantly less propofol (p < 0.001). No patient showed a burst suppression pattern. Whereas the absolute power in all frequency bands decreased significantly with the patient's age, the spectral composition did not change throughout the extended induction period.
Slow anesthesia induction may be a suitable approach for geriatric patients to preserve spectral composition patterns typically found in younger brains and to individually identify anesthetic requirements reducing the risk of excessive anesthetic effects.
{"title":"Overcoming age: Slow anesthesia induction may prevent geriatric patients from developing burst suppression and help developing intraoperative EEG signatures of a younger brain","authors":"D.P. Obert , P.O. Sepúlveda , V. Adriazola , F. Zurita , J. Brouse , G. Schneider , M. Kreuzer","doi":"10.1016/j.jclinane.2024.111672","DOIUrl":"10.1016/j.jclinane.2024.111672","url":null,"abstract":"<div><div>Elderly patients are prone to develop postoperative neurocognitive deficits potentially precipitated by inadequate anesthetic management. To investigate the potential of EEG-guided individualized anesthetic titration we evaluated the effect of the patient's age on the spectral composition of the EEG during slow propofol induction.</div><div>Twenty-six young (<65 years) and 25 old (≥65 years) patients received propofol until loss of responsiveness (LOR). After LOR, we switched from a flow rate-based to a target-controlled infusion mode keeping the calculated effect-site concentration at LOR stable. We recorded a frontal EEG and calculated the power spectral density (PSD) and the band powers. For the comparison of the spectral composition of old and young patients, we used an effect size, the area under the receiver operating characteristic curve.</div><div>The older patients received significantly less propofol (<em>p</em> < 0.001). No patient showed a burst suppression pattern. Whereas the absolute power in all frequency bands decreased significantly with the patient's age, the spectral composition did not change throughout the extended induction period.</div><div>Slow anesthesia induction may be a suitable approach for geriatric patients to preserve spectral composition patterns typically found in younger brains and to individually identify anesthetic requirements reducing the risk of excessive anesthetic effects.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111672"},"PeriodicalIF":5.0,"publicationDate":"2024-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142554674","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-30DOI: 10.1016/j.jclinane.2024.111665
Andreas Ranft M.D. , Sebastian Berger M.S. , Martin Schubert M.D. , Silke Wunderlich M.D. , Tobias Boeckh-Behrens M.D. , Gerhard Schneider M.D. , Alexander Hapfelmeier M.S.
Study Objective
Blood pressure drops during endovascular treatment of acute ischemic stroke have been associated with worse outcomes for stroke patients. We aimed to evaluate this observation in our patient population.
Design
Retrospective study.
Setting
University hospital.
Patients
Records from patients who underwent endovascular treatment of acute ischaemic stroke under general anaesthesia at a university hospital from 2017 to 2020 were screened. 586 patients aged 78 years (interquartile range [IQR] 67–84) with a mean National Institutes of Health Stroke Scale score of 15 (IQR 8–19) were included.
Interventions
None.
Measurements
Good functional outcome was defined as a three-month modified Rankin Scale (mRS) value between 0 and 2, or a mRS value less than or equal to the pre-stroke baseline.
Main Results
In addition to well-established predictors, blood pressure before reperfusion was found to be associated with good functional outcomes. Per five minutes that systolic arterial pressure spent below 140 mmHg, the odds of good outcome decreased by 11.1 %.
Conclusions
In this retrospective study of general anaesthesia for endovascular stroke therapy, blood pressure drops during the intervention were associated with reduced odds of a good functional outcome three months later. Before a clinical recommendation can be made, a prospective study must clarify effective and safe target ranges of blood pressure support and augmentation.
{"title":"Clinical outcome after endovascular stroke Thrombectomy: Association with pre-reperfusion blood pressure","authors":"Andreas Ranft M.D. , Sebastian Berger M.S. , Martin Schubert M.D. , Silke Wunderlich M.D. , Tobias Boeckh-Behrens M.D. , Gerhard Schneider M.D. , Alexander Hapfelmeier M.S.","doi":"10.1016/j.jclinane.2024.111665","DOIUrl":"10.1016/j.jclinane.2024.111665","url":null,"abstract":"<div><h3>Study Objective</h3><div>Blood pressure drops during endovascular treatment of acute ischemic stroke have been associated with worse outcomes for stroke patients. We aimed to evaluate this observation in our patient population.</div></div><div><h3>Design</h3><div>Retrospective study.</div></div><div><h3>Setting</h3><div>University hospital.</div></div><div><h3>Patients</h3><div>Records from patients who underwent endovascular treatment of acute ischaemic stroke under general anaesthesia at a university hospital from 2017 to 2020 were screened. 586 patients aged 78 years (interquartile range [IQR] 67–84) with a mean National Institutes of Health Stroke Scale score of 15 (IQR 8–19) were included.</div></div><div><h3>Interventions</h3><div>None.</div></div><div><h3>Measurements</h3><div>Good functional outcome was defined as a three-month modified Rankin Scale (mRS) value between 0 and 2, or a mRS value less than or equal to the pre-stroke baseline.</div></div><div><h3>Main Results</h3><div>In addition to well-established predictors, blood pressure before reperfusion was found to be associated with good functional outcomes. Per five minutes that systolic arterial pressure spent below 140 mmHg, the odds of good outcome decreased by 11.1 %.</div></div><div><h3>Conclusions</h3><div>In this retrospective study of general anaesthesia for endovascular stroke therapy, blood pressure drops during the intervention were associated with reduced odds of a good functional outcome three months later. Before a clinical recommendation can be made, a prospective study must clarify effective and safe target ranges of blood pressure support and augmentation.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111665"},"PeriodicalIF":5.0,"publicationDate":"2024-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142545753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-28DOI: 10.1016/j.jclinane.2024.111671
Lotte E. Terwindt MD , Johan T.M. Tol MD , Ward H. van der Ven MD , Vincent C. Kurucz MD , Sijm H. Noteboom MSc , Jennifer S. Breel MSc , Björn J.P. van der Ster PhD , Eline Kho PhD , Rogier V. Immink MD, PhD , Jimmy Schenk PhD , Alexander P.J. Vlaar MD, PhD , Markus W. Hollmann MD, PhD , Denise P. Veelo MD, PhD
Study objectives
To identify the influence of modifiable factors in anesthesia induction strategy on post-induction hypotension (PIH), specifically the type, dosage and speed of administration of induction agents. A secondary aim was to identify patient related non-modifiable factors associated with PIH.
Adult, ASA I-IV patients undergoing elective, non-cardiac surgery under general anesthesia (GA).
Interventions
None.
Measurements
Continuous non-invasive blood pressure using finger-cuff technology. PIH was defined as mean arterial pressure (MAP) <65 mmHg ≥1 min, and, separately, as a > 30 % decrease from baseline MAP ≥1 min.
Main results
Study measurements were performed in 760 patients, of which 720 were suitable for analysis. A total of 238 patients (33.1 %) experienced PIH according to the 65 mmHg threshold, and 287 (39.9 %) using the 30 % decrease in MAP threshold. Remifentanil administration was associated with increased risk of PIH according to either definition (MAP <65 mmHg: OR 1.88, 95 %CI 1.31–2.69, p < 0.001, 30 % MAP decrease: OR 1.66, 95 %CI 1.15–2.40, p = 0.007). Pre-emptive vasopressor use (before or during first minute of GA) was associated with reduced risk of PIH (MAP <65 mmHg: OR 0.65, 95 %CI 0.45–0.95, p = 0.027, MAP 30 % decrease: OR 0.58, 95 %CI 0.40–0.84, p = 0.004). Speed of propofol bolus administration, propofol bolus dose, and esketamine use were not associated with PIH in multivariable analysis. Propofol bolus dose decreased with increasing age and American Society of Anesthesiologists physical status classification.
Conclusions
PIH was common in this patient cohort, regardless of the definition used. Two of the five examined modifiable factors were associated with PIH: remifentanil infusion was associated with an increased risk, and pre-emptive vasopressor use was associated with a decreased risk of PIH. No association between propofol dose and PIH was found, most likely due dose adjustment based on clinical assessment rather than a true absence of effect.
Clinical registration number
This study was registered in the Dutch Medical Research in Humans (OMON) register on 18 June 2019 (ID: NL7810). The study was approved by the Medical Ethics Committee of the Amsterdam UMC, location AMC, the Netherlands in December 2018 (NL 6748.018.18; 2018).
{"title":"The influence of anesthetic drug strategy on the incidence of post induction hypotension in elective, non-cardiac surgery – A prospective observational cohort study","authors":"Lotte E. Terwindt MD , Johan T.M. Tol MD , Ward H. van der Ven MD , Vincent C. Kurucz MD , Sijm H. Noteboom MSc , Jennifer S. Breel MSc , Björn J.P. van der Ster PhD , Eline Kho PhD , Rogier V. Immink MD, PhD , Jimmy Schenk PhD , Alexander P.J. Vlaar MD, PhD , Markus W. Hollmann MD, PhD , Denise P. Veelo MD, PhD","doi":"10.1016/j.jclinane.2024.111671","DOIUrl":"10.1016/j.jclinane.2024.111671","url":null,"abstract":"<div><h3>Study objectives</h3><div>To identify the influence of modifiable factors in anesthesia induction strategy on post-induction hypotension (PIH), specifically the type, dosage and speed of administration of induction agents. A secondary aim was to identify patient related non-modifiable factors associated with PIH.</div></div><div><h3>Design</h3><div>Single-center, prospective observational cohort study.</div></div><div><h3>Setting</h3><div>Operating room.</div></div><div><h3>Patients</h3><div>Adult, ASA I-IV patients undergoing elective, non-cardiac surgery under general anesthesia (GA).</div></div><div><h3>Interventions</h3><div>None.</div></div><div><h3>Measurements</h3><div>Continuous non-invasive blood pressure using finger-cuff technology. PIH was defined as mean arterial pressure (MAP) <65 mmHg ≥1 min, and, separately, as a > 30 % decrease from baseline MAP ≥1 min.</div></div><div><h3>Main results</h3><div>Study measurements were performed in 760 patients, of which 720 were suitable for analysis. A total of 238 patients (33.1 %) experienced PIH according to the 65 mmHg threshold, and 287 (39.9 %) using the 30 % decrease in MAP threshold. Remifentanil administration was associated with increased risk of PIH according to either definition (MAP <65 mmHg: OR 1.88, 95 %CI 1.31–2.69, <em>p</em> < 0.001, 30 % MAP decrease: OR 1.66, 95 %CI 1.15–2.40, <em>p</em> = 0.007). Pre-emptive vasopressor use (before or during first minute of GA) was associated with reduced risk of PIH (MAP <65 mmHg: OR 0.65, 95 %CI 0.45–0.95, <em>p</em> = 0.027, MAP 30 % decrease: OR 0.58, 95 %CI 0.40–0.84, <em>p</em> = 0.004). Speed of propofol bolus administration, propofol bolus dose, and esketamine use were not associated with PIH in multivariable analysis. Propofol bolus dose decreased with increasing age and American Society of Anesthesiologists physical status classification.</div></div><div><h3>Conclusions</h3><div>PIH was common in this patient cohort, regardless of the definition used. Two of the five examined modifiable factors were associated with PIH: remifentanil infusion was associated with an increased risk, and pre-emptive vasopressor use was associated with a decreased risk of PIH. No association between propofol dose and PIH was found, most likely due dose adjustment based on clinical assessment rather than a true absence of effect.</div></div><div><h3>Clinical registration number</h3><div>This study was registered in the Dutch Medical Research in Humans (OMON) register on 18 June 2019 (ID: NL7810). The study was approved by the Medical Ethics Committee of the Amsterdam UMC, location AMC, the Netherlands in December 2018 (NL 6748.018.18; 2018).</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111671"},"PeriodicalIF":5.0,"publicationDate":"2024-10-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142539405","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-24DOI: 10.1016/j.jclinane.2024.111657
Zih-Sian Yang , Hou-Chuan Lai , Hong-Jie Jhou , Wei-Hung Chan , Po-Huang Chen
Study objective
Peripheral nerve blocks (PNBs) are widely used for postoperative analgesia, but rebound pain following block resolution poses a significant clinical challenge. Dexamethasone, administered either intravenously (IV) or perineurally, has shown promise in reducing rebound pain incidence, but the optimal route remains unclear. This network meta-analysis (NMA) aims to compare the effectiveness of different routes of dexamethasone administration, including IV, perineural, and control, in reducing the incidence of rebound pain following PNBs.
Design
Network meta-analysis.
Setting
Operating room, postoperative recovery area and ward.
Intravenous and perineural dexamethasone compared to control for preventing rebound pain.
Measurements
The primary outcome was the incidence of rebound pain. Secondary outcomes included median time to first analgesic request, rebound pain resolution time, difference in pain scores before and after PNB resolution, and nausea/vomiting.
Main results
Both IV and perineural dexamethasone significantly reduced the incidence of rebound pain following peripheral nerve blocks compared to the control group. IV dexamethasone ranked first based on P-score (OR, 0.13; 95 % CI, 0.07–0.23; P-score, 0.92). Secondary outcomes, including time to the first analgesic request, pain score difference, and nausea/vomiting, also favored both IV and perineural dexamethasone over the control group.
Conclusion
Both IV and perineural dexamethasone are preferred over no dexamethasone for preventing rebound pain after PNBs, with IV dexamethasone being the more effective route. Despite limitations, these findings provide valuable insights for clinical decision-making in postoperative pain management.
研究目的周围神经阻滞（PNB）被广泛用于术后镇痛，但阻滞缓解后的反跳痛是一项重大的临床挑战。静脉注射（IV）或会阴部注射地塞米松有望降低反跳痛的发生率，但最佳途径仍不明确。本网络荟萃分析（NMA）旨在比较地塞米松不同给药途径（包括静脉注射、经皮注射和对照组）在降低PNB术后反跳痛发生率方面的效果：设计：网络荟萃分析：手术室、术后恢复区和病房：七项随机对照试验，涉及 561 名接受周围神经阻滞术后疼痛治疗的患者：干预措施：静脉注射和硬膜外注射地塞米松与对照组比较，以防止反跳痛：主要结果是反跳痛的发生率。次要结果包括首次申请镇痛药的中位时间、反跳痛缓解时间、PNB缓解前后疼痛评分的差异以及恶心/呕吐：主要结果：与对照组相比，静脉注射和硬膜外注射地塞米松均能显著降低周围神经阻滞术后反跳痛的发生率。根据 P 值，静脉注射地塞米松排名第一（OR，0.13；95 % CI，0.07-0.23；P 值，0.92）。次要结果包括首次镇痛请求时间、疼痛评分差异和恶心/呕吐，静脉注射和硬膜外地塞米松均优于对照组：结论：静脉注射和硬膜外注射地塞米松都比不注射地塞米松更能预防腹腔镜手术后的反跳痛，其中静脉注射地塞米松是更有效的途径。尽管存在局限性，但这些发现为术后疼痛管理的临床决策提供了有价值的见解：系统综述注册：PREMCORD42024530943。
{"title":"Rebound pain prevention after peripheral nerve block: A network meta-analysis comparing intravenous, perineural dexamethasone, and control","authors":"Zih-Sian Yang , Hou-Chuan Lai , Hong-Jie Jhou , Wei-Hung Chan , Po-Huang Chen","doi":"10.1016/j.jclinane.2024.111657","DOIUrl":"10.1016/j.jclinane.2024.111657","url":null,"abstract":"<div><h3>Study objective</h3><div>Peripheral nerve blocks (PNBs) are widely used for postoperative analgesia, but rebound pain following block resolution poses a significant clinical challenge. Dexamethasone, administered either intravenously (IV) or perineurally, has shown promise in reducing rebound pain incidence, but the optimal route remains unclear. This network meta-analysis (NMA) aims to compare the effectiveness of different routes of dexamethasone administration, including IV, perineural, and control, in reducing the incidence of rebound pain following PNBs.</div></div><div><h3>Design</h3><div>Network meta-analysis.</div></div><div><h3>Setting</h3><div>Operating room, postoperative recovery area and ward.</div></div><div><h3>Patients</h3><div>Seven randomized controlled trials involving 561 patients undergoing peripheral nerve block for postoperative pain management.</div></div><div><h3>Interventions</h3><div>Intravenous and perineural dexamethasone compared to control for preventing rebound pain.</div></div><div><h3>Measurements</h3><div>The primary outcome was the incidence of rebound pain. Secondary outcomes included median time to first analgesic request, rebound pain resolution time, difference in pain scores before and after PNB resolution, and nausea/vomiting.</div></div><div><h3>Main results</h3><div>Both IV and perineural dexamethasone significantly reduced the incidence of rebound pain following peripheral nerve blocks compared to the control group. IV dexamethasone ranked first based on P-score (OR, 0.13; 95 % CI, 0.07–0.23; P-score, 0.92). Secondary outcomes, including time to the first analgesic request, pain score difference, and nausea/vomiting, also favored both IV and perineural dexamethasone over the control group.</div></div><div><h3>Conclusion</h3><div>Both IV and perineural dexamethasone are preferred over no dexamethasone for preventing rebound pain after PNBs, with IV dexamethasone being the more effective route. Despite limitations, these findings provide valuable insights for clinical decision-making in postoperative pain management.</div><div><strong>Systematic review registration:</strong> PROSPERO CRD42024530943.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111657"},"PeriodicalIF":5.0,"publicationDate":"2024-10-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142501297","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-23DOI: 10.1016/j.jclinane.2024.111659
Louis Morisson , Hakim Harkouk , Alexandra Othenin-Girard , Walid Oulehri , Pascal Laferrière-Langlois , Marie-Eve Bélanger , Moulay Idrissi , Nadia Godin , Olivier Verdonck , Louis-Philippe Fortier , Madeleine Poirier , Margaret Henri , Jean-François Latulippe , Jean-François Tremblay , Jean-Sebastien Trépanier , Yves Bendavid , Julien Raft , Philippe Richebé
Study objective
Evaluate the impact of deep neuromuscular blockade on intraoperative nociception Deep neuromuscular blockade has been shown to improve surgical conditions and postoperative outcomes compared to moderate neuromuscular blockade in laparoscopic surgery. Still, its impact on intraoperative nociception and opioid requirement has never been assessed.
Design
Monocentric randomised controlled trial.
Setting
Operating room.
Patients
We included 100 ASA I to III patients who underwent colorectal laparoscopic surgery with desflurane-remifentanil anesthesia.
Interventions
Patients were randomised into two groups to achieve either moderate (1–3 train of four response) or deep (1–2 post-tetanic count) neuromuscular block (NMB) with repeated boluses of rocuronium. The Nociception Level (NOL) index guided intraoperative remifentanil administration in both groups.
Measurements
The primary endpoint was total intraoperative remifentanil administration per hour of surgery. Secondary endpoints included, Leiden Surgical Rating Scale (L-SRS), intra-abdominal pressure, postoperative pain scores and opioids' consumption.
Main results
Ninety-three patients were analysed. Forty-five in the deep group and 48 patients in moderate group. Intraoperative administration of remifentanil was 348 (228–472) μg.h−1 in the deep NMB group compared to 494 (392–618) μg.h−1 in the moderate NMB group (P < 0.001). Lowest L-SRS was 5 (4–5) in the deep NMB group versus 3 (2–5) (P < 0.001) in the moderate NMB group. Mean intra-abdominal pressure was 11.9 (1.3) in the deep NMB group versus 13 (1.3) (P < 0.001) in the moderate NMB group. Secondary postoperative outcomes including pain scores and analgesics administration were not significantly different.
Conclusions
This study shows that deep neuromuscular blockade reduces intraoperative NOL-guided administration of remifentanil in colorectal laparoscopic surgeries. It also improves surgical conditions.
Trial registration
The study was registered at ClinicalTrials.gov under NCT03910998.
{"title":"Impact of deep neuromuscular blockade on intraoperative NOL-guided remifentanil requirement during desflurane anesthesia in laparoscopic colorectal surgeries: A randomised controlled trial","authors":"Louis Morisson , Hakim Harkouk , Alexandra Othenin-Girard , Walid Oulehri , Pascal Laferrière-Langlois , Marie-Eve Bélanger , Moulay Idrissi , Nadia Godin , Olivier Verdonck , Louis-Philippe Fortier , Madeleine Poirier , Margaret Henri , Jean-François Latulippe , Jean-François Tremblay , Jean-Sebastien Trépanier , Yves Bendavid , Julien Raft , Philippe Richebé","doi":"10.1016/j.jclinane.2024.111659","DOIUrl":"10.1016/j.jclinane.2024.111659","url":null,"abstract":"<div><h3>Study objective</h3><div>Evaluate the impact of deep neuromuscular blockade on intraoperative nociception Deep neuromuscular blockade has been shown to improve surgical conditions and postoperative outcomes compared to moderate neuromuscular blockade in laparoscopic surgery. Still, its impact on intraoperative nociception and opioid requirement has never been assessed.</div></div><div><h3>Design</h3><div>Monocentric randomised controlled trial.</div></div><div><h3>Setting</h3><div>Operating room.</div></div><div><h3>Patients</h3><div>We included 100 ASA I to III patients who underwent colorectal laparoscopic surgery with desflurane-remifentanil anesthesia.</div></div><div><h3>Interventions</h3><div>Patients were randomised into two groups to achieve either moderate (1–3 train of four response) or deep (1–2 post-tetanic count) neuromuscular block (NMB) with repeated boluses of rocuronium. The Nociception Level (NOL) index guided intraoperative remifentanil administration in both groups.</div></div><div><h3>Measurements</h3><div>The primary endpoint was total intraoperative remifentanil administration per hour of surgery. Secondary endpoints included, Leiden Surgical Rating Scale (L-SRS), intra-abdominal pressure, postoperative pain scores and opioids' consumption.</div></div><div><h3>Main results</h3><div>Ninety-three patients were analysed. Forty-five in the deep group and 48 patients in moderate group. Intraoperative administration of remifentanil was 348 (228–472) μg.h<sup>−1</sup> in the deep NMB group compared to 494 (392–618) μg.h<sup>−1</sup> in the moderate NMB group (<em>P</em> < 0.001). Lowest L-SRS was 5 (4–5) in the deep NMB group versus 3 (2–5) (P < 0.001) in the moderate NMB group. Mean intra-abdominal pressure was 11.9 (1.3) in the deep NMB group versus 13 (1.3) (P < 0.001) in the moderate NMB group. Secondary postoperative outcomes including pain scores and analgesics administration were not significantly different.</div></div><div><h3>Conclusions</h3><div>This study shows that deep neuromuscular blockade reduces intraoperative NOL-guided administration of remifentanil in colorectal laparoscopic surgeries. It also improves surgical conditions.</div></div><div><h3>Trial registration</h3><div>The study was registered at <span><span>ClinicalTrials.gov</span><svg><path></path></svg></span> under <span><span>NCT03910998</span><svg><path></path></svg></span>.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111659"},"PeriodicalIF":5.0,"publicationDate":"2024-10-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142501295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-22DOI: 10.1016/j.jclinane.2024.111664
Sina Grape , Kariem El-Boghdadly , Cécile Jaques , Eric Albrecht
Study objective
Neuraxial hydromorphone provides postoperative pain relief. However, the magnitude of this effect and the optimal dose remain unknown. The objective of this study is to clarify these uncertainties.
Design
Systematic review and meta-analysis with trial sequential analysis.
Setting
Postoperative recovery area and ward, up to 24 h.
Patients
Any patient undergoing any type of surgery or being in labor.
Interventions
Neuraxial hydromorphone versus control.
Measurements
Our primary outcome was rest pain score (analogue scale, 0–10) at 24 h according to route of administration (epidural versus spinal) and type of surgery (orthopedic versus other). Secondary outcomes included rest pain score at 0–4 and 8–12 h; rates of postoperative nausea and vomiting, and pruritus at 24 h.
Main results
Six trials, including 436 patients, were identified. Rest pain score at 24 postoperative hours was significantly reduced in the hydromorphone group, with a mean difference (95 %CI) of −0.4 (−0.8 to −0.1), I2 = 74 %, p = 0.01. Neuraxial hydromorphone did not increase postoperative nausea and vomiting (risk ratio [95 %CI]: 1.2 [0.8–1.8], I2 = 27 %, p = 0.47), but increases pruritus (risk ratio [95 %CI]: 3.1 [1.6–5.9], I2 = 0 %, p = 0.0005). The quality of evidence was very low for our primary and secondary outcomes. In conclusion, there is very low level of evidence that neuraxial hydromorphone provides effective analgesia after surgery or labor, at the expense of an increased rate of pruritus. The improvement in pain scores appears to be clinically insignificant. With only six trials published over a period of 30 years, we were unable to perform a meta-regression.
Conclusions
If neuraxial hydromorphone is to be used regularly, trials focusing on the optimal dose and side-effects should be performed before widely administering this medication into the neuraxial space.
More trials focusing on the optimal dose and side-effects should be performed before widely administering this medication into the neuraxial space.
{"title":"Efficacy and safety of neuraxial hydromorphone: A systematic review and meta-analysis with trial sequential analysis","authors":"Sina Grape , Kariem El-Boghdadly , Cécile Jaques , Eric Albrecht","doi":"10.1016/j.jclinane.2024.111664","DOIUrl":"10.1016/j.jclinane.2024.111664","url":null,"abstract":"<div><h3>Study objective</h3><div>Neuraxial hydromorphone provides postoperative pain relief. However, the magnitude of this effect and the optimal dose remain unknown. The objective of this study is to clarify these uncertainties.</div></div><div><h3>Design</h3><div>Systematic review and meta-analysis with trial sequential analysis.</div></div><div><h3>Setting</h3><div>Postoperative recovery area and ward, up to 24 h.</div></div><div><h3>Patients</h3><div>Any patient undergoing any type of surgery or being in labor.</div></div><div><h3>Interventions</h3><div>Neuraxial hydromorphone versus control.</div></div><div><h3>Measurements</h3><div>Our primary outcome was rest pain score (analogue scale, 0–10) at 24 h according to route of administration (epidural versus spinal) and type of surgery (orthopedic versus other). Secondary outcomes included rest pain score at 0–4 and 8–12 h; rates of postoperative nausea and vomiting, and pruritus at 24 h.</div></div><div><h3>Main results</h3><div>Six trials, including 436 patients, were identified. Rest pain score at 24 postoperative hours was significantly reduced in the hydromorphone group, with a mean difference (95 %CI) of −0.4 (−0.8 to −0.1), I<sup>2</sup> = 74 %, <em>p</em> = 0.01. Neuraxial hydromorphone did not increase postoperative nausea and vomiting (risk ratio [95 %CI]: 1.2 [0.8–1.8], I<sup>2</sup> = 27 %, <em>p</em> = 0.47), but increases pruritus (risk ratio [95 %CI]: 3.1 [1.6–5.9], I<sup>2</sup> = 0 %, <em>p</em> = 0.0005). The quality of evidence was very low for our primary and secondary outcomes. In conclusion, there is very low level of evidence that neuraxial hydromorphone provides effective analgesia after surgery or labor, at the expense of an increased rate of pruritus. The improvement in pain scores appears to be clinically insignificant. With only six trials published over a period of 30 years, we were unable to perform a meta-regression.</div></div><div><h3>Conclusions</h3><div>If neuraxial hydromorphone is to be used regularly, trials focusing on the optimal dose and side-effects should be performed before widely administering this medication into the neuraxial space.</div><div>More trials focusing on the optimal dose and side-effects should be performed before widely administering this medication into the neuraxial space.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111664"},"PeriodicalIF":5.0,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142501294","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-22DOI: 10.1016/j.jclinane.2024.111662
Alessandro De Cassai
{"title":"Spinal cord ischemia after ESP block","authors":"Alessandro De Cassai","doi":"10.1016/j.jclinane.2024.111662","DOIUrl":"10.1016/j.jclinane.2024.111662","url":null,"abstract":"","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111662"},"PeriodicalIF":5.0,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142501298","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-22DOI: 10.1016/j.jclinane.2024.111663
Bing-Yan Cai M.D. , Shu-Ting He M.D. , Yan Zhang M.D. , Jia-Hui Ma Ph.D , Dong-Liang Mu M.D. , Dong-Xin Wang M.D., Ph.D
Study objective
To test the hypothesis that emergence delirium might be associated with worse long-term survival.
Design
A longitudinal prospective observational study.
Setting
A tertiary hospital in Beijing, China.
Patients
A total of 942 patients aged 65–90 years who were admitted to post-anesthesia care unit (PACU) after major noncardiac surgery under general anesthesia.
Exposures
Emergence delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit during PACU stay.
Measurements
Patients were followed up once a year for at least 3 years. Our primary endpoint was overall survival. Secondary endpoints included recurrence-free and event-free survivals. Associations between emergence delirium and long-term survivals were analyzed with the Cox proportional hazard models.
Main results
Among enrolled patients, 915 completed perioperative assessments; 906 completed long-term follow-up (mean age 72 years; 60 % [545/906] male; 73 % [660/906] cancer surgery). At the end of follow-up (median 43 months), there were 69 deaths in 331 patients (21 %) with emergence delirium versus 114 deaths in 575 patients (20 %) without: unadjusted hazard ratio 1.10 (95 % CI: 0.81 to 1.48); P = 0.547; adjusted hazard ratio 0.96 (95 % CI: 0.70 to 1.32); P = 0.797. Recurrence-free survival was 73/331 (22 %) in patients with emergence delirium versus 121/575 (21 %) without: unadjusted hazard ratio 1.08 (95 % CI: 0.81 to 1.45); P = 0.598; adjusted hazard ratio 0.94 (95 % CI: 0.69 to 1.28); P = 0.695. Event-free survival was 159/331 (48 %) in patients with emergence delirium versus 268/575 (47 %) without: unadjusted hazard ratio 1.06 (95 % CI: 0.87 to 1.29); P = 0.563; adjusted hazard ratio 0.98 (95 % CI: 0.80 to 1.21); P = 0.875.
Conclusions
We did not find significant association between emergence delirium and worse long-term survival in older patients after general anesthesia and major surgery mainly for cancer. The effects of emergence delirium on long-term outcomes deserve further investigation.
{"title":"Impact of emergence delirium on long-term survival in older patients after major noncardiac surgery: A longitudinal prospective observational study","authors":"Bing-Yan Cai M.D. , Shu-Ting He M.D. , Yan Zhang M.D. , Jia-Hui Ma Ph.D , Dong-Liang Mu M.D. , Dong-Xin Wang M.D., Ph.D","doi":"10.1016/j.jclinane.2024.111663","DOIUrl":"10.1016/j.jclinane.2024.111663","url":null,"abstract":"<div><h3>Study objective</h3><div>To test the hypothesis that emergence delirium might be associated with worse long-term survival.</div></div><div><h3>Design</h3><div>A longitudinal prospective observational study.</div></div><div><h3>Setting</h3><div>A tertiary hospital in Beijing, China.</div></div><div><h3>Patients</h3><div>A total of 942 patients aged 65–90 years who were admitted to post-anesthesia care unit (PACU) after major noncardiac surgery under general anesthesia.</div></div><div><h3>Exposures</h3><div>Emergence delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit during PACU stay.</div></div><div><h3>Measurements</h3><div>Patients were followed up once a year for at least 3 years. Our primary endpoint was overall survival. Secondary endpoints included recurrence-free and event-free survivals. Associations between emergence delirium and long-term survivals were analyzed with the Cox proportional hazard models.</div></div><div><h3>Main results</h3><div>Among enrolled patients, 915 completed perioperative assessments; 906 completed long-term follow-up (mean age 72 years; 60 % [545/906] male; 73 % [660/906] cancer surgery). At the end of follow-up (median 43 months), there were 69 deaths in 331 patients (21 %) with emergence delirium versus 114 deaths in 575 patients (20 %) without: unadjusted hazard ratio 1.10 (95 % CI: 0.81 to 1.48); <em>P</em> = 0.547; adjusted hazard ratio 0.96 (95 % CI: 0.70 to 1.32); <em>P</em> = 0.797. Recurrence-free survival was 73/331 (22 %) in patients with emergence delirium versus 121/575 (21 %) without: unadjusted hazard ratio 1.08 (95 % CI: 0.81 to 1.45); <em>P</em> = 0.598; adjusted hazard ratio 0.94 (95 % CI: 0.69 to 1.28); <em>P</em> = 0.695. Event-free survival was 159/331 (48 %) in patients with emergence delirium versus 268/575 (47 %) without: unadjusted hazard ratio 1.06 (95 % CI: 0.87 to 1.29); <em>P</em> = 0.563; adjusted hazard ratio 0.98 (95 % CI: 0.80 to 1.21); <em>P</em> = 0.875.</div></div><div><h3>Conclusions</h3><div>We did not find significant association between emergence delirium and worse long-term survival in older patients after general anesthesia and major surgery mainly for cancer. The effects of emergence delirium on long-term outcomes deserve further investigation.</div><div><strong>Clinical trial registrations</strong>: <span><span>www.chictr.org.cn</span><svg><path></path></svg></span>; ChiCTR-OOC-17012734.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111663"},"PeriodicalIF":5.0,"publicationDate":"2024-10-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142501296","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-21DOI: 10.1016/j.jclinane.2024.111651
Dieter Adelmann M.D., Ph.D. , Mallika Reddy , George P. Zhou M.D. , Kyota Fukazawa M.D., Ph.D. , Ryan Wang M.D. , Cale Kassel M.D. , Christine Nguyen-Buckley M.D. , Javier Bastidas M.D., M.Sc , Lorenzo De Marchi M.D., FASE , Elizabeth A. Wilson M.D. , Ryan Nazemian M.D., Ph.D. , Ana Fernandez-Bustamante M.D., Ph.D., FASA , Alexandra Anderson M.D. , Ryan M. Chadha M.D. , Jiapeng Huang M.D., Ph.D. , Marina Moguilevitch M.D. , Elizabeth Townsend M.D., Ph.D. , David M. Rosenfeld M.D. , Rishi P. Kothari M.D.
{"title":"The perioperative care in liver transplantation multicenter database: Building the foundation for research collaboration in liver transplantation","authors":"Dieter Adelmann M.D., Ph.D. , Mallika Reddy , George P. Zhou M.D. , Kyota Fukazawa M.D., Ph.D. , Ryan Wang M.D. , Cale Kassel M.D. , Christine Nguyen-Buckley M.D. , Javier Bastidas M.D., M.Sc , Lorenzo De Marchi M.D., FASE , Elizabeth A. Wilson M.D. , Ryan Nazemian M.D., Ph.D. , Ana Fernandez-Bustamante M.D., Ph.D., FASA , Alexandra Anderson M.D. , Ryan M. Chadha M.D. , Jiapeng Huang M.D., Ph.D. , Marina Moguilevitch M.D. , Elizabeth Townsend M.D., Ph.D. , David M. Rosenfeld M.D. , Rishi P. Kothari M.D.","doi":"10.1016/j.jclinane.2024.111651","DOIUrl":"10.1016/j.jclinane.2024.111651","url":null,"abstract":"","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111651"},"PeriodicalIF":5.0,"publicationDate":"2024-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142501299","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We conducted a non-inferiority study to assess the postoperative quality of recovery (QoR) in elderly patients receiving ciprofol or propofol total intravenous anesthersia(TIVA)after elective laparoscopic major abdominal surgery, with QoR-15 scores as the main measure.
Design
A prospective, double-blind, randomized non-inferiority trial was conducted in the theater, post-anesthesia care unit (PACU), and the ward.
Participants
144 elderly patients (age ≥ 65 years) were randomly assigned to either the ciprofol group or the propofol group.
Interventions
The ciprofol group received continuous infusion of ciprofol with remifentanil, and the propofol group received infusion of propofol with remifentanil.
Outcome measures
The primary outcome was the QoR-15 on the first postoperative day (POD1), assessed in both intention-to-treat and per-protocol populations, with the mean difference between groups compared to a non-inferiority threshold of −8. Additional assessments included QoR-15 scores on POD2, 3, and 5 for both analysis sets. Other evaluated perioperative value factors included hemodynamic parameters and injection discomfort in the intention-to-treat analysis. A linear mixed model was utilized to examine the impact of group-time interactions on hemodynamic data and QoR-15.
Main results
The QoR-15 scores on POD1 in the ciprofol group were non-inferior to those in the propofol group both in intention-to-treat set (mean [95 %CI], 95.9[93.7–98.2] vs. 95.6 [93.3–97.8]; mean difference [95 % CI], 0.4 [−2.8–3.5]; P<0.001 for noninferiority) and per-protocol set (mean [95 %CI], 96.7 [94.4–99.0] vs. 95.7 [93.4–98.0]; mean difference [95 % CI], 1.0 [−2.2–4.3]; P<0.001 for noninferiority). Comparable outcomes were noted on postoperative days 2, 3, and 5 following the procedure in both analysis sets. Additionally: compared with propofol group, the occurrence of injection pain was lower (2.8 % vs. 27.8 %, P < 0.001); the hypotension was less frequent (33.3 % vs. 54.2 %, P = 0.012); the bradycardia was more common (38.9 % vs. 23.6 %, P = 0.048).
Conclusions
Ciprofol is not inferior to propofol in QoR. Ciprofol can be suitably administered to elderly patients undergoing elective laparoscopic major abdominal surgery.
{"title":"Postoperative quality of recovery comparison between ciprofol and propofol in total intravenous anesthesia for elderly patients undergoing laparoscopic major abdominal surgery: A randomized, controlled, double-blind, non-inferiority trial","authors":"Zenghui Liang MMed , Jing Liu MMed , Shuhan Chen MMed , Xiaona Zhao MMed , Gezi Chen MMed , Yanle Xie MMed , Dongmei Wang MMed , Fei Xing MMed , Yuanyuan Mao MMed , Wei Zhang MD , Zhongyu Wang MD , Jingjing Yuan MD","doi":"10.1016/j.jclinane.2024.111660","DOIUrl":"10.1016/j.jclinane.2024.111660","url":null,"abstract":"<div><h3>Study objectives</h3><div>We conducted a non-inferiority study to assess the postoperative quality of recovery (QoR) in elderly patients receiving ciprofol or propofol total intravenous anesthersia(TIVA)after elective laparoscopic major abdominal surgery, with QoR-15 scores as the main measure.</div></div><div><h3>Design</h3><div>A prospective, double-blind, randomized non-inferiority trial was conducted in the theater, post-anesthesia care unit (PACU), and the ward.</div></div><div><h3>Participants</h3><div>144 elderly patients (age ≥ 65 years) were randomly assigned to either the ciprofol group or the propofol group.</div></div><div><h3>Interventions</h3><div>The ciprofol group received continuous infusion of ciprofol with remifentanil, and the propofol group received infusion of propofol with remifentanil.</div></div><div><h3>Outcome measures</h3><div>The primary outcome was the QoR-15 on the first postoperative day (POD1), assessed in both intention-to-treat and per-protocol populations, with the mean difference between groups compared to a non-inferiority threshold of −8. Additional assessments included QoR-15 scores on POD2, 3, and 5 for both analysis sets. Other evaluated perioperative value factors included hemodynamic parameters and injection discomfort in the intention-to-treat analysis. A linear mixed model was utilized to examine the impact of group-time interactions on hemodynamic data and QoR-15.</div></div><div><h3>Main results</h3><div>The QoR-15 scores on POD1 in the ciprofol group were non-inferior to those in the propofol group both in intention-to-treat set (mean [95 %CI], 95.9[93.7–98.2] vs. 95.6 [93.3–97.8]; mean difference [95 % CI], 0.4 [−2.8–3.5]; <em>P</em><0.001 for noninferiority) and per-protocol set (mean [95 %CI], 96.7 [94.4–99.0] vs. 95.7 [93.4–98.0]; mean difference [95 % CI], 1.0 [−2.2–4.3]; <em>P</em><0.001 for noninferiority). Comparable outcomes were noted on postoperative days 2, 3, and 5 following the procedure in both analysis sets. Additionally: compared with propofol group, the occurrence of injection pain was lower (2.8 % vs. 27.8 %, <em>P</em> < 0.001); the hypotension was less frequent (33.3 % vs. 54.2 %, <em>P</em> = 0.012); the bradycardia was more common (38.9 % vs. 23.6 %, <em>P</em> = 0.048).</div></div><div><h3>Conclusions</h3><div>Ciprofol is not inferior to propofol in QoR. Ciprofol can be suitably administered to elderly patients undergoing elective laparoscopic major abdominal surgery.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"99 ","pages":"Article 111660"},"PeriodicalIF":5.0,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142466708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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