Saudi Journal of Anaesthesia最新文献

Regional anesthesia has been proven useful in hand surgery after trauma, most commonly via brachial plexus blocks (BPB), with widely established benefits. Distal nerve blocks at the elbow are used much less frequently. A 15-year-old boy was admitted because of traumatic amputation of the 4^th digit on his right hand. Difficult intubation was suspected. History was indicative of obstructive sleep apnea, and nil per os status was confirmed, with no apparent risk factors for regurgitation. Ultrasound-guided blocks of the median, radial, and ulnar nerves at the elbow were performed with 2% Lidocaine and 0.5% Levobupivacaine. Sedation was maintained with Propofol 3-4 mg/kg/h, with oxygen support via nasal cannula at 3 L/min. Basic monitoring of vital functions was applied. Throughout the procedure, the patient maintained perfect hemodynamic and respiratory stability. Postoperative analgesia was adequate, with no nonsteroidal anti-inflammatory drugs administered in the first 12 h postoperatively. Distal nerve blocks at the elbow may present a safe and effective anesthetic technique when managing traumatic injuries of the fingers, presenting a simpler and less risky technique than BPB and requiring less provider expertise. Previous studies have demonstrated the use of these blocks in acute pain management following fractures, but to our knowledge, no inquiry has been made into the use of these blocks for surgical anesthesia in amputation management. One needs to keep in mind the dermatomal distribution of innervation as other digits may not require covering all three nerves as the 4^th digit does. Caution must be taken to account for any possibility of increased risk of regurgitation, as well as the use of an upper arm pneumatic tourniquet.

Becker muscular dystrophy (BMD) is a genetic disorder caused by partial deficiency of dystrophin, leading to progressive skeletal muscle weakness and cardiac failure. Up to one-third of affected individuals develop dilated cardiomyopathy, eventually requiring heart transplantation at a young age. Although BMD is not directly linked to malignant hyperthermia (MH), patients may experience severe MH-like reactions, particularly when exposed to succinylcholine or volatile anesthetics. Therefore, total intravenous anesthesia (TIVA) is often preferred in this population, despite the cardioprotective benefits of volatile agents through myocardial preconditioning. We report the case of a teenager with BMD and advanced cardiomyopathy who successfully underwent heart transplantation under TIVA. Anesthesia was maintained with target-controlled infusion (TCI) of propofol and remifentanil. Additional boluses of ketamine and midazolam were administered to maintain a bispectral index (BIS) between 40 and 60. Postoperatively, the patient was admitted to the intensive care unit receiving low-dose infusions of dobutamine, sodium nitroprusside, and inhaled nitric oxide, and was safely extubated 3 h later. This case highlights the feasibility and safety of TIVA in patients with BMD undergoing major cardiac surgery.

Background: Subarachnoid block (SAB) is a preferred anesthetic technique for infraumbilical surgeries. However, in obese patients, landmark identification for SAB can be difficult, increasing the risk of procedural failure and complications. This study is determined to compare the efficacy of ultrasound (USG)-guided, C-arm fluoroscopy-guided, and anatomical landmark-guided SAB in obese patients.

Methods: Sixty patients of 18-80 years with BMI ≥30 kg/m² of American Society of Anaesthesiologist Physical Status (ASA PS) II-III scheduled for infraumbilical surgeries were randomized into three equal groups: Group A, Group B, and Group C for USG-guided, C-arm-guided, and Landmark-guided SAB, respectively. Each received 0.5% hyperbaric bupivacaine intrathecally using a 25-G Quincke's needle. Total time taken for the procedure, number of spinal needle insertion attempts, patient satisfaction score, success rate, and complications in each group were recorded.

Results: All groups were comparable demographically. Group B had the significantly highest total time taken for the procedure, 380.4 ± 46.2 seconds, compared to Group A, 273.6 ± 7.5 seconds, and Group C, 165.7 ± 23.2 seconds. The number of spinal needle insertion attempts was lowest in Groups A and B, with higher patient satisfaction scores. Complications occurred only in Group C.

Conclusion: Imaging modalities-guided SAB in obese patients took a prolonged procedure time but had fewer spinal needle insertion attempts and better patient satisfaction than the landmark-guided SAB. Between the imaging modalities, USG-guided SAB was faster, required fewer needle insertions, and gave better patient satisfaction than C-arm guided SAB.

Background: Despite being considered routine, breast surgery is associated with a high incidence of acute and chronic postoperative pain, which can significantly impact recovery and quality of life. Regional anesthesia techniques have become increasingly relevant within multimodal analgesic strategies, yet clinical practice remains heterogeneous and lacks clear guidance. To address this, we aimed to develop a multidisciplinary, evidence-based consensus on the role of regional anesthesia in breast surgery.

Methods: An expert panel was appointed by the Italian Chapter of the European Society of Regional Anaesthesia, including anesthesiologists and breast surgeons (in partnership with the Italian National Association of Breast Surgeons). A four-round Delphi method was applied to refine an initial set of 24 PICO-formulated questions. Each question was evaluated for relevance and clarity using a 9-point Likert scale (1 = not relevant/clear, 9 = extremely relevant/clear). Finalized questions underwent systematic review or network meta-analysis depending on data availability.

Results: Eleven clinically relevant and clearly formulated PICO questions were identified after four Delphi rounds. These questions encompass acute and chronic pain control, block safety in anticoagulated patients, awake surgery, and the comparative efficacy of single-shot versus continuous blocks, among others. Each question will guide a systematic review and support the development of graded consensus statements.

Conclusion: This consensus project establishes a transparent, multidisciplinary framework for guiding the use of regional anesthesia in breast surgery. The ultimate objective is to formulate a set of consensus statements, graded according to evidence strength, which will serve as a foundation for future guidelines and standardized clinical decision-making.

Background: The supraclavicular brachial plexus block is widely used for upper limb surgeries due to its effectiveness in providing anesthesia. Conventionally, success is gauged through sensory and motor assessments, which are not only subjective but also require active patient cooperation. This poses challenges for patients who are sedated or under general anesthesia. Additionally, repeated sensory testing can be uncomfortable. Therefore, an objective and noninvasive method to assess block success is needed. Perfusion index (PI), derived from pulse oximetry, reflects peripheral perfusion changes following sympathetic blockade and could serve as a useful surrogate marker. This study aimed to assess the utility of PI and the PI ratio as early indicators of successful block onset and to identify optimal threshold values correlating with effective anesthesia.

Methods: Seventy patients undergoing elective upper limb orthopedic procedures received ultrasound-guided supraclavicular blocks. Data for PI were collected from the affected and unaffected limbs at the initial time point and again at 10, 15, and 20 minutes after the block was given. The PI ratio was derived by comparing values between limbs at each time point.

Results: In successful blocks, the PI increased significantly in the affected limb. A PI > 2.94 showed 50% sensitivity and 91.67% specificity, while a PI ratio > 1.25 offered 50.78% sensitivity and 100% specificity at 10 minutes, confirmed by receiver operating characteristic (ROC) analysis.

Conclusion: Both PI and PI ratio are effective in predicting block success, with the PI ratio proving more reliable, especially at the 10-minute mark.

Background: In this prospective observational study, we aimed to determine the perioperative incidence and the risk factors of acute kidney injury after elective major abdominal surgery.

Methods: Adult patients who had undergone major elective abdominal surgery were included in the study. The patients were divided into Group AKI + and Group AKI, according to KDIGO criteria at 48 hours. Patients' demographic data, preoperative status, and laboratory data, operation-related data, and postoperative laboratory and follow-up data were noted. The patients were followed up for complications and mortality within three months after the operation date.

Results: In 425 patients included in the statistical analysis, the incidence of acute kidney injury after elective major abdominal surgery in our hospital was found to be 11.52% (49/425). In the multivariate analysis, postoperative continuation of vasopressor, mean arterial pressure <50 mmHg for at least 5 minutes, intraoperative 6% hydroxy-ethyl starch use, and high body mass index were found to be independent risk factors, in order of importance in increasing risk (OR 5.1, CI [1.4-18.9], P = 0,016; OR 3.9, CI [1.3-11.6], P = 0,014; OR 2.7, CI [1.1-6.8], P = 0,029; OR 1.2, CI [1.1-1.2], P < 0,001, respectively). 30- and 90-day mortality was found more frequently in patients who developed acute kidney injury.

Conclusions: In this study, we recommend modifying risk factors if possible, including avoiding 6% HES use and close blood pressure monitoring to reduce the incidence of postoperative acute kidney injury.

Objective: Postoperative airway complications pose significant risks in pediatric patients and are often multifactorial. Anatomical and physiological differences in children make predicting these complications challenging. This study examines the association between ultrasonographic (USG) measurements and postoperative airway complications, primarily focusing on the subglottic diameter-to-wall thickness difference ratio.

Methods: This prospective, double-blind study included pediatric patients aged 1-11 undergoing elective surgery between January and July 2024. Demographic and perioperative data, USG-measured airway diameters, wall thicknesses, and endotracheal tube (ETT) positions were recorded. The subglottic diameter-to-wall thickness difference ratio was the primary ultrasonographic measurement. Airway complications were assessed within the first postoperative hour, including cough, dysphonia, and laryngospasm. The relationship between USG measurements and complications was analyzed.

Results: Eighty patients were included, and airway complications were observed in 37.5% (n = 30). Patients with complications had lower height, subglottic diameter, and subglottic diameter-to-wall thickness difference ratio but higher subglottic wall and vocal cord thickness differences. In 70% (n = 20) of these cases, ETT had shifted superiorly from the second tracheal ring. The subglottic diameter-to-wall thickness difference ratio was significantly associated with complications (AUC 0.896, cutoff 32, sensitivity 80%, specificity 92%). ETT positioned above the second tracheal ring was also associated with increased complication risk (OR = 107.747, 95% CI: 5.305-2188.504, P = 0.002).

Conclusion: USG appears to be a valuable tool for assessing the association between the subglottic diameter-to-wall thickness difference ratio and postoperative airway complications in pediatric patients. Accurate evaluation of subglottic edema and proper ETT placement using USG may enhance patient safety.

Background: Ketamine has been shown to be an effective treatment at sub-anesthetic doses for various chronic pain conditions. This study assesses the relationship between oral ketamine and the incidence of adverse side effects in patients receiving long-term, moderate to high-dose tablets for chronic pain.

Materials and methods: All adult patients given prescriptions for oral ketamine from November 2019 to October 2023 were identified for our initial cohort. Patients were excluded if they failed to reach at least 80 mg per day during their treatment period or if their treatment periods lasted less than 90 days. Demographic variables, comorbidities, prescription information, and patient-reported side effects were recorded.

Results: This study identified 193 patients who received oral ketamine prescriptions at our institution. One hundred forty-nine patients received 80 mg-159 mg per day, 24 patients received 160 mg-199 mg per day, and 20 patients received 200 mg-240 mg per day. In Group 1, 9 of the 149 patients (6.0%) reported 12 instances of side effects; in Group 2, 2 of the 24 patients (8.3%) reported 6 instances of side effects; in Group 3, 2 of the 20 patients (10%) reported 2 instances of side effects. The maximum average daily dosage was not associated with the number of reported side effects (P = 0.10). Age was the only covariate associated with the number of adverse side effects (P = 0.04).

Conclusion: Our results suggest that at daily doses above 80 mg and up to 240 mg, oral ketamine does not show a dose-dependent relationship in predicting the number of patient-reported side effects.

Background: Pneumatic tourniquets are used in orthopedic surgeries to provide a bloodless surgical area and reduce blood loss. Tourniquet inflation causes metabolic changes, leading to cerebral vasodilatation and increased intracranial pressure (ICP). A new noninvasive method to measure optic nerve sheath diameter (ONSD) via ultrasonography to detect the raised ICP is reliable, inexpensive, and can be repeated many times.

Materials and methods: In this prospective observational study, 23 patients aged between 16 and 60 years, undergoing elective lower limb orthopedic surgeries under spinal anesthesia were included. After pre-anesthetic evaluation and obtaining informed written consent, an ocular ultrasound was performed to measure baseline ONSD in both eyes. Spinal anesthesia was administered and A pneumatic thigh tourniquet was applied as close as possible to the limb root and inflated to 150 mmHg-250 mmHg above the systolic blood pressure. A total of 5 measurements of ONSD were taken by the investigator (anesthetist): before giving spinal anesthesia, after giving spinal anesthesia, before tourniquet deflation, within 5 min, and after 10 min of tourniquet deflation.

Results: In our study, the mean age of subjects was 34.57 ± 13.5 years. The majority were males (83%). The subjects showed an increase in ONSD after pneumatic tourniquet deflation in comparison with the baseline values, in the left eye [0.543 cm ± 0.021, P < 0.001] and the right eye [0.549 cm ± 0.021, P < 0.001], which were statistically significant.

Conclusion: The impact of pneumatic tourniquet deflation on ONSD measurements recorded by ultrasound in lower limb orthopedic surgeries was significant and this change occurred with a simultaneous increase in end-tidal carbon dioxide (EtCO₂).

Sturge-Weber Syndrome (SWS) is a non-familial neurocutaneous disease related to capillary-venous malformations affecting many parts, such as the brain, skin, eyes, face, and respiratory tract and characterized by facial capillary malformation (port wine stain), which is a highly complex and significant challenge for anaesthesiologists. Difficult ventilation and intubation are expected in patients with airway, mouth, lip, and facial involvement of angiomas. Soft induction intubation and extubation are required to prevent increased intracranial (ICP) and intraocular pressure (IOP). We aimed to present the case of a 36-year-old female patient with a hemangioma covering three-quarters of the oral cavity, pharynx, larynx, floor of the mouth, face, neck, and both arms, and her lower lip was significantly swollen and protruding due to the angioma, and she had macroglossia. Therefore, a comprehensive preoperative multidisciplinary approach to examining, evaluating, and closely monitoring these patients is crucial for successful anesthesia management.