Anesthesia and pain medicine最新文献

Background: High B-type natriuretic peptide (BNP) levels within the first 3 postoperative days (postBNPPOD3) after liver transplantation (LT) are greatly predictive of the 30-day mortality. We evaluated clinical impact of transient decrease in postBNPPOD3 compared to pretransplant BNP (preBNP) level on mortality and major adverse cardiac event (MACE) within 30 days after LT.

Methods: We retrospectively evaluated 3,811 LT patients who measured delta BNP (deltaBNP), defined by serial postBNPPOD3 minus preBNP. Thirty-day all-cause mortality and MACE were estimated in patients with deltaBNP < 0 (n = 594, 15.6%) and > 0 (n = 3,217, 84.4%), respectively. Kaplan-Meier survival and multivariable Cox regression analysis were used.

Results: Within 30 days, 100 (2.6%) of all patients died. Unexpectedly, 30-day mortality rate (6.1% [95% CI: 4.2-8.4%] vs. 2.0% [95% CI: 1.5-2.5%], P < 0.001) and MACE (24.2% [95% CI: 20.4-28.5%] vs. 15.3% [95% CI: 14.0-16.7%], P < 0.001) were higher in patients with deltaBNP < 0 compared to those with deltaBNP > 0, respectively. Patients with deltaBNP < 0 had higher preBNP level (median [interquartile range], 251 [118, 586] vs. 43 [21, 92] pg/ml, P < 0.001) and model for end-stage liver disease score (26 [14, 37] vs. 14 [9, 23], P < 0.001) and more transfused intraoperatively. DeltaBNP < 0 remained significant after adjustments for potential confounders in multivariable analysis of 30-day mortality and MACE.

Conclusions: DeltaBNP < 0 within the first 3 postoperative days is mainly attributed to pre-LT severe liver and cardiac disease status, therefore, transient decrease in BNP level after LT does not ensure favorable post-LT 30-day outcomes.

Background: Common regional anesthesia approaches for video-assisted thoracoscopic surgery (VATS) include paravertebral block (PVB) and erector spinae plane block (ESPB). PVB is considered a deep nerve block which is contraindicated in antithrombotic therapy. ESPB is effective when administered as a bolus, as well as continuously. However, the recently proposed intertransverse process block (ITPB) ensures more effective diffusion of the local anesthetic into the paravertebral space.

Case: We report cases of three patients who received bolus ITPB (costotransverse foramen block and mid-point transverse process-to-pleura block in one and two cases, respectively) combined with continuous ESPB when a deep nerve block could not be administered. Opioids were not required postoperatively, and all postoperative numerical rating scale scores (0-10) at rest were maintained below 4.

Conclusions: The combination of bolus ITPB and continuous ESPB may be an alternative analgesic method when deep nerve blocks are contraindicated in VATS.

Background: Regional anesthesia techniques are commonly used for postoperative pain management during laparoscopic surgery. Our aim was to compare the analgesic efficacy of pre-incisional subcutaneous wound infiltration (WI) with that of the transversus abdominis plane (TAP) block as part of a multimodal analgesic approach in laparoscopic radical prostatectomy.

Methods: In this prospective, double-blinded, randomized controlled clinical trial, 60 patients were assigned to either TAP or WI group. The main outcome was acute postoperative pain control assessed using the mean numeric rating scale (NRS) at the 24 hours postoperatively. The secondary outcomes were opioid requirements, procedure-related complications, overall complications, and length of stay.

Results: In this study, 60 patients were randomized: 30 to TAP group and 28 to WI (two were excluded due to conversion to open surgery). We found no significant difference in the median (1Q, 3Q) NRS scores during the 24 h postoperatively neither at rest (TAP, 0 (0, 1) vs. WI, 0 (0, 1), P = 0.812), nor during movement (TAP, 1 (0, 2) vs. WI, 1 (0, 2), P = 0.708). There were no statistical differences in the postoperative intravenous morphine requirements in the TAP vs. WI groups during the same period (1.7 ± 3.1 vs. 1.8 ± 4.1 mg; P = 0.910). Only one patient in the TAP group presented with postoperative nausea and vomiting.

Conclusions: Both pre-incisional subcutaneous WI and TAP blockade were associated with very low pain scores as part of a non-opioid multimodal analgesic regimen in laparoscopic radical prostatectomy. This study did not demonstrate the benefits of WI over TAP.

Background: Difficult airway occurs due to anatomical abnormalities of the airway that can be predicted through airway assessments; however, abnormalities beyond the vocal cord can be clinically asymptomatic and undetected until intubation failure to advance the endotracheal tube.

Case: We present a case of an unanticipated difficult airway in a stuporous 80-year-old female with a recent history of intracerebral hemorrhage and prolonged intubation. She required emergency ventriculo-peritoneal shunt surgery due to the progression of her hydrocephalus. Under anesthesia, facemask ventilation was easy and video laryngoscopy provided a full view of the glottis; however, endotracheal tube (ETT) entry failed. We suspected stenosis beyond the vocal cord, and a smaller diameter ETT was inserted and maintained for airway management during emergency surgery. Postoperative neck computed tomography findings revealed laryngotracheal stenosis (LTS).

Conclusions: Anesthesiologists should be aware that LTS may be asymptomatic and consider difficult airway guidelines in patients with history of prolonged endotracheal intubation.

Background: The endothelial glycocalyx (EG) is an important structure that regulates vascular homeostasis. Deep inferior epigastric perforator (DIEP) flap is expected to cause substantial EG breakdown owing to the long procedural duration and ischemia- reperfusion injury. This prospective, randomized, controlled study aimed to compare syndecan-1 levels during sevoflurane-remifentanil and propofol-remifentanil anesthesia in patients who underwent DIEP flap breast reconstruction.

Methods: Fifty-one patients were randomized to either sevoflurane (n = 26) or propofol (n = 25) groups. Anesthesia was maintained with remifentanil in combination with either sevoflurane or propofol. The primary endpoint was the concentration of serum syndecan-1 measured at 1 h after surgery.

Results: Fifty patients (98.0%) completed the study. Patients in the propofol group had significantly lower levels of syndecan-1 than patients in the sevoflurane group at 1 h after operation (23.8 ± 1.6 vs. 30.9 ± 1.7 ng/ml, respectively; Bonferroni corrected P = 0.012). There were no significant differences between groups in postoperative complications. The postoperative hospital stay was 8.4 ± 2.5 days in the sevoflurane group and 7.4 ± 1.0 days in the propofol group (P = 0.077).

Conclusions: Propofol-remifentanil anesthesia resulted in lesser increases in syndecan-1 levels compared to increases with sevoflurane-remifentanil anesthesia in patients who underwent DIEP flap reconstruction. Our results suggest that propofol-remifentanil anesthesia shows protective effects against EG damage during DIEP flap breast reconstruction in contrast to sevoflurane-remifentanil anesthesia.

Preprints are preliminary research reports that have not yet been peer-reviewed. They have been widely adopted to promote the timely dissemination of research across many scientific fields. In August 1991, Paul Ginsparg launched an electronic bulletin board intended to serve a few hundred colleagues working in a subfield of theoretical high-energy physics, thus launching arXiv, the first and largest preprint platform. Additional preprint servers have since been implemented in different academic fields, such as BioRxiv (2013, Biology; www.biorxiv.org) and medRxiv (2019, Health Science; www.medrxiv.org). While preprint availability has made valuable research resources accessible to the general public, thus bridging the gap between academic and non-academic audiences, it has also facilitated the spread of unsupported conclusions through various media channels. Issues surrounding the preprint policies of a journal must be addressed, ultimately, by editors and include the acceptance of preprint manuscripts, allowing the citation of preprints, maintaining a double-blind peer review process, changes to the preprint's content and authors' list, scoop priorities, commenting on preprints, and preventing the influence of social media. Editors must be able to deal with these issues adequately, to maintain the scientific integrity of their journal. In this review, the history, current status, and strengths and weaknesses of preprints as well as ongoing concerns regarding journal articles with preprints are discussed. An optimal approach to preprints is suggested for editorial board members, authors, and researchers.

Since the patient's airway is shared between an anesthesiologist and a surgeon, airway management during upper airway surgery can be challenging. Beyond the conventional method of general anesthesia, high-flow nasal oxygenation (HFNO) has recently been used as a key technique for tubeless anesthesia. HFNO provides humidified, heated oxygen up to 70 L/min, which promises improved oxygenation and ventilation, allowing for prolonged apneic oxygenation. In previous physiological and clinical studies, HFNO has been demonstrated that tubeless anesthesia safely provide an uninterrupted surgical field during laryngeal surgeries. Although tubeless anesthesia remains uncommon, it can be a good alternative to conventional anesthesia if an anesthesiologist and a surgeon select appropriate patients together with sufficient experience. A safe strategy for tubeless anesthesia, along with appropriate backup plans, including endotracheal intubation and high-frequency jet ventilation, should be considered for upper airway surgery.

Background: The Gasserian ganglion is a well-known target for facial pain management, and patients with cancer present an anatomical challenge owing to tumor progression or treatment itself. Computed tomography (CT) is an alternative method for guiding these procedures.

Methods: This was an observational retrospective analysis of patients with cancer-related facial pain who underwent CT-guided Gasserian ganglion interventions using local anesthetics, local anesthetics with steroids, phenol, and radiofrequency. Demographic, clinical, and procedure-related variables were collected from January 1, 2015, to December 30, 2018, at the National Cancer Institute. Data distribution was determined using the Kolmogorov-Smirnov test. A paired sample t-test (with a cut-off of P < 0.05 for statistical significance) was used for comparing outcome.

Results: We observed a significant reduction in numerical rating scale (NRS) and douleur neuropathique 4 (DN4) scores from 7.6 ± 1.4 and 4.4 ± 1.4 to 3.2 ± 2.0 and 2.2 ± 1.4 points, respectively (P < 0.001). After the procedure, 70.8% of the patients were satisfied; 16.7% were very satisfied, and 12.5% were unsatisfied. No intra- or postoperative complications were observed. The most common neoplasms were head and neck tumors (83.3%).

Conclusions: Our data suggest that CT guidance is an effective and safe option for managing cancer-related facial pain in patients with complex anatomy, resulting in a significant reduction in pain, high satisfaction rates, and no mechanical complications. Future research should aim to refine the role of CT guidance in multimodal pain management in this population.

This article describes the anesthetic management of patients with traumatic brain injury (TBI) undergoing non-neurosurgery, primarily targeting intraoperative management for multiple-trauma surgery. The aim of this review is to promote the best clinical practice for patients with TBI in order to prevent secondary brain injury. Based on the current clinical guidelines and evidence, anesthetic selection and administration; maintenance of optimal cerebral perfusion pressure, oxygenation and ventilation; coagulation monitoring; glucose control; and temperature management are addressed. Neurological recovery, which is critical for improving the patient's quality of life, is most important; therefore, future research needs to be focused on this aspect.