Asian journal of anesthesiology最新文献

Background: The withdrawal or continuation of angiotensin II receptor blockers (ARBs) before surgery continues to be debated. We hypothesized that this is because ARBs with different half-lives have not been studied individually. This retrospective study aimed to clarify whether the degree of hypotension during anesthesia induction differs among ARBs with different half-lives.

Methods: We included patients who received general anesthesia with regular oral administration of telmisartan (group T) or valsartan (group V), which have half-lives of approximately 24 and 6 hours, respectively. The frequency of hypotension and vasopressor frequency and dose during anesthesia induction were compared between the two groups. At our hospital, ARBs were withdrawn on the day of surgery in all patients.

Results: Groups T and V included 190 and 132 patients, respectively. Patient backgrounds in group V were significantly more strongly associated with the use of calcium channel blockers. No significant differences were observed in the use of other concomitant antihypertensive medications, cardiovascular complications, or renal function. The time during which the mean arterial blood pressure was < 60 mmHg during anesthesia induction was significantly greater in group T than in group V (11 min vs. 7 min, P=0.030). The proportion of patients who used vasopressors was significantly higher in group T than that in group V (74.2% vs. 56.0%, P < 0.001).

Conclusion: Patients taking telmisartan showed more hypotensive during the induction of general anesthesia than those taking valsartan, even after withdrawal on the day of surgery.

Elderly patients are more vulnerable to cognitive dysfunction in the postoperative period. Patients who are apparently well in cognitive functions in the preoperative period after undergoing anesthesia in noncardiac surgery will develop symptoms of cognitive dysfunction. Postoperative cognitive dysfunction (POCD) doesn't continue for a long duration and usually undergoes self-resolution. Proper definitions and congruous tests for diagnosis are absent. Rigorous preoperative assessment of cognitive function and distinguishing risk factors are indispensable for recognizing the range of POCD and its association with surgery and anesthesia. Recent studies haven't revealed any anesthesia technique or drug which can significantly reduce the incidence of POCD. Therefore, giving accurate information to patients can be challenging.

Liver transplantation (LT) is frequently complicated by coagulopathy associated with end-stage liver disease, which is often multifactorial and associated with hemostatic disturbances affecting both the procoagulant and anticoagulant systems. This rebalanced coagulation system may lead to bleeding diathesis or increased clot formation. Conventional coagulation tests cannot reflect these complex changes because they can only illustrate deficiencies in the procoagulant system. Viscoelastic tests such as rotational thromboelastometry (ROTEM) have been used in LT and have shown useful for detecting coagulopathy and guiding transfusions. Implementation of ROTEM-guided bleeding management algorithms has proven effectiveness in reducing bleeding, transfusion needs, complication rates, and healthcare costs in LT. This document is intended to provide a practice algorithm for the management of major bleeding and coagulopathy during LT and to encourage adaptation of the guidelines to individual institutional circumstances and resources.

Infective endocarditis (IE) remains a rare yet critically severe condition, representing a considerable diagnostic challenge, especially among patients with pre-existing structural heart anomalies. This report details the clinical journal of a 49-year-old male with a known bicuspid aortic valve who initially exhibited nonspecific symptoms, leading to rapid clinical deterioration and the emergence of uncommon complications. The patient experienced an aortic root rupture and pericardial tamponade, necessitating urgent surgical intervention. Transesophageal echocardiography (TEE) was instrumental in confirming the diagnosis and facilitating the decision to perform a Bentall's procedure. This care highlights the critical role of TEE in diagnosing complex cases of IE and the imperative for swift intervention.

Background: Postoperative pain and postanesthesia shivering are the two common problems in patients undergoing surgery under spinal anesthesia (SA). The present study aimed to compare the preemptive prescription of the single dose of intravenous (IV) ketorolac versus nalbuphine on postoperative shivering and pain in patients undergoing surgery under SA.

Methods: Present study was a prospective, randomized double-blind study, conducted on patients of either gender, with American Society of Anesthesiologists physical status class I or II, aged 21-60 years, posted for elective lower abdominal surgeries under SA. Patients were randomized by computer-generated random numbers into two groups of 50 patients each: group N (received 0.2 mg/kg nalbuphine IV) and group K (received 0.5 mg/kg ketorolac IV).

Results: The incidence of postoperative shivering was 22 % and 36 % in groups N and K respectively and the difference was statistically significant. The first request for analgesia (minutes) was later in group N (295.17 ± 54.62) than in group K (223.80 ± 15.34) and the difference was statistically significant. Increased total analgesic consumption was noted more in group K (131.34 ± 43.27) than in group N (79.23 ± 21.34), and the difference was statistically significant (P < 0.0001). The incidence of side effects was comparable among both groups.

Conclusion: Preemptive nalbuphine had less incidence of postoperative shivering, delayed first request for analgesia, and less total analgesic consumption than ketorolac in patients undergoing surgery under SA.

Background: The quadratus lumborum block (QLB) is an effective technique to provide analgesia for upper and lower abdominal surgeries. There are various approaches described in the literature, but the best approach is still to be explored. This study aims to compare the analgesic efficacy of three different approaches of QLBs.

Methods: Sixty-five patients, aged 18-70 years posted for elective laparoscopic abdominal surgery under general anesthesia were enrolled after taking written informed consent. QLB was given using bupivacaine 0.25% 40 mL with injection dexmedetomidine 1 mcg/kg in all the groups. In Group 1 and Group 2, the drug was injected into the anterior and posterior aspects of the muscle respectively. In Group 3, a combination of the anterior-posterior approach was used. Pain scores at various intervals along with analgesic consumption and complications were observed.

Results: The demographic variables, hemodynamic parameters, and complications were comparable among the three groups. There were statistically significant differences between treatment groups in fentanyl requirement as assessed using the Kruskal-Wallis test (P = 0.012). Pairwise post-hoc analysis between block groups showed that the differences between Group 1 & Group 2 and Group 2 & Group 3 were significant (P = 0.0098 and P = 0.013). The tramadol requirement was comparable in all the groups (P = 0.75). Patient satisfaction was significantly higher in Group 3 compared to other groups (P = 0.024).

Conclusion: Further studies can be planned to evaluate the best approach for QLB in terms of perioperative analgesia, which remains a dilemma in this pilot study. The anterior, posterior, and combined anterior-posterior QLB approaches appear equally efficacious as a component of multimodal analgesia in laparoscopic abdominal surgeries.

Background: Inadequate postoperative analgesia may cause postoperative complications, such as pulmonary complications. This study evaluated the analgesic effectiveness of a single preoperative injection of dinalbuphine sebacate (DS) in patients undergoing video-assisted thoracoscopic wedge resection and assessed whether it can reduce the incidence of postoperative pulmonary complications (PPCs).

Methods: In this study, the data of 757 patients who underwent VATS wedge resection at a medical center were retrospectively reviewed. The patients were divided into the DS group and the conventional analgesia (CA) group. The following parameters were analyzed: analgesic consumption during hospitalization, the incidence of PPCs, and the postoperative use of oxygen therapy.

Results: Compared with the CA group, the DS group had lower nalbuphine, tramadol, parecoxib, acetaminophen, diclofenac, and utraphen consumption during the postoperative period; higher morphine and ketorolac consumption; and comparable fentanyl consumption. Nonetheless, the frequency of requesting pain relief was significantly lower in the DS group. No significant between-group differences were noted in the incidence of PPCs. However, the DS group had fewer requirements for oxygen therapy in the ward, early removal of chest tubes, and shorter length of hospital stay.

Conclusion: A single preoperative injection of DS reduced the frequency of salvage analgesic administration and total consumption of certain postoperative analgesics, suggesting the effective pain relief of DS, and it did not increase the incidence of PPCs. Additionally, it reduced the need for postoperative oxygen therapy, which may suggest a better prognosis and smoother postoperative pulmonary recovery for patients.

Introduction: Deep neuromuscular blockade (d-NMB) is an essential requirement for carboperitoneum during laparoscopy surgery. However, sustaining d-NMB till the completion of surgery delays the reversal of the residual block. Therefore, there is a merit in exploring the effect of synergistic vecuronium-atracurium combination on the duration-of-action of d-NMB during "laparoscopic" surgery when we compare intubating bolus non-depolarizers (atracurium, vecuronium) administered alone. This study aims to evaluate whether the synergistic effect atracurium-vecuronium combination increases duration-of-action of d-NMB "laparoscopic" surgery settings.

Methods: Forty-eight patients (18-60 years, American Society of Anesthesiologists physical status- II/III, either sex) undergoing laparoscopic cholecystectomy were randomly allocated to receive vecuronium (vecuronium group, n = 16) or atracurium (atracurium group, n = 16) or vecuroniumatr-acurium combination (vecuronium-atracurium combination group, n = 16) and analyzed for the effects on the duration-of-action (primary objective); onset-of-action, reversibility, and quality of intubating conditions (secondary objectives) profile of neuromuscular blockade in patients undergoing laparoscopic cholecystectomy.

Results: Duration-of-action of neuromuscular blockade was significantly longer in patients who received atracurium-vecuronium combination (53.9 ± 9.7 minutes) versus atracurium-alone (41.1 ± 3.8 minutes) or vecuronium-alone (43.5 ± 9.2 minutes) (P = 0.000). No difference was found for the time to onset-of-action (vecuronium [198.1 ± 34.9 seconds], atracurium [188.5 ± 50.6 seconds], or atracurium-vecuronium combination [196.3 ± 46.3 seconds] [P = 0.829]); time for the reversal of muscle relaxation effect (vecuronium [559.9 ± 216.2 seconds], atracurium [584.7 ± 258.3 seconds], and atracurium-vecuronium combination [555.0 ± 205.4 seconds] [P = 0.925]); and quality-of-intubating conditions (vecuronium group [9.6 ± 1.3]; atracurium group [10.0 ± 0.0]; atracurium-vecuronium group [10.0 ± 0.0] [P = 0.182]).

Conclusion: The synergistic effect of the atracurium-vecuronium combination leads to an increased duration-of-action of d-NMB during laparoscopic cholecystectomy without impacting onset-of-action, quality of intubating conditions, and reversal of muscle relaxant effect.

Background: Advancing a tracheal tube over a tracheal tube exchanger into the trachea frequently causes difficulties because of the tube impingement on laryngeal structures. In the present study, we measured the resistance of tube advancement both objectively and subjectively with a variety of combinations of tube exchanger sizes and tracheal tubes using a manikin simulator.

Methods: Lubricated 7.5 mm ID standard and Parker Flex-Tip (PFT) tracheal tubes were railroaded over the tube exchangers (OD 1-6 mm) into the trachea through the oral route in a manikin. Consequently, 12 combinations of tracheal tube-exchanger tube assemblies were evaluated. Tube advancing resistance at the laryngeal inlet was subjectively evaluated. The objective tube advancing resistance (force) at the laryngeal inlet was evaluated using a digital force gauge. The execution of each tracheal tube-exchanger trial was conducted 10 times.

Results: With a 1-mm tube exchanger, all intubation attempts with both standard and PFT tubes failed. Esophageal intubation or severe impingement at the right arytenoid accompanied with a bent tracheal tube was observed. With a 2-mm tube exchanger, during intubation with a standard tracheal tube, rotation of the tube was sometimes required; however, all other intubations were done without problems. When PFT tubes were used, all intubation attempts were performed without problems. The rest of the trials were successfully performed regardless of the combinations of tube exchangers and tracheal tubes; however, one attempt of intubation with a combination of a 5 mm tube exchanger and a standard tracheal tube required withdrawal and rotation of the tube because of impingement at the epiglottis. In cases where there was no gap resistance, which means tube advancing resistance generated by a gap between an introducer and a tracheal tube, the pressing force was approximately less than 10 N. However, in the cases requiring some interventions to overcome the gap, the pressing force reached around 15 N. When intubation failed, for example when the tube bent, or esophageal intubation, the pressing force reached around 30 N.

Conclusions: Impingement due to the gap between the tube exchanger and the tracheal tube is thought to occur in the PFT tube less frequently. Once an impingement occurs, we can feel approximately twice the amount of resistance as usual, which may be a chance to consider taking some interventions. When the impingement is not released, regardless of interventions, excessive force may result in esophageal intubation or tracheal injury.