Asian journal of anesthesiology最新文献

Background: Successful placement of an endotracheal tube (ETT) and its timely confirmation in obese patients is of utmost importance. Chest auscultation might be misleading in the obese. Considering the need for an additional efficient method, the present study compared tracheal and pleural ultrasonography (USG) for confirming ETT placement in overweight and obese patients.

Methods: A prospective, comparative, randomized, single-blinded study enrolled a total of 64 overweight, obese class I and class II patients aged between 18 and 60 years, American Society of Anesthesiologists grades I or II, scheduled for elective surgeries under general anesthesia with endotracheal intubation. Patients were randomized into two groups of 32 each based on the USG technique used for confirmation of ETT placement. Group T is Tracheal USG, and Group P is Pleural USG. The primary outcome was a comparison of the time required by tracheal and pleural ultrasonography techniques for confirmation of ETT placement, while the secondary outcome was a comparison of the time required by both USG techniques with the time for auscultation and capnographic confirmation of ETT placement.

Results: Tracheal USG took the least time (4.19 ± 0.89 seconds) compared to pleural USG (10.88 ± 1.16 seconds) and proved to be faster. Time taken for auscultation (P < 0.001) was longer than both USG methods, but less than capnography time. Capnographic confirmation took the maximum time when compared to USG and auscultation (P < 0.001).

Conclusion: Tracheal USG provides a faster confirmation of endotracheal intubation than pleural USG in overweight and obese patients. Pleural USG has the added advantage of diagnosing endobronchial intubation.

Regional anesthesia offers benefits such as improved pain control and reduced opioid use, but controversies remain regarding techniques and outcomes. This review examines key debates in the field, including the necessity of circumferential spread of local anesthetics, the impact of regional anesthesia on diagnosing compartment syndrome, the choice of diluent, and the safety of performing peripheral nerve blocks (PNBs) in awake versus anesthetized patients. To explore these topics, we conducted a literature search to synthesize relevant studies and expert perspectives, offering a comprehensive analysis of current evidence. While circumferential spread may enhance block onset, studies show that it does not consistently improve success. The potential for regional anesthesia to mask compartment syndrome is not definitively supported, as ischemic pain often breaks through analgesia. Dextrose diluents accelerate sensory block onset compared to saline, though effects vary with different anesthetics. In awake versus anesthetized PNBs, sedation and general anesthesia provide safety and comfort, especially for non-cooperative patients, with no clear superiority. Overall, regional anesthesia techniques should be tailored to individual patient needs, and further research is necessary to refine best practices.

Background: Postoperative pain after cesarean section (CS) can significantly impact patient recovery and morbidity if not managed effectively. This study compares the efficacy of two multimodal analgesic combinations-paracetamol with ibuprofen (PI) and paracetamol with ketorolac (PK)-in managing postoperative pain after CS, and assesses the incidence of side effects.

Methods: This single-blind clinical trial was conducted from June to July 2024 at Prof. Dr. W. Z. Johannes Hospital, Kupang, Indonesia, involving 60 patients undergoing elective CS under spinal anesthesia, randomly assigned into two groups. The PI group received 400 mg of intravenous ibuprofen post-delivery, followed by 1,000 mg of oral paracetamol and 400 mg of ibuprofen every 8 hours. The PK group was given 30 mg of intravenous ketorolac, followed by 1,000 mg of oral paracetamol and 30 mg of intravenous ketorolac every 8 hours. Pain was assessed using the numeric rating scale (NRS) at 8, 24, and 48 hours postoperatively, while opioid rescue use (NRS > 4) and side effects such as nausea, vomiting, and epigastric pain were also recorded.

Results: Pain scores were significantly lower in the PI group at 8 and 24 hours postoperatively (P < 0.05). No significant difference was found between the groups at 48 hours (P = 0.094). There was no significant difference between the groups (P = 0.656 and P = 0.095) in terms of total morphine rescue dose or the incidence of postoperative nausea and vomiting (PONV). The incidence of epigastric pain was significantly lower in the PI group (P = 0.038).

Conclusion: PI may represent a more favorable option for early postoperative pain control and lower epigastric pain effect, pending further validation in larger, multicenter trials. Both combinations had similar outcomes in terms of opioid use and PONV.

Background: Neuropathic pain is caused by lesions in the somatosensory nervous system. Pain occurs spontaneously, and responses to noxious and innocuous stimuli are pathologically amplified. Despite the abundant functional magnetic resonance imaging studies in awake human subjects, there is no available report on the behavioral correlate of differential brain areas involved in spontaneous and evoked pain symptoms in a conscious animal model. We investigated whether positron emission tomography (PET) imaging could depict the spatial changes in glucose metabolic activity in the awake male rat brain during spontaneous- and evoked-pain conditions on a spared nerve injury (SNI) model of neuropathic pain.

Methods: Two major branches of the sciatic nerve, the tibial and common peroneal nerves, were transected under anesthesia. Two PET experiments were performed. In the spontaneous pain behavior group, abnormal paw-lifting behaviors were recorded during fluorodeoxyglucose (FDG) uptake. In the allodynia group, the ipsilateral side of the lesion hindpaw was stimulated with a 6-g von Frey fi lament once every 5 seconds for 20 minutes during FDG uptake. Each rat was scanned twice in both experiments: once before and once from 3 to 7 days after SNI surgery. Nerves were isolated but not transected in the sham-operated control group.

Results: After SNI surgery, rats displayed spontaneous jerky paw lifting and mechanical sensitization lasting at least 4 weeks. In the spontaneous pain behavior group, glucose metabolic activity in the SNI condition significantly increased in the ipsilateral posterior insular cortex (PIC) compared to pre-surgery and the sham-operated controls. The glucose metabolic activity of the PIC was linearly correlated with the frequency of spontaneous paw lifting. In the allodynia group, changes in glucose metabolic activities in the SNI condition significantly increased in the bilateral primary somatosensory cortex, contralateral secondary somatosensory cortex, contralateral primary motor cortex, ipsilateral secondary motor cortex, ipsilateral rostral insular cortex, PIC, hypothalamus, medial thalamus (including the medial dorsal nucleus and anterior periventricular thalamic nucleus), and medial cerebellum.

Conclusions: Differential brain areas in rats with peripheral neuropathic pain were activated between mechanical hypersensitivity and spontaneous pain-related behaviors. The data suggest that PET is a useful imaging technique to establish the link between behavioral correlates and topographical representation in awake rats suffering from spontaneous pain and allodynia of neuropathic pain.

Background: Sedation/analgesia (S/A) is widely used to relieve patients' anxiety and discomfort during colonoscopy. Their effects on abdominal pain after colonoscopy have never been fully investigated.

Methods: The prospective study consecutively recruited 494 healthy patients having a screen colonoscopy examination as part of their health checkup. They were divided into two groups based on individuals' decision to receive sedation and analgesia or not. In the S/A group, 374 patients received midazolam and alfentanil during colonoscopy with standard monitoring, while in the non-sedation/analgesia (NSA) group, 120 patients received no analgesics. Severity and duration of abdominal pain (ordinal scale: 1 = none, 4 = severe) were assessed at the end of stay in the postanesthetic care unit (the S/A group) or examination room (the NSA group) and before discharge. Side effects S/A during (hypotension, hypoxemia) and after (nausea, vomiting, dizziness) colonoscopy were also recorded. All patients were closely monitored during the whole course of the health check-up package.

Results: The mean doses of midazolam and alfentanil were 4.06 mg and 813.12 μg, respectively. Patients in the NSA group had two-fold risks of moderate to severe abdominal pain compared to those in the S/ A group (16.67% vs. 9.36%, odds ratio = 1.937, 95% confidence interval: 1.010-3.625). The NSA group also had a higher incidence of abdominal pain 120 minutes after examination (33.33% vs. 16.04%, P < 0.001). Duration of abdominal pain in those patients who did have abdominal pain was longer in the S/ A group than in the NSA group (153.3 ± 49.9 vs. 118.7 ± 47.5 minutes, P < 0.001). The incidence of hypotension and hypoxemia in the group S/A was 5.6% and 2.9%, respectively. More patients in the S/ A group felt dizzy or sleepy than those in the NSA group (14.7% vs. 3.3%, P < 0.001). The incidence of nausea and vomiting was similar between the two groups.

Conclusion: Optimal S/A with midazolam and alfentanil decreases the severity and duration of postcolonoscopic abdominal pain.

Background: This study used the National Taiwan Health Insurance database, including prescribed medications, underlying systemic diseases, and surgical types, to evaluate the relationship between those factors and mortality after general anesthesia.

Method: This retrospective, population-based study was retrieved from the National Health Insurance Research Database in Taiwan between January 1, 2005, and December 31, 2013. We proposed a logistic regression model that can significantly predict postanesthesia mortality, which was validated in another set of databases. Moreover, we subgroup the study population into four major comparison groups, which include major organ transplantation, cardiovascular (CV) surgery, major neurosurgery, and others according to the diagnostic codes of the International Classification of Diseases, ninth revision, clinical modification codes.

Results: A total of 681,779 subjects were analyzed in this study, and the most common comorbidity was hypertension. Age was an important determinant associated with postoperative mortality among different surgical types. Perioperative prescription could reduce the risks of the operation. The major surgeries (major organ transplantation, CV surgery, and neurosurgery) were associated with increasing postoperative mortality. The prediction model performed well in the validation group (area under receiver operating characteristic curve [AUROC] = 0.8753 for in-hospital mortality; AUROC = 0.8767 for 30-day mortality).

Conclusions: The prediction model that we proposed from this nationwide study could identify the predictors for postoperative mortality. The potentially protective effects of anti-lipid, hypoglycemic, and anti-hypertensive agents were encouraging in the geriatric preoperative group. It is expected that applying this prediction model and prescription into clinical practice could improve surgical risk stratification and further improve patient outcomes.

Goal-directed fluid therapy (GDFT) has been proposed to optimize fluid management and reduce perioperative complications in the elderly. This meta-analysis evaluates the effects of intraoperative GDFT compared to conventional fluid therapy (CFT) on postoperative outcomes in elderly surgical patients. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, randomized controlled trials (RCTs) were identified from six databases. Outcomes assessed included overall postoperative complications, 30-day mortality, hospital length of stay (LOS), and total fluid administered. Ten RCTs met the inclusion criteria, of which nine (n = 1,001) were included in the quantitative synthesis after excluding studies employing outdated protocols. GDFT significantly reduced overall complication rates (risk ratios [RR] = 0.80 [95% confidence interval (CI): 0.69-0.92]; P = 0.002), LOS (mean difference [MD] = -1.31 days [95% CI: -2.55 to -0.07]; P = 0.04), and intraoperative fluid volume (MD = -258.74 mL [95% CI: -450.86 to -66.68]; P = 0.008) compared to CFT. GDFT was also associated with lower 30-day mortality (RR = 0.42 [95% CI: 0.17-1.04]), though not statistically significant (P = 0.06). Substantial heterogeneity was noted for LOS and fluid volume. Subgroup analysis had no impact on LOS but decreased heterogeneity in intraoperative volume, with significant fluid-sparing effects only in the gastrointestinal surgery subgroup. Sensitivity analyses further revealed that the exclusion of specific studies influenced the results for mortality and LOS. In conclusion, when compared with CFT, intraoperative GDFT offers benefits in reducing postoperative complications, hospital stay, and fluid use in elderly patients. Further research is necessary to optimize protocols and address the observed heterogeneity.

Background: Dexamethasone is widely used in anesthesia practise as prophylaxis for postoperative nausea and vomiting (PONV). Our aims were to evaluate the postoperative glycemic profile after a single dose of intraoperative dexamethasone in non-diabetic and diabetic patients and to evaluate the PONV.

Methods: This double-blinded, randomized, controlled study was done for 6 months from June to December 2024 in a tertiary care hospital after obtaining ethical committee clearance and CTRI registration. Patients were allocated to one of four groups: nondiabetics receiving saline, nondiabetics receiving dexamethasone, diabetics receiving saline, and diabetics receiving dexamethasone. The study drug or saline control was administered at the induction of anesthesia. Blood sugar values, two hours after dexamethasone/placebo administration as well as fasting blood sugar and postprandial blood sugar on postoperative day 1, 2 were taken as primary endpoints. PONV was assessed in the first 24 hours after surgery.

Results: The rise in blood glucose levels was higher in the group receiving dexamethasone compared to saline in both diabetics and nondiabetics (P < 0.05). None of the patients had blood glucose values more than 180 mg/dL after 2 hours and 8 hours of dexamethasone administration.

Conclusions: Dexamethasone can be considered as prophylaxis for PONV in well controlled diabetics and nondiabetics despite the increase in blood glucose levels as a hyperglycemic response (blood glucose value 180 mg/dL) to a single dose was not observed in our study.

Background: Anesthesia for interventional bronchoscopy (IB) presents significant challenges, primarily due to unpredictable responses such as coughing, airway spasms, and desaturation, even with monitored anesthetic care. However, the nociception inducing such responses and the impact of adding topical anesthesia (TA) have rarely been investigated. This study aims to map the timing and intensity of nociception, determine TA onset, and clarify TA's role in blocking nociception with subsequent IB procedures.

Methods: Analgesia nociception index (ANI) and mean arterial blood pressure (MBP) were collected in patients undergoing IB procedures with bispectral index (BIS)-controlled intravenous anesthesia. Data were compared and analyzed along with various stages: anesthetic induction with iGel insertion, fibro-optic bronchoscopy (FOB) insertion, and applying TA with the spray-as-you-go (SAYGO) method using xylocaine, up to 30 minutes with subsequent IB procedures.

Results: Data from 82 patients were analyzed. Under BIS-controlled anesthesia, iGel insertion decreased ANI significantly (P < 0.001). Following stabilization, ANI decreased significantly with SAYGO (P < 0.001), returned toward baseline within 5 minutes, and remained stably higher than baseline for up to 30 minutes. The changes on MBP were similar to those of ANI. No significant correlations were observed between BIS levels and ANI.

Conclusions: ANI offers a valuable perspective on nociception, serves as a helpful reference for precise anesthetic management for IB. The key action, such as an ultrashort-acting anesthetic just before FOB insertion to block nociception from the establishment of TA without prolonged effect, is suggested for smooth, subsequent IB procedures.