Anesthesia progress最新文献

Incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), are produced in the gut and play critical roles linking the processes of eating and digestion with the release of insulin from the pancreas and glucose homeostasis. GLP-1 receptor agonist and combination GLP-1/GIP receptor agonist medications are exogenous incretins that mimic their endogenous counterparts, but their significantly longer half-lives allow them to be clinically useful for managing diabetes mellitus type 2 (DMT2) and obesity. Recently, their use for weight loss has grown exponentially, increasing the potential that a provider of sedation or general anesthesia for dentistry will encounter a patient taking a GLP-1 or GLP-1/GIP combination receptor agonist. One of the clinical effects produced by these medications is decreased gastric emptying which increases satiety and decreases oral intake. While these medications are effective in the management of DMT2 and obesity, delayed gastric emptying can cause concerns for sedation and general anesthesia providers. Retained gastric contents can increase risks for emesis and subsequent pulmonary aspiration in the perioperative period. In 2024, a multisociety guidance document was published to provide recommendations for the management of these patients in the perioperative period. Recommendations emphasized risk stratification of individual patients and weighing the risks vs the benefits of holding or continuing GLP-1 and GLP-1/GIP combination receptor agonist medications. The recommendations also suggested shared decision making between the sedation or general anesthesia provider, the prescribing physician, and the patient should be used when developing a plan regarding the preoperative use of these medications.

Objective: This study aimed to compare the efficacy of dexamethasone alone and dexamethasone-ondansetron combined for preventing postoperative nausea and vomiting (PONV) in patients undergoing orthognathic surgery.

Methods: Patients scheduled to undergo mandibular orthognathic surgery who were 18 to 50 years of age and American Society of Anesthesiologists physical status I or II were enrolled. Dexamethasone 6.6 mg was administered after intubation, followed by either ondansetron 4 mg (group DO) or saline placebo (group D) 15 minutes before the end of surgery. Nausea severity was assessed at 3 times postoperatively (immediately after the end of anesthesia, 2 hours later, and 24 hours later) using a 11-point numeric rating scale (NRS). If a patient complained of postoperative nausea or vomited, the NRS score was reevaluated. If the NRS score was 3 or higher, intravenous metoclopramide 10 mg was administered for PONV rescue. Assessed data included nausea NRS scores, vomiting, metoclopramide use, and other patient demographics.

Results: Mean nausea NRS scores at 2 hours were significantly lower in group DO vs group D (0.3 vs 2.1; P = .003), but differences in vomiting rates were not significant (P > .05). PONV rescue rates with metoclopramide were lower overall and at 2 hours later in group DO (P < .001).

Conclusion: Dexamethasone combined with ondansetron was more effective in preventing early postoperative nausea and reducing need for PONV rescue than dexamethasone alone for patients undergoing orthognathic surgery.

Objective: Tracheal intubation (TI) consistently induces tachycardia and elevated blood pressure which may be deleterious to patients, particularly those with existing cardiac conditions. Use of dexmedetomidine or esmolol has been described to attenuate this sympathetic response. This study aimed to determine the effectiveness of dexmedetomidine vs esmolol in attenuating the hemodynamic response during TI.

Methods: A systematic review and meta-analysis were performed using PRISMA guidelines. A systematic literature search in electronic databases and grey literature was completed. Researchers assessed article eligibility, performed data extraction, and completed risk of bias assessment. Results were expressed as pooled differences for cardiovascular parameters between the drugs as the weighted mean difference with 95% CI. A P < .05 was considered statistically significant. Heterogeneity was quantified using the I2 statistic. Subgroup analyses exploring different drug regimens were performed.

Results: Of 112 publications, 19 randomized controlled trials were included for descriptive analysis and 15 were selected for the meta-analysis with 948 patients. The use of dexmedetomidine vs esmolol provided lower heart rates and mean arterial pressures at 1, 3, 5, and 10 minutes and lower systolic and diastolic pressures at 1, 3, and 5 minutes after TI.

Conclusion: Dexmedetomidine blunts the hemodynamic response to TI more effectively vs esmolol.

General anesthesia in patients with undiagnosed hypothyroidism can lead to neurological, pulmonary, and cardiovascular complications. We report a case of hypothyroidism in a patient with treatment-resistant depression detected intraoperatively based on multiple clinical findings. A 49-year-old woman was scheduled for orthognathic surgery for mandibular prognathism. She had depression since the age of 36 and was taking multiple psychotropic medications. After induction, she had persistent hypotension, bradycardia, low bispectral index, and hypothermia that were resistant to treatment. After ruling out common causes and reducing the anesthetic agents, blood tests were performed intraoperatively to examine thyroid function which revealed hypothyroidism. No delayed recovery or postoperative abnormalities were observed. Lithium carbonate was identified as the most likely cause of hypothyroidism by an endocrinologist. Given the overlap in signs and symptoms, hypothyroidism may be overlooked in a patient with depression. The possibility of hypothyroidism should be considered especially noted in patients taking lithium carbonate. Furthermore, suspicion of hypothyroidism based on clinical findings during anesthesia may prompt the need for further evaluation.

We successfully anesthetized a 15-year-old male dental patient with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome using remimazolam and remifentanil. During the rapid sequence induction, we administered intravenous continuous infusions of remimazolam and remfentanil along with boluses of fentanyl and rocuronium to quickly induce general anesthesia without complications. General anesthesia was maintained during the operation with continuous infusions of remimazolam (0.8-1.0 mg/kg/h) and remifentanil (0.15-0.2 μg/kg/min) while using a SedLine monitor to help assess anesthetic depth. Except for immediately after extubation, the patient was stable postoperatively. He progressed satisfactorily and was discharged safely the following day. This experience suggests that the combination of remimazolam and remifentanil is an effective anesthetic for adolescent patients with MELAS syndrome undergoing dental procedures requiring general anesthesia.

Objective: This study aimed to determine whether PONV rates differed over time and to identify potential differences in PONV risk factors for oral surgery patients undergoing general inhalational anesthesia (IA) or propofol-based total intravenous anesthesia (TIVA).

Methods: This retrospective cohort study included patients between 16 and 85 years of age and who received intubated general anesthesia with either IA or TIVA for minor oral surgery between January 2021 and July 2022. Primary outcomes were PONV overall (onset at 0-24 hours), early (onset at 0-2 hours), and late (onset at 2-24 hours). Known PONV risk factors as identified from existing literature were included for analysis.

Results: Data were obtained from 188 patients. A total of 41 (21.8%) patients developed overall PONV, 35 patients (18.6%) had early PONV, and 14 patients (7.4%) had late PONV. Any PONV that occurred across 2 periods was categorized in each period. IA compared with TIVA had higher overall PONV (29.6% vs 13.3%; P = .008) and early PONV (25.5% vs 11.1%; P = .034). Female sex and increased Apfel scores were associated with increased overall, early, and late PONV. Per multivariate analysis, females were 2.5 to 6 times higher than males to have overall, early, and late PONV (P < .05), and IA was 3 times higher than TIVA to have overall and early, but not late, PONV (P < .05).

Conclusion: Our results suggested that the method of anesthesia may impact the incidence of overall and early PONV and that female sex and increase Apfel scores correlated with increased PONV through all times.

The analgesic efficacy and safety of liposomal bupivacaine (LB) in third molar extraction was evaluated in this phase 3, double-blind, placebo-controlled study of subjects undergoing bilateral third molar extraction. Subjects were randomized 2: 1 to infiltration with LB (133 mg/10 mL) or placebo, and received opioid rescue medication as needed. Primary efficacy measure was cumulative area under the curve (AUC) of numeric rating scale (NRS) pain severity scores through 48 hours (AUC of NRS0-48) postsurgery. Other measures included AUC of NRS0-24, AUC of NRS0-72, and AUC of NRS0-96, and incidence of adverse events. There were 150 subjects in the primary efficacy population (n = 99 LB, n = 51 placebo) and 89 in the per-protocol population (n = 59 LB, n = 30 placebo). Least-squares mean for AUC of NRS0-48 was 172.3 LB versus 194.7 placebo (P = .227) in the primary efficacy population and 120.8 LB versus 183.3 placebo (P = .023) in the per-protocol population. At all time points, between-group differences in AUC of NRS scores were significant in the per-protocol population (LB lower than placebo, P < .05) but not in the primary efficacy population. The adverse event profile was similar between groups. LB produced significantly lower cumulative pain scores versus placebo at all time points in the per-protocol analysis but not in the primary efficacy analysis because of protocol violations. This study indicates significant improvement in pain scores in the third molar model, but because of extensive protocol violations additional studies are warranted to demonstrate effectiveness.