Exploring Artificial Intelligence in Anesthesia: A Primer on Ethics, and Clinical Applications

The field of anesthesia has always been at the forefront of innovation and technology, and the integration of Artificial Intelligence (AI) represents the next frontier in anesthesia care. The use of AI and its subtypes, such as machine learning, has the potential to improve efficiency, reduce costs, and ameliorate patient outcomes. AI can assist with decision making, but its primary advantage lies in empowering anesthesiologists to adopt a proactive approach to address clinical issues. The potential uses of AI in anesthesia can be schematically grouped into clinical decision support and pharmacologic and mechanical robotic applications. Tele-anesthesia includes strategies of telemedicine, as well as device networking, for improving logistics in the operating room, and augmented reality approaches for training and assistance. Despite the growing scientific interest, further research and validation are needed to fully understand the benefits and limitations of these applications in clinical practice. Moreover, the ethical implications of AI in anesthesia must also be considered to ensure that patient safety and privacy are not compromised. This paper aims to provide a comprehensive overview of AI in anesthesia, including its current and potential applications, and the ethical considerations that must be considered to ensure the safe and effective use of the technology.

A multicenter randomized phase 4 trial comparing sodium picosulphate plus magnesium citrate vs. polyethylene glycol plus ascorbic acid for bowel preparation before colonoscopy. The PRECOL trial

Background

Adequate bowel preparation before colonoscopy is crucial. Unfortunately, 25% of colonoscopies have inadequate bowel cleansing. From a patient perspective, bowel preparation is the main obstacle to colonoscopy. Several low-volume bowel preparations have been formulated to provide more tolerable purgative solutions without loss of efficacy.

Objectives

Investigate efficacy, safety, and tolerability of Sodium Picosulphate plus Magnesium Citrate (SPMC) vs. Polyethylene Glycol plus Ascorbic Acid (PEG-ASC) solutions in patients undergoing diagnostic colonoscopy.

Materials and methods

In this phase 4, randomized, multicenter, two-arm trial, adult outpatients received either SPMC or PEG-ASC for bowel preparation before colonoscopy. The primary aims were quality of bowel cleansing (primary endpoint scored according to Boston Bowel Preparation Scale) and patient acceptance (measured with six visual analogue scales). The study was open for treatment assignment and blinded for primary endpoint assessment. This was done independently with videotaped colonoscopies reviewed by two endoscopists unaware of study arms. A sample size of 525 patients was calculated to recognize a difference of 10% in the proportion of successes between the arms with a two-sided alpha error of 0.05 and 90% statistical power.

Results

Overall 550 subjects (279 assigned to PEG-ASC and 271 assigned to SPMC) represented the analysis population. There was no statistically significant difference in success rate according to BBPS: 94.4% with PEG-ASC and 95.7% with SPMC (P = 0.49). Acceptance and willing to repeat colonoscopy were significantly better for SPMC with all the scales. Compliance was less than full in 6.6 and 9.9% of cases with PEG-ASC and SPMC, respectively (P = 0.17). Nausea and meteorism were significantly more bothersome with PEG-ASC than SPMC. There were no serious adverse events in either group.

Conclusion

SPMC and PEG-ASC are not different in terms of efficacy, but SPMC is better tolerated than PEG-ASC. SPMC could be an alternative to low-volume PEG based purgative solutions for bowel preparation.

Clinical trial registration

[ClinicalTrials.gov], Identifier [NCT01649674 and EudraCT 2011-000587-10].

Bibliometric Network Analysis on Rapid-Onset Opioids for Breakthrough Cancer Pain Treatment

BACKGROUND AND OBJECTIVES

Proper breakthrough cancer pain (BTcP) management is of pivotal importance. Although rapid-acting, oral and nasal transmucosal, fentanyl formulations (rapid-onset opioids, ROOs) are licensed for BTcP treatment, not all guidelines recommend their use. Presumably, some research gaps need to be bridged to produce solid evidence. We present a bibliometric network analysis on ROOs for BTcP treatment.

METHODS

Documents were retrieved from the Web of Science (WOS) online database. The string was "rapid onset opioids" or "transmucosal fentanyl" and "breakthrough cancer pain". Year of publication, journal metrics (impact factor and quartile), title, document type, topic, and clinical setting (in-patients, outpatients, and palliative care) were extracted. The software tool VOSviewer (version 1.6.17) was used to analyze the semantic network analyzes, bibliographic coupling, journals analysis, and research networks.

RESULTS

502 articles were found in WOS. A declining trend in published articles from 2014 to 2021 was observed. Approximately 50% of documents regard top quartile (Q1) journals. Most articles focused on ROOs efficacy, but abuse and misuse issues are poorly addressed. With respect to article type, we calculated 132 clinical investigations. The semantic network analysis found interconnections between the terms "breakthrough cancer pain," "opioids," and "cancers." The top co-cited article was published in 2000 and addressed pain assessment. The largest number of partnerships regarded the United States, Italy, and England.

CONCLUSION

In this research area, most articles are published in top-ranked journals. Nevertheless, paramount topics should be better addressed, and the implementation of research networks is needed.

Advantages and issues of concern regarding approaches to peripheral nerve block for total hip arthroplasty

In older patients with comorbidities, hip fractures are both an important and debilitating condition. Since multimodal and multidisciplinary perioperative strategies can hasten functional recovery after surgery improving clinical outcomes, the choice of the most effective and safest pathway represents a great challenge. A key point of concern is the anesthetic approach and above all the choice of the locoregional anesthesia combined with general or neuraxial anesthesia.

Limitation in monitoring depth of anesthesia: a case report

Although we describe a clinical situation that most likely occurs in hundreds of operatory rooms in the world, we report this case as provocation. It concerns an unexpected awakening from an appropriate depth of anesthesia, although the BIS monitor showed a BIS index of less than 50 for a prolonged period before and after the event. Approximately 30 min after induction of anesthesia, the patient had a hypothetic sudden arousal of consciousness, with spontaneous movements, facial muscle activation, intolerance to the tracheal tube, and tearing. After immediate intravenous administration of midazolam (4 mg), the patient returned to a depth of anesthesia status, and surgery was completed uneventfully. The patient had no recall of the event when questioned during the episode, at emergence, or at 24 h, 36 h, and 7 days after surgery. Were these events spinal reflexes to pain or stimulation although the cortex was still anesthetized? Maybe this is the more rational explanation. Was the patient awake but not aware? Is it possible that our patient experienced only a transient arousal from consciousness, and that he did not have recall because the arousal time was short and we blocked memory consolidation? The latter hypothesis provides an opportunity to discuss the evidence that at the moment there is no device to assess the depth of anesthesia. We also focus on the possibility of interfering with memory processing under anesthesia.

Whole blood pumping with a microthrottle pump

We have previously reported that microthrottle pumps (MTPs) display the capacity to pump solid phase suspensions such as polystyrene beads which prove challenging to most microfluidic pumps. In this paper we report employing a linear microthrottle pump (LMTP) to pump whole, undiluted, anticoagulated, human venous blood at 200 μl min(-1) with minimal erythrocyte lysis and no observed pump blockage. LMTPs are particularly well suited to particle suspension transport by virtue of their relatively unimpeded internal flow-path. Micropumping of whole blood represents a rigorous real-world test of cell suspension transport given blood's high cell content by volume and erythrocytes' relative fragility. A modification of the standard Drabkin method and its validation to spectrophotometrically quantify low levels of erythrocyte lysis by hemoglobin release is also reported. Erythrocyte lysis rates resulting from transport via LMTP are determined to be below one cell in 500 at a pumping rate of 102 μl min(-1).

Endoscopic surveillance for hereditary non-polyposis colorectal cancer (HNPCC) family members in a Southern Italian region

BACKGROUND

Surveillance in hereditary non-polyposis colorectal cancer (HNPCC) family members recommends baseline colonoscopy starting at age 20 and then surveillance colonoscopy every 1-2 years.

AIMS

To verify adherence to the guidelines for HNPCC family members enrolled in endoscopic surveillance.

METHODS

Data regarding 11 HNPCC families was retrieved from our database. Excluding 11 probands, 106 family members were evaluated and 40 underwent surveillance.

RESULTS

At baseline colonoscopy, 7 colorectal cancers (CRC), 14 polyps (PO) [1 inflammatory, 2 hyperplastic, 10 adenomas with low grade dysplasia (LGD-AD) and 1 adenoma with high-grade dysplasia (HGD-AD)] were diagnosed in sixteen individuals. Twenty-eight HNPCC family members underwent endoscopic surveillance, with a total of 94 surveillance colonoscopies. Of these, 45 were positive (4 CRC, 3 inflammatory PO, 34 hyperplastic PO, 21 LGD-AD and 5 HGD-AD). Mean time between two consecutive surveillance colonoscopies was 24.6 months (range 4-168). Median time to first positive surveillance colonoscopy was 84 months for HNPCC family members with negative baseline colonoscopy, and 60 months for those with positive baseline colonoscopy (p=0.21).

CONCLUSIONS

Our data suggests that surveillance colonoscopy every 2 years is adequate to diagnose advanced lesions in HNPCC family members, and improves their compliance with surveillance.

Class II HLA allele polymorphism: DRB1, DQB1 and DPB1 alleles and haplotypes in the New Zealand Maori population

Class II alleles of interest to transplantation comprise the DRB1, DQB1 and DPB1 loci. Sequence-based typing was used to determine the class II allelic variability present in New Zealand Maori, a population with close genetic ties to Polynesia and known anthropological and linguistic connections to mainland Asia. The most common DRB1 alleles identified were DRB1*1201, DRB1*110101, DRB1*0403 and DRB1*080302, with frequencies of 21.5%, 14%, 11.25% and 9.25%, respectively. Standard linkages between the DRB1 locus and the DRB3, 4 and 5 loci were maintained, with no novel patterns identified. The most common DQB1 alleles identified were DQB1*030101, DQB1*060101, DQB1*020101, DQB1*0602 and DQB1*050201, with frequencies of 29.5%, 8%, 7.8%, 6.4% and 6.2%, respectively. The most common DPB1 alleles identified were DPB1*0501, DPB1*040101 and DPB1*020102, with frequencies of 40.2%, 28.89% and 15.83%, respectively. A total of 80 estimated DRB1-DQB1 two-locus haplotypes were detected. DRB1*1201-DQB1*030101 was the most frequent (15.40%) haplotype, followed by DRB1*110101-DQB1*030101 (9.97%), DRB1*0403-DQB1*030201 (7.37%) and DRB1*080302-DQB1*060101 (5.96%). The allelic variation determined is being used in further analysis of the requirement for bone marrow transplantation in the New Zealand Maori population and has implications for optimal ethnic donor distribution on the New Zealand Bone Marrow Donor Registry, anthropological studies and disease association.

Microfluidic solid phase suspension transport with an elastomer-based, single piezo-actuator, micro throttle pump

We report a Micro Throttle Pump (MTP) which has been shown to pump 5 microm diameter polystyrene beads at a concentration of 4.5 x 10(7) beads ml(-1). This new MTP design is constructed in a straightforward manner and actuated by a single piezoelectric (PZT) element. Maximum flow rates at 800 Hz drive frequency of 132 microl min(-1) with water and 108 microl min(-1) with a bead suspension were obtained. Maximum back-pressures of 6 kPa were observed in both cases. The reported MTP employs specific location of distinct internal microfluid structures cast in a single compliant elastomeric substrate to exploit the opposing directions of flexure of regions of a piezoelectric-glass composite bonded to the elastomer. By this novel means, distinct flexural regions, exhibiting compressive and tensile stresses respectively, allow both the pump's integrated input and output throttles and its pump chamber to be actuated concurrently by a single PZT. To support MTP design we also report the characterisation of an individual throttle's resistance as a function of actuator deflection and discuss the underlying mechanism of the throttling effect.

Elastomer-glass micropump employing active throttles

We report a reciprocating microfluidic pump, the Micro Throttle Pump (MTP), constructed in a relatively uncomplicated manner from glass and microstructured poly(dimethylsiloxane)(PDMS). Unconventionally, the MTP employs throttling of fluid flow as distinct from fully-closing valve structures. Accordingly, this technique offers the prospect of solid-phase suspension tolerance. The reported MTP employs piezoelectrically (PZT) actuated deformation of flow constrictions (throttles) fabricated from PDMS at the two ports of a central, PZT actuated pump chamber. By appropriate time-sequencing of the individual PZTs' actuation, pumping can be induced in either direction. PDMS' elasticity further facilitates throttle operation by virtue of allowing significant PZT flexure that is substantially independent of the underlying PDMS microstructure. In contrast, in a rigid substrate such as silicon, deformation is constrained to where underlying microstructured cavities exist and this restricts design options. We describe the construction and performance of a prototype MTP capable of pumping 300 microl min(-1) or alternatively generating a back-pressure of 5.5 kPa. Preliminary modelling of MTP operation is also presented.

A novel instrument for studying the flow behaviour of erythrocytes through microchannels simulating human blood capillaries

A novel instrument has been developed to study the microrheology of erythrocytes as they flow through channels of dimensions similar to human blood capillaries. The channels are produced in silicon substrates using microengineering technology. Accurately defined, physiological driving pressures and temperatures are employed whilst precise, real-time image processing allows individual cells to be monitored continuously during their transit. The instrument characterises each cell in a sample of ca. 1000 in terms of its volume and flow velocity profile during its transit through a channel. The unique representation of the data in volume/velocity space provides new insight into the microrheological behaviour of blood. The image processing and subsequent data analysis enable the system to reject anomalous events such as multiple cell transits, thereby ensuring integrity of the resulting data. By employing an array of microfluidic flow channels we can integrate a number of different but precise and highly reproducible channel sizes and geometries within one array, thereby allowing multiple, concurrent isobaric measurements on one sample. As an illustration of the performance of the system, volume/velocity data sets recorded in a microfluidic device incorporating multiple channels of 100 microns length and individual widths ranging between 3.0 and 4.0 microns are presented.

A silicon micromachined device for use in blood cell deformability studies

An application of silicon micromachining to the analysis of blood cell rheology is described. The system, based upon a micromachined flow cell, provides a specific measurement of each cell in a statistically significant population in terms of both flow velocity profile and an index of cell volume while the cells flow through an array of microchannels. The rationale, design, and fabrication of the silicon micromachined flow cell is discussed. Interrelated considerations determining the design of the associated fluidic, mechanical, imaging, and real-time image analysis subsystems are examined. Sample data comparing normal and iron deficiency anaemic blood are presented to illustrate the potential of this technique.