Glucose measurements with accu check inform II versus hexokinase plasma method during surgery under general anesthesia, an observational cohort study

PURPOSE

Limited research exists on translation of in-vitro glucose measurement interfering compounds to the in-vivo situation. We investigated whether Point-of-Care glucose measurements by Accu Chek Inform II (ACI II) were accurate to monitor glucose concentrations during surgery with general anesthesia by comparing with the reference laboratory hexokinase plasma glucose test.

METHOD

Patients undergoing surgery with general anesthesia were included. Anesthesia was maintained with either Sevoflurane or Total intravenous anesthesia (TIVA). Prior to and after induction, blood glucose was measured with ACI II and the hexokinase test. Bland-Altman analysis was performed to assess method agreement. Subgroup analyses on glucose measurement differences per type of maintenance anesthesia were performed.

RESULTS

Thirty-nine patients were included, and 78 measurements were performed. All paired measurements had clinically acceptable agreement with a percentage error of 10.0% (95% CI 8.0 to 11.9). The mean difference (95% limits of agreement) between ACI II and hexokinase for all measurements was 0.0 mmol/L (-0.7 to 0.7 mmol/L). Before induction (n = 39), mean difference was -0.1 mmol/L (-0.6 to 0.4 mmol/L), and after induction (n = 39), mean difference was 0.1 mmol/L (-0.8 to 0.9 mmol/L). Further investigation showed the difference varied per test for patients receiving Sevoflurane compared to patients receiving TIVA (-0.2 ± 0.4 mmol/L vs. 0.4 ± 0.3 mmol/L, p < 0.001). Before and after induction, the difference between ACI II and hexokinase measurements increased for patients receiving Sevoflurane compared to patients receiving TIVA (0.4 ± 0.4 mmol/L vs. -0.4 ± 0.3 mmol/L, p < 0.001).

CONCLUSION

The agreement between glucose measurements using ACI II and the reference laboratory hexokinase test was clinically acceptable with a percentage error of 10.0% (95% CI 8.0 to 11.9). The use of TIVA may negatively affect the measurement performance of the ACI II.

Safety and Efficacy of Ketamine Without Intubation in the Management of Refractory Seizures: A Case Series

BACKGROUND

Continuous infusion ketamine has demonstrated efficacy in the management of refractory seizures yet does not suppress respiratory drive like other continuous infusion anesthetics (CIAs) used for this indication. The aim of this study is to describe the safety and efficacy of ketamine infusions in patients with refractory seizure without intubation.

METHODS

We analyzed a retrospective cohort of adult patients who were not intubated at the time of initiation of a ketamine infusion for refractory seizures. Seizure onset was determined to be the first clinical seizure or nonconvulsive seizure reported on electroencephalography (EEG) or the start time of EEG for patients with seizures at EEG initiation. Responders were defined as patients with resolution of seizures within 24 h of initiation without the need for intubation or an additional CIA.

RESULTS

A total of 28 patients were analyzed (median age 62 years, 64.3% female, 82.1% African American, 82.1% with structural seizure etiology, and 85.7% focal seizures). Of patients, 78.5% received an initial bolus averaging 0.9 mg/kg, and the majority (89.3%) were initiated on an infusion at 10 μg/kg/minute; median duration was 39.8 h. Maximum infusion rates were 10 μg/kg/minute in 16 patients, 20 μg/kg/minute in seven patients, and 30 μg/kg/minute in five patients. Of patients, 71.4% were assessed to be ketamine responders; six of the eight nonresponders required intubation and an additional CIA. Responders were 80% more likely to have received ketamine 5 or more hours earlier than nonresponders. Hypotension (systolic blood pressure < 90 mmHg) occurred in 31.8% of patients receiving only ketamine, which did not correlate with duration or maximum dose of ketamine; hypertension (systolic blood pressure > 180 mmHg) occurred in 39.3%.

CONCLUSIONS

Ketamine represents a safe and effective treatment option for refractory seizures and has potential to reduce morbidity associated with intubation in a carefully selected patient population. Early initiation may increase the likelihood of success.

Cognitive trajectories after surgery: Guideline hints for assessment and treatment

Elderly patients who undergo major surgery (not-neurosurgical) under general anaesthesia frequently complain about cognitive difficulties, especially during the first weeks after surgical "trauma". Although recovery usually occurs within a month, about one out of four patients develops full-blown postoperative Neurocognitive disorders (NCD) which compromise quality of life or daily autonomy. Mild/Major NCD affect approximately 10% of patients from three months to one year after major surgery. Neuroinflammation has emerged to have a critical role in the postoperative NCDs pathogenesis, through microglial activation and the release of pro-inflammatory cytokines which increase blood-brain-barrier permeability, enhance movement of leukocytes into the central nervous system (CNS) and favour the neuronal damage. Moreover, pre-existing Mild Cognitive Impairment, alcohol or drugs consumption, depression and other factors, together with several intraoperative and post-operative sequelae, can exacerbate the severity and duration of NCDs. In this context it is crucial rely on current progresses in serum and CSF biomarker analysis to frame neuroinflammation levels, along with establishing standard protocol for neuropsychological assessment (with specific set of tools) and to apply cognitive training or neuromodulation techniques to reduce the incidence of postoperative NCDs when required. It is recommended to identify those patients who would need such preventive intervention early, by including them in pre-operative and post-operative comprehensive evaluation and prevent the development of a full-blown dementia after surgery. This contribution reports all the recent progresses in the NCDs diagnostic classification, pathogenesis discoveries and possible treatments, with the aim to systematize current evidences and provide guidelines for multidisciplinary care.

Impact of anesthetics on rat hippocampus and neocortex: A comprehensive proteomic study based on label-free mass spectrometry

Anesthesia is regarded as an important milestone in medicine. However, the negative effect on memory and learning has been observed. In addition, the impact of anesthetics on postoperative cognitive functions is still discussed. In this work, in vivo experiment simulating a general anesthesia and ICU sedation was designed to assess the impact of two intravenous (midazolam, dexmedetomidine) and two inhalational (isoflurane, desflurane) agents on neuronal centers for cognition (neocortex), learning, and memory (hippocampus). More than 3600 proteins were quantified across both neocortex and hippocampus. Proteomic study revealed relatively mild effects of anesthetics, nevertheless, protein dysregulation uncovered possible different effect of isoflurane (and midazolam) compared to desflurane (and dexmedetomidine) to neocortical and hippocampal proteins. Isoflurane induced the upregulation of hippocampal NMDAR and other proteins of postsynaptic density and downregulation of GABA signaling, whereas desflurane and dexmedetomidine rather targeted mitochondrial VDAC isoforms and protein regulating apoptotic activity.

The effect of simultaneous administration of occipital nerve block and cervical myofascial trigger point injection (MTrPI) on headache parameters in chronic migraine patients

BACKGROUND AND AIM

Peripheral myofascial mechanisms have been identified as contributors to migraine pathophysiology. The specific comorbid relationship between migraine and cervical trigger points may exacerbate the occurrence and severity of migraine attacks. Trigger point injections (TPIs) are frequently employed to address headaches and alleviate migraine symptoms. The current study explores the impact of concurrent myofascial trigger point injection (MTrPI) and occipital nerve block (greater occipital nerve block [GONB] + lesser occipital nerve block [LONB]) on the severity of headaches and the number of migraine attacks in individuals with chronic migraine (CM) and cervical myofascial trigger points (MTrPs), with a comparison of occipital nerve block alone (GONB + LONB). During trigger point examination and injection, trapezius, levator scapulae, splenius capitis, temporalis, and sternocleidomastoid muscles were targeted. We planned the treatment based on whether they were in the muscle groups we determined, rather than the number of trigger points.

MATERIALS AND METHOD

This study enrolled 62 individuals experiencing CM with bilateral headache and cervical MTrP who sought care at the Algology Unit within the Departments of Neurology and Physical Therapy and Rehabilitation at Siirt Training and Research Hospital between 2020 and 2022. The CM cohort was stratified into two groups: group 1 received trigger point injections (TrPI), while group 2 underwent concurrent bilateral occipital nerve block (GONB + LONB) and TrPI. Both groups underwent three treatment sessions with bupivacaine 0.5% (1 ml = 5 mg) in weeks 1, 2, and 4. Visual analog scale (VAS) was used to measure the patients' pain intensity. The evaluation included the assessment of the monthly migraine frequency and visual analog scale (VAS) p score for pain before treatment (BT) and after treatment (AT), conducted at baseline and during follow-up visits. Analysis of the data was conducted utilizing IBM SPSS Statistics for Windows version 28.0 software.

RESULTS

Among patients diagnosed with CM and MTrPs, 32 individuals (51.6%) underwent GONB and LONB, while 30 patients (48.4%) received simultaneous GONB, LONB, and cervical MTrPI. Within the entire sample, 51 participants (82.3%) were female, and 11 (17.7%) were male, with a mean age of 32.81 ± 10.75 years. With an average age of 32.81 ± 10.75 years, there was no statistically significant variance between the two groups (p = 0.516). Of the total cohort, 45 individuals (72.6%) reported experiencing headaches persisting for 12 months or longer. Among CM patients, 80% had active trigger points, while 20% had latent trigger points. No statistically significant difference was observed between the groups concerning TrPs (p = 0.158), and the distribution of TrPs was homogenous across the two groups. In group 1, the median (min-max) monthly frequency of migraines reduced from 18.5 days (range: 15.0 to 25.0 days) before treatment to 12.0 days (range: 7.0 to 17.0 days) after treatment (p = 0.000). In group 2, the median monthly frequency of migraines reduced from 16.5 days (range: 15.0 to 22.0 days) before treatment to 4.0 days (range: 2.0 to 8.0 days) after treatment (p = 0.000). The median (min-max) VAS score in group 1 was 8.0 (range: 5.0 to 9.0) before treatment, 4.0 (range: 2.0 to 6.0) at week 1, and 5.0 (range: 4.0 to 8.0) at week 4 (p = 0.000). In group 2, the median VAS score was 7.0 (range: 5.0 to 9.0) before treatment, 0.0 (range: 0.0 to 0.3) at week 1, and 2.0 (range: 0.0 to 0.3) at week 4 (p = 0.000). There were significant distinctions between the groups in terms of both the monthly count of migraine days and the severity of headaches (p = 0.000).

CONCLUSION

The combination of repeated MTrPIs and ONB proves more effective than ONB alone in managing patients with CM and cervical MTrP. In patients with CM, performing TrPs examination and adding treatments for this may contribute to the treatment. In cases where patients endure prolonged episodes of headache associated with chronic migraine, the inclusion of trigger point injections alongside peripheral nerve blocks may offer enhanced therapeutic benefits.

A prospective, randomized trial of liposomal bupivacaine compared to conventional bupivacaine on pain control and postoperative opioid use in adults receiving adductor canal blocks for total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a commonly performed procedure to alleviate pain and improve functional limitations caused by end-stage joint damage. Effective management of postoperative pain following TKA is crucial to the prevention of complications and enhancement of recovery. Adductor canal blocks (ACB) with conventional bupivacaine (CB) provide adequate analgesia after TKA, but carry a risk of rebound pain following block resolution. Liposomal bupivacaine (LB) is an extended-release local anesthetic that can provide up to 72 h of pain relief. The objective of this study was to compare postoperative outcomes between ACBs using LB and CB after TKA.

METHODS

This single institution, prospective, randomized, clinical trial enrolled patients scheduled for TKA. Participants were randomized to receive ACB with either LB or CB. Pain scores up to 72 h postoperatively were assessed as the primary outcome. Opioid consumption and length of stay were evaluated as secondary outcomes.

RESULTS

A total of 80 patients were enrolled. Demographic and clinical characteristics were similar between the two groups. LB group showed significantly lower cumulative opioid use during the 72 h evaluated (P = 0.016). There were no differences in pain scores or length of stay between the groups.

CONCLUSION

The study demonstrated that LB ACBs led to significantly lower opioid consumption in the days following TKA without affecting pain scores or length of stay. This finding has important implications for improving postoperative outcomes and reducing opioid use in TKA patients. Previous studies have reported inconsistent results regarding the benefits of LB, highlighting the need for further research.

TRIAL REGISTRATION

This project was retrospectively registered with clinicaltrials.gov ( NCT05635916 ) on 2 December 2022.

Exploring the effects of eugenol, menthol, and lidocaine as anesthetics on zebrafish glucose homeostasis

Zebrafish (Danio rerio) are widely employed as an experimental model in various scientific fields. The investigation of glucose metabolism dysfunctions has gained recent significant prominence. Considering that certain anesthetics may impact glycemic levels, it is imperative to carefully select an anesthetic that does not induce such side effects, thereby mitigating potential adverse influences on research outcomes. In this sense, this study aimed to evaluate potential glucose alterations and induction and recovery times resulting from the use of eugenol, menthol and lidocaine as anesthetics in zebrafish. A total of 150 adult male and female zebrafish were divided into ten groups, comprising a control group euthanized by rapid chilling, and three groups anesthetized with low (40 mg/L eugenol, 60 mg/L menthol, 100 mg/L lidocaine), intermediate (60 mg/L eugenol, 90 mg/L menthol, 225 mg/L lidocaine), and high (80 mg/L eugenol, 120 mg/L menthol, 350 mg/L lidocaine) anesthetic concentrations. Glucose levels and induction and recovery times were assessed. The findings reveal that eugenol and menthol did not cause glucose level alterations at any of the investigated concentrations, while lidocaine caused a non-concentration-dependent hyperglycemia. Eugenol and menthol also exhibited similar recovery times at different concentrations, while lidocaine recovery times were concentration-dependent. This study, therefore, concludes that eugenol and menthol are safe and satisfactory anesthetics for use in zebrafish research involving glucose analyses, while lidocaine use can cause biases due to altered glucose levels and safety concerns. Researchers should, therefore, carefully consider anesthetic selection to ensure reliable results in zebrafish assessments.

α5GABAA receptor: A potential therapeutic target for perioperative neurocognitive disorders, a review of preclinical studies

Perioperative neurocognitive disorders (PND) are a common complication in elderly patients following surgery, which not only prolongs the recovery period but also affects their future quality of life and imposes a significant burden on their family and society. Multiple factors, including aging, vulnerability, anesthetic drugs, cerebral oxygen desaturation, and severe pain, have been associated with PND. Unfortunately, no effective drug is currently available to prevent PND. α5 γ-aminobutyric acid subtype A (α5GABAA) receptors have been implicated in cognitive function modulation. Positive or negative allosteric modulators of α5GABAA receptors have been found to improve cognitive impairment under different conditions. Therefore, targeting α5GABAA receptors may represent a promising treatment strategy for PND. This review focuses on preclinical studies of α5GABAA receptors and the risk factors associated with PND, primarily including aging, anesthetics, and neuroinflammation. Specifically, positive allosteric modulators of α5GABAA receptors have improved cognitive function in aged experimental animals. In contrast, negative allosteric modulators of α5GABAA receptors have been found to facilitate cognitive recovery in aged or adult experimental animals undergoing anesthesia and surgery but not in aged experimental animals under anesthesia alone. The reasons for the discordant findings have yet to be elucidated. In preclinical studies, different strategies of drug administration, as well as various behavioral tests, may influence the stability of the results. These issues need to be carefully considered in future studies.

Risk factors for postoperative pulmonary complications in neonates: a retrospective cohort study

Objective

Postoperative pulmonary complications (PPCs) are an important quality indicator and are associated with significantly increased mortality in infants. The objective of this study was to identify risk factors for PPCs in neonates undergoing non-cardiothoracic surgery.

Methods

In this retrospective study, all neonates who underwent non-cardiothoracic surgery in a children's hospital from October 2020 to September 2022 were included for analysis. Demographic data and perioperative variables were obtained. The primary outcome was the occurrence of PPCs. Univariate analysis and multivariable logistic regression analysis were used to investigate the effect of patient-related factors on the occurrence of PPCs.

Results

Totally, 867 neonatal surgery patients met the inclusion criteria in this study, among which 35.3% (306/867) patients experienced pulmonary complications within 1 week postoperatively. The PPCs observed in this study were 51 exacerbations of pre-existing pneumonia, 198 new patchy shadows, 123 new pulmonary atelectasis, 10 new pneumothorax, and 6 new pleural effusion. Patients were divided into two groups: PPCs (n=306) and non-PPCs (n=561). The multivariate stepwise logistic regression analysis revealed five independent risk factors for PPCs: corrected gestational age (OR=0.938; 95% CI 0.890 to 0.988), preoperative pneumonia (OR=2.139; 95% CI 1.033 to 4.426), length of surgery (> 60 min) (OR=1.699; 95% CI 1.134 to 2.548), preoperative mechanical ventilation (OR=1.857; 95% CI 1.169 to 2.951), and intraoperative albumin infusion (OR=1.456; 95% CI 1.041 to 2.036) in neonates undergoing non-cardiothoracic surgery.

Conclusion

Identifying risk factors for neonatal PPCs will allow for the identification of patients who are at higher risk and intervention for any modifiable risk factors identified.

Impact of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children: a prospective, randomized controlled trial

Objective

To compare the efficacy of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children.

Methods

Patients with obstructive sleep apnea syndrome scheduled for adenotonsillectomy were randomly divided into group A (patients received intravenous nalbuphine 0.2 mg/kg before anesthesia induction), group B (patients received intravenous nalbuphine 0.2 mg/kg 10 min before the end of surgery), and group C (patients did not receive nalbuphine injection). The time points for measuring outcomes were before anesthesia induction (T0), extubation (T1), and 0, 15, 30, or 45 min in the postanesthesia care unit (PACU) (T2-T5, respectively).

Results

There were 40 patients in group A, 41 patients in group B and 39 patients in group C. Patients in group B had significantly lower FLACC (Face, Legs, Activity, Cry, Consolability) pain scores at T2-T5 than those in group C (all p<0.05). Patients in group B had higher Ramsay Sedation Score at T2-T4 than those in group C (all p<0.05). The proportion of patients who received remedial analgesia in the PACU in group A (17.5%, p=0.008) and group B (9.8%, p<0.001) was significantly lower than that in group C (46.2%).

Conclusion

Intravenous administration of nalbuphine 10 min before the end of adenotonsillectomy in children could decrease pain intensity and increase sedation levels during the recovery period with the reduction of remedial analgesia in the PACU.Trial registration number ChiCTR2200060118.

Association between preoperative respiratory symptoms and perioperative respiratory adverse events in pediatric patients with positive viral testing

STUDY OBJECTIVE

To determine the association between the presence of upper respiratory tract viral infection symptoms and occurrence of perioperative respiratory adverse events (PRAE) in children with positive viral screening, and to analyze the risk of PRAE in children with SARS-CoV-2 compared to non-SARS-CoV-2 infection.

DESIGN

A prospective cohort study.

SETTING

A tertiary, freestanding pediatric hospital in Dallas, Texas.

PATIENTS

Children <18 years of age with positive respiratory viral testing who underwent general anesthesia.

INTERVENTION

Measurement of incidence of PRAE and severe adverse events during the first 7 postoperative days.

MEASUREMENTS

The primary outcome was a composite of PRAE: oxygen saturation < 90% for >5 min, supplemental oxygen for >2 h after anesthesia, laryngospasm, and bronchospasm. The secondary outcome was severe adverse events: high flow nasal cannula >6 l of oxygen per minute, admission to the ICU for escalation of respiratory support post-anesthetic, acute respiratory distress syndrome, postoperative pneumonia, cardiovascular arrest, extracorporeal life support, and death.

MAIN RESULTS

In this convenience sample of 196 children, 83 were symptomatic and 113 were asymptomatic. The risk of PRAE was similar in children with active viral symptoms and asymptomatic children (risk difference: -1.9%; 95% CI: -10.9, 7.9%), but higher among children with documented fever within 48 h of the anesthetic (risk difference: 20.8%; 95% CI: 5.3, 39.7%). The multivariable adjusted odds ratio of PRAE was 0.68 (95% CI: 0.25, 1.85) for symptomatic compared to asymptomatic patients, and 0.46 (95% CI: 0.14, 1.44) for patients with SARS-CoV-2 compared to non-SARS-CoV-2 infection.

CONCLUSIONS

There was no significant difference in the incidence of PRAE between symptomatic and asymptomatic children with laboratory confirmed viral respiratory infection, and between children with the Omicron variant of SARS-CoV-2 compared to non-SARS-CoV-2 respiratory viruses. However, the risk was increased in children with recent fever.

A synopsis of multitarget therapeutic effects of anesthetics on depression

Depression is a profound mental disorder that dampens the mood and undermines volition, which exhibited an increased incidence over the years. Although drug-based interventions remain the primary approach for depression treatment, the available medications still can't satisfy the patients. In recent years, the newly discovered therapeutic targets such as N-methyl-D-aspartate (NMDA) receptor, α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA) receptor, and tyrosine kinase B (TrkB) have brought new breakthroughs in the development of antidepressant drugs. Moreover, it has come to light that certain anesthetics possess pharmacological mechanisms intricately linked to the aforementioned therapeutic targets for depression. At present, numerous preclinical and clinical studies have explored the therapeutic effects of anesthetic drugs such as ketamine, isoflurane, N2O, and propofol, on depression. These investigations suggested that these drugs can swiftly ameliorate patients' depression symptoms and engender long-term effects. In this paper, we provide a comprehensive review of the research progress and potential molecular mechanisms of various anesthetic drugs for depression treatment. By shedding light on this subject, we aim to facilitate the development and clinical implementation of new antidepressant drugs based on anesthetic medications.

The sniffing position facilitated easier light wand guided endotracheal intubation compared with the neutral position with chin-lift

BACKGROUND

Traditionally, the patient's head is placed in a neutral position with a chin-lift to facilitate light wand guided endotracheal intubation. However, our study found that the sniffing position was more effective. In this study, we aimed to compare the two positions of light wand guided endotracheal intubation.

METHODS

Sixty adult patients were included in the study, after obtaining informed consent, and were randomly assigned to one of two groups: a control group in a neutral position with a chin-lift (group C, n = 30) and a sniffing position group (group S, n = 30). In group C, the anesthesiologist inserted a light wand after lifting the patient's mandible using the thumb of their non-dominant hand inside the patient's mouth. In group S, a light wand was inserted after the patient's head was flexed with the neck extended. We assessed variables such as light-search time, number of intubation attempts, time to achieve intubation, and side effects including blood tinge on the endotracheal tube, hoarseness, sore throat, and anesthesiologist satisfaction.

RESULTS

The light-search and intubation times were shorter in group S than in group C. The incidence of blood tinge on the endotracheal tube was higher in group C than in group S. Anesthesiologist satisfaction was higher in group S than in group C.

CONCLUSIONS

The sniffing position was more effective in facilitating light wand guided endotracheal intubation than the neutral position with a chin-lift.

Pain management in periodontal therapy using local anesthetics and other drugs: an integrative review

Background

Surgical and non-surgical periodontal procedures often lead to postoperative pain. Clinicians use pharmacological methods such as anesthetics, anti-inflammatory drugs, and analgesics for relief. However, the multitude of options makes it challenging to select the best approach for routine dental care.

Objective

This review aimed to describe previous studies regarding the pharmacological management used for pain control during periodontal procedures as well as factors that may interfere with patients' perception of pain.

Methods

We included studies (period of 2000-2023, whose approach corresponded to the pharmacological protocols used for preoperative, trans-operative, and postoperative pain control in adult patients undergoing surgical and non-surgical periodontal therapy.

Results

A total of 32 studies were included in the analysis, of which 17 (53%) were related to anesthetic methods and 15 (47%) were related to therapeutic protocols (anti-inflammatory/analgesic agents). These studies predominantly involved nonsurgical periodontal procedures. Studies have reported that factors related to age, type of procedure, and anxiety can influence pain perception; however, only seven of these studies evaluated anxiety.

Conclusions

Numerous methods for pain control can be applied in periodontal therapy, which are accomplished through anesthetic methods and/or therapeutic protocols. Factors such as anxiety, age, and type of procedure are related to pain perception in patients. Thus, it is the responsibility of dentists to evaluate each clinical situation and define the best protocol to follow based on the literature.

Role of ferroptosis in effects of anesthetics on multiple organ diseases: A literature review

Anesthesiologists are often faced with patients combined with a series of organ injuries, such as acute lung injury, myocardial ischemia-reperfusion injury, and neurodegenerative diseases. With the in-depth study of these diseases, we are more aware of the choice and rational use of anesthetics for the prognosis of these patients. Ferroptosis is a new type of programmed cell death. This unique pattern of cell death, driven by an imbalance between oxides and antioxidants, is regulated by multiple cellular metabolic events, including redox homeostasis, iron handling, mitochondrial activity, and lipids peroxidation. Numerous studies confirmed that anesthetics modulate ferroptosis by interfering its machineries such as cystine-import-glutathione-glutathione peroxidase 4 axis, Heme oxygenase 1, nuclear factor erythroid 2-related factor 2, and iron homeostasis system. In this literature review, we systemically illustrated possible involvement of ferroptosis in effects of anesthetics and adjuvant drugs on multiple organ diseases, hoping our work may serve as a basis for further studies on regulating ferroptosis through anesthetics related pharmacological modulation and promoting the rational use of anesthetics.

[Anafilaxia perioperatoria a sevoflurano, un caso muy raro]

Background

Perioperative anaphylaxis can be life-threatening. The global incidence is estimated to be 1 in 10,000-20,000 procedures. The most common agents are neuromuscular blockers, latex, and antibiotics. There are very few reports of allergies to inhaled anesthetics such as sevoflurane, which is considered relatively safe in patients with drug allergies.

Case report

12-year-old patient, admitted to oncology, diagnosed with acute lymphoblastic leukemia. History of two perioperative hypersensitivity reactions. In the first event, lidocaine and rupivacaine were administered, he presented urticaria, managed with an antihistamine. On the second occasion, he received only sevoflurane and presented anaphylaxis, treated with intramuscular adrenaline. Later during intrathecal therapy, he received sevoflurane, he presented rash and arterial hypotension, managed again with adrenaline, with total remission of symptoms. Retrospectively Brighton criteria level I of certainty, classified as serious by Brown. Hypersensitivity to sevoflurane was suspected, ruling out other anesthetics such as lidocaine and rupivacaine with negative intradermal skin tests. Molecular components for latex were requested with negative results for Hev b 1, Hev b 3, Hev b 6. Due to the above and associated with the characteristics of the drug, a basophil activation test for sevoflurane was performed with an activation percentage of 50% (positive). Perioperative anaphylaxis due to sevoflurane is confirmed.

Conclusion

All drugs involved in perioperative hypersensitivity reactions should be considered to establish adequate and safe treatment alternatives for this small group of patients.

Comparison of the Sevoflurane versus Desflurane Anaesthesia on the Recovery of Airway Reflexes and Cognitive Function: An Original Research

Background and Objectives

Sevoflurane and desflurane virtually equally dissolve in blood gases, yet current research suggests that desflurane helps in a quick return of airway reflex than sevoflurane however the return of cognitive activity fluctuates greatly. In order to compare the lengths of time required to recover after sevoflurane and desflurane anesthesia, the current research was conducted.

Materials and Methods

Current study was randomized that included 100 subjects who were posted for cholecystectomy (elective). Only adult and non-obese subjects were included in the study. The intended anesthetic agents sevoflurane and desflurane were utilized in the study and all the protocols were followed for the surgery. After the end of the surgery, tests for regaining cognitive function and airway reflexes were carried out, and different time intervals were recorded. The values were recorded and compared for the variances while considering the P < 0.05 as significant.

Results

The mean T1 was 8.19 ± 3.28 min for sevoflurane and was 5.82 ± 4.02 min. There was no significant variance between the two agents for the T1, 2 (P = 0.013 and 0.110 respectively). After the inhalation anesthetics ceased at T1, desflurane patients responded to verbal commands more quickly than sevoflurane patients (5.824.02 vs. 8.193.28 min). The SOMCT and swallowing test were similarly completed more quickly by desflurane-treated patients than by sevoflurane-treated patients (T3VST4) (13.693.37 vs. 10.024.86 min, P = 0.008 and (14.094.30 vs. 9.824.50 min, P 0.001, respectively). For the T3, 4-time intervals, there was a significant difference between the sevoflurane and desflurane groups.

Conclusion

Desflurane causes patients to recover more quickly from laparoscopic cholecystectomy under controlled circumstances than sevoflurane does.

Reducing pain and discomfort associated with rubber dam clamp placement in children and adolescents: a systematic review and meta-analysis of effectiveness

BACKGROUND

The application of rubber dams is a widely accepted method of tooth isolation in dental practice. Placement of the rubber dam clamp might be associated with levels of pain and discomfort, especially in younger patients. The purpose of the present systematic review is to evaluate the efficacy of the methods for reducing pain and discomfort associated with rubber dam clamp placement in children and adolescents.

MATERIALS AND METHODS

English-language literature from inception until September 6th, 2022 was searched in MEDLINE (via PubMed), SCOPUS, Web of Science, Cochrane, EMBASE, and ProQuest Dissertations & Theses Database Global for articles. Randomized controlled trials (RCTs) comparing methods of reducing the pain and/or discomfort associated with rubber dam clamp placement in children and adolescents were retrieved. Risk of bias assessment was performed using a Cochrane risk of bias-2 (RoB-2) risk assessment tool and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence profile. Studies were summarized and pooled estimates of pain intensity scores and incidence of pain were calculated. The meta-analysis was conducted in the following groups according to type of interventions (LA, audiovisual (AV) distraction, behavior management (BM), electronic dental anesthesia (EDA), mandibular infiltration, inferior alveolar nerve block (IANB), TA), outcome (intensity or incidence of pain), and assessment tool (face - legs - activity - cry - consolability (FLACC), color scale, sounds - motor - ocular changes, and faces pain scale (FPS)): (a) pain intensity using (LA + AV) vs (LA + BM), (b) pain intensity using EDA vs LA (c) presence or absence of pain using EDA vs LA (d) presence or absence of pain using mandibular infiltration vs IANB (e) Comparing pain intensity using TA vs placebo (f) Presence or absence of pain using TA vs placebo. Meta-analysis was conducted using StataMP software, version 17.0 (StataCorp, College Station, Texas). Restricted maximum-likelihood random effect model (REML), Mean difference (MD) with 95% confidence interval, and log odds ratio (OR) with 95% CI were calculated were calculated.

RESULTS

Initially, 1452 articles were retrieved. Sixteen RCTs were finally included for reviewing and summarizing. Nine articles with a total of 867 patients were included for quantitative meta-analysis. The differences in pain intensity scores were not significant in any comparison groups (group a: [MD = -0.04 (95% CI =  - 0.56, 0.47), P = 0.87, I2 = 0.00%], group b: [MD = 0.25 (95% CI = -0.08, 0.58), P = 0.14, I2 = 0.00%], group c [MD = -0.48 (95% CI = -1.41, 0.45), P = 0.31, I 2 = 0.00%], group d: [MD = -0.67 (95% CI = -3.17, 1.83), P = 0.60, I 2 = 0.00%], group e: [MD = -0.46 (95% CI = -l.08, 0.15), P = 0.14, I 2 = 90.67%], and group f: [MD = 0.61 (95% CI = -0.01, 1.23), P = 0.06, I 2 = 41.20%]. Eight studies were judged as having some concern for risk of bias and the remaining studies were considered as low risk for bias. The certainty of evidence was considered medium for all comparison groups.

DISCUSSION

In the present meta-analysis, a considerable difference was obtained between the included studies regarding intervention methods and pain assessment tools and the analysis was performed in groups with small numbers of the studies. Owing to the mentioned variabilities and the small number of studies, the results of the analysis should be interpreted with caution. The indistinguishability of the manifestations of pain/discomfort from fear/anxiety, particularly in children, should also be considered while using the results of the present study. Within the limitations of the current study, no significant differences were found between the proposed methods for reducing pain and discomfort associated with rubber dam clamp placement in children and adolescents. A larger number of more homogenous studies regarding intervention methods and pain assessment tools need to be conducted in order to draw stronger conclusions.

TRIAL REGISTRATION

This study was registered in PROSPERO (ID number: CRD42021274835) and research deputy of Mashhad University of Medical Sciences with ID number 4000838 ( https://research.mums.ac.ir/ ).

Enhancement of the technical and non-technical skills of nurse anesthesia students using the Anesthetic List Management Assessment Tool in Iran: a quasi-experimental study

PURPOSE

This study investigated the effect of evaluations based on the Anesthetic List Management Assessment Tool (ALMAT) form on improving the technical and non-technical skills of final-year nurse anesthesia students at Ahvaz Jundishapur University of Medical Sciences (AJUMS).

METHODS

This was a semi-experimental study with a pre-test and post-test design. It included 45 final-year nurse anesthesia students of AJUMS and lasted for 3 months. The technical and non-technical skills of the intervention group were assessed at 4 university hospitals using formative-feedback evaluation based on the ALMAT form, from induction of anesthesia until reaching mastery and independence. Finally, the students' degree of improvement in technical and non-technical skills was compared between the intervention and control groups. Statistical tests (the independent t-test, paired t-test, and Mann-Whitney test) were used to analyze the data.

RESULTS

The rate of improvement in post-test scores of technical skills was significantly higher in the intervention group than in the control group (P˂0.0001). Similarly, the students in the intervention group received significantly higher post-test scores for non-technical skills than the students in the control group (P˂0.0001).

CONCLUSION

The findings of this study showed that the use of ALMAT as a formative-feedback evaluation method to evaluate technical and non-technical skills had a significant effect on improving these skills and was effective in helping students learn and reach mastery and independence.

Effects of right stellate ganglion block combined with topical anesthesia on heart rate variability in awake patients receiving tracheal intubation

Objective

General anesthesia is commonly performed with tracheal intubation. We aimed to evaluate the effects of right stellate ganglion block combined with topical anesthesia on the heart rate variability in awake patients receiving tracheal intubation.

Methods

A total of 120 eligible patients were equally divided into observation and control groups using a random number table. The observation group underwent right stellate ganglion block combined with topical anesthesia. The excellent and good rate of anesthesia, indicators of vital signs and heart rate variability, incidence rate of adverse reactions, success rate and time consumption of tracheal intubation, postoperative resuscitation and cognitive function score of the two groups were compared.

Results

The systolic pressure, diastolic pressure and heart rate significantly increased in both groups during tracheal intubation compared with those before tracheal intubation, which they were lower in the observation group than those in the control group during tracheal intubation (P<0.05). Low-frequency power, ratio of low-frequency power to high-frequency power and heart rate variability index significantly decreased in both groups during tracheal intubation compared with those before tracheal intubation (P<0.05).

Conclusion

Right stellate ganglion block combined with topical anesthesia can work well for awake patients during tracheal intubation.

[Diagnostics of drug allergies and intolerances]

The prevalence of hypersensitivity reactions to drugs is increasing. Currently, this affects more than 7% of the world population. Nonsteroidal anti-inflammatory drugs (NSAID) and beta-lactam antibiotics (BLA) are by far the most common pharmaceutical preparations involved in hypersensitivity reactions to drugs. Misdiagnoses are frequent and BLA allergies present a danger that can lead to adverse health outcomes. Therefore, delabeling (exclusion of a suspected diagnosis) is paramount for those affected. Following the occurrence of uncomplicated maculopapular exanthemas, outpatient oral drug provocation can be safely considered in children without prior skin tests. Immediate perioperative reactions are rare. The approach to studying these complex reactions requires collaboration between allergologists and anesthesiologists to provide the best possible care for these patients.

"Anti-cancer" effect of ketamine in comparison with MK801 on neuroglioma and lung cancer cells

Ketamine, a N-methyl-D-aspartate (NMDA) receptor antagonist, is commonly used to induce anaesthesia during cancer surgery and relieve neuropathic and cancer pain. This study was conducted to assess whether ketamine has any inhibiting effects on neuroglioma (H4) and lung cancer cells (A549) in vitro. The cultured H4 and A549 cells were treated with ketamine and MK801 (0.1, 1, 10, 100, or 1000 μM) for 24 h. The expressions of glutamate receptors on both types of cancer cells were assessed with qRT-PCR. In addition, cell proliferation and migration were assessed with cell counting Kit-8 and wound healing assays. Cyclin D1, matrix metalloproteinase 9 (MMP9), phosphorylation of extracellular signal-regulated kinase (pERK), and cleaved-caspase-3 expression together with reactive oxygen species (ROS) were also assessed with Western blot, immunostaining, and/or flowcytometry. NMDA and α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptors were expressed on both H4 and A549 cells. Ketamine inhibited cancer cell proliferation and migration in a dose-dependent manner by suppressing the cell cycle and inducing apoptosis. Ketamine decreased cyclin D1, pERK, and MMP9 expression. In addition, ketamine increased ROS and cleaved caspase-3 expression and induced apoptosis. The anti-cancer effect of ketamine was more pronounced in A549 cells when compared with H4 cells. MK801 showed similar effects to those of ketamine. Ketamine suppressed cell proliferation and migration in both neuroglioma and lung cancer cells, likely through the antagonization of NMDA receptors.

Evaluation of the effects of bupivacaine combined with sugammadex on the duration of the nociceptive blockade in sciatic nerve blocks: a controlled, double-blind animal study

BACKGROUND

Animal and other experimental studies have demonstrated increased block time and quality when α- and β-cyclodextrin drugs are combined with local anesthetics. However, to our knowledge, no study has utilized γ-cyclodextrins in such a combination. In the present study, we used an animal model to evaluate the effects of different doses of the combined administration of γ-cyclodextrin (sugammadex) and bupivacaine on the duration of sciatic nerve blocks in rats.

METHODS

Sciatic nerve blocks were performed with a 0.20 ml mixture in all groups. For the non-experimental groups, this mixture consisted of 0.2 ml saline (Sham group), 0.2 ml sugammadex (Group S), or 0.16 ml bupivacaine 0.5% and 0.04 ml saline (Group B). For the experimental groups, 0.16 ml bupivacaine 0.5% was administered along with 0.01 ml sugammadex and 0.03 ml saline (Group BS1), 0.02 ml sugammadex and 0.02 ml saline (Group BS2), or 0.04 ml sugammadex (Group BS4). Proprioception, nociception, and motor function were evaluated until the sciatic block was completely reversed.

RESULTS

Motor, proprioceptive, and nociceptive blockades occurred within 5 min in all experimental groups. In Group BS4, the duration of the motor, proprioceptive, and nociceptive blockades was significantly increased compared with the other experimental groups. However, in Groups BS1 and BS2, only the duration of the nociceptive blockade was significantly increased.

CONCLUSIONS

The combined administration of sugammadex and bupivacaine for sciatic nerve blocks in rats led to a significant increase in the duration of motor, proprioceptive, and nociceptive blockades.

A primordial target: Mitochondria mediate both primary and collateral anesthetic effects of volatile anesthetics

One of the unsolved mysteries of medicine is how do volatile anesthetics (VAs) cause a patient to reversibly lose consciousness. In addition, identifying mechanisms for the collateral effects of VAs, including anesthetic-induced neurotoxicity (AiN) and anesthetic preconditioning (AP), has proven challenging. Multiple classes of molecules (lipids, proteins, and water) have been considered as potential VA targets, but recently proteins have received the most attention. Studies targeting neuronal receptors or ion channels had limited success in identifying the critical targets of VAs mediating either the phenotype of "anesthesia" or their collateral effects. Recent studies in both nematodes and fruit flies may provide a paradigm shift by suggesting that mitochondria may harbor the upstream molecular switch activating both primary and collateral effects. The disruption of a specific step of electron transfer within the mitochondrion causes hypersensitivity to VAs, from nematodes to Drosophila and to humans, while also modulating the sensitivity to collateral effects. The downstream effects from mitochondrial inhibition are potentially legion, but inhibition of presynaptic neurotransmitter cycling appears to be specifically sensitive to the mitochondrial effects. These findings are perhaps of even broader interest since two recent reports indicate that mitochondrial damage may well underlie neurotoxic and neuroprotective effects of VAs in the central nervous system (CNS). It is, therefore, important to understand how anesthetics interact with mitochondria to affect CNS function, not just for the desired facets of general anesthesia but also for significant collateral effects, both harmful and beneficial. A tantalizing possibility exists that both the primary (anesthesia) and secondary (AiN, AP) mechanisms may at least partially overlap in the mitochondrial electron transport chain (ETC).

The Missing Piece? A Case for Microglia's Prominent Role in the Therapeutic Action of Anesthetics, Ketamine, and Psychedelics

There is much excitement surrounding recent research of promising, mechanistically novel psychotherapeutics - psychedelic, anesthetic, and dissociative agents - as they have demonstrated surprising efficacy in treating central nervous system (CNS) disorders, such as mood disorders and addiction. However, the mechanisms by which these drugs provide such profound psychological benefits are still to be fully elucidated. Microglia, the CNS's resident innate immune cells, are emerging as a cellular target for psychiatric disorders because of their critical role in regulating neuroplasticity and the inflammatory environment of the brain. The following paper is a review of recent literature surrounding these neuropharmacological therapies and their demonstrated or hypothesized interactions with microglia. Through investigating the mechanism of action of psychedelics, such as psilocybin and lysergic acid diethylamide, ketamine, and propofol, we demonstrate a largely under-investigated role for microglia in much of the emerging research surrounding these pharmacological agents. Among others, we detail sigma-1 receptors, serotonergic and γ-aminobutyric acid signalling, and tryptophan metabolism as pathways through which these agents modulate microglial phagocytic activity and inflammatory mediator release, inducing their therapeutic effects. The current review includes a discussion on future directions in the field of microglial pharmacology and covers bidirectional implications of microglia and these novel pharmacological agents in aging and age-related disease, glial cell heterogeneity, and state-of-the-art methodologies in microglial research.

Design, synthesis and evaluation of heterocyclic 2-phenylacetate derivatives as water-soluble rapid recovery hypnotics

In this work, a series of novel heterocyclic 2-phenylacetate derivatives were designed and synthesized as water-soluble and rapid recovery hypnotic agents. After introducing heterocyclic ring to the amide group of propanidid, the obtained propanidid derivatives showed greatly improved hydrophilicity and good anesthetic activity. In three animal experiments (mice, rats, and rabbits), compounds 13-15 showed potent hypnotic potency (HD₅₀ = 7.6, 6.5, 7.4 mg/kg in rabbits, respectively) and higher therapeutic indexes (TI = 17.3, 16.6, 15.2 in rabbits, respectively) than propanidid (TI = 14.7 in rabbits) or propofol (TI = 5.4 in rabbits). Moreover, the recovery time of compounds 13-15 (time to walk, 96.6, 79.6, 81.4 s in rabbits, respectively) were shorter than that of propanidid (124.5 s in rabbits) or propofol (425.3 s in rabbits). The experimental results suggested the potential of compounds 13-15 as water-soluble anesthetics with rapid recovery profile.

Can pre-operative intraarticular injection predict pain relief after total hip arthroplasty?

BACKGROUND

To study if pain relief after injection and arthroplasty correlate.

METHODS

A retrospective cohort study included consecutive patients (n = 88; median age 64 (interquartile range (IQR) 22) years, 49 (56%) females) that received fluoroscopic-guided intra-articular hip injection with contrast agent, anaesthetic (diagnostic), and corticosteroid (therapeutic) before implantation of primary total hip arthroplasty. Pain scores were assessed pre-injection, post-injection after 15 min (diagnostic phase) at first clinical follow up (therapeutic phase; median 2 (IQR 2) months), and postoperatively (last follow up (median 15 (IQR 5) months)). Responders had reduction in pain score ≥ 20 (numeric rating scale 0-100) points. The primary outcome was the same (or inverse) response to injection and arthroplasty.

RESULTS

The median pain scores were higher pre-injection (68 (IQR 30) points) compared to the diagnostic phase (18 (IQR 40) points; p < 0.001), therapeutic phase (50 (IQR 40) points; p < 0.001), and post-operatively (2 (IQR 15) points; p < 0.001). On the one hand, 69 (78%) cases had the same response in the diagnostic phase and post-operatively (rho = 0.58; p < 0.001; sensitivity 83%); on the other hand 32 (36%) cases had the same response in the therapeutic phase and post-operatively (rho = 0.25; p < 0.001; sensitivity 33%). Furthermore, 57% and 91% of patients had an even better response post-operatively than in the diagnostic and therapeutic phases.

CONCLUSIONS

Pre-operative intraarticular injection can predict pain relief after primary total hip arthroplasty. A positive response to hip arthroplasty may be better predicted by the response to local anaesthetic (diagnostic phase) than corticosteroids. Most patients (91%) with osteoarthritis may expect better pain relief after arthroplasty compared to the therapeutic phase after injection.

Maximum Voided Volume Is a Better Clinical Parameter for Bladder Capacity Than Maximum Cystometric Capacity in Patients With Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: A Prospective Cohort Study

PURPOSE

Bladder capacity is an important parameter in the diagnosis of lower urinary tract dysfunction. We aimed to determine whether the maximum bladder capacity (MCC) measured during a urodynamic study was affected by involuntary detrusor contraction (IDC) in patients with Lower Urinary Tract Symptoms (LUTS)/Benign Prostatic Hyperplasia (BPH).

METHODS

Between March 2020 and April 2021, we obtained maximum voided volume (MVV) from a 3-day frequency-volume chart, MCC during filling cystometry, and maximum anesthetic bladder capacity (MABC) during holmium laser enucleation of the prostate under spinal or general anesthesia in 139 men with LUTS/BPH aged >50 years. Patients were divided according to the presence of IDC during filling cystometry. We assumed that the MABC is close to the true value of the MCC, as it is measured under the condition of minimizing neural influence over the bladder.

RESULTS

There was no difference in demographic and clinical characteristics between the non-IDC (n=20) and IDC groups (n=119) (mean age, 71.5±7.4) (P>0.05). The non-IDC group had greater bladder volume to feel the first sensation, first desire, and strong desire than the IDC group (P<0.001). In all patients, MABC and MVV were correlated (r=0.41, P<0.001); however, there was no correlation between MCC and MABC (r=0.19, P=0.02). There was no significant difference in MABC between the non-IDC and IDC groups (P=0.19), but MVV and MCC were significantly greater in the non-IDC group (P<0.001). There was no significant difference between MABC and MVV (MABC-MVV, P=0.54; MVV/MABC, P=0.07), but there was a significant difference between MABC and MCC between the non-IDC and IDC groups (MABC-MCC, P<0.001; MCC/MABC, P<0.001).

CONCLUSION

Maximum bladder capacity from a urodynamic study does not represent true bladder capacity because of involuntary contractions.

Intraoperative Intravenous Infusion of Esmketamine Has Opioid-Sparing Effect and Improves the Quality of Recovery in Patients Undergoing Thoracic Surgery: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

BACKGROUND

Postoperative thoracic surgery is often accompanied by severe pain, and opioids are a cornerstone of postoperative pain management, but their use may be limited by many adverse events. Several studies have shown that the perioperative application of esketamine adjuvant therapy can reduce postoperative opioid consumption. However, whether esketamine has an opioid-sparing effect after thoracic surgery is unclear.

OBJECTIVES

To explore the opioid-sparing effect of different doses of esketamine infusion during thoracic surgery and its impact on patient recovery.

STUDY DESIGN

Randomized controlled study.

SETTING

A single-center study with a total of 120 patients.

METHODS

Patients were randomly allocated to 1 or 3 groups receiving intraoperative intravenous infusions of esketamine 0.15 mg · kg-1· h-1 (group K1), esketamine 0.25 mg · kg-1· h-1(group K2), or placebo (group C). Postoperative opioid consumption, and postoperative indicators like extubation time, PACU stay time, and adverse events were recorded for each group.

RESULTS

The consumption of hydromorphone during the first 24 and 48 postoperative hours was significantly reduced in patients of group K2 compared to those of group C and group K1. The time to extubation and post anesthesia care unit (PACU) stay were significantly shorter in group K2 than in group K1 and group C. The time to first feed and off the bed time after surgery were shorter in groups K1 and K2 than in group C. Patients in group K2 were significantly satisfied with patient controlled intravenous analgesia (PCIA) than in groups K1 and C.

LIMITATIONS

The sample size calculation was based mainly on the index of hydromorphone consumption.

CONCLUSIONS

Intraoperative intravenous esketamine at 0.25 mg · kg-1 · h-1 reduced postoperative opioids consumption by 34% in postoperative 24 hours and 30% in postoperative 48 hours in patients undergoing thoracic surgery. It also improved the quality of perioperative recovery.

Techniques and complications of popliteal nerve blocks

BACKGROUND

Use of popliteal nerve blocks (PNBs) as an alternative or adjunctive therapy to traditional methods of pain control (e.g., systemic or spinal anesthesia and opioids) is increasingly popular in foot and ankle surgery.

METHODS

We reviewed online databases for literature on PNBs in foot and ankle surgery to analyze the various techniques and positioning used, the influence of drugs on their efficacy, and possible complications associated with their use. Thirty articles were identified with a predefined search criteria, followed by a review process for relevance.

RESULTS

Patient demographics, procedure specifics, and block techniques, such as anesthetic used, can impact the duration and success of a PNB. Administration with ultrasound guidance proved superior to nerve stimulation, and preoperative administration was superior to postoperative administration.

CONCLUSIONS

PNBs are an effective method to control postoperative pain with minimal complications, leading to decreased analgesic use, earlier discharge, and higher patient satisfaction.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Efficacy evaluation of True Lift®, a nonsurgical facial ligament retightening injection technique: Two case reports

BACKGROUND

With aging, four major facial retaining ligaments become elongated, leading to facial sagging and wrinkling. Even though synthetic fillers are popular, however, it cannot address the problems of soft tissue descent alone, and injection of these fillers requires knowledge of the injection technique including the selection of injection sites, the amount of filler, and the dosage used per injection site.

CASE SUMMARY

This report aimed to assess the safety and efficacy of a nonsurgical retightening technique to lift and tighten the true ligaments of the face, to improve age-related skin sagging and wrinkling. We objectively quantified the aesthetic lifting effect of a nonsurgical facial retightening procedure that strategically injected high G’ fillers into the base of the true retaining ligaments of the face in two female patients. Facial images were recorded with a three-dimensional facial imaging system for comparison of the clinical outcome. The primary efficacy outcome was the change in facial anthropometric measurements obtained prior to and after injection. The patients were followed for 6 mo after the procedure. Skin retightening was observed, with an evident lift in the orbital, zygomatic, and mandibular regions, and the lifting effect was still observable at the 6-mo follow-up. Few mild adverse events, such as mild-to-moderate pain, tenderness, and itching, occurred during the 1st week after the procedure. No adverse events were reported 1 mo post-procedure.

CONCLUSION

The results of this study demonstrated that our nonsurgical retightening procedure with strategically placed high G’ fillers achieved quantifiable aesthetic improvements in the orbital, zygomatic, and mandibular regions of two patients. Future research with a larger sample could provide a more in-depth evaluation and validation of the aesthetic improvements observed in this study.

Photocatalytic degradation of pharmaceuticals by pore-structured graphitic carbon nitride with carbon vacancy in water: Identification of intermediate degradants and effects of active species

Pharmaceuticals are increasingly used in daily life and have been massively discharged to the aquatic environment. The removal of pharmaceuticals from water by various nanomaterials including graphitic carbon nitride (g-C₃N₄) has received extensive attention. Herein, we synthesized a carbon-defective carbon nitride with pore structure through a simple thermal polymerization method for photodegradation of lidocaine, mepivacaine and ropivacaine (typical amide local anesthetics). The results showed that the degradation process conformed to the pseudo-first-order reaction kinetics, and the degradation rate constant of organic pollutants using CCN-600 (i.e., g-C₃N₄ synthesized at 600 °C) reached 5.05 × 10^-2 min^-1, about 2.5 times higher than that of the prototype g-C₃N₄ (2.09 × 10^-2 min^-1). The capture experiment of active species and the electron paramagnetic resonance (EPR) test demonstrated that superoxide radical (O₂^-) played a major role in the degradation process. Based on the possible photodegraded intermediate products identified, the degradation pathways were deduced. This study provides not only a new strategy for fabrication of pore-structured g-C₃N₄ with carbon vacancy, but also a reference method for the treatment of pharmaceuticals in water bodies.

[Environmental Sustainability in Healthcare Systems: The Role of Anaesthesiology]

N/a.

Comparison of ultrasound guided pulsed radiofrequency of genicular nerve with local anesthetic and steroid block for management of osteoarthritis knee pain

Background

To compare ultrasound-guided pulsed radiofrequency (PRF) of the genicular nerve with the genicular nerve block using local anesthetic and steroid for management of osteoarthritis (OA) knee pain.

Methods

Thirty patients with OA knee were randomly allocated to receive either ultrasound-guided PRF of the genicular nerve (PRF group) or nerve block with bupivacaine and methylprednisolone acetate (local anesthetic steroid [LAS] group). Verbal numeric rating scale (VNRS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) scores were measured at pre-procedure and 1-, 4-, and 12-weeks post-procedure.

Results

VNRS scores decreased significantly (P < 0.001) in both the groups at 12 weeks and other follow up times compared to baseline. Seventy-three percent of patients in the PRF group and 66% in the LAS group achieved effective pain relief (≥ 50% pain reduction) at 12 weeks (P > 0.999). There was also a statistically significant (P < 0.001) improvement in WOMAC scores in both groups at all follow up times. However, there was no intergroup difference in VNRS (P = 0.893) and WOMAC scores (P = 0.983). No complications were reported.

Conclusions

Both ultrasound-guided PRF of the genicular nerve and blocks of genicular nerve with local anesthetic and a steroid provided comparable pain relief without any complications. However, PRF of the genicular nerve is a procedure that takes much more time and equipment than the genicular nerve block.

Redistribution of critical drugs in shortage during the first wave of COVID-19 in France: from operating theaters to intensive care units

Background

Tension in the supply of highly consumed drugs for patients with COVID-19 (propofol, midazolam, curares) led the French government to set up a centralized supply of hospitals with distribution based on the number of resuscitation beds in March 2020. The French Societies of Clinical Pharmacy and of Anesthesia and Critical Care aimed to evaluate the changes in total needs and the distribution between anesthesia and critical care activities (CCU), to prepare resumed surgical activity.

Methods

National declarative survey among pharmacists, via an online form (SurveyMonkey®), was conducted in April and May 2020. The analysis focused on quantities dispensed during the whole year 2019, and March and April of year 2019 and 2020 for the drugs subject to quota, and on their distribution in CCU and operating theaters.

Results

For the 358 establishments (47% public, 53% private), dispensations in CCU in March 2020 compared to March 2019 increased, respectively: propofol (+81%), midazolam (+125%), cisatracurium (+311%), atracurium (+138%), rocuronium (+119%); and decreased for anaesthesia: propofol (−27%), midazolam (-10%), cisatracurium (−19%), atracurium (−27%), rocuronium (+16%).

Conclusions

Variation of dispensations between CCU and others was directly related to the increase of COVID patients in CCU and the decrease in surgical activity. Each establishment could receive up to five or six different presentations and concentrations, leading to a major risk of medication error. This collaborative national survey provided accurate data on the drugs’ usual consumption. This work emphasized the need for a strong collaboration between pharmacists and anesthesiologists and intensive care physicians. It was further used by the Health Ministry to adjust the drug distribution.

Current status of nitrous oxide use in pediatric patients

Nitrous oxide is one of the most commonly used inhalational anesthetic agents used in practice. It is a cost-effective, pleasant, safe, and versatile anesthetic agent with many desirable properties like good quality analgesia, decreased awareness, accelerated induction and recovery from anesthesia, and reduced utilization of other expensive inhalational agents with potential cost savings. The use of nitrous oxide has been questioned by a lot of studies and case reports perceiving its adverse systemic, hematological, immune, and neurologic adverse effects. However, the literature in the recent past has tried to resolve the controversies related to its use. The concerns over an increase in cardiovascular complications and mortality following nitrous oxide use have been negated by recent data. However, its use in certain vulnerable populations like children with cobalamin and folate deficiency or defects in their metabolic pathways remains a cause of concern for its toxic effects. In this narrative review, we aim to discuss the pharmacological properties of nitrous oxide, the potential advantages and drawbacks of the use of nitrous oxide in children, address the neurodevelopmental and other systemic effects, and throw light on the evidence regarding the safety of nitrous oxide use and its current role in pediatric procedural sedation and anesthesia practice. The literature related to its use in the pediatric population for painful procedures and surgeries has been summarized.

Addressing the need for patient-friendly medical communications: adaptation of the 2019 recommendations for the management of MPS VI and MPS IVA

BACKGROUND

Patients are the most important stakeholders in the care of any disease and have an educational need to learn about their condition and the treatment they should receive. Considering this need for patient-focused materials, we present a directed approach for mucopolysaccharidosis (MPS) VI and MPS IVA, a pair of rare, inherited diseases that affects multiple organs and parts of the body. Independent guidelines on the treatment of these diseases were recently published, providing evidence- and expertise-driven recommendations to optimize patient management. However, while healthcare providers may have the training and knowledge to understand these guidelines, patients and their caregivers can find the technical content challenging. Hence, we aimed to develop plain language summaries (PLS) of the MPS VI and MPS IVA guidelines with patients as the primary audience.

RESULTS

A review of the guidelines by an expert team identified six domains of information relevant to patients: The multidisciplinary team, regular tests and check-ups, disease-modifying and supportive treatments, general anesthetics, ear-nose-throat/respiratory care, and surgeries. This information was adapted into a series of infographics specific to either MPS VI or MPS IVA, designed to appeal to patients and clearly present information in a concise manner.

CONCLUSIONS

The use of patient-friendly materials, like the infographics we have developed, has the potential to better inform patients and engage them in their care. We issue a "call to arms" to the medical community for the development of similar PLS materials in rare diseases intended to inform and empower patients.

Effects of anesthetics on expression of dopamine and acetylcholine receptors in the rat brain in vivo

Dopamine D₂ and acetylcholine M₁ receptors might be related to post-operative cognitive dysfunction. The aim of the present study is to investigate whether several anesthetics which are used for general anesthesia and/or sedation, affect expression of dopamine D₂ and acetylcholine M₁ receptors in the rat brain. Thirty-six male rats aged 5-9 weeks old were divided into six groups (n = 6 in each group); five groups for anesthetics and one for control. The five groups were anesthetized with either dexmedetomidine 0.4 µg/kg/min, propofol 50 mg/kg/h, midazolam 25 mg/kg/h, sevoflurane 3.3%, or nitrous oxide 75% for 4 h. Then, the rats were decapitated, and the cerebral cortex, hippocampus, corpus striatum, brain stem, and cerebellum were collected from all rats. Then, real-time polymerase chain reaction was performed to examine the expression of Drd2 (cord dopamine D₂ receptor) and Chrm1 (cord acetylcholine M₁ receptor). There were no significant differences among the groups regarding Drd2 and Chrm1 mRNA expression of each region of the brain. Postsynaptic changes of dopamine D₂ and acetylcholine M₁ receptors due to administration of dexmedetomidine, propofol, midazolam, sevoflurane, and nitrous oxide are unlikely to occur at the doses of each anesthetic used in the present study.

Predictive value of immediate pain relief after lumbar transforaminal epidural injection with local anesthetics and steroids for single level radiculopathy

OBJECTIVE

To assess the predictive value of immediate pain-relief after CT-guided transforaminal epidural steroid injection (TFESI) including local anesthetics for longer-term pain relief and patients' global impression of change (PGIC) after 4 weeks.

MATERIALS AND METHODS

One hundred ninety-three patients (age 55.4 ± 14.9) with single-level discogenic lumbar radiculopathy and subsequent TFESI were included. Pain scores were recorded before (NRS₀), 15 min (NRS_15min), and 4 weeks (NRS_4w) after treatment using a numerical-rating-scale (NRS; 0, no pain; 10, intolerable pain). Additionally, the PGIC was assessed after 4 weeks. Two fellowship-trained musculoskeletal radiologists evaluated nerve compression of the injected level and contrast dispersion. Spearman's rank and point-biserial correlation were applied to assess associations between outcome variables and demographics/imaging findings. A p-value < 0.05 was considered to be statistically significant.

RESULTS

There was a significant positive correlation between immediate pain-relief and longer-term pain-reduction (r = 0.24, p = 0.001) with an odds ratio of 2.0 (CI: 1.1-3.6). A good short-term response (NRS_15min ≥ 50% reduction) was associated with a persistent longer-term good response (NRS_4w ≥ 50% reduction) in 59.7% (CI: 50.9-68.0%) of patients. There was no association between short-term pain-relief and PGIC after 4 weeks (p = 0.18). Extent and location of nerve compression and contrast dispersion during TFESI did not correlate with longer-term pain-relief (all p ≥ 0.07).

CONCLUSION

Our results indicate a significant positive correlation between immediate post-procedural and longer-term pain relief after TFESI in patients with lumbar radiculopathy; however, no effect of short-term pain relief is seen on PGIC after 4 weeks. Patients with good longer-term outcome (≥ 50% pain reduction) are twice as likely to have already shown good immediate pain reduction after TFESI.

The influence of anesthesia and surgery on fear extinction

Accumulating evidence has demonstrated significant clinical post-traumatic stress disorder (PTSD) symptoms after anesthesia or surgery. Fear extinction dysfunction is a notable feature of PTSD. Although anesthetics and surgery profoundly affect memory processes, their designated effects on fear extinction have not been dissertated. Previous studies have suggested that innate immune system activation disrupts fear extinction, and surgery has been shown to increase the inflammatory response. Thus, in the current study, we examined the effects of propofol, sevoflurane, dexmedetomidine and surgery on fear extinction in adolescent mice, and further tested whether dexmedetomidine could reverse the injury effect of surgery on fear extinction through its anti-inflammatory effects. Our results showed that propofol (200 mg/kg) impaired the acquisition and recall of cued fear extinction, and surgery disrupted cued fear extinction acquisition/recall and consolidation. In contrast to cued fear extinction, contextual fear extinction was not affected by propofol or surgery. Moreover, dexmedetomidine prevented surgery-induced impairment of cued extinction acquisition and recall but not consolidation. Finally, TNF-α and IL-6 levels in the ventromedial prefrontal cortex were not necessary for the dexmedetomidine treatment effect of surgery-induced fear extinction dysfunction. The study results showed that propofol and surgery selective impaired the cued fear extinction stage in adolescent mice, and dexmedetomidine may unleash a protective effect in preventing postoperative PTSD.

The Protective Effect of Picroside II on Isoflurane-Induced Neuronal Injury in Rats via Downregulating miR-195

INTRODUCTION

Numerous pieces of evidence demonstrated that isoflurane induces hippocampal cell injury and cognitive impairments. Picroside II has been investigated for its anti-apoptosis and antioxidant neuroprotective effects. We aimed to explore the protective effects of picroside II and the role of microRNA-195 (miR-195) on isoflurane-induced neuronal injury in rats.

METHODS

The Morris water maze test was used to evaluate the effects of isoflurane on rats regarding escape latency and time in quadrant parameters. Real-time quantitative PCR was used to detect the expression levels of miR-195 and pro-inflammatory cytokines, including inter-leukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) mRNA, in the hippocampal tissues and neuronal cells.

RESULTS

The picroside II significantly improves isoflurane-induced higher escape latency and lower time spent in the quadrant compared with the control rats. Picroside II also promotes cell viability and suppresses cell apoptosis of isoflurane-induced neuronal cells. Besides, picroside II suppresses the expression of pro-inflammatory cytokines (IL-1β, IL-6, and TNF-α) and miR-195 in vivo and in vitro. Furthermore, overexpression of miR-195 abrogates the effects of picroside II on the expression of pro-inflammatory cytokines. The appropriate dose of picroside II is 20 mg/kg.

CONCLUSION

Picroside II could protect the nervous system possibly through inhibiting the inflammatory response in the isoflurane-induced neuronal injury of rats. The protective effect of picroside II may be achieved by downregulating the expression of miR-195 and then inhibiting the inflammatory response.

The Routes of Administration for Acute Postoperative Pain Medication

Effective treatment of postoperative acute pain, together with early mobilization and nutrition, is one of the perioperative strategies advocated to improve surgical outcome and reduce the costs of hospitalization. Moreover, adequate pain control reduces perioperative morbidity related to surgical stress and can also prevent the incidence of chronic postoperative pain syndromes, whose treatment is still a challenge. The choice of the most appropriate analgesics depends not only on the drug class, but also on the most suitable route of administration, the best dosage for that route, and unique limitations and contraindications for every patient. In the present review, a comprehensive analysis was performed on the different routes of administration of acute postoperative pain medications and their indications and limitations, focusing on recent evidence and international recommendations.

Anesthetics mediated the immunomodulatory effects via regulation of TLR signaling

Anesthetics have been widely used in surgery and found to suppress inflammatory injury and affect the outcomes of the surgery and diseases. In contrast, anesthetics are also found to induce neuronal injury and inflammation. However, the immune-modulation mechanism of anesthetics is still not clear. Recent studies have shown that the immune-modulation of anesthetics is associated with the regulation of toll-like receptor (TLR)-mediated signaling. Moreover, the regulation of anesthetics in TLR signaling is related to modulations of non-coding RNAs (nc RNAs). Consistently, nc RNAs are mainly divided into micro RNAs (miRs) and long non-coding RNAs (lnc RNAs), which have been found to exert regulatory effects on the immune system. In this review, we summarize the immunomodulatory functions of the widely used anesthetic agents, which are associated with regulation of TLR signaling. In addition, we also focus on the roles of nc RNAs induced by anesthetics in regulations of TLR signaling.

Study of anesthetics for euthanasia in rats and mice: A systematic review and meta-analysis on the impact upon biological outcomes (SAFE-RM)

AIM

To summarize the knowledge on the effect of anesthetics employed right before euthanasia on biological outcomes.

DATA SOURCE

A systematic review of the literature to find studies with isoflurane, ketamine, halothane, pentobarbital, or thiopental just before euthanasia of laboratory rats or mice.

STUDY SELECTION

Controlled studies with quantitative data available.

DATA EXTRACTION

The search, data extraction, and risk of bias (RoB) were performed independently by two reviewers using a structured form. For each outcome, an effect size (ES) was calculated relative to the control group. Meta-analysis was performed using robust variance meta-regression for hierarchical data structures, with adjustment for small samples.

DATA SYNTHESIS

We included 20 studies with 407 biological outcomes (110 unique). RoB analysis indicated that 87.5% of the domains evaluated showed unclear risk, 2% high risk, and 10.5% low risk. The effect size for all anesthetics considered together was 0.99 (CI_95% = 0.75-1.23; p < 0.0001). Sub-analyses indicate high effect sizes for pentobarbital (1.14; CI_95% = 0.75-1.52; p < 0.0001), and isoflurane (1.01; CI_95% = 0.58-1.44; p = 0.0005) but not for ketamine (1.49; CI_95% = -7.95-10.9; p = 0.295).

CONCLUSION

We showed that anesthetics interfere differently with the majority of the outcomes assessed. However, our data did not support the use of one anesthetic over others or even the killing without anesthetics. We conclude that outcomes cannot be compared among studies without considering the killing method. This protocol was registered at Prospero (CRD42019119520).

FUNDING

There was no direct funding for this research.

Topical Lidocaine plus Diclofenac as a Local Anesthetic Agent in Central Venous Catheterization; a Randomized Controlled Clinical Trial

Introduction:

Various methods of analgesia can be used to reduce or prevent procedural pain in emergency department (ED). This study aimed to evaluate the effectiveness of topical lidocaine-diclofenac combination compared to lidocaine-prilocaine combination (Xyla-P) in reduction of the pain during central venous catheter (CVC) insertion.

Methods:

In this randomized clinical trial, 100 adult patients requiring CVC insertion in the ED were enrolled. These patients were randomly divided into two groups. The site of CVC insertion was covered with 2 g of topical Xyla-P cream in the first group, and 2 g of topical lidocaine-diclofenac cream in the second group. The primary outcome was the pain during CVC implantation. The secondary outcomes were physician satisfaction and the incidence of side effects.

Results:

 On the visual analog scale (VAS), the pain score during CVC insertion was significantly lower in the second group (p = 0.027). However, there was no difference in pain scores during lidocaine injection between the two groups (p = 0.386). Also, there was no significant difference in the rate of side effects between the two groups (p = 1.0). The physician’s satisfaction with the first group was significantly lower than the second group (p = 0.042).

Conclusion:

Although the CVC insertion pain was significantly lower in patients who received the topical combination of Lidocaine plus Diclofenac, there was no clinically important difference between the two groups and both topical anesthetics were effective and safe in reducing pain intensity. Also, lidocaine-diclofenac combination cream was more cost-effective than Xyla-P cream.

[From ether anesthesia to "green" anesthesia : Challenges in anesthesiology over the last 175 years]

The first public demonstration of ether anesthesia took place 175 years ago. Since that time, insensitivity to pain during surgical operations has been possible. The "Ether Day" has been portrayed in many ways. News of the event soon reached Europe and the rest of the world. The development of suitable apparatuses and anesthetics pathed the way for acceptance of the new method. Since the end of the nineteenth century, quality management has become more and more important. In the first half of the twentieth century the use of anesthetic apparatuses prevailed. In Germany, the medical discipline of anesthesiology was established only after 1945. This happened with support from Anglo-American countries. Further methods, such as intubation and muscle relaxation were introduced. The development of atraumatic cannulas made of plastic greatly facilitated the application of drugs. Consideration of workplace safety as a problem was a long time coming. The first concepts were not developed until the late 1970s. By the 1980s the essential elements of modern anesthesia had finally been implemented. In the beginning of the twenty-first century, the focus was initially on procedures that saved allogeneic blood. New topics emerged, ranging from the effects of anesthesia on tumors up to climate change. Anesthesiology must continue to face new challenges in the future.

The relationship between the effect-site concentration of propofol and sedation scale in children: a pharmacodynamic modeling study

Background

Continuous infusion of propofol has been used to achieve sedation in children. However, the relationship between the effect-site concentration (C_e) of propofol and sedation scale has not been previously examined. The objective of this study was to investigate the relationship between the C_e of propofol and the University of Michigan Sedation Scale (UMSS) score in children with population pharmacodynamic modeling.

Methods

A total of 30 patients (aged 3 to 6 years) who underwent surgery under general anesthesia with propofol and remifentanil lasting more than 1 h were enrolled in this study. Sedation levels were evaluated using the UMSS score every 20 s by a 1 μg/mL stepwise increase in the C_e of propofol during the induction of anesthesia. The pharmacodynamic relationship between the C_e of propofol and UMSS score was analyzed by logistic regression with nonlinear mixed-effect modeling.

Results

The estimated C_e50 (95% confidence interval) of propofol to yield UMSS scores equal to or greater than n were 1.84 (1.54–2.14), 2.64 (2.20–3.08), 3.98 (3.66–4.30), and 4.78 (4.53–5.03) μg/mL for n = 1, 2, 3, and 4, respectively. The slope steepness for the relationship of the C_e versus sedative response to propofol (95% confidence interval) was 5.76 (4.00–7.52).

Conclusions

We quantified the pharmacodynamic relationship between the C_e of propofol and UMSS score, and this finding may be helpful to predict the sedation score at the target C_e of propofol in children.

Trial registration

http://www.clinicaltrials.gov (No.: NCT03195686, Date of registration: 22/06/2017).

Risk assessment of occupational exposure to anesthesia Isoflurane in the hospital and veterinary settings

Despite the modern ventilation and waste anesthetic gas (WAG) scavenging systems, occupational exposure to common volatile anesthesia, isoflurane, can occur in the hospital and veterinary settings, but limited information exists on potential exposure and health risk of isoflurane. We assessed exposure dose rates and risks among clinicians and veterinary professionals from occupational exposure to isoflurane. Through a critical review of open literature (1965 to 2020), we summarized potential adverse effects and exposure scenarios of isoflurane among the professional groups, including anesthetists, nurses, operating room personnel, researchers, and/or veterinarians. Deterministic United States National Research Council/Environmental Protection Agency's risk assessment framework (hazard identification, dose-response relationship, exposure assessment and risk characterization) was used to compute inhalation Reference Doses (RfDs), Average Daily Doses (ADDs), and Hazard Quotient (HQ) values-an established measure of non-carcinogenic (systemic) risks-from exposure to isoflurane to workers in hospital and veterinary settings. We identified the central nervous system as the main target for isoflurane, and that isoflurane has dose-dependent effects on cardiac hemodynamics, can impair pulmonary functions and potentially cross the utero-placental barrier leading to congenital malformation in fetus. Based on the modelled RfDs (range 0.8003-7.55 mg/kg-day) and ADDs (range 0.071-1.9617 mg/kg-day), we estimated 56 different HQ values, of which 5 HQs were higher than 1 (range 1.099-2.4512) under high exposure scenarios. Our results suggest a significant non-carcinogenic risk from isoflurane exposures among workers in the occupational settings. The findings underscore the need to significantly minimize isoflurane release to protect workers' health in the hospital and veterinary environments.