Comparison of remimazolam and desflurane in emergence agitation after general anesthesia for nasal surgery: A prospective randomized controlled study

Background

Remimazolam is an ultrashort-acting benzodiazepine. Few studies have evaluated the effects of remimazolam-based total intravenous anesthesia (TIVA) on emergence agitation (EA). This study aimed to compare the incidence and severity of EA between TIVA using remimazolam and desflurane.

Methods

This prospective randomized controlled study enrolled 76 patients who underwent nasal surgery under general anesthesia. Patients were randomized into two groups of 38 each: desflurane-nitrous oxide (N2O) (DN) and remimazolam-remifentanil (RR) groups. The same protocol was used for each group from induction to emergence, except for the use of different anesthetics during maintenance of anesthesia according to the assigned group: desflurane and nitrous oxide for the DN group and remimazolam and remifentanil for the RR group. The incidence of EA as the primary outcome was evaluated using three scales: Ricker Sedation-Agitation Scale, Richmond Agitation-Sedation Scale, and Aono's four-point agitation scale. Additionally, hemodynamic changes during emergence and postoperative sense of suffocation were compared.

Results

The incidence of EA was significantly lower in the RR group than in the DN group in all three types of EA assessment scales (all P < 0.001). During emergence, the change in heart rate differed between the two groups (P = 0.002). The sense of suffocation was lower in the RR group than in the DN group (P = 0.027).

Conclusions

RR reduced the incidence and severity of EA in patients undergoing nasal surgery under general anesthesia. In addition, RR was favorable for managing hemodynamics and postoperative sense of suffocation.

Effects of anesthesia on long-term survival in cancer surgery: A systematic review and meta-analysis

Backgrounds

The association between anesthesia and long-term oncological outcome after cancer surgery remains controversial. This study aimed to investigate the effect of propofol-based anesthesia and inhalation anesthesia on long-term survival in cancer surgery.

Methods

A comprehensive literature search was performed in PubMed, Medline, Embase, and the Cochrane Library until November 15, 2023. The outcomes included overall survival (OS) and recurrence-free survival (RFS). The hazard ratio (HR) and 95 % confidence interval (CI) were calculated with a random-effects model.

Results

We included forty-two retrospective cohort studies and two randomized controlled trials (RCTs) with 686,923 patients. Propofol-based anesthesia was associated with improved OS (HR = 0.82, 95 % CI:0.76-0.88, P < 0.00001) and RFS (HR = 0.80, 95 % CI:0.73-0.88, P < 0.00001) than inhalation anesthesia after cancer surgery. However, these positive results were only observed in single-center studies (OS: HR = 0.76, 95 % CI:0.68-0.84, P < 0.00001; RFS: HR = 0.76, 95 % CI:0.66-0.87, P < 0.0001), but not in multicenter studies (OS: HR = 0.98, 95 % CI:0.94-1.03, P = 0.51; RFS: HR = 0.95, 95 % CI:0.87-1.04, P = 0.26). The subgroup analysis revealed that propofol-based anesthesia provided OS and RFS advantages in hepatobiliary cancer (OS: HR = 0.58, 95 % CI:0.40-0.86, P = 0.005; RFS: HR = 0.62, 95 % CI:0.44-0.86, P = 0.005), gynecological cancer (OS: HR = 0.52, 95 % CI:0.33-0.81, P = 0.004; RFS: HR = 0.51, 95 % CI:0.36-0.72, P = 0.0001), and osteosarcoma (OS: HR = 0.30, 95 % CI:0.11-0.81, P = 0.02; RFS: HR = 0.32, 95 % CI:0.14-0.75, P = 0.008) surgeries.

Conclusion

Propofol-based anesthesia may be associated with improved OS and RFS than inhalation anesthesia in some cancer surgeries. Considering the inherent weaknesses of retrospective designs and the strong publication bias, our findings should be interpreted with caution. Well-designed multicenter RCTs are still urgent to further confirm these findings.

Randomized controlled trial of the effect of general anesthetics on postoperative recovery after minimally invasive nephrectomy

BACKGROUND

General anesthetic techniques can affect postoperative recovery. We compared the effect of propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia on postoperative recovery.

METHODS

In this randomized trial, 150 patients undergoing robot-assisted or laparoscopic nephrectomy for renal cancer were randomly allocated to either the TIVA or desflurane anesthesia (DES) group. Postoperative recovery was evaluated using the Korean version of the Quality of Recovery-15 questionnaire (QoR-15K) at 24 h, 48 h, and 72 h postoperatively. A generalized estimating equation (GEE) was performed to analyze longitudinal QoR-15K data. Fentanyl consumption, pain severity, postoperative nausea and vomiting, and quality of life three weeks after discharge were also compared.

RESULTS

Data were analyzed for 70 patients in each group. The TIVA group showed significantly higher QoR-15K scores at 24 and 48 h postoperatively (24 h: DES, 96 [77, 109] vs. TIVA, 104 [82, 117], median difference 8 [95% CI: 1, 15], P = 0.029; 48 h: 110 [95, 128] vs. 125 [109, 130], median difference 8 [95% CI: 1, 15], P = 0.022), however not at 72 h (P = 0.400). The GEE revealed significant effects of group (adjusted mean difference 6.2, 95% CI: 0.39, 12.1, P = 0.037) and time (P < 0.001) on postoperative QoR-15K scores without group-time interaction (P = 0.051). However, there were no significant differences in other outcomes, except for fentanyl consumption, within the first 24 h postoperatively.

CONCLUSIONS

Propofol-based TIVA showed only a transient improvement in postoperative recovery than desflurane anesthesia, without significant differences in other outcomes.

Hemodynamic impact of increasing time between fentanyl and propofol administration during anesthesia induction: a randomised, clinical trial

BACKGROUND AND OBJECTIVE

Anesthesia induction can produce severe propofol dose-dependent hypotension. Fentanyl coadministration reduces the catecholaminergic response to orotracheal intubation allowing propofol dose reduction. The aim of this study is to determine whether the hemodynamic response is improved by increasing the time between fentanyl and propofol administration and reducing the dose of the latter without increasing the time to achieve optimal hypnosis.

METHODS

After approval by the Research Ethics Committee, patients undergoing non-cardiac surgery with endotracheal intubation were randomized by a computer-generated table into six time-dose groups (1 or 2...minutes/1, 1.5, or 2...mg.kg-1 of propofol). Patients with high bronchoaspiration risk, a difficult airway, hemodynamic instability, or anesthetic allergies were excluded. After giving intravenous fentanyl (2.....g.kg-1), each group received different doses of propofol after 1 or 2...minutes. Noninvasive blood pressure (BP) and heart rate (HR) were measured at pre-induction, pre-intubation, and post-intubation. Time to hypnosis (bispectral index < 60) was also recorded.

RESULTS

Of the 192 recruited patients, 186 completed the study (1...min group n...=...94; 2...min group n...=...92). It was observed that HR and BP decreased after propofol administration and increased after intubation in all groups (p...<...0.0001). In patients over 55 years, the 2 min ... 2 mg.kg-1 group showed the greatest systolic BP reduction (36........12%) at pre-intubation, while the 1...min.........1.5...mg.kg-1 group showed the least hemodynamic alteration between pre- and post-intubation (-4........13%). No significant differences were found in younger patients or in the time to reach hypnosis between the six groups. While no cases of severe bradycardia were recorded, 5,4% of the sample required vasopressors.

CONCLUSION

Increasing the time between the administration of fentanyl and propofol by up to two minutes results in greater hypotension in patients over 55 years.

A difficult airway approach in a merosin-deficient congenital muscular dystrophy patient: a case report

Merosin-deficient muscular dystrophy is caused by an autosomal recessive mutation on laminin-..2 gene characterized by severe progressive muscle weakness associated with neuromuscular scoliosis and restrictive lung disease. In this case report, we describe an alternative airway approach performed in a child with anticipated difficult airway and merosin-deficient muscular dystrophy. Significant anesthetic implications may increase the perioperative risk, requiring accurate knowledge to anticipate an adequate management and provide patient-safety strategies.

Comparison of the recovery profile of remimazolam with flumazenil and propofol anesthesia for open thyroidectomy

BACKGROUND

Previous studies have consistently reported a slower recovery of consciousness following remimazolam-based total intravenous anesthesia without flumazenil than with propofol. This study aimed to compare the reversal effect of flumazenil on the recovery of consciousness after remimazolam-based total intravenous anesthesia with the propofol recovery profile.

METHODS

This prospective, single-blinded, randomized trial included 57 patients undergoing elective open thyroidectomy at a tertiary university hospital. Patients were randomly allocated to receive either remimazolam- or propofol-based total intravenous anesthesia (remimazolam group: 28 patients, propofol group: 29 patients). The primary outcome was the time from the end of general anesthesia to first eye opening (min). The secondary outcomes were the time from the end of the general anesthesia to extubation (min), initial modified Aldrete score measured at the post-anesthesia care unit, length of stay at the post-anesthesia care unit (min), occurrence of postoperative nausea and vomiting during the first 24 h postoperatively, and Korean version of Quality of Recovery-15 score at 24 h postoperatively.

RESULTS

The remimazolam group showed significantly faster first eye opening time (2.3 [interquartile range, IQR: 1.8-3.3] min vs. 5.0 [IQR: 3.5-7.8] min, median difference:-2.7 [95% confidence interval, CI: -3.7 to -1.5] min, P < 0.001) and extubation time (3.2 [IQR: 2.4-4.2] min vs. 5.7 [IQR: 4.7-8.3] min, median difference: -2.7 [97.5% CI: -5.0 to -1.6] min, P < 0.001). There were no significant differences in other postoperative outcomes.

CONCLUSIONS

The planned incorporation of flumazenil with remimazolam-based total intravenous anesthesia provided rapid and reliable recovery of consciousness.

A randomized controlled trial

Background and Aims

Considerable importance has been attached to early recovery and discharge readiness after surgeries. Many centers use total intravenous anesthesia (TIVA) as their anesthesia technique of choice. Target-controlled infusions (TCI) have been proposed as a method to precisely deliver continuous infusions of propofol and opioids as compared to the traditionally used manual-controlled infusion (MCI) methods. However, TCI has also been shown to result in the administration of larger doses of propofol which could cause delayed emergence and recovery from anesthesia. Studies involving TCI have focused mainly on its effects on anesthesia induction but not much literature is available on recovery profiles of patients on TCI. This study was designed to compare the effect of conventionally used MCI methods versus the target-controlled infusion (TCI) method of administering TIVA on recovery characteristics in patients undergoing laparoscopic surgery.

Material and Methods

This was a prospective randomized interventional study on 54 patients. Our primary objective was to compare the rates of recovery from anesthesia as judged by four parameters. Time to return of spontaneous ventilation, time to respond to verbal commands, time to extubation, and time to shift patient out of the operating room after stoppage of propofol infusion. As secondary objectives, intraoperative average bispectral index (BIS) values and total anesthetic drugs (propofol and fentanyl) consumption were also compared.

Results

We noted that for laparoscopic surgeries lasting less than 4 hours, both MCI and TCI techniques of TIVA have comparable rates of recovery after the stoppage of propofol infusion. Total consumption of propofol and fentanyl was also similar; however, with the use of the TCI method of TIVA, better depth of anesthesia as evidenced by lower average BIS levels was noted.

Conclusion

Recovery rates after TIVA using a target-controlled infusion (TCI) system are similar to BIS-guided MCIs in patients undergoing laparoscopic surgery lasting less than 4 hours. TCI resulted in better depths of anesthesia though per kg/min consumption of propofol was found to be more.

Comparison of adjuvant therapy with midazolam, paracetamol, tramadol, or magnesium sulfate during intravenous regional anesthesia with ropivacaine: A randomized clinical trial

Background

Intravenous (IV) regional anesthesia is an easy, safe, reliable, and efficient option for inducing anesthesia during surgeries but with tourniquet-related pain. This study aimed to evaluate midazolam, paracetamol, tramadol, and magnesium sulfate administration as adjuvants with ropivacaine on pain relief and hemodynamic changes in IV regional anesthesia.

Methods

A randomized, double-blind, placebo-controlled trial was conducted in subjects undergoing forearm surgery with IV regional anesthesia. The block randomization method was used to assign eligible participants to each of five study groups. Hemodynamic parameters were assessed before applying the tourniquet, at prespecified time points (5, 10, 15, and 20 min), then and every subsequent 10 min until surgery completion. A Visual Analog Scale was used to assess pain severity at baseline followed by every 15 min until completion of the surgery, and after tourniquet deflation every 30 min to 2 h, and at 6, 12, and 24 h postoperative. Data were analyzed using Chi-square and analysis of variance with repeated data testing.

Results

The shortest onset and the longest duration of sensory block were observed in the tramadol group and the shortest onset of motor block in the midazolam group (P < 0.001). Pain score was estimated to be significantly lower in the tramadol group at the time of tourniquet application and release, and 15 min to 12 h after tourniquet release (P < 0.05). In addition, the lowest dose of pethidine consumption was observed in the tramadol group (P < 0.001).

Conclusion

Tramadol appeared to be able to effectively relieve pain, shorten the onset of sensory block, prolong the duration of sensory block, and achieve the lowest consumption of pethidine.

Contemporary Anesthetic Evaluation and Management for Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a medical treatment most often used in patients with severe major depression that has not responded to other treatments. ECT is also indicated for patients with other severe psychiatric conditions, including bipolar disorder, schizophrenia, schizoaffective disorders, catatonia, and neuroleptic malignant syndrome. Contemporary "modified ECT" involves inducing general anesthesia with neuromuscular blockade before inducing the therapeutic seizure. The goal of this review is to combine an evidence-based update with the experience of the author's institution to provide a practical approach to anesthetic care for the patient undergoing ECT.

Determination of the 95% effective dose of remimazolam to achieve loss of consciousness during anesthesia induction in different age groups

BACKGROUND

Remimazolam is a new ultra short-acting benzodiazepine originally developed as an improved version of midazolam. Recent studies have demonstrated non-inferiority of remimazolam to propofol in general anesthesia. However, to date, few studies have investigated the induction bolus dose of remimazolam required to achieve general anesthesia. We aimed to determine the 95% effective dose (ED95) of remimazolam bolus required to achieve loss of consciousness (LOC) and the appropriate doses for different age groups.

METHODS

Patients aged 20-79 years with the American Society of Anesthesiologists physical status of I or II were enrolled in this study. A total of 120 patients were included representing young, middle-aged, and elderly groups. Loss of eyelash reflex and verbal response after the administration of remimazolam was considered successful LOC. The ED95 of remimazolam was determined using a biased coin up-and-down design with sequential allocation and the isotonic regression method.

RESULTS

The ED95 of remimazolam for induction of general anesthesia was 0.367 mg/kg (95% CI [0.277, 0.392]) in the young group, 0.369 mg/kg (95% CI [0.266, 0.394]) in the middle-aged group, and 0.249 mg/kg (95% CI [0.199, 0.288]) in the elderly group. During the study period, none of the patients required rescue medications for hypotension or bradycardia.

CONCLUSIONS

This study investigated the ED95 of remimazolam bolus for anesthesia induction. The precise dosing of the ED95 can help maintain hemodynamic stability during the induction of anesthesia.

Bispectral index-guided propofol sedation during endoscopic ultrasonography

Background/Aims

Bispectral index (BIS) monitors process and display electroencephalographic data are used to assess the depth of anesthesia. This study retrospectively evaluated the usefulness of BIS monitoring during endoscopic ultrasonography (EUS).

Methods

This study included 725 consecutive patients who underwent EUS under sedation with propofol. BIS monitoring was used in 364 patients and was not used in 361. The following parameters were evaluated: (1) median dose of propofol; (2) respiratory and circulatory depression; (3) occurrence of body movements; (4) awakening score >8 at the time; and (5) awakening score 2 hours after leaving the endoscopy room.

Results

The BIS group received a significantly lower median dose of propofol than the non-BIS group (159.2 mg vs. 167.5 mg; p=0.015) in all age groups. For patients aged ≥75 years, the reduction in heart rate was significantly lower in the BIS group than in the non-BIS group (1.2% vs. 9.1%; p=0.023). Moreover, the occurrence of body movements was markedly lower in the BIS group than in the non-BIS group (8.5% vs. 39.4%; p<0.001).

Conclusions

During EUS examination, BIS monitoring is useful for maintaining a constant depth of anesthesia, especially in patients 75 years of age or older.

Effect of remimazolam on intraoperative neuromonitoring during thyroid surgery: a case series

Intraoperative neuromonitoring is widely used to prevent accidental injury during thyroid surgery. Anesthesia should be performed without muscle relaxant or agents with high muscle-relaxant potency. Remimazolam, a novel intravenous anesthetic, became available for clinical use in 2020. Remimazolam is an ultra-short-acting benzodiazepine with a very high clearance rate. However, there are very few data regarding its effect on currently used intraoperative neurological monitoring. Five patients underwent thyroid surgery using intraoperative recurrent laryngeal neuromonitoring. In all cases, intubation was performed after the administration of rocuronium. Anesthesia was maintained by continuous administration of remimazolam at the recommended dose and remifentanil, and no additional rocuronium or sugammadex was administered. Recurrent laryngeal nerve activity could be detected at the first stimulus after surgery was started, and monitoring continued thereafter. Intraoperative monitoring was performed without problems and all surgeries were completed without any complications. Anesthesia with remimazolam at the normal dose did not prolong the time to first positive electromyogram in patients undergoing thyroid surgery, and enables intraoperative recurrent laryngeal nerve monitoring to be performed without any serious perioperative adverse events. Remimazolam may provide a comparable quality of anesthesia to that of existing drugs for neuromonitoring during thyroid surgery.

Effects of continuous intravenous infusion of propofol on intestinal flora in rats

Under normal circumstances, the gut microbiota, host, and external environment establish a dynamic ecological balance and maintain human health. Once this balance is broken, the intestinal flora dysregulation will form, manifested by changes in the diversity, richness, proportion, location and biological characteristics of the gut microbiota. The hypothesis that propofol alters gut microbes was tested in a rat model with continuous intravenous infusion of propofol. Eight male wistar rats underwent tail vein puncture and catheterization respectively, and were continuously pumped with propofol for 3 h. Feces were collected from each rat before and on the 1 st, 3rd, 7th and 14th days after intervention. Finally, the effect of continuous intravenous infusion of propofol on the intestinal flora of rats was analyzed by high-throughput 16S rRNA gene amplification sequencing. Through high-throughput 16S rRNA gene amplicon sequencing analysis, we found that continuous intravenous infusion of propofol had little effect on intestinal flora in rats. Analysis of Alpha (shannon diversity index) showed that group A-7 was different from group P and group A-1 (P = 0.034), and recovered on the 14th day. Although the species diversity analysis showed a significant difference among the five groups (P = 0.049), the distribution of most fecal samples in the PCoA showed a clustered distribution, indicating similarity. In addition, no significant difference was found in the statistical KEGG difference pathway through LEfSe analysis.

[Comparison of post-operative nausea and vomiting with intravenous versus inhalational anesthesia in laparotomic abdominal surgery: a randomized clinical trial]

BACKGROUND

Postoperative Nausea and Vomiting (PONV) is a multifactorial surgical complication with an unclear underlying cause. Anesthetic methods, patients' characteristics and the type of surgery are considered as factors affecting PONV. This study was designed to compare the effect of inhalational and intravenous anesthesia in abdominal surgery on the incidence and severity of PONV.

METHODS

A single-blinded prospective randomized clinical trial on 105 patients aged 18-65 years was carried out. Patients were divided in two groups of Total Intravenous Anesthesia (TIVA) and Inhalational anesthesia. The incidence and severity of PONV were examined at 0, 2, 6, 12, and 24hours after the surgery. The use of a rescue antiemetic was also evaluated.

RESULTS

Fifty point nine percent of the patients in the inhalation group and 17.3% of the patients in the intravenous group developed PONV (p <0.001). The incidence of vomiting was reported in 11.3% of the Inhalational group and 3.8% of the TIVA group (p=0.15), and 24.5% of patients in the Inhalation group and 9.6% of patients in the intravenous group needed an antiemetic medication (p=0.043).

CONCLUSION

The incidence of postoperative nausea and vomiting and the need for administration of an antiemetic rescue drug, and the severity of nausea in patients were significantly lower in the TIVA group.

Can anesthetics affect bladder cancer recurrence? Total intravenous versus volatile anesthesia in patients undergoing robot-assisted radical cystectomy: A single institution retrospective analysis

BACKGROUND

Radical cystectomy is standard of care and part of a multidisciplinary approach for long-term survival in patients with muscle-invasive bladder cancer (MIBC) or high-grade non-MIBC. Recent data have suggested that anesthetic technique can affect long-term survival and recurrence in patients undergoing cancer related surgery.

METHODS

The records of all patients who underwent robot-assisted radical cystectomy for high-risk non-MIBC or MIBC at a single academic institution from 2014 to 2020 were retrospectively reviewed. Patients were grouped according to whether they received total intravenous (TIVA) or volatile inhalation anesthesia (VIA). Univariable and multivariable cox proportional hazards models were used to compare hazard ratios for distant recurrence. Kaplan-Meier recurrence-free survival curves were constructed from the date of surgery to recurrence.

RESULTS

A total of 231 patients were included, of which 126 (55%) received TIVA and 105 (45%) received VIA. Distant recurrence occurred in 8.7% and 26.7% of patients who received TIVA and VIA, respectively (P < 0.001). Kaplan-Meier analysis demonstrated significant improvement in distant recurrence-free survival with TIVA (log-rank P < 0.001). Multivariable analysis revealed a significant increase in recurrence risk with VIA (HR: 3.4, 95%CI: 1.5-7.7, P < 0.01) and increasing tumor pathological stage (pT2, pT3, pT4, all P < 0.05).

CONCLUSIONS

The use of volatile inhalation anesthetics during robot-assisted radical cystectomy may be associated with an increased risk of distant recurrence. Further studies will be necessary to validate these findings.

Modelling the PSI response in general anesthesia

In anesthesia automation, one of the main important issues is the availability of a reliable measurement of the depth of consciousness level (hypnosis) of the patient. According to this value, the hypnotic drug dosage can be adequately calculated. One of the most studied hypnosis indexes is the bispectral index (BIS). In this article we analyzed an alternative called patient state index (PSI). The objectives of this study are, first, to validate the accuracy of the PSI describing the hypnosis level during the maintenance phase of general anesthesia, by comparing with the BIS and, second, to model the relationship between propofol infusion rate and PSI values, obtained from a SEDLine monitor. For this, real data from patients undergoing general anesthesia simultaneously monitored with both BIS and PSI signals was used. Results obtained are interesting for a correct interpretation of PSI signal in clinical practice.

Which Anesthesia Regimen Is Best to Reduce Pulmonary Complications After Head and Neck Surgery?

OBJECTIVES/HYPOTHESIS

The differences between intravenous and inhalation anesthesia in clinical postoperative pulmonary complications (PPCs) have been studied in cardiac and lung resection surgery. Clinical evidence for the effects of these two anesthetics on PPCs in other types of surgery is still missing. We aimed to assess the impact of sevoflurane and propofol on the incidence of PPCs in patients undergoing surgery for head and neck cancer.

STUDY DESIGN

Double-blind, randomized, controlled trial.

METHODS

We assigned 220 adults at intermediate-to-high risk of PPCs scheduled for head and neck cancer surgery with radial forearm or fibular flap reconstruction to either propofol or sevoflurane as a general anesthetic. The occurrence of pulmonary complications according to the Clavien-Dindo score was defined as the primary (within 7 days after surgery) outcome.

RESULTS

The PPC incidence during 7 days after surgery was 32.4% and 18.2% in the propofol and sevoflurane groups, respectively (P = .027). The corresponding incidence of PPCs in patients who underwent tracheotomy at the end of surgery in the two groups was 44.8% and 24.5%, respectively (P = .030). In addition, the Clavien-Dindo classification showed significant differences between groups in minor complications (grades I and II) but not in major complications (grades III-V).

CONCLUSIONS

Compared with intravenous anesthesia, the administration of sevoflurane reduces the incidence of minor PPCs (grades I and II) in moderate- and high-risk patients who have undergone tracheotomy after head and neck cancer surgery with radial forearm or fibular flap reconstruction.

LEVEL OF EVIDENCE

2 Laryngoscope, 131:E108-E115, 2021.

Impact of Instituting General Anesthesia on Oral Sedation Care in a Tertiary Care Pediatric Dental Clinic

Tertiary pediatric medical centers disproportionately care for low-income, underserved children with significant dental needs. Long wait times for hospital operating room treatment increase tooth loss rather than restoration. Oral sedation has commonly been provided to avoid the long waits for operating room treatment. However, this can be challenging with young, anxious patients. High failure rates and repeat visits for oral sedation have resulted in continued waiting for definitive dental services in the operating room. The Division of Dentistry requested the Department of Anesthesiology to create a general anesthesia program in the dental clinic to increase the use of anesthesia services but align the cost of the anesthetic with the revenue stream. Our aim was to objectively measure the performance of a dental clinic anesthesia service by comparing the percentage of case completions, percentage of complete radiographs, and number of serious adverse events to clinic-based oral sedations. We were also interested in total number of cases completed. We retrospectively studied data regarding an in-office general anesthesia (IOGA) program for dentistry and compared it to oral sedations before and after instituting the IOGA program. Patients received either a general endotracheal anesthetic or nonintubated total intravenous general anesthesia. Successful case completion increased from 88.6% (oral sedation) to 99.5% (IOGA). One hundred percent of IOGA cases had complete radiographs, as opposed to 63.4% for oral sedation. This was an increase from 53.5% from the previous 2 years with oral sedation. Serious adverse event rate was 0% (0/508) for oral sedation and 0.2% (1/418) for IOGA. Comparing 2 years before and after IOGA revealed a decrease in oral sedations from 930 to 508, whereas IOGA increased from 0 to 418 cases. Anesthesia services in dental clinic increased complete dental care and complete radiographs, reduced failed sedations, and were performed safely.

Dexmedetomidine as a non-triggering anesthetic agent in a patient with MELAS syndrome and systemic sepsis - A case report

Background

The selection of anesthetic agents is important in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome patient because serious and unexpected complications can occur after anesthetic exposure.

Case

A 30-year-old man with MELAS syndrome and sepsis underwent colectomy. Propofol was administered by step-wise until target effect-site concentration (Ce) 1.0 μg/ml and stopped for the loss of consciousness and to avoid hemodynamic instability. After the loss of consciousness, total intravenous anesthesia (TIVA) using dexmedetomidine (1.0 μg/ml/h) and remifentanil (1–4 ng/ml of Ce) was performed for the maintenance of anesthesia to avoid malignant hyperthermia and mitochondrial dysfunction. During the surgery, the bispectral index score stayed between 26 and 44, and increased to 97 after the end of anesthesia.

Conclusions

TIVA with dexmedetomidine and remifentanil as non-triggering anesthetic agents in patients with MELAS syndrome and systemic sepsis may have advantages to decrease damages associated with mitochondrial stress and metabolic burden.

Perioperative anesthetic management of patients with malignant pleural mesothelioma undergoing cytoreductive surgery and intraoperative chemotherapy

INTRODUCTION

Cytoreductive surgery with hyperthermic intraoperative chemotherapy (HITHOC) is a therapeutic option for treatment of malignant pleural mesothelioma. Anesthetic management might be challenging.

PATIENTS AND METHODS

A descriptive analysis of a case series is presented. Seven patients with malignant pleural mesothelioma diagnostic undergoing HITHOC surgery were studied. Combined general and epidural anesthesia were administered. An intensive hemodynamic monitorization was implemented. Data regarding perioperative course was analyzed.

RESULTS

Between May 2015 and October 2018 7patients underwent HITHOC procedure. Blood transfusions were administered in all patients, and 5of the 7patients required vasoactive drug administration. Extubation at the end of the procedure was able in 6of the 7patients. The median length of stay in ICU was 4 days, and 29 days for the whole hospitalary stay. No significant postoperative pain was observed.

CONCLUSIONS

HITHOC surgery is a complex procedure in which several hemodynamic changes occur. An intensive intraoperative monitorization was useful for controlling complications.

Efficacy of novel sedation using the combination of dexmedetomidine and midazolam during endoscopic submucosal dissection for esophageal squamous cell carcinoma

BACKGROUND

Endoscopic submucosal dissection (ESD) is the preferred treatment for esophageal squamous cell carcinoma (ESCC). However, ESD can be difficult when patients move due to insufficient sedation. We conducted a prospective confirmatory single arm study to evaluate the efficacy of using dexmedetomidine (DEX) in combination with midazolam as a novel sedation for ESD.

METHODS

Endoscopic submucosal dissection was performed without intubation in 65 patients. The primary outcome was the proportion of patients who did not move or require restraint during ESD, compared to historical control of ESD performed under midazolam sedation. Secondary outcomes included the frequency of complications and self-report questionnaires from patients and endoscopists.

RESULTS

Restraint was not required in 97% of patients sedated using the combination of DEX and midazolam. Depressed respiration, low blood pressure, and bradycardia occurred in 23, 37, and 26% of patients, respectively. All patients recovered without severe complication. Occurrence of low blood pressure and bradycardia were higher, while respiratory depression was lower for the combination group than for the historical control group. The amount of midazolam used was significantly lower than in the control. Of note, 94% of patients had no painful sensations, with 3 reporting chest pain and 3 having a recollection of the procedure. Endoscopists were satisfied with the sedation in 94% of cases. All lesions were resected in en bloc fashion, without perforation.

CONCLUSIONS

The combination of DEX and midazolam provided effective sedation for ESD for ESCC.

Comparative analysis of tracheal intubation anesthesia vs non-tracheal intubation anesthesia for endoscopic treatment of esophago-gastric varices

BACKGROUND

Esophageal-gastro varices (EGV) is one of the common complications of cirrhosis, and esophageal gastric variceal bleeding (EGVB), characterized by acute onset and high severity, is one of the main causes of death in patients with cirrhosis. Painless endoscopic treatment is an important measure for the management of EGV rupture. At present, there are two ways of anesthesia: endotracheal intubation and non-tracheal intubation anesthesia.

AIM

To compare the safety and economy of endotracheal intubation and non-tracheal intubation anesthesia for endoscopic treatment of EGV.

METHODS

The study was performed in 58 patients with inactive bleeding who underwent endoscopic treatment for EGV from September 2017 to August 2018. They were randomly divided into an intravenous anesthesia group (non-intubation group) and a tracheal intubation anesthesia plus intravenous anesthesia group (intubation group). They were compared and analyzed in terms of basic conditions, safety, and economy. Measurement data were analyzed by the t test or rank sum test, and count data were analyzed by the chi-square test.

RESULTS

SpO₂ was significantly lower in the non-intubation group compared with the intubation group (P < 0.05), and there were no significant differences in blood pressure, heart rate, or other vital signs between the two groups (P > 0.05). The intraoperative incidence of adverse reactions such as nausea, cough, hiccup, and snoring was significantly higher in the non-intubation group than in the intubation group, but these had little effect on the operation. The induction time, recovery time, and total operative time of the non-intubation group were significantly shorter than those of the intubation group (P < 0.01). There was no significant difference in endoscopic treatment time, endoscopic treatment cost, total hospitalization cost, or hospitalization days between the two groups (P > 0.05), but the anesthesia cost was higher in the intubation group than in the non-intubation group (P < 0.01).

CONCLUSION

For patients with inactive bleeding undergoing endoscopic treatment for EGV, both tracheal intubation and non-tracheal intubation anesthesia can provide good anesthetic effects, and non-tracheal intubation anesthesia has shorter induction time, quicker recovery and lower anesthesia cost, representing a safe and economical anesthesia method.

Pediatric Electroconvulsive Therapy: An Anesthesiologist's Perspective

Proper planning and communication between psychiatry and anesthesiology teams is vital to conferring the greatest therapeutic benefit to children presenting for electroconvulsive therapy while minimizing risk. Anesthesia for the child undergoing electroconvulsive therapy should ideally provide deep hypnosis, ensure muscle relaxation to reduce injury, have minimal effect on seizure dynamics, and allow for rapid recovery to baseline neurologic and cardiopulmonary status. Unique factors for pediatric electroconvulsive therapy include the potential need for preoperative anxiolytic and inhalational induction of anesthesia, which must be weighed against the detrimental effects of anesthetic agents on the evoked seizure quality required for a successful treatment.

A high risk of sleep apnea is associated with less postoperative cognitive dysfunction after intravenous anesthesia: results of an observational pilot study

Background

The obstructive sleep apnea syndrome (OSAS) is characterized by temporary cerebral hypoxia which can cause cognitive dysfunction. On the other hand, hypoxia induced neurocognitive deficits are detectable after general anesthesia.

The objective of this study was to evaluate the impact of a high risk of OSAS on the postoperative cognitive dysfunction after intravenous anesthesia.

Methods

In this single center trial between June 2012 and June 2013 43 patients aged 55 to 80 years with an estimated hospital stay of at least 3 days undergoing surgery were enrolled. Patients were screened for a high risk of OSAS using the STOP-BANG test. The cognitive function was assessed using a neuropsychological test battery, including the DemTect test for cognitive impairment and the RMBT test for memory, the day before surgery and within 36 h after extubation.

Results

Twenty-two of the 43 analyzed patients were identified as patients with a high risk of OSAS. Preoperatively, OSAS patients showed a significant worse performance only for the DemTect (p = 0.0043). However, when comparing pre- and postoperative test results, the OSAS patients did not show a significant loss in any test but significantly improved in RMBT test, whereas the control group showed a significant worse performance in three of eight tests. In five tests, we found a significant difference between the two groups with respect to the change from pre- to postoperative cognitive function.

Conclusion

Patients with a high risk of OSAS showed a less impairment of memory function and work memory performance after intravenous anesthesia. This might be explained by a beneficial effect of intrinsic hypoxic preconditioning in these patients.

[Anesthesia recovery comparison between remifentanil-propofol and remifentanil-desflurane guided by Bispectral Index® monitoring]

BACKGROUND AND OBJECTIVES

There is a strong demand for fast and predictable anesthesia recovery with few side effects. Choice of the hypnotic agent could impact on that. This study investigated the differences between recoveries after remifentanil-propofol and remifentanil-desflurane anesthesias guided by bispectral index (BIS^®).

METHODS

Forty patients were randomly assigned into 2 groups according to the anesthesia technique applied: remifentanil-propofol (REM-PRO) and remifentanil-desflurane (REM-DES). After the discontinuation of the anesthetics, the times to extubation, to obey commands and to recover the airway protection reflex were recorted. In the post-anesthetic recovery room (PACU) it was recorded the occurrence of nausea and vomiting (PONV), scores of Ramsay sedation scale and of numeric pain scale (NPS), morphine dose and length of stay in the unit.

RESULTS

Data from 38 patients were analyzed: 18 from REM-PRO and 20 from REM-DES group. Anesthesia times were similar (REM-PRO=193min, SD 79.9 vs. 175.7min, SD 87.9 REM-DES; p=0.5). REM-DES had shorter times than REM-PRO group: time to follow command (8.5min; SD 3.0 vs. 5.6min; SD 2.5; p=0.0) and extubation time (6.2 minutes; 3.1-8.5 vs. 9.5 minutes; 4.9-14.4; p=0.0). Times to recover airway protective reflex were similar: 16 patients from REM-PRO (88.9%) restored the airway protective reflex 2min after extubation vs. 17 from REM-DES (89.5%); and 2 patients from REM-PRO (11.1%) vs. 2 from REM-DES (10.5%) 6min after extubation, p=1. Ramsay sedation score, NPS, PONV incidents, morphine dose and PACU stay of length PACU were also similar.

CONCLUSION

Remifentanil-desflurane-based anesthesia has a faster extubation time and to follow command than remifentanil-propofol-based anesthesia when both guided by BIS^®.

Clinical effects of intravenous anesthesia with etomidate plus propofol for subpyloric endoscopic ultrasonography

AIM

To investigate the clinical effects of intravenous anesthesia with etomidate plus propofol for deep sedation during subpyloric endoscopic ultrasonography (EUS).

METHODS

We recruited 60 patients who would undergo subpyloric EUS examination. They were randomly allocated into three groups to receive intravenous etomidate alone (group E, n = 20), intravenous propofol alone (group P, n = 20) and etomidate combined with propofol (group EP, n = 20), respectively. The change of patients' vital signs, examination duration, time to awakening, and adverse effects were observed.

RESULTS

There was no significant difference in the onset time of anesthesia, examination duration or time to awakening among all groups (P > 0.05). There was a significant circulatory fluctuation in group E and group P. In group E, 7 cases had myoclonus and a total of 15 cases developed adverse effects, and the rates of myoclonus and overall adverse effects were significantly higher than those in the other two groups (P < 0.05).

CONCLUSION

Intravenous anesthesia with etomidate plus propofol can be safely and effectively applied to ubpyloric EUS with few adverse effects.

Benefit of general anesthesia monitored by bispectral index compared with monitoring guided only by clinical parameters. Systematic review and meta-analysis

BACKGROUND

The bispectral index parameter is used to guide the titration of general anesthesia; however, many studies have shown conflicting results regarding the benefits of bispectral index monitoring. The objective of this systematic review with meta-analysis is to evaluate the clinical impact of monitoring with the bispectral index parameter.

METHODS

The search for evidence in scientific information sources was conducted during December 2013 to January 2015, the following primary databases: Medline/PubMed, LILACS, Cochrane, CINAHL, Ovid, SCOPUS and TESES. The criteria for inclusion in the study were randomized controlled trials, comparing general anesthesia monitored, with bispectral index parameter with anesthesia guided solely by clinical parameters, and patients aged over 18 years. The criteria for exclusion were studies involving anesthesia or sedation for diagnostic procedures, and intraoperative wake-up test for surgery of the spine.

RESULTS

The use of monitoring with the bispectral index has shown benefits reducing time to extubation, orientation in time and place, and discharge from both the operating room and post anesthetic care unit. The risk of nausea and vomiting after surgery was reduced by 12% in patients monitored with bispectral index. Occurred a reduction of 3% in the risk of cognitive impairment postoperatively at 3 months postoperatively and 6% reduction in the risk of postoperative delirium in patients monitored with bispectral index. Furthermore, the risk of intraoperative memory has been reduced by 1%.

CONCLUSION

Clinically, anesthesia monitoring with the BIS can be justified because it allows advantages from reducing the recovery time after waking, mainly by reducing the administration of general anesthetics as well as the risk of adverse events.

A History of Intravenous Anesthesia in War (1656-1988)

The practice of anesthesia in war places significant restraints on the choice of anesthetic technique used; these include, but are not limited to, safety, simplicity, and portability. Ever since intravenous anesthesia became a practical alternative, there have been military doctors who felt that this technique was particularly suited to this environment. The challenge, as in civilian practice, has been to find the appropriate drugs as well as simple and safe delivery systems. The urgency of war has always stimulated innovation in medicine to counteract the ongoing development of weapons of war and their effects on the human body and to achieve improved survival as public expectations rise. This article traces the development of and the use of intravenous anesthesia by military physicians for battle casualties. The story starts long before the era of modern anesthesia, and the discussion concludes in the dog days of the cold war. The rapidly increasing interest in intravenous anesthesia in both civilian and military practice since the early 1990s is left for other authors to examine.

Effect on thermoregulatory responses in patients undergoing a tympanoplasty in accordance to the anesthetic techniques during PEEP: a comparison between inhalation anesthesia with desflurane and TIVA

BACKGROUND

It has been known that positive end-expiratory pressure (PEEP) increases the vasoconstriction threshold by baroreceptor unloading. We compared the effect on the thermoregulatory responses according to anesthetic techniques between an inhalation anesthesia with desflurane and a total intravenous anesthesia (TIVA) with propofol and reminfentanil when PEEP was applied in patients undergoing tympanoplasty.

METHODS

Forty-six patients with a scheduled tympanoplasty were enrolled and the patients were divided in two study groups. Desflurane was used as an inhalation anesthetic in group 1 (n = 22), while TIVA with propofol and remifentanil was used in group 2 (n = 24). PEEP was applied by 5 cmH2O in both groups and an ambient temperature was maintained at 22-24℃ during surgery. The core temperature and the difference of skin temperature between forearm and fingertip were monitored for about 180 minutes before and after the induction of general anesthesia.

RESULTS

The final core temperature was significantly higher in group 2 (35.4 ± 0.7℃) than in group 1 (34.9 ± 0.5℃). Peripheral thermoregulatory vasoconstriction was found in 5 subjects (23%) in group 1 and in 21 subjects (88%) in group 2. The time taken for reaching the thermoregulatory vasoconstriction threshold was 151.4 ± 19.7 minutes in group 1 and 88.9 ± 14.4 minutes in group 2.

CONCLUSIONS

When PEEP will be applied, anesthesia with TIVA may have more advantages in core temperature preservation than an inhalation anesthesia with desflurane.

The efficacy of the time-scheduled decremental continuous infusion of fentanyl for postoperative patient-controlled analgesia after total intravenous anesthesia

BACKGROUND

Intravenous fentanyl has been used for acute postoperative pain management, but has not always provided reliable adequate analgesia, including patient-controlled analgesia (PCA). The purpose of this study was to investigate the efficacy of time-scheduled decremental infusion of fentanyl for postoperative analgesia.

METHODS

Ninety-nine patients, aged 20-65 years, undergoing laparoscopic-assisted hysterectomy using total intravenous anesthesia (TIVA) were randomly assigned into one of the three groups. Their background infusions of fentanyl diluent (2 ml/hr of diluent was equivalent with 0.5 µg/kg/hr of fentanyl) with PCA were maintained at the fixed-rate of 2 ml/hr until the postoperative 24 hr (FX2-2-2), or at the decremental rates of 6.0, 4.0, 2.0 ml/hr (D6-4-2) and 8.0, 4.0, 2.0 ml/hr (D8-4-2). The visual analogue score (VAS), incidence of inadequate analgesia, frequency of PCA intervention, and side effects were evaluated.

RESULTS

VAS was significantly higher in FX2-2-2 than in D6-4-2 and D8-4-2 until postoperative 3 hr (P < 0.05). After postoperative 4 hr, VAS was significantly higher in FX2-2-2 than D8-4-2 (P < 0.05). The incidence of inadequate analgesia of FX2-2-2 was significantly greater than D6-4-2 (P = 0.038) and D8-4-2 (P < 0.001) until postoperative 1 hr. None of the patients had ventilatory depression, and postoperative nausea and vomiting were not significant among the groups.

CONCLUSIONS

The time-scheduled decremental background infusion regimens of fentanyl, based on the pharmacokinetic model, could provide more effective postoperative pain management after TIVA, and the side effects and the risk for morbidity were not different from the fixed-rate infusion regimen.

Effect of tracheal lidocaine on intubating conditions during propofol-remifentanil target-controlled infusion without neuromuscular blockade in day-case anesthesia

BACKGROUND

Lidocaine is a useful intravenous and topical adjunct to facilitate tracheal intubation. We evaluated the effect of tracheal lidocaine on tracheal intubating conditions without neuromuscular blocking agent and hemodynamics during anesthesia induction with propofol and remifentanil target-controlled infusion (TCI).

METHODS

Fifty patients, aged 18-60 years, scheduled for closed reduction of fractured nasal bone were randomly assigned to the control group (n = 25) or lidocaine group (n = 25). Anesthesia was induced with propofol-remifentanil TCI with the effect-site concentration of 5 µg/ml and 5 ng/ml. Four minutes after the start of propofol-remifentanil TCI, 4% lidocaine or saline 3 ml was instilled to larynx and trachea, and intubation was performed 1 min later. Acceptable intubation was defined as excellent or good intubating conditions. Hemodynamic data, induction and recovery profiles were recorded.

RESULTS

Intubating condition was clinically acceptable in 13 out of 25 (52%) patients in the control group and in 22 out of 25 (88%) in the lidocaine group, and there was a significant difference between the two groups in regard to acceptable intubating conditions (P = 0.005). Mean arterial pressure change over time was significantly different between the two groups. There were no significant differences in the heart rate between the two groups.

CONCLUSIONS

This study demonstrated that laryngotracheal administration of 4% lidocaine could increase the percentage of acceptable conditions for tracheal intubation during propofol and remifentanil anesthesia without neuromuscular blockade.

General anesthesia with endotracheal intubation for the patient with spinal muscular atrophy: A case report

Spinal muscular atrophy (SMA) is a rare lower motor neuron disease without sensory loss that needs special care of anesthesiologists due to increased sensitivity to muscle relaxants, potential for aspiration and respiratory weakness. We anesthetized a 10 year-old girl with type 3 SMA for resection of sebaceous cyst in her occiput. We used intravenous anesthetic technique and intubated the patient without any muscle relaxants. The anesthetic and recovery courses were successful. So we present our general anesthetic case under the endotracheal intubation without any muscle relaxants as one of the anesthetic methods for the patients with SMA.

Application of different anesthetics in colonoscopy and their nursing supports

AIM: To compare the effectiveness and safety between fentanyl in combination with midazolam and propofol intravenous anesthesia in colonoscopy.

METHODS: A total of 130 cases of American Anesthetist Association (ASA) Ⅰ-Ⅱ were included in this study. The patients were randomly divided into 2 groups: FM group (intravenous infusion of fentany and midzolam, n = 75) and FP group (intravenous infusion of fentany and propofol, n = 55). The grade of sedation and analgesia, oblivious degree, onset time, recovery time, satisfaction of endoscopic inspection, respiratory inhibition, mean arterial pressure (MAP), heart rate (HR), and S_pO₂ were recorded.

RESULTS: Satisfactory sedation and analgesia were achieved in both FP and FM group, especially in FP group (t = 29.33, P < 0.01; t = 15.35, P < 0.01). The onset time (t = 6.63, P < 0.01), recovery time (t = 7.83, P < 0.01), oblivious rate (χ² = 22.70, P < 0.01), and satisfaction of endoscopic inspection (P < 0.01 or P < 0.05) in FP group were also superior to that in FM group. The variations of HR, MAP and S_pO₂ in FM group were less than that in FP group (P < 0.05). The incidence rates of respiratory inhibition (S_pO₂ < 90%) were respectively 4% (FM) and 3.6% (FP), which had no significant different (P > 0.05).

CONCLUSION: Both of the two methods can produce safe and effective sedation and anesthesia in colonoscopy. The nursing supports such as respiratory and electrocardiac monitor as well as observation of the sedation depth must be strengthened.