Comparison of distal radius fracture plating surgery under wide-awake local anesthesia no tourniquet technique and balanced anesthesia: a retrospective cohort study

BACKGROUND

Distal radius fractures (DRF) are frequently treated with internal fixation under general anesthesia or a brachial plexus block. Recently, the wide-awake local anesthesia with no tourniquet (WALANT) technique has been suggested as a method that results in higher patient satisfaction. This study aimed to evaluate the functional outcomes, complications, and patient-reported outcomes of DRF plating surgery under both the WALANT and balanced anesthesia (BA).

METHODS

Ninety-three patients with DRFs who underwent open reduction and plating were included. Regarding the anesthetic technique, 38 patients received WALANT, while 55 received BA, comprised of multimodal pain control brachial plexus anesthesia with light general support. The patient's overall satisfaction in both groups and the intraoperative numerical rating scale of pain and anxiety (0-10) in the WALANT group were recorded. The peri-operative radiographic parameters were measured; the clinical outcomes, including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist mobility, and grip strength, were recorded in up to 1-year follow-up. Results presented with a mean difference and 95% confidence intervals and mean ± standard deviation.

RESULTS

The mean age of patients in the WALANT group was higher than in the BA group (63 ± 17 vs. 54 ± 17, P = 0.005), and there were fewer intra-articular DRF fractures in the WALANT group than in the BA group (AO type A/B/C: 30/3/5 vs. 26/10/19, P = 0.009). The reduction and plating quality were similar in both groups. The clinical outcomes at follow-up were comparable between the two groups, except the WALANT group had worse postoperative 3-month pronation (88% vs. 96%; - 8.0% [ - 15.7 to - 0.2%]) and 6-month pronation (92% vs. 100%; - 9.1% [ - 17.0 to - 1.2%]), and better postoperative 1-year flexion (94% vs. 82%; 12.0% [2.0-22.1%]). The overall satisfaction was comparable in the WALANT and BA groups (8.7 vs. 8.5; 0.2 [ - 0.8 to 1.2]). Patients in the WALANT group reported an injection pain scale of 1.7 ± 2.0, an intraoperative pain scale of 1.2 ± 1.9, and an intraoperative anxiety scale of 2.3 ± 2.8.

CONCLUSION

The reduction quality, functional outcomes, and overall satisfaction were comparable between the WALANT and BA groups. With meticulous preoperative planning, the WALANT technique could be an alternative for DRF plating surgery in selected patients. Trial registration This retrospective study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (KMUHIRB-E(I)-20210201).

Adjuvants for balanced anesthesia in ambulatory surgery

Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.

Effect of balanced opioid-free anaesthesia on postoperative nausea and vomiting after video-assisted thoracoscopic lung resection: protocol for a randomised controlled trial

INTRODUCTION

Opioid-free anaesthesia (OFA) may reduce opioid-related side effects such as postoperative nausea and vomiting (PONV) and hyperalgesia. This study aims to investigate the effects of balanced OFA on PONV and pain outcomes in patients undergoing video-assisted thoracoscopic surgery (VATS).

METHODS AND ANALYSIS

This randomised controlled trial will be conducted at the First Affiliated Hospital of Soochow University in Suzhou, China. A total of 120 adults scheduled for VATS lung resection will be randomly assigned with a 1:1 ratio to either an OFA group or a control group, stratified by sex (n=60 in each group). Patients will receive balanced anaesthesia with esketamine, dexmedetomidine and sevoflurane (the OFA group), or sufentanil and sevoflurane (the control group). All patients will receive PONV prophylaxis with intraoperative dexamethasone and ondansetron. Multimodal analgesia consists of intraoperative flurbiprofen axetil, ropivacaine infiltration at the end of surgery and postoperative patient-controlled sufentanil. The primary outcome is the incidence of PONV within 48 hours after surgery. Secondary outcomes are nausea, vomiting, need for antiemetic therapy, pain scores at rest and while coughing, postoperative sufentanil consumption, need for rescue analgesia, length of post-anaesthesia care unit stay, length of postoperative hospital stay, and 30-day and 90-day post-surgical pain and mortality. Safety outcomes are hypotension, bradycardia, hypertension, tachycardia, interventions for haemodynamic events, level of sedation, headache, dizziness, nightmare and hallucination. All analyses will be performed in the modified intention-to-treat population.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the First Affiliated Hospital of Soochow University (2022-042). All patients will provide written informed consent. The results of this study will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2200059710).

Cardiovascular effects of equipotent doses of isoflurane alone and isoflurane plus fentanyl in New Zealand White rabbits (Oryctolagus cuniculus)

OBJECTIVE To determine effects of equipotent concentrations of fentanyl and isoflurane, compared with isoflurane alone, on cardiovascular variables in New Zealand White rabbits (Oryctolagus cuniculus). ANIMALS 6 adult female New Zealand White rabbits. PROCEDURES Rabbits were anesthetized with isoflurane, and lungs were mechanically ventilated. The minimum alveolar concentration (MAC) of isoflurane alone (baseline) and with fentanyl administered IV to achieve 3 targeted plasma concentrations was determined for each rabbit by means of an electrical stimulus. Cardiovascular variables were measured in a separate experiment at 1.3X isoflurane MAC and equipotent doses of isoflurane plus fentanyl at the same 3 targeted plasma concentrations. Blood samples were collected for measurement of blood gas variables and plasma fentanyl concentrations. Treatment effects were evaluated by repeated-measures ANOVA followed by 2-tailed paired t tests with sequentially rejective Bonferroni correction. RESULTS Mean ± SD MAC of isoflurane was 1.95 ± 0.27%. Mean measured plasma fentanyl concentrations of 4.97, 8.93, and 17.19 ng/mL reduced isoflurane MAC by 17%, 37%, and 56%, respectively. Mean measured plasma fentanyl concentrations during cardiovascular measurements were 5.49, 10.26, and 18.40 ng/mL. Compared with baseline measurements, heart rate was significantly lower at all 3 plasma fentanyl concentrations, mean arterial blood pressure and systemic vascular resistance were significantly higher at mean fentanyl concentrations of 10.26 and 18.40 ng/mL, and cardiac output was significantly higher at 18.40 ng of fentanyl/mL. CONCLUSIONS AND CLINICAL RELEVANCE Administration of fentanyl in isoflurane-anesthetized rabbits resulted in improved mean arterial blood pressure and cardiac output, compared with isoflurane alone. This balanced anesthesia technique may prove useful in the management of clinical cases in this species.

[The Hemodynamics and Bispectral Index Score during Lower Abdominal Surgery under Balanced Anesthesia with the Two Different Combination Doses of Desflurane and Remifentanil]

BACKGROUND

The purpose of this study was to examine the hemodynamics and bispectral index score during lower abdominal surgery under balanced anesthesia with the two different combination doses of desflurane and remifentanil.

METHODS

Twenty patients undergoing total hysterectomy were allocated into two groups; 1) 10 patients received 4.5% end-tidal concentration of desflurane combined with remifentanil 0.125 μg x kg(-1) x min(-1) (H group) and 2) 10 patients received 3.0% end-tidal concentration of desflurane combined with remifentanil 0.2 μg x kg(-1) X min(-1) (L group). Mean arterial pressure (MAP), heart rate (HR) and BIS were recorded 5 times (on admission to operating room, immediately before surgery, 5 minutes after the skin incision, at the moment of uterine extraction and during retroperitoneal closure).

RESULTS

MAP and HR during surgery did not increase compared with those on admission to operating room, and BIS was unchanged throughout the study in both two groups.

CONCLUSIONS

The patients could be anesthetized adequately during lower abdominal surgery under balanced anesthesia with the two different combination doses of desflurane and remifentanil.

[Dexmedetomidine improves oxygenation during one-lung ventilation in balanced anesthesia with propofol-fentanyl in adults]

OBJECTIVE

To investigate the effect of dexmedetomidine on oxygenation function in adult patients with balanced anesthesia by propofol-fentanyl under one-lung ventilation (OLV).

METHODS

Twenty-two patients undergoing thoracic operation were randomly divided into the study group and control group, both receiving propofol and fentanyl balanced anesthesia. In the study group, additional infusion of dexmedetomidine (0.3 µg/kg loading dose, 0.3 µg·kg(-1)·h(-1) maintenance dose) was administered, and the patients in the control group received only normal saline. Arterial blood samples were obtained at 4 time points from each patient during anesthesia for blood gas analysis.

RESULTS

In the study group, the pH values remained stable, the oxygenation index tended to decline progressively, but the incidence of hypoxemia was low; in the control group, the pH value and oxygenation index both declined progressively with a higher incidence of hypoxemia.

CONCLUSION

Dexmedetomidine can better maintain the oxygenation function of OLV patients in balanced anesthesia by propofol and fentanyl, and its mechanism may be related to the decreased dose of propofol used.

[Migration of a stent implanted in the pulmonary artery of a patient with tetralogy of Fallot]

Tetralogy of Fallot is a congenital heart disease that accounts for 11-13% of the congenital cardiomyopathies. Stenosis and hyperplasia of the pulmonary arteries occur in a high proportion of them as this disease causes a native stenosis of the pulmonary branch, which can be surgically repaired with a stent. The use of balloon expandable intravascular stents is an alternative technique to further surgery in patients with congenital heart diseases. However, despite the gradual increase in their use, the limited number of procedures, combined with the wide anatomical variability and different characteristics of these patients, even in expert hands, stent implants are associated with a not inconsiderable incidence of complications. These are not always obvious and often require performing surgery in patients who have already had multiple interventions, thus increasing the complexity and the risk.