Taming Postoperative Delirium with Dexmedetomidine: A Review of the Therapeutic Agent's Neuroprotective Effects following Surgery.

Postoperative delirium (POD) represents a perioperative neurocognitive disorder that has dreaded ramifications on a patient's recovery from surgery. Dexmedetomidine displays multiple mechanisms of neuroprotection to assist in preventing POD as a part of a comprehensive anesthetic care plan. This review will cover dexmedetomidine's pharmacological overlap with the current etiological theories behind POD along with pre-clinical and clinical studies on POD prevention with dexmedetomidine. While the body of evidence surrounding the use of dexmedetomidine for POD prevention still requires further development, promising evidence exists for the use of dexmedetomidine in select dosing and circumstances to enhance recovery from surgery.

Caudal block vs. transversus abdominis plane block for pediatric surgery: a systematic review and meta-analysis.

Background: The caudal block and transversus abdominis plane block (TAP) are commonly used in combination with general anesthesia for pediatric lower abdominal, inguinal, and genitourinary surgeries. There is limited data directly comparing the impact of these techniques on recovery. In this meta-analysis, we compare the duration of postoperative analgesia between these two techniques. Objective: This review examined the duration of analgesia in pediatric patients (age 0-18 years) undergoing surgery who received caudal or TAP block after induction of general anesthesia. The primary outcome was duration of analgesia, defined as the time to first rescue analgesic dose. Secondary outcomes included number of rescue analgesic doses, acetaminophen usage within 24 h postoperatively, 24 h pain score area under the curve, and postoperative nausea and vomiting. Evidence review: We systematically searched Pubmed, Central, EMBASE, CINAHL, Google Scholar, Web of Science citation index, the US clinical trials register, and abstracts from prominent 2020-2022 anesthesia conferences for randomized controlled trials that compared these blocks and reported analgesia duration. Findings: Twelve RCTs inclusive of 825 patients were identified. TAP block was associated with longer analgesia duration (Mean difference = 1.76 h, 95% CI: 0.70-2.81, p = 0.001) and reduced doses of rescue analgesic within 24 h (Mean difference = 0.50 doses, 95% CI: 0.02-0.98, p = 0.04). No statistically significant differences were detected in other outcomes. Conclusion: This meta-analysis suggests that TAP block provides greater duration of analgesia than caudal block after pediatric surgeries. TAP block was also associated with fewer rescue analgesic doses in the first 24 h without increased pain scores. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=380876, identifier: CRD42022380876.

Effectiveness of Thoracic Wall Blocks in Video-Assisted Thoracoscopic Surgery, a Network Meta-Analysis.

Introduction: Thoracic epidural analgesia (TEA) and thoracic paravertebral blocks (PVB) are well-established techniques for pain management in thoracotomy. Here, we examine the efficacy of various thoracic fascial plane blocks vs TEA and PVB for intraoperative and postoperative analgesia for video assisted thoracoscopy surgery (VATS) with network meta-analysis. Methods: A search for prospective randomized control studies using adult patients undergoing VATS with general anesthesia. The interventions of interest were any regional anesthesia techniques used for postoperative pain control after VATS. Primary outcomes of interest were 24-hour opioid requirement and 24-hour pain scores. A Bayesian network meta-analysis was conducted. Results: We identified 42 studies that fulfilled our inclusion criteria. For patients who underwent VATS, TEA (MD = -27MME, 95% CI = -46.2 to -9MME), ESP (MD = -20MME, 95% CI -33 to -7.9MME), PVB (MD = -15MME, 95% CI = -26 to -4.5MME) demonstrated significant opioid sparing efficacy, as well as reduction in cumulative 24-hour static pain scores. However, exclusion of one study due to high risk of bias revealed that TEA did not significantly reduce opioid consumption, nor did it reduce the incidence of PONV, pulmonary complications, or LOS when compared to ESP, SAP, PVB, ICN, or PECS blocks. Conclusion: Our findings suggest that TEA did not provide superior pain relief compared to ESP, SAP, PVB, ICN, or PECS blocks following VATS. Therefore, we propose ESP as a suitable intervention for the prevention of postoperative pain after VATS.

Race-insurance disparities in prostate patients' magnetic resonance imaging biopsies and their subsequent cancer care: a New York State cohort study.

For organ-confined prostate cancer, socioeconomic factors influencing Magnetic Resonance Imaging (MRI)-guided biopsy utilization and downstream prostate cancer patients' care are unknown. This retrospective, observational cohort study used the New York Statewide Planning and Research Cooperative System (SPARCS) billing-code driven database to examine the impact of prostate patients' socioeconomic characteristics on prostate cancer care defined as initial biopsy, 2-month post-biopsy cancer diagnoses, and within 1-year cancer-related intervention, controlling for other risk factors. From 2011-2017, the population studied (n = 18,253) included all New York State-based, male, residents aged 18 to 75 without a prior prostatectomy receiving a first-time biopsy; 760 such patient records in 2016 were removed due to data quality concerns. Major exposures included patient age, race, ethnicity and insurance. The major outcome included receipt of MRI biopsy versus standard biopsy and for these sub-populations, subsequent 2-month post-biopsy metastatic versus non-metastatic prostate cancer diagnosis and within 1-year prostate cancer treatment (prostatectomy with or without radiation versus prostatectomy-only) were compared using dichotomous (primary) and time-to-event (secondary) endpoints. Of 17,493 patients with a first-time prostate biopsy, 3.89% had MRI guided biopsies; of the 17,128 patients with no pre-biopsy cancer diagnosis, the subsequent prostate cancer diagnosis rate was 42.59%. For 6,754 non-metastatic prostate cancer patients with 1-year follow-up, 1,674 (24.79%) received surgery (with or without radiation) and 495 (7.33%) received radiation-only. Holding other factors constant, multivariable regression models identified that race-insurance was a primary predictor of MRI-guided biopsy use. Compared to commercially insured White patients, Black patients across all insurance categories received MRI-guided biopsies less frequently; Commercially insured and self-pay Black patients also had increased chance of prostate cancer diagnosis. Across all insurers, Black patients had lower likelihood of prostatectomies. In contrast, Black and White patients with government insurance were more likely to have within 1-year radiation-only treatments versus commercially insured White patients. Thus, across the prostate cancer care continuum, race-insurance affected prostate cancer-related service utilization. Future research should evaluate the generalizability of these New York State findings.