Opioid-Sparing Analgesic Effects from Interscalene Block Impact Anesthetic Management During Shoulder Arthroscopy: A Retrospective Observational Study.

Purpose: Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB. Patients and Methods: In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery. Results: Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward. Conclusion: Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.

Analgesic and Anesthetic Efficacy of Rocuronium/Sugammadex in Otorhinolaryngologic Surgery: A Propensity Score-Matched Analysis.

The use of rocuronium/sugammadex in otorhinolaryngologic surgery improves intubation conditions and surgical rating scales. This study primarily aimed to evaluate the effect of the combination of rocuronium and sugammadex on intraoperative anesthetic consumption. The secondary outcomes were the intraoperative and postoperative morphine milligram equivalent (MME) consumption, duration of intraoperative hypertension, extubation time, incidence of delayed extubation and postoperative nausea and vomiting, pain score, and length of stay. A total of 2848 patients underwent otorhinolaryngologic surgery at a tertiary medical center in southern Taiwan. After applying the exclusion criteria, 2648 of these cases were included, with 167 and 2481 in the rocuronium/sugammadex and cisatracurium/neostigmine groups, respectively. To reduce potential bias, 119 patients in each group were matched by propensity scores for sex, age, body weight, and type of surgery. We found that the rocuronium/sugammadex group was associated with significant preservation of the intraoperative sevoflurane and MME consumption, with reductions of 14.2% (p = 0.009) and 11.8% (p = 0.035), respectively. The use of the combination of rocuronium and sugammadex also significantly increased the dose of intraoperative labetalol (p = 0.002), although there was no significant difference in intraoperative hypertensive events between both groups. In conclusion, our results may encourage the use of the combination of rocuronium and sugammadex as part of volatile-sparing and opioid-sparing anesthesia in otorhinolaryngologic surgery.

Is Prevention of Postoperative Vomiting Surgery Dependent? A Retrospective Cohort Study of Total Knee Arthroplasty.

The study of postoperative nausea and vomiting (PONV) has been ongoing since the early days of general anesthesia. The search for risk factors of PONV and the development of new agents to treat PONV are the two main strategies to combat the adverse side effects of general anesthesia. Female sex, non-smoking status, a history of PONV/motion sickness, and postoperative opioid use are the four independent risk factors for PONV derived after a series of prospective studies, evidence-based systematic reviews, and meta-analyses. The two frequently asked questions that arise ask whether risk factors apply to different clinical settings and whether prevention measures of PONV can be surgery dependent. We conducted a comprehensive review of 665 patients who underwent primary total knee arthroplasty (TKA) between January and December 2019. As nausea is subjective and its measurement is not standardized, postoperative vomiting (POV) was used as a study endpoint. The exclusion criteria were desflurane anesthesia, spinal anesthesia, anesthesia without bispectral index monitoring, and day surgery. Three well-recognized risk factors, consisting of body weight, sevoflurane consumption, and postoperative opioid consumption, were not considered as independent risk factors of POV, while female sex, preoperative adductor canal block (ACB), and dexamethasone were identified as being so in this study. The risk of POV in the female sex was 2.49 times that in the male sex; however, when dexamethasone was used, this risk was reduced by >40% compared with no antiemetic use, and by >50% when patients received preoperative ACB compared with those without the block. The clinical characteristics of our TKA patients-female dominance, old age, and their fairly constant body weights that were distinct from those of other surgical patients-suggested that age may play a crucial role in determining the relative contributions of the different risk factors of POV. We concluded that risk factors of POV are dependent on clinical settings. Based on these results, it is reasonable to speculate that a surgery-dependent plan for the prevention of POV is feasible for patients in similar clinical settings.

Is There an Optimal Timing of Adductor Canal Block for Total Knee Arthroplasty?-A Retrospective Cohort Study.

Adductor canal block (ACB) has gained popularity for postoperative pain control after total knee arthroplasty (TKA). However, its role in TKA has been questioned recently. Our study aimed to clarify the role of ACB in reducing postoperative pain after TKA and to elucidate an optimal timing to perform ACB for better outcomes. We conducted a comprehensive review of the perioperative records of 652 patients undergoing primary TKA from January 2019 to December 2019. Patients were divided into three groups: Group A received general anesthesia without ACB, Group B received ACB before inducing general anesthesia, and Group C received ACB at the post-anesthesia recovery unit (PACU). Patients in Groups B and C had lower pain visual analogue scale (VAS) scores than patients in Group A at the PACU. Opioid consumption was similar among the three groups; however, a slightly higher dose was required by Group A patients. Higher VAS scores were recorded in the ward in Group A than in Groups B and C with the leg at rest. In addition, higher VAS scores were recorded in Group A than in Groups B and C with the leg in continuous passive motion (CPM) training. More patients in Group A (34.9%) quit their first CPM training after a few cycles than those in Groups B (27.0%) and C (20.1%). Group A patients required a higher per kg dose of opioids in the ward than Groups B and C patients. Additionally, the hourly consumption of sevoflurane was similar among the three groups of patients, while Group A and C patients required a higher hourly per kg dose of intraoperative opioids than Group B patients. More patients in Group A (67.6%) and C (61.7%) developed intraoperative hypertension than patients in Group B (52.7%). There was no significant difference in PON (postoperative nausea), POV (postoperative vomiting), postoperative dizziness, or patient satisfaction among the three groups of patients. Group A patients had a longer length of hospital stay compared to Group B and C patients. In conclusion, preoperative ACB could be a better choice for patients undergoing TKA as it decreases intraoperative opioid consumption and facilitates a stable hemodynamic state during surgery.

The effect of cricoid pressure on tracheal intubation in adult patients: a systematic review and meta-analysis.

PURPOSE: This meta-analysis aimed to assess the impact of cricoid pressure (CP) application on intubation outcomes. SOURCE: Electronic databases (i.e., MEDLINE, PubMed, Embase, and Cochrane review) were searched from inception to 2 June 2020 for randomized-controlled trials that assessed the intubation outcomes in adult patients using laryngoscopic approaches with and without the application of CP (i.e., CP vs non-CP group). The primary outcome was the successful first-attempt intubation rate (SFAIR), and the secondary outcomes were intubation time, incidences of poor laryngoscopic views (i.e., Cormack and Lehane grade 3-4), airway complications, and pulmonary aspiration. PRINCIPAL FINDINGS: A total of five trials (published from 2005 to 2018) were included, and all tracheal intubations were performed by anesthesiologists or nurse anesthetists with a video (n = 3) or Macintosh laryngoscope (n = 2) in the operating room. We found no significant difference in SFAIR (risk ratio [RR], 0.98; P = 0.37), incidence of poor laryngoscopic views (RR, 1.49; P = 0.21), and risk of sore throat (RR, 1.17; P = 0.73) between the two groups. Nevertheless, the intubation time on the first successful attempt was slightly longer (weighted mean difference = 4.40 sec, P = 0.002) and risk of hoarseness was higher (RR, 1.70; P = 0.03) in the CP group compared with in the non-CP group. The secondary outcome "pulmonary aspiration" was not analyzed because only one trial was available. CONCLUSION: The application of CP did not have a negative impact on the SFAIR or laryngoscopic view. Nevertheless, this maneuver may slightly prolong intubation time and increase the risk of postoperative hoarseness.

RéSUMé: OBJECTIF : Cette méta-analyse a pour but d'évaluer l'impact de l'application d'une pression cricoïdienne (PC) sur les résultats de l'intubation. SOURCE : Les bases de données électroniques (c.-à-d., MEDLINE, PubMed, Embase, et Cochrane review) ont été examinées de leur création jusqu'au 2 juin 2020 pour en tirer les études randomisées contrôlées évaluant les résultats d'intubation chez les patients adultes utilisant des approches laryngoscopiques avec ou sans application de PC (soit groupe PC et non-PC). Le critère d'évaluation principal était le taux d'intubations réussies à la première tentative, et les critères secondaires incluaient le temps d'intubation, l'incidence de mauvaises vues laryngoscopies (grades 3-4 de Cormack et Lehane), les complications au niveau des voies aériennes et l'aspiration pulmonaire. CONSTATATIONS PRINCIPALES : Cinq études au total (publiées entre 2005 et 2018) ont été incluses, et toutes les intubations trachéales ont été réalisées par des anesthésiologistes ou infirmiers anesthésistes à l'aide d'un vidéolaryngoscope (n = 3) ou d'une lame de Macintosh (n = 2) en salle d'opération. Nous n'avons trouvé aucune différence significative dans le taux d'intubations réussies à la première tentative (risque relatif [RR], 0,98; P = 0,37), dans l'incidence de mauvaises vues laryngoscopiques (RR, 1,49; P = 0,21) ou dans le risque de maux de gorge (RR, 1,17; P = 0,73) entre les deux groupes. En revanche, le temps d'intubation lors de la première tentative réussie était légèrement plus long (différence moyenne pondérée = 4,40 sec, P = 0,002) et le risque d'enrouement était plus élevé (RR, 1,70; P = 0,03) dans le groupe PC que dans le groupe non-PC. Le critère d'évaluation secondaire « aspiration pulmonaire ¼ n'a pas été analysé parce qu'une seule étude le mesurait. CONCLUSION : L'application de PC n'a pas eu d'impact négatif sur le taux d'intubations réussies à la première tentative ou la vue laryngoscopique. Par contre, cette manœuvre pourrait légèrement prolonger le temps d'intubation et augmenter le risque d'enrouement postopératoire.