Effectiveness of Erector Spinae Plane Block as Perioperative Analgesia in Midline Sternotomies: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

ABSTRACT: With the advancements in regional anesthesia and ultrasound techniques, the use of non-neuraxial blocks like the erector spinae plane block (ESPB) has been increasing in cardiac surgeries with promising outcomes. A total of 3,264 articles were identified through a literature search. Intervention was defined as ESPB. Comparators were no regional technique performed or sham blocks. Four studies with a total of 226 patients were included. Postoperative opioid consumption was lower in the group that received ESPB than the group that did not (weighted mean difference [WMD]: -204.08; 95% CI: -239.98 to -168.19; P < 0.00001). Intraoperative opioid consumption did not differ between the two groups (WMD: -398.14; 95% CI: -812.17 to 15.98; P = 0.06). Pain scores at 0 hours were lower in the group that received ESPB than the group that did not (WMD: -1.27; 95% CI: -1.99 to -0.56; P = 0.0005). Pain scores did not differ between the two groups at 4-6 hours (WMD: -0.79; 95% CI: -1.70 to 0.13; P = 0.09) and 12 hours (WMD: -0.83; 95% CI: -1.82 to 0.16; P = 0.10). Duration of mechanical ventilation in minutes was lower in the group that received ESPB than the group that did not (WMD: -45.12; 95% CI: -68.82 to -21.43; P = 0.0002). Given the limited number of studies and the substantial heterogeneity of measured outcomes and interventions, further studies are required to assess the benefit of ESPB in midline sternotomies.

Perioperative Autonomic Dysfunction in a Patient With Charcot-Marie-Tooth Disease: A Case Report.

Autonomic dysfunction can lead to unexpected hemodynamic instability during surgery, and best practices for the perioperative care of patients with this condition are not well-defined. We report the case of a 63-year-old woman with Charcot-Marie-Tooth disease who experienced perioperative autonomic dysfunction characterized by severe fluctuations in blood pressure while under spinal anesthesia. However, <1 month later, a second hip surgery performed under general anesthesia with special precautions resulted in an uncomplicated perioperative course, with only mild fluctuations in blood pressure.

Prone Vs. Supine Position Ventilation in Intubated COVID-19 Patients: A Systematic Review and Meta-Analysis.

Whether prone positioning of patients undergoing mechanical ventilation for COVID-19 pneumonia has benefits over supine positioning is not clear. We conducted a systematic review with meta-analysis to determine whether prone versus supine positioning during ventilation resulted in different outcomes for patients with COVID-19 pneumonia. We searched Ovid Medline, Embase, and Web of Science for prospective and retrospective studies up through April 2023. We included studies that compared outcomes of patients with COVID-19 after ventilation in prone and supine positions. The primary outcomes were three mortality measures: hospital, overall, and intensive care unit (ICU). Secondary outcomes were mechanical ventilation days, intensive care unit (ICU) length of stay, and hospital length of stay. We conducted risk of bias analysis and used meta-analysis software to analyze results. Mean difference (MD) was used for continuous data, and odds ratio (OR) was used for dichotomous data, both with 95% CIs. Significant heterogeneity (I2) was considered if I2 was >50%. A statistically significant result was considered if the p-value was <0.05. Of 1787 articles identified, 93 were retrieved, and seven retrospective cohort studies encompassing 5216 patients with COVID-19 were analyzed. ICU mortality was significantly higher in the prone group (OR 2.22, 95% CI 1.43-3.43; p=0.0004). No statistically significant difference was observed between prone and supine groups for hospital mortality (OR, 0.95; 95% CI, 0.66-1.37; p=0.78) or overall mortality (OR, 1.08; 95% CI, 0.72-1.64; p=0.71). Studies that analyzed primary outcomes had significant heterogeneity. Hospital length of stay was significantly higher in the prone than in the supine group (MD, 6.06; 95 % CI, 3.15-8.97; p<0.0001). ICU length of stay and days of mechanical ventilation did not differ between the two groups. In conclusion, mechanical ventilation with prone positioning for all patients with COVID-19 pneumonia may not provide a mortality benefit over supine positioning.

Apneic Oxygenation: A Summarized Review and Stepwise Approach.

Apneic oxygenation is a technique used during airway management procedures to maintain oxygenation and prevent desaturation during a lack of ventilation. Despite its importance, there is a lack of comprehensive information on how to achieve effective apneic oxygenation, leading to misunderstandings and suboptimal utilization of this technique. Apneic oxygenation involves several key steps. Firstly, patient selection is crucial, considering factors such as anticipated difficulty with airway management, reduced functional residual capacity, increased oxygen consumption, and medical conditions associated with impaired oxygenation. Secondly, adequate preoxygenation is essential to optimize oxygen reserves before the onset of apnea, utilizing methods like non-rebreather oxygen masks or specific breathing techniques. Thirdly, maintaining airway patency through techniques such as jaw thrust or nasopharyngeal airway placement allows for unobstructed airflow during the apneic period. Lastly, the selection of the appropriate oxygen delivery method, such as high-flow nasal oxygen or nasal cannula, depends on the patient's existing respiratory support. Despite the growing body of literature on apneic oxygenation, current review articles often lack a stepwise approach for its proper execution. This knowledge gap contributes to the misunderstanding and underutilization of this important tool during intubation and airway management. In conclusion, apneic oxygenation is a valuable technique for maintaining oxygenation during periods of apnea. However, the lack of comprehensive information and stepwise guidance in the current literature hinders its optimal utilization. Clear guidelines and educational resources should be developed to address this knowledge gap and ensure the safe and effective implementation of apneic oxygenation. By following a stepwise approach that includes patient selection, adequate preoxygenation, airway patency, and appropriate oxygen delivery, healthcare providers can enhance patient outcomes and minimize the risk of desaturation during airway management procedures.

Chronic Proton-Pump Inhibitor Therapy and Fracture Risk in Women Aged Between 50 and 65 years: A Retrospective Case-Control Study.

Introduction Chronic proton-pump inhibitor (PPI) prescription is on the rise in the last decade with an increased prevalence in the elderly population. For most patients, this class of drugs is the primary treatment for various diseases. Even though PPIs are generally safe, long-term use has been associated with multiple adverse effects like bone fractures. The extent of the association between PPI and fracture is still unclear in women aged between 50 and 65 years. Besides, many other variables and risk factors must be accounted for in the analysis of this relation. Methods This is a retrospective case-control study looking at women 50-65 years of age who presented to Genesys Health for a low-impact fall. Data were extracted from electronic medical records and fracture outcomes; PPI therapy exposure and duration were determined. Chi-square analysis was performed to determine the association between chronic PPI therapy and fracture outcome and independently analyzed for major risk factors of osteoporosis, including smoking, low body mass index, and cancer. Results Patients in the chronic PPI therapy group were found to have a decreased fracture outcome overall in each subcategory of risk factors. When adjusting for all risk factors, there was a significant but weak association between chronic PPI therapy and increased fracture outcome. Conclusion With different results from previous studies, this study sheds new light on this debate. More studies need to be carried out to determine the association between chronic PPI therapy and fracture outcomes in postmenopausal women.