Impact of Sugammadex Versus Neostigmine Reversal on Postoperative Recovery Time in Patients With Obstructive Sleep Apnea Undergoing Bariatric Surgery: A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Residual neuromuscular blockade can be associated with serious postoperative complications. Sugammadex is a newer neuromuscular blocking drug (NMBD) reversal agent that rapidly and completely reverses rocuronium. Whether sugammadex has any advantages over neostigmine in morbidly obese patients with obstructive sleep apnea (OSA) is unclear. We investigated whether sugammadex would reduce discharge time from the operating room (OR) compared with neostigmine in morbidly obese patients with OSA undergoing bariatric surgery. METHODS: This was a prospective, double-blinded randomized controlled superiority trial with 2 parallel groups. Patients were randomized 1:1 into reversal of NMBD with sugammadex or neostigmine. Our inclusion criteria were morbidly obese adult patients with OSA undergoing elective bariatric surgery under general anesthesia. Our exclusion criteria were allergy to rocuronium, sugammadex or neostigmine, malignant hyperthermia, hepatic or renal insufficiency, neuromuscular diseases, and an inability to give consent. The primary outcome was the time from administration of the NMBD reversal agent to discharge from the OR. Secondary outcomes included the time from administration of the NMBD reversal agent to the time the patient opened eyes to command, and the time to extubation. The Mann-Whitney test was used to compare the outcomes between treatment groups. RESULTS: We randomized 120 patients into 2 groups of 60 patients. Overall median body mass index (BMI) was 48.1 kg/m2 ([interquartile range, IQR]) [43.0-53.5]. The time from drug administration to discharge from OR was 13.0 minutes [10.0-17.0] in the sugammadex group and 13.5 minutes [11.0-18.3] in the neostigmine group (P = .27). The treatment effect estimate with a bootstrapped 95% confidence interval [CI] for time from admission to discharge from OR was -0.5 [-2.5 to 3]. No differences were observed in postoperative complications and other secondary outcomes. CONCLUSIONS: No difference was observed in OR discharge time in morbidly obese patients with OSA when sugammadex was administered instead of neostigmine.

Point-of-Care Gastric Ultrasound to Identify a Full Stomach on a Diabetic Patient Taking a Glucagon-Like Peptide 1 Receptor Agonist.

Recently, there has been increased interest in the relationship between glucagon-like peptide 1 (GLP-1) receptor agonists, delayed gastric emptying, and subsequent risk of aspiration in the perioperative setting. This case illustrates how gastric ultrasound can be incorporated at the bedside to assess the risk of aspiration in patients taking this type of medication for diabetes or weight loss and guide clinical management and anesthetic technique to reduce the risk of aspiration.

Gastric Volume and Antral Area in the Fasting State: A Meta-analysis of Individual Patient Data.

BACKGROUND: Pulmonary aspiration of gastric content is a serious anesthetic complication. Gastric point-of-care ultrasound can determine the type and volume of gastric content when clinical information is equivocal. However, a cutoff value of either antral cross-sectional area or volume that may be considered as the upper limit of normal in fasting subjects is still controversial. The aim of this study is to characterize the distribution of baseline antral area and volume in fasting adult subjects and to identify an upper limit (95th percentile) of these distributions. METHODS: The authors conducted a meta-analysis of individual participant data of primary studies from an academic research network of investigators collaborating in gastric ultrasound. Studies between January 2009 and December 2020 were included. RESULTS: Twelve primary studies met inclusion criteria and were included in the analysis with a sample size of 1,203 subjects. The 95th percentile of area values (measured in the right lateral decubitus) was 9.9 cm2 (95% CI, 9.4 to 10.4), and of volume, 2.3 ml/kg (95% CI, 2.3 to 2.4). In addition, an antrum grade 0 or 1 indicates a 98% probability of an antral area below the 95th percentile. CONCLUSIONS: An area of 10 cm2 measured in the right lateral decubitus could be a simple, data-driven upper limit of antral area that could serve as a surrogate of upper limit of normal gastric volume values in fasting adults. These results are limited by the highly selected sampling of the studies included.

Baseline Gastric Volume in Fasting Diabetic Patients Is Not Higher than That in Nondiabetic Patients: A Cross-sectional Noninferiority Study.

BACKGROUND: The physiology of diabetes mellitus can increase the risk of perioperative aspiration, but there is limited and contradictory evidence on the incidence of "full stomach" in fasting diabetic patients. The aim of this study is to assess the baseline gastric content (using gastric ultrasound) in diabetic and nondiabetic patients scheduled for elective surgery who have followed standard preoperative fasting instructions. METHODS: This was a prospective, noninferiority study of 180 patients (84 diabetic and 96 nondiabetic patients). Bedside ultrasound was used for qualitative and quantitative assessment of the gastric antrum in the supine and right lateral decubitus positions. Fasting gastric volume was estimated based on the cross-sectional area of the gastric antrum and a validated model. The hypothesis was that diabetic patients would not have a higher baseline fasting gastric volume compared to nondiabetic patients, with a noninferiority margin of 0.4 ml/kg. Secondary aims included the comparison of the incidence of full stomach (solid content or more than 1.5 mL/kg of clear fluid), estimation of the 95th percentile of the gastric volume distribution in both groups, and examination of the association between gastric volume, glycemic control, and diabetic comorbidities. RESULTS: The baseline gastric volume was not higher in diabetic patients (0.81 ± 0.61 ml/kg) compared to nondiabetic patients (0.87 ± 0.53 ml/kg) with a mean difference of -0.07 ml/kg (95% CI, -0.24 to 0.10 ml/kg). A total of 13 (15.5%) diabetic and 11 (11.5%) nondiabetic patients presented more than 1.5 ml/kg of gastric volume (95% CI for difference, -7.1 to 15.2%). There was little correlation between the gastric volume and either the time since diagnosis or HbA1C. CONCLUSIONS: The data suggest that the baseline gastric volume in diabetic patients who have followed standard fasting instructions is not higher than that in nondiabetic patients.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of upper and lower limb nerve blocks.

BACKGROUND: Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks. METHODS: We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research. CONCLUSIONS: We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Validation of a novel point-of-care ultrasound method to assess diaphragmatic excursion.

INTRODUCTION: Point-of-care ultrasound can assess diaphragmatic function and rule in or rule out paresis of the diaphragm. While this is a useful bedside tool, established methods have significant limitations. This study explores a new method to assess diaphragmatic motion by measuring the excursion of the uppermost point of the zone of apposition (ZOA) at the mid-axillary line using a high-frequency linear ultrasound probe and compares it with two previously established methods: the assessment of the excursion of the dome of the diaphragm (DOD) and the thickening ratio at the ZOA. METHODS: This is a single-centre, prospective comparative study on elective surgical patients with normal diaphragmatic function. Following research ethics board approval and patient written consent, 75 elective surgical patients with normal diaphragmatic function were evaluated preoperatively. Three ultrasound methods were compared: (1) assessment of the excursion of the DOD using a curvilinear probe through an abdominal window; (2) assessment of the thickening fraction of the ZOA; and (3) assessment of the excursion of the ZOA. The last two methods performed with a linear probe on the lateral aspect of the chest. RESULTS: Seventy-five patients were studied. We found that the evaluation of the excursion of the ZOA was more consistently successful (100% bilaterally) than the evaluation of the excursion of the DOD (98.7% and 34.7% on the right and left sides, respectively). The absolute values of the excursion of the ZOA were greater than and well correlated with the values of the DOD. CONCLUSION: Our preliminary data from this exploratory study suggest that the evaluation of the excursion of the ZOA on the lateral aspect of the chest using a linear probe is consistently successful on both right and left sides. Future studies are needed to establish the distribution of normal values and suggest diagnostic criteria for diaphragmatic paresis or paralysis. TRIAL REGISTRATION NUMBER: NCT03225508.

Gastric Point of Care Ultrasound in Adults: Image Acquisition and Interpretation.

Over the past two decades, diagnostic point-of-care ultrasound (POCUS) has emerged as a rapid and non-invasive bedside tool for addressing clinical inquiries related to gastric content. One emerging concern pertains to patients about to undergo sedation and/or endotracheal intubation: the elevated risk of aspiration from the patient's stomach contents. Aspiration of gastric contents into the lungs poses a serious and potentially life-threatening complication. This occurs more frequently when the stomach is considered "full" and can be affected by the techniques employed for airway management, making it potentially preventable. To mitigate the risk of peri-procedural aspiration, two distinct medical specialties (anesthesiology and critical care medicine) have independently developed techniques to utilize ultrasonography for identifying patients requiring "full stomach" precautions. Due to these separate specialties, the work of each group remains relatively unfamiliar outside its respective field. This article presents descriptions of both techniques for gastric ultrasound. Furthermore, it explains how these approaches can complement each other when one of them falls short. Regarding image acquisition, the article covers the following topics: indications and contraindications, selection of the appropriate probe, patient positioning, and troubleshooting. The article also delves into image interpretation, complete with example images. Additionally, it demonstrates how one of the two techniques can be employed to estimate gastric fluid volume. Lastly, the article briefly discusses medical decision-making based on the findings of this examination.

A hood shield reduces postdoffing contamination during simulated COVID-19 airway management: an exploratory, simulation-based randomized study.

PURPOSE: SARS-CoV-2 poses a significant occupational health threat to health care workers performing aerosol-generating medical procedures, with a threefold increased risk of a positive test and predicted infection compared with the general population. Nevertheless, the personal protective equipment (PPE) configuration that provides better protection with lower contamination rates is still unknown. METHODS: We enrolled 40 practitioners with airway management training (anesthesiologists, anesthesia assistants/nurses) in an exploratory, simulation-based randomized study. We evaluated the performance of a novel, locally designed hood (n = 20) in terms of protection from surrogate contamination using an ultraviolet (UV) marker during a standardized urgent intubation procedure and a simulated episode of coughing in a high-fidelity simulation setting compared with standard PPE (n = 20). The primary outcome was the presence of residual UV fluorescent contamination on any base clothing or exposed skin of the upper body after doffing PPE assessed by a blinded evaluator. RESULTS: The proportion of participants with residual contamination on any base clothing or exposed skin of the upper body after doffing was less than half in the hood PPE group compared with the standard PPE group (8/20 [40%] vs 18/20 [90%], respectively; P = 0.002). CONCLUSIONS: Compared with standard PPE, enhanced PPE with a locally designed prototype hood was associated with reduced contamination of the upper torso and fewer body areas being exposed to droplets after a simulated aerosol-generating scenario without designed airflow. STUDY REGISTRATION: ClinicalTrials.gov (NCT04373096); registered 4 May 2020.

RéSUMé: OBJECTIF: Le SRAS-CoV-2 représente une menace importante pour la santé au travail des travailleurs de la santé réalisant des interventions médicales générant des aérosols, avec un risque trois fois plus élevé de test positif au SRAS-CoV-2 et d'infection prédite au SRAS-CoV-2 par rapport à la population générale. Néanmoins, la configuration optimale des équipements de protection individuelle (EPI) offrant la meilleure protection avec des taux de contamination plus faibles est encore inconnue. MéTHODE: Nous avons recruté 40 praticiens ayant une formation en prise en charge des voies aériennes (anesthésiologistes, assistants en anesthésie/personnel infirmier) dans le cadre d'une étude exploratoire randomisée de simulation. Nous avons évalué la performance d'un nouveau capuchon conçu localement (n = 20) par rapport aux EPI standards (n = 20) en termes de protection contre la contamination de substitution à l'aide d'un marqueur ultraviolet (UV) au cours d'une procédure d'intubation urgente normalisée et d'un épisode simulé de toux dans un environnement de simulation haute fidélité. Le critère d'évaluation principal était la présence d'une contamination résiduelle par fluorescence UV sur les vêtements de base ou la peau exposée du haut du corps après le retrait des EPI telle qu'évaluée par un évaluateur en aveugle. RéSULTATS: La proportion de participants présentant une contamination résiduelle sur les vêtements de base ou la peau exposée du haut du corps après le retrait des équipements de protection était de moins de la moitié dans le groupe ayant porté le capuchon par rapport au groupe EPI standard (8/20 [40 %] vs 18/20 [90 %], respectivement; P = 0,002). CONCLUSION: Par rapport aux EPI standards, les EPI améliorés avec un prototype de capuchon conçu localement étaient associés à une contamination réduite du haut du torse et à moins de zones du corps exposées aux gouttelettes après une mise en situation simulée de génération d'aérosols sans flux d'air préconçu. ENREGISTREMENT DE L'éTUDE: clinicaltrials.gov (NCT04373096); enregistrée le 4 mai 2020.

Preoperative fasting for the infusion of "yerba mate": a randomized clinical trial with ultrasound evaluation of gastric contents

Abstract Background The traditional infusion of "yerba mate" is widely consumed in South America and exported to countries around the world. Although generally considered a "clear fluid", there is no data to date on the gastric emptying time of yerba mate and safe preoperative fasting intervals. The objective of this study was to evaluate the gastric emptying time of a standardized infusion of yerba mate using bedside ultrasound and compare it with the time confirm of hot and cold tea. Methods This was a prospective, randomized crossover experimental study. Thirty healthy volunteers were evaluated after 8 hours of fasting for both fluids and solids. Gastric antral area and gastric volume were evaluated at baseline and every 20 minutes after drinking 300 mL of randomly assigned infusion of "yerba mate", hot tea, or cold tea. Results The mean gastric emptying time was: 69.7 ± 22.1 min, 63.1 ± 14.5 min, and 64.3 ± 23.5 min for the mate, hot tea, and cold tea respectively. No significant differences were found in emptying time among the infusion groups (p-value = 0.043). When same time measures were compared, the only significant difference detected was between hot teas and mate infusion at 20 minutes (p-value = 0.012) Conclusion Yerba mate infusion has a similar gastric emptying time to that of tea. All subject's gastric volume returned to baseline values by 100 minutes. It is reasonable to recommend a similar fasting period of 2 hours for mate infusion prior to elective surgery.

No Benefits of Adding Dexmedetomidine, Ketamine, Dexamethasone, and Nerve Blocks to an Established Multimodal Analgesic Regimen after Total Knee Arthroplasty.

BACKGROUND: An optimal opioid-sparing multimodal analgesic regimen to treat severe pain can enhance recovery after total knee arthroplasty. The hypothesis was that adding five recently described intravenous and regional interventions to multimodal analgesic regimen can further reduce opioid consumption. METHODS: In a double-blinded fashion, 78 patients undergoing elective total knee arthroplasty were randomized to either (1) a control group (n = 39) that received spinal anesthesia with intrathecal morphine, periarticular local anesthesia infiltration, intravenous dexamethasone, and a single injection adductor canal block or (2) a study group (n = 39) that received the same set of analgesic treatments plus five additional interventions: local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intraoperative intravenous dexmedetomidine and ketamine, and postoperatively, one additional intravenous dexamethasone bolus and two additional adductor canal block injections. The primary outcome measure was 24-h cumulative opioid consumption after surgery and secondary outcomes were other analgesics, patient recovery, functional outcomes, and adverse events. RESULTS: Opioid consumption was not different between groups at 24 h (oral morphine equivalents, mean ± SD; study: 23.7 ± 18.0 mg vs. control: 29.3 ± 18.7 mg; mean difference [95% CI], -5.6 mg [-2.7 to 13.9]; P = 0.189) and all other time points after surgery. There were no major differences in pain scores, quality of recovery, or time to reach rehabilitation milestones. Hypotensive episodes occurred more frequently in the study group (25 of 39 [64.1%] vs. 13 of 39 [33.3%]; P = 0.010). CONCLUSIONS: In the presence of periarticular local anesthesia infiltration, intrathecal morphine, single-shot adductor canal block and dexamethasone, the addition of five analgesic interventions-local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intravenous dexmedetomidine, intravenous ketamine, an additional intravenous dexamethasone dose, and repeated adductor canal block injections-failed to further reduce opioid consumption or pain scores or to improve functional outcomes after total knee arthroplasty.

Preoperative fasting for the infusion of "yerba mate": a randomized clinical trial with ultrasound evaluation of gastric contents.

BACKGROUND: The traditional infusion of "yerba mate" is widely consumed in South America and exported to countries around the world. Although generally considered a "clear fluid", there is no data to date on the gastric emptying time of yerba mate and safe preoperative fasting intervals. The objective of this study was to evaluate the gastric emptying time of a standardized infusion of yerba mate using bedside ultrasound and compare it with the time confirm of hot and cold tea. METHODS: This was a prospective, randomized crossover experimental study. Thirty healthy volunteers were evaluated after 8 hours of fasting for both fluids and solids. Gastric antral area and gastric volume were evaluated at baseline and every 20 minutes after drinking 300 mL of randomly assigned infusion of "yerba mate", hot tea, or cold tea. RESULTS: The mean gastric emptying time was: 69.7 ± 22.1 min, 63.1 ± 14.5 min, and 64.3 ± 23.5 min for the mate, hot tea, and cold tea respectively. No significant differences were found in emptying time among the infusion groups (p-value = 0.043). When same time measures were compared, the only significant difference detected was between hot teas and mate infusion at 20 minutes (p-value = 0.012) CONCLUSION: Yerba mate infusion has a similar gastric emptying time to that of tea. All subject's gastric volume returned to baseline values by 100 minutes. It is reasonable to recommend a similar fasting period of 2 hours for mate infusion prior to elective surgery.

Impact of fasting on the gastric volume of critically ill patients before extubation: a prospective observational study using gastric ultrasound.

Background: A period of fasting before tracheal extubation of ventilated patients in the ICU is common practice, aiming to reduce gastric volume and aspiration risk. As the volume of gastric content is unknown at the time of extubation, the efficacy of this practice is uncertain. Methods: A prospective, observational study using gastric ultrasound was undertaken. Images were obtained at four time points: (i) at baseline, with gastric feeds running; (ii) after suctioning of gastric contents through a gastric tube; (iii) after a 4 h period with no gastric feed running; and (iv) after both a 4 h fasting period and gastric tube suctioning. The primary outcome was the proportion of patients classed as low risk of aspiration with each intervention, using qualitative and quantitative gastric ultrasound. Results: Fifty-four patients in the ICU were enrolled. Forty-four (81%) subjects had images that were suitable for analysis. Suctioning of stomach content through a gastric tube and fasting were equivalent with 39/44 (88.6%) and 5/44 (11.4%) subjects classified as low risk and at risk of aspiration, respectively. A period of fasting followed by suction resulted in 41/44 (93.2%) patients being at low risk. Conclusions: Suctioning of stomach contents through the gastric tube and a 4 h fasting period appear equivalent at reducing gastric volume below a safe threshold. A small percentage did not reach the threshold despite all interventions.

Diagnostic Point-of-Care Ultrasound: Recommendations From an Expert Panel.

Diagnostic point-of-care ultrasound (PoCUS) has emerged as a powerful tool to help anesthesiologists guide patient care in both the perioperative setting and the subspecialty arenas. Although anesthesiologists can turn to guideline statements pertaining to other aspects of ultrasound use, to date there remains little in the way of published guidance regarding diagnostic PoCUS. To this end, in 2018, the American Society of Anesthesiologists chartered an ad hoc committee consisting of 23 American Society of Anesthesiologists members to provide recommendations on this topic. The ad hoc committee convened and developed a committee work product. This work product was updated in 2021 by an expert panel of the ad hoc committee to produce the document presented herein. The document, which represents the consensus opinion of a group of practicing anesthesiologists with established expertise in diagnostic ultrasound, addresses the following issues: (1) affirms the practice of diagnostic PoCUS by adequately trained anesthesiologists, (2) identifies the scope of practice of diagnostic PoCUS relevant to anesthesiologists, (3) suggests the minimum level of training needed to achieve competence, (4) provides recommendations for how diagnostic PoCUS can be used safely and ethically, and (5) provides broad guidance about diagnostic ultrasound billing.