Effect of nociception level-directed analgesic management on opioid usage in robot-assisted laparoscopic radical prostatectomy: a single-center, single-blinded, randomized controlled trial.

PURPOSE: To assess the importance of appropriate opioid administration methods according to nociceptive monitoring. METHODS: We conducted a randomized controlled trial involving 54 patients who underwent robot-assisted laparoscopic radical prostatectomy at our hospital. Patients were randomly allocated to either receive nociception level (NOL)-directed intraoperative opioid management with a minimum flow of remifentanil (NOL group) or conventional intraoperative analgesic management (control group). The primary outcome was the mean intraoperative remifentanil infusion flow rate (intraoperative remifentanil usage [µg]/ideal body weight [kg]/operation time [min]). The main secondary outcomes were plasma concentrations of three perioperative inflammatory biomarkers (interleukin-6, C-reactive protein [CRP], and cortisol levels) and postoperative pain (Numeric Rating Scale [NRS]) scores 2 h postoperatively and on postoperative days 1, 2, 3, and 7. RESULTS: Compared with standard analgesia management, NOL-directed analgesic management reduced remifentanil consumption by 20% ( - 0.038; 95% confidence interval, - 0.059 to - 0.017; p = 0.0007). NOL-directed management did not lead to an increase in IL-6, CRP, or cortisol levels compared with conventional analgesic management. Furthermore, this protocol led to improvements in the NRS scores at rest 2 h postoperatively and upon movement up to postoperative day 3. CONCLUSION: NOL-directed analgesic management reduced remifentanil consumption by 20% and the NRS scores at rest 2 h postoperatively and upon movement up to postoperative day 3 without an increase in inflammatory marker levels. REGISTRY NUMBER: Japan Registry of Clinical Trials, JRCTs052220034.

Effect of individualized anesthesia and analgesia on postoperative pain in patients stratified for pain sensitivity: A study protocol for the PeriOPerative individualization trial randomized controlled trial.

BACKGROUND: Despite advancements in surgical and anesthesia techniques, acute and persistent postoperative pain are still a common challenge. Postoperative pain has direct effects on individual patient care and outcome, as well as putting strain on limited health care resources. Several prediction methods for postoperative pain have been described. One such method is the assessment of pain during peripheral venous cannulation (VCP). It is not known if different approaches to anesthesia and analgesia, depending on the evaluation of risk for postoperative pain, can improve outcome. The aim of this study is to evaluate if individualized anesthesia and analgesia can affect postoperative pain and recovery after surgery, in patients stratified by VCP. METHODS: Adult patients scheduled for laparoscopic surgery undergo pain-sensitivity stratification using VCP on the day of surgery. Patients scoring VCP ≥2.0 on the visual analogue scale (pain-sensitive) are randomized to multimodal anaesthesia and analgesia with opioids or standard of care. Patients scoring VCP ≤1.9 (pain-tolerant) are randomized to opioid-free anaesthesia or standard of care. The primary outcome is acute postoperative pain measured with numeric rating scale in the postoperative care unit. Secondary outcomes include analysis of pain after 24 h, persistent postoperative pain and quality of recovery. DISCUSSION: Individualized perioperative pain management has the potential to improve patient care. This study will examine the impact of different anesthesia and analgesia regimes, in patients with differing pain sensitivity, on postoperative pain. TRIAL REGISTRATION: Prospectively posted at ClinicalTrials.gov, identifier NCT04751812.

Sedation modality in acute respiratory distress syndrome: does method of sedation affect length of stay, outcomes, or adverse events? A systematic review.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) is a life-threatening, diffuse inflammatory pulmonary condition characterised by the Berlin criteria. Incidence of ARDS is estimated at 2.5-19% globally with high mortality and morbidity. Interest has been increasing in the use of inhaled sedatives because of a more rapid awakening and fewer adverse effects compared with intravenous propofol. The primary aim of this systematic review protocol is to investigate the length of critical care stay between ARDS patients who have been mechanically ventilated with inhaled anaesthetic sedatives (ie, sevoflurane and isoflurane) compared with those patients who are prescribed conventional sedatives (ie, propofol). METHODS AND ANALYSIS: Cochrane Central Register of Controlled Trials, Ovid (Embase, MEDLINE), PubMed, EBSCO (CINAHL Plus), Google Scholar will be searched and stratified by the reviewers. The literature search will be limited to English articles. Published full text peer-reviewed articles will be included.The International Prospective Register of Systematic Reviews (PROSPERO) Registration number is: CRD42023390988. ETHICS AND DISSEMINATION: Ethics approval is not required for this systematic review. The results will be presented at local/regional meetings and dissemination will occur through peer-reviewed publication.

Haemodynamic effects of intravenous acetaminophen in critically ill paediatric patients: a retrospective chart review.

OBJECTIVES: Haemodynamic changes following intravenous acetaminophen are well studied in adults. Limited data are published in critically ill paediatric patients, especially from the Middle East. We aim to investigate haemodynamic effects and incidence of hypotension with intravenous acetaminophen in critically ill children, with a focus on understanding factors influencing these effects. METHODS: We retrospectively reviewed patients who received intravenous acetaminophen between July and December 2022. A haemodynamic event was defined as drop of >15% in systolic blood pressure (SBP) or mean arterial blood pressure (MAP) within 120 min after drug administration. Hypotension was defined as either drop in SBP below the 5th percentile for age, or a haemodynamic event associated with tachycardia, increased lactate or treatment with fluid/vasopressors. Logistic regression was performed to quantify relationships between patients' characteristics and the occurrence of haemodynamic event and hypotension. RESULTS: A haemodynamic event was observed in 50/156 patients (32%) post-acetaminophen. Mean MAP (SD) before and after acetaminophen was 69.6 mm Hg (14.8) and 67.4 mm Hg (13.9), respectively (p=0.001). Mean SBP (SD) before and after acetaminophen was 95.4 mm Hg (18.2) and 92.8 mm Hg (19.2), respectively (p=0.006). Baseline MAP, median (interquartile range (IQR)) was 76.0 (64.0-85.3) and 66.0 (57.0-74.5) in patients with and without haemodynamic events, respectively (p=0.004). Only 38/156 patients (24%) met the definition for hypotension. Baseline MAP, median (IQR) was 62.0 (51.8-79.0) in patients with, and 68.5 (62.0, 79.3) in patients without hypotension (p=0.036). Baseline shock, vasoactives, mechanical ventilation and paediatric sequential organ failure assessment were not significantly associated with hypotension. Only MAP was found to be associated with both haemodynamic event (adjusted odds ratio (AOR) 1.05, 95% CI 1.02-1.10) and hypotension (AOR 1.06, 95% CI 1.02-1.10) even after controlling for other confounders. CONCLUSIONS: Administration of intravenous acetaminophen in critically ill children can lead to haemodynamic changes, including clinically significant hypotensive events.

Quadratus Lumborum Block for Ovarian Cystectomy Surgery in a Patient With Severe Kyphoscoliosis.

Quadratus lumborum block (QLB) has been described as a regional analgesic technique in various abdominal surgeries. We present a case report of a high-risk patient who underwent ovarian cystectomy with QLB and deep sedation after failed neuraxial anesthesia. A 29-year-old female patient with comorbidities osteogenesis imperfecta, severe kyphoscoliosis with restrictive lung disease, and cervical syringomyelia with cranio-cervical junction stenosis (C2/C3). The patient had large ovarian cysts with associated dyspnea. She accepted surgery-an open bilateral ovarian cystectomy-despite being advised that general anesthesia would be high-risk. Regional anesthetic options were limited and challenging, given her anatomy and difficulty in positioning. Neuraxial anesthesia was attempted but was unsuccessful. The patient safely underwent surgery (lower midline laparotomy) using QLB. This clinically challenging case demonstrates the feasibility of QLB as the mainstay multimodal anesthetic approach (without general and neuraxial anesthesia) for abdominal surgery under exceptional circumstances.

Efficacy of analgesia promoted by lidocaine and articaine in third molar extraction surgery. A split-mouth, randomized, controlled trial.

PURPOSE: The aim of this study was to compare the analgesic efficacy of 4% articaine associated with epinephrine (1:100,000), and 2% lidocaine associated with epinephrine (1:100,000) in third molar extraction surgery. METHODS: Sixty patients who underwent surgeries to extract upper and lower third molars were included in this split-mouth, double-blind, randomized, controlled trial. The groups in this study were divided according to the anesthetic solution used to provide local anesthesia during extraction of upper and lower third molars: (1) 4% articaine associated with epinephrine (1:100,000); (2) 2% lidocaine associated with epinephrine (1:100,000). The time to the beginning and end of the sensation of analgesia, pain sensation according to the VAS scale, and number of anesthetic tubes necessary for supplementation were analyzed. RESULTS: It was found that the onset time for analgesia was shorter on the side anesthetized with articaine compared to the side anesthetized with lidocaine (122.1 ± 52.90 s vs. 144.5 ± 68.85 s) (p < 0.05). In addition, the number of tubes used for anesthetic supplementation was also reduced on the articaine side compared to the lidocaine side (0.26 ± 0.48 vs. 0.50 ± 0.75) (p < 0.05). There were no differences between the anesthetic solutions in the other evaluated parameters. CONCLUSION: It can be concluded that the use of 4% articaine associated with epinephrine (1:100,000) reduced the time of onset of analgesia and the necessity for anesthetic supplementation in third molar extraction surgeries compared to the use of 2% lidocaine associated with epinephrine (1:100,000).

Combination of a propofol emulsion with alpha-2 adrenergic receptor agonists used for multimodal analgesia or sedation in intensive care units: a physicochemical stability study.

OBJECTIVES: To assess the physicochemical stability of the combination of a propofol emulsion with an alpha-2 (α2) adrenergic receptor agonist (α2A; clonidine or dexmedetomidine) under conditions mimicking routine practice in an intensive care unit or in multimodal analgesia procedures. METHODS: We developed and validated three stability-indicating methods based on high-performance liquid chromatography with ultraviolet (HPLC-UV) detection. Eight different conditions per combination were evaluated in triplicate, with variations in the simulated, bodyweight-adjusted dose level and the drugs' flow rate. The drugs were mixed in clinically relevant concentrations and proportions and then stored unprotected from light, in clear glass vials at room temperature for 96 hours. At each sampling point, we assessed the chemical stability (the HPLC-UV drug level, pH, and osmolality) and physical compatibility (visual aspect, zeta potential (ZP), mean droplet diameter (MDD, Z-average) and polydispersity index (PDI)). We validated our stability findings in positive and negative control experiments. RESULTS: Over the 96-hour test, the concentrations of propofol, clonidine and dexmedetomidine did not fall below 90% of the initial value, and the pH and osmolality were stable. The visual aspect of the mixed propofol emulsions did not change. The MDD remained below 500 nm (range 165-195 nm). The PDI was always below 0.4; 78.7% of the measurements were below 0.1 and 21.3% were between 0.1 and 0.4. The ZP measurements (-31.3 to -42.9 mV) suggested that the emulsion was stable. The MDD and PDI increased slightly at 96 hours under some conditions, which might indicate early destabilisation of the emulsion. Given that the MDD remained below 500 nm, these emulsions are compatible with intravenous administration. CONCLUSIONS: Our results demonstrate the chemical and physical compatibility of propofol-α2 agonist mixtures at concentrations and in proportions representative of standard protocols when stored unprotected from light at room temperature for 96 hours.

Open Approach to the Transversus Abdominis Plane in Horses: A Cadaver Feasibility Study.

The study's objective was to evaluate the feasibility and dispersion of an open approach to the transversus abdominis plane (TAP) block in eight adult equine cadavers. A ventral midline incision was made, starting 2 cm cranial to the umbilicus and extending 25 cm cranially. In total, 0.5 mL/kg of new methylene blue (NMB) was injected per horse, divided into six injections. Using an 18 g, 8 cm Tuohy needle, three injections were made per side. The needle was guided blindly into the TAP using palpation. A 60 mL syringe was attached directly to the needle, depositing ~0.08 mL/kg at each site. The time to complete the injections was recorded for each cadaver. Following injection, the ventral body wall was dissected to determine if the dye was present within the TAP space as well as to measure the extent of the dispersion of the dye, the cranial to caudal extent, and the width of the dye's spread. Complete deposition of NMB into the TAP (six of six sites) was achieved in 5/8 horses. The median time needed to perform all the injections was 263 s. Increased adiposity (retroperitoneal fat) was associated with unsuccessful injections. This approach to the TAP was easily and quickly performed, though less successful in horses with increased retroperitoneal fat and increased BCS.

Omission of perioperative morphine reduces postoperative pain in proctological interventions: a single-center analysis.

There is an increase in outpatient procedures and this trend will continue in the future. For hemorrhoidectomy, it is the standard of treatment in many health care systems. Perioperative management including adequate pain control is of paramount importance to ensure successful ambulatory surgery. This study investigates the role and effect of morphine compared to short-acting opiates applied before, during, or after proctological interventions and with focus on hemorrhoidectomy. A retrospective analysis of a prospective database was conducted comparing two populations. The control cohort received morphine (Yes-Mô) intra- and postoperatively, while the intervention group did not receive morphine (No-Mô) between January 2018 and January 2020. Both cohorts were balanced by propensity score matching. The outcomes were postoperative pain measured by numeric ratings scale (NRS) one hour postoperatively, pain 24 h postoperatively, success rate of outpatient management, and complication rate including postoperative nausea and vomiting as well as urinary retention. The intervention population comprised 54 patients and the control group contained 79 patients. One hour after surgery, patients in No-Mô reported lower NRS (1.44 ± 1.41) compared to Yes-Mô (2.48 ± 2.30) (p = 0.029). However, there was no difference in NRS 24 h postoperatively (No-Mô: 1.61 ± 1.41 vs Yes-Mô: 1.63 ± 1.72; p = 0.738). 100% of No-Mô was managed as outpatients while only 50% of Yes-Mô was dismissed on the day of the operation (p = < 0.001). There was no difference in postoperative complications (including postoperative nausea and vomiting (PONV) and urinary retention) between the two groups (PONV No-Mô 7.4% vs Yes-Mô 5.6%, p = 1.0 and urinary retention No-Mô 3.7% vs Yes-Mô 7.4%, p = 0.679). No-Mô received an oral morphine equivalent of 227.25 ± 140.35 mg intraoperatively and 11.02 ± 18.02 mg postoperatively. Yes-Mô received 263.17 ± 153.60 mg intraoperatively and 15.97 ± 14.17 mg postoperatively. The difference in received morphine equivalent between the groups was not significant after matching for the intraoperative (p = 0.212) and postoperative (p = 0.119) received equivalent. Omission of perioperative morphine is a viable but yet not understood method for reducing postoperative pain. Omission of morphine leads to a lower use of total morphine equivalent to attain satisfactory analgesia. The reduction of the overall opiate load and using opiates with a very short half-life potentially leads to a reduction of side effects like sedation. This in turn promotes discharge of the patient on the day of surgery. Omission of morphine is safe and does not increase postoperative complications.

The dilutional volume of morphine and xylazine administered via caudal epidural catheter affects cranial spread of analgesia in healthy standing horses.

OBJECTIVE: To test the influence of increasing injectate volumes on the regional effects of xylazine and morphine epidural analgesia, with the hypothesis that increasing volume produces more cranial spread of analgesia as determined by thermal threshold (TT) testing. ANIMALS: 6 university-owned research/teaching horses (2 mares, 4 geldings) deemed healthy on physical examination and basic lameness evaluation, aged 6-19 years and weighing 420-560 kg, were used in this prospective, randomized, blinded, cross-over experimental study. METHODS: After routine placement of a caudal epidural catheter, all animals were subsequently instrumented with a TT testing system at the withers (Location A), the cranial (Location B), and caudal (Location C) abdominal area, over the tuber coxae (Location D), and the hind limb dorsal pasterns (Location E). All horses underwent five testing cycles with 0.2 mg/kg morphine and 0.2 mg/kg xylazine diluted to 20, 35, 50, 75, and 100 mL. TT testing was performed at 2, 4, 6, 8, and 10 hours by blinded investigators. RESULTS: With increased epidural volume, significantly greater cranial spread of analgesic effect was noted. All epidural volumes caused significant changes in TT testing at location E but only the largest volume resulted in a significant TT testing change at location A. CLINICAL RELEVANCE: Volume influences the regional effects of caudal epidural analgesia in horses but might affect analgesic reliability.

Perioperative Pain Management Simulation Course: Improving Anesthesia Trainees' Confidence in the Management of Perioperative Pain and the Associated Critical Incidents.

Introduction Pain management is a crucial aspect of patients' perioperative journey and a fundamental duty of every anesthetist. Throughout anesthesia training, there is an emphasis on the management of critical incidents, several of which surround pain management. With changes to the anesthesia curriculum over recent years, variable exposure to training opportunities, and a reduction in clinical hours during training, many trainees report feeling underprepared for their future roles as consultants. However, pain management remains a small fragment of the core anesthesia curriculum with no pain-focused simulation courses currently available across the UK. Simulation has proven to aid learning transfer in complicated and stressful scenarios with a substantial improvement in knowledge retention and prevention of skill loss while eliminating the risk of harm to patients. Aim A novel perioperative pain management simulation course was designed and implemented in the East of England to equip junior anesthesia trainees with the knowledge, skills, and confidence to manage perioperative pain and the associated critical incidents. Methods A multidisciplinary team (MDT) was involved in the course design. The faculty consisted of anesthesia consultants, trainees, pain nurses, and simulation technicians. The course ran twice over a six-month period both locally and regionally. A blended learning approach was adopted where 17 trainees attended PowerPoint presentations providing an overview of basic pain theories, perioperative pain management, regional anesthesia, and labor analgesia. Trainees then underwent telecasted simulation training using replicated patient notes, imaging, blood gas analysis, and a high-fidelity SimMan®. A debriefing period followed each scenario using Pendleton's model. An anonymized questionnaire was completed by all trainees before and after the course to assess improvement in their knowledge and confidence levels across four domains covering the management of perioperative pain. Results All 17 trainees completed the questionnaire; therefore, the entire dataset was analyzed. The pre-course questionnaire showed that using a scale of zero to 10, the vast majority of trainees reported low levels of confidence (<6/10) in the management of chronic pain during the perioperative period (82%), intraoperative pain management (76%), regional anesthesia (88%), and labor analgesia (65%). Following the simulation training, the results showed an overwhelmingly positive improvement in all 17 trainees' knowledge and confidence across all four tested domains. All 17 trainees (100%) also showed an improvement in their understanding of local pain protocols. The subjective feedback was positive, highlighting the overall usefulness of the course and that the tailored complexity of each simulation scenario was appropriate to each candidate's prior level of experience. Trainees also reported feeling more confident in starting their anesthesia on-calls. Conclusion This novel simulation course is the first of its kind in pain management. It has shown great improvements in trainee confidence in managing perioperative pain and the associated critical incidents. Subjective feedback has also been positively reassuring. Its inclusion into the East of England anesthesia training program and national training curriculum would greatly enhance trainee's knowledge and experience in pain management in the perioperative setting.

Effect of regional anesthesia and analgesia on long-term survival following abdominal cancer Surgery-A systematic review with meta-analysis.

Background: The impact of regional anesthesia and analgesia (RAA) on long-term survival following cancer surgery is a topic of debate. The aim of this study was to investigate the effects of perioperative RAA on long-term oncological outcomes in patients undergoing major abdominal cancer surgery. Methods: The authors searched computerized databases and reference lists from inception to December 20, 2022. All studies that investigated the effects of perioperative RAA on long-term oncological outcomes following major abdominal cancer surgery were included. Using the inverse variance method with a random-effects model, hazard ratios (HR) and 95% confidence intervals (CI) were calculated. Results: The systematic review included 51 retrospective studies, one prospective study, and three randomized controlled trials (RCTs), with a total of 95,046 patients. The results showed that perioperative RAA may improve long-term overall survival (HR: 0.85, 95% CI: 0.80 to 0.91, P = 0.00, I2 = 60.2%). However, there was no significant association between perioperative RAA and reduced cancer recurrence (HR: 0.98, 95% CI: 0.90 to 1.03, P = 0.31, I2 = 52.3%). When performing a pooled analysis of the data from the three RCTs, no statistically significant effect of RAA was found in either case. Conclusion: The systematic review suggests perioperative RAA may improve long-term overall survival but does not appear to reduce cancer recurrence in patients undergoing major abdominal cancer surgery. The limited number of RCTs included in this study did not confirm this finding, highlighting the need for further RCTs to corroborate these results.

Predicción de toxicidad de la quimioterapia y radioterapia en el paciente oncológico quirúrgico

Fundamento la toxicidad asociada a los tratamientos de quimioterapia y radioterapia eleva la morbilidad y la mortalidad en los pacientes oncológicos. Objetivo diseñar un modelo predictivo de toxicidad de la quimioterapia y la radioterapia en el paciente oncológico quirúrgico. Métodos estudio analítico, de casos y controles, en pacientes oncológicos quirúrgicos que cumplieron los criterios de inclusión para la predicción de toxicidad preoperatoria, en el periodo enero a diciembre de 2022, en el Hospital Provincial Docente Oncológico María Curie, de Camagüey. Mediante el paquete estadístico Statistical Package for the Social Sciences, se seleccionó una muestra aleatoria de 334 pacientes, 197 sin toxicidad (grupo control) y 137 con toxicidad (grupo de estudio). Se realizó estimación de predictores de toxicidad mediante regresión logística binaria. Se seleccionó el modelo de mejor ajuste. Resultados el modelo en el paso tres predice un porcentaje global de 83,5 % con respecto a los valores observados. La sensibilidad resultó ser de 81,8; y la especificidad, 84,8. El modelo presentó buen poder discriminativo. Las variables en la ecuación fueron: hipertensión arterial, fracción de eyección del ventrículo izquierdo y anemia. La comparación de la predicción con la realidad, mediante curva Receiver Operating Characteristic determinó un área bajo la curva de 0,901. Conclusión se obtuvo una función de regresión logística que permitió la estimación de la probabilidad de toxicidad en pacientes oncológicos quirúrgicos electivos, la cual proporcionó una herramienta para su predicción desde el preoperatorio.

Foundation the toxicity associated with chemotherapy and radiotherapy treatments increases morbidity and mortality in cancer patients. Objective to design a predictive model of chemotherapy and radiotherapy toxicity in surgical cancer patients. Methods analytical, case-control study, in surgical oncology patients who met the inclusion criteria for the prediction of preoperative toxicity, from January to December 2022, at the María Curie Provincial Teaching Oncology Hospital in Camagüey. Using the Statistical Package for the Social Sciences, a random sample of 334 patients was selected, 197 without toxicity (control group) and 137 with toxicity (study group). Toxicity predictors were estimated using binary logistic regression. The model with the best fit was selected. Results the model in step three predicts an overall percentage of 83.5% with respect to the observed values. The sensitivity turned out to be 81.8; and the specificity, 84.8. The model presented good discriminative power. The variables in the equation were: arterial hypertension, left ventricular ejection fraction, and anemia. The comparison of the prediction with reality, using the Receiver Operating Characteristic curve, determined an area under the curve of 0.901. Conclusion a logistic regression function was obtained that allowed the estimation of the toxicity probability elective surgical cancer patients, which provided a tool for its prediction from the preoperative period.

Monitored Anesthesia Care Using Remimazolam and Ketamine Combination for Brief Gynecological Surgeries: A Report for Four Cases.

Remimazolam is a benzodiazepine with rapid onset and recovery time. Ketamine provides analgesia and sedation without compromising hemodynamics. Combining both agents may provide good anesthesia and analgesia with fewer complications. We report four cases of monitored anesthesia care with a combination of remimazolam and ketamine for brief gynecological surgeries. We applied 0.5 mg/kg bolus ketamine and infused patients with remimazolam at 6 mg/kg/h for induction and 1 mg/kg/h for maintenance. Then, 25 µg of fentanyl was administered for analgesia 4 min before the procedure, and additional fentanyl was administered as needed. Remimazolam was discontinued shortly after surgery. We conducted satisfactory monitored anesthesia care with a combination of remimazolam and ketamine in all four cases.

Fetal heart rate changes and labor neuraxial analgesia: a machine learning approach.

BACKGROUND: Neuraxial labor analgesia has been associated with fetal heart rate changes. Fetal bradycardia is multifactorial, and predicting it poses a significant challenge to clinicians. Machine learning algorithms may assist the clinician to predict fetal bradycardia and identify predictors associated with its presentation. METHODS: A retrospective analysis of 1077 healthy laboring parturients receiving neuraxial analgesia was conducted. We compared a principal components regression model with tree-based random forest, ridge regression, multiple regression, a general additive model, and elastic net in terms of prediction accuracy and interpretability for inference purposes. RESULTS: Multiple regression identified combined spinal-epidural (CSE) (p = 0.02), interaction between CSE and dose of phenylephrine (p < 0.0001), decelerations (p < 0.001), and the total dose of bupivacaine (p = 0.03) as associated with decrease in fetal heart rate. Random forest exhibited good predictive accuracy (mean standard error of 0.92). CONCLUSION: Use of CSE, presence of decelerations, total dose of bupivacaine, and total dose of vasopressors after CSE are associated with decreases in fetal heart rate in healthy parturients during labor. Prediction of changes in fetal heart rate can be approached with a tree-based random forest model with good accuracy with important variables that are key for the prediction, such as CSE, BMI, duration of stage 1 of labor, and dose of bupivacaine.

Analgesic effects of intrathecal morphine and bupivacaine during robotic-assisted surgery: A prospective randomized controlled study.

BACKGROUND: Limited data exist concerning the management of postoperative pain after robotic-assisted surgery. The present study was performed to investigate the efficacy of intrathecal morphine and bupivacaine to treat postoperative pain in adult women undergoing robot-assisted laparoscopic hysterectomy. METHODS: The primary outcomes of this study were opioid consumption and pain scores during and after robotic surgery. 96 patients were prospectively enrolled and randomized to a nonspinal group (n = 48) and a spinal group (n = 48). The intrathecal regimen consisted of 100 µg morphine and 15 mg of bupivacaine. The numeric rating scale scores (NRS) were assessed every 15 min in the postoperative care unit (PACU) and pain was treated with iv fentanyl or morphine when NRS was above 5 and orally oxycodone when NRS was 3-5. Cumulative iv opioid-consumption and NRS scores were compared. RESULTS: Intrathecal morphine and bupivacaine resulted in a significantly lower cumulative total iv opioid (morphine equivalents) consumption (9.4 ± 3.9 vs. 22.8 ± 6.1 mg equivalents). Highest recorded NRS scores in the PACU were also significantly lower in the spinal group (2.0 ± 2.6 vs. 5.3 ± 3.2). CONCLUSION: Intrathecal morphine and bupivacaine to treat postoperative pain after robotic-assisted laparoscopic hysterectomy decrease total opioid consumption and NRS pain scores. This might be of great importance to diminish the rate of other serious disadvantages related to opioids.