Assessing the Efficacy of Thoracic Erector Spinae Plane Block for Postoperative Analgesia in Lumbosacral Spine Surgery: A Prospective Quasi-experimental Study.

Background and aims Optimal postoperative care and analgesia are the key factors in the management of cases of lumbosacral spine surgery. The erector spinae plane (ESP) block is a recently evolving entity and has a dynamic role in postoperative pain management. However, its role in the management of pain in lumber spinal surgeries is still not clear, and the literature remains anecdotal. Therefore, we planned to study the efficacy of ultrasound-guided preoperative ESP block at the T12 level using levobupivacaine for perioperative analgesia in lumbosacral spine surgeries. Methods A total of 60 patients scheduled for elective or emergency lumbosacral spine surgery were divided into two groups - the GA group received standard general anesthesia (GA) and the GA+ESP group received standard general anesthesia along with ultra-sound guided ESP block at the T12 level with a bilateral injection of 20 ml 0.25% levobupivacaine. Perioperative analgesia was assessed by total intra-operative fentanyl dose and frequency, intra-operative hemodynamic parameters, post-operative numeric rating scale (NRS) scores, time of first systemic rescue analgesia, tramadol usage, mobilization day, and hospital stay duration.  Results Intraoperative fentanyl sparing was observed in 83% of the GA+ESP group compared to 33% in the GA group. Postoperative tramadol sparing was observed in 80% of the GA+ESP group compared to 26.7% of the GA group. Twenty-four-hour postoperative NRS scores >3/10 were observed in 20% of the GA+ ESP group compared to 73.3% of the GA group. Conclusion In this study, superior perioperative analgesia, opioid-sparing effect, and decreased requirement of postoperative rescue analgesia were observed with ESP block.

Comparative Evaluation of Oral and Intranasal Administration of Midazolam as Preanesthetic Medication in Pediatric Dental Patients Treated under General Anesthesia.

Aims and background: Midazolam is commonly used as a preanesthetic medication for behavior management of children. The current study is conducted to find out the effect of midazolam through nasal and oral routes as a premedicament in pediatric patients treated under general anesthesia. The main aims of the study were: to compare the effect of oral syrup and intranasal spray as preanesthetic medication; to record the undesirable side effects of midazolam by both routes. Materials and methods: The patients aged 2-6 years of either sex were randomly divided into two equal groups of 30 each-group I: oral; group II: intranasal. Results: The oral and intranasal routes of midazolam were found to be equally effective and provided adequate sedation for easy separation from the parents and cooperation from children during the induction of anesthesia with minimal side effects. Conclusion: Based on the study results, we can conclude that both oral and intranasal midazolam can be used as preanesthetic medication for pediatric dental patients treated under general anesthesia. Clinical significance: In pediatric patients, the oral route should be preferred for midazolam premedication in comparison to the intranasal route. How to cite this article: Swati, Shah RK, Tandon S, et al. Comparative Evaluation of Oral and Intranasal Administration of Midazolam as Preanesthetic Medication in Pediatric Dental Patients Treated under General Anesthesia. Int J Clin Pediatr Dent 2024;17(8):881-886.

Impact of dexmedetomidine-assisted anesthesia in elderly patients undergoing radical resection of colon cancer.

BACKGROUND: Radical resection of colon cancer under general anesthesia is one of the main treatment methods for this malignancy. However, due to the physiological characteristics of elderly patients, the safety of perioperative anesthesia needs special attention. As an α2-adrenergic receptor agonist, dexmedetomidine (Dex) has attracted much attention from anesthesiologists due to its stabilizing effect on heart rate and blood pressure, inhibitory effect on inflammation, and sedative and analgesic effects. Its application in general anesthesia may have a positive impact on the quality of anesthesia and postoperative recovery in elderly patients undergoing radical resection of colon cancer. AIM: To investigate the anesthetic effects of Dex during radical surgery for colon cancer under general anesthesia in elderly patients. METHODS: A total of 165 colon cancer patients who underwent radical surgery for colon cancer under general anesthesia at Qingdao University Affiliated Haici Hospital, Qingdao, China were recruited and divided into two groups: A and B. In group A, Dex was administered 30 min before surgery, while group B received an equivalent amount of normal saline. The hemodynamic changes, pulmonary compliance, airway pressure, inflammatory factors, confusion assessment method scores, Ramsay Sedation-Agitation Scale scores, and cellular immune function indicators were compared between the two groups. RESULTS: Group A showed less intraoperative hemodynamic fluctuations, better pulmonary compliance, and lower airway resistance compared with group B. Twelve hours after the surgery, the serum levels of TLR-2, TLR-4, IL-6, and TNF-α in group A were significantly lower than those of group B (P < 0.05). After extubation, the Ramsay Sedation-Agitation Scale score of group A patients was significantly higher than that of group B patients, indicating a higher level of sedation. The incidence of delirium was significantly lower in group A than in group B (P < 0.05). CONCLUSION: The use of Dex as an adjunct to general anesthesia for radical surgery in elderly patients with colon cancer results in better effectiveness of anesthesia.

The Impact of Bispectral Index Monitoring on Outcomes in Spinal Cord Stimulation for Chronic Disorders of Consciousness.

Objective: To observe whether maintaining the appropriate depth of anesthesia with Bispectral Index (BIS) can improve the prognosis of Spinal Cord stimulation (SCS) implantation in patients with chronic Disorders of consciousness (DoC). Methods: 103 patients with DoC undergoing SCS implantation were reviewed, and 83 patients with DoC were included according to the standard of inclusion and exclusion Criteria. Patients were divided into a BIS group (n =45) and a non-BIS group (n =38) according to whether BIS monitoring was used during the operation. The depth of anesthesia in the BIS group was maintained between 40-60. The anesthesiologist adjusted the depth of anesthesia in the non-BIS group according to clinical experience. Relevant information such as disease course, cause, anesthesia time, and operation time were collected. Preoperative CRS-R(preoperative) score, postoperative CRS-R(24h), and postoperative CRS-R(3m) changes were collected. Results: The CRS-R(3m) score in the BIS group was higher than that in the non-BIS group (preoperative), and the difference was statistically significant (P < 0.05). In CRS-R (24h), the BIS group was higher than the non-BIS group, and the difference was statistically significant (X2=8.787, P =0.004). The improvement of consciousness was included in the multivariate Logistic regression analysis model, and it was found that the thalamus was an independent factor affecting the improvement of consciousness (P < 0.05). During follow-up, 1 patient in the BIS group had a decrease in consciousness from MCS- to VS/ UWS and 2 patients in the non-BIS group died during follow-up. Conclusion: Patients can be benefit in hearing in CRS-R (24h). We recommend the use of BIS to monitor the depth of anesthesia in patients with DoC to improve patient outcomes.

Effects of prophylactic nalbuphine on emergence agitation and postoperative pain in pediatric patients undergoing ENT surgery with sevoflurane anesthesia.

Background: Emergence agitation (EA) is a common complication in the pediatric population. This study aimed to investigate the effect of the prophylactic nalbuphine on EA in pediatric patients receiving sevoflurane anesthesia. Methods: The children undergoing ear, nose, and throat (ENT) surgery were administered 0.2 mg/kg nalbuphine (the nalbuphine group) or the same volume of normal saline (the control group) 5 min before the end of the surgery. The extubating time, time to eye-opening and duration of the post-anesthesia care unit (PACU) were recorded. Heart rate and blood pressure were monitored before and 5 min after nalbuphine administration. Pain was assessed using Face Legs Activity Cry and Consolability (FLACC) scales, and the drug-related postoperative complications (e.g., EA, delayed awakening, nausea and vomiting, and respiratory depression) were recorded. Results: One-hundred and thirty pediatric patients were randomly divided into nalbuphine and control groups (n = 65). The nalbuphine group showed a significantly lower incidence of EA than the control group (20% vs. 46.2%, P = 0.002). No significant differences between the two groups were observed in heart rate and blood pressure 5 min after nalbuphine administration (P > 0.05). No significant differences were observed between the two groups regarding extubating time, time to eye-opening, and duration of PACU. The FLACC scales demonstrated lower values in the nalbuphine group than in the control group during the initial 4 h after the surgery. However, the FLACC scales showed similar values between 5 and 12 h after the surgery. Conclusions: In summary, the results of this study demonstrated that prophylactic natbuphine could minimize the incidence of EA in pediatric patients following ENT surgery without increasing the extubating time and PACU duration. Clinical Trial Registration: http://www.chictr.org.cn, identifier [ChiCTR2300070046].

Characteristics of cases for which esophageal endoscopic submucosal dissection under general anesthesia is recommended.

BACKGROUND/AIMS: Esophageal endoscopic submucosal dissection (ESD) performed under general anesthesia can potentially provide more stable treatment in difficult cases than that under sedation. We evaluated the clinical characteristics and outcomes of ESD performed under general anesthesia compared with those under propofol sedation and discussed the cases in which general anesthesia is recommended. PATIENTS AND METHODS: In total, 292 lesions in 265 consecutive patients undergoing esophageal ESD at Yamaguchi University Hospital from 2013 to 2023 were included in this retrospective study. RESULTS: ESD was performed under general anesthesia for 92 lesions in 81 patients and under propofol sedation for 200 lesions in 184 patients. Tumor long-axis diameter was larger (39.8 ± 14.4 mm vs. 32.4 ± 9.9 mm, p < 0.01) and dissection speed was faster (10.5 ± 5.9 mm2/min vs. 7.5 ± 4.2 mm2/min, p < 0.01) in the general anesthesia group versus the sedation group. In the sedation group, a treatment history of pharyngeal cancer was significantly associated with a slower dissection speed (p = 0.037). The sedation group showed higher frequencies of hypoxemia (0% vs 9.8%, p < 0.01), interruption due to body movement (0% vs 13%, p < 0.01), and acute adverse events (21.7% vs 33.5%, p = 0.05). A treatment history of pharyngeal cancer was shown to be the significant factor contributing to acute adverse events (p = 0.018). CONCLUSION: Esophageal ESD under general anesthesia can be a treatment option in patients with difficulty in performing stable procedures with propofol sedation. Especially in patients with a treatment history of pharyngeal cancer in whom ESD is more difficult to be performed and who are at higher risk for acute adverse events, general anesthesia can be considered.

Variational Mode Decomposition Analysis of Electroencephalograms during General Anesthesia: Using the Grey Wolf Optimizer to Determine Hyperparameters.

Frequency analysis via electroencephalography (EEG) during general anesthesia is used to develop techniques for measuring anesthesia depth. Variational mode decomposition (VMD) enables mathematical optimization methods to decompose EEG signals into natural number intrinsic mode functions with distinct narrow bands. However, the analysis requires the a priori determination of hyperparameters, including the decomposition number (K) and the penalty factor (PF). In the VMD analysis of EEGs derived from a noninterventional and noninvasive retrospective observational study, we adapted the grey wolf optimizer (GWO) to determine the K and PF hyperparameters of the VMD. As a metric for optimization, we calculated the envelope function of the IMF decomposed via the VMD method and used its envelope entropy as the fitness function. The K and PF values varied in each epoch, with one epoch being the analytical unit of EEG; however, the fitness values showed convergence at an early stage in the GWO algorithm. The K value was set to 2 to capture the α wave enhancement observed during the maintenance phase of general anesthesia in intrinsic mode function 2 (IMF-2). This study suggests that using the GWO to optimize VMD hyperparameters enables the construction of a robust analytical model for examining the EEG frequency characteristics involved in the effects of general anesthesia.

Comparing subjective quality of recovery between remimazolam- and propofol-based total intravenous anesthesia for surgical procedures: a meta-analysis.

BACKGROUND: Remimazolam is a novel ultra-short-acting benzodiazepine that has been recently introduced as an alternative to propofol for general anesthesia. While both agents have been compared in terms of safety and efficacy, their relative effects on postoperative quality of recovery (QoR) remain unclear. Therefore, this meta-analysis aimed to compare the effects of remimazolam and propofol on subjective QoR in surgical patients who underwent general anesthesia. METHODS: Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched from inception to May 28, 2024 to identify randomized controlled trials comparing remimazolam and propofol in terms of postoperative QoR. The Cochrane risk-of-bias tool (RoB 2) was used to assess study quality. QoR score on postoperative day (POD) 1 (primary outcome), QoR scores on PODs 2-3, QoR dimensions, time to loss of consciousness, other recovery characteristics, and rescue analgesia requirement were evaluated using random-effects meta-analyses. RESULTS: This meta-analysis included 13 studies published between 2022 and 2024 involving 1,418 patients. QoR was evaluated using either the QoR-15 (10 studies) or QoR-40 (3 studies) questionnaire. The pooled results indicated no significant difference in the QoR scores on POD 1 (standardized mean difference: 0.02, 95% confidence interval [CI]: - 0.20, 0.23, P = 0.88, I2 = 73%) and PODs 2-3 between remimazolam and propofol. Furthermore, no significant differences were observed in QoR dimensions, length of postanesthesia care unit (PACU) stay, and time to extubation as well as in the risks of agitation and postoperative nausea and vomiting. Patients administered remimazolam exhibited slower anesthetic induction (mean difference (MD): 32.27 s) but faster recovery of consciousness (MD: - 1.60 min) than those administered propofol. Moreover, remimazolam was associated with a lower risk of rescue analgesia requirement in the PACU (risk ratio: 0.62, 95% CI: 0.43, 0.89, P = 0.009, I2 = 0%) but not in the ward. CONCLUSION: Remimazolam is a potential alternative to propofol for general anesthesia as it offers similar QoR to the latter and has advantages in terms of consciousness recovery and immediate postoperative analgesia requirement.

Effect of different anesthesia depths on perioperative heart rate variability and hemodynamics in middle-aged and elderly patients undergoing general anesthesia.

BACKGROUND: To analyze the effects of different anesthesia depths on perioperative heart rate variability and hemodynamics in middle-aged and elderly patients undergoing general anesthesia, and to provide a basis for clinical application. METHODS: A total of 111 patients with gastric cancer who were treated with epidural anesthesia combined with general anesthesia were selected as the study subjects, and the patients were randomly divided into group A, group B and group C. The bispectral index (BIS) was maintained by adjusting the infusion speed of anesthetics, the BIS of group A was maintained at 50 ~ 59, the BIS of group B was maintained at 40 ~ 49, and the BIS of group C was maintained at 30 ~ 39. The high-frequency power (HFP), low-frequency power (LFP), total power (TP), mean arterial pressure (MAP), heart rate (HR), diastolic blood pressure (DBP), and systolic blood pressure (SBP) were measured before anesthesia induction (T1), immediately after intubation (T2), 3 min after intubation (T3), and 6 min after extubation (T4). The cognitive function of the patients was evaluated before and 48 h after surgery. RESULTS: The HFP, LFP/HFP, TP, HR, DBP and SBP between the three groups at T1 ~ T3 are significantly difference from each other (P < 0.05). There were significant differences in spontaneous breathing recovery time, eye opening time and extubation time among group A, B and C groups, and group B had the lowest spontaneous breathing recovery time, eye opening time and extubation time (P < 0.05). There was no significant difference in the incidence of adverse reactions during anesthesia between the three groups. The cognitive function score of group B was significantly higher than that of group A and group C (P < 0.05). CONCLUSIONS: BIS maintenance of 40 ~ 49 has little effect on perioperative heart rate variability and hemodynamics in middle-aged and elderly patients undergoing general anesthesia, which is helpful for postoperative recovery.

Correlation between anesthetic concentration and low Apgar scores in neonates born via Cesarean sections under general anesthesia.

OBJECTIVES: This study aimed to compare plasma concentrations of anesthetic drugs administered during Cesarean section with low Apgar score in neonates deliveried under general anesthesia and analyze associated risk factors. METHODS: Data from 76 neonates undergoing Cesarean section under general anesthesia with blood concentrations of anesthetic drugs were analyzed. A low Apgar score was defined as ≤ 7. Perioperative maternal and neonatal data were collected and analyzed. Neonates were divided into a control group (Group CON, n = 65) and a low Apgar score group (Group LAS, n = 11) based on Apgar score. RESULTS: There were no significant differences in the plasma concentrations of anesthetic drugs in maternal artery, umbilical vein or umbilical artery blood between the two groups. Risk factors for neonatal low Apgar scores during Cesarean section under general anesthesia were premature delivery (aOR 10.2, 95% CI = 1.8-56.9) and preoperative fetal distress (aOR 9.6, 95% CI = 1.3-69.0). The prediction model was: probability = 1/(e­Y), Y= -4.607 + 2.318× (premature delivery) + 2.261× (fetal distress) (yes = 1, no = 0). The Hosmer-Lemeshow test showed χ²= 9.587, P = 0.213, and the area under the curve (AUC) was 0.850 (0.670 ~ 1.000). With a cutoff value of 0.695, sensitivity and specificity were 81.8% and 87.7%, respectively. CONCLUSIONS: There was no correlation between blood concentration of general anesthetic drugs and Apgar score or occurrence of neonatal low Apgar scores. Premature delivery and preoperative fetal distress were identified as independent risk factors for neonatal low Apgar scores after Cesarean section under general anesthesia.

Efficacy and Safety of General Anesthesia Induction with Ciprofol in Hip Fracture Surgery of Elderly Patients: A Randomized Controlled Trial.

Background: Ciprofol is a new intravenous sedative / anesthetic drug. In recent years, many clinical studies have also confirmed the sedative effect of ciprofol. However, more clinical research is still needed on its clinical application characteristics in special populations. Objective: The aim of this study was to compare the clinical effects of ciprofol and propofol in general anesthesia induction of elderly patients. Methods: 60 elderly (aged ≥ 75 years) patients underwent hip fracture surgery were randomly into two groups of a 1:1 ratio. Group C (ciprofol group): 0.3mg/kg ciprofol was infused. Group P (propofol group): 1.5mg/kg propofol was infused. The observation period was from the infusion of test drug to 5 min after endotracheal intubation. The primary outcomes included the incidence of severe hypotension and hypotension during the observation period. The secondary outcomes were as follows: the success rate of general anesthesia induction, the number of additional sedation, the time of loss of consciousness (LOC), Δ MAP, Δ HR, adverse events and the frequency of vasoactive drugs used. Results: Finally, 60 subjects completed the study. Compared with Group P, the incidence of severe hypotension in Group C was lower (26.7% vs 53.3%, P = 0.035), the incidence of hypotension was also lower (36.7% vs 63.3%, P = 0.037), Δ MAP in Group C was significantly lower (31.4 ± 11.4 vs 39.6 ± 15.7, P = 0.025), the frequency of ephedrine used and the incidence of injection pain in Group C were also significantly lower. Conclusion: Ciprofol showed similar efficacy to propofol when used for general anesthesia induction in elderly patients underwent hip fracture surgery and could maintain more stable blood pressure.

Massive subcutaneous emphysema and bilateral tension pneumothorax following laparoscopic inguinal hernia repair under general anesthesia: A case report.

The escalating adoption of laparoscopic surgical techniques has demonstrated their capacity to yield improved clinical outcomes. However, concomitant with the advantages of this minimally invasive approach, certain adverse complications have been reported. In this report, we present a noteworthy case involving a 72-year-old male patient who underwent laparoscopic inguinal hernia repair. The surgical procedure proceeded without noteworthy complications, and the patient maintained hemodynamic stability throughout. However, the post-anesthetic recovery was compromised by the onset of subcutaneous emphysema and bilateral tension pneumothorax. Immediate intervention was imperative, prompting the performance of an emergent needle thoracostomy, subsequently followed by the implementation of a closed drainage system within the thoracic cavity. These interventions proved efficacious in mitigating the patient's distressing symptoms. Although pneumothorax complications in the context of laparoscopic surgery are infrequent, it is imperative for anesthetists to remain vigilant regarding the potential occurrence of subcutaneous emphysema and pneumothorax in the perioperative period. This case underscores the significance of meticulous perioperative monitoring and rapid intervention, particularly in laparoscopic procedures, where the insufflation of carbon dioxide into the abdominal cavity can predispose patients to these rare yet potentially life-threatening complications. Heightened awareness among healthcare providers regarding the possibility of such events is pivotal in ensuring the safety and well-being of surgical patients.

Management of Congenital Methemoglobinemia in the Perioperative Setting: A Case Report and Review of Current Literature.

Background: Methemoglobin is an altered state of hemoglobin where iron in hemoglobin is oxidized and incapable of binding oxygen; leading to complications such as cyanosis, dyspnea, headache, and heart failure. Methemoglobinemia can be congenital or acquired. Congenital methemoglobinemia is a rare disease and its worldwide incidence is unclear. We recently encountered the first documented case of congenital methemoglobinemia at our institution, necessitating perioperative care. Case Presentation: In the present case, a 22-year-old man with congenital methemoglobinemia underwent general anesthesia for dental extraction. The surgeon was informed to avoid local anesthetics and oxygenation was performed with FiO2 of 1.0. Arterial blood gas analysis showed a PH of 7.337, PaO2 of 302 mm Hg, PaCO2 of 44 mm Hg, oxyhemoglobin level of 63.4%, and methemoglobin level of 37.8%. The patient had a stable course. No methylene blue therapy was required, although cyanosis was observed during surgery. Conclusion: In summary, though rare, congenital methemoglobinemia poses fatal risks during surgery. Its management involves preoperative recognition and optimization, oxygenation status, multidisciplinary care, avoiding precipitating or oxidizing agents, discussing treatment options, maintaining cardiopulmonary stability, and ensuring perioperative safety measures with the medical team.

Decrease of the peak heights of EEG bicoherence indicated insufficiency of analgesia during surgery under general anesthesia.

BACKGROUND: Studies show that the two peak heights of electroencephalographic bicoherence (pBIC-high, pBIC-low) decrease after incision and are restored by fentanyl administration. We investigated whether pBICs are good indicators for adequacy of analgesia during surgery. METHODS: After local ethical committee approval, we enrolled 50 patients (27-65 years, ASA-PS I or II) who were scheduled elective surgery. Besides standard anesthesia monitors, to assess pBICs, we used a BIS monitor and freeware Bispectrum Analyzer for A2000. Fentanyl 5 µg/kg was completely administered before incision, and anesthesia was maintained with sevoflurane. After skin incision, when the peak of pBIC-high or pBIC-low decreased by 10% in absolute value (named LT10-high and LT10-low groups in order) or when either peak decreased to below 20% (BL20-high and BL20-low groups), an additional 1 g/kg of fentanyl was administered to examine its effect on the peak that showed a decrease. RESULTS: The mean values and standard deviation for pBIC-high 5 min before fentanyl administration, at the time of fentanyl administration, and 5 min after fentanyl administration for LT10-high group were 39.8% (10.9%), 26.9% (10.5%), and 35.7% (12.5%). And those for pBIC-low for LT10-low group were 39.5% (6.0%), 26.8% (6.4%) and 35.0% (7.0%). Those for pBIC-high for BL20-high group were 26.3% (5.6%), 16.5% (2.6%), and 25.7% (7.0%). And those for pBIC-low for BL20-low group were 26.7% (4.8%), 17.4% (1.8%) and 26.9% (5.7%), respectively. Meanwhile, at these trigger points, hemodynamic parameters didn't show significant changes. CONCLUSION: Superior to standard anesthesia monitoring, pBICs are better indicators of analgesia during surgery. TRIAL REGISTRY: Clinical trial Number and registry URL: UMIN ID: UMIN000042843 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno = R000048907.

Efficacy of a self-made tracheostomy oxygen delivery device for oxygen therapy during postoperative anesthesia recovery.

BACKGROUND: Patients with tracheotomy are often monitored in the anesthesia recovery room after reoperation. During this period, oxygen therapy is necessary, and the existing tracheostomy oxygen supply device has many defects. OBJECTIVE: To evaluate the efficacy of a self-made tracheostomy oxygen delivery device on oxygen therapy during postoperative anesthesia recovery. METHODS: Patients were randomly divided into two groups, E and C, with 30 patients in each group, and admitted to the post-anesthesia care unit (PACU). Patients in group E received oxygen through a self-made tracheostomy oxygen delivery device, while patients in group C were supplied oxygen through a unilateral nasal cannula. Respiration (R), pulse oximetry (SpO2), and the number of patients on ventilators were recorded at the time of admission (T0) and one hour after admission (T1). Rapid dry blood gas analyses were performed on 0.6 ml samples of arterial blood collected at T0 and T1. RESULTS: Compared to group C, patients in group E had significantly higher arterial partial pressure of oxygen (PaO2), arterial oxygen saturation (SaO2), total carbon dioxide (T-CO2), and actual bicarbonate (AB), while arterial partial pressure of carbon dioxide (PaCO2) was significantly reduced (P< 0.01 or < 0.05). Compared to T0, PaO2 decreased in both groups at T1, PaCO2 decreased in group E, while SaO2, T-CO2, and AB decreased in group C (P< 0.01 or < 0.05). CONCLUSION: We found that using the self-made tracheostomy oxygen delivery device in postoperative anesthesia recovery had advantages such as a secure connection to the tracheostoma, adjustable oxygen concentration, air filtration, and the ability to switch oxygen supply between the ventilator and humidifier.

Preoperative biomarkers associated with delayed neurocognitive recovery.

To identify baseline biomarkers of delayed neurocognitive recovery (dNCR) using monitors commonly used in anesthesia. In this sub-study of observational prospective cohorts, we evaluated adult patients submitted to general anesthesia in a tertiary academic center in the United States. Electroencephalographic (EEG) features and cerebral oximetry were assessed in the perioperative period. The primary outcome was dNCR, defined as a decrease of 2 scores in the global Montreal Cognitive Assessment (MoCA) between the baseline and postoperative period. Forty-six adults (median [IQR] age, 65 [15]; 57% females; 65% American Society of Anesthesiologists (ASA) 3 were analyzed. Thirty-one patients developed dNCR (67%). Baseline higher EEG power in the lower alpha band (AUC = 0.73 (95% CI 0.48-0.93)) and lower alpha peak frequency (AUC = 0.83 (95% CI 0.48-1)), as well as lower cerebral oximetry (68 [5] vs 72 [3], p = 0.011) were associated with dNCR. Higher EEG power in the lower alpha band, lower alpha peak frequency, and lower cerebral oximetry values can be surrogates of baseline brain vulnerability.

Reduction of the acquisition time needed to obtain somatosensory evoked potentials by estimation of the required averaging sweep count by an algorithm.

Somatosensory evoked potentials are frequently acquired by stimulation of the median or tibial nerves (mSEPs and tSEPs) for intraoperative monitoring of sensory pathways. Due to their low amplitudes it is common practice to average 200 or more sweeps to discern the evoked potentials from the background EEG. The aim of this study was to investigate if an algorithm designed to determine the lowest sweep count needed to obtain reproducible evoked potentials in each patient significantly reduces the median necessary sweep count to under 200. 30 patients undergoing spinal surgery at the Department of Neurosurgery were included in the study. Beginning with a sweep count of 200 an algorithm was designed to determine the lowest sweep count that yielded reproducible evoked potentials in each patient. By this algorithm the minimal sweep count was determined in 15 patients for mSEPs and in 15 patients for tSEPs. The required sweep count was below 200 in 14 of 15 patients for mSEPs (93.3%) with a mean sweep count of 56 ± 51. For tSEPs the sweep count was below 200 in 11 of 15 patients (73.3%) with a mean sweep count of 106 ± 70 (mean ± SD). The calculated mean time to average the potentials could thereby be reduced from 48.8s to 13.7s for mSEPs and from 48.8s to 25.9s for tSEPs. The proposed algorithm allowed sweep count and acquisition time reduction in roughly 90% of all patients for mSEPs and in 70% of all patients for tSEPs.

Remimazolam Anesthesia for a Pediatric Patient With Glutaric Aciduria Type I: A Case Report.

Glutaric aciduria type I (GA-1) is a rare metabolic disorder caused by an autosomal, recessive, inherited deficiency of glutaryl-CoA dehydrogenase. Reports on the anesthetic management of patients with GA-1 are limited. It has been suggested that inhalation anesthesia is safer than propofol due to the mitochondrial dysfunction inherent in GA-1. However, inhalation anesthesia poses a risk, albeit rare, of malignant hyperthermia, which can result in severe neurological damage in GA-1 patients. Therefore, we considered that management using remimazolam might be effective and, provided a successful general anesthesia using it for a pediatric patient with GA-1. We report a case of a four-year-old girl with GA-1 who underwent a laparoscopic gastrostomy under general anesthesia. Remimazolam was used for both induction and maintenance of anesthesia. Our perioperative management also included measures to prevent a hypercatabolic condition such as adequate hydration and blood glucose control. The patient had an uneventful perioperative course and was discharged on postoperative day 7. Thus, remimazolam is proposed as a new option for anesthetic management in patients with GA-1. Additionally, tailored perioperative management that addresses the unique characteristics of GA-1 is crucial for favorable outcomes.

Acromio-Axillo-Suprasternal Notch Index Performance in Predicting Difficult Visualization of the Larynx: An Observational Prospective Study.

Bedside screening tests for predicting difficult intubation play a crucial role in clinical practice, although their utility remains limited. This prospective observational study aimed to assess the predictive value of the Acromio-Axillo-Suprasternal Notch Index (AASI) for difficult visualization of the larynx (DVL). Following approval from the Institutional Ethics Sub-Committee (Research Protocol No.: IESC/FP/68/2023), this prospective, observational, single-center study involved a sample size of 100 consecutive adult patients, both male and female, aged 20 to 65 years. The participants were classified as American Society of Anesthesiologists (ASA) grade I or II and were scheduled for elective surgeries necessitating endotracheal intubation. Before the operation, the following factors were assessed: AASI, modified Mallampati test (MMT), sternomental distance (SMD), thyromental distance (TMD), and inter-incisor distance (IID). Larynx visualization was evaluated using the Cormack-Lehane (CL) grading system, where grades III and IV indicate difficult laryngeal visualization. Qualified anesthesiologists performed direct laryngoscopy while remaining unaware of the outcomes of the airway predictors being assessed. The main aim of the investigation was to assess the efficacy of the AASI as a means of predicting DVL. The research study's secondary goals involved evaluating the accuracy of AASI in predicting challenging airways compared to other predictors such as MMT, SMD, TMD, and IID. DVL was observed in 21% of patients, out of which 10 and 11 were males and females, respectively. The sensitivity, specificity, and area under the curve (AUC) of the AASI were observed and reported with a 95% confidence interval (CI), being 98.73% (93.2-99.9%), 71.43% (47.8-88.7%), and 0.851 (0.732-0.970), respectively. AUC analysis revealed that AASI outperformed MMT, SMD, TMD, and IID as a predictor of DVL. AASI (≥0.5) serves as an excellent predictor for DVL during direct laryngoscopy. This finding suggests the clinical utility of AASI in identifying patients who may require special consideration during intubation procedures.

Sequential recruitment of body fluid spaces for increasing volumes of crystalloid fluid.

Introduction: The interstitial space harbours two fluid compartments linked serially to the plasma. This study explores conditions that lead to fluid accumulation in the most secluded compartment, termed the "third space". Methods: Retrospective data was collected from 326 experiments in which intravenous crystalloid fluid was administered to conscious volunteers as well as a small group of anaesthetized patients. The urinary excretion and plasma dilution derived from haemoglobin served as input variables in nine population volume kinetic analyses representing subtly different settings. Results: An infusion of 250-500 mL of Ringer's solution expanded only the central fluid space (plasma), whereas the infusion of 500-1,000 mL extended into a rapidly exchanging interstitial fluid space. When more than 1 L was infused over 30 min, it was distributed across plasma and both interstitial fluid compartments. The remote space, characterized by slow turnover, abruptly accommodated fluid upon accumulation of 700-800 mL in the rapidly exchanging space, equivalent to an 11%-13% volume increase. However, larger expansion was necessary to trigger this event in a perioperative setting. The plasma half-life of crystalloid fluid was 25 times longer when 2,000-2,700 mL expanded all three fluid compartments compared to when only 250-500 mL expanded the central space (14 h versus 30 min). Conclusion: As the volume of crystalloid fluid increases, it apparently occupies a larger proportion of the interstitial space. When more than 1 L is administered at a high rate, there is expansion of a remote "third space", which considerably extends the intravascular half-life.