Perioperative dexmedetomidine for pain management in craniotomy: a systematic review and meta-analysis.

BACKGROUND: Craniotomy is associated with several undesirable effects including postoperative pain. This systematic review and meta-analysis aimed to evaluate evidence on the efficacy and safety of dexmedetomidine (DEX) for pain management in patients undergoing craniotomy. METHODS: We followed PRISMA guidelines. The protocol was registered in Open Science Framework. We searched for existing randomized controlled studies (RCTs) published before June 2023 that used dexmedetomidine during the perioperative period in craniotomy in PubMed, Scopus, and the Cochrane Library. A meta-analysis was conducted in RevMan. Cochrane RoB2 and GRADE were used for quality assessment. RESULTS: A total of 19 RCTs comprising 3,153 patients were included. Pain intensity was lower in the DEX group than the control group at a mean difference (MD) [95% confidence interval (CI)] of -0.64 [-1.16, -0.13], p-value=0.01. The DEX group overall consumed less opioids in comparison with the control group at an MD=-4.00 [-6.16, -1.83], p-value=0.0003. However, heterogeneity was considerable for both outcomes (I2=81% and I2=96%, respectively). There was no difference between the DEX and control groups in the time to first post-analgesic requirement, hypertension, hypotension, or cough. CONCLUSIONS: The results showed that the use of dexmedetomidine was associated with lower pain intensity and less opioid use. Patients in the DEX group experienced fewer episodes of nausea and vomiting, agitation, and shivering but more episodes of bradycardia. There was no difference between DEX and control groups in other adverse events.

Comparison of Propofol-Based Total Intravenous Anesthesia versus Volatile Anesthesia with Sevoflurane for Postoperative Delirium in Adult Coronary Artery Bypass Grafting Surgery: A Prospective Randomized Single-Blinded Study.

OBJECTIVES: To compare the incidence of delirium and early (at 1 week) postoperative cognitive dysfunction (POCD) between propofol-based total intravenous anesthesia (TIVA) and volatile anesthesia with sevoflurane in adult patients undergoing elective coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CPB). DESIGN: This was a prospective randomized single-blinded study. SETTING: The study was conducted at a single institution, the Sree Chitra Tirunal Institute for Medical Sciences and Technology, a tertiary care institution and university-level teaching hospital. PARTICIPANTS: Seventy-two patients undergoing elective CABG under CPB participated in this study. INTERVENTIONS: This study was conducted on 72 adult patients (>18 years) undergoing elective CABG under CPB who were randomized to receive propofol or sevoflurane. Anesthetic depth was monitored to maintain the bispectral index between 40 and 60. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit. Early POCD was diagnosed when there was a reduction of >2 points in the Montreal Cognitive Assessment score compared to baseline. Cerebral oximetry changes using near-infrared spectroscopy (NIRS), atheroma grades, and intraoperative variables were compared between the 2 groups. MEASUREMENTS & MAIN RESULTS: Seventy-two patients were randomized to receive propofol (n = 36) or sevoflurane (n = 36). The mean patient age was 59.4 ± 8.6 years. The baseline and intraoperative variables, including atheroma grades, NIRS values, hemoglobin, glycemic control, and oxygenation, were comparable in the 2 groups. Fifteen patients (21.7%) patients developed delirium, and 31 patients (44.9%) had early POCD. The incidence of delirium was higher with sevoflurane (n = 12; 34.2%) compared to propofol (n = 3; 8.8%) (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.13-2.62; p = 0.027)*. POCD was higher with sevoflurane (n = 20; 57.1%) compared to propofol (n = 11; 32.3%) (OR, 1.63; 95% CI, 1.01-2.62; p = 0.038)*. In patients aged >65 years, delirium was higher with sevoflurane (7/11; 63.6%) compared to propofol (1/7; 14.2%) (p = 0.03)*. CONCLUSIONS: Propofol-based TIVA was associated with a lower incidence of delirium and POCD compared to sevoflurane in this cohort of patients undergoing CABG under CPB. Large-scale, multicenter randomized trials with longer follow-up are needed to substantiate the clinical relevance of this observation.

Comparison of remimazolam tosilate and propofol during induction and maintenance of general anesthesia in patients undergoing laparoscopic cholecystectomy: a prospective, single center, randomized controlled trial.

BACKGROUND: Remimazolam tosilate (RT) is a new, ultrashort-acting benzodiazepine. Here, we investigated the efficacy and safety of RT for general anesthesia in patients undergoing Laparoscopic Cholecystectomy (LC). METHODS: In this study, 122 patients undergoing laparoscopic cholecystectomy were randomly allocated to receive either remimazolam tosilate (Group RT) or propofol group (Group P). RT was administered as a slow bolus of 0.3 mg kg- 1 for induction, followed by 1.0-2.0 mg kg- 1 h- 1 for maintenance of general anesthesia. Propofol was started at 2 mg kg- 1 and followed by 4-10 mg kg- 1 h- 1 until the end of surgery. The primary outcome was the time to bispectral index (BIS) ≤ 60. The secondary outcome included the time to loss of consciousness (LoC), and the time to extubation. Adverse events were also assessed. RESULTS: A total of 112 patients were recruited for study participation. Among them, the time to BIS ≤ 60 in Group RT was longer than that in Group P (Group RT: 89.3 ± 10.7 s; Group P: 85.9 ± 9.7 s, P > 0.05). While the time to LoC comparing remimazolam and propofol showed no statistical significance (Group RT: 74.4 ± 10.3 s; Group P: 74.7 ± 9.3 s, P > 0.05). The time to extubation in Group RT was significantly longer than that in Group P (Group RT: 16.0 ± 2.6 min; Group P: 8.8 ± 4.3 min, P < 0.001). Remimazolam tosilate had more stable hemodynamics and a lower incidence of hypotension during general anesthesia. CONCLUSIONS: Remimazolam tosilate can be safely and effectively used for general anesthesia in patients undergoing Laparoscopic Cholecystectomy. It maintains stable hemodynamics during induction and maintenance of general anesthesia compared with propofol. Further studies are needed to validate the findings. TRIAL REGISTRATION: Chictr.org.cn ChiCTR2300071256 (date of registration: 09/05/2023).

Total Intravenous Anesthesia Is Preferred Over Volatile Agents in Cardiac Surgery.

The choice of maintenance anesthetic during cardiopulmonary bypass has been a subject of ongoing debate. Systematic reviews on the topic have so far failed to demonstrate a difference between volatile agents and total intravenous anesthesia (TIVA) in terms of mortality, myocardial injury, and neurological outcomes. Studies using animal models and noncardiac surgical populations suggest numerous mechanisms whereby TIVA has been associated with more favorable outcomes. However, even if the different anesthetic methods are assumed to equivalent in terms of patient outcomes in the context of cardiac surgery, additional factors, namely variables of occupational exposure and environmental impact, strongly support the preferred use of TIVA.

Non-intubated bronchoscopic tracheobronchial surgeries with electroencephalogram-monitored intravenous anesthesia: feasibility and outcomes.

Background: Anesthesia remains challenging for bronchoscopic tracheobronchial surgeries (BTS) involving surgical manipulations for central airway obstruction within shared airways. To provide complete airway use through intervention with spontaneous breathing without endotracheal tubes, monitored non-intubated anesthesia has been successfully applied with electroencephalogram-derived monitored total intravenous anesthesia. This study evaluated the feasibility and the outcomes of BTS with monitored non-intubated anesthesia. The factors associated with desaturation and complications were also analyzed. Methods: Data from patients receiving non-intubated BTS performed between October 2019 and August 2022 were retrospectively collected. Intraoperative results and postoperative outcomes were analyzed. Results: Data of 92 patients were collected. Supraglottic airways devices and high-flow nasal oxygen were used in 68 and 24 patients respectively. Surgery was successfully completed in 87 patients (94.6%), whereas three patients required conversion to intubation because of substantial bleeding. In total, 11% of patients experienced desaturation [oxygen saturation (SpO2) <90%] for an average of 9 minutes. Unexpected admission to the intensive care unit (ICU) occurred in 12.2% (5/41) of patients from outpatient department and 7.8% (4/51) of hospitalization settings because of high-grade surgical bleeding. With comparable desaturation incidence, tracheal surgery had significantly longer desaturation times (14.5±6.9 min) than bronchial surgeries (5.8±2.6 min) did. Conclusions: Monitored non-intubated anesthesia with spontaneous breathing is feasible for BTS, with high success rate, few complications, and rapid recovery. High-grade bleeding remains the most unpredictable risk for intraoperative desaturation and postoperative ICU admission, especially in tracheal obstruction cases.

Influence of intravenous fentanyl or dexmedetomidine infusions, combined with lidocaine and ketamine, on cardiovascular response, sevoflurane requirement and postoperative pain in dogs anesthetized for unilateral mastectomy.

OBJECTIVE: To compare the effects of constant rate infusions (CRI) of fentanyl or dexmedetomidine, combined with lidocaine and ketamine, on cardiovascular response during surgery, sevoflurane requirement and postoperative pain in dogs undergoing mastectomy. STUDY DESIGN: Prospective, randomized, blinded, clinical trial. ANIMALS: A total of 29 female dogs with mammary tumors. METHODS: Premedication consisted of intramuscular acepromazine and morphine. General anesthesia was induced with intravenous propofol and maintained with sevoflurane. Dogs were randomized to be administered intravenous DLK [dexmedetomidine 1 µg kg-1 loading dose (LD) and 1 µg kg-1 hour-1; lidocaine 2 mg kg-1 LD and 3 mg kg-1 hour-1; ketamine 1 mg kg-1 LD and 0.6 mg kg-1 hour-1; n = 14] or FLK (fentanyl 5 µg kg-1 LD and 9 µg kg-1 hour-1; same doses of lidocaine and ketamine; n = 15) during anesthesia. Cardiorespiratory variables and end-tidal sevoflurane (Fe'Sevo) were recorded during surgery. The number of dogs administered ephedrine to treat arterial hypotension [mean arterial pressure (MAP) < 60 mmHg] was recorded. Meloxicam was administered to both groups. Postoperative pain and rescue analgesia requirement were assessed for 24 hours using the short form of the Glasgow Composite Measure Pain Scale. Data were compared using a mixed effects model or a Mann-Whitney test. RESULTS: More dogs required ephedrine in FLK than in DLK (67% versus 7%). Heart rate was not significantly different between groups, whereas lower values of MAP (p ≤ 0.01) and Fe'Sevo (p = 0.018) were observed in FLK than in DLK. Rescue analgesia was administered to 2/15 dogs in FLK and 0/14 dogs in DLK. CONCLUSIONS AND CLINICAL RELEVANCE: Based on the cardiovascular response during surgery, intraoperative infusions of FLK and DLK provided adequate antinociception. Infusion of DLK provided greater stability of blood pressure. Both protocols resulted in minimal need for additional analgesia within 24 hours postoperatively.

Relationship between age and remimazolam dose required for inducing loss of consciousness in older surgical patients.

Background: Remimazolam is a new ultra-short-acting benzodiazepine for procedural sedation and general anaesthesia, characterised by rapid onset of action, quick recovery, and organ-independent metabolism. Older patients tend to sustain more treatment-emergent adverse events (TEAEs) and worse perioperative prognoses after receiving remimazolam. However, few studies have investigated the appropriate dose of remimazolam for loss of consciousness (LOC) in geriatric patients. We designed this study to provide evidence for dose references and elucidate the relationship between age and remimazolam requirement for inducing LOC during anaesthesia induction. Methods: Exactly 120 patients scheduled for general surgery under general anaesthesia were included and divided into two groups: Group A (60 patients, 18-64 years) and Group B (60 patients, ≥ 65 years). LOC, defined as a Modified Observer's Assessment of Alertness and Sedation score at 1 had been reached, emerged after all participants received a continuous infusion of remimazolam at a rate of 0.05 mg/kg/min. Results: The remimazolam required for inducing LOC was 0.26 and 0.19 mg/kg in groups A and B, respectively, and the remimazolam dose in group B decreased by 26.9% compared to group A. According to the bivariate linear correlation analysis, remimazolam requirement was negatively correlated with age. Multivariable linear regression models and further adjustments for potential impact factors indicated that age was an independent factor for the remimazolam dose required for LOC. Conclusion: This study demonstrated that age was significantly and independently correlated with the remimazolam requirement for inducing LOC. To obtain haemodynamic stability during the induction of general anaesthesia, appropriately reducing the remimazolam dose is recommended for geriatric patients.

Comparison of remimazolam and desflurane in emergence agitation after general anesthesia for nasal surgery: A prospective randomized controlled study.

Background: Remimazolam is an ultrashort-acting benzodiazepine. Few studies have evaluated the effects of remimazolam-based total intravenous anesthesia (TIVA) on emergence agitation (EA). This study aimed to compare the incidence and severity of EA between TIVA using remimazolam and desflurane. Methods: This prospective randomized controlled study enrolled 76 patients who underwent nasal surgery under general anesthesia. Patients were randomized into two groups of 38 each: desflurane-nitrous oxide (N2O) (DN) and remimazolam-remifentanil (RR) groups. The same protocol was used for each group from induction to emergence, except for the use of different anesthetics during maintenance of anesthesia according to the assigned group: desflurane and nitrous oxide for the DN group and remimazolam and remifentanil for the RR group. The incidence of EA as the primary outcome was evaluated using three scales: Ricker Sedation-Agitation Scale, Richmond Agitation-Sedation Scale, and Aono's four-point agitation scale. Additionally, hemodynamic changes during emergence and postoperative sense of suffocation were compared. Results: The incidence of EA was significantly lower in the RR group than in the DN group in all three types of EA assessment scales (all P < 0.001). During emergence, the change in heart rate differed between the two groups (P = 0.002). The sense of suffocation was lower in the RR group than in the DN group (P = 0.027). Conclusions: RR reduced the incidence and severity of EA in patients undergoing nasal surgery under general anesthesia. In addition, RR was favorable for managing hemodynamics and postoperative sense of suffocation.

Exploring Ciprofol Alternatives: A Comprehensive Review of Intravenous Anesthesia Options.

Ciprofol is a recently developed, short-acting γ-aminobutyric acid receptor agonist sedative that is more potent than propofol. Still, there have been few clinical studies of this agent to date. This review explores alternative intravenous anesthesia options to ciprofol, considering their pharmacology, clinical efficacy, safety profile, and practical considerations. While ciprofol offers advantages such as rapid onset and predictable offset, concerns regarding its safety profile and individual variability in response have prompted the search for alternatives. Propofol, etomidate, ketamine, and dexmedetomidine are discussed as established options, each with unique characteristics and potential benefits. Emerging agents, including remimazolam, sufentanil, alfaxalone, and brexanolone, are examined for their potential role in anesthesia management. Recommendations for future research include large-scale comparative studies, optimization of dosing strategies, and personalized approaches guided by pharmacogenomic insights. Ultimately, the future of intravenous anesthesia lies in a multifaceted approach that integrates evidence-based practices, technological innovations, and individualized patient care to enhance safety, efficacy, and patient satisfaction across the perioperative continuum. Collaboration among stakeholders will be crucial in advancing the field and shaping the future landscape of intravenous anesthesia options.

Cardiopulmonary function, anesthetic effects, quality of arousal, hematology, and blood biochemistry during continuous intravenous infusion of a combination solution of xylazine, butorphanol, and propofol in calves.

General anesthesia in calves is easier to perform under field conditions, total intravenous anesthesia (TIVA) than using inhalation anesthesia. In the present study, cardiopulmonary function, anesthetic effects, quality of arousal, hematology, and blood biochemistry were assessed during continuous infusion of a combination solution of 0.01% xylazine, 0.001% butorphanol, and 0.2% propofol (XBP) at doses of 6 (G6; 10 µg/kg/min xylazine, 1 µg/kg/min butorphanol, 200 µg/kg/min propofol) and 9 mL/kg/h (G9; 15 µg/kg/min xylazine, 1.5 µg/kg/min butorphanol 300 µg/kg/min propofol). For both groups, five castrated Holstein calves received intravenous injections of xylazine (0.2 mg/kg) and propofol (2 mg/kg), followed by a continuous infusion of XBP for 60 min to maintain anesthesia. Respiratory management consisted of tracheal intubation followed by spontaneous inhalation of pure oxygen. Cardiopulmonary, anesthesia, hematology, and blood biochemistry variables were assessed at rest (baseline) and every 5 or 15 min after the start of the XBP infusion. Quality of arousal was assessed based on the swallowing reflex recovery time from the stop of XBP infusion, and the sternal position time and standing time after atipamezole administration. XBP produced adequate sedation, analgesia, and muscle relaxation in all calves and maintained stable anesthesia for 60 min. As XBP infusion time passed, rectal temperature and heart rate became lower, and mean arterial blood pressure increased. In both groups, hematologic and blood biochemical effects were mild. The quality of arousal was not different, and all calves were standing. The results of the present study suggested that XBP is useful for TIVA in calves.

Relationship between preinduction electroencephalogram patterns and propofol sensitivity in adult patients.

PURPOSE: To determine the precise induction dose, an objective assessment of individual propofol sensitivity is necessary. This study aimed to investigate whether preinduction electroencephalogram (EEG) data are useful in determining the optimal propofol dose for the induction of general anesthesia in healthy adult patients. METHODS: Seventy healthy adult patients underwent total intravenous anesthesia (TIVA), and the effect-site target concentration of propofol was observed to measure each individual's propofol requirements for loss of responsiveness. We analyzed preinduction EEG data to assess its relationship with propofol requirements and conducted multiple regression analyses considering various patient-related factors. RESULTS: Patients with higher relative delta power (ρ = 0.47, p < 0.01) and higher absolute delta power (ρ = 0.34, p = 0.01) required a greater amount of propofol for anesthesia induction. In contrast, patients with higher relative beta power (ρ = -0.33, p < 0.01) required less propofol to achieve unresponsiveness. Multiple regression analysis revealed an independent association between relative delta power and propofol requirements. CONCLUSION: Preinduction EEG, particularly relative delta power, is associated with propofol requirements during the induction of general anesthesia. The utilization of preinduction EEG data may improve the precision of induction dose selection for individuals.

[The Russian priority of development of intravenous anesthesia (Report I).]

The article analyses research activities of the discoverers of "Russian narcosis" from the Military Medical Academy of St. Petersburg: the head of the Department of Pharmacology N. P. Kravkov, the head of the Department of Hospital Surgery S. P. Fedorov and his resident A. P. Eremich. They for the first time in the world developed ideas of comprehensive experimental substantiation and then safe clinical administration of preparation "hedonal" to achieve stage of safe general anesthesia and implementation of long-term and traumatic operations. The scientific works of Russian discoverers indicated fundamentally new direction in formation of anesthesiology in the Russian Empire and in the world. A. P. Eremich at stage of preparatory tests, working out technique of intravenous infusion, determination of range of safe therapeutic doses and creation of special installation facilitating work with hedonal during operations of Professor S. P. Fedorov, can be recognized as the first Russian anesthesiologist and also as the first National resuscitator.

PRESS (Propofol, Remifentanil, Electricity/EEG, Setup and Setting) to Start: Introducing a Total Intravenous Anaesthesia Checklist at a Large Teaching Hospital.

Total intravenous anaesthesia (TIVA) is becoming more widely used, and as of yet there are few safety checks for the use of TIVA when compared to inhaled anaesthesia. This study aims to assess the feasibility and utility of introducing a TIVA checklist at a large teaching hospital. Methods A survey was sent out to all consultant and trainee anaesthetists at our hospital regarding their use of TIVA and errors in practice related to its use. A checklist was created based on common errors reported in the survey, errors described in NAP5 and our hospital's standard operating procedure. The checklist was introduced, and another survey was distributed a month later to assess compliance and utility and to gain feedback. Results In the first survey, there were 39 responses. A total of 64% had seen an error with the use of TIVA. For those using TIVA 70% of the time or more, 31% had seen an error in the last three months. Twelve per cent of those who had seen errors found that the errors led to patient harm. Only 33% used a method to double-check for errors prior to commencing TIVA. In the follow-up survey, 80% of those who used the checklist had found it useful, and 30% had corrected an error while using the checklist. Eighty-seven per cent felt the checklist would prevent errors from being made. Eighty per cent of respondents said they would use the checklist in their future practice. The checklist was found to be more useful for trainees, and for those who use TIVA less often. Discussion The 'PRESS to start TIVA" checklist has been shown to be a useful tool to prevent errors and a majority of anaesthetists at our hospital plan to use it going forward. Our data suggests that anaesthetists who are less experienced with TIVA benefit more from having a checklist. There was a marked increase in the number of anaesthetists who would use a checklist in the future, compared to those who used one in the initial survey. This shows that introducing a checklist is feasible and is likely to reduce errors going forward.

Quality of Postoperative Recovery in Total Intravenous Anesthesia between Remimazolam and Propofol for Intraoperative Neurophysiological Monitoring: A Prospective Double-Blind Randomized Controlled Trial.

This study compared the overall postoperative recovery of patients who underwent total intravenous anesthesia with remimazolam or propofol, using the Quality of Recovery-15 questionnaire (QoR-15). Seventy-two patients who underwent spine surgery with intraoperative neurophysiological monitoring (IONM) were randomly categorized into the remimazolam group (group R) or propofol group (group P). On the first postoperative day, the QoR-15 scores for groups P and R were 114 and 112, respectively, indicating no significant difference (p = 0.691). Similarly, group-time interaction effects on QoR-15 scores were not significantly different. In the post-anesthesia care unit, the pain intensity at rest was notably higher in group P than in group R (3.0 [0.0] vs. 2.8 [0.5], respectively, p = 0.009). Although the intraoperative consumption of remifentanil was higher in group R (1452.4 µg vs. 2066.8 µg, respectively, p < 0.001), the intraoperative use of vasopressors was lower in group R (1705.6 µg vs. 286.1 µg, respectively, p < 0.001) compared to group P. Group R exhibited significantly lower variability in mean blood pressure over time compared to group P. Remimazolam was viewed as a promising intravenous agent for general anesthesia, showing potential to replace propofol in spine surgery with IONM, considering both recovery quality and intraoperative hemodynamic stability.

Target-controlled infusion: A comparative, prospective, observational study of the conventional TCI pump and the novel smartphone-based application iTIVA.

Background and Aims: Empirically adjusted, standard drug doses fail to address interindividual pharmacokinetic and pharmacodynamics variability. Target-controlled infusion (TCI) delivers drugs in calibrated boluses to achieve and maintain a selected target plateau drug level (plasma or effect site). Interactive total intravenous anesthesia (iTIVA™) smartphone software simulates TCI and employs 31 established pharmacokinetic models for 11 different intravenous agents and is coupled with standard volumetric infusion pumps for administering TCI. Material and Methods: This prospective, observational, study investigates the degree of agreement between iTIVA and a conventional TCI pump (CTP) for the volume of propofol infused using the Schnider pharmacokinetic model in adult patients of either sex undergoing oncosurgery lasting 1-3 h under total intravenous anesthesia. Bland-Altman analysis of 124 data pairs from 30 patients provided bias, precision, and limits of agreement between the volumes infused by CTP and iTIVA (V-CTP and V-iTIVA) during specific identical time periods. Spearman's rho and Kendall's tau rank correlation coefficients provided the degree of association between V-CTP and V-iTIVA. Results: Spearman's rho and Kendall's tau were 0.996 and 0.964, respectively. Bias or the mean of differences was -0.02, while the limits of agreement were 0.58 and -0.63, respectively (Bland-Altman plot). The maximum allowed difference of 2 ml was much larger than the 95% confidence intervals for the limits of agreement. The Mountain plot was short tailed (-1.28 to 1.55) and centred over zero (0.01). Conclusion: The volume of propofol infused using TCI pump was similar to that calculated by iTIVA in identical time periods, confirming the clinical applicability of iTIVA.

Effects of Total Intravenous Anesthesia on Circadian Rhythms in Patients Undergoing Cardiac Transcatheter Closure.

Objective To evaluate the effects of total intravenous anesthesia on the circadian rhythms in the patients undergoing cardiac transcatheter closure. Methods Thirty patients undergoing cardiac transcatheter closure under elective intravenous anesthesia were included in this study.Paired t-tests were performed to compare the mRNA levels of the genes encoding circadian locomotor output cycles kaput(CLOCK),brain and muscle ARNT-1 like protein-1(BMAL1),cryptochrome 1(CRY1),and period circadian clock 2(PER2),the Munich Chronotype Questionnaire(MCTQ)score,and the Pittsburgh Sleep Quality Index(PSQI)score before and after anesthesia.Multiple stepwise regression analysis was performed to screen the factors influencing sleep chronotype and PSQI total score one week after surgery. Results The postoperative mRNA level of CLOCK was higher [1.38±1.23 vs.1.90±1.47;MD(95%CI):0.52(0.20-0.84),t=3.327,P=0.002] and the postoperative mRNA levels of CRY1 [1.56±1.50 vs.1.13±0.98;MD(95%CI):-0.43(-0.81--0.05),t=-2.319,P=0.028] and PER2 [0.82±0.63 vs.0.50±0.31;MD(95%CI):-0.33(-0.53--0.12),t=-3.202,P=0.003] were lower than the preoperative levels.One week after surgery,the patients presented advanced sleep chronotype [3∶03±0∶59 vs.2∶42±0∶37;MD(95%CI):-21(-40--1),t=-2.172,P=0.038],shortened sleep latency [(67±64)min vs.(37±21)min;MD(95%CI):-30.33(-55.28--5.39),t=-2.487,P=0.019],lengthened sleep duration [(436±83)min vs.(499±83)min;MD(95%CI):62.80(26.93-98.67),t=3.581,P=0.001],increased sleep efficiency [(87.59±10.35)% vs.(92.98±4.27)%;MD(95%CI):5.39(1.21-9.58),t=2.636,P=0.013],decreased sleep quality score [1.13±0.78 vs.0.80±0.71;MD(95%CI):-0.33(-0.62--0.05),t=-2.408,P=0.023],and declined PSQI total score [6.60±3.17 vs.4.03±2.58;MD(95%CI):-2.57(-3.87--1.27),t=-4.039,P<0.001].Body mass index(BMI)(B=-227.460,SE=95.475,t=-2.382,P=0.025),anesthesia duration(B=-47.079,SE=18.506,t=-2.544,P=0.017),and mRNA level of PER2(B=2815.804,SE=1080.183,t=2.607,P=0.015)collectively influenced the sleep chronotype,and the amount of anesthesia medicine(B=0.067,SE=0.028,t=2.385,P=0.024)independently influenced the PSQI one week after surgery. Conclusions Total intravenous anesthesia can improve sleep habits by advancing sleep chronotype.BMI,anesthesia duration,and mRNA level of PER2 collectively influence sleep chronotype one week after surgery.The amount of anesthesia medicine independently influences the PSQI total score one week after surgery.

Comparing Perioperative Outcomes of Total Intravenous Anesthesia (TIVA) With Volatile Anesthesia in Patients With Obesity: A Systematic Review.

In this systematic review, the perioperative outcomes of total intravenous anesthesia (TIVA) and volatile anesthesia were compared in obese adults (BMI ≥ 30 kg/m²) undergoing elective surgery. The review analyzed data from 12 randomized-controlled trials involving 935 patients, sourced from PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), Cochrane, Scopus, and Web of Science databases. The focus was on intraoperative vital signs, emergence time, postoperative nausea and vomiting (PONV), duration of post-anesthesia care unit (PACU) stay, and ICU admission rates. Findings showed that TIVA (using propofol) might reduce PONV, but there were no significant differences in other outcomes compared to volatile anesthesia (with desflurane as the most common agent). The review highlights the need for more research, especially comparing sevoflurane with TIVA, to establish clear clinical guidelines for anesthesia in obese patients.

Are there beneficial effects to hybrid anesthesia*?

As the COVID-19 pandemic increased the use of propofol in the intensive care unit for the management of respiratory sequelae and supply had become a major issue. Indeed, most hospitals in Japan were forced to use propofol only for induction of anesthesia with inhalational maintenance. Large amounts of propofol remain in the syringe which exacerbates the problems by increased waste. I propose that use of low dose propofol in combination with a low concentration inhaled anesthetic as an alternative and call this hybrid anesthesia. Several advantages of hybrid anesthesia are evident in the literature. Volatile anesthesia has several disadvantages such as cancer progression, emergence agitation, marked reduction in motor evoked potentials (MEP), laryngospasm with desflurane and postoperative nausea and vomiting (PONV). Volatile anesthesia exerts some beneficial actions such as myocardial protection and fast emergence with desflurane. In contrast, total intravenous anesthesia (TIVA) provides better survival in patients undergoing radical cancer surgery, reduction in emergence agitation, laryngospasm, PONV and better MEP trace Intraoperative awareness occurs more often during TIVA. When intravenous and volatile anesthesia are combined (hybrid anesthesia), the disadvantages of both methods may be offset by clear advantages. Thus, hybrid anesthesia may, therefore, be a viable anesthetic choice.

Preliminary Experience With Remimazolam for Procedural Sedation and as an Adjunct to General Anesthesia During Diagnostic and Interventional Cardiac Procedures.

Background: Remimazolam is a benzodiazepine which, like midazolam, has sedative, anxiolytic, and amnestic properties. Ester metabolism results in a half-life of 5 - 10 min, a limited context sensitive half-life, and rapid recovery when the infusion is discontinued. Methods: Following the Institutional Review Board (IRB) approval, we performed a retrospective chart review of patients who received remimazolam in the cardiac catheterization, cardiac magnetic resonance imaging (MRI), and electrophysiology suites. The primary objective was to assess efficacy and safety. The secondary objective was to describe bolus and infusion dosing of remimazolam and the need for adjunctive agents to optimize procedural sedation conditions. Results: The study cohort included 26 patients with a median age of 18 years and a total of 33 anesthetic encounters. The most common procedures were endomyocardial biopsy or isolated hemodynamic assessment (right or left heart catheterization). Remimazolam was the primary agent for sedation in 82% of the procedures. The majority of cases (25 encounters, 76%) included a bolus dose of remimazolam prior to the start of an infusion. For those patients who received a starting bolus dose, dosing typically ranged between 30 and 110 µg/kg. Continuous infusion rates of remimazolam varied from 5 to 20 µg/kg/min. No adverse hemodynamic or respiratory effects were noted. Midazolam, fentanyl, and dexmedetomidine were the most frequently used adjunctive agents. One patient required transition to general anesthesia due to the need for a surgical intervention based on the findings of the cardiac catheterization. All other patients were effectively sedated. Conclusions: Our preliminary experience demonstrates that remimazolam effectively provided sedation for diagnostic and therapeutic cardiovascular procedures. Future studies are needed to further define dosing parameters for both bolus dosing and continuous infusion as well as to compare remimazolam to other commonly used for procedural sedation in patients with congenital and acquired heart disease.