The latest medical research on Anesthesiology

background
methods
results
conclusions

The use of erector spinae plane block and rectus sheath block for postoperative analgesia in midline abdominal procedures is becoming more common. However, the most effective and appropriate method remains unclear. We aimed to compare the postoperative analgesic effecacy of ultrasound-guided bilateral erector spinae plane blocks with rectus sheath blocks for midline abdominal surgery in a low- and middle-income country.

We allocated randomly 72 patients aged 18-65 y undergoing midline abdominal surgery to an erector spinae plane block (n = 36) or a rectus sheath block (n = 36) utilising a prospective, parallel study design. Patients, care providers and outcome assessors were blinded to the interventions. The primary outcome measures were total postoperative analgesia consumption, postoperative pain severity and time to first rescue analgesic administration. Secondary outcomes included the incidence of postoperative complications and adverse events.

Of 78 patients assessed for eligibility, six were excluded, leaving 72 for analysis. Patients allocated to erector spinae plane block had a lower mean (SD) postoperative opioid consumption compared with those allocated to rectus sheath block (3.5 (8.7) morphine milligram equivalents vs. 8.2 (2.8) morphine milligram equivalents, respectively; p = 0.003). Time to first analgesic request was greater in patients allocated to erector spinae plane block compared with those allocated to rectus sheath block (mean (95%CI) 16 (13-17) h vs. 12 (11-13) h, respectively; p < 0.001). There were no block-related complications in either group.

Erector spinae plane blocks are more effective than rectus sheath blocks for the management of postoperative pain following midline abdominal surgery. Integration of erector spinae plane blocks into multimodal opioid-sparing analgesic strategies after midline abdominal surgeries may promote enhanced patient recovery in low-and middle-income countries.

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Electroencephalogram burst suppression can be associated with postoperative delirium; however, the results of relevant studies are discrepant. This systematic review and meta-analysis aimed to assess the association between intraoperative burst suppression and postoperative delirium in adult surgical patients.

PubMed, MEDLINE, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials were systematically searched and updated in May 2023. We included cohort studies, case-control studies, and randomized-controlled studies reporting on postoperative delirium incidence with documented intraoperative burst suppression in adults receiving general anesthesia for any surgery. The primary outcome was the pooled odds ratio (OR) for postoperative delirium in cases with intraoperative burst suppression compared to those without burst suppression, calculated using a random-effects model. Two independent investigators extracted the data. The protocol was prospectively registered in PROSPERO (registration number: CRD42022326479); the results were reported according to PRISMA guidelines.

Fourteen studies (6435 patients) were included in the analysis. The overall incidence of postoperative delirium was 21.1% (1358/6435). Patients with intraoperative burst suppression had a higher incidence of postoperative delirium than those without burst suppression (pooled OR, 1.492; 95% confidence interval (CI) [1.022-2.178]; I2 =44%; 95% CI [0%-75%]; τ2 = 0.110). The intraoperative duration of burst suppression was significantly longer in patients who developed postoperative delirium (standardized mean difference [SMD] 0.462 [95% CI, 0.293-0.632]; I2 = 63%; 95% CI [16%-84%]; τ2 = 0.027). The burst suppression ratio was significantly higher in the delirium group (SMD 0.150; 95% CI [0.055-0.245]; I2 = 0%; 95% CI [0%-85%]; τ2 = 0.00).

Our meta-analysis suggests an association between intraoperative burst suppression and postoperative delirium; however, the quality of evidence was very low. The limited number of studies and substantial heterogeneity across them emphasize the need for further high-quality studies to establish a more robust conclusion.

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conclusions

Drug shortages are a frequent challenge in current clinical practice. Certain drugs, (e.g., protamine) lack alternatives and inadequate supplies can limit access to services. Conventional protamine dosing uses heparin ratio-based calculations for heparin reversal following CPB and may result in excess protamine utilization, and potential harm due to its intrinsic anticoagulation. We hypothesized that a fixed 250-mg protamine dose would be comparable, as measured by the activated clotting time, to a 1:1 (1 mg for every 100 U) protamine to heparin ratio-based strategy for heparin reversal and that protamine would be conserved.

In a single-center, double-blinded trial, consenting elective adult cardiac surgical patients without pre-existing coagulopathy or ongoing anticoagulation, and a calculated initial heparin dose of ≥ 27500 U were randomized to receive, following CPB, protamine as a fixed dose (250 mg) or a ratio-based dose (1 mg:100 U heparin). The primary outcome was the activated clotting time following initial protamine administration, assessed by Student's t-test. Secondary outcomes included total protamine, the need for additional protamine, and the cumulative 24-h chest tube output.

There were 62 and 63 patients in the fixed- and ratio-based dose groups, respectively. The mean post-protamine ACT was not different between groups (-2.0 s, 95% CI -7.2 to 3.3 s, P = 0.47). Less total protamine per case was administered in the fixed-dose group (2.1 50-mg vials, 95% CI -2.4 to -1.8, P < 0.0001). There was no difference in the cumulative 24-h chest tube output (difference = -77 ml, 95% CI 220 to 65 ml, P = 0.28).

A 1: 1 heparin ratio-based protamine dosing strategy compared to a fixed 250-mg dose resulted in the administration of a larger total dose of protamine no difference in either the initial ACT or the amount postoperative chest-tube bleeding.

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Propofol has been used in medical practice as an anaesthetic drug for producing and sustaining general anaesthesia due to its advantages. However, it also has drawbacks, including injection-related discomfort. Recently, ciprofol has emerged as a promising anaesthetic drug that may overcome many drawbacks associated with propofol. In this systematic review and meta-analysis, we assess the efficacy and safety of ciprofol compared to propofol in different anaesthesia procedures.

The study protocol was registered in the International Prospective Register of Systematic Reviews (ID: CRD42023458170). Central, PubMed, EMBASE, Scopus and WOS were searched for English literature until 26 February 2024. Meta-analysis was performed using RevMan. The risk of bias was assessed using the RoB 2.0 tool. Results were reported as risk ratios (RRs), mean differences (MDs) and 95% confidence intervals (CIs).

Nineteen randomised controlled trials were included in our analysis, with 2841 participants. There was no difference between ciprofol and propofol in the success rate of endoscopy (RR: 1.01, 95% CI: 0.99, 1.02; P = 0.44), while ciprofol showed a significant increase in the success rate of general anaesthesia/sedation (RR: 1.01, 95% CI: 1.00, 1.02; P = 0.04). Ciprofol showed significantly lower pain on injection (RR: 0.14, 95% CI: 0.09, 0.22; P < 0.001), lower adverse events (RR: 0.80, 95% CI: 0.69, 0.92; P = 0.002) and higher patient satisfaction (standardised mean difference (SMD): 0.36, 95% CI: 0.24, 0.48; P < 0.001).

Ciprofol exhibited a comparable efficacy to propofol in inducing general anaesthesia and sedation with fewer adverse events, less pain on injection and higher patient satisfaction. These collective findings may suggest that ciprofol can be used as an alternative drug to ensure effective general anaesthesia/sedation induction in the future.

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Carotid endarterectomy (CEA) is a common procedure conducted under regional anaesthesia, providing real-time cerebral function monitoring. Many different combinations of regional cervical blocks exist, and most offer adequate analgesia in intraoperative and postoperative recovery. This research compares a superficial cervical plexus block (SCB) alone and combined with an ultrasound (US)-guided carotid sheath block (CSB). The primary objective was to explore the length of the sensory block after combining SCB and CSB.

Patients scheduled for nonemergency CEA surgery were randomised into two cohorts. The Subject group (28 participants) received US-guided CSB and SCB. The Control group (31 participants) received only an SCB. Both groups received 0.5% levobupivacaine (2 mg/kg) along with 2% lidocaine (2 mg/kg). The sensory block time and its initiation, analgesia and neutrophil-to-lymphocyte ratio (NLR) were recorded before and after the block. The numeric pain rating scale (NPRS) was used to evaluate analgesia every 2 h for 12 h post block. Analysis of variance, Mann-Whitney U or log-rank test was used to analyse the distinction of selected variables.

The demographic characteristics were comparable across the cohorts. The Subject group demonstrated a significantly accelerated onset of sensory block (P = 0.029) and an extended time to first analgesia (P = 0.003). The sensory block was also substantially extended in the Subject group (P = 0.040). Postoperative pain (NPRS ≥1) within the first 12 h was more recurrent in the Control group (P = 0.048). NLR showed minimal disparity between the groups (P = 0.125).

Combining SCB and US-guided CSB effectively and safely extends postoperative analgesia for CEA surgery.

background and aims
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One major limitation of the spinal block remains the inability to extend the duration of the block intraoperatively unless planned before with spinal or epidural catheters and/or intrathecal additives. This study was designed to compare the effects of intravenous dexmedetomidine versus low-dose ketamine-dexmedetomidine combination infusion on spinal anaesthesia in lower limb orthopaedic surgeries.

This randomised study was conducted in 60 patients scheduled for unilateral lower limb surgeries under spinal anaesthesia. Patients were randomised into Group D (n = 30) (0.5 µg/kg of intravenous (IV) dexmedetomidine bolus followed by maintenance infusion at 0.5 µg/kg/h) and Group LKD (n = 30) (IV bolus of 0.5 µg/kg of dexmedetomidine and 0.2 mg/kg of ketamine, followed by maintenance infusions of dexmedetomidine and ketamine at 0.5 µg/kg/h and 0.2 mg/kg/h, respectively). Ramsay Sedation Scale score of 3-4 was maintained. The t-test or the Wilcoxon-Mann-Whitney U test was used to compare the parameters between groups.

The mean sacral segment 1 (S1) regression time was 390.3 [standard deviation (SD):84.38] [95% confidence interval (CI): 360.13, 420.53] versus 393.23 (SD: 93.01) (95% CI: 363.04, 423.43) min in Group D versus Group LKD respectively ((P = 0.701). The number of episodes of hypotension was significantly higher in Group D (19 patients) compared to Group LKD (nine patients) (P = 0.001). Pre- and postoperative stress markers (24 h) and the incidence of postoperative nausea and shivering were comparable between the two groups (P > 0.05). Tramadol requirement in the postoperative period was significantly less in Group LKD compared to Group D (P = 0.003).

The duration of S1 regression was similar between group dexmedetomidine (Group D) and group low-dose ketamine and dexmedetomidine (Group LKD).

background and aims
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Preoperative parental anxiety can have a profound impact on their children undergoing surgery. The present study was done to analyse the correlation between preoperative parental anxiety and their child's anxiety in paediatric patients undergoing elective surgery.

Paediatric patients aged 2-12 years, scheduled for elective surgeries under general anaesthesia, were included in the study. The child's behaviour and anxiety were assessed in the preoperative area using the modified Yale Preoperative Anxiety Scale (m-YPAS). The parent filled out the demographic questionnaire and the Spielberger State-Trait Anxiety Inventory (STAI) form in the preoperative area on the day of surgery. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS) statistics software version 23.0 (IBM Corp, Armonk, NY, USA).

A total of 150 children undergoing elective surgery were analysed. Our results showed a strong positive correlation between a child's m-YPAS and his/her parents' anxiety on the day of the surgery (STAI-state) (r = 0.545, P < 0.001). However, the correlation between a child's m-YPAS and his/her parents' anxiety levels (STAI-trait) was not found to be significant (r = 0.109, P = 0.188). A positive correlation was observed between a parent's STAI-state and STAI-trait (r = 0.366, P < 0.001). Factors like area of residence, type of surgery and previous hospitalisation had an influence on the anxiety levels of the child. The birth order of the child, previous hospitalisation and gender of the parent also influenced parental anxiety.

Parental anxiety has a significant impact on the child's anxiety during the preoperative period.

background and aims
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conclusion

Existing literature does not establish the superiority of the erector spinae plane (ESP) block or the thoracolumbar interfascial plane (TLIP) block in pain relief and reducing opioid consumption in lumbar spine surgeries. This systematic review and meta-analysis was aimed to discern their relative efficacy and safety.

This meta-analysis included randomised controlled trials (RCTs) comparing ESP and TLIP blocks in lumbar spine surgeries. The primary outcome was 24-h opioid consumption, and secondary outcomes were visual analogue scale (VAS) scores at 1 h and 24 h and various complications. PubMed, Central Register of Controlled Trials, SCOPUS, EMBASE databases and cross-references were electronically searched. Two authors extracted data independently, cross-checked, and analysed them using RevMan 5.4. Binary outcomes were reported as odds ratios (OR), while continuous outcomes were presented as standardised mean differences (SMDs) accompanied by 95% confidence intervals (95% CIs).

Among 1107 articles, six RCTs (492 patients) were finally included. The ESP block demonstrated lower 24-h opioid consumption compared to TLIP [SMD -0.32 (95% CI: -0.50, -0.14); P < 0.001, I 2 = 83%]. At 1 and 24 h, ESPB yielded significantly lower VAS scores compared to TLIP [1 h: SMD -0.38 (95% CI: -0.57, -0.18); P < 0.001, I 2 = 83%; 24 h: SMD -0.57 (95% CI: -0.76, -0.37); P < 0.001, I 2 = 73%]. No significant difference was noted in adverse events.

In comparison to the TLIP block, the ESP block has significantly lower 24-h opioid consumption and VAS scores at 1 and 24 h in patients undergoing lumbar spine surgery.

background and aims
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conclusion

The time paediatric patients should resume oral intake after surgery is still ill-defined. No specific evidence suggests that the usual practice of postoperative fasting of 4-6 h to reduce postoperative nausea and vomiting (PONV) is beneficial. The primary objective of this study was to assess the occurrence of PONV with early oral feeding compared to conventional feeding in children undergoing daycare surgery under general anaesthesia.

A randomised controlled trial was conducted in 300 children undergoing daycare surgery under general anaesthesia. Children were randomised into the early feeding group (Group EF, n = 150) or the conventional feeding group (Group CF, n = 150). Group EF received carbohydrate-containing oral fluids when the child demanded feed in the postoperative period. Group CF received oral fluids 4 h post-anaesthesia. All patients were monitored for occurrence of PONV, postoperative pain, duration of hospital stay and parental satisfaction. The incidence of PONV was compared using the Chi-squared test, while other continuous variables were compared using the Student's t-test.

Both groups were comparable regarding PONV (12% in Group EF vs. 18.7% in Group CF, P = 0.109). The Face, Legs, Activity, Cry, Consolability scores were significantly lower in Group EF at 0 min (P = 0.011), 30 min (P = 0.001) and 1 h (P < 0.001). Patients in Group EF had a significantly shorter duration of hospital stay, that is, 6.31 [standard deviation (SD): 3.52] [95% confidence interval (CI): 1.45-12.24] h in EF versus 10.13 (SD: 2.99) (95% CI: 5.12-16.33) h in CF (P < 0.001). Parents of the children in Group EF had significantly better parental satisfaction scores (P < 0.001).

Early postoperative feeding in children undergoing lower abdominal, non-gastrointestinal surgery under general anaesthesia does not increase the incidence of PONV.

background and aims
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conclusion

Postoperative nausea and vomiting (PONV) is a common complication after surgery. Preventing PONV in high-risk patients often requires a multimodal approach combining antiemetic drugs with diverse mechanisms. While aprepitant, a neurokinin-1 receptor antagonist, is recognised as highly effective for PONV prevention, uncertainties remain regarding its effectiveness.

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The analysis assessed the effectiveness of aprepitant (A), aprepitant plus ondansetron (AO) and aprepitant plus dexamethasone and ondansetron (ADO) in preventing PONV compared to ondansetron alone (O) or in combination with dexamethasone (DO).

In the analysis of 12 studies involving 2729 patients, aprepitant demonstrated significant efficacy in preventing PONV compared to ondansetron alone (A versus [vs.] O: PONV incidence 12.5% vs. 28.5%, relative risk [RR] = 0.45, P < 0.001; complete response rate 55.97% vs. 50.35%, RR = 1.13, P = 0.010). The combination of aprepitant with ondansetron (AO) also showed a significantly lower incidence of PONV compared to ondansetron alone (11.3% vs. 26.8%, RR = 0.43, P < 0.001) and a higher complete response rate (38.1% vs. 26.84%, RR = 1.41, P = 0.020). In addition, ADO significantly reduced PONV incidence compared to DO (ADO vs. DO: 13.63% vs. 35.38%, RR = 0.38, P = 0.006).

Aprepitant, whether used alone or in combination with ondansetron or both ondansetron and dexamethasone, consistently outperforms ondansetron in achieving a complete response as it lowers vomiting rates and reduces the need for rescue therapy during the crucial 24-48-h postoperative period.

background and aims
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conclusion

Surgeons often request a Valsalva manoeuvre (VM) at the end of surgery (head-neck surgery, craniotomy) to check haemostasis and to unmask covert venous bleeders. We aimed to compare an anaesthesia machine-generated objective technique for delivering VM under pressure-control (PC) mode with the traditional subjective technique of delivering VM in manual mode.

This randomised controlled study included 60 adult patients randomised to manual (Group M) and controlled ventilation (Group C) groups. Our primary outcome measure was internal jugular vein (IJV) diameter at pre-determined time points (T0 = baseline, T1 = VM initiation, T2 = 20 s after VM initiation, T3 = immediately after VM release, and T4 = 1 min, T5 = 2 min and T6 = 5 min post-VM release). Secondary outcome measures included mean arterial pressure (MAP), heart rate, time to desired plateau airway pressure, number of patients with bleeders unmasked and surgeon satisfaction. Independent/paired sample t-tests were applied. Results are expressed as mean (standard deviation), mean difference (95% confidence interval), dotted box-whisker plots and trendlines. P <0.05 is considered statistically significant.

Mean differences in diameter changes in IJV (in centimetres) in the mediolateral and anteroposterior directions between Group C and Group M were -0.136 (-0.227, -0.044) and -0.073 (-0.143, -0.002), respectively. VM in the PC mode produced more significant IJV dilatation (P = 0.004, P = 0.044). MAP at T0 and T1 was comparable. At T2 and T3, there was a more significant fall in MAP in Group C versus Group M (P = 0.018 and P = 0.021, respectively). At T4, T5 and T6, MAP was comparable.

Performing VM in PC mode is a better technique based on IJV diameter, haemodynamics, bleeder unmasking and surgeon satisfaction.

background
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conclusions

Norepinephrine has recently been suggested to be as effective as phenylephrine for the prevention of hypotension after spinal anesthesia for cesarean delivery. Moreover, compared to phenylephrine, norepinephrine may be superior in maintaining heart rate (HR) and consequently, cardiac output (CO). A recent study demonstrated that norepinephrine given as a single intravenous bolus is approximately 13 times more potent than phenylephrine. However, it is uncertain whether this finding can be applied when these vasopressors are administered as infusions. Therefore, the optimum infusion rate of norepinephrine remains unknown. We aimed to determine the median effective dose (ED50; defined as the rate of vasopressor infusion required to prevent spinal hypotension in 50% of subjects) of both drugs needed to maintain maternal systolic blood pressure within 20% of the baseline after spinal anesthesia for cesarean delivery and to derive the relative potency ratio.

Sixty healthy patients undergoing elective cesarean delivery with standardized spinal anesthesia were randomized into 2 groups. The first patient in group 1 received phenylephrine 1200 µg in normal saline 0.9% w/v 60 mL at 60 mL/h infusion rate (20 µg.min-1). The first patient in group 2 received norepinephrine 96 µg in normal saline 0.9% w/v 60 mL at 60 mL/h infusion rate (1.6 µg.min-1). Using up-down sequential allocation technique, the vasopressor dose for every subsequent patient was determined by the response in the previous patient. If effective, the next patient received a dose reduced by 150 µg of phenylephrine (2.5 µg.min-1) or 12 µg (0.2 µg.min-1) of norepinephrine. If ineffective, the dose for the next patient was increased by the same amount. The ED50s were determined according to the Dixon-Massey formula. Stroke volume (SV), HR, and CO were also measured.

The ED50 was 12.7 µg.min-1 (95% CI, 10.5-14.9) for phenylephrine and 1.01 µg.min-1 (95% CI, 0.84-1.18) for norepinephrine, giving a potency ratio of 12.6 (95% CI, 9.92-15.9). HR, SV, and CO did not differ between the groups.

Norepinephrine is more potent than phenylephrine by a factor of approximately 13 when administered as infusion for equivalent maternal blood pressure control. Based on these findings, we recommend a variable rate prophylactic infusion of norepinephrine to be initiated at 1.9 to 3.8 µg.min-1 for the management of hypotension during cesarean delivery under spinal anesthesia.

The latest medical research on Anesthesiology

Postoperative analgesic effectiveness of ultrasound-guided bilateral erector spinae plane block vs. rectus sheath block for midline abdominal surgery in a low- and middle-income country: a randomised controlled trial.

Association between intraoperative electroencephalogram burst suppression and postoperative delirium: A systematic review and meta-analysis.

Protamine Dosing for Heparin Reversal Following Cardiopulmonary Bypass: A Double-Blinded Prospective Randomized Control Trial Comparing Two Strategies.

Efficacy and safety of ciprofol versus propofol for induction of general anaesthesia or sedation: A systematic review and meta-analysis of randomised controlled trials.

Enhancing postoperative analgesia in carotid endarterectomy patients: The potential of ultrasound-guided carotid sheath block combined with superficial cervical plexus block: A randomised trial.

Comparison of intravenous dexmedetomidine versus ketamine-dexmedetomidine combination on spinal block characteristics in patients undergoing lower limb orthopaedic surgery - A randomised clinical trial.

Prediction of correlation between preoperative parents' anxiety and their child's anxiety before elective surgery under anaesthesia: An observational study.

Comparison of efficacy of ultrasound-guided erector spinae plane block versus thoracolumbar interfascial plane block in patients undergoing lumbar spine surgeries: A systematic review and trial sequential meta-analysis.

A randomised controlled trial to compare the occurrence of postoperative nausea and vomiting in early versus conventional feeding in children undergoing daycare surgery under general anaesthesia.

Comparison of aprepitant versus ondansetron for prevention of postoperative nausea and vomiting: A systematic review and meta-analysis with trial sequential analysis.

Comparison of two techniques of administering the Valsalva manoeuvre in patients under general anaesthesia: A randomised controlled study.

Optimal Infusion Rate of Norepinephrine for Prevention of Spinal Hypotension for Cesarean Delivery: A Randomized Controlled Trial, Using Up-Down Sequential Allocation.

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