Anesthesia Research

Abstract

Background: Language discordance occurs when the patient and the healthcare provider are not proficient in the same language. Language discordance in the critical care setting is a significant global issue because of its implications in the quality of care and outcomes of patients [...] Read more.

Background: Language discordance occurs when the patient and the healthcare provider are not proficient in the same language. Language discordance in the critical care setting is a significant global issue because of its implications in the quality of care and outcomes of patients who do not speak the primary language of the country in which they receive healthcare. Studies show that language-discordant, critically ill patients have increased use of restraints during mechanical ventilation, increased length of stay, and more frequent complications. Communication challenges are magnified in the intensive care unit because of the medical complexity and frequent need for challenging conversations regarding goals of care. To address language-based disparities in critical care, numerous qualitative studies in recent years have attempted to understand the barriers that providers face when caring for language-discordant patients. Our systematic review is the first to analyze this developing body of literature and identify barriers for which solutions must be sought to ensure equitable care. Methods: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Embase, and Scopus from inception up to 20 February 2024. From among 2150 articles, nine articles were selected, which included eight qualitative studies and one cross-sectional study. Three studies were high quality, five were moderate quality, and one was low quality. Results: We found four major barriers to caring for language-discordant patients in the critical care setting. These included limitations in providers’ knowledge of best practices in professional medical interpreter use, challenges in navigating interpreters’ multiple roles, and limitations with different interpretive modalities and system constraints. These barriers caused clinicians distress due to clinicians’ desire to provide empathic care that respected patients’ autonomy and ensured patients’ safety and understanding. Conclusion: Interventions to increase providers’ knowledge of best practices, integrate interpreters into the critical care team, strategize the use of interpretation modalities, and address system-based barriers are needed to improve the care of language-discordant, critically ill patients worldwide. Full article

Abstract

Introduction: Cardiopulmonary exercise testing (CPET) is the gold-standard assessment of functional capacity and predicts postoperative outcomes in major abdominal and thoracic surgery, as well as in older individuals undergoing elective surgery for colorectal cancer. However, CPET is resource-intensive and not universally available. Simpler [...] Read more.

Introduction: Cardiopulmonary exercise testing (CPET) is the gold-standard assessment of functional capacity and predicts postoperative outcomes in major abdominal and thoracic surgery, as well as in older individuals undergoing elective surgery for colorectal cancer. However, CPET is resource-intensive and not universally available. Simpler objective assessments of functional capacity, such as Clinical Frailty Scale (CFS) scoring, predict postoperative complications and may be useful in aiding shared decision and perioperative planning. Objectives: This study aimed to assess local cohort data and investigate the association between Clinical Frailty Scoring, CPET outcomes, and length of hospital stay. Methods: We conducted a retrospective cohort analysis of all patients who had received a cardiopulmonary exercise test as part of their preoperative assessment for major abdominal and thoracic surgery between May 2018 and December 2022 in four district general hospitals. Results: This study featured 174 patients, age 73 (mean), CFS 3 (mean), who underwent CPET with associated CFS scoring. The CFS scores were weakly correlated with the anaerobic threshold, VO₂ peak, and ventilatory equivalents, coefficients measuring −0.34, −0.36, and 0.31 (all p < 0.001), respectively. Linear regression demonstrated a negative coefficient for the association of CFS with the VO₂ peak and the AT, measuring −1.22 and −1.70, respectively, both p < 0.001. The CFS score was not predictive of 1-year mortality in this group. In a subgroup analysis (n = 59), there was no association between the CFS score and the length of stay. Conclusions: Our data suggest a weak relationship between the CFS score and the CPET results. Further investigations with larger prospective datasets are required to explore the use of CFS as a surrogate for CPET and its use as an independent predictor for perioperative outcomes. This study supports the limited literature available on this subject. Full article

Abstract

Introduction: Difficult airway management is a critical challenge in anesthesia, often necessitating advanced techniques to ensure patient safety. A patient presented with a malignant lesion on the epiglottis, significantly altering the airway anatomy. Flexible rhinolaryngoscopy revealed a laryngeal carcinoma affecting the entire epiglottis, [...] Read more.

Introduction: Difficult airway management is a critical challenge in anesthesia, often necessitating advanced techniques to ensure patient safety. A patient presented with a malignant lesion on the epiglottis, significantly altering the airway anatomy. Flexible rhinolaryngoscopy revealed a laryngeal carcinoma affecting the entire epiglottis, causing thickening and displacement, which suggested the potential for difficult intubation. Methods: Given the expected feasibility of bag-mask ventilation and front-of-neck access, an asleep intubation technique was selected. The combined use of a McGrath video laryngoscope and C-MAC video stylet allowed for fast and easy atraumatic intubation on the first attempt. The anesthetic and surgical course was uneventful. Discussion: This case report highlights the successful use of a combined approach involving a video laryngoscope and video stylet for intubation in a patient with known difficulties in airway management, providing insights into the benefits of enhanced visualization and maneuverability. The rigid design and steerable tip of the C-MAC video stylet provide advantages over traditional flexible optics, offering better maneuverability and reducing the need for a second operator. Although this technique was successful in this case, its use in patients with complex airway pathologies warrants careful preoperative assessment and collaboration with an experienced airway management team. Full article

Abstract

Background/Objectives: The rapid development of Large Language Models (LLMs) presents promising applications in healthcare, including patient education. In anesthesia, where patient anxiety is common due to misunderstandings and fears, LLMs could alleviate perioperative anxiety by providing accessible and accurate information. This study explores [...] Read more.

Background/Objectives: The rapid development of Large Language Models (LLMs) presents promising applications in healthcare, including patient education. In anesthesia, where patient anxiety is common due to misunderstandings and fears, LLMs could alleviate perioperative anxiety by providing accessible and accurate information. This study explores the potential of LLMs to enhance patient education on anesthetic and perioperative care, addressing time constraints faced by anesthetists. Methods: Three language models—ChatGPT-4, Claude 3, and Gemini—were evaluated using three common patient prompts. To minimize bias, incognito mode was used. Readability was assessed with the Flesch–Kincaid, Flesch Reading Ease, and Coleman–Liau indices. Response quality was rated for clarity, comprehension, and informativeness using the DISCERN score and Likert Scale. Results: Claude 3 required the highest reading level, delivering detailed responses but lacking citations. ChatGPT-4o offered accessible and concise answers but missed key details. Gemini provided reliable and comprehensive information and emphasized professional guidance but lacked citations. According to DISCERN and Likert scores, Gemini had the highest rank for reliability and patient friendliness. Conclusions: This study found that Gemini provided the most reliable information, followed by Claude 3, although no significant differences were observed. All models showed limitations in bias and lacked sufficient citations. While ChatGPT-4o was the most comprehensible, it lacked clinical depth. Further research is needed to balance simplicity with clinical accuracy, explore Artificial Intelligence (AI)–physician collaboration, and assess AI’s impact on patient safety and medical education. Full article

Abstract

Background: While multimodal analgesia is the standard of care for postoperative pain relief, opioid medications continue to be a part of the treatment regimen, especially for more invasive surgeries such as spinal fusion, craniofacial reconstruction, laparotomy, and others. In pediatric patients, safe [...] Read more.

Background: While multimodal analgesia is the standard of care for postoperative pain relief, opioid medications continue to be a part of the treatment regimen, especially for more invasive surgeries such as spinal fusion, craniofacial reconstruction, laparotomy, and others. In pediatric patients, safe usage, storage, and dosing are especially important, along with clear instructions to caregivers on how to manage their child’s pain. Combination opioids such as hydrocodone with acetaminophen and acetaminophen with codeine are the most commonly prescribed opioid medications for postoperative pain control. However, these combination products can lead to acetaminophen toxicity, limit the ability to prescribe acetaminophen or ibuprofen, and add to caregiver confusion. Administering acetaminophen and ibuprofen individually rather than in combination products allows the maximal dosing of these nonopioid medications. The primary aim of this quality improvement (QI) project was to increase the utilization of single-agent opioids for postoperative pain control, primarily oxycodone, by the various surgical groups here at Cook Children’s Medical Center (CCMC). Methods: The project setting was a tertiary-level children’s hospital with a level 2 trauma center, performing over 20,000 surgeries annually. The opioid stewardship committee (OSC) mapped the steps and overlapping activities in the intervention that led to changes in providers’ prescription practices. A Plan–Do–Study–Act continuous improvement cycle allowed for an assessment and modification of implementation strategies. Statistical control process charts were used to detect the average percentage change in surgical specialties using single-agent opioid therapy. Data were monitored for three periods: one-year pre-intervention, one-year post-intervention, and one-year sustainment periods. Results: There were 4885 (41%) pre-intervention procedures, 3973 (33%) post-intervention procedures, and 3180 (26%) sustainment period procedures that received opioids. During the pre-intervention period, the average proportion of single-agent opioids prescribed was 8%. This average shifted to 89% for the first five months of the post-intervention period, then to 91% for the remainder of the study. Conclusions: The methodical application of process improvement strategies can result in a sustained change from outpatient post-surgical combination opioid prescriptions to single-agent opioid prescriptions in multiple surgical departments. Full article

Abstract

Background: In Germany, over 16 million pre-anesthesia consultations (PAC) are conducted annually, which is associated with a significant investment of time and high costs. However, some PACs do not lead to surgery, which is inefficient and results in wasted resources. This study evaluates [...] Read more.

Background: In Germany, over 16 million pre-anesthesia consultations (PAC) are conducted annually, which is associated with a significant investment of time and high costs. However, some PACs do not lead to surgery, which is inefficient and results in wasted resources. This study evaluates the costs and time loss associated with PACs that did not result in anesthesia-required surgery or diagnostic procedures and identifies the predictors of these cancellations. Methods: A total of 1357 PACs conducted in September 2023 at the University Hospital Aachen were retrospectively analyzed. The study groups included patients whose PACs resulted in anesthesia-required surgery or diagnostic procedures (SURG group) and those whose PACs did not (NoSURG group). The primary outcomes were costs in EUR and the hours lost due to PACs not resulting in anesthesia for patients in the NoSURG group, and the secondary outcomes included the predictors of surgery cancellations, the frequency of missing test results, necessary pre-anesthesia re-consultations due to missing tests, and hospital length of stay for NoSURG patients. Results: In September 2023, 7.3% (99/1357) of PACs did not result in anesthesia-required procedures. ASA scores were higher in the NoSURG group, with almost two-thirds classified as ASA III or higher (p = 0.001). The NoSURG group had more planned postoperative IMC stays (16.2% vs. 9.3%; p = 0.027) and fewer medical report letters available (50.5% vs. 97.1%; p < 0.001). The reasons for surgery cancellation were often undetermined (47.5%). Other reasons included surgeons opting for a conservative approach (19.2%), patient decisions (9.1%), surgery no longer indicated (8.1%), hospital capacity constraints (5.1%), patient transfers (3.0%), and high surgical risk (8.1%). The annual projected cost for the NoSURG group was EUR 29,182, with 888 h of time loss. The median hospital length of stay for the NoSURG group was 5 (2; 15) days. Conclusions: PACs that were carried out but were not followed by anesthesiology services led to substantial costs and time loss. Improving medical report availability and assessing procedure necessity beforehand might help to reduce these expenses and time losses. Full article

Abstract

Background/Objectives: Hemolysis has been associated with acute kidney injury (AKI) in infants and neonates after surgery involving cardiopulmonary bypass (CPB). Erythrocyte hemolysis and subsequent end-organ injury have been shown to be a complex process involving the liberation of multiple molecules that mediate the [...] Read more.

Background/Objectives: Hemolysis has been associated with acute kidney injury (AKI) in infants and neonates after surgery involving cardiopulmonary bypass (CPB). Erythrocyte hemolysis and subsequent end-organ injury have been shown to be a complex process involving the liberation of multiple molecules that mediate the loss of nitric oxide and oxidative damage. This study assesses the association of multiple products of erythrocyte hemolysis with the evolution of AKI in neonates and infants undergoing CPB surgery. Methods: Blood and urine samples were collected at multiple time points before and after CPB and stored within an institutional biorepository. Twenty-one patients with AKI were matched with twenty-one non-Aki patients based on demographic and case complexity data. Results: Samples were analyzed for cell-free hemoglobin, heme, non-transferrin-bound iron, haptoglobin, hemopexin, and nitrite/nitrate. NGAL and KIM-1 were measured to index AKI. Cell-free hemoglobin was higher, haptoglobin was lower, and haptoglobin:hemoglobin ratio was lower in AKI compared to non-AKI patients. Conclusions: AKI in neonates and infants after CPB is associated with a pre and postoperative decrease in serum haptoglobin. These results confirm the need for future studies to prevent injury from hemolysis during CPB and potentially identify at-risk patients with decreased haptoglobin levels before surgery if delay is an option. Full article

Abstract

(1) Background: chronic pain following thoracic surgery is associated with dysaesthesia, which may be caused by intraoperative damage to intercostal nerves. This study’s primary aim was to compare, in the early postoperative period, the total area of dysaesthesia on the operated vs. the [...] Read more.

(1) Background: chronic pain following thoracic surgery is associated with dysaesthesia, which may be caused by intraoperative damage to intercostal nerves. This study’s primary aim was to compare, in the early postoperative period, the total area of dysaesthesia on the operated vs. the non-operated side of the thorax. Our secondary aims were to compare the total area of dysaesthesia between thoracotomy and video-assisted thoracic surgery (VATS) and to determine whether the area was associated with acute pain. (2) Methods: adult patients undergoing thoracic surgery underwent sensory examinations of the thorax using a monofilament and pin. Identified areas of hypoalgesia, hyperalgesia, allodynia and hypoaesthesia were marked on the skin, then copied onto tracing paper. Areas of dysaesthesia were estimated by weighing the cut-out, traced areas of paper and multiplying the weights by the paper’s known weight per area. Acute pain was assessed using a verbal rating score. (3) Results: the total area of dysaesthesia on the operated side [89 interquartile range (IQR) 8–167) cm²] was significantly greater than the non-operated side [0 (IQR 0–22) cm²] (p = 0.017), but not significantly different between thoracotomy [126 (IQR 16–392) cm²] and VATS [79 (IQR 4–161) cm²] (p = 1.0).The total area of dysaesthesia was not significantly correlated with acute pain severity after inspiration (r = 0.1, p = 1) or at rest (r = 0.1 p = 0.6). Conclusions: in the early postoperative period, thoracic surgery was associated with a larger total area of dysaesthesia on the operated compared to the non-operated side and the area was unrelated to acute pain, nor was it different between thoracotomy and VATS. Full article

Abstract

Background: In this manuscript, the challenges encountered during research into patient outcomes following transfusion during spine surgery are explored. Method: A narrative review of transfusion research over decades. Results: An estimated 310 million major surgeries occur in the world each year, and 15% [...] Read more.

Background: In this manuscript, the challenges encountered during research into patient outcomes following transfusion during spine surgery are explored. Method: A narrative review of transfusion research over decades. Results: An estimated 310 million major surgeries occur in the world each year, and 15% of these patients experience serious adverse outcomes (the United States of America, n 5,880,829). Many adverse outcomes are associated with allogeneic blood transfusion (ABT) and are potentially avoided by intraoperative cell salvage (ICS). The incidence of perioperative transfusion in patients who undergo spine surgery varies between 8 and 36%. Conclusions: Knowledge gaps remain due to the complexity of the field of study, confounding factors, the inability to define optimal transfusion triggers, challenges countered in study design, requirements for large sample sizes, and the inability to conduct randomised controlled trials (RCTs). The surgical complexity, subtle patient factors, and differences in policies and procedures across hospitals and countries are difficult to define and add further complexity. Solutions demand well-designed prospective collaborative research projects. Full article

Abstract

Background/Objective: POCUS is an invaluable tool for anatomical variation assessment, guidance of invasive interventions, and diagnosis of critical conditions that may change the anesthesiologist’s plan of care. This technology increases success rate, decreases time to surgery, and maximizes outcomes. The objective of this [...] Read more.

Background/Objective: POCUS is an invaluable tool for anatomical variation assessment, guidance of invasive interventions, and diagnosis of critical conditions that may change the anesthesiologist’s plan of care. This technology increases success rate, decreases time to surgery, and maximizes outcomes. The objective of this pilot program evaluation was to identify the anesthesiologists’ systems and processes for utilizing POCUS in clinical decision-making for patients during the perioperative phases of care for improved outcomes. Materials/Methods: A Multivariate Analysis of Variance (MANOVA) was conducted to identify differences across groups (scan type). The independent variable was the type of POCUS examination. The dependent variables included the patient’s: (1) Perioperative Status; (2) Cardiothoracic Anesthesiologist’s Review of Patient History and Formulating the Clinical Question; (3) Overall Risk Potential; (4) Aspiration Potential; (5) Issues Related to Cardiovascular Hemodynamics; (6) Issues Related to Volume Status; (7) Clinical Question Answered by POCUS; (8) Change in Plan of Care; (9) Interventions; and (10) Pharmacological Interventions. Results: MANOVA findings (Wilks’ λ) identified a statistically significant interaction between POCUS scan type and the cardiothoracic anesthesiologist’s clinical decision-making (p < 0.0001). The following four criteria were statistically significant: (1) patients (64%) were examined with POCUS preoperatively (p < 0.05); (2) patients (95%) identified as having some type of overall risk potential (p < 0.05); (3) patients (36%) specifically identified as an aspiration risk (p < 0.0001); and (4) patients (41%) identified with issues related to cardiovascular hemodynamics (p < 0.001). Conclusions: POCUS is a proven imaging modality that is easy, portable, sensitive, and specific for identifying various anatomical landmarks. POCUS utilization in the perioperative setting has potential to have a profound impact on successful surgical completion. Full article

Abstract

Thoracic surgery is a highly complex field requiring collaboration between surgeons, anesthesiologists, pulmonologists, and other specialists. Successful outcomes depend on thorough preoperative evaluations that consider the patient’s overall health, lifestyle habits, and surgical risks. Key elements include proper intraoperative anesthesia management, postoperative pain [...] Read more.

Thoracic surgery is a highly complex field requiring collaboration between surgeons, anesthesiologists, pulmonologists, and other specialists. Successful outcomes depend on thorough preoperative evaluations that consider the patient’s overall health, lifestyle habits, and surgical risks. Key elements include proper intraoperative anesthesia management, postoperative pain control, and the integration of enhanced recovery after surgery (ERAS) protocols to optimize recovery. Double-lumen tubes (DLTs) are essential for one-lung ventilation during thoracic procedures, although they can be invasive. Recent advancements, such as video-assisted laryngoscopes, have improved the success of DLTs and reduced the invasiveness of DLT intubation and extubation. Postoperative pain management is crucial for minimizing complications and enhancing recovery. Techniques like epidural analgesia, nerve blocks, and patient-controlled analgesia improve patient outcomes by allowing early mobility and deep breathing. Dexmedetomidine (DEX), a sedative with minimal respiratory impact, has shown promise in reducing delirium and aiding recovery. This review highlights the importance of teamwork, pain management, and emerging technologies in improving thoracic surgery outcomes. Advances in these areas, particularly within ERAS protocols, continue to enhance patient care and overall surgical success. Full article

Abstract

Background: Approximately 25% of adolescents live with chronic pain, with many reporting symptoms of functional impairment and poor sleep quality. Both chronic pain and poor sleep quality can negatively impact brain functional connectivity and efficiency. Better sleep quality may improve pain outcomes through [...] Read more.

Background: Approximately 25% of adolescents live with chronic pain, with many reporting symptoms of functional impairment and poor sleep quality. Both chronic pain and poor sleep quality can negatively impact brain functional connectivity and efficiency. Better sleep quality may improve pain outcomes through its relationship with brain functional connectivity. Methods: This pilot prospective cohort study used data from 24 adolescents with chronic pain (aged 10–18 years) participating in an Intensive Interdisciplinary Pain Treatment (IIPT) at the Alberta Children’s Hospital. Data were collected within the first couple of weeks prior to starting IIPT and on the last day of the 3-week IIPT program. Sleep quality was assessed using the modified Adolescent Sleep-Wake Scale. Resting-state functional MRI data were obtained, and graph-theory metrics were applied to assess small-world brain networks. Questionnaires were used to obtain self-reported functional disability data. Paired t-tests were applied to evaluate changes in outcomes from pre- to post-IIPT, and moderation analyses were used to examine the relationships between sleep, small-world brain network connectivity, and functional disability. Results: Total sleep quality (p = 0.005) increased, and functional disability (p = 0.020) decreased, between baseline and discharge from IIPT. Small-world brain networks did not change pre- to post-IIPT (p > 0.05). Unlike adolescents with high small-worldness (p = 0.665), adolescents with low to moderate small-world brain characteristics (1SD below or at the mean) who reported better sleep quality reported less functional disability (all p ≤ 0.001) over time. Conclusions: The IIPT program was associated with improvements in sleep quality and functional disability. Better sleep quality together with greater small-worldness was associated with less pain-related disability. This suggests that it is equally important for IIPTs to target sleep problems in adolescents with chronic pain, as this may have a key role in producing long-term improvements in pain outcomes. Full article

Abstract

Background: Meta-analyses and randomized controlled trials were inconclusive regarding the role of gabapentinoids in patients undergoing joint arthroplasties. The aim of the present study was to investigate the effect of a preoperative low dose of gabapentin in patients undergoing total hip (THA) and [...] Read more.

Background: Meta-analyses and randomized controlled trials were inconclusive regarding the role of gabapentinoids in patients undergoing joint arthroplasties. The aim of the present study was to investigate the effect of a preoperative low dose of gabapentin in patients undergoing total hip (THA) and knee arthroplasties (TKA). Methods: A retrospective observational study was conducted on 135 patients undergoing THA and TKA at the National Orthopedic Hospital Cappagh, Dublin, from July to December 2022. The primary outcome was the assessment of numerical rating scores (NRS) for postoperative pain at various time intervals. Results: During the observation period, 55 patients received a preoperative dose of gabapentin, while 80 patients did not. Statistically significant differences in numerical rating scores (NRS) were found at 6 (3 vs. 0, p < 0.001), 12 (4 vs. 2, p < 0.001), 18 (4 vs. 3, p < 0.001), and 24 h (4 vs. 3, p = 0.010) after surgery, in favor of the group receiving gabapentin. A reduction in opioid consumption, measured as morphine equivalents, was also noted in the gabapentin group (40 vs. 30 mg, p = 0.040). Conclusions: A low preoperative dose of gabapentin was associated with reduced postoperative pain and opioid consumption in patients undergoing TKA and THA, without impacting hospital stay. Prospectively designed trials are encouraged to assess the safety and effect on pain control of a preoperative low dose of gabapentin. Full article

Abstract

Background: Climate change has been identified as the greatest global health threat of the 21st century, with the healthcare sector contributing approximately 4–5% of global greenhouse gas (GHG) emissions. Within this sector, anesthetic practices are significant contributors due to the use of inhaled [...] Read more.

Background: Climate change has been identified as the greatest global health threat of the 21st century, with the healthcare sector contributing approximately 4–5% of global greenhouse gas (GHG) emissions. Within this sector, anesthetic practices are significant contributors due to the use of inhaled anesthetic gases such as desflurane, sevoflurane, and isoflurane, which possess high Global Warming Potentials (GWPs) and long atmospheric lifetimes. As concerns over climate change intensify, the anesthesia community must reassess its practices and adopt more sustainable approaches that align with environmental goals while maintaining patient safety. Methods: This manuscript reviews the environmental impacts of commonly used anesthetic gases and explores sustainable strategies, including the adoption of anesthetics with lower GWPs, enhancement of recycling and waste reduction methods, transition to intravenous anesthesia, and implementation of low-flow anesthesia techniques. Barriers to these strategies, such as technological limitations, resistance to change, policy restrictions, and educational gaps within the anesthesia community, are also examined. Results: The analysis indicates that transitioning to anesthetics with lower GWPs, such as replacing desflurane with sevoflurane and employing low-flow anesthesia, can significantly reduce GHG emissions. Although recycling and waste reduction pose logistical challenges, they offer additional environmental benefits. Transitioning to intravenous anesthesia can eliminate direct GHG emissions from volatile anesthetics. However, overcoming barriers to these strategies requires comprehensive education, advocacy for research and innovation, strategic change management, and supportive policy frameworks. Conclusions: Continuous monitoring and evaluation are essential for the success of sustainable practices in anesthesia. Establishing robust Key Performance Indicators (KPIs) and leveraging advanced analytical tools will enable adaptation and refinement of practices within the anesthesia community. Collaborative efforts among clinicians, policy makers, and stakeholders are crucial for reducing the environmental impact of anesthesia and promoting ecological responsibility within healthcare. Full article

Abstract

Background: Procedural sedation and analgesia (PSA) is commonly performed in emergency departments (EDs) to reduce anxiety, discomfort, or pain during a procedure. The primary goal of PSA is to produce a state of relaxation and drowsiness without eliminating the patient’s protective reflexes. Despite [...] Read more.

Background: Procedural sedation and analgesia (PSA) is commonly performed in emergency departments (EDs) to reduce anxiety, discomfort, or pain during a procedure. The primary goal of PSA is to produce a state of relaxation and drowsiness without eliminating the patient’s protective reflexes. Despite the discovery of new techniques and medications to deliver PSA, there is a paucity of research evaluating PSA in EDs over the last decade. We aim to describe the current practice of PSA in an Australian tertiary mixed ED with 75,000 presentations per year. Methods: A retrospective study of the initial 3 months of a PSA registry, which was part of the Tasmanian Emergency Care Outcomes Registry, was analyzed; Results: All told, 80 consecutive cases were entered over a 3-month period, with pediatric patients (<14 years old) making up 35% of all cases. Joint reductions (17, 39%) and fracture reductions (13, 29%) were the most common indications for the adult population, whilst fracture reductions (9, 36%), laceration repairs (7, 28%), and other distressing procedures (7, 28%) were the most common indications in the pediatric cohort. Pharmacological approaches also differed between groups, with ketamine (25, 92%) preferred in the pediatric cohort whilst the combination of propofol and fentanyl (22, 42%) was preferred in the adult cohort. No adverse events were recorded in the pediatric cohort whilst 6 (8%) minor events occurred in the adult population, with no severe events occurring for either cohort. PSA also occurred more frequently at 0900–1000 and the incidence was reduced between 0000 and 0800. Conclusions: PSA is commonly performed in our tertiary mixed ED and is both safe and effective, with non-severe complication rates similar to those in the reported literature. Severe complications are rare and therefore a larger cohort will be required to assess this aspect. The approach to ED PSA is also different between pediatric and adult populations and therefore research needs to differentiate both populations. Full article

Abstract

Background: Lung resection is the primary treatment option for many patients with lung cancer; however, it is a high-risk surgery with many potentially lethal perioperative complications. The aim of this review is to examine the capability of forced expiratory volume in one second [...] Read more.

Background: Lung resection is the primary treatment option for many patients with lung cancer; however, it is a high-risk surgery with many potentially lethal perioperative complications. The aim of this review is to examine the capability of forced expiratory volume in one second (FEV1), diffusing capacity of the lung for carbon monoxide (DLCO), maximal oxygen uptake in exercise (VO_2max), and maximal inspiratory and expiratory pressures (PI_max and PE_max, respectively) to predict postoperative lung function. Methods: A literature review was performed using PubMed and the Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) guidelines. The research included articles after 2000. Experimental studies on animals, studies before 2000, and studies in a language other than English were excluded. Results: A total of 11 studies were included in this review. The main findings were highlighted. In addition, the optimal threshold values of FEV1, DLCO, VO_2max, and PI_max as well as PE_max were discussed. Conclusions: Preoperative FEV1, DLCO, VO_2max, and PI_max as well as PE_max have all proven to be independent risk factors for the prediction of postoperative morbidity, mortality, and cardiopulmonary complications after lung resection surgery. Full article

Abstract

Sepsis is a complex syndrome with heterogeneous clinical presentation and outcome, characterized by an abnormal inflammatory response, potentially leading to multiorgan damage and hemodynamic instability. Early resuscitation with fluids and timely control of the source of sepsis are key treatment targets in septic [...] Read more.

Sepsis is a complex syndrome with heterogeneous clinical presentation and outcome, characterized by an abnormal inflammatory response, potentially leading to multiorgan damage and hemodynamic instability. Early resuscitation with fluids and timely control of the source of sepsis are key treatment targets in septic patients. Recommendations on when to add vasopressors and inotropes are mostly empirical and anecdotal, therefore remaining a topic of debate. This narrative review was developed to present and discuss current options in the early management of hemodynamic derangement induced by sepsis. We discuss the strengths and drawbacks of the recommended treatment with fluids and how to optimize volume resuscitation in order to avoid fluid overload or under-resuscitation. The choice and timing of vasopressor use represent hot topics in the early management of septic patients. We describe the advantages and limitations of the early introduction of vasopressors and new catecholamine-sparing strategies. We conclude with a description of the inotropes, considering that the heart plays a key role in the pathophysiology of septic shock. Full article

Abstract

Although astaxanthin (AST) has demonstrated a modulatory effect on voltage-gated Ca²⁺ (Cav) channels and excitatory glutamate neuronal transmission in vitro, particularly on the excitability of nociceptive sensory neurons, its action in vivo remains to be determined. This research sought to determine if [...] Read more.

Although astaxanthin (AST) has demonstrated a modulatory effect on voltage-gated Ca²⁺ (Cav) channels and excitatory glutamate neuronal transmission in vitro, particularly on the excitability of nociceptive sensory neurons, its action in vivo remains to be determined. This research sought to determine if an acute intravenous administration of AST in rats reduces the excitability of wide-dynamic range (WDR) spinal trigeminal nucleus caudalis (SpVc) neurons in response to nociceptive and non-nociceptive mechanical stimulation in vivo. In anesthetized rats, extracellular single-unit recordings were carried out on SpVc neurons following mechanical stimulation of the orofacial area. The average firing rate of SpVc WDR neurons in response to both gentle and painful mechanical stimuli significantly and dose-dependently decreased after the application of AST (1–5 mM, i.v.), and maximum suppression of discharge frequency for both non-noxious and nociceptive mechanical stimuli occurred within 10 min. These suppressive effects persisted for about 20 min. These results suggest that acute intravenous AST administration suppresses the SpVc nociceptive transmission, possibly by inhibiting Cav channels and excitatory glutamate neuronal transmission, implicating AST as a potential therapeutic agent for the treatment of trigeminal nociceptive pain without side effects. Full article

Abstract

The C-MAC video stylet (Karl Storz KG, Tuttlingen, Germany) is proposed as a successor to the familiar retromolar intubation endoscope. With its flexible tip, it may be especially useful for patients with a limited mouth opening. An awake or sedated airway management technique [...] Read more.

The C-MAC video stylet (Karl Storz KG, Tuttlingen, Germany) is proposed as a successor to the familiar retromolar intubation endoscope. With its flexible tip, it may be especially useful for patients with a limited mouth opening. An awake or sedated airway management technique is often preferred when a difficult airway is anticipated. Due to the challenges in preparation, sedation, topical airway anesthesia and the execution of such an airway management technique itself, these techniques are often clinically underused. The C-MAC video stylet seems to be well suited for an awake or sedated airway approach, as its handling is easier and faster than a flexible fiberscope. It does not exert pressure on the tongue as direct laryngoscopy or video laryngoscopy do. We report two cases of a difficult airway in which intubation was performed by using the C-MAC video stylet in sedated, spontaneously breathing patients. After a low dose of 3 mg midazolam IV, remimazolam was administered continuously (0.46–0.92 mg/kg/h). This was supplemented with a low dose of remifentanil (0.04–0.05 µg/kg/min). The Trachospray device (MedSpray Anesthesia BV, Enschede, The Netherlands) was used for topicalization of the upper airway by means of 4 mL of lidocaine 5%. In addition, a further 5 mL of lidocaine 5% was sprayed via an epidural catheter advanced through the oxygenation port of the C-MAC video stylet for further topicalization of the vocal cords and proximal part of the trachea. The well-coordinated steps described in these two cases may represent a blueprint and a good starting point for future studies with a larger number of patients. Full article