Anesthesia Research

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

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

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

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

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

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

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

Background: Neurological injury poses a significant challenge in aortic surgery, encompassing spinal cord injury from thoraco-abdominal aorta intervention or stroke post-surgery on the arch and ascending aorta. Despite ample literature and proposals, a fully effective strategy for preventing or treating neurological injury remains elusive. This narrative review aims to analyze the most common neuroprotective strategies implemented for aortic arch surgery and aortic surgery. Results: Results from the reviewed studies showed that several strategies, including deep hypothermia cardiac induction (DHCA) and cerebral perfusion techniques (retrograde cerebral perfusion, RCP, and selective anterograde cerebral perfusion, SACP) aim to mitigate these risks. Monitoring methods such as electroencephalogram (EEG), somatosensory evoked potential (SEPs), and near-infrared spectroscopy (NIRS) offer valuable insights into cerebral function during surgery, aiding in the management of hypothermia and perfusion. Pharmacological agents and blood gas management (pH stat vs. alpha stat, hematocrit level, glycemic control) are crucial in preventing post-operative complications. Additionally meticulous management of atheromatous debris is essential to minimize embolic risks during surgery. Methods: For this narrative review, PubMed, Scopus, and Medline have been used to search articles about neuroprotection strategies in aortic and aortic arch surgeries. The search was narrowed to articles between 1975 and 2024. A total of 3418 articles were initially identified to be potentially relevant for this review. A total of 66 articles were included and were found to match the inclusion criteria. Conclusions: While an overabundance of neuroprotection strategies exists for cardiac surgery, particularly in procedures involving the aorta and the arch, their efficacy varies, with some well-documented and others still under scrutiny. Further research is imperative to advance our comprehension and refine prevention techniques for cardiac-surgery-related brain injury. This is crucial given its substantial contribution to both mortality and, notably, post-operative morbidity. Full article

Background: Infants are at risk of cerebral hypoperfusion from low blood pressure during anesthesia. We conducted a retrospective observational study to determine the patient and perioperative factors associated with low systolic blood pressure (SBP) in healthy infants. Methods: We obtained perioperative data of 266 infants aged 0–6 months who underwent inguinal hernia repair between January 2015 and March 2019 at our institution. SBP was analyzed during two phases: the preparation phase (20 min before procedure start until incision) and the surgical phase (15 to 35 min after procedure start). Low SBP was defined as a value lower than two standard deviations below the 50th percentile for a phase- and weight-specific reference value. Results: Low SBP was observed in 11% (29/265) and 5% (13/259) of patients during the preparation and surgical phases, respectively. Neuromuscular blockade use was associated with normal SBP in both phases (regression coefficient β = 6.15 and p = 0.002, regression coefficient β = 6.52 and p < 0.001, respectively). SBP was more strongly associated with weight than with age (ratio of adjusted standardized regression coefficient = 2.0 in both phases). After controlling for covariates, patients given neuromuscular blockade had significantly fewer low SBP measurements during the preparation phase (regression coefficient β = −1.99 and p < 0.001). Conclusions: With respect to patient factors, in healthy infants under general anesthesia, weight was more strongly associated with SBP than age. A neuromuscular blocking agent administered during anesthesia induction was associated with fewer low SBP measurements in the preparation phase. Full article

Digital mucous cysts (DMCs) are common soft tissue tumors affecting interphalangeal joints. Various treatment options exist, with surgical excision being the standard. Ultrasound-guided cortisone (CC) injection into the distal interphalangeal (DIP) joint has been proposed as a therapeutic alternative. This study aims to assess the technical success and clinical efficacy of US-IPI in terms of swelling resolution and pain control. Fifty-two patients with DMCs underwent CCs DIP joint ultrasound-guided infiltration. Eighty-three percent of patients exhibited a positive response to US-IPI, with a significant reduction in NRS pain scores (p < 0.01). Persistent pain in 17% of patients was effectively managed with marked improvement after a secondary infiltration. Joint swelling was reduced in 68% of patients within 1 month, with complete resolution by 3 to 6 months. No recurrence was reported at the 6-month follow-up. Pain assessment using the Numeric Rating Scale and joint swelling evaluation were conducted at follow-ups of 2 weeks, 1, 3, and 6 months. Statistical analysis was performed to compare pre- and post-procedure NRS pain scores. Here, we show that US-IPI of DMCs is an effective therapeutic option that provides immediate pain relief and long-term aesthetic improvement, resulting in an alternative option to surgical excision. Full article

Background: Pediatric intensive care units (ICUs) face shortages of intensivists, posing challenges in delivering specialized care, especially in underserved regions. While studies on telecritical care in the adult ICU have demonstrated decreased complications and mortality, research on telemedicine in the pediatric ICU setting remains limited. This systematic review evaluates the safety and efficacy of audiovisual telemedicine in pediatric ICUs, assessing patient-centered outcomes when compared to in-person intensivist care. Methods: Two reviewers independently assessed studies from PubMed, MEDLINE (Ovid), Global Health, and EMBASE on the pediatric population in the ICU setting that were provided care by intensivists via telemedicine. Studies without a comparison group of in-person intensivists were excluded. Selected studies were graded using the Newcastle–Ottawa scale and the Levels of Evidence Rating Scale for Therapeutic Studies. Results: Of the 2419 articles identified, 7 met the inclusion criteria. Strong evidence suggested that telemedicine increases access to intensive care. Moderate evidence demonstrated that telemedicine facilitates real-time clinical decision-making, reliable remote clinical assessments, improved ICU process measures (i.e., days on a ventilator, days on antibiotics), and decreased length of stay. Weaker evidence supported that telemedicine decreases complications and mortality. Conclusions: Telemedicine may serve as a promising solution to pediatric ICUs with limited intensivist coverage, particularly in low-resource rural and international settings. Full article

Transforaminal epidural steroid injections are commonly used for the treatment of radicular pain. Some providers opt for an antero-superior approach and others a postero-inferior approach. In this retrospective cohort study, we evaluated MRI evident anatomic differences between the antero-superior and postero-inferior neural foramen at L5-S1 that may be relevant when choosing an approach for injections. A total of 29 L5-S1 neural foramina that were targeted for transforaminal epidural steroid injections were included. Pre-procedure MRIs were assessed for the distribution of the fat within the foramen. Additionally, the presence of foraminal vessels and foraminal stenosis and the presence/absence of anterolisthesis was also observed. Final imaging data were obtained by majority opinion of three or four radiologists. There was a statistically significant difference in the distribution of foraminal fat between the postero-inferior foramen and the antero-superior foramen (p < 0.001), with more fat generally in the postero-inferior foramen. Foraminal vessels were not consistently visualized. There was weak inter-reader reliability for the presence of vessels. In conclusion, this study suggests that there is a difference in the distribution of foraminal epidural fat between the postero-inferior and antero-superior foramen at L5-S1. Through MRI, vessels are inconsistently visualized and cannot be reliably detected on conventional MRI between readers. Full article

This article examines the intersection of simulation-based education and the AI revolution in anesthesia medicine. With AI technologies reshaping perioperative management, simulation education faces both challenges and opportunities. The integration of AI into anesthesia practice offers personalized management possibilities, particularly in preoperative assessment and monitoring. However, the ethical, legal, and social implications necessitate careful navigation, emphasizing patient data privacy and accountability. Anesthesiologists must develop non-technical skills, including ethical decision-making and effective AI management, to adapt to the AI era. The experience-based medical education (EXPBME) framework underscores reflective learning and AI literacy acquisition, fostering lifelong learning and adaptation. Learner-centered approaches are pivotal in anesthesia education, promoting active engagement and self-regulated learning. Simulation-based learning, augmented by AI technologies, provides a dynamic platform for technical and non-technical skills development. Ultimately, by prioritizing non-technical skills, embracing learner-centered education, and responsibly leveraging AI technologies, anesthesiologists can contribute to enhanced patient care and safety in the evolving perioperative landscape. Full article

Introduction: Monitoring cerebral perfusion in patients with brain injury is a major clinical challenge. Monitoring cerebral oxygenation (rSO2) via NIRS was introduced in the early 1980s, and many clinicians believed it to be a valuable method for assessing cerebral perfusion and subsequent measures to optimize cerebral flow. The main problem with the use of NIRS is the presence of intermediate structures—the skin, skull, meninges, cerebrospinal fluid—and their influence on the test result. Therefore, it seems that NIRS assessment performed on a patient during brain death can give an idea of the magnitude of the influence of these intermediate structures on the monitoring result. Case presentation: We present a case study of cerebral oxygenation measurements in a patient undergoing a brain death diagnostic procedure. A clinical situation in which cerebral blood flow is stopped can give an idea of the specificity of this method, in particular of the influence of intermediate structures on the monitoring result. In this case, the result obtained using NIRS is increased by the patient’s oxygenation before the apnea test. The influence of chromophores in the tissues surrounding the CNS and reflections and scattering of the light wave spectrum have a very significant effect on the final result of cerebral saturation measurement. Discussion: The majority of observations in existing research describing changes in cerebral perfusion or its optimization may be burdened by the problem described here, i.e., by the significant influence of measured intermediate structure oxygenation. The specificity of NIRS in assessing cerebral perfusion requires careful analysis. The therapeutic implications of monitoring cerebral oxygenation with NIRS are of great importance, and based on the example presented and the literature provided, this method should be used with caution. It has been shown that in a patient with brain death, the result of NIRS oxygenation measurements depends on the structures surrounding the brain. Full article

The purpose of this case series report is to demonstrate the current state of the art regarding tracheal intubation of an evoked electromyography-endotracheal tube (EMG-ET tube) for continuous intraoperative recurrent laryngeal nerve monitoring (IONM) in patients undergoing thyroid surgery. Both direct laryngoscopy (DL) and videolaryngoscopy (VL) are popular for routine tracheal intubation of an EMG-ET tube. A new intubating technique (styletubation), using a video-assisted intubating stylet (VS), provides less traumatic and swift intubation. Styletubation combined with VL ensures the precise placement of the EMG-ET tube. This novel intubation technique improves the outcome of intubating an EMG-ET tube for IONM. Full article

Background: Electrical impedance tomography (EIT) is a non-invasive, radiation-free imaging method that enables the continuous bedside monitoring of regional ventilation and lung volume changes. The technique is based on the estimation of the resistivity changes that occur across the lungs with breathing. Methods: We present two case reports of patients affected by acute respiratory distress syndrome successfully managed with prone-positioning-based regional ventilation shown on EIT. Results: Both patients were submitted to cycles of prone-positioning-guided EIT and were successfully extubated and discharged from intensive care unit. Conclusions: EIT is a functional imaging method that has the potential to improve respiratory care by providing real-time, continuous monitoring of regional ventilation and lung volume changes at the bedside. Further research is needed to evaluate its efficacy in different clinical scenarios and to optimize its use in respiratory care. Full article