Ultrasound-Guided Lumbar Plexus Block Reduces Emergence Agitation in Children Undergoing Hip Surgery: A Prospective Randomized Controlled Trial

Background Emergence agitation (EA) is a common and challenging postoperative problem in children emerging from general anesthesia. It is associated with self-injury, increases stress on healthcare team members and postoperative maladaptive behavioral changes. However, no completely effective prevention has been found for EA. Pain is considered to be an important contributor to EA. Ultrasound-guided lumbar plexus block is a safe and effective anesthetic technique that can provide satisfactory pain relief in pediatric hip surgery. We aim to investigate the effect of ultrasound-guided lumbar plexus block on emergence agitation in children undergoing hip surgery. Methods This prospective, randomized, controlled study was conducted in children aged 1-6 yr undergoing elective hip surgery. Subjects were randomly assigned to receive either ultrasound-guided lumbar plexus block combined with general anesthesia (Group Block, n=60) or routine general anesthesia (Group Control, n=60). The primary outcome was the incidence of EA at 30 min after emergence from general anesthesia, assessed using the Pediatric Anesthesia Emergence Delirium (PAED) scale. The secondary outcomes included the incidence of severe EA, postoperative pain evaluated by the Children’s Hospital of eastern Ontario Pain Scale (CHEOPS) and the incidence of postoperative adverse complications. PAED, CHEOPS were measured at 0, 5, 10, 20, and 30 min after emergence from anesthesia. Results The incidence of EA was significantly lower in Group Block than in Group Control [13.3% vs. 43.3%, odds ratio (OR) 0.201, 95% confidence interval (CI) 0.082to 0.496, p<0.001]. Group Block had a lower incidence of severe EA than Group Control [3.3% vs. 18.3%, odds ratio (OR) 0.154, 95% confidence interval (CI) 0.032 to 0.727, p=0.019]. CHEOPS was lower in Group Block than in Group Control [mean (95%CI), 4.5(4.4-4.6) vs.4.9 (4.8-5.0), p<0.001]. Conclusion Ultrasound-guided lumbar plexus block could decrease the incidence and severity of emergence agitation in children undergoing hip surgery effectively. Trial registration: Chinese Clinical Trial Registry: ChiCTR-INR-17011525 (30/05/2017)

Neuraxial and general anesthesia for outpatient total joint arthroplasty result in similarly low rates of major perioperative complications: a multicentered cohort study

BackgroundNeuraxial anesthesia when compared with general anesthesia has shown to improve outcomes following lower extremity total joint arthroplasty. It is unclear whether these benefits are present in outpatient surgery given the selection of healthier patients.ObjectiveTo compare the effects of neuraxial versus general anesthesia on outcomes following ambulatory hip and knee arthroplasty.MethodsMulticentered retrospective cohort study in ambulatory hip or knee arthroplasty patients between January 2017 and December 2019. Primary endpoint examined 30-day major postoperative complications (mortality, myocardial infarction, deep venous thromboembolism, pulmonary embolism, stroke, and acute renal failure).ResultsOf 11 523 eligible patients identified, 10 003 received neuraxial anesthesia, while 1520 received general anesthesia. 30-day major complications did not differ between neuraxial anesthesia and general anesthesia groups (1.8% vs 2.3%; aOR=0.85, CI: 0.56 to 1.27, p=0.39). There was no difference in 30-day minor complications (surgical site infection, pneumonia, urinary tract infection; 3.3% vs 4.1%; aOR=0.83, CI: 0.62 to 1.14, p=0.23). The neuraxial group demonstrated reduced pain and analgesia requirements and had less postoperative nausea and vomiting (PONV). Median recovery room length of stay was shorter by 52 min in the general anesthesia group, but these patients were more likely to fail same day discharge (33% vs 23.4%; p<0.01).ConclusionAnesthesia type was not associated with an increased risk for complications. However, neuraxial anesthesia improved outcomes that predict readiness for discharge: patients had less pain, required less opioids, and had a lower incidence of PONV, thus improving the rate of same day discharge.Trial registration numberNCT04203732.

Lumboperitoneal Shunt Surgery Under Rachianesthesia

Purpose: In the very elderly, complications such as postoperative pneumonia or delirium, which are directly associated with longer hospitalization, are more frequent. In order to overcome these drawbacks, we switched from general anesthesia to rachianesthesia for the lumboperitoneal shunt (LPS) procedure in idiopathic normal pressure hydrocephalus (iNPH) patients. This is because iNPH suffers particularly elderly patients, and neuraxial anesthesia techniques such as rachianesthesia reportedly decrease postoperative complications in patients of very advanced age as compared with general anesthesia. Methods: We retrospectively analyzed 45 patients who underwent LPS in our institution, and divided them into two groups based on the anesthetic approach; 1) general anesthesia, 2) rachianesthesia. We analyzed these two groups with regard to postoperative delirium score and the hospital stay.Results: In the general anesthesia group, two patients had respiratory complications after the surgery. The mean postoperative delirium score using the intensive care delirium screening checklist (ICDSC) was 1.3 (1.4) and the length of hospital stay was 13.9 (4.7) days. In the rachianesthesia group, no patients had respiratory complications. The postoperative mean ICDSC was 1.3 (1.4), and the length of hospital stay was 10.8 (2.1) days. The statistical analysis showed the rachianesthesia group to have significantly shorter hospital stays.Conclusions: LPS under rachianesthesia is an alternative to performing this procedure under general anesthesia in elderly patients.

Association between General Anesthesia and the Occurrence of Cerebrovascular Accidents in Hip Fracture Patients

Background. General anesthesia is an important factor leading to postoperative complications, and cerebrovascular accidents take the first place in the causes of postoperative death. Therefore, it is extremely important to explore the correlation between general anesthesia and the occurrence of cerebrovascular accidents in hip fracture patients. Objective. To explore the association between general anesthesia and the occurrence of cerebrovascular accidents in hip fracture patients. Methods. The data of 240 hip fracture patients treated in our hospital from February 2017 to February 2021 were retrospectively analyzed, and the patients were divided into the general anesthesia group (n = 120) and nongeneral anesthesia group (n = 120) according to whether or not they received general anesthesia, so as to compare their incidence rate of cerebrovascular accidents between the two groups, record their hemodynamic changes, and analyze the association between various risk factors under general anesthesia and the occurrence of cerebrovascular accidents. Results. No statistical differences in patients’ general information such as age and gender between the two groups were observed ( P > 0.05); compared with the nongeneral anesthesia group, the incidence rate of cerebrovascular accidents was significantly higher in the general anesthesia group ( P < 0.001); between the two groups, the heart rates and mean arterial pressure (MAP) at 15 min after anesthesia, at the time of skin incision, and 15 min before the end of surgery were significantly different ( P < 0.05); according to the multiple logistic regression analysis, general anesthesia was a risk factor affecting the occurrence of cerebrovascular accidents in hip fracture patients, and under general anesthesia, age ≥80 years, BMI ≥23 kg/m2, types of anesthetic drugs ≥4, intraoperative blood pressure ≥140 mmHg, and intraoperative heart rate ≥80 bpm were also regarded as the risk factors. Conclusion. General anesthesia is a risk factor affecting the occurrence of cerebrovascular accidents in hip fracture patients, and under general anesthesia, age ≥80 years, BMI ≥23 kg/m2, types of anesthetic drugs ≥4, intraoperative blood pressure ≥140 mmHg, and intraoperative heart rate ≥80 bpm will further increase the possibility of cerebrovascular accidents.

Sealing-type Three-cavities Ventilation Joint: A New Device in Painless Bronchoscopy

Background: To observe the clinical effect and safety of the sealing-type three-cavities ventilation joint in painless bronchoscopy. To compare the respiratory mechanics between I-gel laryngeal mask and tracheal tube-controlled breath during bronchoscopy. Methods: 200 patients underwent bronchoscopy were recruited and randomly assigned to general anesthesia group (group Ⅰ, n = 100) and local anesthesia group (group Ⅱ, n = 100). General anesthesia group were divided into two groups, the I-gel laryngeal mask combined with sealing-type three-cavities ventilation joint group group(n=50) and the endotracheal tube combined with sealing-type three-cavities ventilation joint group(n=50). Patients in Group I were adopted by I-gel laryngeal mask or endotracheal tube with the sealing-type three-cavities ventilation joint after the induction anesthesia with remifentanil, propofol and succinylcholine. In group II, patients were anaesthetized with lidocaine and followed by 2mg/ kg propofol iv, and spontaneous respirations were retained with nasal cannula. All patients’ vital signs, endoscopic related adverse reactions and arterial blood gas analysis were recorded during the procedure. Results: Group I showed little changes of vital signs (P <0.05), and less adverse reaction such as the intraoperative hypoxia and intraoperative body movement (P <0.05), and no significant decrease of oxygen partial pressure (P <0.05). There is no significant difference in respiratory mechanics including tidal volume and airway pressure between two subgroups in group I(P>0.05). Conclusion: Sealing-type three-cavities ventilation joint prevents the oxygen deficit and makes it possible for us to examine patients through bronchoscope under general anesthesia without gas leakage. Moreover, sealing-type three-cavities ventilation joint provides safe and effective airway control while it does not change respiratory mechanics in endotracheal tube group compared with I-gel laryngeal mask makes endotracheal tube an alternative solution in bronchoscope. Take all these in consideration, sealing-type three-cavities ventilation joint proves to be a feasible method in bronchoscope.

Comparison of efficacy and safety of general anesthesia alone with those of combined epidural/general anesthesia in Chinese patients with gastric cancer undergoing laparoscopy-assisted tumor resection

Purpose: To compare postoperative opioid consumption, inflammatory response, survival/clinical outcomes and safety profile of epidural combined with general anesthesia (GA) versus GA in stage 1 gastric cancer patients undergoing surgical intervention by laparoscopy.Method: Chinese patients with early-stage gastric cancer undergoing laparoscopic-assisted tumor resection were enrolled and received either epidural combined with general anesthesia (group EA + GA) or general anesthesia only (group GA) in allocation ratio of 1:1. The following efficacy variables were assessed: 1) Pain score was measured on VAS scale; 2) post-operative consumption; 3) Quality of recovery; 4) inflammatory response; and 5) survival outcome. Safety was assessed throughout the study period.Results: Data for 200 subjects were analyzed. Compared to GA alone, combination of EA + GA demonstrate significantly greater reduction in post-operative pain with decrease postoperative opioid consumption. Also, the combination of GA and EA inhibited inflammatory response when compared to patients who received GA only. Moreover, the combination of GA and EA did not demonstrate any clinical benefit in survival outcome, when compared to patients who received GA alone, indicating that GA + EA has no role in improving survival outcome among patients undergoing gastric cancer surgery. Additionally, EA + GA was also associated with a shorter length of hospital stay, compared to GA.Conclusion: Overall, the results favor the use of GA + EA in Chinese patients with early-stage gastric cancer undergoing laparoscopic-assisted tumor resection. GA + EA combination improves immune response by inhibiting the inflammatory response but has no significant effect on survival outcome.

Comparison of Analgesic Efficacy between Bupivacaine with Dexamethasone and Bupivacaine Alone in Caudal Block for Pediatric Patients Undergoing Open Inguinal Hernia Repair

Background Open inguinal hernial repair surgeries are one of the most frequently performed surgical procedures in the pediatric population. Using optimal analgesic regimen provide safe and effective analgesia, reduce postoperative stress response and accelerate recovery from surgery. Regional anesthetic techniques are commonly used to facilitate pain control in pediatric surgical procedures. The most used techniques in pediatrics is caudal block. Objective To evaluate the analgesic effect of dexamethasone when given caudally as an adjuvant to caudal block vs bupivacaine alone in caudal block for children undergoing open inguinal hernial repair surgeries. Methods The study is a prospective double – blinded randomized controlled trial conducted on 50 randomly chosen patients in Ain Shams University Hospitals after approval of the medical ethical committee. Patients were divided randomly into two groups; each group consisted of 25 patients. After preoperative assessment and obtaining baseline vital data, all patients received general anesthesia. Group BD who would receive caudal dexamethasone added to Bupivacaine and Group B who would receive caudal block with Bupivacaine. Results Dexamethasone addition shows statistically significance difference between two groups according to FLACC scale at 4h, 8h and 12h. The duration of adequate analgesia (FLACC pain score 4 or less) was significantly higher in group BD compared to group B. Conclusion Dexamethasone 0.1 mg/kg, when used as an adjuvant to caudal anesthesia, can significantly prolong the duration of postoperative analgesia. It is better than bupivacaine alone in caudal block at similar doses in controlling postoperative pain.

A comparative study between Levobupivacaine alone and in combination with Dexmedetomidine in caudal analgesia of hernia repair in pediatrics

Background Inguinal hernia repair is one of the most frequently performed surgical procedures in the pediatric population. Using optimal analgesic regimen provides safe and effective analgesia, reduce postoperative stress response and accelerate recovery from surgery. Aim of the Work to examine the effect of Dexmedetomidine as an adjuvant to Levobupivacaine in caudal anesthesia, mainly its effect in enhancing and prolonging post-operative analgesia. Patients and Methods The study was conducted on 50 randomly chosen patients in Ain Shams University Hospitals after approval of the medical ethical committee. Patients were divided randomly into two groups, each group consisted of 25 patients. After preoperative assessment and obtaining baseline vital data, all patients received general anesthesia. Group A: Patients in this group received caudal anesthesia with Levobupivacaine 0.25% at a dose of 2 mg·kg−1 (0.8 ml·kg−1) before the beginning of the procedure. Group B: Patients in this group received Levobupivacaine 0.25% at a dose of 2 mg·kg−1 (0.8 ml·kg−1) in addition to Dexmedetomidine 1 μg·kg−1 in 1 ml normal saline before the beginning of the procedure. Results The results of the study revealed that there was significant reduction in FLACC score in group B at 4, 8, and 12 hours postoperatively compared to group A, at the twenty-fourth hour there was no significant difference. Regarding the duration of analgesia postoperatively we found statistically significant increase in group B compared to that in group A (p-value &lt;0.001). Regarding the number of doses of analgesia required post operatively (Paracetamol 15ml/kg/dose) there was a statistically significant decrease in patients requirement in group B compared to that in group A (p-value &lt;0.001). Conclusion Dexmedetomidine as adjuvant to Levobupivacaine provided significantly prolonged postoperative analgesia, reduced the postoperative analgesic requirements and better parents’ satisfaction as compared with caudal analgesia using Levobupivacaine alone in children undergoing hernia repair.

Artificial Bee Colony Algorithm-Based Ultrasound Image Features in the Analysis of the Influence of Different Anesthesia Methods on Lung Air Volume in Orthopedic Surgery Patients

This study aimed to provide a quantitative evaluation of the lung gas content in orthopedic surgery patients under different anesthesia using ultrasound images based on the artificial bee colony algorithm. The ultrasound image features based on an artificial bee colony algorithm were applied to analyze segmentation images to investigate the influence of different anesthesia methods on the lung air content of patients undergoing orthopedic surgery and the clinical features of such patients. They were also adopted for the anesthesia in orthopedic surgery to assist clinicians in the diagnosis of diseases. 160 orthopedic surgery patients who were hospitalized were treated with different anesthesia methods. The first group (traditional general anesthesia group) received general anesthesia and traditional ultrasound; the second group (ABC general anesthesia group) was used for ultrasound image analysis based on the artificial bee colony algorithm; the third group (traditional sclerosis group) was anesthetized with combined sclerosis block; ultrasound images of patients from the fourth group (ABC sclerosis group) were analyzed based on the artificial bee colony algorithm. Analysis was conducted at three time points. The LUS score of the traditional sclerosis group and ABC sclerosis group was hugely higher than the score of the traditional general anesthesia group and ABC general anesthesia group at T2 time, with statistical significance ( P < 0.005 ). At time point T3, the score of the traditional sclerosis group rose greatly compared with the general anesthesia group, and that of the ABC group was generally higher than that of the traditional ultrasound group ( P < 0.005 ). When the threshold value was 4, the fitness value of ABC algorithm was 2680.4461, and the fitness value of the control group was 1736.815. The difference between the two groups was 943.6311 ( P < 0.05 ). The operation time of ABC algorithm was 1.83, while that of the control group was 1.05, and the difference between the two groups was 0.78 ( P < 0.05 ). In conclusion, the feature analysis of ultrasonic images based on the artificial bee colony algorithm could effectively improve the accuracy of ultrasonic images and the accuracy of focus recognition. It can promote medical efficiency and accurately identify the lung air content of patients in future clinical case measurement and auxiliary treatment of fracture, which has great application potential in improving surgical anesthesia effect.

Delirium in Older Patients after Combined Epidural–General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial

Background Delirium is a common and serious postoperative complication, especially in the elderly. Epidural anesthesia may reduce delirium by improving analgesia, reducing opioid consumption, and blunting stress response to surgery. This trial therefore tested the hypothesis that combined epidural–general anesthesia reduces the incidence of postoperative delirium in elderly patients recovering from major noncardiac surgery. Methods Patients aged 60 to 90 yr scheduled for major noncardiac thoracic or abdominal surgeries expected to last 2 h or more were enrolled. Participants were randomized 1:1 to either combined epidural–general anesthesia with postoperative epidural analgesia or general anesthesia with postoperative intravenous analgesia. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the initial 7 postoperative days. Results Between November 2011 and May 2015, 1,802 patients were randomized to combined epidural–general anesthesia (n = 901) or general anesthesia alone (n = 901). Among these, 1,720 patients (mean age, 70 yr; 35% women) completed the study and were included in the intention-to-treat analysis. Delirium was significantly less common in the combined epidural–general anesthesia group (15 [1.8%] of 857 patients) than in the general anesthesia group (43 [5.0%] of 863 patients; relative risk, 0.351; 95% CI, 0.197 to 0.627; P &lt; 0.001; number needed to treat 31). Intraoperative hypotension (systolic blood pressure less than 80 mmHg) was more common in patients assigned to epidural anesthesia (421 [49%] vs. 288 [33%]; relative risk, 1.47, 95% CI, 1.31 to 1.65; P &lt; 0.001), and more epidural patients were given vasopressors (495 [58%] vs. 387 [45%]; relative risk, 1.29; 95% CI, 1.17 to 1.41; P &lt; 0.001). Conclusions Older patients randomized to combined epidural–general anesthesia for major thoracic and abdominal surgeries had one third as much delirium but 50% more hypotension. Clinicians should consider combining epidural and general anesthesia in patients at risk of postoperative delirium, and avoiding the combination in patients at risk of hypotension. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New