Efficacy and Safety of Dexmedetomidine Premedication in Balanced Anesthesia: A Systematic Review and Meta-Analysis in Dogs

Dexmedetomidine is commonly used in small animal anesthesia for its potent sedative and analgesic properties; however, concerns regarding its cardiovascular effects prevent its full adoption into veterinary clinical practice. This meta-analysis was to determine the effects of dexmedetomidine on sedation, analgesia, cardiovascular and adverse reactions in dogs compared to other premedications. Following the study protocol based on the Cochrane Review Methods, thirteen studies were included in this meta-analysis ultimately, involving a total of 576 dogs. Dexmedetomidine administration probably improved in sedation and analgesia in comparison to acepromazine, ketamine and lidocaine (MD: 1.96, 95% CI: [−0.08, 4.00], p = 0.06; MD: −0.95, 95% CI: [−1.52, −0.37] p = 0.001; respectively). Hemodynamic outcomes showed that dogs probably experienced lower heart rate and higher systolic arterial blood pressure and mean arterial blood pressure with dexmedetomidine at 30 min after premedication (MD: −13.25, 95% CI: [−19.67, −6.81], p < 0.0001; MD: 7.78, 95% CI: [1.83, 13.74], p = 0.01; MD: 8.32, 95% CI: [3.95, 12.70], p = 0.0002; respectively). The incidence of adverse effects was comparable between dexmedetomidine and other premedications (RR = 0.86, 95% CI [0.58, 1.29], p = 0.47). In summary, dexmedetomidine provides satisfactory sedative and analgesic effects, and its safety is proved despite its significant hemodynamic effects as part of balanced anesthesia of dogs.

Anesthetic management “Abdominal Aortic Aneurysm” in the well-known case with Wolff-Parkinson-White syndrome

Wolff-Parkinson-White syndrome is an electrophysiological disorder of the heart caused by pre-stimulation of an abnormal lateral pathway that can be asymptomatic or may be accompanied by palpitations or shortness of breath. We reported a case of a 66-yearold man with a history of Wolff-Parkinson syndrome who was transferred to the operating room for simultaneous nephrectomy due to RCC and abdominal aortic aneurysm. Managing the anesthesia of these patients is challenging because they are prone to life-threatening tachyarrhythmias. Observance of all necessary precautions to prevent tachyarrhythmias, balanced anesthesia, careful monitoring and preparation with the necessary drugs and equipment to treat any complication, is the cornerstone of a positive surgical outcome. Keywords: Wolff Parkinson white syndrome; abdominal aortic aneurysm; electrophysiological disorder; anesthetic management.

ESTIMATION OF THE EFFECTIVENESS OF ASSOCIATED ANESTHESIA BASED ON EPIDURAL BLOCKADE IN CESARIAN SECTION IN PATIENTS WITH «EVIDENT» MITRAL STENOSIS

aim. To assess the efficacy and safety of general associated balanced anesthesia based on epidural block during cesarean section in patients with “severe” mitral stenosis.Material and methods. The results of clinical observations, and a complex of clinical, functional and biochemical studies during cesarian section of 26 women aged 18-30 years, with a gestation period of 32-34 weeks had been studied. All patients had «severe» MS (according to A.N. Okorokov, s classifications). Depending on the method of anesthesia all patients were divided into two equal groups Patients of group I (n=13) were operated under conditions of associated balanced anesthesia (CBA) on the basis of epidural blockade (EB) patients of group II (n=13) were operated under conditions of one of the most common variants of multicomponent anesthesia (MCA). The operations were performed in a planned method, their durations made 35-60 minutes. The duration of anesthesia were 50-110 minutesResults. Significant advantages of CBA on the basis of EB became apparent: minimal expense of narcotic preparations and muscular relaxants: rapid rehabilitation of reflex muscular activity, making it possible to carry out extubations of trachea in earlier term: opportunity of using epidural catheter in postoperative period in order to receive prolonged postoperative analgesia. Conclusion. CBA on the basis of EB provides reliable antinociceptive protections of the body from surgical aggression, ensures a smooth course of anesthesia and early postoperative period and therefore has an obvious advantage over the traditional version of GMCA with AVL.K

Artificial Intelligence-Based CT Images in Analysis of Postoperative Recovery of Patients Undergoing Laparoscopic Cholecystectomy under Balanced Anesthesia

To explore whether preoperative processing can promote the recovery of gastrointestinal function after laparoscopic cholecystectomy (LC) surgery, in the study, an artificial intelligence-based algorithm was used to segment the CT images to assist doctors in decision making. The patients were divided into observation group (balanced anesthesia) and control group (general anesthesia) with SPSS. The observation group received balanced anesthesia half a day before the operation. The method of balanced anesthesia was to induce 0.2 mg/kg midazolam, 3 mg/kg propofol, 2 μg/kg remifentanil, 0.2 mg/kg vecuronium, 4∼5 mg/(kg·h) propofol, and 9∼11 μg/(kg·h) remifentanil continuous intravenous infusion to maintain anesthesia, and it was stopped once the patient defecated; the control group had general anesthesia in the afternoon after the operation, and it was stopped once the patient defecated. The time before the first exhaust and defecation after the surgery as well as the recovery time of bowel sound was recorded, and the degree of abdominal pain, abdominal distension, and gastrointestinal adverse reactions was evaluated at 22 hours, 46 hours, and 70 hours after the surgery. It was found that the accuracy of the artificial intelligence-based segmentation algorithm was 81%. The reconstruction accuracy of multidimensional liver could be observed at any angle, and the reconstruction accuracy was not lower than the resolution of original input CT. The calculation error was less than 9%, and the volume of whole liver, liver segment, preresection liver, and residual liver was less than 9%. The simulation accuracy of virtual liver surgery was not lower than the resolution of original input CT. The time before the first exhaust and defecation was shorter in the observation group versus the control group ( P < 0.05). The recovery time of bowel sound in the observation group was shorter than that in the control group ( P < 0.05). There was a significant difference in the scores of abdominal distension between the two groups at 22 h and 46 h after surgery ( P < 0.05). It suggested that both the observation group and the control group could improve the symptoms of gastrointestinal adverse reactions after surgery. Nevertheless, balanced anesthesia can shorten the time before the first exhaust and defecation after surgery and promote the recovery of postoperative bowel sound. Furthermore, balanced anesthesia can alleviate abdominal distension, abdominal pain, and gastrointestinal adverse reactions, which should be promoted in clinic.

Efficacy of a combination of regional methods of anesthesia with general anesthesia in corneal transplantation

Background. Despite the significant development of modern anesthesiology, the pain relief of surgical patients is still unsatisfactory. Inadequate pain management causes psychological discomfort and complications. The combination of general anesthesia with various options for local anesthesia allows one to get closer to solving the problem of pain. The aim of the study was to compare the effect of multicomponent balanced anesthesia (intravenous + inhalation) and multicomponent balanced anesthesia, supplemented by pterygopalatine fossa blockade on the safety and efficacy of anesthesia for corneal transplantation. Materials and methods. The study included 73 patients, divided into two groups. Group С received multicomponent balanced anesthesia, group B — pterygopalatine fossa blockade additionally. The main criteria for evaluating the results of the study were: stability of hemodynamics and gas exchange during surgery, the severity of intraoperative pain syndrome by recording the analgesia nociception index, the severity of postoperative pain syndrome and the incidence of postoperative nausea and vomiting. Results. Both schemes of anesthetic management made it possible to avoid pronounced fluctuations in hemodynamic and gas exchange parameters at all stages of the study. Analyzing the severity of intraoperative pain, we found that in group С, pain relief could be considered insufficient during the first 7 minutes of the most traumatic stage of the operation, while in group B the analgesia nociception index did not decrease below 50. Statistically significant differences were obtained during 8 out of 10 minutes of the stage. Analysis of the pain relief quality in the postoperative period has shown that the level of pain according to the visual analogue scale upon awakening was equal to 0 in both groups, at the next three stages of the study (two and six hours after surgery and on the morning of the next day) the level pain in group C was significantly higher than in group B. Conclusions. The addition of regional blockade to multicomponent general anesthesia allows for adequate control of postoperative pain without compromising the safety profile.

Hemodynamic changes after spinal anesthesia in children below the age of four years

Introduction: Introduction: Spinal anesthesia has become the anesthesia of choice for most of the surgeries of the abdominal-pelvic region. Cited with benefits such as lesser risks of apnea, minimal cardiopulmonary alteration, and abnormalities associated with neurocognitive development, it incorporates all components of balanced anesthesia, especially in pediatric surgeries. Encouraging results on the safety, efficacy, and feasibility of spinal anesthesia has increased its utility. The objective of our study was to assess the hemodynamic change occurring in children below four years undergoing lower abdominal and pelvic surgeries following spinal anesthesia. Method: This is a cross-sectional study conducted over 2 years and includes children undergoing surgery of the lower abdomen in Kathmandu Model Hospital. The information was data regarding patients' demography, hemodynamic status prior, during, and after the procedure of spinal anesthesia, measuring systolic blood pressure (SBP), diastolic blood pressure (SBP), mean arterial pressure (MAP), heart rate (HR), sensory and motor block characteristics (modified Bromage scale) and complications. Result: The intraoperative and postoperative hemodynamics did not show major differences. The mean peak sensory level was T4 (C7-T10) during the block. Recovery of sensory and motor blocks was complete in all patients. Modified Bromage scale was 1 in 57(98.27%), 2 h post-surgery. The average duration of the block was 75 min (30-180). 1(1.72%) patient developed apnea during the surgery. Conclusion: Spinal anesthesia in small children showed minimal variation in intraoperative and postoperative hemodynamics and is a safer mode of anesthesia with sparing of respiratory alterations seen with general anesthesia.

Clinical Randomized Comparison of Medetomidine and Xylazine for Isoflurane Balanced Anesthesia in Horses

Introduction: To assess drug plasma levels, preanesthetic sedation, cardiopulmonary effects during anesthesia and recovery in horses anesthetized with isoflurane combined with medetomidine or xylazine.Study design: Prospective blinded randomized clinical study.Animals: Sixty horses undergoing elective surgery.Methods: Thirty minutes after administration of antibiotics, flunixine meglumine or phenylbutazone and acepromazine horses received medetomidine 7 μg kg−1 (group MED) or xylazine 1.1 mg kg−1 (group XYL) slowly intravenously (IV) and sedation was assessed 3 min later. Anesthesia was induced with ketamine/diazepam and maintained with isoflurane in oxygen/air and medetomidine 3.5 μg kg−1 h−1 or xylazine 0.69 mg kg−1 h−1. Ringer's acetate 10 mL kg−1 h−1 and dobutamine were administered to maintain normotension. All horses were mechanically ventilated to maintain end-tidal carbon dioxide pressures at 45 ± 5 mmHg (5.3–6.7 kPa). Heart rate (HR), invasive arterial blood pressures, inspired and expired gas compositions, pH, arterial blood gases, electrolytes, lactate and glucose were measured. For recovery all horses received intramuscular morphine 0.1 mg kg−1 and medetomidine 2 μg kg−1 or xylazine 0.3 mg kg−1 IV. Recovery was timed and scored using three different scoring systems. Plasma samples to measure medetomidine and xylazine concentrations were collected at predetermined timepoints. Repeatedly measured parameters were analyzed using a two-way repeated-measures analysis of variance for differences between groups and over time; p &lt; 0.05 was considered statistically significant.Results: Mean arterial blood pressures (MAP) stayed within normal ranges but were higher (p = 0.011) in group XYL despite significant lower dobutamine doses (p = 0.0003). Other measured parameters were within clinically acceptable ranges. Plasma levels were at steady state during anesthesia (MED 2.194 ± 0.073; XYL 708 ± 18.791 ng mL−1). During recovery lateral recumbency (MED 42.7 ± 2.51; XYL 34.3 ± 2.63 min; p = 0.027) and time to standing (MED 62.0 ± 2.86; XYL 48.8 ± 3.01 min; p = 0.002) were significantly shorter in group XYL compared to group MED. Recovery scores did not differ significantly between groups.Conclusion and Clinical Relevance: In horses anesthetized with isoflurane and medetomidine or xylazine, xylazine maintained higher MAP, reduced the dobutamine consumption and recovery time, whilst overall recovery quality was unaffected.

Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery

Background It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil. Methods Patients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting. Results The study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay. Conclusions This trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Does a combined intravenous-volatile anesthesia offer advantages compared to an intravenous or volatile anesthesia alone: a systematic review and meta-analysis

Background In anesthesia, additive drug interactions are used for reducing dose and dose-dependent side-effects. The combination of propofol with volatile anesthetics is rather unusual but might have advantages compared to the single use regarding PONV, time to extubation, movement during surgery and postoperative pain perception. Methods We searched PubMed, Scopus, Web of Science, and CENTRAL for relevant studies comparing combined intravenous volatile anesthesia with total intravenous or balanced anesthesia. The studies identified were summarized in a meta-analysis with the standardized mean difference or risk ratio as the effect size. Results Ten studies provided data. The risk for PONV in the recovery room was significantly reduced for a combined anesthesia compared to a balanced anesthesia (RR 0.657, CI 0.502–0.860, p-value 0.002). There was no significant difference detected either in the time to extubation or in pain perception. Movement during surgery was significantly reduced for a combined compared to a total intravenous anesthesia (RR 0.241, CI 0.135–0.428, p-value 0.000). Conclusions The combination of propofol and volatiles may have some advantages in the early occurrence of PONV compared to a balanced anesthesia. To sufficiently evaluate potential advantages of a combination of volatiles and propofol further high-quality trials are needed. Trial registration PROSPERO CRD42019126627.

Etomidate anesthesia in chicks: Effect of xylazine

The current study aimed to evaluate the etomidate anesthetic action, its toxicity profile and safety alone and to determine the benefit of xylazine coadministration to enhance its anesthetic duration, efficacy and to reach a state of balanced anesthesia in chicks. By using the up-and-down technique, it was found that the hypnotic Median Effective Dose (ED50) of the etomidate was 4.30 mg/kg, IM, whereas the acute Median Toxic Dose (TD50) was 17.90 mg/kg, IM in the chicks. In response, the calculated Therapeutic Index (TI) and Standard Safety Margin (SSM) indicate that the etomidate has a wide safety margin. Etomidate injection at 4, 8 and 16 mg/kg, IM yields a significant dose-response and dependent hypnosis in the chicks by evaluating the onset of the righting reflex loss, its period and regaining from it. The combination composed of etomidate and xylazine at 5 mg/kg, IM for each, reduced the onset of hypnosis and significantly distended its period besides a significant rise of the recovery time when compared with the group receiving etomidate alone. At the same time, this coadministered drugs elicited a significant raise in analgesic efficacy. Concerning plasma glucose, Alanine Transaminase (ALT) and Aspartate Transaminase (AST) concentrations, neither etomidate nor etomidate plus xylazine differ significantly from the control group. The results of this study propose the likelihood of using etomidate as an anesthetic agent for short surgical trials in the chickens that can be more effective by using xylazine to yield balanced anesthesia without causing significant side effects.