Impact on grafted kidney function of rocuronium-sugammadex vs cisatracurium-neostigmine strategy for neuromuscular block management. An Italian single-center, 2014-2017 retrospective cohort case-control study

Background The impact of sugammadex in patients with end-stage renal disease undergoing kidney transplantation is still far from being defined. The aim of the study is to compare sugammadex to neostigmine for reversal of rocuronium- and cisatracurium-induced neuromuscular block (NMB), respectively, in patients undergoing kidney transplantation. Methods A single-center, 2014-2017 retrospective cohort case-control study was performed. A total of 350 patients undergoing kidney transplantation, equally divided between a sugammadex group (175 patients) and a neostigmine group (175 patients), were considered. Postoperative kidney function, evaluated by monitoring of serum creatinine and urea and estimated glomerular filtration rate (eGFR), was the endpoint. Other endpoints were anesthetic and surgical times, post-anesthesia care unit length of stay, postoperative intensive care unit admission, and recurrent NMB or complications. Results No significant differences in patient or, with the exception of drugs involved in NMB management, anesthetic, and surgical characteristics, were observed between the two groups. Serum creatinine (median [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.0] μmol/L, p = 0.0128) and serum urea (14.9 [10.8-21.6] vs 17.1 [13.1-22.0] mmol/L, p = 0.0486) were lower, while eGFR (8.0 [6.0-11.0] vs 8.0 [6.0-10.0], p = 0.0473) was higher in the sugammadex group than in the neostigmine group after surgery. The sugammadex group showed significantly lower incidence of postoperative severe hypoxemia (0.6% vs 6.3%, p = 0.006), shorter PACU stay (70 [60-90] min vs 90 [60-105] min, p < 0.001), and reduced ICU admissions (0.6% vs 8.0%, p = 0.001). Conclusions Compared to cisatracurium-neostigmine, the rocuronium-sugammadex strategy for reversal of NMB showed a better recovery profile in patients undergoing kidney transplantation.

Perioperative Morbidity and Complications in Patients With an Established Ileostomy Undergoing Major Abdominal Surgery: A Retrospective Study

Background: Recently formed ileostomies may produce an average of 1,200 ml of watery stool per day, while an established ileostomy output varies between 600–800 ml per day. The reported incidence of renal impartment in patients with ileostomy is 8–20%, which could be caused by dehydration (up to 50%) or high output stoma (up to 40%). There is a lack of evidence if an ileostomy could influence perioperative fluid management and/or surgical outcomes.Methods: Subjects aged ≥18 years old with an established ileostomy scheduled to undergo an elective non-ileostomy-related major abdominal surgery under general anesthesia lasting more than 2 h and requiring hospitalization were included in the study. The primary outcome was to assess the incidence of perioperative complications within 30 days after surgery.Results: A total of 552 potential subjects who underwent non-ileostomy-related abdominal surgery were screened, but only 12 were included in the statistical analysis. In our study cohort, 66.7% of the subjects were men and the median age was 56 years old (interquartile range [IQR] 48-59). The median time from the creation of ileostomy to the qualifying surgery was 17.7 months (IQR: 8.3, 32.6). The most prevalent comorbidities in the study group were psychiatric disorders (58.3%), hypertension (50%), and cardiovascular disease (41.7%). The most predominant surgical approach was open (8 [67%]). The median surgical and anesthesia length was 3.4 h (IQR: 2.5, 5.7) and 4 h (IQR: 3, 6.5), respectively. The median post-anesthesia care unit (PACU) stay was 2 h (IQR:0.9, 3.1), while the median length of hospital stay (LOS) was 5.6 days (IQR: 4.1, 10.6). The overall incidence of postoperative complications was 50% (n = 6). Two subjects (16.7%) had a moderate surgical wound infection, and two subjects (16.7%) experienced a mild surgical wound infection. In addition, one subject (7.6%) developed a major postoperative complication with atrial fibrillation in conjunction with moderate hemorrhage.Conclusions: Our findings suggest that the presence of a well-established ileostomy might not represent a relevant risk factor for significant perioperative complications related to fluid management or hospital readmission. However, the presence of peristomal skin complications could trigger a higher incidence of surgical wound infections.

The Effect of Dexmedetomidine Infusion Versus Magnesium Sulphate Infusion on Emergence Delirium in Pediatric Patients Undergoing Lower Abdominal Surgery

Background Emergence delirium (ED) is a clinical state during emergence from general anesthesia in which patients are awake but have an altered mental state. Its underlying cause remains unknown. Age, preoperative anxiety, anesthetic technique or agents, surgical procedure and pain are all suggested to play a role in its development. Several drugs were used to lower it's incidence in children. Objective Evaluating the incidence and intensity of emergence delirium in pediatric patients undergoing lower abdominal surgery after using either intravenous dexmedetomidine infusion or magnesium sulphate infusion intraoperatively. Patients and Methods 100 patients were randomized to receive intraoperatively either dexmedetomidine loading dose (0.5 µg/kg) over 10 min. followed by infusion rate of (0.2 µg / kg / hr.) or magnesium sulphate loading dose (30 mg/kg) followed by infusion rate of (10 mg/kg/hr) after induction with sevoflurane, LMA application and administration of caudal block. PEAD score was used for assessing emergence delirium. Results Incidence of emergence delirium according to PAED scale ≥10 was significantly lower in dexmedetomidine group than magnesium sulphate group with Pvalue &lt;0.001, &lt;0.001, 0.031, 0.012, 0.012 at 0,5,10,15,20 min. respectively during PACU stay. This statistically significant vanishes after 20 min. stay in PACU. There were no significant differences as regard fentanyl top up doses, postoperative FLACC pain score, postoperative fentanyl requirements. Conclusion This study shows that intraoperative administration of dexmedetomidine infusion is more effective than magnesium sulphate infusion in lowering the incidence of emergence delirium during the first 20 minutes postoperatively. In preschool aged children undergoing lower abdominal surgeries.

Monitoring postoperative lung recovery using electrical impedance tomography in post anesthesia care unit: an observational study

With electrical impedance tomography (EIT) recruitment and de-recruitment phenomena can be quantified and monitored at bedside. The aim was to examine the feasibility of EIT with respect to monitor atelectasis formation and resolution in the post anesthesia care unit (PACU). In this observational study, 107 postoperative patients were investigated regarding the presence and recovery of atelectasis described by the EIT-derived parameters Global Inhomogeneity Index (GI Index), tidal impedance variation (TIV), and the changes in end-expiratory lung impedance (ΔEELI). We examined whether the presence of obesity (ADP group) has an influence on pulmonary recovery compared to normal weight patients (NWP group). During the stay at PACU, measurements were taken every 15 min. GI Index, TIV, and ΔEELI were calculated for each time point. 107 patients were monitored and EIT-data of 16 patients were excluded for various reasons. EIT-data of 91 patients were analyzed off-line. Their length of stay averaged 80 min (25th and 75th quartile 52–112). The ADP group demonstrated a significantly higher GI Index at PACU arrival (p < 0.001). This finding disappeared during their stay at the PACU. Additionally, the ADP group showed a significant increase in ΔEELI between PACU arrival and discharge (p = 0.025). Furthermore, TIV showed a significantly lower value during the first 90 min of PACU stay as compared to the time period thereafter (p = 0.036). Our findings demonstrate that obesity has an influence on intraoperative atelectasis formation and de-recruitment during PACU stay. The application of EIT in spontaneously breathing PACU patients seems meaningful in monitoring pulmonary recovery.

Effects of lidocaine, dexmedetomidine, and their combination infusion on postoperative nausea and vomiting following laparoscopic hysterectomy: a randomized controlled trial

Background A few studies have reported that administration of lidocaine and dexmedetomidine relieves the incidence of postoperative nausea and vomiting (PONV). We explored whether combined infusion of lidocaine plus dexmedetomidine had lower occurrence of PONV undergoing laparoscopic hysterectomy with general anesthesia. Methods A total of 248 women undergoing elective laparoscopic hysterectomy were allocated into the following four groups: the control group (group C, n = 62) received an equal volume of saline, the lidocaine group (group L, n = 62) received intravenous lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion), the dexmedetomidine group (group D, n = 62) received dexmedetomidine administration (bolus infusion of 0.5 µg/kg over 10 min, 0.4 µg/kg/h continuous infusion), and the lidocaine plus dexmedetomidine group (group LD, n = 62) received combination of lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion) and dexmedetomidine administration (bolus infusion of 0.5 µg/kg over 10 min, 0.4 µg/kg/h continuous infusion). The primary outcome was the incidence of nausea, vomiting, and PONV during the first 48 h after surgery. The secondary outcomes included the incidence of total 24 h PONV after surgery, intraoperative remifentanil requirement, postoperative pain visual analogue scale (VAS) scores and fentanyl consumption, the incidence of bradycardia, agitation, shivering, and mouth dry during post-anesthesia care unit (PACU) stay period. Results The occurrence of nausea and PONV in group LD (5.0 and 8.3%) at 0–2 h after operation was lower than group C (21.7 and 28.3%) (P < 0.05). There was no statistically significant difference with respect to occurrence of nausea and PONV in groups L (13.3 and 20.0%) and D (8.3 and 13.3%) at 0–2 h after operation compared to group C (21.7 and 28.3%). The incidence of nausea, vomiting, and PONV at 2–24 and 24–48 h after surgery in all four groups was not statistically significant. The incidence of total 24 h PONV in group LD (33.3%) was significantly decreased compared to group C (60.0%) (P < 0.05). The cumulative consumption of fentanyl at 6 and 12 h after surgery was significantly reduced in group LD compared to other three groups (P < 0.05). The pain VAS scores were significantly decreased at 2, 6, and 12 h after operation in group LD compared to other three groups (P < 0.05). Remifentanil dose in the intraoperative period was significantly lower in groups LD and D compared with groups C and L (P < 0.05). The number of mouth dry, bradycardia, and over sedation during the PACU stay period was markedly increased in group LD (28.3, 30.0, and 35.0%, respectively) compared with groups C (1.7, 1.7, and 3.3%, respectively) and L (3.3, 5.0, and 6.7%, respectively) (P < 0.05). Conclusions Lidocaine combined with dexmedetomidine infusion markedly decreased the occurrence of nausea and PONV at 0–2 h as well as the total 24 h PONV. However, it significantly increased the incidence of mouth dry, bradycardia, and over sedation during the PACU stay period after laparoscopic hysterectomy with general anesthesia. Trial registration ClinicalTrials.gov (NCT03809923), registered on January 18, 2019.

The association between residual neuromuscular blockade (RNMB) and critical respiratory events: a prospective cohort study

Background Inadequate neuromuscular recovery might impair pulmonary function among adult patients who undergo general anaesthesia and might thus contribute to critical respiratory events in the post-anaesthesia care unit (PACU). The pilot study aims to understand the baseline incidence of residual neuromuscular blockade (RNMB) and postoperative critical respiratory events (CREs), which are described in a modified Murphy’s criteria in the PACU. Method This is a prospective cohort study from January to March 2017 from a tertiary hospital in Saudi Arabia with thirty adult patients over 18 years old scheduled for elective surgery under general anaesthesia with neuromuscular blocking drugs (NMBDs) who were enrolled in the study. The Mann-Whitney U tests, chi-square tests and independent-samples T tests were used. The train-of-four (TOF) ratios were measured upon arrival in the PACU by using acceleromyography with TOF-Scan. Subjects’ demographics, perioperative data and the occurrence of postoperative CREs in the PACU were recorded. Results Twenty-six (86.7%) patients out of thirty in the study have received rocuronium as NMBDs whilst neostigmine as a reversal drug with only 23 (76.7%). The incidence of RNMB (TOF ratio < 0.9) was in 16 patients (53.3%). The incidence of RNMB was significantly higher in female patients (p = 0.033), in patients who had not undergone quantitative neuromuscular monitoring before extubation (p = 0.046) and in patients with a shorter duration of surgery (p = 0.001). Postoperative CREs occurred in twenty patients (66.7%), and there were significantly more of these CREs among patients with RNMB (p = 0.001). In addition, a statistically significant difference was observed in the occurrence of CREs according to body mass index (p = 0.047). Conclusion This research showed that RNMB is a significant contributing factor to the development of critical respiratory events during PACU stay. Therefore, routine quantitative neuromuscular monitoring is recommended to reduce the incidence of RNMB.

The effect of intravenous ketamine and pethidine on postoperative shivering in surgical patients under general anesthesia in Tikur anbessa specialized hospital, Addis Ababa, Ethiopia: A prospective observational cohort study

Background: Postanesthesia shivering is one of the potential complications of anesthesia which may increase patient morbidity. Various methods have been employed to control postoperative shivering. This study assessed the effectiveness of prophylactic low-dose intravenous ketamine and pethidine for postoperative shivering after general anesthesia.Methods and materials: This prospective cohort study recruited 76 ASA I and II patients aged 18-65 years old and underwent elective surgery under general anesthesia. The patients were grouped based on either ketamine 0.5mg/kg or pethidine 0.5 mg/kg having been administered by the anaesthetist in charge as a prophylaxis for postoperative shivering 20 minutes before completion of the surgery. The incidence and severity of postoperative shivering were compared between the two groups every 10 minutes until one hour postoperatively. The side effects of the study drugs were also compared between the two groups in the recovery room. Categorical data were analyzed with the Chi-Square test. Parametric and nonparametric data between the groups were analyzed using independent samples t-test and Mann-Whitney U test, respectively. A p-value of <0.05 was considered statistically significant. Results: The incidence of shivering between the ketamine and pethidine groups was 11(28.2%) and 14(35.9%), respectively (p=0.467). The severity of shivering was not significantly different between the two groups (p=0.893). The occurrence of nausea and vomiting and sedation attributed to the drugs was significantly less in the ketamine group (p<0.05). PACU stay duration and occurrence of hallucinations among the groups were comparable. (p>0.05)Conclusion and Recommendation: This study revealed administering low-dose IV ketamine (0.5mg/kg) 20 minutes before completion of surgery reduced postoperative shivering as nearly equally as pethidine. The study also showed clinically better outcomes in favor of ketamine since it was associated with fewer side effects. Thus, we recommend low-dose IV ketamine 20 minutes before completion of surgery under general anesthesia to prevent postoperative shivering.

Integrated pulmonary index can predict respiratory compromise in high‐risk patients in the post‐anesthesia care unit: a prospective, observational study

Background Respiratory compromise (RC) including hypoxia and hypoventilation is likely to be missed in the postoperative period. Integrated pulmonary index (IPI) is a comprehensive respiratory parameter evaluating ventilation and oxygenation. It is calculated from four parameters: end-tidal carbon dioxide, respiratory rate, oxygen saturation measured by pulse oximetry (SpO2), and pulse rate. We hypothesized that IPI monitoring can help predict the occurrence of RC in patients at high-risk of hypoventilation in post-anesthesia care units (PACUs). Methods This prospective observational study was conducted in two centers and included older adults (≥ 75-year-old) or obese (body mass index ≥ 28) patients who were at high-risk of hypoventilation. Monitoring was started on admission to the PACU after elective surgery under general anesthesia. We investigated the onset of RC defined as respiratory events with prolonged stay in the PACU or transfer to the intensive care units; airway narrowing, hypoxemia, hypercapnia, wheezing, apnea, and any other events that were judged to require interventions. We evaluated the relationship between several initial parameters in the PACU and the occurrence of RC. Additionally, we analyzed the relationship between IPI fluctuation during PACU stay and the occurrences of RC using individual standard deviations of the IPI every five minutes (IPI-SDs). Results In total, 288 patients were included (199 elderly, 66 obese, and 23 elderly and obese). Among them, 18 patients (6.3 %) developed RC. The initial IPI and SpO2 values in the PACU in the RC group were significantly lower than those in the non-RC group (6.7 ± 2.5 vs. 9.0 ± 1.3, p < 0.001 and 95.9 ± 4.2 % vs. 98.3 ± 1.9 %, p = 0.040, respectively). We used the area under the receiver operating characteristic curves (AUC) to evaluate their ability to predict RC. The AUCs of the IPI and SpO2 were 0.80 (0.69–0.91) and 0.64 (0.48–0.80), respectively. The IPI-SD, evaluating fluctuation, was significantly greater in the RC group than in the non-RC group (1.47 ± 0.74 vs. 0.93 ± 0.74, p = 0.002). Conclusions Our study showed that low value of the initial IPI and the fluctuating IPI after admission to the PACU predict the occurrence of RC. The IPI might be useful for respiratory monitoring in PACUs and ICUs after general anesthesia.

The effect of intravenous ketamine and pethidine on postoperative shivering in surgical patients under general anesthesia in Tikur anbessa specialized hospital, Addis Ababa, Ethiopia: A prospective observational cohort study

Background Postanesthesia shivering is one of the potential complications of anesthesia which may increase patient morbidity. Various methods have been employed to control postoperative shivering. This study assessed the effectiveness of prophylactic low-dose intravenous ketamine and pethidine for postoperative shivering after general anesthesia. Methods and materials: This prospective cohort study recruited 76 ASA I and II patients aged 18–65 years old and underwent elective surgery under general anesthesia. The patients were grouped based on either ketamine 0.5mg/kg or pethidine 0.5 mg/kg having been administered by the anaesthetist in charge as a prophylaxis for postoperative shivering 20 minutes before completion of the surgery. The incidence and severity of postoperative shivering were compared between the two groups every 10 minutes until one hour postoperatively. The side effects of the study drugs were also compared between the two groups in the recovery room. Categorical data were analyzed with the Chi-Square test. Parametric and nonparametric data between the groups were analyzed using independent samples t-test and Mann-Whitney U test, respectively. A p-value of < 0.05 was considered statistically significant. Results The incidence of shivering between the ketamine and pethidine groups was 11(28.2%) and 14(35.9%), respectively (p = 0.467). The severity of shivering was not significantly different between the two groups (p = 0.893). The occurrence of nausea and vomiting and sedation attributed to the drugs was significantly less in the ketamine group (p < 0.05). PACU stay duration and occurrence of hallucinations among the groups were comparable. (p > 0.05) Conclusion and Recommendation: This study revealed administering low-dose IV ketamine (0.5mg/kg) 20 minutes before completion of surgery reduced postoperative shivering as nearly equally as pethidine. The study also showed clinically better outcomes in favor of ketamine since it was associated with fewer side effects. Thus, we recommend low-dose IV ketamine 20 minutes before completion of surgery under general anesthesia to prevent postoperative shivering.

Sugammadex Compared to Neostigmine for Reversal of Neuromuscular Block in Patients Undergoing Kidney Transplantation. A Retrospective Cohort, Case-Control Study.

Background: The impact of sugammadex in patients with end-stage renal disease undergoing kidney transplantation is still far from being defined. The aim of the study is to compare sugammadex to neostigmine for reversal of rocuronium- and cisatracurium-induced neuromuscular block (NMB), respectively, in patients undergoing kidney transplantation.Methods: A retrospective, observational study was performed. A total of 350 patients undergoing kidney transplantation, equally divided between a sugammadex group (175 patients) and a neostigmine group (175 patients), were considered. Postoperative kidney function, evaluated by monitoring of serum creatinine and urea and estimated glomerular filtration rate (eGFR), was the endpoint. Other endpoints were anaesthetic and surgical times, post-anaesthesia care unit length of stay, postoperative intensive care unit admission, and recurrent NMB or complications.Results: No significant differences in patient or, with the exception of drugs involved in NMB management, anaesthetic and surgical characteristics were observed between the two groups. Serum creatinine (median [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.0] μmol/L, p=0.0128) and serum urea (14.9 [10.8-21.6] vs 17.1 [13.1-22.0] mmol/L, p=0.0486) were lower, while eGFR (8.0 [6.0-11.0] vs 8.0 [6.0-10.0], p=0.0473) was higher in the sugammadex group than in the neostigmine group after surgery. The sugammadex group showed significant lower incidence of postoperative severe hypoxemia (0.6% vs 6.3%, p=0.006), shorter PACU stay (70 [60-90] min vs 90 [60-105] min, p<0.001), and reduced ICU admissions (0.6% vs 8.0%, p=0.001).Conclusions: Compared to neostigmine for reversal of NMB, sugammadex resulted in a better recovery profile in patients undergoing kidney transplantation.