Inadvertent severe hypercapnia during general anesthesia: drop-in oxygen saturation or electrocardiography changes; which one warns us earlier?

Background During general anesthesia especially when the nurse or anesthesiologist forgets to change manual to controlled mode after successful endotracheal intubation, capnography shows End-tidal Co2 above 20 mmHg after checking the place of the tracheal tube and will remain on the screen permanently. In this scenario, the patient receives a high concentration of oxygen, and Spo2 (oxygen saturation) does not drop for a long time which is too late to intervene. It has been all-time questionable which one of the cardiac dysrhythmias or Spo2 dropping occurs earlier. Results Medical records of seven deceased patients reviewed. All of them had electrocardiogram changes including premature ventricular contraction or bradycardia as a first warning sign. Oxygen saturation remains above 95% even with cardiac dysrhythmia. Conclusions Bradycardia and premature ventricular contraction were the first warning findings for severe hypercapnia during general anesthesia and occurred earlier than dropping oxygen saturation. Furthermore, the normal capnography waveform is more reliable than the End-tidal Co2 number for monitoring.

Can vena cava ultrasound-guided volume repletion prevent general induced hypotension in elderly patients? A mini-fluid challenge

Background Hypotension is often occurring after induction of general anesthesia (IGA) and can cause organ hypoperfusion and ischemia which associated with adverse outcomes in patients having both cardiac and non-cardiac surgery. Elderly patients are particularly more vulnerable and at increased risk to the depressant effect of anesthetic drugs. So, recognition and prevention of such event are of clinical importance. This study recruited patients aged above 60 years, with ASA physical status classification I-II-III who were scheduled for surgery under general anesthesia with the aim to assess the effectiveness of preoperative IVC ultrasonography in predicting hypotension which develops following IGA and its association with the volume status in elderly patients receiving general anesthesia, through measurements of the maximum inferior vena cava diameter (dIVCmax), minimum inferior vena cava diameter (dIVCmin), inferior vena cava collapsibility index (IVC-CI), and basal and post-induction mean arterial pressure (MAP). Results Thirty-nine (44.3%) of the 88 patients developed hypotension after IGA, and it was significantly more in patients who did not receive preoperative fluid (p = 0.045). The cut-off for dIVCmax was found as 16.250 mm with the ROC analysis. Specificity and sensitivity for the cut-off value of 16.250 mm were calculated as 61.2% and 76.9%, respectively. The cut-off for IVC-CI was found as 33.600% with the ROC analysis. Specificity and sensitivity for the cut-off value of 33.600% were calculated as 68.7% and 87.2%, respectively. Conclusions IVC ultrasonography may be helpful in the prediction of preoperative hypovolemia in elderly patients in the form of high IVC-CI and low dIVCmax. The incidence of hypotension was lower in patients who received fluid infusion before IGA.

Magnesium sulphate within multimodal analgesia, pre-emptive, or preventive analgesia

Background Magnesium (Mg) is a non-competitive N-methyl d-aspartate receptor antagonist with antinociceptive effects. Multimodal therapy is the optimal strategy for perioperative pain control to minimize the need for opioids. Inflammation caused by tissue trauma or direct nerve injury is responsible for the perioperative pain. The concept of “pre-emptive” analgesia, analgesic strategies administered prior to the stimulus, can modify the peripheral and central nervous system processing of noxious stimuli, thereby reducing central sensitization, hyperalgesia, and allodynia remains controversial. A more encompassing approach to the reduction of postoperative pain is the concept of “preventive” analgesia. The purpose of the study is to detect the proper use of MgSO4 as an analgesic being a non-competitive N-methyl d-aspartate (NMDA). Results There is no statistically significant difference in the haemodynamic parameters, intraoperative (33% vs 20%) and postoperative requirement for analgesics 6.6% vs 10% among groups I and II, respectively. There is no significant difference in the numerical analogue scale, where 16 vs 17 patients with no pain, 12 vs 10 with mild pain, and 2 vs 3 with moderate pain in groups I and II, respectively. Conclusion The use of MgSO4 in a bolus with or without infusion is comparable in the control of intraoperative and postoperative pain.

Accuracy and precision of non-invasive continuous haemoglobin concentration monitoring in diabetic patients

Background Accuracy and precision of non-invasive continuous haemoglobin concentration (SpHb) provided by Masimo device in diabetic patients is poorly studied. This retrospective analysis aimed to provide data on SpHb accuracy and precision in diabetic patients. Results The sample size population consisted of 14 patients, with 56 SpHb/Lab data pairs. Lab value showed a mean ± standard deviation (SD) of 13.2 ± 1.2 g/dL, whilst SpHb showed a mean ± SD of 11.8 ± 1.1 g/dL. Linear regression analysis between Lab/SpHb data pairs showed a r of 0.8960 (CI95% 0.8281-0.9379, p value < 0.0001). SpHb underestimated the real Hb values provided by Lab. Bland-Altman analysis showed that SpHb accuracy was −1.37 g/dL (CI95% −1.51 to −1.22 g/dL, p value < 0.0001), precision of 0.55 g/dL, lower LOA −2.45 g/dL (CI95% −2.71 to −2.20 g/dL) and upper LOA −0.28 g/dL (CI95% −0.53 to −0.02 g/dL). Conclusions For the first time, we provided data on SpHb accuracy and precision in the diabetic population. SpHb showed a high correlation coefficient when compared with Lab values, but the wide LOA limits its accuracy.

Is lumbar erector spinae plane block (L-ESPB) a lumbar plexus block?: a case report of three cases

Background Lumbar erector spinae plane block (L-ESPB) is being used in fractured hip patients for the postoperative pain relief and as a sole anesthetic technique. Various clinical and cadaveric studies have differences of opinion about its mechanism of action and pathways of local anesthetic spread; however, the role of lumbar plexus (LP) in the mechanism of action is still not considered. In our clinical experience, we observed that the action on LP could be a pathway for the analgesic action of local anesthetic along with paravertebral spread. Case presentation We report here three cases of the fractured hip who were given L-ESPB for postoperative pain management. The radiological examination was done after injection of non-ionic contrast to know the spread of local anesthetic. In two cases, the contrast spread was seen towards LP and in one case spread of contrast was observed towards the paravertebral area. Conclusions Effect of local anesthetic on the lumbar plexus is one of the plausible pathways in L-ESPB for its analgesic mechanism of action.

Iatrogenic operative hysteroscopic intravascular absorption syndrome: a recurring possibility!

Background Operative hysteroscopic intravascular absorption syndrome (OHIA) is the constellation of signs and symptoms due to fluid overload during hysteroscopic procedures. It can present with hyponatremia, deranged coagulation, pulmonary, and cerebral edema which are life-threatening issues. To our knowledge, this is the first reported case of recurrent OHIA syndrome which was managed uneventfully. Case presentation A 26-year-old American Society of Anesthesiologist (ASA) patient presented with primary infertility and prolonged, heavy menstruation. The abdominal and transvaginal ultrasound (USG) revealed a large posterior intramural fibroid of size 6.1 cm × 4.2 cm with submucosal intracavitary extension. She was planned for two-step laparoscopic and hysteroscopic evaluation and resection of the myoma under general anesthesia. Severe OHIA syndrome occurred with 1.5% glycine in phase 1 resection and recurred with 0.9% sodium chloride in phase 2 resection of intrauterine myoma at two different surgical settings. The uniqueness of this case is recurrence of OHIA syndrome in the same patient despite the use of normal saline (NS) due to lack of precautionary measures for fluid management. Conclusions Normal saline as an irrigating medium may not eliminate the risk of OHIA. Lack of adequate fluid management strategies can be detrimental especially in cases of hysteroscopic myoma resections. Following a standard protocol for vigilant monitoring under general anesthesia is the key in successful management.

Efficacy of neural prolotherapy versus local corticosteroid soft tissue injection for treatment of chronic anserine bursitis: a prospective randomized clinical trial

Background Anserine bursitis is characterized by the presence of spontaneous pain with tenderness at the inferomedial aspect of the knee joint. Neural prolotherapy aims to relieve pain of a variety of chronic musculoskeletal disorders. The study aim was to explore the short-term efficacy of neural prolotherapy (subcutaneous perineural injection of dextrose 5% solution) versus local corticosteroid injection for pain relief and improvement of function in patients with chronic anserine bursitis. The enrolled patients were randomly assigned to receive neural prolotherapy (subcutaneous perineural injection of dextrose 5% solution) (neural prolotherapy group) or a single local soft tissue injection of corticosteroid (corticosteroid group). Outcome measures included Western Ontario McMasters Universities osteoarthritis index, assessment of overall anserine bursitis pain severity using the visual analogue scale, patient’s global assessment of anserine bursitis severity using the visual analogue scale, and clinical assessment for the presence of tenderness on the anserine bursa region. Patients were evaluated before injection and after intervention by 4 weeks. Results The study included 67 lower limbs from 43 patients with chronic anserine bursitis. No significant differences were found between both treatment groups regarding all assessed parameters at the start of the study. After 4 weeks, within-group analysis showed that there was a statistically significant improvement in Western Ontario McMasters Universities osteoarthritis index and its subscales (P ≤ 0.0001), overall anserine bursitis pain severity (P ≤ 0.0001), and patient’s global assessment of anserine bursitis severity (P ≤ 0.0001), as well as there was significant improvement regarding the presence of tenderness at the anserine bursa region in both groups in comparison to the preinjection assessment. At the postinjection assessment, between-group analysis showed that there were no significant differences regarding all assessed outcome parameters. All patients in both groups tolerated the injection procedure and were satisfied with the procedure. There was no significant difference between the two groups regarding patients’ satisfaction to the procedure results. Improvement was achieved in 86.4% of patients included in the neural prolotherapy group versus 95.2% of patients included in the corticosteroid group. Conclusions Neural prolotherapy was effective in relieving pain, improving local tenderness and function in patients with chronic anserine bursitis similar to local corticosteroid injection. Trial registration ClinicalTrials.gov, registration number: NCT04509440. Registered 12 August 2020—Retrospectively registered,

The accuracy of Pleth Variability Index for directed fluid optimization in donors in living donor liver transplantation

Background Fluid management strongly affects hepatic resection and aims to reduce intraoperative bleeding during living donation. The Pleth Variability Index (PVI) is a tool to assess the fluid responsiveness from the pulse oximeter waveform; we evaluated the efficacy and accuracy of finger PVI compared to pulse pressure variation (PPV) from arterial waveform in predicting the fluid response in donor hepatectomy patients with the guide of non-invasive cardiac output (CO) measurements. We recruited forty patients who were candidates for right lobe hepatectomy for liver transplantation under conventional general anesthesia methods. During periods of intraoperative hypovolemia not affected by surgical manipulation, PVI, PPV, and CO were recorded then compared with definitive values after fluid bolus administration of 3–5 ml/kg aiming to give a 10% increase in CO which classified the patients into responders and non-responders. Results Both PPV and PVI showed a significant drop after fluid bolus dose (P < 0.001) leading to an increase of the CO (P < 0.0001), and the area under the curve was 0.934, 0.842 (95% confidence interval, 0.809 to 0.988, 0.692 to 0.938) and the standard error was 0.0336, 0.124, respectively. Pairwise comparison of PPV and PVI showed non-significant predictive value between the two variables (P = 0.4605); the difference between the two areas was 0.0921 (SE 0125 and 95% CI − 0.152 to 0.337). Conclusions PVI is an unreliable indicator for fluid response in low-risk donors undergoing right lobe hepatectomy compared to PPV. We need further studies with unbiased PVI monitors in order to implement a non-invasive and safe method for fluid responsiveness.

Comparison between single-dose suxamethonium and rocuronium after pretreatment with dexmedetomidine in rapid sequence induction

Background Rapid sequence induction is a well-established anesthetic procedure used in patients with a high risk of gastric aspiration. Suxamethonium has been the drug of choice; however, it carries potential risks and sometimes fatal outcomes. The aim of our study was to compare rocuronium after pretreatment with dexmedetomidine, to suxamethonium in providing excellent intubating conditions in rapid sequence induction in adults. Patients were randomly allocated to one of two groups, of 120 each. Control group (SS), patients received pretreatment with 10 ml 0.9% saline over 10 min and suxamethonium 1mg/kg. Experimental group (DR), received pretreatment with dexmedetomidine 1 μg/kg in 10 ml 0.9% saline over 10 min and rocuronium 0.6 mg/kg. Our primary endpoint was the number of patients who scored “excellent” on intubation conditions score, while secondary outcomes were hemodynamics and adverse events. Results The rate of excellent intubating conditions in the DR group 46% was insignificantly less (P value = 0.548) than that of the SS group 49% (relative risk (RR) of DR compared to SS = 1.04, with a confidence interval (CI) of 0.91–1.48. The percentage of patients with adverse events in the SS group was (30%) nearly more than twofold higher than that of the DR group (11%). A significant difference (P value = 0.016) in the incidence of excellent intubating conditions was higher in the female gender 59% compared to the male gender 38% (adjusted RR = 0.98, with a confidence interval of 0.79–1.1). Conclusion A combination of dexmedetomidine 1μg/kg and standard intubating dose of rocuronium 0.6 mg/kg provided comparable endotracheal intubation conditions to suxamethonium 1 mg/kg during RSI and might be used as an alternative to suxamethonium in situations where suxamethonium is contraindicated. Trial registration ClinicalTrials.gov Identifier: NCT04709315

Serratus anterior plane block for cardiothoracic surgeries: a meta-analysis of randomized trials

Background Comparison of serratus anterior plane block to different analgesic methods for anterolateral thoracic wall incisions. Meta-analysis was used to address this concern. Authors systemically searched the MEDLINE, EMBASE, PubMed, and Cochrane databases to identify all published randomized and prospective clinical trials, comparing the SAPB with other methods that used for analgesia in different thoracic surgical procedures and trauma. Results Ten studies were identified for inclusion in this study, involving a total of 735 patients. Meta-analysis showed that, compared with thoracic wall analgesia and PCA methods, the SAPB group resulted in a significant decrease in pain scores, significant decrease in consumption of analgesic drugs, and a significant decrease in the incidence of nausea and vomiting with no difference in the rate of hypotension. Conclusions The use of SAPB in cardiothoracic surgery and trauma is a safe and effective option for thoracic analgesia.