Nalbuphine reduces the incidence of emergence agitation in children undergoing Adenotonsillectomy: A prospective,randomized, double-blind,multicenter study

ObjectiveTo evaluate the effect of nalbuphine on emergence agitation (EA) in children undergoing adenotonsillectomy.DesignMulticenter, prospective, double-blind, randomized controlled trial.SettingThe First People's Hospital of Foshan and three other participating institutions in China, from April 2020 to December 2021.PatientsEight hundred patients, 3–9 years of age, American Society of Anesthesiologists (ASA) classification I or II, undergoing elective adenotonsillectomy were included.InterventionsNalbuphine (0.1 mg/kg) or saline was administered intravenously.MeasurementsThe incidence of EA; the pediatric anesthesia emergence delirium (PAED) scale; and the faces, legs, activity, cry, and consolability (FLACC) scales. Extubation time, duration of post-anesthesia care unit (PACU) stay, anesthesia nurses' and parents' satisfaction, and other side effects.Main resultsThe incidence of EA in the nalbuphine group was lower than that in the saline group 30 min after extubation (10.28% vs. 28.39%, P = 0.000). In addition, the FLACC scores in the nalbuphine group were lower than those in the saline group 30 min after extubation (P < 0.05). Furthermore, the proportion of moderate-to-severe pain cases (FLACC scores >3) was significantly lower in the nalbuphine group than in the saline group (33.58% vs. 60.05%, P = 0.000). Adjusting the imbalance of postoperative pain intensity, the risk of EA was still lower in the nalbuphine group at 0 min (OR, 0.39; 95% CI, 0.26–0.60; P = 0.000), (OR, odds ratio; CI, confidence interval), 10 min (OR, 0.39; 95% CI, 0.19–0.79; P = 0.01), and 20 min (OR, 0.27; 95% CI, 0.08–0.99; P = 0.046) than in the saline group. There were no significant differences in extubation time, duration of PACU stay, nausea and vomiting, or respiratory depression between the two groups (P > 0.05).ConclusionNalbuphine reduced the incidence of EA in children after adenotonsillectomy under general anesthesia, which may be involved in both analgesic and non-analgesic pathways.     

Sevoflurane versus desflurane for early postoperative vomiting after general anesthesia in hospitalized adults: A systematic review and meta-analysis of randomized controlled trials

Study objectiveThis systematic review and meta-analysis aimed at assessing the effects of two commonly used anesthetics in general anesthesia (GA), sevoflurane and desflurane, on early postoperative vomiting (POV) in hospitalized adults.DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).SettingEarly postoperative vomiting after GA.PatientsA total of 266 adult patients receiving inpatient surgeries under GA maintained with sevoflurane or desflurane.InterventionsWe searched PubMed, Medline, Cochrane Central Register of Controlled Trials, ScienceDirect, and Embase for eligible RCTs comparing postoperative outcomes following sevoflurane- or desflurane-maintained anesthesia.MeasurementsThe primary outcome was early POV. Secondary outcomes included late POV, early and late postoperative nausea (PON), time to extubation, and emergence time.Main resultsEight trials were included. There was no significant difference in the risk of early POV (risk ratio [RR] 1.03, 95% confidence interval [CI] 0.64–1.64, p = 0.91). No significant difference in early PON was observed (RR 1.09; 95% CI, 0.77–1.56; p = 0.62). Nevertheless, the incidence of late POV and late PON were significantly lower in the sevoflurane group than that in the desflurane group (RR 0.47, 95% CI 0.23–0.94, p = 0.03; RR 0.45, 95% CI 0.24–0.84, p = 0.01, respectively). The extubation time was longer in the sevoflurane group than in the desflurane group (standardized mean difference [SMD] 0.56, 95% CI 0.14–0.97, p = 0.009). The emergence time of patients in the sevoflurane group was longer than that in those receiving desflurane (SMD 0.76, 95% CI 0.1–1.42, p = 0.02).ConclusionsDesflurane had the same effects on early POV and early PON as sevoflurane. However, the association between late POV and late PON with desflurane was stronger than that with sevoflurane if the effects of opioids were not considered. The desflurane group had shorter time to extubation and emergence time than the sevoflurane group. PROSPERO registration number: CRD42020218988.     

Dexmedetomidine versus other sedatives for non-painful pediatric examinations: A systematic review and meta-analysis of randomized controlled trials

Study objectiveProcedural sedation for non-painful pediatric examinations outside the operating room remains a challenge, this study was designed to compare the safety and effectiveness of sedation provided by dexmedetomidine versus other sedatives including chloral hydrate, midazolam, and pentobarbital for pediatric patients to complete diagnostic examinations.DesignSystematic review and meta-analysis of RCTs.SettingPediatric procedural sedation.InterventionsComparison of sedation by dexmedetomidine and chloral hydrate, or pentobarbital, or midazolam for pediatric non-painful sedation.PatientsThe PubMed, Embase, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched and limited the studies to those published in English through July 30, 2018.MeasurementsProspective randomized clinical trials (RCTs) comparing dexmedetomidine to chloral hydrate, pentobarbital, and midazolam for pediatric procedural examinations outside the operating room were included in the meta-analysis. Search terms included dexmedetomidine, precede, adrenergic alpha-2 receptor agonists, adrenergic alpha 2 agonists, adrenergic alpha-agonists, adrenergic alpha 2 receptor agonists, chloral hydrate, pentobarbital, midazolam, AND sedation.Main resultsA total of 1486 studies were screened and nine RCTs were identified; 1076 patients were analyzed. Sedation with dexmedetomidine provided statistically higher incidences in completing examinations with fewer episodes of desaturation than the other sedatives did (OR 2.90, 95% CI: 1.39–6.07, P = 0.005, I² = 77%; OR 0.29, 95% CI: 0.15–0.57, P = 0.0004, I² = 0%, respectively).ConclusionsThe meta-analysis shows that sedation by dexmedetomidine has lower incidence of respiratory depression and provides higher success rates in completing examinations than other traditional sedatives without compromising safety, indicating a prospective clinical use for procedural sedation.     

Incidência de delírio ao despertar e fatores de risco após o uso de sevoflurano em pacientes pediátricos para cirurgia ambulatorial,Kingston, Jamaica

Background and objectivesEmergence delirium is a distressing complication of the use of sevoflurane for general anesthesia. This study sought to determine the incidence of emergence delirium and risk factors in patients at a specialist pediatric hospital in Kingston, Jamaica.MethodsThis was a cross‐sectional, observational study including pediatric patients aged 3–10 years, ASA I and II, undergoing general anesthesia with sevoflurane for elective day‐case procedures. Data collected included patients’ level of anxiety pre‐operatively using the modified Yale Preoperative Anxiety Scale, surgery performed, anesthetic duration and analgesics administered. Postoperatively, patients were assessed for emergence delirium, defined as agitation with non‐purposeful movement, restlessness or thrashing; inconsolability and unresponsiveness to nursing and/or parental presence. The need for pharmacological treatment and post‐operative complications related to emergence delirium episodes were also noted.Results145 children were included, with emergence delirium occurring in 28 (19.3%). Emergence delirium episodes had a mean duration of 6.9 ± 7.8 min, required pharmacologic intervention in 19 (67.8%) children and were associated with a prolonged recovery time (49.4 ± 11.9 versus 29.7 ± 10.8 min for non‐agitated children; p < 0.001). Factors positively associated with emergence delirium included younger age (p = 0.01, OR 3.3, 95% CI 1.2–8.6) and moderate and severe anxiety prior to induction (p < 0.001, OR 5.6, 95% CI 2.3–13.0). Complications of emergence delirium included intravenous line removal (n = 1), and surgical site bleeding (n = 3).ConclusionChildren of younger age with greater preoperative anxiety are at increased risk of developing emergence delirium following general anesthesia with sevoflurane. The overall incidence of emergence delirium was 19%.     

Comparison of auditory evoked potential index and clinical signs as indicator for laryngeal mask airway insertion

ObjectiveAuditory evoked potential (AEP) index is one of the several physiological parameters for assessing the depth of anesthesia. The purpose of this study was to investigate whether the AEP monitoring could provide a better information for assessment of anesthesia level in classic laryngeal mask airway (C-LMA) insertion than the use of clinical signs in general anesthesia with single standard dose of intravenous propofol and fentanyl.MethodsOne hundred and seventy adult patients requiring general anesthesia for minor surgery were recruited and randomized to receive AEP monitoring (group A) or judgment of clinical signs (group B) for assessment of anesthesia depth and optimal condition to insert the C-LMA. The insertion conditions, including jaw relaxation, movements, presence of airway trauma and airway reflex, successful insertion rate and induction time were recorded and compared.ResultsThe two groups were demographically similar. In group A, baseline heart rate was slower than group B (74 ± 14 vs. 78 ± 14 beats/min, p = 0.0267) and persisted throughout the whole study period. There was no significant difference in the change of heart rate during induction of general anesthesia between both groups. The incidence of movement was reduced in group A patients with AEP monitoring in comparison with group B patients (2.4% vs. 28.2%, p < 0.0001); of the unwanted events, swallowing was 0% versus 7.1%, p = 0.0126; laryngospasm was 0% versus 4.7%, p  = 0.0430 and emergence of airway reflex was 1.2% versus 11.8%, p = 0.0050; the successful insertion rate was 100% versus 94.1%, p = 0.0232; and jaw relaxation was 83.5% versus 70.6%, p = 0.0448. There were no differences between both groups in trauma and induction time.ConclusionThis study demonstrated that AEP index provided better information for C-LMA insertion with higher successful rate, less emergence of airway reflex and lower incidence of movement during induction of general anesthesia with single dose of intravenous propofol and fentanyl.     

Perioperative dexmedetomidine administration to prevent delirium in adults after non-cardiac surgery: A systematic review and meta-analysis

Study objectiveTo evaluate the efficacy of perioperative dexmedetomidine (DEX) administration for preventing delirium in adults after non-cardiac surgery.DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).InterventionsPerioperative administration of DEX to prevent delirium in adults following non-cardiac surgery.MeasurementsThe incidence of postoperative delirium (POD).MethodsThe databases of PubMed, Embase and Cochrane Central Register were searched from inception to Mar 4, 2021 for all available RCTs that assessed DEX for POD in adults after non-cardiac surgery. Risk ratio (RR) with a 95% confidence interval (CI) was calculated for dichotomous data. Standardized mean difference (SMD) was calculated for continuous data. Risk of bias was assessed using the second version of the Cochrane risk-of-bias tool for RCTs (RoB 2.0), and the level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.Main resultsThirteen studies, including the meta-analysis with a total of 4015 patients (DEX group: 2050 patients; placebo group: 1965 patients), showed that DEX significantly reduced the incidence of POD in adults after non-cardiac surgery compared with control group (RR: 0.60; 95%CI: 0.46 to 0.77, P = 0.0001, I² = 55%, GRADE = moderate). Meanwhile, there was a statistical difference by the subgroup analysis between the mean age ≥ 65 years group and the mean age<65 years group. There were no statistical differences in length of hospital stay following surgery (SMD: -0.36; 95%CI: −0.80 to 0.07, P = 0.1, I² = 97%, GRADE = low) and all-cause mortality rate (RR:0.57; 95%CI: 0.25 to 1.28, P < 0.17, I² = 0%, GRADE = moderate) compared with placebo group. However, Meta-analysis showed that DEX administration significantly resulted in intraoperative bradycardia when compared with placebo group (RR: 1.39; 95%CI: 1.14 to 1.69, P = 0.0009, I² = 0%, GRADE = high), and as well as intraoperative hypotension (RR: 1.25; 95%CI: 1.11 to 1.42, P = 0.0004, I² = 0%, GRADE = high).ConclusionThis systematic review and meta-analysis suggests that perioperative administration of DEX could significantly reduce the incidence of POD in patients elder than 65 years following non-cardiac surgery. However, there was no definite evidence that perioperative DEX could reduce the incidence of POD in patients younger than 65 years of age after non-cardiac surgery. In addition, perioperative DEX administration was associated with an elevated risk of bradycardia and hypotension.     

Perioperative very low-dose ketamine infusion actually increases the incidence of postoperative remifentanil-induced shivering–double-blind randomized trial

IntroductionLow-dose ketamine infusion (blood concentration around 100 ng/mL) during surgery reduces the incidence of postoperative shivering after remifentanil-based anesthesia. We hypothesized that perioperative infusion of very low-dose ketamine (blood concentration around 40 ng/mL) during remifentanil-based anesthesia may also prevent the development of remifentanil-induced shivering during the 2-hour period after the end of anesthesia.Materials and methodsFifty female patients scheduled to undergo laparoscopic cystectomy or oophorectomy were assigned to one of two groups: (1) ketamine group, in which the patients received ketamine infusion (0.1 mg/kg/hour) from induction of anesthesia to emergence from anesthesia; and (2) control group, in which the patients received saline infusion from induction up till emergence from anesthesia. Anesthesia was induced and maintained by target-controlled infusion of propofol (estimated blood concentration: 2–4 μg/mL) and infusion of remifentanil, at 0.2–0.3 μg/kg/minute. Patients were observed for shivering from the end of anesthesia to 120 minutes after anesthesia. The time point at which the patient began to shiver was recorded and assigned to one of four time periods: at emergence, from emergence to 30 minutes after anesthesia, from 30 minutes to 60 minutes after anesthesia, and >60 minutes after anesthesia.ResultsDuring the 120-minute observation period, the number of patients who shivered was higher in the ketamine group than the in control group (18 vs. 8, ketamine group vs. control group, p = 0.01). The time period during which patients began to shiver was different between the two groups (1 patient, 4 patients, and 13 patients vs. 3 patients, 2 patients, and 3 patients at emergence, from emergence to 30 minutes, and from 30 minutes to 60 minutes after anesthesia, respectively; ketamine group vs. control group, p = 0.007).ConclusionIntraoperative infusion of very low-dose ketamine during remifentanil-based anesthesia may increase the incidence of postoperative shivering.     

Lower incidence of emergence agitation in children after propofol anesthesia compared with sevoflurane: a meta-analysis of randomized controlled trials

Background

Emergence agitation (EA) from general anesthesia has been reported as an adverse effect of sevoflurane in children. We describe a meta-analysis of randomized controlled trials that compared the incidence of EA between children who underwent sevoflurane anesthesia and those who underwent propofol anesthesia.

Methods

A literature search was conducted to identify clinical trials that met our inclusion criteria. Prospective randomized trials comparing sevoflurane and propofol anesthesia in children less than 15 years of age were included in the meta-analysis. Data from each trial were combined using the random effects model to calculate pooled odds ratios (ORs) and their corresponding 95 % confidence intervals (CIs). The heterogeneity of data was assessed by Cochran’s Q and I ² tests. Sensitivity analysis was conducted for study quality, patient age, and type of surgical procedure.

Results

The meta-analysis included 14 studies, in which 560 patients received sevoflurane and 548 received propofol. The pooled OR for EA was 0.25 with a 95 % CI of 0.16–0.39 (P = 0.000), which indicates that propofol anesthesia resulted in a lower incidence of EA. The heterogeneity of data was not statistically supported (P = 0.191). All sensitivity analyses strengthened the evidence for the lower incidence of EA with propofol.

Conclusions

Our meta-analysis demonstrated that EA in children is less likely to occur after propofol anesthesia compared with sevoflurane anesthesia.     

Sevoflurane requirements during electroencephalogram (EEG)-guided vs standard anesthesia Care in Children: A randomized controlled trial

Study ObjectivesIntra-operative electroencephalographic (EEG) monitoring utilizing the spectrogram allows visualization of children's brain response during anesthesia and may complement routine cardiorespiratory monitoring to facilitate titration of anesthetic doses. We aimed to determine if EEG-guided anesthesia will result in lower sevoflurane requirements, lower incidence of burst suppression and improved emergence characteristics in children undergoing routine general anesthesia, compared to standard care.DesignRandomized controlled trial.SettingTertiary pediatric hospital.Patients200 children aged 1 to 6 years, ASA 1 or 2, undergoing routine sevoflurane anesthesia for minor surgery lasting 30 to 240 min.InterventionsChildren were randomized to either EEG-guided anesthesia (EEG-G) or standard care (SC). EEG-G group had sevoflurane titrated to maintain continuous slow/delta oscillations on the raw EEG and spectrogram, aiming to avoid burst suppression and, as far as possible, maintain a patient state index (PSI) between 25 and50. SC group received standard anesthesia care and the anesthesia teams were blinded to EEG waveforms.MeasurementsThe primary outcomes were the average end-tidal sevoflurane concentration during induction and maintenance of anesthesia. Secondary outcomes include incidence and duration of intra-operative burst suppression and Pediatric Anesthesia Emergence Delirium (PAED) scores.ResultsThe EEG-G group received lower end-tidal sevoflurane concentrations during induction [4.80% vs 5.67%, −0.88% (−1.45, −0.31) p = 0.003] and maintenance of anesthesia [2.23% vs 2.38%, −0.15% (−0.25, −0.05) p = 0.005], and had a lower incidence of burst suppression [3.1% vs 10.9%, p = 0.044] compared to the SC group. PAED scores were similar between groups. Children <2 years old required higher average end-tidal sevoflurane concentrations, regardless of group.ConclusionsEEG-guided anesthesia care reduces sevoflurane requirements in children undergoing general anesthesia, possibly lowering the incidence of burst suppression, without altering emergence characteristics. EEG monitoring allows direct visualization of brain responses in real time and allows clearer appreciation of varying sevoflurane requirements in children of different ages.     

The effect of nebulized lidocaine hydrochloride on emergence from sevoflurane anesthesia in children undergoing Tonsillectomy

BackgroundSevoflurane-related emergence agitation (EA) is considered a significant problem that interferes with children’s recovery; our aim was to evaluate the efficacy of nebulized lidocaine hydrochloride when given before sevoflurane anesthesia in attenuating EA in children undergoing tonsillectomy.Materials and methodsA randomized clinical study was conducted on eighty children ASA I and II who underwent tonsillectomy. The children were randomized to one of two groups according to the nebulizer contents. Lidocaine group (group L) received nebulized solution of 4 mg/kg lidocaine hydrochloride and placebo group (group P) received nebulized solution contains 0.9% normal saline.ResultsThe number of agitated patients were significantly lowered in the lidocaine group compared to the placebo group; p value (0.012).ConclusionThe use of nebulized lidocaine before sevoflurane anesthesia for pediatric patients undergoing tonsillectomy attenuated the sevoflurane-related EA with no side effects.     

Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis

Study objectiveThis updated network meta-analysis aims at exploring whether the concurrent use of midazolam or antiemetics may enhance the efficacy of other pharmacological regimens for delirium prophylaxis in pediatric population after general anesthesia (GA).DesignNetwork meta-analysis (PROSPERO registration: CRD42020179483).SettingPostoperative recovery area.PatientsPediatric patients undergoing GA with sevoflurane.InterventionsPharmacological interventions applied during GA with sevoflurane.MeasurementsThis network meta-analysis of randomized controlled trials (RCTs) was conducted with a frequentist model. PubMed, Embase, ProQuest, ScienceDirect, Cochrane CENTRAL, ClinicalKey, Web of Science, and ClinicalTrials.gov were searched from their inception dates to April 12, 2020, for RCTs of either placebo-controlled or active-controlled design containing information on the incidence of emergence delirium in pediatric patients undergoing sevoflurane anesthesia.Main resultsSeventy studies comprising 6904 participants were included for the analysis of 30 pharmacological interventions. Based on surface under the cumulative ranking curve (SUCRA) analysis, midazolam was ranked the lowest in therapeutic effect (SUCRA: 20%), while antiemetics as a monotherapy had no effect on delirium prophylaxis. However, there was a trend that most combination therapies with midazolam or antiemetics were superior to monotherapies for delirium prophylaxis. Subgroup analyses based on age (i.e., ≤7 years) and a validated scoring system (i.e., the Pediatric Anesthesia Emergence Delirium scale) for delirium also suggested a better efficacy of combination therapies than monotherapies. Overall, combination therapies with midazolam or antiemetics did not have a negative impact on the incidence of postoperative nausea and vomiting, length of stay in the postanesthesia care unit, or time to extubation. The dexmedetomidine-midazolam-antiemetic combination was the most effective strategy for the prevention of emergence delirium.ConclusionsThis network meta-analysis suggested that the incorporation of midazolam or antiemetics as adjuncts for combination therapies may have synergistic effects against pediatric postoperative emergence delirium. Future large-scale placebo-controlled RCTs are warranted to validate our findings.     

Perioperative intravenous S-ketamine for acute postoperative pain in adults: A systematic review and meta-analysis

Study objectiveTo evaluate the effectiveness and safety of S-ketamine for pain relief and analgesic consumption in surgical patients.DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).SettingPerioperative setting.PatientsA total of 905 adult patients undergoing surgery using general anesthesia: 504 patients in the S-ketamine group and 401 patients in the placebo group.InterventionIntravenous S-ketamine as an adjuvant to general anesthesia compared with placebo.MeasurementsThe primary outcomes were resting and movement pain scores (VAS/NRS 0–10) and morphine consumption within 4, 12, 24 and 48 h after surgery. The secondary outcomes included postoperative complications such as nausea, vomiting, and psychotomimetic adverse events. We used the guidelines of the Recommendation Assessment, Development, and Evaluation (GRADE) system to evaluate the level of certainty for the main results.Main resultsA total of 12 studies were included. The types of surgery included abdominal surgery, thoracotomy, gynecologic surgery, arthroscopic anterior cruciate ligament repair, cardiac surgery, laparoscopic cholecystectomy, lumbar spinal fusion surgery, radical prostatectomy, and hemorrhoidectomy. There were significant improvements in resting pain scores at 4, 12 and 24 h with S-ketamine versus placebo [4 h: standardized mean difference (SMD) -1.11; 95% confidence interval (CI): −1.53, −0.68, p < 0.00001; GRADE = moderate; 12 h: SMD −0.88; 95%CI: −1.42, −0.34, p = 0.001; GRADE = moderate; 24 h: SMD -0.39; 95%CI: −0.73, −0.06, p = 0.02; GRADE = moderate]. The incidence of pain scores at 48 h showed no statistical difference between the two groups (SMD -0.27; 95%CI: −1.12, 0.58, p = 0.53, GRADE = moderate). The movement pain scores were not significantly different between the two groups at each time point (4 h: SMD −0.34; 95%CI: −0.73, 0.05, p = 0.09, GRADE = moderate; 12 h: SMD −0.42; 95%CI: −1.46, 0.63, p = 0.44, GRADE = low; 24 h: SMD −0.58; 95%CI: −1.25, 0.09, p = 0.09, GRADE = moderate; 48 h: SMD −0.49; 95%CI: −1.11, 0.14, p = 0.13, GRADE = low). At 4 and 12 h after surgery, the consumption of morphine was significantly reduced in the S-ketamine group (4 h: SMD −0.98; 95%CI: −1.37, −0.06, p < 0.00001, GRADE = moderate; 12 h: SMD −1.36; 95%CI: −2.26, −0.46, p = 0.003, GRADE = low). There were no significant differences in morphine use at 24 and 48 h between the two groups (24 h: SMD −0.70; 95%CI: −1.42, 0.02, p = 0.06, GRADE = low; 48 h: SMD −0.79; 95%CI: −2.26, 1.03, p = 0.39, GRADE = low). The risk for nausea [relative risk (RR) = 1.04; 95%CI: 0.83, 1.30, p = 0.73], vomiting (RR = 1.07; 95%CI: 0.84, 1.38, p = 0.57), and psychotomimetic adverse events (RR = 1.57; 95%CI: 0.82, 2.99, p = 0.17) showed no significant increase in the S-ketamine group.ConclusionsIntravenous S-ketamine as an adjunct to general anesthesia is effective for assisting analgesia and decreases the intensity of pain and opioid requirements in a short period of time after surgery, but it may increase the psychotomimetic adverse event rate. Overall, the level of certainty is moderate to low.     

Recurarization with magnesium sulfate administered after two minutes sugammadex reversal: A randomized,double-blind,controlled trial

Study objectiveThe current study tested the hypothesis that magnesium sulfate after reversal with sugammadex causes recurarization.DesignA single-center, prospective, randomized, double-blind, controlled trial.SettingTerciary care hospital in Rio de Janeiro, Brazil.PatientsIncluded 60 patients undergoing for elective otolaryngological surgery.InterventionsAll patients received total intravenous anesthesia and a single dose of rocuronium (0.6 mg/kg). In 30 patients, the neuromuscular blockade was reversed with sugammadex (4 mg/kg) at the reappearance of one or two posttetanic counts (deep-blockade series). In 30 other patients, sugammadex (2 mg/kg) was administered at the reappearance of the second twitch of the train-of-four (moderate-blockade series). After the normalized train-of-four ratio recovered to ≥0.9, the patients in each series were randomized to receive intravenous magnesium sulfate (60 mg/kg) or placebo for 10 min. Neuromuscular function was measured by acceleromyography.MeasurementsThe primary outcome was the number of patients who exhibited recurarization (normalized train-of-four ratio < 0.9). The secondary outcome was rescue with an additional dose of sugammadex after 60 min.Main resultsIn the deep-blockade series, a normalized train-of-four ratio < 0.9 occurred in 9/14 (64%) patients receiving magnesium sulfate and 1/14 (7%) receiving placebo, RR 9.0 (95% CI: 62–1.30), and (p = 0.002), with four rescues with sugammadex. In the moderate-blockade series, neuromuscular blockade recurred in 11/15 (73%) patients receiving magnesium sulfate and in 0/14 (0%) receiving placebo (p < 0.001), with two rescues. The absolute differences in recurarization were 57% and 73% in the deep-blockade and moderate-blockade, respectively.ConclusionsSingle-dose magnesium sulfate led to a normalized train-of-four ratio < 0.9, 2 min after recovery from rocuronium-induced deep and moderate neuromuscular blockade using sugammadex. Additional sugammadex reversed prolonged recurarization.     

Effect of prone versus supine position in COVID-19 patients: A systematic review and meta-analysis

Study objectiveTo review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19).DesignSystematic review and meta-analysis of non-randomized trials.PatientsDatabases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021.InterventionsCOVID-19 patients being positioned in the prone position either whilst awake or mechanically ventilated.MeasurementsPrimary outcomes were oxygenation parameters (PaO₂/FiO₂ ratio, PaCO₂, SpO₂). Secondary outcomes included the rate of intubation and mortality rate.ResultsThirty-five studies (n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO₂/FiO₂ ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO₂ (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups.ConclusionOur meta-analysis demonstrated that prone position improved PaO₂/FiO₂ ratio with better SpO₂ than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence.PROSPERO Registration: CRD42021234050     

The largest report on thoracoscopic surgery for recurrent tracheoesophageal fistula after esophageal atresia repair

BackgroundAlthough thoracoscopic surgery has become the routine surgical method for esophageal atresia/tracheoesophageal fistula (EA/TEF), thoracoscopic treatment for recurrent tracheoesophageal fistula (rTEF) is far from popularized.ObjectivesWe aimed to explore the safety and efficacy of thoracoscopic treatment for rTEF with a large-cohort study.MethodsWe retrospectively analyzed the clinical characteristics and outcomes of 103 consecutive patients who underwent thoracoscopic surgery for rTEF by one surgeon after EA/TEF repair at two different institutions in China from 2014 to 2021.ResultsOne hundred and three pediatric patients (67 boys) were enrolled and the primary operations were performed via thoracoscopic (n = 75, 72.82%) or open surgery (n = 28, 27.18%). The median age at rTEF diagnosis was 5 (3, 10) months after the primary repair. Patients were diagnosed with recurrent fistula to the trachea (n = 97, 94.17%), bronchi (n = 4, 3.88%), and lung parenchyma (n = 2, 1.94%), and all of them underwent thoracoscopic surgery at a median age of 7 (5, 14) months with a median weight of 6200 (4870, 7650) g. After the repair of rTEF, the incidence of esophageal leakage, esophageal stricture, and TEF recurrence were 12.8%, 33.4%, and 10.8%, respectively. After the follow-up, 87 patients survived, 6 died, and 10 were lost to follow-up.ConclusionsThe results of thoracoscopic surgery for rTEF were comparable with previously reported thoracotomy surgery. Owing to the clear field during the operation, rapid patient recovery and esthetic results, the thoracoscopic approach could be a better choice for experienced pediatric surgeons.Level of EvidenceLEVEL IV     

Effect of intraoperative subhypnotic infusion of propofol on postoperative nausea and vomiting: A retrospective analysis

Study objectiveTo measure the possible association between subhypnotic propofol infusion during general balanced anesthesia and the incidence of PONV.DesignRetrospective Cohort Analysis Using Propensity Score Matching.SettingPostanesthesia care unit and inpatient unit.PatientsPatients with American Society of Anesthesiologists (ASA) physical status I-IV, undergoing non-cardiac surgery lasting >2 h were included. Patients were excluded if transferred to the intensive care unit after surgery or received ketamine. Initially 70,976 patients were screened, and a cohort of 51,707 eligible adult patients undergoing non-cardiac surgery under general balanced anesthesia between 2015 and 2019 were included. Using a propensity score matching, 3185 patients who received subhypnotic propofol during general balanced anesthesia were matched with 5826 patients who did not receive subhypnotic propofol in a 1:2 ratio.InterventionsNone.MeasurementsThe primary outcome was the incidence of PONV during PACU stay. The secondary outcome was the incidence of PONV within the first 24 h after surgery. Exploratory outcomes were time-to-extubation and length of hospital stay.Main resultsA total of 9011 patients were included (3185 patients who received propofol infusion, and 5826 patients who did not receive propofol infusion) after propensity score matching. The adjusted odds ratio for PONV incidence was 1.03 (95% CI: 0.90, 1.18; p = 0.635) in PACU, and 1.05 (95% CI: 0.90, 1.23; P = 0.50) within 24 h after surgery. The length of hospital stay was 6 h shorter (ratio of means (95% CI) of 0.92, 0.89, 0.94), p < 0.001) and time-to-extubation was 2 min longer (ratio of means 1.24 (1.20, 1.28), p < 0.001) in patients receiving subhypnotic propofol infusion.ConclusionsOur study suggests that subhypnotic propofol infusion during general balanced anesthesia is not associated with a reduction in the incidence of PONV during PACU stay and within the first 24 h after surgery. However, it is associated with decreased LOS and increased time-to-extubation, but differences in neither outcome were clinically important.     

Immediate Extubation in the Operating Room Following Pediatric Liver Transplantation: A Retrospective Cohort Study

BackgroundAlthough immediate extubation in the operating room following pediatric liver transplantation can be safe and beneficial for select patients, many surgeons and anesthesiologists are still cautious. The study aimed to evaluate the safety and efficiency of immediate extubation in the operating room following pediatric liver transplantation.MethodsSixty-four pediatric liver transplant recipients were included in this retrospective study. Patients were divided into 2 groups: immediate extubation (IE) (those who were extubated in the operating room) and delayed extubation (DE) (those who were extubated in the intensive care unit). Preoperative, intraoperative, and postoperative variables were recorded.ResultsAlthough a total of 19 (29.7%) patients were extubated in the pediatric intensive care unit (group DE), 45 (70.3%) were extubated in the operating room at the end of surgery (group IE). The use of fresh frozen plasma and platelets was statistically higher in group DE (P = .017 and P = .002, respectively). Duration of anesthesia and length of stay in the pediatric intensive care unit was statistically longer in group DE (P = .020 and P = .0001, respectively). Three (15.8%) patients required reintubation in group DE and 2 (4.4%) in group IE. Hospital stay was statistically longer in group DE (P = .012).ConclusionsThe current study demonstrated that immediate extubation in the operating room after surgery for pediatric patients who have undergone liver transplantation was safe. The duration of anesthesia and the intraoperative use of blood products such as platelet and fresh frozen plasma can effectively decide immediate extubation.     

Cemented Total Knee Arthroplasty Shows Less Blood Loss but a Higher Rate of Aseptic Loosening Compared With Cementless Fixation: An Updated Meta-Analysis of Comparative Studies

BackgroundThe aim of this study was to update the current evidence on functional outcomes, complications, and reoperation rates between cemented and cementless total knee arthroplasty (TKA) by evaluating comparative studies published over the past 15 years.MethodsThe PubMed, MEDLINE, Scopus, and the Cochrane Central databases were used to search keywords and a total of 18 studies were included. Random and fixed effect models were used for the meta-analysis of pooled mean differences (MDs) and odds ratios (ORs).ResultsA total of 5,222 patients were identified with a mean age of 64.4 ± 9.4 and 63 ± 8.6 years for the cemented and cementless TKA groups, respectively. The mean follow-up was 107.9 ± 30 and 104.3 ± 10 months for the cemented and cementless TKA groups, respectively. Cemented TKA showed a significantly greater postoperative Knee Society Score (MD = ?0.95, 95% CI [?1.57, 0.33], P = .003) and range of motion (MD = ?1.09, 95% CI [?1.88, ?0.29], P = .0007), but no differences in other outcome scores were found. The incidence of periprosthetic joint infection, radiolucent lines, instability, and polyethylene wear was also comparable. Cemented TKA showed less perioperative blood loss (SMD = ?438.41, 95% CI [?541.69, ?35.14], P < .0001) but a higher rate of manipulation under anesthesia (OR = 3.39, 95% CI [1.64, 6.99], P = .001) and aseptic loosening (OR = 1.62, 95% CI [1.09, 2.41], P = .02) than cementless TKA. No differences were found in terms of the reoperation rate.ConclusionWhen cemented and cementless fixations are compared in primary TKA, comparable functional outcomes and reoperation rates can be achieved. Cemented TKA showed less blood loss but a higher rate of manipulation under anesthesia and aseptic loosening.     

Pre-operative breathing training based on video learning reduces emergence delirium in preschool children: A randomized clinical trial

Study objectiveEmergence delirium is a common complication in preschool children after general anesthesia and may result in undesirable complications. This study aimed to determine whether breathing training after watching an informative video during the pre-operative visit could reduce the incidence of emergence delirium in preschool children after otorhinolaryngologic surgery under general anesthesia.DesignA single-center, double-blinded, randomized controlled trial.SettingPerioperative care.PatientsA total of 170 children undergoing otorhinolaryngologic surgery, aged 3–7 years, ASA physical status I or II were involved.InterventionsPatients were randomized to receive breathing training during the pre-operative visit (Training group) or to receive pre-operative visit only (Control group) the day before surgery.MeasurementsEmergence delirium was measured by the Pediatric Anesthesia Emergence Delirium score during the anesthesia recovery time. Data regarding extubation time and post-anesthesia care unit stay time were collected.Main resultsChildren who received breathing training during the pre-operative visit had a significantly lower incidence of emergence delirium than those who only underwent the pre-operative visit (10.4% vs. 35.1%, P < 0.001). The awakening time score and the maximum score in the post-anesthesia care unit were significantly lower in the training group compared with the control group [4.4 ± 3.4 vs. 6.9 ± 4.2, P < 0.001 and 5.0 (5.0) vs 7.0 (7.0), P = 0.001, respectively]. We found no differences in the extubation time and post-anesthesia care unit stay time between groups.ConclusionsWe concluded that breathing training based on video learning during the pre-operative visit in preschool children undergoing otorhinolaryngologic surgery could significantly decrease the incidence of emergence delirium.Trial registrationChinese Clinical Trial Registry (Reference number: ChiCTR1900026162); registered on September 24, 2019.     

Effect of oral dextromethorphan versus oral ketamine on sevoflurane related emergence agitation in children undergoing adenotonsillectomy

BackgroundEmergence agitation is a popular phenomenon after sevoflurane anesthesia. Our aim was to study the efficacy of oral dextromethorphan compared to oral ketamine on sevoflurane related agitation.MethodsIn a prospective, randomized, double- blinded study 120, ASA I, aged 4–10 years old children undergoing adenotonsillectomy were randomly divided into three groups to receive oral dextromethorphan 1 mg/kg (Group D, n = 39), oral ketamine 5 mg/kg (Group K, n = 39) or placebo(Group C, n = 38) as premedication 1 h before surgery. Standard general anesthesia was induced and maintained with sevoflurane in N₂O/O₂. The following were recorded by a blinded anesthetist; Child separation and cooperation at induction, duration of operation, duration of anesthesia, duration of extubation, duration of emergence, state of emergence on admission to PACU using emergence agitation scale, number of patients required postoperative fentanyl to control agitation, duration of discharge from PACU, vital signs (heart rate, blood pressure, and Spo₂) in PACU, and side effects (Nausea, vomiting, respiratory depression, and hallucination).ResultsThe agitated patients that required fentanyl treatment were statistically significant low in groups D and K compared to group C (p < 0.05). Child separation and child cooperation at induction from parents was successful in all children in group K with statistical significant difference compared to other groups (p < 0.05). There were increases in duration of anesthesia, extubation, and emergence in group K compared to other groups without increase in the duration of stay in PACU.ConclusionOral premedication with either dextromethorphan 1 mg/kg or ketamine 5 mg/kg were comparable in reducing significantly the incidence of postoperative sevoflurane related emergence agitation in comparison to placebo treated group without reported side effects in children undergoing adenotonsillectomy.