Preoperative anxiety about spinal surgery under general anesthesia

Purpose

No study has investigated preoperative anxiety about spinal surgery under general anesthesia. The purposes of this study were (1) to determine how many patients have preoperative anxiety about spinal surgery and general anesthesia, (2) to evaluate the level of anxiety, (3) to identify patient factors potentially associated with the level of anxiety, and (4) to describe the characteristics of the anxiety that patients experience during the perioperative period.

Methods

This study was performed in 175 consecutive patients undergoing laminectomy for lumbar stenosis or discectomy for herniated nucleus pulposus under general anesthesia. Demographic data, information related to surgery, and characteristics of anxiety were obtained using a questionnaire. The level of anxiety was assessed using a visual analog scale of anxiety (VAS-anxiety). Patient factors potentially associated with the level of anxiety were investigated using multiple stepwise regression analysis.

Results

Of 157 patients finally included in this study, 137 (87 %) had preoperative anxiety (VAS-anxiety > 0). The mean VAS-anxiety score for spinal surgery was significantly higher than that for general anesthesia (4.6 ± 3.0 vs. 3.2 ± 2.7; P < 0.001). Sex and age were significant patient factors related to the level of anxiety about spinal surgery (P = 0.009) and general anesthesia (P = 0.018); female patients had a higher level of anxiety about spinal surgery, and elderly patients had a higher level of anxiety about general anesthesia. The most helpful factors in overcoming anxiety before surgery and in reducing anxiety after surgery were faith in the medical staff (48.9 %) and surgeon’s explanation of the surgery performed (72.3 %), respectively.

Conclusions

Patients awaiting laminectomy or discectomy feared spinal surgery more than general anesthesia. This study also found that medical staff and surgeons play important roles in overcoming and reducing patient anxiety during the perioperative period.

     

Medial canthus single-injection peribulbar anesthesia: a prospective randomized comparison with classic double-injection peribulbar anesthesia

BACKGROUND AND OBJECTIVES: The authors report the first prospective randomized comparison of the medial canthus single-injection peribulbar anesthesia (also called caruncular anesthesia) with the classic double-injection peribulbar technique. METHODS: One hundred patients scheduled for cataract surgery were randomly assigned to either a single medial canthus injection or a double peribulbar injection of mepivacaine 2%. The amount of anesthetic agent injected was clinically adapted to each patient. Akinesia, volume injected, pain, reinjections, and complications were assessed after the procedure. RESULTS: The medial canthus single-injection peribulbar anesthesia was significantly less painful and required less anesthetic agent than the double-injection peribulbar anesthesia. Akinesia score and the reinjection rate were similar in the 2 groups, whereas chemosis was significantly more frequent in the double-injection group. CONCLUSIONS: Medial canthus single-injection peribulbar anesthesia appears to be an effective alternative to the usual double-injection peribulbar anesthesia.     

多感官唤醒方案在全身麻醉胸科手术患者中的应用

目的 探讨多感官唤醒方案在全身麻醉胸科手术患者中的应用效果。方法 将2021年1~8月的胸科手术患者按住院时间分为对照组与干预组各51例,对照组采用传统语音唤醒方案,干预组采用多感官唤醒方案,比较两组自主呼吸恢复时间、苏醒室停留时间,咽喉痛、躁动发生程度以及平均动脉压波动发生率。结果 干预组自主呼吸恢复时间、苏醒室停留时间显著短于对照组（均P＜0.05）;干预组咽痛、躁动发生程度显著低于对照组,平均动脉压波动发生率显著低于对照组（均P＜0.05）。结论 多感官唤醒方案扩展了原有单一感官的唤醒模式,能缩短胸科手术患者的苏醒时间及苏醒室停留时间,提高苏醒质量。     

Ophthalmic regional anesthesia: medial canthus episcleral (sub-tenon) anesthesia is more efficient than peribulbar anesthesia: A double-blind randomized study

BACKGROUND: Regional anesthesia and especially peribulbar anesthesia commonly is used for cataract surgery. Failure rates and need for reinjection remains high, however, with peribulbar anesthesia. Single-injection high-volume medial canthus episcleral (sub-Tenon's) anesthesia has proven to be an efficient and safe alternative to peribulbar anesthesia. METHODS: The authors, in a blind study, compared the effectiveness of both techniques in 66 patients randomly assigned to episcleral anesthesia or single-injection peribulbar anesthesia. Motor blockade (akinesia) was used as the main index of anesthesia effectiveness. It was assessed using an 18-point scale (0-3 for each of the four directions of the gaze, lid opening, and lid closing, the total being from 0 = normal mobility to 18 = no movement at all). This score was compared between the groups 1, 5, 10, and 15 min after injection and at the end of the surgical procedures. Time to onset of the blockade also was compared between the two groups, as was the incidence of incomplete blockade with a need for supplemental injection and the satisfaction of the surgeon, patient, and anesthesiologist. RESULTS: Episcleral anesthesia provided a quicker onset of anesthesia, a better akinesia score, and a lower rate of incomplete blockade necessitating reinjection (0 vs. 39%; P < 0.0001) than peribulbar anesthesia. Even after supplemental injection, peribulbar anesthesia had a lower akinesia score than did episcleral anesthesia. Peribulbar anesthesia began to wear off during surgery, whereas episcleral anesthesia did not. CONCLUSION: Medial canthus single-injection episcleral anesthesia is a suitable alternative to peribulbar anesthesia. It provides better akinesia, with a quicker onset and more constancy in effectiveness.     

Use of clonidine as a component of the peribulbar block in patients undergoing cataract surgery.

BACKGROUND AND OBJECTIVES: This study was designed to determine whether administration of clonidine as a component of a peribulbar block enhanced analgesia increased sedation, improved akinesia, or decreased intraocular pressure. METHODS: A randomized, double-blinded study was undertaken at a University-affiliated tertiary care hospital. Forty outpatients undergoing unilateral cataract surgery by a single surgeon (J.P.) under peribulbar blockade were evaluated. Patients received either 100 microg (1 mL) clonidine or 1 mL preservative-free normal saline mixed with the local anesthetic (7 mL 1% preservative-free lidocaine). A Honan adapter was applied for 10 minutes after block placement. The outcome measures included sedation scores, intraocular pressure (IOP) before and after peribulbar block, need for supplemental block, 24-hour analgesic requirement, and patient satisfaction. RESULTS: There were no differences between groups with respect to pain, sedation, or satisfaction scores. There was no difference with respect to onset of akinesia. This study revealed no significant difference in baseline IOP and postperibulbar IOP. CONCLUSIONS: Clonidine did not alter, in any appreciable way, the perioperative course for patients undergoing cataract operations. We do not recommend clonidine as a component of a peribulbar block in patients undergoing cataract extraction operations.     

Effects of peribulbar bupivacaine as an adjunct to general anaesthesia on peri-operative outcome following retinal detachment surgery

Sixty premedicated, ASA physical status I or II patients weighing > 25 kg scheduled for elective retinal detachment repair were randomly assigned to receive either peribulbar block with 10 ml of 0.25% bupivacaine (block group) or intravenous morphine 150 microg.kg-1 (morphine group), prior to the induction of general anaesthesia (n = 30 in each group). Patients were evaluated for intra-operative oculocardiac reflex, peri-operative pain relief, recovery from anaesthesia and postoperative nausea and vomiting. Apart from significantly reducing the incidence of oculocardiac reflex (30% vs. 70%, p = 0.0019), peribulbar bupivacaine also attenuated the severity of the reflex. Postoperative pain relief was superior in the block group. More block group patients had the maximum recovery score in the immediate postoperative period (80% vs. 27%, p < 0. 0001) and they achieved complete recovery significantly faster than the morphine group (17.3 (14.7) min vs. 66.7 (29.7) min, p < 0.0001). The incidence (40% vs. 77%, p = 0.004) and severity of postoperative nausea and vomiting were significantly less in the block group. In summary, peribulbar bupivacaine, when administered together with general anaesthesia, attenuated oculocardiac reflex, provided comparable intra-operative and superior postoperative analgesia, resulted in significantly earlier and better recovery from anaesthesia, and significantly reduced the incidence and severity of postoperative nausea and vomiting.     

Near-death experience in a boy undergoing uneventful elective surgery under general anesthesia

Near-death experience (NDE) is a complex subjective experience, which may include affective elements such as a sense of peacefulness, paranormal components such as a sensation of floating out of the body, and a perception of being in a dark tunnel and seeing a brilliant light. It is usually reported to occur in association with a wide range of life-threatening situations, as for instance, cardiopulmonary resuscitation. We report on an episode of NDE that occurred in a 12-year-old boy who underwent a general anesthesia for an elective uncomplicated surgery. To our knowledge, this is the first case of NDE in a child that has been reported in this context.     

Comparison of general anesthesia and monitored anesthesia care in patients undergoing breast cancer surgery using a combination of ultrasound-guided thoracic paravertebral block and local infiltration anesthesia: a retrospective study

Purpose

The aim of this study was to compare post-anesthesia recovery time and the incidence of hypotension episodes during anesthesia in breast cancer surgery between general anesthesia (GA) and monitored anesthesia care (MAC) retrospectively. Both techniques were combined with ultrasound-guided paravertebral block (US-PVB) and local infiltration anesthesia (LIA).

Methods

We reviewed the medical records of patients who received US-PVB for breast cancer surgery retrospectively and divided them into two groups based on the method of anesthetic management. In the GA group, anesthesia was induced using propofol and maintained by sevoflurane inhalation via a laryngeal mask airway after US-PVB was performed under sedation with midazolam. In the MAC group, US-PVB and surgery were carried out under sedation with propofol and remifentanil and supplemental oxygen through a facemask. All patients in both groups breathed spontaneously and received US-PVB and LIA with 0.5 % ropivacaine and diclofenac suppository for pain relief.

Results

Times from post-anesthesia care unit admission to fluid intake (mean ± SD; 79 ± 34 vs. 99 ± 33 min, P = 0.034) and gait (77 ± 45 vs. 109 ± 45 min, P = 0.013) were significantly shorter in the MAC group (n = 29) than in the GA group (n = 29). Average systolic blood pressure (SBP) was significantly lower (89 ± 11 vs. 99 ± 16 mmHg, P = 0.011) and the incidence of hypotension (SBP < 70 mmHg) was higher (52 vs. 21 %, P = 0.014) in the GA group than in the MAC group during anesthesia.

Conclusion

MAC with US-PVB and LIA exhibited faster post-anesthesia recovery and a lower incidence of hypotension episodes during anesthesia than GA with US-PVB and LIA in breast cancer surgery.

     

Postoperative recovery after general anaesthesia with and without retrobulbar block in retinal detachment surgery

This study was to determine whether general anaesthesia plus retrobulbar block would be a better anaesthetic technique than general anaesthesia alone in retinal detachment surgery. Twenty-eight patients were allocated randomly to either general anaesthesia with retrobulbar block or general anaesthesia alone. The anaesthetist involved was blinded as to whether a retrobulbar block was performed or not. Significantly fewer patients in the general anaesthesia plus block group complained of postoperative pain than patients in the general anaesthesia group (21.4% as compared with 64.3%, p less than 0.05). Those who received general anaesthesia plus block recovered significantly more rapidly than those receiving general anaesthesia alone. The time to opening of eyes on command (p less than 0.05), telling the correct date of birth (p less than 0.01), reaching a full recovery score (p less than 0.005) and performing a simple motor task (p less than 0.025) was shorter in patients with general anaesthesia plus block. Thus general anaesthesia plus retrobulbar block was superior to general anaesthesia alone in terms of pain and recovery after operation.     

Preoperative risk factors of intraoperative hypothermia in major surgery under general anesthesia

Preoperative factors, such as age and body habitus, affect intraoperative hypothermia during general anesthesia. In a preliminary study, we developed a logistic model to retrospectively evaluate predictors of intraoperative hypothermia in patients who received major surgery. The following factors were selected to develop the model: Z = -15.014 + 0.097 x (Age) + 0.263 x (Height) - 0.323 x (Weight) - 0.055 x (Preoperative systolic blood pressure) - 0.121 x (Preoperative heart rate). By using this model, the probability of hypothermia can be estimated by applying the following formula: Probability = 1/(1 + e(-)(Z)). If an estimated probability of hypothermia was >0.5, the sensibility of prediction was 81.5% and the specificity was 83%. In the second study, the model was applied prospectively to other patients, and the validity of the logistic model was evaluated. The core temperature showed a significant decrease in patients with a probability >0.7, who were predicted to be hypothermic, and their thermoregulatory vasoconstriction threshold also showed a significant decrease, compared with the patients with a probability <==0.3, who were predicted to be normothermic. We concluded that intraoperative hypothermia could be predicted from preoperative characteristics such as age, height, weight, systolic blood pressure, and heart rate. IMPLICATIONS: Increases in age and height and decreases in weight systolic blood pressure and heart rate are major preoperative risk factors of intraoperative hypothermia during major surgery.     

Usefulness of pre-emptive peribulbar block in pediatric vitreoretinal surgery: a prospective study

BACKGROUND AND OBJECTIVES: Vitreoretinal (VR) surgery with or without scleral buckling is associated with significant postoperative pain and emesis in adults, and recent studies have addressed the effect of retro or peribulbar block on these parameters. VR surgery in children has received little attention regarding the incidence of pain and emesis, and the role of regional anesthesia in modifying these parameters. In this study, we compared peribulbar block with conventional opioid analgesia in children undergoing VR surgery. METHODS: In a prospective, randomized, single-blind study, 85 children (ages 6 to 13 years) were allocated to receive peribulbar block (n = 42) or intravenous meperidine 1 mg/kg (n = 43) after induction of general anesthesia. Parameters compared were: intraoperative incidence of oculocardiac reflex and requirement for additional analgesic; postoperative pain intensity; incidence of postoperative emesis; time to first analgesic, total number of postoperative analgesic supplements; and parental assessment of the child's postoperative comfort at 24 hours. RESULTS: The incidence of intraoperative oculocardiac reflex was significantly less in the peribulbar group (P =.0001). Significantly more children receiving peribulbar block were pain free on awakening (P =.0004) and throughout the postoperative period. The number of children requiring opioid was significantly lower with peribulbar block (P =.008), and a significant number of children did not vomit throughout the postoperative period (P =.001). CONCLUSIONS: Peribulbar block appears to be a safe and clinically superior alternative to intravenous opioid for pediatric VR surgery.     

Arthroscopic shoulder surgery under general anesthesia with brachial plexus block

Objective

Changes in respiratory parameters and pulmonary function tests were evaluated after shoulder arthroscopic surgery with brachial plexus block (BPB). The purpose of this study was to identify the mechanism of respiratory dysfunction after this type of surgery.

Methods

Patients undergoing arthroscopic rotator cuff repair under general anesthesia (GA) with BPB were enrolled in the arthroscopy group (n?=?30) while those undergoing open reduction of a clavicle or humerus fracture under GA were enrolled in the control group (n?=?30). Forced vital capacity (FVC) and forced expiratory volume 1 s (FEV₁) were measured at the outpatient clinic stage (#1) before (#2) and 20 min after BPB (#3) and 1 h after extubation (#4). Respiratory variable measurements along with the cuff leak test were performed 5 min after surgical positioning (T1) and at the start of skin closure (T2). Respiratory discomfort was evaluated after extubation. The upper airway diameters and soft tissue depth of chest wall were also measured by ultrasonography at stages #3 and #4.

Results

Static compliance decreased significantly at T2 in the arthroscopy group (50?±?11 at T1 vs. 44?±?9 ml/cm H₂O at T2, p?=0.035) but not in the control group. The incidence of positive cuff leak tests at T2 was significantly higher in the arthroscopy group than in the control group (47% in the arthroscopy group vs. 17% in controls, p?=0.010). While FEV₁ and FVC remained stable at stages #1 and #2, FVC and FEV₁ decreased at stages #3 and #4 only in the arthroscopy group (FVC in arthroscopy group, #2: 3.26?±?0.77 l; #3: 2.55?±?0.63 l, p?=0.015 vs. #2; #4: 2.66?±?0.41 l, p?=0.040 vs. #2). The subglottic diameter decreased at #4 in the arthroscopy group, while no changes occurred in the control group (0.70?±?0.21 cm vs. 0.85?±?0.23 cm in the arthroscopy and control groups, respectively, p?=0.011). Depth of skin to pleura increased at both intercostal spaces 1–2 and 3–4 in the arthroscopy group. There were three cases of hypoxia (S_pO₂?<?95%) with room air in the arthroscopy group while none occurred in the controls.

Conclusion

Shoulder arthroscopic surgery under GA with BPB induced both restrictive and obstructive pathologies. It is important to maintain a high level of awareness for the potential negative respiratory effects of this surgery especially for subjects with pre-existing cardiopulmonary disease. The measurements in this study would be useful to monitor the risk of respiratory dysfunction in these patients.     

Dexmedetomidine as an anaesthetic adjuvant in patients undergoing intracranial tumour surgery: a double-blind, randomized and placebo-controlled study

Background. Dexmedetomidine (DEX) has been shown to providegood perioperative haemodynamic stability with decreased intraoperativeopioid requirements. It may have neural protective effects,and thus may be a suitable anaesthetic adjuvant to neurosurgicalanaesthesia. Methods. Fifty-four patients scheduled for elective surgeryof supratentorial brain tumour were randomized to receive ina double-blind manner a continuous DEX infusion (plasma targetconcentration 0.2 or 0.4 ng ml^–1) or placebo, beginning20 min before anaesthesia and continuing until the start ofskin closure. The DEX groups received fentanyl 2 µg kg^–1at the induction of anaesthesia and before the start of operation,the placebo group 4 µg kg^–1, respectively. Anaesthesiawas maintained with nitrous oxide in oxygen and isoflurane. Results. The median times from the termination of N₂O to extubationwere 6 (3–27), 3 (0–20) and 4 (0–13) min inplacebo, DEX-0.2 and DEX-0.4 groups, respectively (P<0.05ANOVA all-over effect). The median percentage of time pointswhen systolic blood pressure was within more or less than 20%of the intraoperative mean was 72, 77 and 85, respectively (P<0.01),DEX-0.4 group differed significantly from the other groups.DEX blunted the tachycardic response to intubation (P<0.01)and the hypertensive response to extubation (P<0.01). DEX-0.4group differed in the heart rate variability from placebo (93vs 82%, P<0.01). Conclusions. DEX increased perioperative haemodynamic stabilityin patients undergoing brain tumour surgery. Compared with fentanyl,the trachea was intubated faster without respiratory depression.      

缩短骨科择期全麻手术患者术前禁食时间的最佳证据实践

目的遴选骨科择期全麻手术患者术前禁食最佳证据,以缩短术前禁食时间,改善手术相关指标结局。方法参照澳大利亚乔安娜布里格斯研究中心(Joanna Briggs Institute)临床证据实践方法,查找最佳证据,制定7条审查标准,制订患者术前个性化禁食方案,修订术前工作流程,将最佳证据嵌入到临床实践中,实施6个月后评价效果。结果第2轮审查,7条审查指标执行率从基线审查的0~20.0%提高至85.0%~92.5%;医务人员术前禁食最佳证据知识回答正确率从13.3%~80.0%提高至90.0%~100%;患者术前禁食、禁饮时间显著缩短,中重度口渴、饥饿发生率及术后24h内恶心呕吐发生率显著降低(P0.05,P0.01);两组均无误吸发生。结论骨科择期手术患者术前个性化禁食及麻醉开始前2h进食清流质安全有效,对医务人员和患者进行针对性培训及教育有利于提高执行率。