RESUMEN

BACKGROUND: Local infiltration analgesia is commonly used for postoperative pain control after several surgical procedures including intra- and peri-articular as well as wound infiltration. Even though, various adjuvants injected with the local anesthetic have been studied in pairwise comparison or compared to peripheral nerve blocks, the question which adjuvant or combination of adjuvants is the most effective in prolonging the duration of different types of local infiltration analgesia (LIA) has not been answered conclusively. OBJECTIVE: The objective of this network meta-analysis was to determine the analgesic effectiveness and safety of adjuvants in local infiltration analgesia. DESIGN: Systematic review of randomized controlled trials with network meta-analyses. DATA SOURCES: A comprehensive literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023. RESULTS: The best interventions to prolong the duration of analgesia were dexamethasone (Ratio of Means (ROM) 3.33) followed by the combinations of clonidine + morphine (ROM 3.35) and morphine + magnesium sulfate (ROM 2.92), fentanyl (ROM 2.27), ketorolac (ROM 2.26), buprenorphine (ROM 2.04), morphine (ROM 1.93), magnesium sulfate (ROM 1.91), clonidine (ROM 1.89), dexmedetomidine (ROM 1.74) and tramadol (ROM 1.58). Serious adverse events were not reported with either investigated adjuvant. CONCLUSION: There is moderate evidence that dexamethasone is the most effective adjuvant to prolong the duration of analgesia in LIA. The evidence for the alpha-2 agonists dexmedetomidine and clonidine is also moderate, but their effectivity to prolong analgesia stays behind dexamethasone. Clonidine and dexmedetomidine had a small detectable effect on pain scores, yet below clinical relevance, but the largest effect on MEQ consumption. The effects of different opioids were homogenous for all endpoints. The prespecified subgroup analysis of LIA of the knee did not show significantly different results than the pooled analysis. STUDY REGISTRATION: PROSPERO 2020 CRD42020176154 (28.04.2020).

Asunto(s)

Anestésicos Locales , Metaanálisis en Red , Dolor Postoperatorio , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Anestésicos Locales/administración & dosificación , Analgesia/métodos , Analgésicos Opioides/administración & dosificación , Clonidina/administración & dosificación , Clonidina/efectos adversos , Analgésicos/administración & dosificación , Analgésicos/efectos adversos , Adyuvantes Anestésicos/administración & dosificación , Adyuvantes Anestésicos/efectos adversos , Manejo del Dolor/métodos , Dimensión del Dolor , Anestesia Local/métodos , Dexametasona/administración & dosificación

RESUMEN

INTRODUCTION: Spinal anesthesia is a common anesthetic technique for lower limb and abdominal surgery. Despite its efficacy, its use is limited because of its duration and potential severe side effects, especially in high-risk patients undergoing major surgery. Adjuvants such as dexamethasone offer the potential to prolong the anesthetic effect and reduce the need for local anesthetics while reducing the incidence of serious adverse events. The purpose of this systematic review is to evaluate the efficacy of dexamethasone as an intrathecal adjuvant in prolonging anesthetic duration, delaying pain onset, and minimizing adverse events (PROSPERO registration: CRD42022350218). EVIDENCE ACQUISITION: We included randomized controlled trials conducted in adult patients undergoing spinal anesthesia for lower limb or abdominal surgery and comparing the performance of dexamethasone with alternative spinal treatments. A comprehensive systematic search was conducted on PubMed/MEDLINE, Scopus, CINAHL, EMBASE, CENTRAL, and Cochrane Library from February to June 2023 without language restriction. Risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB2). EVIDENCE SYNTHESIS: Ten studies, nine of which were at high risk of bias, were included (N.=685 patients). Overall, intrathecal dexamethasone was associated with a longer duration of sensory block, improvement in the duration or extent of postoperative analgesia, and significant shortening of block onset. The role of dexamethasone in prolonging motor block was not clear. The incidence of adverse events was low. Intrathecal dexamethasone has been shown to be a potentially valuable adjuvant to prolong the duration of sensory block and improve postoperative analgesia without increasing adverse events. CONCLUSIONS: Given the wide heterogeneity of methodological approaches, further investigation is needed. Considering the limitations of the included studies and awaiting more conclusive evidence, the prudent use of dexamethasone could be recommended in those specific situations where general anesthesia or higher local anesthetics should be avoided.

Asunto(s)

Anestesia Raquidea , Dexametasona , Inyecciones Espinales , Dexametasona/administración & dosificación , Dexametasona/uso terapéutico , Humanos , Anestesia Raquidea/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Adyuvantes Anestésicos/administración & dosificación , Abdomen/cirugía , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control

RESUMEN

BACKGROUND: Superiority of perineural over intravenous dexamethasone at extending nerve block analgesia has been suggested but without considering the dose-response relationships for each route of administration. METHODS: Randomised control studies that evaluated intravenous or perineural dexamethasone as an adjuvant to unilateral peripheral nerve blocks in adults were searched up to October 2023 in MEDLINE, Central, Google Scholar, and reference lists of previous systematic reviews. The Cochrane Risk-of-Bias tool was used. A maximum effect (Emax) model-based network meta-analysis was undertaken to evaluate the dose-response relationships of dexamethasone. RESULTS: A total of 118 studies were selected (9284 patients; 35 with intravenous dexamethasone; 106 with perineural dexamethasone; dose range 1-16 mg). Studies with unclear or high risk of bias overestimated the effect of dexamethasone. Bias-corrected estimates indicated a maximum fold increase in analgesia duration of 1.7 (95% credible interval (CrI) 1.4-1.9) with dexamethasone, with no difference between perineural and intravenous routes. Trial simulations indicated that 4 mg of perineural dexamethasone increased the mean duration of analgesia for long-acting local anaesthetics from 11.1 h (95% CrI 9.4-13.1) to 16.5 h (95% CrI 14.0-19.3) and halved the rate of postoperative nausea and vomiting. A similar magnitude of effect was observed with 8 mg of intravenous dexamethasone. CONCLUSIONS: Used as an adjuvant for peripheral nerve block, intravenous dexamethasone can be as effective as perineural dexamethasone in prolonging analgesic duration, but is less potent, hence requiring higher doses. The evidence is limited because of the observational nature of the dose-response relationships and the quality of the included studies. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42020141689.

Asunto(s)

Dexametasona , Relación Dosis-Respuesta a Droga , Bloqueo Nervioso , Metaanálisis en Red , Dexametasona/administración & dosificación , Humanos , Bloqueo Nervioso/métodos , Nervios Periféricos/efectos de los fármacos , Administración Intravenosa , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Ensayos Clínicos Controlados Aleatorios como Asunto , Adyuvantes Anestésicos/administración & dosificación

RESUMEN

BACKGROUND AND OBJECTIVES: Local anesthetics (LAs) are widely used to infiltrate into surgical wounds for postoperative analgesia. Different adjuvants like dexamethasone and dexmedetomidine, when added to LA agents, could improve and prolong analgesia. The aim of this trial was to evaluate the analgesic efficacy and opioid-sparing properties of dexamethasone and dexmedetomidine when added to ropivacaine for wound infiltration in transforaminal lumbar interbody fusion (TLIF). METHODS: We conducted a controlled study among 68 adult patients undergoing TLIF, which was prospective, randomized and double-blind in nature. The participants were divided into four equal groups at random. Group R was given 150 mg of 1% ropivacaine (15 mL) and 15 mL of normal saline. Group R + DXM received 150 mg of 1% ropivacaine (15 mL) and 10 mg of dexamethasone (15 mL). Group R + DEX received 150 mg of 1% ropivacaine (15 mL) and 1 µg/kg of dexmedetomidine (15 mL). Lastly, group R + DXM + DEX was given 150 mg of 1% ropivacaine (15 mL), 10 mg of dexamethasone and 1 µg/kg of dexmedetomidine (15 mL). The primary focus was on the length of pain relief provided. Additionally, secondary evaluations included the amount of hydromorphone taken after surgery, the numerical rating scale and safety assessments within 48 h after the operation. RESULTS: Based on the p value (P > 0.05), there was no significant variance in the duration of pain relief or the total usage of hydromorphone after surgery across the four groups. Similarly, the numerical rating scale scores at rest and during activity at 6-, 12-, 24- and 48-h post-surgery for all four groups showed no difference (P > 0.05). However, the incidence of delayed anesthesia recovery was slightly higher in group R + DEX and group R + DXM + DEX when compared to group R or group R + DXM. Furthermore, there were no significant differences between the four groups in terms of vomiting, nausea, dizziness or delayed anesthesia recovery. CONCLUSION: For wound infiltration in TLIF, the addition of dexamethasone and dexmedetomidine to ropivacaine did not result in any clinically significant reduction in pain or opioid consumption and could prompt some side effects.

Asunto(s)

Adyuvantes Anestésicos , Analgesia , Dexametasona , Dexmedetomidina , Fusión Vertebral , Adulto , Humanos , Analgesia/métodos , Analgésicos Opioides , Dexametasona/administración & dosificación , Dexmedetomidina/administración & dosificación , Hidromorfona , Vértebras Lumbares/cirugía , Dolor , Estudios Prospectivos , Ropivacaína/administración & dosificación , Fusión Vertebral/efectos adversos , Adyuvantes Anestésicos/administración & dosificación , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Anestesia Local/métodos

RESUMEN

BACKGROUND: We explored the analgesic efficacy of two non-opioid adjuvants (midazolam and dexmedetomidine) with ropivacaine in children undergoing infraumbilical surgeries. METHODS: In this parallel group randomized controlled trial, 135 children aged between 2 and 8 years were recruited. Children were randomly allocated to one of three groups: RD received 1 mL/kg of ropivacaine (0.2%) with dexmedetomidine 1 µg/kg, RM received 1 mL/kg of ropivacaine (0.2%) with midazolam 30 µg/kg, and R received 1 mL/kg of ropivacaine (0.2%) with 1 mL normal saline. The primary outcome of the present study was to determine the duration of postoperative analgesia. Secondary outcomes were assessing postoperative face, leg, activity, cry, consolability (FLACC) pain score, rescue analgesics, hemodynamics, sedation scores, and adverse effects. RESULTS: The analgesia duration was significantly prolonged in the RD and RM group (600.0 [480.0-720.0] minutes and 600.0 [480.0-720.0] minutes, respectively) compared to the R group 360.0 (300.0-480.0) minutes (P < 0.001). The FLACC score was comparatively higher in the R group compared to the RD and RM groups postoperatively. Time for the first rescue analgesia was more prolonged in RD and RM groups when compared with the R group. Postoperative sedation was higher in the RM group up to 120 minutes postoperatively compared to the RD and R groups. CONCLUSION: The combination of dexmedetomidine or midazolam with local anesthetics significantly increases the analgesia duration while minimizing adverse effects.

Asunto(s)

Adyuvantes Anestésicos , Dexmedetomidina , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Midazolam , Dolor Postoperatorio , Niño , Preescolar , Humanos , Dexmedetomidina/administración & dosificación , Midazolam/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Ropivacaína/administración & dosificación , Adyuvantes Anestésicos/administración & dosificación

RESUMEN

Introdução: O monitoramento neurofisiológico intraoperatório (MNIO) é uma técnica valiosa, empregada durante procedimentos neurocirúrgicos complexos. Ao monitorar continuamente as vias neurais, o MNIO fornece feedback em tempo real aos cirurgiões durante o procedimento, permitindo tomada de decisões críticas e redução do risco de déficits neurológicos. O papel do anestesiologista na identificação e correção dos fatores de risco modificáveis é fundamental para a prevenção de lesões neurológicas e otimização dos resultados. Sendo assim, a compreensão das limitações do MNIO e das evidências que orientam seu uso é de fundamental importância. Objetivo: Descrever o manejo de uma anestesia multimodal, realizada em conjunto com a equipe de neurofisiologia, para ressecção de um tumor cerebral recidivante e o seu desfecho clinico. Método: Trata-se de relato de caso atendido no Hospital do Servidor Público Municipal de São Paulo. Os dados para realização deste trabalho foram coletados durante a cirurgia, sendo a coleta autorizada pelo paciente por meio da assinatura de termo de consentimento livre e esclarecido. Relato do Caso: Paciente, sexo masculino, 64 anos, ASA II, hipertenso, com história prévia de meningioma atípico, submetido a neurocirurgia e radioterapia em 2021, em uso de anticonvulsivante oral para profilaxia de crises convulsivas. Apresenta lesão tumoral cerebral recidivante em região frontal bilateral. Após a indução anestésica, foi realizada passagem de acesso venoso central em veia jugular interna direita com auxílio de ultrassonografia, monitoração da pressão arterial invasiva após cateterização de artéria radial direita, sondagem vesical de demora, termômetro esofágico, otimização do posicionamento na mesa cirúrgica, índice bispectral e Scalp Block com 20 ml de ropicavaína a 0,375%. Realizou- se manutenção da anestesia com propofol (4-6 mg/kg/h) e remifentanil (0,1 mcg/kg/min) em infusão contínua associado a dexmedetomidina (0,2-0,6 mcg/kg/h) mantendo valores do índice bispectral entre 40-60. As respostas dos potenciais evocados foram obtidas nas extremidades superiores e inferiores durante todo o procedimento pela equipe de neurofisiologia. Durante a manipulação tumoral, foi detectada queda superior a 40% do potencial evocado motor em dimídio corporal esquerdo, e emitido o alerta à equipe cirúrgica. Nenhuma outra intercorrência foi registrada durante o procedimento. Conclusões: Propofol, dexmedetomidina, lidocaína, opioides e anestésicos voláteis potentes de baixa dosagem (menos de 0,5 CAM) associado a técnicas de bloqueios periféricos, fornecem condições compatíveis com monitoramento neurofisiológico intraoperatório. O MNIO contínuo é um complemento indispensável no período perioperatório para pacientes com alto risco de desenvolver complicações neurológicas. Os anestesistas devem fornecer um meio fisiológico e anestésico estável para facilitar a interpretação significativa das mudanças de sinal e precisa orientação cirúrgica. Palavras-chave: Adjuvantes Anestésicos. Potenciais Evocados. Neurocirurgia. Monitorização Neurofisiológica Intraoperatória.

Asunto(s)

Humanos , Masculino , Persona de Mediana Edad , Propofol/administración & dosificación , Procedimientos Neuroquirúrgicos/métodos , Dexmedetomidina/administración & dosificación , Remifentanilo/administración & dosificación , Analgésicos Opioides/administración & dosificación , Anestesia/métodos , Adyuvantes Anestésicos/administración & dosificación , Anestésicos/administración & dosificación , Lidocaína/administración & dosificación , Meningioma/fisiopatología , Anticonvulsivantes/administración & dosificación , Neurocirugia/métodos

Asunto(s)

Muñones de Amputación , Glicopirrolato/administración & dosificación , Hiperhidrosis/tratamiento farmacológico , Extremidad Inferior/cirugía , Adyuvantes Anestésicos/administración & dosificación , Administración Tópica , Progresión de la Enfermedad , Femenino , Humanos , Hiperhidrosis/diagnóstico , Persona de Mediana Edad

RESUMEN

OBJECTIVE: To assess the QTc interval variation after low-dose droperidol in a population of undifferentiated, stable, and non-agitated patients receiving droperidol in the emergency department. METHODS: Prospective cohort study of patients aged ≥12 years of age who received low-dose droperidol (≤ 2.5 mg) for indications other than acute behavioral disturbances. QTc intervals were monitored in real-time during pre-specified observation periods in the ED. Primary outcome was variation of QTc interval after droperidol administration, defined as the maximum delta (change) of QTc interval. Other outcomes included proportion of patients with a QTc ≥ 500 ms after droperidol, delta ≥ +60 ms, and incidence of clinical adverse events. Patients were monitored up to 30 min after IV bolus and up to 46 min after infusion. RESULTS: A total of 68 patients were included (mean age 42.1 years, 66.2% females). The median dose of droperidol was 1.875 mg (range 0.625 mg, 2.5 mg) and 94.1% received droperidol for headache management. Most patients received droperidol as a 2-min bolus (n = 41, 60.3%). The mean maximum delta of QTc interval after droperidol across all 68 patients was +29.9 ms (SD 15). A total of 12 patients (17.6%) experienced a QTc interval ≥ 500 ms during the observation period after droperidol, and 3 patients (4.4%) had a delta QTc ≥ +60 ms. There were no serious arrhythmias, such as TdP, or deaths among the 68 participants in this study (0/68). However, 13.2% (n = 9) had at least one non-serious adverse event including restlessness and/or anxiety. CONCLUSION: The QTc interval slightly increased after droperidol administration, but these prolongations were brief, mostly below 500 msec and did not lead to serious arrhythmias. The yield of continuous cardiac monitoring in patients receiving low doses of droperidol is likely low.

Asunto(s)

Adyuvantes Anestésicos/administración & dosificación , Antieméticos/administración & dosificación , Droperidol/administración & dosificación , Síndrome de QT Prolongado/inducido químicamente , Adyuvantes Anestésicos/efectos adversos , Adulto , Antieméticos/efectos adversos , Relación Dosis-Respuesta a Droga , Droperidol/efectos adversos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Masculino , Estudios Prospectivos , Adulto Joven

RESUMEN

BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) has become an important treatment modality for benign prostate hypertrophy. The aim of the present study was to compare regional anesthesia methods for HoLEP operation and to determine the optimal technique. METHODS: Sixty patients with American Society of Anesthesiologists scores of I-III were randomly allocated into 3 groups. Patients in group E received an epidural block with 75 mg of bupivacaine plus 50 µg of fentanyl. In group S, 15 mg of bupivacaine and 50 µg fentanyl were used for spinal anesthesia. In group SA, patients received saddle block with 15 mg of bupivacaine and 50 µg of fentanyl. RESULTS: Time to T10 dermatome block and to maximal level block were longest in group E (P < .05), and maximal sensorial block level was higher in group E than group SA (P < .05). There was a significant difference in postoperative motor block, but no difference in systolic blood pressure and heart rate. CONCLUSION: Among 3 techniques, saddle block might be preferable in HoLEP because an adequate sensorial level was achieved with lower motor block and stable hemodynamics.

Asunto(s)

Anestesia Epidural/métodos , Anestesia Raquidea/métodos , Terapia por Láser/métodos , Láseres de Estado Sólido/uso terapéutico , Prostatectomía/métodos , Hiperplasia Prostática/cirugía , Adyuvantes Anestésicos/administración & dosificación , Anciano , Anciano de 80 o más Años , Anestésicos Locales/administración & dosificación , Índice de Masa Corporal , Bupivacaína/administración & dosificación , Fentanilo/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Tiempo

RESUMEN

BACKGROUND: Caudal block is one of the most preferred regional anesthesia for sub-umbilical region surgeries in the pediatric population. However, few studies are available on caudal block performed in laparoscopic-assisted Soave pull-through of Hirschsprung disease (HD). We aimed to compare general anesthesia (GA) and general anesthesia combined with caudal block (GA + CA) in laparoscopic-assisted Soave pull-through of HD. METHODS: A retrospective review was performed in children with HD operated in our hospital between 2017 and 2020. Patients were divided into the GA and GA + CA group. The primary outcome was the duration of operation, and secondary outcomes included intraoperative hemodynamic changes, the Face, Legs, Activity, Cry, Consolability (FLACC) scale, dose of anesthetics, and incidence of side effects. RESULTS: A total of 47 children with HD were included in the study, including 20 in the GA group and 27 in the GA + CA Group. The two groups were similar in age, gender, weight and type of HD (P > 0.05). The GA + CA group had significantly shorter duration of operation (especially the transanal operation time) (median 1.20 h vs. 0.83 h, P < 0.01) and recovery time (mean 18.05 min vs. 11.89 min, P < 0.01). The mean doses of sufentanil and rocuronium bromide during the procedure and FLACC scores at 1 h and 6 h after surgery were also lower in the GA + CA group (p < 0.01). The hemodynamic changes in the GA + CA group were more stable at time of t2 (during transanal operation) and t3 (10 min after transanal operation), but there was no significant difference in the incidence of postoperative side effects between the two groups (P = 1.000). CONCLUSION: General anesthesia combined with caudal block can shorten the duration of operation, and provide more stable intraoperative hemodynamics and better postoperative analgesia.

Asunto(s)

Anestesia de Conducción , Anestesia General , Enfermedad de Hirschsprung/cirugía , Laparoscopía , Adyuvantes Anestésicos/administración & dosificación , Periodo de Recuperación de la Anestesia , Femenino , Hemodinámica , Humanos , Lactante , Masculino , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Tempo Operativo , Estudios Retrospectivos , Rocuronio/administración & dosificación , Sufentanilo/administración & dosificación

RESUMEN

α2 -Adrenoceptor agonists such as clonidine and dexmedetomidine are used as adjuvants to local anesthetics in regional anesthesia. Fadolmidine is an α2 -adrenoceptor agonist developed especially as a spinal analgesic. The current studies investigate the effects of intrathecally administered fadolmidine with a local anesthetic, bupivacaine, on antinociception and motor block in conscious rats and dogs. The antinociceptive effects of intrathecal fadolmidine and bupivacaine alone or in combination were tested in the rat tail-flick and the dog's skin twitch models. The durations of motor block in rats and in dogs were also assessed. In addition, the effects on sedation, mean arterial blood pressure, heart rate, respiratory rate and body temperature were evaluated in telemetrized dogs. Concentrations of fadolmidine in plasma and spinal cord were determined after intrathecal and intravenous administration in rats. Co-administration of intrathecal fadolmidine with bupivacaine increased the magnitude and duration of the antinociceptive effects and prolonged motor block without hypotension. The interaction of the antinociceptive effect was synergistic in its nature in rats. Concentration of fadolmidine in plasma was very low after intrathecal dosing. Taken together, these studies show that fadolmidine as an adjuvant to intrathecal bupivacaine provides enhanced sensory-motor block and enables a reduction of the doses of both drugs. The results indicate that co-administration of fadolmidine with intrathecal bupivacaine was able to achieve an enhanced antinociceptive effect without hypotension and could thus represent a suitable combination for spinal anesthesia.

Asunto(s)

Adyuvantes Anestésicos/administración & dosificación , Agonistas de Receptores Adrenérgicos alfa 2/administración & dosificación , Analgésicos/administración & dosificación , Anestesia Raquidea , Anestésicos Locales , Bupivacaína , Imidazoles/administración & dosificación , Indanos/administración & dosificación , Adyuvantes Anestésicos/sangre , Adyuvantes Anestésicos/farmacocinética , Agonistas de Receptores Adrenérgicos alfa 2/sangre , Agonistas de Receptores Adrenérgicos alfa 2/farmacocinética , Analgésicos/sangre , Analgésicos/farmacocinética , Animales , Presión Arterial/efectos de los fármacos , Temperatura Corporal/efectos de los fármacos , Perros , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Imidazoles/sangre , Imidazoles/farmacocinética , Indanos/sangre , Indanos/farmacocinética , Masculino , Ratas Sprague-Dawley , Frecuencia Respiratoria/efectos de los fármacos , Prueba de Desempeño de Rotación con Aceleración Constante , Médula Espinal/metabolismo

RESUMEN

BACKGROUND: Peripheral nerve block (PNB) with perineural local anesthetic is used for anesthesia or analgesia with many benefits. To extend these benefits, various adjuvant drugs have been used to prolong the duration of analgesia. We aimed to evaluate the effectiveness of various adjuvants at prolonging the duration of sensory and motor blockade for PNB. METHODS: A network meta-analysis of placebo-controlled and active randomized controlled trials was performed comparing 10 adjuvants. Embase, PubMed, Web of Science, and Cochrane library were searched, with articles before May 21, 2020 included. Two authors independently selected studies and extracted data. The primary outcomes were sensory block (SB) and motor block (MB) time, and the secondary outcome was time of first analgesia rescue (FAR). Effect size measures were described as mean differences (MD) with 95% confidence intervals (CIs). Confidence in evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The study protocol was preregistered with the prospectively registered systematic reviews in health and social care international database (PROSPERO), as number CRD42020187866. RESULTS: Overall 16,364 citations were identified, of which 53 studies were included with data for 3649 patients. In network meta-analyses, 4 of 7 included treatment strategies were associated with more efficacious analgesia compared with placebo therapy, including dexamethasone (SB time: 5.73 hours, 95% CI, 4.16-7.30; MB time: 4.20 hours, 95% CI, 2.51-5.89; time of FAR: 8.71 hours, 95% CI, 6.63-10.79), dexmedetomidine (SB time: 4.51 hours, 95% CI, 3.52-5.50; MB time: 4.04 hours, 95% CI, 2.98-5.11; time of FAR: 5.25 hours, 95% CI, 4.08-6.43), fentanyl (SB time: 3.59 hours, 95% CI, 0.11-7.06; MB time: 4.42 hours, 95% CI, 0.78-8.06), and clonidine (SB time: 2.75 hours, 95% CI, 1.46-4.04; MB time: 2.93 hours, 95% CI, 1.69-4.16; time of FAR: 3.35 hours, 95% CI, 1.82-4.87). In a subgroup analysis, addition of dexamethasone to ropivacaine significantly increased the time of FAR when compared to dexmedetomidine (time of FAR: 5.23 hours, 95% CI, 2.92-7.54) or clonidine (time of FAR: 6.61 hours, 95% CI, 4.29-8.92) with ropivacaine. CONCLUSIONS: These findings provide evidence for the consideration of dexmedetomidine, dexamethasone, and clonidine as adjuvants to prolong the duration of PNB. The addition of dexamethasone to ropivacaine has a longer time of FAR compared with clonidine or dexmedetomidine.

Asunto(s)

Adyuvantes Anestésicos/administración & dosificación , Anestésicos Locales/administración & dosificación , Actividad Motora/efectos de los fármacos , Bloqueo Nervioso , Sistema Nervioso Periférico/efectos de los fármacos , Umbral Sensorial/efectos de los fármacos , Adyuvantes Anestésicos/efectos adversos , Anestésicos Locales/efectos adversos , Clonidina/administración & dosificación , Dexmedetomidina/administración & dosificación , Esquema de Medicación , Interacciones Farmacológicas , Humanos , Bloqueo Nervioso/efectos adversos , Metaanálisis en Red , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo

RESUMEN

ABSTRACT: Although dental treatment with sedation is performed increasingly in special needs patients, data on adding midazolam to intravenous propofol sedation are very limited for this group. The purpose of this study was to identify the factors and procedure time associated with the use of intravenous sedation with propofol alone or propofol combined with midazolam in dental patients with special needs.This was a retrospective data analysis. The sedation medications and relevant covariates, including demographic parameters, disability levels, oral health conditions, dental procedures, treatment time, and side effects, of 718 patients with special needs were collected between April 2013 and September 2014. The unfavorable side effects by sedation types were reported. Factors associated with procedure time and the sedation medications were assessed with multiple logistic regression analyses.Of 718 patients, 8 patients experienced unfavorable side effects (vomiting, sleepiness, or emotional disturbance) after the dental procedures; the rate was 0.6% in the 509 patients who received propofol only. In 209 patients who received propofol and midazolam, 2.4% experienced the side effects. Sedation time was associated with body mass index (BMI) < 25 (adjusted odds ratio [aOR] = 1.45, 95% confidence interval [CI]: 1.04-2.04) and the performance of multiple dental procedures (aOR = 1.44, 95% CI: 1.06-1.97) but not associated with the sedation types. A significant odds ratio for the combined use of propofol and midazolam was shown for adolescents (aOR = 2.22, 95% CI: 1.28-3.86), men (aOR = 2.05, 95% CI: 1.41-2.98), patients with cognitive impairment (aOR = 1.99, 95% CI: 1.21-3.29), and patients undergoing scaling procedures (aOR = 1.64, 95% CI: 1.13-2.39).With the acceptable side effects of the use of propofol alone and propofol combined with midazolam, multiple dental procedures increase the sedation time and the factors associated with the combined use of propofol and midazolam are younger age, male sex, recognition problems, and the type dental procedure in the dental treatment of patients with special needs.

Asunto(s)

Sedación Consciente/estadística & datos numéricos , Atención Odontológica/normas , Midazolam/administración & dosificación , Propofol/administración & dosificación , Adyuvantes Anestésicos/administración & dosificación , Adyuvantes Anestésicos/efectos adversos , Administración Intravenosa , Adolescente , Adulto , Síntomas Afectivos/inducido químicamente , Niño , Disfunción Cognitiva/complicaciones , Sedación Consciente/efectos adversos , Atención Odontológica/estadística & datos numéricos , Raspado Dental/estadística & datos numéricos , Combinación de Medicamentos , Femenino , Humanos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Masculino , Midazolam/efectos adversos , Persona de Mediana Edad , Propofol/efectos adversos , Estudios Retrospectivos , Somnolencia , Vómitos/inducido químicamente

RESUMEN

BACKGROUND: Nebulized lidocaine reduced stress response for endotracheal intubation. However, the impact of novel lidocaine aerosol inhalation for intubation by ultrasonic atomizer was unclear. Hence, we designed aerosol inhalation of lidocaine by ultrasonic atomizer, to seek whether the dosage of sufentanil for intubation could be less or not. METHODS: Intravenous injection of sufentanil started at 0.5 µg/kg, and sufentanil dosage was increased/decreased (step-size 0.05 µg/kg for sufentanil) using Dixon's up and down method. The observation was terminated after 8 reflexes. RESULTS: The EC50 and EC95 of sufentanil with lidocaine by ultrasonic atomizer for intubation were found to be 0.232 µg/kg (95% CI: 0.187-0.270 µg/kg) and 0.447 µg/kg (95% CI: 0.364-0.703 µg/kg). 55.88% out of 34 patients showed hemodynamic index change < 20% of baseline during intubation. CONCLUSION: Aerosol inhalation of lidocaine by ultrasonic atomizer reduced the dosage of sufentanil for endotracheal intubation. Lidocaine inhalation by ultrasonic atomizer for airway anesthesia with minimal dosage of sufentanil could be recommended, particularly in patients who need more stable hemodynamic changes or spontaneous respiration. TRIAL REGISTRATION: Chinese Registry of Central Trial, ChiCTR-IOR-17014198 . Registered 28 December 2017.

Asunto(s)

Intubación Intratraqueal , Lidocaína/administración & dosificación , Nebulizadores y Vaporizadores , Sufentanilo/administración & dosificación , Ultrasonido , Adyuvantes Anestésicos/administración & dosificación , Adulto , Anestésicos Locales/administración & dosificación , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto Joven

RESUMEN

BACKGROUND: Nerve damage is consistently demonstrated after subepineural injection in animal studies, but not after purposeful injection in patients participating in clinical studies. There is a need to better visualise nerves in order to understand the structural changes that occur during subepineural injection. METHODS: We scanned the brachial plexuses of three anaesthetised pigs using micro-ultrasound imaging (55-22 MHz probe), inserted 21 gauge block needles into the radial, median, and axillary nerves, and injected two 0.5 ml boluses of saline into nerves at a rate of 12 ml min-1. Our objectives were to measure the area and diameter of nerves and fascicles, and to describe changes in nerve anatomy, comparing our findings with histology. RESULTS: Images were acquired at 42 sites across 18 nerves in three pigs and compared dimensions (geometric ratio; 95% confidence interval; P value). As expected, the nerve cross-sectional area was greater in the proximal brachial plexus compared with the mid-plexus (2.10; 1.07-4.11; P<0.001) and the distal plexus (2.64; 1.42-4.87; P<0.001). Nerve area expanded after 0.5 ml injection (2.13; 1.48-3.08; P<0.001). Using microultrasound, subepineural injection was characterised by nerve and fascicle rotation, uniform, or localised swelling and epineural rupture. Micro-ultrasound revealed a unique pattern suggestive of subperineural injection after a median nerve injection, and good face validity with histology. Histology showed epineural trauma and inflammation to the perineurium. CONCLUSION: We accurately identified fascicles and real-time structural changes to peripheral nerves using micro-ultrasound. This is the first study to visualise in vivo and in real-time the motion of nerves and fascicles in response to anaesthetic needle insertion and fluid injection.

Asunto(s)

Bloqueo del Plexo Braquial/métodos , Plexo Braquial/diagnóstico por imagen , Sistemas de Computación , Transductores , Ultrasonografía Intervencional/métodos , Adyuvantes Anestésicos/administración & dosificación , Anestésicos Disociativos/administración & dosificación , Animales , Plexo Braquial/efectos de los fármacos , Masculino , Nervios Periféricos/diagnóstico por imagen , Nervios Periféricos/efectos de los fármacos , Porcinos

RESUMEN

BACKGROUND: Dexamethasone has been widely used in brachial plexus block to enhance the effects of brachial plexus block. However, the clinical findings are not consistent with the dosage of dexamethasone prolonging local anesthetic nerve block. Therefore, the purpose of this study was to explore the effects of different doses of dexamethasone as local anesthetic adjuvant on brachial plexus block through network meta-analysis. METHODS: We searched PubMed, Web of Science, Cochrane Library, and Embase databases to collect all randomized controlled trials (RCTs) of different doses of dexamethasone as local anesthetic adjuvant on brachial plexus block until March 2021. Two researchers then independently screened articles, extracted data, and evaluated the quality of selected literatures. All data was processed by Stata 14.0 and WinBUGS 1.4.3.software. RESULTS: The results of this meta-analysis will be submitted to a peer-reviewed journal for publication. CONCLUSION: Our study is expected to provide high-quality evidence-based medicine advice for the effects of different doses of dexamethasone as local anesthetic adjuvant on brachial plexus block. ETHICS AND DISSEMINATION: Ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms. OSF REGISTRATION NUMBER: DOI 10.17605/OSF.IO/PZ5WR.

Asunto(s)

Adyuvantes Anestésicos/administración & dosificación , Anestésicos Locales/administración & dosificación , Bloqueo del Plexo Braquial/métodos , Dexametasona/administración & dosificación , Adulto , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Masculino , Metaanálisis en Red , Ensayos Clínicos Controlados Aleatorios como Asunto , Proyectos de Investigación , Revisiones Sistemáticas como Asunto , Resultado del Tratamiento

RESUMEN

In humans and other mammals, general anesthesia impairs thermoregulation, leading to warm core blood redistributing to the periphery. This redistribution is an important contributor to hypothermia that can be reduced with pre-warming before anesthesia. Additionally, sedation following premedication has been associated with hypothermia in dogs. In a prospective, randomized, cross-over study, 8 adult male and female rats (weighing 388 to 755 g) were sedated with intramuscular ketamine-midazolam-hydromorphone, then placed in an unwarmed cage or warmed box for 14 minutes, followed by 30 minutes of isoflurane anesthesia with active warming. Core body temperature was monitored throughout. After sedation, warmed rats gained 0.28°C ± 0.13°C and unwarmed rats lost 0.19°C ± 0.43°C, a significant difference between groups (P = 0.004). After anesthesia, warmed rats maintained higher core temperatures (P < 0.0001) with 2/8 and 6/8 of warmed and unwarmed rats becoming hypothermic, respectively. Pre-warming during sedation and active warming during general anesthesia is effective in minimizing hypothermia.

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Chez l'humain et les autres mammifères, l'anesthésie générale perturbe la thermorégulation, menant au sang chaud interne se redistribuant vers la périphérie. Cette redistribution est une composante majeure de l'hypothermie et peut être réduite par le réchauffement préemptif. De plus, la sédation suivant la prémédication a été associé à l'hypothermie chez les chiens. Dans cette étude prospective, randomisée et croisée, 8 rats adultes mâles et femelles (388 à 755 g) ont été sédationnés avec ketamine-midazolam-hydromorphone au niveau intramusculaire puis placés dans une cage non-chauffée ou une boîte réchauffée durant 14 minutes, suivi d'une période d'anesthésie générale de 30 minutes sur tapis chauffant. La température interne a été suivi tout au long de l'expérimentation. Après la sédation, les rats réchauffés ont gagné 0,28 °C ± 0,13 °C alors que les rats non-réchauffés ont perdu 0,19 °C ± 0,43 °C, une différence significative entre les groupes (P = 0,004). Après l'anesthésie, les rats réchauffés ont maintenu une température interne supérieure (P < 0,0001) avec 2/8 et 6/8 des rats réchauffés et non-réchauffés hypothermes, respectivement. Le réchauffement préemptif durant la sédation suivi de réchauffement actif durant l'anesthésie générale est efficace pour minimiser l'hypothermie.(Traduit par les auteurs).

Asunto(s)

Anestesia/efectos adversos , Hipotermia/prevención & control , Premedicación , Cuidados Preoperatorios , Adyuvantes Anestésicos/administración & dosificación , Adyuvantes Anestésicos/farmacología , Analgésicos/administración & dosificación , Analgésicos/farmacología , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/farmacología , Anestésicos por Inhalación/farmacología , Animales , Estudios Cruzados , Femenino , Calor , Hidromorfona/administración & dosificación , Hidromorfona/farmacología , Isoflurano/farmacología , Ketamina/administración & dosificación , Ketamina/farmacología , Masculino , Midazolam/administración & dosificación , Midazolam/farmacología , Distribución Aleatoria , Ratas , Ratas Sprague-Dawley

RESUMEN

BACKGROUND: Postoperative delirium is common among older surgical patients and may be associated with anesthetic management during the perioperative period. The aim of this study is to assess whether intravenous midazolam, a short-acting benzodiazepine used frequently as premedication, increased the incidence of postoperative delirium. METHODS: Analyses of existing data were conducted using a database created from 3 prospective studies in patients aged 65 years or older who underwent elective major noncardiac surgery. Postoperative delirium occurring on the first postoperative day was measured using the confusion assessment method. We assessed the association between the use or nonuse of premedication with midazolam and postoperative delirium using a χ2 test, using propensity scores to match up with 3 midazolam patients for each control patient who did not receive midazolam. RESULTS: A total of 1266 patients were included in this study. Intravenous midazolam was administered as premedication in 909 patients (72%), and 357 patients did not receive midazolam. Those who did and did not receive midazolam significantly differed in age, Charlson comorbidity scores, preoperative cognitive status, preoperative use of benzodiazepines, type of surgery, and year of surgery. Propensity score matching for these variables and American Society of Anesthesiology physical status scores resulted in propensity score-matched samples with 1-3 patients who used midazolam (N = 749) for each patient who did not receive midazolam (N = 357). After propensity score matching, all standardized differences in preoperative patient characteristics ranged from -0.07 to 0.06, indicating good balance on baseline variables between the 2 exposure groups. No association was found between premedication with midazolam and incident delirium on the morning of the first postoperative day in the matched dataset, with odds ratio (95% confidence interval) of 0.91 (0.65-1.29), P = .67. CONCLUSIONS: Premedication using midazolam was not associated with higher incidence of delirium on the first postoperative day in older patients undergoing major noncardiac surgery.

Asunto(s)

Adyuvantes Anestésicos/administración & dosificación , Delirio/epidemiología , Midazolam/administración & dosificación , Medicación Preanestésica , Procedimientos Quirúrgicos Operativos/efectos adversos , Adyuvantes Anestésicos/efectos adversos , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Delirio/diagnóstico , Delirio/psicología , Esquema de Medicación , Femenino , Humanos , Incidencia , Masculino , Midazolam/efectos adversos , Medicación Preanestésica/efectos adversos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

BACKGROUND: Anesthesia in lactating women is frequently indicated for time-sensitive procedures such as postpartum tubal ligation. Ketamine and diazepam are two of the most commonly used anesthetic agents in low resource settings, but their safety profile in lactating women has not been established. METHODS: Medical records of post-partum tubal ligations between 2013 and 2018 at clinics of the Shoklo Malaria Research Unit were reviewed for completeness of key outcome variables. Logistic regression identified presence or absence of associations between drug doses and adverse neonatal outcomes: clinically significant weight loss (≥95th percentile) and neonatal hyperbilirubinemia requiring phototherapy. RESULTS: Of 358 records reviewed, 298 were lactating women with singleton, term neonates. There were no severe outcomes in mothers or neonates. On the first postoperative day 98.0% (290/296) of neonates were reported to be breastfeeding well and 6.4% (19/298) had clinically significant weight loss. Phototherapy was required for 13.8% (41/298) of neonates. There was no association between either of the outcomes and increasing ketamine doses (up to 3.8 mg/kg), preoperative oral diazepam (5 mg), or increasing lidocaine doses (up to 200 mg). Preoperative oral diazepam resulted in lower doses of intraoperative anesthetics. Doses of intravenous diazepam above 0.1 mg/kg were associated with increased risk (adjusted odds ratio per 0.1 mg/kg increase, 95%CI) of weight loss (1.95, 95%CI 1.13-3.35, p = 0.016) and jaundice requiring phototherapy (1.87, 95%CI 1.11-3.13, p = 0.017). CONCLUSIONS: In resource-limited settings ketamine use appears safe in lactating women and uninterrupted breastfeeding should be encouraged and supported. Preoperative oral diazepam may help reduce intraoperative anesthetic doses, but intravenous diazepam should be used with caution and avoided in high doses in lactating women.

Asunto(s)

Lactancia Materna , Diazepam/administración & dosificación , Ketamina/administración & dosificación , Periodo Posparto , Esterilización Tubaria , Adyuvantes Anestésicos/administración & dosificación , Adulto , Analgésicos/administración & dosificación , Femenino , Humanos , Recién Nacido , Lactancia , Persona de Mediana Edad , Premedicación , Estudios Retrospectivos , Tailandia , Adulto Joven

RESUMEN

Both perineural and intravenous dexamethasone and dexmedetomidine are used as local anaesthetic adjuncts to enhance peripheral nerve block characteristics. However, the effects of dexamethasone and dexmedetomidine based on their administration routes have not been directly compared, and the relative extent to which each adjunct prolongs sensory blockade remains unclear. This network meta-analysis sought to compare and rank the effects of perineural and intravenous dexamethasone and dexmedetomidine as supraclavicular block adjuncts. We sought randomised trials investigating the effects of adding perineural and intravenous dexamethasone or dexmedetomidine to long-acting local anaesthetics on supraclavicular block characteristics, including time to block onset and durations of sensory, motor and analgesic blockade. Data were compared and ranked according to relative effectiveness for each outcome. Our primary outcome was sensory block duration, with a 2-h difference considered clinically important. We performed a frequentist analysis, using the GRADE framework to appraise evidence. One-hundred trials (5728 patients) were included. Expressed as mean (95%CI), the control group (local anaesthetic alone) had a duration of sensory block of 401 (366-435) min, motor block duration of 369 (330-408) min and analgesic duration of 435 (386-483) min. Compared with control, sensory block was prolonged most by intravenous dexamethasone [mean difference (95%CI) 477 (160-795) min], followed by perineural dexamethasone [411 (343-480) min] and perineural dexmedetomidine [284 (235-333) min]. Motor block was prolonged most by perineural dexamethasone [mean difference (95%CI) 294 (236-352) min], followed by intravenous dexamethasone [289 (129-448)min] and perineural dexmedetomidine [258 (212-304)min]. Analgesic duration was prolonged most by perineural dexamethasone [mean difference (95%CI) 518 (448-589) min], followed by intravenous dexamethasone [478 (277-679) min] and perineural dexmedetomidine [318 (266-371) min]. Intravenous dexmedetomidine did not prolong sensory, motor or analgesic block durations. No major network inconsistencies were found. The quality of evidence for intravenous dexamethasone, perineural dexamethasone and perineural dexmedetomidine for prolongation of supraclavicular sensory block duration was 'low', 'very low' and 'low', respectively. Regardless of route, dexamethasone as an adjunct prolonged the durations of sensory and analgesic blockade to a greater extent than dexmedetomidine. Differences in block characteristics between perineural and intravenous dexamethasone were not clinically important. Intravenous dexmedetomidine did not affect block characteristics.

Asunto(s)

Adyuvantes Anestésicos/administración & dosificación , Anestésicos Locales/administración & dosificación , Bloqueo del Plexo Braquial/métodos , Dexametasona/administración & dosificación , Dexmedetomidina/administración & dosificación , Administración Intravenosa , Humanos , Metaanálisis en Red