BACKGROUND:Despite multiple studies suggesting the significant benefits of epidural lysis for failed back surgery syndrome (FBSS), comparative evaluations with different approaches of epidural lysis remain limited. The present study aims to investigate the efficacy of caudal catheter-based epidural lysis of adhesions techniques versus transforaminal epidural lysis in treating pain and disability after L5-S1 lumbar surgery. METHODS:This study was a double-blinded randomized clinical trial conducted on patients diagnosed with FBSS after lumbar spine surgery at the level of L5-S1 and complained of pain for more than 3 months. These patients who were referred to the Imam Reza Hospital pain clinic in Mashhad, Iran, in 2023, were randomly assigned to one of two groups: one undergoing caudal epidural lysis of adhesions with a catheter, and the other received L5-S1 transforaminal epidural lysis. The intensity of patients' pain and their motor and sensory function were evaluated before intervention and 4 weeks, and 12 weeks post-intervention. Outcomes were compared within and between the two groups using the Numerical Rating Scale (NRS) and the Oswestry Disability Index (ODI) questionnaire to assess their functional status. RESULTS:During follow-up, the ODI, back NRS, and leg NRS scores were significantly lower in patients who underwent epidural lysis with catheter compared to the transforaminal group ( P < 0.05). The caudal catheter group showed success rates of ODI, back NRS, and leg NRS factors among 73.5%, 79.4%, and 70.6% of patients, respectively. The transforaminal lysis group was successful in 54.5%, 48.5%, and 48.5% of patients in terms of ODI, back NRS, and leg NRS factors, respectively. Additionally, at the 12-week follow-up, the rate of treatment success in terms of ODI (χ 2 = 4.53, P = 0.02) and back NRS (χ 2 = 5.78, P = 0.01) was significantly higher in the caudal lysis group compared to the transforaminal lysis group. However, no significant difference was observed in leg NRS outcomes at 12 weeks after treatment (χ 2 = 0.25, P = 0.109). CONCLUSION:In conclusion, this study indicates that caudal epidural lysis with a catheter is more effective than transforaminal lysis in terms of pain reduction and functional improvement for patients with L5-S1 level FBSS.
BACKGROUND:General anesthetics can alter the gut microbiota, but the longitudinal and sex-specific effects of sevoflurane remain unclear. This study examined whether a single exposure to sevoflurane anesthesia induces significant compositional changes in the murine gut microbiome over two weeks, with a secondary focus on sex-specific patterns of alteration. METHODS:A controlled animal exposure study was conducted at a tertiary-care academic laboratory animal facility in southern India, approved by an institutional animal ethics committee. Twenty albino mice (6-8 weeks old, ~12 g; both females and males) were randomized to sevoflurane or control groups, subdivided by sex. All animals were housed under standard conditions and completed the study protocol. Experimental animals underwent a single 4-hour exposure to sevoflurane in a controlled chamber; controls experienced identical procedures without sevoflurane. Primary endpoints were gut microbiota alpha and beta diversity (Bray-Curtis distance, Shannon, Simpson indices, richness), phylum- and genus-level differential abundance, and derived Firmicutes: Bacteroidetes and Proteobacteria metrics from serial fecal samples across five time points up to Day 14. RESULTS:Sevoflurane exposure led to significant beta diversity separation between groups at both phylum (P = 0.004) and genus levels (P = 0.034), with additional sex effects (P = 0.035 for genus level); alpha diversity indices were significantly reduced in males (P = 0.0079), but not in females. Phylum-level differential abundance was significant in females but not in males. Group and sex effects were present throughout, and derived dysbiosis metrics varied temporally and by sex Conclusion: A single prolonged exposure to sevoflurane induces significant, durable, and sexually dimorphic shifts in the murine gut microbiome. These findings highlight the importance of considering sex as a biological variable in studies of anesthetic effects on gut health.
The systemic immune-inflammation index (SII) (SII = platelet count × neutrophil count/lymphocyte count) is an emerging inflammatory biomarker. We examined correlations between preoperative SII, medication count as a marker of multimorbidity, and established perioperative risk scores in patients undergoing elective noncardiac surgery. This cross-sectional study included 300 adults undergoing elective surgery. SII was calculated from preoperative blood counts. We assessed correlations between SII and clinical variables using Spearman's rank correlation coefficient, including American Society of Anesthesiologists Physical Status Classification System, Revised Cardiac Risk Index (RCRI), Surgical Outcome Risk Tool (SORT) mortality, and medication count. We investigated polypharmacy (≥ 4 medications) as a multimorbidity indicator. Multivariable regression identified predictors of elevated SII (≥ 754 × 10^9 cells/L). This study examined associations only. Mean age was 63.5 ± 9.6 years, 50.7% male. Median SII was 633 × 10^9/L. SII showed weak correlations with RCRI (ρ = 0.15, P = 0.008) and SORT (ρ = 0.12, P = 0.033). The strongest correlation was with medication count (ρ = 0.77, P < 0.001), reflecting multimorbidity burden. In the analysis, polypharmacy (odds ratio [OR], 6.82; 95% CI, 2.05-22.7), higher SORT mortality (OR, 1.69 per 1% increase), and RCRI (OR, 1.48 per point) predicted elevated SII. This cross-sectional association study found weak correlations between SII and risk scores. The strong association with polypharmacy suggests that both measures capture the multimorbidity burden, raising the question of whether SII offers advantages over counting medications. Prospective studies with actual perioperative outcomes are required before SII can be recommended for clinical risk stratification.
BACKGROUND:The ongoing debate regarding the preferred technique between single-site and double-site injection procedures for supraclavicular block remains unresolved. We conducted this research to evaluate the clinical outcomes of single-site versus double-site injection in patients undergoing upper limb surgery. METHODS:A literature search was conducted up to September 2023 to identify randomized controlled trials (RCTs) comparing the single-site injection group (SG) with the double-site injection group (DG) for the supraclavicular block. The analysis was conducted using Review Manager 5.4, employing either a fixed-effects or random-effects model (PROSPERO; no. CRD42023492703). RESULTS:Based on the 10 RCTs included in the quantitative analysis, there were no significant differences in success rates (i.e., the primary outcome), surgical anesthesia, total anesthesia-related time, time to first rescue analgesic, and adverse events. However, significant differences were observed in several secondary outcomes. SG showed advantages in terms of shorter performance time (mean difference [MD], -1.02 minutes [95% confidence interval [CI], -1.79 to -0.25; P = 0.01; I^2 = 91%]) and lower blockade pain scores (MD, -0.30 minutes [95% CI, -0.60 to 0.00; P = 0.05; I^2 = 0%]). Conversely, DG demonstrated superiority in terms of faster block onset time (MD, 5.73 minutes [95% CI, 4.91, 6.54; P < 0.00001; I^2 = 1%]), longer duration of the sensory block (MD, -71.77 minutes [95% CI, -139.50 to -4.03; P = 0.04; I^2 = 98%]), and longer duration of the motor block (MD, -33.13 minutes [95% CI, -39.64 to -26.63; P < 0.00001; I^2 = 0%]). CONCLUSION:This meta-analysis provides evidence that SG and DG had equivalent success rates. SG revealed favorable outcomes in terms of shorter performance time and lower blockade pain scores. However, DG was considered superior in terms of faster block onset and longer durations of sensory and motor block.
BACKGROUND:Fascia iliaca compartment block (FICB) is one of the regional blocks used to reduce postoperative pain after total hip arthroplasty (THA). Administration of dexamethasone in the loading dose might lengthen pain-free duration and reduce anesthetic consumption. METHODS:Sixty patients undergoing THA with spinal anesthesia and patient-controlled FICB were randomly assigned to receive either 20 mL of 0.25% ropivacaine with 8 mg dexamethasone (Group D, n = 30) or 20 mL of 0.25% ropivacaine alone (Group C, n = 30). Postoperative pain scores, analgesic use, and side effects were assessed over 72 hours. RESULTS:Postoperative visual analogue scale scores did not differ significantly between groups. The time to first bolus was longer in Group D than in Group C (407.10 ± 305.68 vs. 308.63 ± 212.99 minutes; P < 0.05). Total ropivacaine consumption over 72 hours was lower in Group D (210.33 ± 79.64 mg) compared to Group C (288.00 ± 91.32 mg), with a similar reduction in bolus frequency (14.53 ± 7.96 vs. 22.30 ± 9.13). The incidence of adverse events, including quadriceps weakness, local effects, and other side effects, was low and comparable between groups. CONCLUSION:The addition of dexamethasone to ropivacaine for FICB after THA can significantly provide a longer duration of analgesia with a lower amount of anesthetic.
BACKGROUND:Sedation/analgesia (S/A) is widely used to relieve patients' anxiety and discomfort during colonoscopy. Their effects on abdominal pain after colonoscopy have never been fully investigated. METHODS:The prospective study consecutively recruited 494 healthy patients having a screen colonoscopy examination as part of their health checkup. They were divided into two groups based on individuals' decision to receive sedation and analgesia or not. In the S/A group, 374 patients received midazolam and alfentanil during colonoscopy with standard monitoring, while in the non-sedation/analgesia (NSA) group, 120 patients received no analgesics. Severity and duration of abdominal pain (ordinal scale: 1 = none, 4 = severe) were assessed at the end of stay in the postanesthetic care unit (the S/A group) or examination room (the NSA group) and before discharge. Side effects S/A during (hypotension, hypoxemia) and after (nausea, vomiting, dizziness) colonoscopy were also recorded. All patients were closely monitored during the whole course of the health check-up package. RESULTS:The mean doses of midazolam and alfentanil were 4.06 mg and 813.12 μg, respectively. Patients in the NSA group had two-fold risks of moderate to severe abdominal pain compared to those in the S/ A group (16.67% vs. 9.36%, odds ratio = 1.937, 95% confidence interval: 1.010-3.625). The NSA group also had a higher incidence of abdominal pain 120 minutes after examination (33.33% vs. 16.04%, P < 0.001). Duration of abdominal pain in those patients who did have abdominal pain was longer in the S/ A group than in the NSA group (153.3 ± 49.9 vs. 118.7 ± 47.5 minutes, P < 0.001). The incidence of hypotension and hypoxemia in the group S/A was 5.6% and 2.9%, respectively. More patients in the S/ A group felt dizzy or sleepy than those in the NSA group (14.7% vs. 3.3%, P < 0.001). The incidence of nausea and vomiting was similar between the two groups. CONCLUSION:Optimal S/A with midazolam and alfentanil decreases the severity and duration of postcolonoscopic abdominal pain.
BACKGROUND:Spinal anesthesia-induced hypotension can lead to adverse consequences for the mother-fetus binomial. We compared two prophylactic phenylephrine infusions with placebo in obese patients during cesarean delivery (CD) under spinal anesthesia. METHODS:In this randomized, placebo-controlled, double-blind study, 121 patients were randomly allocated to receive 0.9% saline in Group C, prophylactic phenylephrine infusion 50 μg/min in Group P50, or prophylactic phenylephrine infusion 100 μg/min in Group P100, starting immediately after anesthesia induction until delivery. The primary outcome was the number of episodes of hypotension. RESULTS:The median (interquartile range) of the number of episodes of hypotension in Group P100 [0.0 (0.0-0.0)] and Group P50 [0.0 (0.0-1.5)] were lower in Group C [3.0 (2.0-5.0)], P < 0.001. There was also a smaller number of episodes of hypotension in Group P100 than in Group P50, P = 0.016. The phenylephrine infusion groups had a significantly lower incidence of hypotension, increased time until the first episode of hypotension, and fewer physician interventions but a higher incidence of reactive hypertension in Group P100 than in Group C. Nausea and vomiting, bradycardia, and neonatal outcomes were not different among the groups. CONCLUSION:Prophylactic phenylephrine infusion of 100 or 50 μg/min in obese women during CD under spinal anesthesia reduced the number of episodes of hypotension, the incidence of hypotension, the number of physician interventions, and the number of rescue phenylephrine boluses, and increased the time until the first hypotension episode. However, 100 μg/min could lead to more reactive hypertension.
BACKGROUND:The purpose of this retrospective study was to determine the effect of surgical operation, age at surgery, sex hormones, and anesthesia modality on the risk of dementia in both sexes. METHODS:Data of females aged between 30 and 70 years old who were diagnosed with dysmenorrhea and underwent hysterectomy/myomectomy or without surgery, and males with benign prostate hyperplasia (BPH) with or without transurethral resection of the prostate (TURP) were identified from the National Health Insurance Research Database 2000-2016. The effect of age at surgery, surgery type, and anesthesia modality on dementia risk was assessed using Cox regression analyses. RESULTS:Among the 855,893 subjects, 10,242 developed dementia. Surgery at older age increased dementia risk in both sexes. Among females, hysterectomy/myomectomy was not significantly associated with dementia risk, although myomectomy was associated with a lower risk for dementia than hysterectomy. In males, TURP significantly increased the risk of dementia. CONCLUSION:Men with BPH and women with dysmenorrhea who were older at surgery have a higher risk of dementia. Regardless of the anesthetic method, surgery increased the risk of dementia in men. Among the data of women, although the surgery factor was not significantly associated with dementia risk, women with myomectomy had a lower risk of dementia than the ones with hysterectomy. These findings together contributed to risk stratification for each sex in such surgical settings.
We presented two cases in which patients with chronic heart failure experienced significant hypotension and respiratory distress during the left lateral decubitus position before spinal anesthesia for orthopedic surgery.
BACKGROUND:Most of the studies on difficult intubation and laryngoscopy focused on American and European populations. However, Indians have distinct anthropometric characteristics compared to these populations. This study aims to determine the gender difference in inter-incisor distance (IID) cut-off marks to assess the ease of intubation in the Indian population. METHODS:A prospective observational study was conducted on 516 patients scheduled for elective surgery under general anesthesia with endotracheal intubation. Preoperative assessments included IID, thyromental distance, neck circumference, sternomental distance (SMD), thyrohyoid distance, mentohyoid distance, and modified mallampatti grading. Intubation difficulty scores (IDSs) were assessed during intubation. The optimal cut-off values of inter incisor gap and difficult intubation were analyzed by receiver operating characteristic curve analysis. RESULTS:The total cohort was grouped into males (Group 1 [n = 258]) and females (Group 2 [n = 258]). Males had a significantly higher mean age (P = 0.04) and weight (P = 0.00) than females. Difficult intubation incidence was 16.3% of males and 6.2% of females. Increased IID (P = 0.039), decreased SMD (P = 0.046), and males (P = 0.002) are identified as predictors of difficult intubation.IID and IDS showed greater specificity than sensitivity, with significant cut-off values of 4.25 and 1.50, respectively. CONCLUSION:The cut-off value of IID did not show a significant difference in gender variation. Despite the low IID in females, intubation difficulties were not observed compared to males.
BACKGROUND:Propofol has been associated with metabolic acidosis in case reports. However, the results of studies in patients undergoing non-cardiac surgery are controversial. On the other hand, there have been no randomized controlled studies addressing this issue in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). In this study, we investigated whether propofol was associated with metabolic acidosis in patients undergoing cardiac surgery with CPB. METHODS:Forty patients undergoing cardiac surgery with CPB were randomly assigned to receive total anesthesia with propofol (intervention group) or sevoflurane (control group), respectively. Except for this, the anesthetic and surgical management was the same in all patients. The primary outcomes were the changes in arterial blood pH, base excess, HCO_3^-, and lactate levels during surgery. The secondary outcomes included serum aspartate transaminase (AST), alanine transaminase (ALT), urea, and creatinine levels, as well as the proportion of patients with increased liver enzymes and kidney damage at the end of surgery, and the proportion of patients with arrhythmia during surgery. RESULTS:The rate of metabolic acidosis with high lactate at the end of surgery in the propofol group (intervention group) was statistically higher than that in the sevoflurane group (control group). Nevertheless, no difference in serum AST, ALT, urea, and creatinine levels between the two groups, and the proportions of patients with increased liver enzymes and kidney damage at the end of surgery, as well as the proportion of patients with arrhythmia during surgery. CONCLUSION:Total anesthesia with propofol was associated with metabolic acidosis but did not significantly affect increased liver enzymes, kidney damage, and arrhythmias when compared with the control group in patients undergoing cardiac surgery with CPB.
Regional anesthesia offers benefits such as improved pain control and reduced opioid use, but controversies remain regarding techniques and outcomes. This review examines key debates in the field, including the necessity of circumferential spread of local anesthetics, the impact of regional anesthesia on diagnosing compartment syndrome, the choice of diluent, and the safety of performing peripheral nerve blocks (PNBs) in awake versus anesthetized patients. To explore these topics, we conducted a literature search to synthesize relevant studies and expert perspectives, offering a comprehensive analysis of current evidence. While circumferential spread may enhance block onset, studies show that it does not consistently improve success. The potential for regional anesthesia to mask compartment syndrome is not definitively supported, as ischemic pain often breaks through analgesia. Dextrose diluents accelerate sensory block onset compared to saline, though effects vary with different anesthetics. In awake versus anesthetized PNBs, sedation and general anesthesia provide safety and comfort, especially for non-cooperative patients, with no clear superiority. Overall, regional anesthesia techniques should be tailored to individual patient needs, and further research is necessary to refine best practices.
BACKGROUND:Postoperative pain after cesarean section (CS) can significantly impact patient recovery and morbidity if not managed effectively. This study compares the efficacy of two multimodal analgesic combinations-paracetamol with ibuprofen (PI) and paracetamol with ketorolac (PK)-in managing postoperative pain after CS, and assesses the incidence of side effects. METHODS:This single-blind clinical trial was conducted from June to July 2024 at Prof. Dr. W. Z. Johannes Hospital, Kupang, Indonesia, involving 60 patients undergoing elective CS under spinal anesthesia, randomly assigned into two groups. The PI group received 400 mg of intravenous ibuprofen post-delivery, followed by 1,000 mg of oral paracetamol and 400 mg of ibuprofen every 8 hours. The PK group was given 30 mg of intravenous ketorolac, followed by 1,000 mg of oral paracetamol and 30 mg of intravenous ketorolac every 8 hours. Pain was assessed using the numeric rating scale (NRS) at 8, 24, and 48 hours postoperatively, while opioid rescue use (NRS > 4) and side effects such as nausea, vomiting, and epigastric pain were also recorded. RESULTS:Pain scores were significantly lower in the PI group at 8 and 24 hours postoperatively (P < 0.05). No significant difference was found between the groups at 48 hours (P = 0.094). There was no significant difference between the groups (P = 0.656 and P = 0.095) in terms of total morphine rescue dose or the incidence of postoperative nausea and vomiting (PONV). The incidence of epigastric pain was significantly lower in the PI group (P = 0.038). CONCLUSION:PI may represent a more favorable option for early postoperative pain control and lower epigastric pain effect, pending further validation in larger, multicenter trials. Both combinations had similar outcomes in terms of opioid use and PONV.
BACKGROUND:Successful placement of an endotracheal tube (ETT) and its timely confirmation in obese patients is of utmost importance. Chest auscultation might be misleading in the obese. Considering the need for an additional efficient method, the present study compared tracheal and pleural ultrasonography (USG) for confirming ETT placement in overweight and obese patients. METHODS:A prospective, comparative, randomized, single-blinded study enrolled a total of 64 overweight, obese class I and class II patients aged between 18 and 60 years, American Society of Anesthesiologists grades I or II, scheduled for elective surgeries under general anesthesia with endotracheal intubation. Patients were randomized into two groups of 32 each based on the USG technique used for confirmation of ETT placement. Group T is Tracheal USG, and Group P is Pleural USG. The primary outcome was a comparison of the time required by tracheal and pleural ultrasonography techniques for confirmation of ETT placement, while the secondary outcome was a comparison of the time required by both USG techniques with the time for auscultation and capnographic confirmation of ETT placement. RESULTS:Tracheal USG took the least time (4.19 ± 0.89 seconds) compared to pleural USG (10.88 ± 1.16 seconds) and proved to be faster. Time taken for auscultation (P < 0.001) was longer than both USG methods, but less than capnography time. Capnographic confirmation took the maximum time when compared to USG and auscultation (P < 0.001). CONCLUSION:Tracheal USG provides a faster confirmation of endotracheal intubation than pleural USG in overweight and obese patients. Pleural USG has the added advantage of diagnosing endobronchial intubation.
BACKGROUND:Anesthesia for interventional bronchoscopy (IB) presents significant challenges, primarily due to unpredictable responses such as coughing, airway spasms, and desaturation, even with monitored anesthetic care. However, the nociception inducing such responses and the impact of adding topical anesthesia (TA) have rarely been investigated. This study aims to map the timing and intensity of nociception, determine TA onset, and clarify TA's role in blocking nociception with subsequent IB procedures. METHODS:Analgesia nociception index (ANI) and mean arterial blood pressure (MBP) were collected in patients undergoing IB procedures with bispectral index (BIS)-controlled intravenous anesthesia. Data were compared and analyzed along with various stages: anesthetic induction with iGel insertion, fibro-optic bronchoscopy (FOB) insertion, and applying TA with the spray-as-you-go (SAYGO) method using xylocaine, up to 30 minutes with subsequent IB procedures. RESULTS:Data from 82 patients were analyzed. Under BIS-controlled anesthesia, iGel insertion decreased ANI significantly (P < 0.001). Following stabilization, ANI decreased significantly with SAYGO (P < 0.001), returned toward baseline within 5 minutes, and remained stably higher than baseline for up to 30 minutes. The changes on MBP were similar to those of ANI. No significant correlations were observed between BIS levels and ANI. CONCLUSIONS:ANI offers a valuable perspective on nociception, serves as a helpful reference for precise anesthetic management for IB. The key action, such as an ultrashort-acting anesthetic just before FOB insertion to block nociception from the establishment of TA without prolonged effect, is suggested for smooth, subsequent IB procedures.
BACKGROUND:Dexamethasone is widely used in anesthesia practise as prophylaxis for postoperative nausea and vomiting (PONV). Our aims were to evaluate the postoperative glycemic profile after a single dose of intraoperative dexamethasone in non-diabetic and diabetic patients and to evaluate the PONV. METHODS:This double-blinded, randomized, controlled study was done for 6 months from June to December 2024 in a tertiary care hospital after obtaining ethical committee clearance and CTRI registration. Patients were allocated to one of four groups: nondiabetics receiving saline, nondiabetics receiving dexamethasone, diabetics receiving saline, and diabetics receiving dexamethasone. The study drug or saline control was administered at the induction of anesthesia. Blood sugar values, two hours after dexamethasone/placebo administration as well as fasting blood sugar and postprandial blood sugar on postoperative day 1, 2 were taken as primary endpoints. PONV was assessed in the first 24 hours after surgery. RESULTS:The rise in blood glucose levels was higher in the group receiving dexamethasone compared to saline in both diabetics and nondiabetics (P < 0.05). None of the patients had blood glucose values more than 180 mg/dL after 2 hours and 8 hours of dexamethasone administration. CONCLUSIONS:Dexamethasone can be considered as prophylaxis for PONV in well controlled diabetics and nondiabetics despite the increase in blood glucose levels as a hyperglycemic response (blood glucose value 180 mg/dL) to a single dose was not observed in our study.
