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Anesthesiology Aug 2023Comparative effectiveness research aims to understand the benefits and harms of different treatments to assist patients and clinicians in making better decisions. Within... (Review)
Review
Comparative effectiveness research aims to understand the benefits and harms of different treatments to assist patients and clinicians in making better decisions. Within anesthesia practice, comparing outcomes of spinal versus general anesthesia in older adults represents an important focus of comparative effectiveness research. The authors review methodologic issues involved in studying this topic and summarize available evidence from randomized studies in patients undergoing hip fracture surgery, elective knee and hip arthroplasty, and vascular surgery. Across contexts, randomized trials show that spinal and general anesthesia are likely to be equivalent in terms of safety and acceptability for most patients without contraindications. Choices between spinal and general anesthesia represent "preference-sensitive" care in which decisions should be guided by patients' preferences and values, informed by best available evidence.
Topics: Aged; Humans; Anesthesia, General; Anesthesia, Spinal; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Comparative Effectiveness Research; Decision Making; Randomized Controlled Trials as Topic
PubMed: 37278667
DOI: 10.1097/ALN.0000000000004604 -
PeerJ 2023Safe and effective local anesthesia is a prerequisite for emergency oral surgeries and most dental treatments. Pregnancy is characterized by complex physiological... (Review)
Review
BACKGROUND
Safe and effective local anesthesia is a prerequisite for emergency oral surgeries and most dental treatments. Pregnancy is characterized by complex physiological changes, and increased sensitivity to pain. Pregnant women are particularly vulnerable to oral diseases, such as caries, gingivitis, pyogenic granuloma and third molar pericoronitis. Maternally administered drugs can affect the fetus through the placenta. Therefore, many physicians and patients are reluctant to provide or accept necessary local anesthesia, which leads to delays in the condition and adverse consequences. This review is intended to comprehensively discuss the instructions for local anesthesia in the oral treatment of pregnant patients.
METHODOLOGY
An in-depth search on Medline, Embase, and the Cochrane Library was performed to review articles concerned with maternal and fetal physiology, local anesthetic pharmacology, and their applications for oral treatment.
RESULTS
Standard oral local anesthesia is safe throughout the pregnancy. At present, 2% lidocaine with 1:200,000 epinephrine is considered to be the anesthetic agent that best balances safety and efficacy for pregnant women. Maternal and fetal considerations must be taken into account to accommodate the physiological and pharmacological changes in the gestation period. Semi-supine position, blood pressure monitoring, and reassurance are suggested for high-risk mothers to reduce the risk of transient changes in blood pressure, hypoxemia, and hypoglycemia. For patients with underlying diseases, such as eclampsia, hypertension, hypotension, and gestational diabetes, the physicians should use epinephrine cautiously and control the dose of anesthetic. New local anesthesia formulations and equipment, which contribute to minimizing injection pain and relieving the anxiety, have and are being developed but remain understudied.
CONCLUSIONS
Understanding the physiological and pharmacological changes during pregnancy is essential to ensure the safety and efficiency of local anesthesia. Optimal outcomes for the mother and fetus hinge on a robust understanding of the physiologic alterations and the appropriate selection of anesthetic drugs and approaches.
Topics: Humans; Female; Pregnancy; Anesthesia, Local; Anesthetics, Local; Lidocaine; Epinephrine; Pain
PubMed: 37404472
DOI: 10.7717/peerj.15585 -
Anesthesiology Mar 2024The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia.
METHODS
A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized.
RESULTS
A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm.
CONCLUSIONS
Long-term outcomes were similar with spinal versus general anesthesia.
Topics: Humans; Anesthesia, General; Anesthesia, Spinal; Canada; Hip Fractures; Treatment Outcome; Male; Female; Middle Aged; Aged
PubMed: 37831596
DOI: 10.1097/ALN.0000000000004807 -
JAMA Network Open Aug 2023Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. Little is known about conversion of DPE-initiated labor analgesia to... (Randomized Controlled Trial)
Randomized Controlled Trial
Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial.
IMPORTANCE
Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. Little is known about conversion of DPE-initiated labor analgesia to surgical anesthesia for cesarean delivery.
OBJECTIVE
To determine whether DPE provides a faster onset and better-quality block compared with the standard epidural technique for cesarean delivery.
DESIGN, SETTING, AND PARTICIPANTS
This double-blind, randomized clinical trial was conducted between April 2019 and October 2022 at a tertiary care university hospital (University of Arkansas for Medical Sciences). Participants included women aged 18 years and older undergoing scheduled cesarean delivery with a singleton pregnancy.
INTERVENTIONS
Participants were randomized to receive DPE or standard epidural in the labor and delivery room. A T10 sensory block was achieved and maintained using a low concentration of bupivacaine with fentanyl through the epidural catheter until the time of surgery. Epidural extension anesthesia was initiated in the operating room.
MAIN OUTCOMES AND MEASURES
The primary outcome was the time taken from chloroprocaine administration to surgical anesthesia (T6 sensory block). The secondary outcome was the quality of epidural anesthesia, as defined by a composite of the following factors: (1) failure to achieve a T10 bilateral block preoperatively in the delivery room, (2) failure to achieve a surgical block at T6 within 15 minutes of chloroprocaine administration, (3) requirement for intraoperative analgesia, (4) repeat neuraxial procedure, and (5) conversion to general anesthesia.
RESULTS
Among 140 women (mean [SD] age, 30.1 [5.2] years), 70 were randomized to the DPE group, and 70 were randomized to the standard epidural group. The DPE group had a faster onset time to surgical anesthesia compared with the standard epidural group (median [IQR], 422 [290-546] seconds vs 655 [437-926] seconds; median [IQR] difference, 233 [104-369] seconds). The composite rates of lower quality anesthesia were 15.7% (11 of 70 women) in the DPE group and 36.3% (24 of 66 women) in the standard epidural group (odds ratio, 0.33; 95% CI, 0.14-0.74; P = .007).
CONCLUSIONS AND RELEVANCE
Anesthesia initiated following a DPE technique resulted in faster onset and improved block quality during epidural extension compared with initiation with a standard epidural technique. Further studies are needed to confirm these findings in the setting of intrapartum cesarean delivery.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03915574.
Topics: Pregnancy; Female; Humans; Adult; Analgesia, Obstetrical; Labor, Obstetric; Anesthesia, Epidural; Punctures
PubMed: 37526934
DOI: 10.1001/jamanetworkopen.2023.26710 -
Agri : Agri (Algoloji) Dernegi'nin... Oct 2023With the increase in ultrasound use, regional anesthesia practices have gained popularity and many novel techniques are being described. However, the rapidly increasing... (Review)
Review
With the increase in ultrasound use, regional anesthesia practices have gained popularity and many novel techniques are being described. However, the rapidly increasing number of new block techniques also led to confusion. Therefore, seven basic regional anesthesia techniques that are effective in most of the surgeries have been listed as 'Plan A Blocks.' The purpose of this review is to introduce the basic sono-anatomy and indications of Plan A blocks.
Topics: Humans; Nerve Block; Anesthesia, Conduction; Ultrasonography; Anesthesia, Local
PubMed: 37886870
DOI: 10.14744/agri.2022.02256 -
Journal of Anesthesia Aug 2023To assess the efficacy of pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve (LFCN) block in controlling postoperative pain and... (Randomized Controlled Trial)
Randomized Controlled Trial
Comparison between pericapsular nerve group (PENG) block with lateral femoral cutaneous nerve block and supra-inguinal fascia iliaca compartment block (S-FICB) for total hip arthroplasty: a randomized controlled trial.
PURPOSE
To assess the efficacy of pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve (LFCN) block in controlling postoperative pain and promoting recovery of lower extremity after total hip arthroplasty (THA), and to compare its effectiveness with supra-inguinal fascia iliaca compartment block (S-FICB).
MATERIALS AND METHODS
92 patients undergoing THA with general anesthesia were randomly allocated to receive either a PENG with LFCN block (n = 46) using 30 ml 0.33% ropivacaine (20 ml for PENG block, 10 ml for LFCN block), or an S-FICB (n = 46) using 30 ml 0.33% ropivacaine. The primary outcome was the time to first postoperative walk. The secondary outcomes included intraoperative remifentanil consumption, postoperative hip flexion degree and muscle strength of the operative lower limbs in the supine position, pain scores (static and dynamic), rescue analgesia, postoperative nausea and vomiting (PONV), and nerve block-related complications.
RESULTS
The combination of PENG with LFCN blocks resulted in an earlier first postoperative walking time (19.6 ± 9.6 h vs 26.5 ± 8.2 h, P < 0.01), greater postoperative hip flexion degree at 6 h, 24 h and 48 h (all P < 0.01), and higher muscle strength of the operative lower limbs at 6 h after surgery (P = 0.03) compared to S-FICB. The difference in pain scores (static and dynamic) was only statistically significant at 48 h (P < 0.05). There were no differences in the other outcomes.
CONCLUSIONS
PENG with LFCN blocks is more effective than S-FICB in shortening the time to first postoperative walk and preservation hip motion after THA, which makes it a suitable addition to enhanced recovery programs following surgery.
Topics: Humans; Arthroplasty, Replacement, Hip; Ropivacaine; Femoral Nerve; Nerve Block; Pain, Postoperative; Lower Extremity; Fascia
PubMed: 37043081
DOI: 10.1007/s00540-023-03192-6 -
Brazilian Journal of Anesthesiology... 2023
Topics: Humans; Anesthesia, Conduction; Ultrasonography; Ultrasonography, Interventional
PubMed: 37783429
DOI: 10.1016/j.bjane.2023.09.006 -
World Journal of Clinical Cases May 2024Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction. The primary pathology in MG involves the presence of autoantibodies to...
Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction. The primary pathology in MG involves the presence of autoantibodies to acetylcholine receptors (AChRs), which results in qualitative and quantitative reductions in the availability of functional AChRs. Cardiac muscles are also affected, resulting in various perioperative cardiac complications. Antistriational antibodies are commonly reported in MG cases with cardiac involvement. In the presence of thymoma, the prevalence of cardiac manifestations in patients with MG increases to approximately 10%-15%. Cardiac involvement in MG may range from asymptomatic electrocardiogram changes to ventricular tachycardia, myocarditis, conduction disorders, heart failure, and sudden death. Increased incidence of atrial fibrillation, ventricular and supraventricular extra systoles, and prolonged QTc have also been reported in patients with MG. Clinicians should consider the evaluation of autonomic dysfunction and risk of cardiovascular disease in patients with MG.
PubMed: 38808348
DOI: 10.12998/wjcc.v12.i13.2147 -
Frontiers in Medicine 2023
PubMed: 37593407
DOI: 10.3389/fmed.2023.1256371