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12 pages, 251 KiB

Open AccessArticle

Anesthetic Management during Robotic-Assisted Minimal Invasive Thymectomy Using the Da Vinci System: A Single Center Experience

by Ahmed Mohamed, Sharaf-Eldin Shehada, Clemens Aigner, Till Ploenes, Yazan Alnajdawi, Lena Van Brakel, Arjang Ruhparwar, Marcel Hochreiter, Marc Moritz Berger, Thorsten Brenner and Ali Haddad

J. Clin. Med. 2022, 11(15), 4274; https://doi.org/10.3390/jcm11154274 - 22 Jul 2022

Cited by 3 | Viewed by 1977

Abstract

Background: Robotic-assisted surgery is gaining more adaption in different surgical specialties. The number of patients undergoing robotic-assisted thymectomy is continuously increasing. Such procedures are accompanied by new challenges for anesthesiologists. We are presenting our primary anesthesiologic experience in such patients. Methods: This is [...] Read more.

Background: Robotic-assisted surgery is gaining more adaption in different surgical specialties. The number of patients undergoing robotic-assisted thymectomy is continuously increasing. Such procedures are accompanied by new challenges for anesthesiologists. We are presenting our primary anesthesiologic experience in such patients. Methods: This is a retrospective single center study, evaluating 28 patients who presented with thymoma or myasthenia gravis (MG) and undergone minimal invasive robotic-assisted thoracic thymectomy between 01/2020–01/2022. We present our fast-track anesthesia management as a component of the enhanced recovery program and its primary results. Results: Mean patient’s age was 46.8 ± 18.1 years, and the mean height was 173.1 ± 9.3 cm. Two-thirds of patients were female (n = 18, 64.3%). The preoperative mean forced expiratory volume in the first second (FEV1) was 3.8 ± 0.7 L, forced vital capacity (FVC) was 4.7 ± 1.1 L, and the FEV1/FVC ratio was 80.4 ± 5.3%. After the creation of capnomediastinum, central venous pressure and airway pressure have been significantly increased from the baseline values (16.5 ± 4.9 mmHg versus 13.4 ± 5.1 mmHg, p < 0.001 and 23.4 ± 4.4 cmH₂O versus 19.3 ± 3.9 cmH₂O, p < 0.001, respectively). Most patients (n = 21, 75%) developed transient arrhythmias episodes with hypotension. All patients were extubated at the end of surgery and discharged awake to the recovery room. The first 16 (57.1%) patients were admitted to the intensive care unit and the last 12 patients were only observed in intermediate care. Postoperatively, one patient developed atelectasis and was treated with non-invasive ventilation therapy. Pneumonia or reintubation was not observed. Finally, no significant difference was observed between MG and thymoma patients regarding analgesics consumption or incidence of complications. Conclusions: Robotic-assisted surgery is a rapidly growing technology with increased adoption in different specialties. Fast-track anesthesia is an important factor in an enhanced recovery program and the anesthetist should be familiar with challenges in this kind of operation to achieve optimal results. So far, our anesthetic management of patients undergoing robotic-assisted thymectomy reports safe and feasible procedures. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

12 pages, 848 KiB

Open AccessArticle

Effects of Remimazolam vs. Sevoflurane Anesthesia on Intraoperative Hemodynamics in Patients with Gastric Cancer Undergoing Robotic Gastrectomy: A Propensity Score-Matched Analysis

by Bahn Lee, Myoung Hwa Kim, Hee Jung Kong, Hye Jung Shin, Sunmo Yang, Na Young Kim and Dongwoo Chae

J. Clin. Med. 2022, 11(9), 2643; https://doi.org/10.3390/jcm11092643 - 8 May 2022

Cited by 22 | Viewed by 2792

Abstract

Remimazolam has been suggested to improve the maintenance of hemodynamic stability when compared with other agents used for general anesthesia. This study aimed to compare the effects of remimazolam and sevoflurane anesthesia on hemodynamic stability in patients undergoing robotic gastrectomy. We retrospectively reviewed [...] Read more.

Remimazolam has been suggested to improve the maintenance of hemodynamic stability when compared with other agents used for general anesthesia. This study aimed to compare the effects of remimazolam and sevoflurane anesthesia on hemodynamic stability in patients undergoing robotic gastrectomy. We retrospectively reviewed the electronic medical records of 199 patients who underwent robotic gastrectomy with sevoflurane (n = 135) or remimazolam (n = 64) anesthesia from January to November 2021. Propensity scores were used for 1:1 matching between the groups. The primary outcome was the difference in use of intraoperative vasopressors between groups. Secondary outcomes included differences in incidence and dose of vasopressors, as well as intraoperative hemodynamic variables, between groups. Remimazolam anesthesia was associated with a significantly less frequent use of ephedrine (odds ratio (OR): 0.13; 95% confidence interval (CI): 0.05–0.38, p < 0.001), phenylephrine (OR: 0.12; 95% CI: 0.04–0.40, p < 0.001), and any vasopressor (OR: 0.06; 95% CI: 0.02–0.25, p < 0.001) compared with sevoflurane anesthesia. Remimazolam anesthesia enables better maintenance of hemodynamic stability than sevoflurane anesthesia. Thus, remimazolam anesthesia may be beneficial for patients who are expected to experience hypotension due to the combined effects of CO₂ pneumoperitoneum and the head-up position utilized during robotic gastrectomy. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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12 pages, 460 KiB

Open AccessArticle

A Single Center Case Series of Gender-Affirming Surgeries and the Evolution of a Specialty Anesthesia Team

by Nelson J. Aquino, Elizabeth R. Boskey, Steven J. Staffa, Oren Ganor, Alyson W. Crest, Kristin V. Gemmill, Joseph P. Cravero and Bistra Vlassakova

J. Clin. Med. 2022, 11(7), 1943; https://doi.org/10.3390/jcm11071943 - 31 Mar 2022

Cited by 9 | Viewed by 7233

Abstract

Most minors and young transgender persons wishing to undergo gender-affirming surgery need to seek specialists affiliated with gender affirmation programs in adult hospitals. Research suggests gender affirmation surgery has been established as an effective and medically indicated treatment for gender dysphoria. Although most [...] Read more.

Most minors and young transgender persons wishing to undergo gender-affirming surgery need to seek specialists affiliated with gender affirmation programs in adult hospitals. Research suggests gender affirmation surgery has been established as an effective and medically indicated treatment for gender dysphoria. Although most data on gender-affirming surgeries are from adult populations, there is growing literature establishing their effectiveness in adolescents and young adults. Therefore, it is critical to evaluate the perioperative outcomes for gender-diverse youth to deliver safe and affirming care. The primary objective of this retrospective case series is to examine the perioperative characteristics and outcomes of patients with gender identity disorders (International Classification of Diseases [ICD]-10-code F64) who underwent chest reconstruction (mastectomy) and genital surgery (phalloplasty, metoidioplasty, and vaginoplasty) in a pediatric academic hospital. The secondary aim is to evaluate the value of a specialized anesthesia team for improving clinical outcomes, interdisciplinary communication, and further advancing the transgender perioperative experience. We identified 204 gender affirmation surgical cases, 177 chests/top surgeries, and 27 genital/bottom surgeries. These findings indicate gender-diverse individuals who underwent life-changing surgery at our institution had a median age of 18 years old, with many patients identifying as transmen. Our data suggests that postoperative pain was significant, but adverse events were minimal. The evolution of a specialty anesthesia team and initiatives (anesthesia management guidelines, scheduling, continuity, and education) necessitate direct care coordination and multidisciplinary planning for gender affirmation surgery in transgender youth. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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7 pages, 445 KiB

Open AccessArticle

Perioperative Acetaminophen and Dexmedetomidine Eliminate Post-Operative Opioid Requirement following Pediatric Tonsillectomy

by Andrew G. Rudikoff, David D. Tieu, Franklin M. Banzali, Carolyn V. Nguyen, Robert L. Rettig, Marlene M. Nashed, Janet Mora-Marquez, Qiaoling Chen, Antonio Hernandez Conte and Keira P. Mason

J. Clin. Med. 2022, 11(3), 561; https://doi.org/10.3390/jcm11030561 - 23 Jan 2022

Cited by 8 | Viewed by 3539

Abstract

Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate [...] Read more.

Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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11 pages, 1095 KiB

Open AccessArticle

Analgesia Nociception Index-Guided Remifentanil versus Standard Care during Propofol Anesthesia: A Randomized Controlled Trial

by Nada Sabourdin, Julien Burey, Sophie Tuffet, Anne Thomin, Alexandra Rousseau, Mossab Al-Hawari, Clementine Taconet, Nicolas Louvet and Isabelle Constant

J. Clin. Med. 2022, 11(2), 333; https://doi.org/10.3390/jcm11020333 - 11 Jan 2022

Cited by 16 | Viewed by 3094

Abstract

The clinical benefits to be expected from intraoperative nociception monitors are currently under investigation. Among these devices, the Analgesia Nociception-Index (ANI) has shown promising results under sevoflurane anesthesia. Our study investigated ANI-guided remifentanil administration under propofol anesthesia. We hypothesized that ANI guidance would [...] Read more.

The clinical benefits to be expected from intraoperative nociception monitors are currently under investigation. Among these devices, the Analgesia Nociception-Index (ANI) has shown promising results under sevoflurane anesthesia. Our study investigated ANI-guided remifentanil administration under propofol anesthesia. We hypothesized that ANI guidance would result in reduced remifentanil consumption compared with standard management. This prospective, randomized, controlled, single-blinded, bi-centric study included women undergoing elective gynecologic surgery under target-controlled infusion of propofol and remifentanil. Patients were randomly assigned to an ANI or Standard group. In the ANI group, remifentanil target concentration was adjusted by 0.5 ng mL⁻¹ steps every 5 min according to the ANI value. In the Standard group, remifentanil was managed according to standard practice. Our primary objective was to compare remifentanil consumption between the groups. Our secondary objectives were to compare the quality of anesthesia, postoperative analgesia and the incidence of chronic pain. Eighty patients were included. Remifentanil consumption was lower in the ANI group: 4.4 (3.3; 5.7) vs. 5.8 (4.9; 7.1) µg kg⁻¹ h⁻¹ (difference = −1.4 (95% CI, −2.6 to −0.2), p = 0.0026). Propofol consumption was not different between the groups. Postoperative pain scores were low in both groups. There was no difference in morphine consumption 24 h after surgery. The proportion of patients reporting pain 3 months after surgery was 18.8% in the ANI group and 30.8% in the Standard group (difference = −12.0 (95% CI, −32.2 to 9.2)). ANI guidance resulted in lower remifentanil consumption compared with standard practice under propofol anesthesia. There was no difference in short- or long-term postoperative analgesia. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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Review

Jump to: Research

21 pages, 1158 KiB

Open AccessReview

Volatile Anaesthesia versus Total Intravenous Anaesthesia for Cardiac Surgery—A Narrative Review

by Mihai Ștefan, Cornelia Predoi, Raluca Goicea and Daniela Filipescu

J. Clin. Med. 2022, 11(20), 6031; https://doi.org/10.3390/jcm11206031 - 13 Oct 2022

Cited by 5 | Viewed by 3742

Abstract

Recent research has contested the previously accepted paradigm that volatile anaesthetics improve outcomes in cardiac surgery patients when compared to intravenous anaesthesia. In this review we summarise the mechanisms of myocardial ischaemia/reperfusion injury and cardioprotection in cardiac surgery. In addition, we make a [...] Read more.

Recent research has contested the previously accepted paradigm that volatile anaesthetics improve outcomes in cardiac surgery patients when compared to intravenous anaesthesia. In this review we summarise the mechanisms of myocardial ischaemia/reperfusion injury and cardioprotection in cardiac surgery. In addition, we make a comprehensive analysis of evidence comparing outcomes in patients undergoing cardiac surgery under volatile or intravenous anaesthesia, in terms of mortality and morbidity (cardiac, neurological, renal, pulmonary). Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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15 pages, 1039 KiB

Open AccessReview

The Use of Intravenous Lidocaine in Perioperative Medicine: Anaesthetic, Analgesic and Immune-Modulatory Aspects

by Ingrid Wing-Sum Lee and Stefan Schraag

J. Clin. Med. 2022, 11(12), 3543; https://doi.org/10.3390/jcm11123543 - 20 Jun 2022

Cited by 23 | Viewed by 6025

Abstract

This narrative review provides an update on the applied pharmacology of lidocaine, its clinical scope in anaesthesia, novel concepts of analgesic and immune-modulatory effects as well as the current controversy around its use in perioperative opioid-sparing multi-modal strategies. Potential benefits of intravenous lidocaine [...] Read more.

This narrative review provides an update on the applied pharmacology of lidocaine, its clinical scope in anaesthesia, novel concepts of analgesic and immune-modulatory effects as well as the current controversy around its use in perioperative opioid-sparing multi-modal strategies. Potential benefits of intravenous lidocaine in the context of cancer, inflammation and chronic pain are discussed against concerns of safety, toxicity and medico-legal constraints. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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14 pages, 601 KiB

Open AccessReview

What’s New in Intravenous Anaesthesia? New Hypnotics, New Models and New Applications

by Remco Vellinga, Beatrijs I. Valk, Anthony R. Absalom, Michel M. R. F. Struys and Clemens R. M. Barends

J. Clin. Med. 2022, 11(12), 3493; https://doi.org/10.3390/jcm11123493 - 17 Jun 2022

Cited by 4 | Viewed by 3728

Abstract

New anaesthetic drugs and new methods to administer anaesthetic drugs are continually becoming available, and the development of new PK-PD models furthers the possibilities of using arget controlled infusion (TCI) for anaesthesia. Additionally, new applications of existing anaesthetic drugs are being investigated. This [...] Read more.

New anaesthetic drugs and new methods to administer anaesthetic drugs are continually becoming available, and the development of new PK-PD models furthers the possibilities of using arget controlled infusion (TCI) for anaesthesia. Additionally, new applications of existing anaesthetic drugs are being investigated. This review describes the current situation of anaesthetic drug development and methods of administration, and what can be expected in the near future. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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20 pages, 2518 KiB

Open AccessReview

Pharmacokinetic Pharmacodynamic Modelling Contributions to Improve Paediatric Anaesthesia Practice

by James D. Morse, Luis Ignacio Cortinez and Brian J. Anderson

J. Clin. Med. 2022, 11(11), 3009; https://doi.org/10.3390/jcm11113009 - 26 May 2022

Cited by 5 | Viewed by 3403

Abstract

The use of pharmacokinetic-pharmacodynamic models has improved anaesthesia practice in children through a better understanding of dose-concentration-response relationships, developmental pharmacokinetic changes, quantification of drug interactions and insights into how covariates (e.g., age, size, organ dysfunction, pharmacogenomics) impact drug prescription. Simulation using information from [...] Read more.

The use of pharmacokinetic-pharmacodynamic models has improved anaesthesia practice in children through a better understanding of dose-concentration-response relationships, developmental pharmacokinetic changes, quantification of drug interactions and insights into how covariates (e.g., age, size, organ dysfunction, pharmacogenomics) impact drug prescription. Simulation using information from these models has enabled the prediction and learning of beneficial and adverse effects and decision-making around clinical scenarios. Covariate information, including the use of allometric size scaling, age and consideration of fat mass, has reduced population parameter variability. The target concentration approach has rationalised dose calculation. Paediatric pharmacokinetic-pharmacodynamic insights have led to better drug delivery systems for total intravenous anaesthesia and an expectation about drug offset when delivery is stopped. Understanding concentration-dependent adverse effects have tempered dose regimens. Quantification of drug interactions has improved the understanding of the effects of drug combinations. Repurposed drugs (e.g., antiviral drugs used for COVID-19) within the community can have important effects on drugs used in paediatric anaesthesia, and the use of simulation educates about these drug vagaries. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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14 pages, 315 KiB

Open AccessReview

General Purpose Pharmacokinetic-Pharmacodynamic Models for Target-Controlled Infusion of Anaesthetic Drugs: A Narrative Review

by Ophélie Vandemoortele, Laura N. Hannivoort, Florian Vanhoorebeeck, Michel M. R. F. Struys and Hugo E. M. Vereecke

J. Clin. Med. 2022, 11(9), 2487; https://doi.org/10.3390/jcm11092487 - 28 Apr 2022

Cited by 17 | Viewed by 5236

Abstract

Target controlled infusion (TCI) is a clinically-available and widely-used computer-controlled method of drug administration, adjusting the drug titration towards user selected plasma- or effect-site concentrations, calculated according to pharmacokinetic-pharmacodynamic (PKPD) models. Although this technology is clinically available for several anaesthetic drugs, the contemporary [...] Read more.

Target controlled infusion (TCI) is a clinically-available and widely-used computer-controlled method of drug administration, adjusting the drug titration towards user selected plasma- or effect-site concentrations, calculated according to pharmacokinetic-pharmacodynamic (PKPD) models. Although this technology is clinically available for several anaesthetic drugs, the contemporary commercialised PKPD models suffer from multiple limitations. First, PKPD models for anaesthetic drugs are developed using deliberately selected patient populations, often excluding the more challenging populations, such as children, obese or elderly patients, of whom the body composition or elimination mechanisms may be structurally different compared to the lean adult patient population. Separate PKPD models have been developed for some of these subcategories, but the availability of multiple PKPD models for a single drug increases the risk for invalid model selection by the user. Second, some models are restricted to the prediction of plasma-concentration without enabling effect-site controlled TCI or they identify the effect-site equilibration rate constant using methods other than PKPD modelling. Advances in computing and the emergence of globally collected databases has allowed the development of new “general purpose” PKPD models. These take on the challenging task of identifying the relationships between patient covariates (age, weight, sex, etc) and the volumes and clearances of multi-compartmental pharmacokinetic models applicable across broad populations from neonates to the elderly, from the underweight to the obese. These models address the issues of allometric scaling of body weight and size, body composition, sex differences, changes with advanced age, and for young children, changes with maturation and growth. General purpose models for propofol, remifentanil and dexmedetomidine have appeared and these greatly reduce the risk of invalid model selection. In this narrative review, we discuss the development, characteristics and validation of several described general purpose PKPD models for anaesthetic drugs. Full article

(This article belongs to the Special Issue New Approaches in Intravenous Anesthesia and Anesthetics—Part II)

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