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Chau, Anthony; Preston, Roanne; Wieczorek, Paul M.; McKeen, Dolores M.; Chow, Lorraine; Edwards, Wesley; Zaphiratos, Valerie
doi: 10.1007/s12630-025-02986-4pmid: 40528133
PurposeThis Special Article aims to synthesize the results of a live audience poll and practice tips from Canadian obstetric anesthesiology experts during a panel session at the Canadian Anesthesiologists’ Society 2024 Annual Meeting (Victoria, BC, Canada). We explored six hypothetical case scenarios, each representing a clinically plausible situation that lack a definitive management approach. These scenarios highlight areas where no consensus exists and no single “correct” solution has been established.SourceWe gathered live poll data about six case scenarios from participants who attended the session and chose to submit a response. The expert panel provided decision analysis of each case.Principal findingsThe literature and expert panel suggest that 0.5% isobaric bupivacaine and 0.5% hyperbaric ropivacaine may be appropriate alternatives during shortages of 0.75% hyperbaric bupivacaine. Both combined spinal epidural and standard epidural techniques are effective first choices for rescuing a failed single-shot spinal anesthesia during elective Cesarean delivery. A decision aid may be helpful when converting an epidural for surgical anesthesia. Epidural dexmedetomidine has been used off-label in some centres to enhance the quality of labour analgesia. Nevertheless, owing to limited data in the literature, its routine use for labour analgesia or Cesarean delivery is not currently recommended. In cases of febrile labouring patients, the expert panel advocates initiating antibiotics before epidural placement as a prudent precaution despite the lack of robust contemporary evidence. An obstetric patient with thrombocytopenia may generally undergo neuraxial techniques if the platelet count exceeds 70 × 109·L−1. The risks and benefits should be carefully considered when the platelet count is between 50 × 109·L−1 and 69 × 109·L−1, taking into account potential changes in platelet quality due to conditions such as hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. If an accidental dural puncture occurs during an epidural blood patch procedure, a cautious approach would involve abandoning the procedure and reattempting after 24 hr to minimize the risk of blood translocation leading to arachnoiditis. Conversely, a pragmatic approach would involve immediately reattempting the procedure at another level, although there is no consensus on the most appropriate course of action.ConclusionsThe range of participant responses highlighted various clinical challenges in obstetric anesthesia where evidence is still limited or inconclusive. Three experts in obstetric anesthesia shared their insights, detailing their decision-making processes and how they would approach each case scenario. They also provided key references, offering valuable take-home messages for anesthesiologists practicing obstetric anesthesia.
Miao, Tyson; Lee, Lik Hang N.; Sun, Terri; Patapoff, Megan; Wang, Erica
doi: 10.1007/s12630-025-02983-7pmid: 40560345
PurposePain management after cardiac surgery is imperative, as inadequate analgesia can increase the risk of myocardial ischemia, thromboembolism, and pulmonary complications. Nonsteroidal anti-inflammatory drugs (NSAIDs) are an important component of multimodal analgesia, but their use in the postoperative cardiac surgery population is controversial owing to concerns of acute kidney injury (AKI), thrombotic events, and bleeding. We aimed to evaluate the rate of AKI, major adverse cardiovascular events (MACE), and major bleeding in patients receiving NSAIDs early after cardiac surgery.MethodsWe conducted a single-centre historical cohort study, which included adult patients who underwent cardiac surgery with sternotomy or thoracotomy between 1 October 2020 and 30 September 2022 and received nonselective NSAIDs postoperatively. The primary outcome was the proportion of patients who developed AKI, MACE, or major bleeding within 7 days of the NSAID exposure during their hospitalization. We used machine learning to identify risk factors associated with adverse events. We assessed pain reduction by analyzing differences in pain scores, opioid use, and supplemental oxygen requirements.ResultsWe included 431 patients in this study. After NSAID administration, 12% experienced AKI, 1% had MACE, and 3% developed major bleeding. Risk factors for AKI included older age; shorter height; a history of stroke; low preoperative estimated glomerular filtration rate (eGFR) and hemoglobin level; high preoperative platelet count, international normalized ratio, and blood urea nitrogen level; and reduced eGFR and platelet count before NSAID exposure.ConclusionIn patients who received nonselective NSAIDs early after cardiac surgery, the rate of AKI was lower than reported in literature, likely due to selection bias. Baseline renal function emerged as the most important factor, with low preoperative eGFR being the strongest predictor of AKI following NSAID administration.
Kang, RyungA; Bang, Yu Jeong; Shim, Jae Woo; Choi, Soo Joo; Kong, So Myung; Hahm, Tae Soo; Park, Jungchan; Sim, Woo Seog; Ko, Justin Sangwook
doi: 10.1007/s12630-025-02992-6pmid: 40542311
Kim, Ha-Jung; Kim, Yeon Ju; Lee, Jungmin; Jeong, Daun; Shin, Young Ho; Ro, Young-Jin; Kim, Hyungtae; Koh, Won Uk
doi: 10.1007/s12630-025-02987-3pmid: 40514628
PurposeThe ideal sedative should have a rapid onset, short duration, and quick and predictable recovery. Despite the increasing use of the recently developed sedative remimazolam for intraoperative sedation, there is a paucity of research on its comparative recovery profile. Our aim was to compare the recovery profiles of intraoperative sedation with propofol, dexmedetomidine, and remimazolam in patients undergoing surgery under regional anesthesia.MethodsWe included 119 patients scheduled to undergo upper limb surgery under brachial plexus blockade in a randomized controlled trial. We randomized patients to receiving intraoperative sedation with propofol, dexmedetomidine, or remimazolam. The primary outcome was the recovery time (from the completion of infusion to attaining a Modified Observer’s Assessment of Alertness and Sedation score of 5). As secondary outcomes, we assessed other recovery profiles, including length of stay, quality of recovery, and the Aldrete score.ResultsThe mean (95% confidence interval [CI]) recovery time was 19 min (95% CI, 16 to 22) for patients in the dexmedetomidine group, 17 min (95% CI, 15 to 19) for the remimazolam group, and 12 min (95% CI, 10 to 13) for the propofol group (P < 0.001). Post hoc analysis revealed that the recovery time in the remimazolam group was longer compared to that in the propofol group (mean difference, 5 min; 95% CI, 3 to 8; Bonferroni adjusted P < 0.001). We found no significant differences among the three groups in the recovery-related secondary outcomes (all P > 0.05).ConclusionsPatients in the propofol group exhibited the most rapid recovery time from intraoperative sedation under regional anesthesia, followed by those in the remimazolam and dexmedetomidine groups. We found no differences in the recovery-related secondary outcomes.Study registration: ClinicalTrials.gov (NCT05688345); first submitted 30 December 2022.
Kim, Yoon Jung; Choe, Hyun Woo; Yoon, Soo Bin; Lee, Hyeonhoon; Kim, Hee-Soo; Seo, Jeong-Hwa
doi: 10.1007/s12630-025-02993-5pmid: 40563070
PurposeBrainwave entrainment with low-frequency binaural beats has shown sedative-sparing and anxiolytic effects. We sought to investigate whether the preoperative use of binaural beats could reduce the propofol dose for the induction of general anesthesia.MethodsWe enrolled patients scheduled for elective surgery under general anesthesia in a randomized controlled trial. In the preoperative waiting area, we randomized patients to hear the binaural beats with frequencies of 432 and 431 Hz in the binaural-beats group (N = 34) or silent sound in the control group (N = 35) for 20 min via stereo headphones. For the induction of general anesthesia, we administered 10 mg of propofol every 15 sec until we observed three clinical signs: the loss of response to verbal commands of “open your eyes” (primary outcome), loss of eyelash reflex, and a patient state index of ≤ 50. We collected processed frontal electroencephalography data during the intervention and assessed anxiety scores before and after the intervention.ResultsThe propofol dose for the loss of response to verbal commands was lower in the binaural-beats group than in the control group (mean [standard deviation], 87 [24] mg vs 105 [32] mg; difference in means, −18 mg; 95% confidence interval, −32 to −5; P = 0.009). There were no significant differences in the delta (P = 0.63), theta (P = 0.28), alpha (P = 0.24), and beta (P = 0.85) bands of the processed frontal electroencephalograms and the anxiety scores (P = 0.50).ConclusionBinaural beats with a frequency of 1 Hz modestly reduced the propofol dose for the induction of general anesthesia, but we observed no significant differences in the processed frontal electroencephalograms and preoperative anxiety levels.Study registrationClinicalTrials.gov (NCT05431881); first submitted 9 June 2022.
Basmaji, John; Tang, J. Elaine; Arntfield, Robert; Desai, Karishma; Ball, Ian M.; Fiorini, Kyle; Slessarev, Marat; Honarmand, Kimia; Jones, Phil; Lau, Vincent; Lewis, Kimberley; Orozco, Nicolas; Meade, Maureen; Park, Brian; Prager, Ross; Rochwerg, Bram;
Showing 1 to 10 of 18 Articles
PurposeWe aimed to evaluate the effects of intravenous dexmedetomidine (DEX) on perioperative opioid requirements, and secondarily on perioperative respiratory adverse events (PRAE), emergence delirium (ED), and postoperative nausea and vomiting in pediatric patients undergoing tonsillectomy.MethodsWe conducted a systematic review with meta-analysis, searching seven databases up to 7 May 2024. We included randomized controlled trials of patients aged 18 yr or younger undergoing tonsillectomy, comparing intravenous DEX and opioids with opioids. Our primary outcome was perioperative opioid requirements, expressed as oral morphine equivalents (OME). The secondary outcomes included the incidences of perioperative respiratory adverse events (PRAE), emergence delirium (ED), and postoperative nausea and vomiting (PONV), We used the Cochrane Risk of Bias 2 tool and assessed the certainty of the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). We used a pairwise random effects model to compute the risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) of the effects of DEX on each outcome. To explore dose-dependent effects of DEX, we used a random effects meta-regression model.ResultsWe included 16 trials in our systematic review, of which we analyzed 7 for opioid requirements, 4 for PRAE, 3 for ED, and 12 for PONV. Dexmedetomidine was associated with lower perioperative opioid requirements (MD, −0.25 mg·kg−1 OME; 95% CI, −0.36 to −0.13; moderate certainty), equivalent to a 40% relative reduction of perioperative OME, and a lower likelihood of ED (RR, 0.24; 95% CI, 0.08 to 0.71; moderate certainty). Despite DEX not having a dose-dependent effect on OME, the RR of ED decreased 87% for each 0.5 µg·kg−1 increment in DEX dose. Dexmedetomidine did not reduce the incidence of sustained or severe cough as a part of PRAE, but it reduced PONV (RR, 0.48; 95% CI, 0.35 to 0.66; I2 = 0%; low certainty).ConclusionDexmedetomidine may improve the perioperative course of children undergoing tonsillectomy by decreasing perioperative opioid requirements and dose-dependently lowering the incidence of ED. Limitations of the present systematic review with meta-analysis include an inconsistent definition of PRAE in trials and heterogeneity due to variability of observed effect sizes.Study registrationPROSPERO (CRD42023392579); first submitted 1 July 2023.
PurposeWe sought to evaluate the efficacy of intravenous dexamethasone in reducing rebound pain post-orthopedic wrist and hand surgery, administered prior to supraclavicular brachial plexus blockade.MethodsWe conducted a randomized placebo-controlled trial on 56 patients scheduled for elective wrist and hand surgery under supraclavicular brachial plexus blockade. We randomized participants into either a control group, receiving 0.9% of intravenous saline, or a dexamethasone group, receiving 0.11 mg·kg−1 of intravenous dexamethasone. The primary outcome was the difference in pain scores before vs after block resolution. Secondary outcomes included the incidence of rebound pain, pain scores, cumulative opioid consumption, patient satisfaction with postoperative analgesia, and block-related complications in the first 24 hr postoperatively.ResultsThe mean (standard deviation [SD]) pain score difference was significantly larger in the control group (7.3 [1.9]) compared with the dexamethasone group (4.7 [2.1]), with a mean difference between groups of 2.6 (95% confidence interval, 1.5 to 3.7; P < 0.001). The incidence of rebound pain was also significantly higher in the control group (79% vs 32%; P < 0.001). The cumulative opioid consumption in 24 hr was greater in the control group than in the dexamethasone group (median [interquartile range (IQR)], 72 [54–97] mg vs 25 [14–60] mg; P < 0.001). We found no significant differences in postoperative complications.ConclusionsPreoperative administration of 0.11 mg·kg−1 intravenous dexamethasone significantly reduced rebound pain within 24 hr after wrist and hand surgery under supraclavicular brachial plexus blockade. The results of our trial support the use of intravenous dexamethasone as an effective method for managing postoperative pain for wrist and hand surgery under supraclavicular brachial plexus blockade.Study registration: www.CRIS.nih.go.kr (KCT0007208); first submitted 5 April 2022.
PurposeSpinal cord stimulation (SCS) is a surgical intervention for patients with neuropathic pain refractory to medical management. There are limited data on its outcomes from Canadian centres. We aimed to describe the indications, patient- and procedure-related characteristics, and outcomes of patients who underwent SCS implantation at a Canadian tertiary centre.MethodsWe conducted a retrospective cohort study of patients who underwent SCS at St. Michael’s Hospital (Toronto, ON, Canada) between 1 January 2020 and 31 July 2023. We collected data on patient demographics, analgesic use, type of SCS trial (percutaneous vs tunneled), indication, antibiotic use during and after surgery, and complications.ResultsWe included 100 patients with a mean (standard deviation) age of 62 (14) yr. Indications included chronic pain after spinal surgery (n = 44), chronic back pain (no prior spine surgery) (n = 22), complex regional pain syndrome (n = 6), spinal stenosis (n = 4), and visceral pain (n = 4). Complications included implantable pulse generator-associated pain (47%), lead migration (14%), lead fracture (9%), surgical site infection (2%), and cerebrospinal fluid leak (6%). Almost all patients were on pharmacotherapy for pain relief at baseline (n = 96) and agents included opioids, nonsteroidal anti-inflammatory drugs, anticonvulsants, and antidepressants.ConclusionsIn this cohort of patients who underwent SCS implantation at a Canadian tertiary centre, infection and lead migration rates were consistent with global estimates (3.8% and up to 27%, respectively); nevertheless, we observed high rates of dural puncture compared with an expected incidence of 0.48%.
doi: 10.1007/s12630-025-02997-1pmid: 40603759
PurposeWe sought to conduct a systematic review to determine the diagnostic test accuracy of point-of-care ultrasound (POCUS) for the specific etiologies and subtypes of shock.MethodsWe searched MEDLINE, Embase, and the grey literature for prospective studies in adult populations with shock. We collected data on study design, patient characteristics, operator characteristics, POCUS protocol, and true and false positives and negatives, and assessed the risk of bias.ResultsWe found 18 eligible studies with a total of N = 2,088 patients. The pooled sensitivity and specificity of POCUS for determining shock subtype were 90% (95% confidence interval [CI], 81 to 95) and 95% (95% CI, 90 to 97) for hypovolemic shock, 95% (95% CI, 84 to 98) and 98% (95% CI, 97 to 99) for cardiogenic shock, 78% (95% CI, 69 to 85) and 97% (95% CI, 94 to 99) for distributive shock, 94% (95% CI, 85 to 97) and 99% (95% CI, 98 to 100) for obstructive shock, and 85% (95% CI, 77 to 91) and 98% (95% CI, 91 to 100) for mixed shock (all low to moderate quality evidence). The pooled sensitivity and specificity of POCUS for determining specific shock etiologies were 78% (95% CI, 18 to 98) and 96% (95% CI, 87 to 99) for sepsis, 92% (95% CI, 71 to 98) and 99% (95% CI, 83 to 100) for pulmonary embolism, and 100% (95% CI, 69 to 100) and 100% (95% CI, 98 to 100) for cardiac tamponade. The quality of the evidence ranged from very low to moderate.ConclusionsOn the basis of very low to moderate quality evidence, POCUS may perform better at ruling in shock subtypes and specific shock etiologies than ruling them out. Point-of-care ultrasound is a promising tool for the diagnosis of shock.Study registrationPROSPERO (CRD42020160001); first submitted 1 December 2019.