Effect of perioperative intravenous ibuprofen versus acetaminophen on postoperative opioid consumption and pain after general anesthesia: a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials.

BACKGROUND: Ibuprofen and acetaminophen are widely used as adjuvant analgesics for postoperative pain. This meta-analysis compared the effects of intravenous (IV) ibuprofen and acetaminophen on postoperative opioid consumption and pain intensity after general anesthesia. METHODS: PubMed/MEDLINE, EMBASE, and Cochrane Library databases were searched to identify relevant studies published up to May 2023. Randomized controlled trials comparing the effects of perioperative IV ibuprofen and acetaminophen on postoperative opioid consumption and pain after general anesthesia were included in the meta-analysis and trial sequential analysis (TSA). RESULTS: Eight studies with 494 participants were included. Compared to IV acetaminophen, IV ibuprofen significantly reduced 24 h opioid consumption, presented as morphine equivalents (mean difference [MD]: -6.01 mg, 95% CI [-8.60, -3.42], P < 0.00001, I2 = 55%), and pain scores (on a scale of 0-10) at 4-6 h (MD: -0.83, 95% CI [-1.29, -0.37], P = 0.0004, I2 = 65%) and 12 h (MD: -0.38, 95% CI [-0.68, -0.08], P = 0.01, I2 = 11%) postoperatively. These results were statistically significant in TSA. Pain scores at 24 h postoperatively and side effects were not significantly different between the two groups in the meta-analysis, and TSA revealed that the sample size was too small to adequately evaluate the effects, requiring further studies for conclusive results. CONCLUSIONS: Perioperative IV ibuprofen reduced 24 h opioid consumption and pain severity up to 12 h postoperatively compared to acetaminophen. Additional research is required to assess pain intensity beyond 12 h and side effects.

Difficult endotracheal intubation in a patient with progressed tracheobronchopathia osteoplastica: A case report.

Tracheobronchopathia osteoplastica is a rare condition involving large airways with multiple bone and cartilage nodules in the tracheobronchial submucosa. This can cause tracheal stenosis, leading to difficulty in endotracheal intubation. A 79-year-old female patient, who had a history of successful endotracheal intubation for general anesthesia 8 years prior, was scheduled for abdominal surgery. Preoperative chest computed tomography and bronchoscopy revealed slight progression of tracheobronchopathia osteoplastica. Attempts to intubate with a smaller endotracheal tube failed; even the smaller endotracheal tube could barely pass. Mechanical ventilation was successfully administered and the surgery was completed without complications. The use of a smaller endotracheal tube may be beneficial for managing difficult airways in patients with tracheobronchopathia osteoplastica. Chest CT and bronchoscopic examination may be beneficial for evaluating the airway and determining the most appropriate airway management strategy. However, relying solely on these measures may lead to unexpected challenges because there is no established method to evaluate airway in patient with tracheobronchopathia osteoplastica. It is crucial for anesthesiologists to be aware of the potential existence of rare conditions such as tracheobronchopathia osteoplastica and be prepared to handle anticipated or unanticipated difficult airway management.

Treatment of postural headache occurred 26 days after spinal pain procedure - A case report.

BACKGROUND: Cerebrospinal fluid (CSF) leakage may cause intracranial hypotension and postural headache. Secondary intracranial hypotension may result from an iatrogenic dural puncture or traumatic injury associated with pain procedures. CASE: A 45-year-old male developed a headache 26 days after spinal pain procedure. Headache was characterized as postural, worsening with standing or sitting and improving while lying down. The pain did not resolve despite the administration of oral and intravenous analgesics. A spinal magnetic resonance imaging revealed epidural venous congestion and a suspicious CSF leak around the left L4/5 level. The patient received an epidural blood patch (EBP), the headache improved dramatically, and the patient was discharged. CONCLUSIONS: Delayed postural headaches may not be directly related to pain management. Nevertheless, intracranial hypotension related to pain management should be suspected even in this case. If confirmed, quickly applying an EBP is an effective treatment option.

Monitored Anesthesia Care in Minimally Invasive Spine Surgery-A Retrospective Case Series Study.

Background and Objectives: Minimally invasive spine surgery (MISS) under monitored anesthesia care (MAC) has emerged as a treatment modality for spinal radiculopathy. It is essential to secure the airway and guarantee spontaneous respiration without endotracheal intubation during MISS in a prone position. Materials and Methods: To evaluate the feasibility and safety of MAC with dexmedetomidine during MISS, we retrospectively reviewed clinical cases. A retrospective review of medical records was conducted between September 2015 and June 2016. A total of 17 patients undergoing MISS were included. Vital signs were analyzed every 15 min. The depth of sedation was assessed using the bispectral index (BIS) and the frequency of rescue sedatives. Adverse events during anesthesia, including bradycardia, hypotension, respiratory depression, postoperative nausea, and vomiting, were evaluated. Results: All cases were completed without the occurrence of airway-related complications. None of the patients needed conversion to general anesthesia. The median maintenance dosage of dexmedetomidine for adequate sedation was 0.40 (IQR 0.40-0.60) mcg/kg/hr with a median loading dose of 0.70 (IQR 0.67-0.82) mcg/kg. The mean BIS during the main procedure was 76.46 ± 10.75. Rescue sedatives were administered in four cases (23.6%) with a mean of 1.5 mg intravenous midazolam. After dexmedetomidine administration, hypotension and bradycardia developed in six (35.3%) and three (17.6%) of the seventeen patients, respectively. Conclusions: MAC using dexmedetomidine is a feasible anesthetic method for MISS in a prone position. Hypotension and bradycardia should be monitored carefully during dexmedetomidine administration.

Complete recovery from segmental zoster paresis confirmed by magnetic resonance imaging: A case report.

BACKGROUND: Segmental zoster paresis, depending on the affected area, can present with severe clinical manifestations and render patients unable to perform activities of daily living. Therefore, it is necessary to diagnose and treat such a condition rapidly. No studies have reported using magnetic resonance imaging (MRI) to identify clinical abnormalities associated with this condition or its complete recovery. This rare case report evaluated the changes in MRI findings before and after the patient's motor symptoms recovered. CASE SUMMARY: A 79-year-old woman with a history of rheumatoid arthritis and psoriasis visited the hospital for skin rashes and pain in the C5-T2 segments. The diagnosis was herpes zoster infection, and treatment was initiated. However, motor weakness suddenly occurred 14 d after the initial symptom presentation. We confirmed abnormal findings in the nerves and muscles invaded by the shingles using electromyography and MRI. After 17 mo, the patient's symptoms had completely normalized, and MRI confirmed that there were no abnormalities. CONCLUSION: MRI can be a useful diagnostic modality for segmental zoster paresis and patient evaluation during recovery from motor complications.

Psychogenic coma after general anesthesia with remimazolam and remifentanil -a case report.

BACKGROUND: Delayed emergence from general anesthesia is associated with life-threatening conditions with pharmacological, neurological, metabolic, and rarely, psychiatric causes. This case report was presented to report psychogenic coma after recovery from anesthesia with remimazolam and remifentanil. CASE: An elderly woman was unresponsive after recovery from anesthesia with remimazolam and remifentanil. Physical examination, laboratory testing, and radiographic imaging did not reveal any obvious organic causes. Pharmacological or metabolic abnormalities were not found. Absence of those causes strongly suggests that prolonged unconsciousness is related to psychiatric origin. The patient spontaneously regained consciousness after 48 h without any neurological complications. CONCLUSIONS: Anesthesiologists should be aware of the possibility of psychogenic coma for patients with unexplained delay in emergence from anesthesia after the exclusion of other causes.

The use of sugammadex in an infant with prolonged neuromuscular blockade - A case report.

BACKGROUND: Residual neuromuscular blockade (RNMB) is a frequent event after general anesthesia, which can lead to serious complications, such as upper airway obstruction. Sugammadex is useful in reversing RNMB. However, its use in infants has not yet been approved by the Food and Drug Administration. Therefore, anesthesiologists can be hesitant use it, even in situations where no other choice is available. CASE: A two-month-old baby presented to the hospital for umbilical polypectomy. At the end of the surgery, neostigmine was administered. Even after waiting for 30 min and injecting an additional dose of neostigmine, neuromuscular blockade was not adequately reversed. Eventually, sugammadex was administered, and spontaneous breathing returned. CONCLUSIONS: If there were no particular causes of delayed return to spontaneous breathing in infants, RNMB should be considered and reversal with sugammadex would be useful.

Anesthesia in a Patient with Potocki-Lupski Syndrome.

INTRODUCTION: Potocki-Lupski syndrome (PTLS) is a rare disease caused by the duplication of a small segment of chromosome 17 (17p11.2). The clinical presentation of this syndrome is quite variable and includes hypotonia, failure to thrive, oropharyngeal dysphagia, developmental delay, and behavioral abnormalities. In addition, congenital heart disease, sleep apnea, and mildly dysmorphic features are common and should be considered during anesthetic management. However, because of the rarity and newness of the syndrome, there are few reports on the anesthetic care of patients with PTLS. Case Report. We report a case of a 4-year-old girl diagnosed with this syndrome who underwent general anesthesia for exotropia surgery. The patient exhibited micrognathia; a mild decrease in muscle tone; and a developmental delay in motor, speech, and cognition. She had a history of swallowing incoordination and gastroesophageal reflux. No abnormalities were found on a preoperative echocardiography. A videolaryngoscope was used for tracheal intubation, and the state of neuromuscular blockade was monitored in addition to standard monitoring. Anesthesia was maintained with sevoflurane and remifentanil. The patient recovered without any adverse events. CONCLUSION: As PTLS patients may have several malformations, preanesthetic evaluation is important. Preoperative echocardiography and cardiologic consultations are required. It is desirable to prepare for the risk of difficult airway and pulmonary aspiration. Postoperatively, close monitoring is needed to prevent airway compromise.

Numbness of the lower lip following urological surgery under general anesthesia - A case report.

BACKGROUND: Peripheral nerve injury is a complication that can occur after general anesthesia. It significantly impairs the patient's quality of life and may lead to permanent disability. Nerves in several areas can be damaged during the perioperative period, but it is very rare that numbness of the lower lip is caused after general anesthesia. CASE: A 73-year-old man with diabetes mellitus underwent urological surgery under general anesthesia. The day after surgery, he complained of numbness on the right lower lip caused by a mental nerve injury. Diabetic mononeuropathy or neurapraxia related to mechanical compression was considered a possible cause. The symptoms resolved spontaneously after six weeks. CONCLUSIONS: Mental nerve injury is a rare perioperative complication in surgical patients under general anesthesia. In this case, patients should be reassured and advised to avoid injuries to the mouth and lips. However, specific treatment is not required.

Prolotherapy for the patients with chronic musculoskeletal pain: systematic review and meta-analysis.

BACKGROUND: Prolotherapy, which stimulates the healing of loosened ligaments and tendons, is a cost-effective and safe treatment modality for chronic musculoskeletal pain. Its benefits may be affected by injection protocols, comparative regimens, and evaluation scales. The aim of this study was to determine the effectiveness of dextrose prolotherapy as a long-term treatment for chronic musculoskeletal pain. METHODS: Medline, Embase, Cochrane Central, KoreaMed, and KMbase databases were searched for studies published up to March 2019. We included randomized controlled trials which compared the effect of dextrose prolotherapy with that of other therapies such as exercise, saline, platelet-rich plasma, and steroid injection. The primary outcome was pain score change during daily life. RESULTS: Ten studies involving 750 participants were included in the final analysis. Pain scores from 6 months to 1 year after dextrose prolotherapy were significantly reduced compared to saline injection (standardized mean difference [SMD] -0.44; 95% confidence interval [CI] -0.76 to -0.11, P = 0.008) and exercise (SMD -0.42; 95% CI -0.77 to -0.07, P = 0.02). Prolotherapy yielded results similar to platelet-rich plasma or steroid injection, that it showed no significant difference in pain score. CONCLUSIONS: Dextrose prolotherapy is more effective in the treatment of chronic pain compared to saline injection or exercise. Its effect was comparable to that of platelet-rich plasma or steroid injection. Adequately powered, homogeneous, and longer-term trials are needed to better elucidate the efficacy of prolotherapy.

Novel alternative for submental intubation - A case report.

BACKGROUND: Submental intubation is commonly used during general anesthesia for maxillofacial surgeries as it provides a safe unrestricted surgical access compared to tracheostomy. During submental intubation, soft tissues and blood clots can become lodged in the endotracheal tube. To overcome this problem, we used a laparoscopic trocar. CASE: A 52-year-old male with maxillofacial injury was scheduled to undergo an open reduction and internal fixation. We performed submental intubation using laparoscopic trocar, which created sufficient space for the insertion of the endotracheal tube. Unlike conventional methods, our method did not require any blunt dissection and caused significantly less soft tissue damage and required significantly less time. CONCLUSIONS: Submental intubation with laparoscopic trocar is a one-step method and is quick and easy-to-perform technique with less complications.

Risk factors associated with outcomes of hip fracture surgery in elderly patients.

BACKGROUND: Hip fracture surgery on elderly patients is associated with a high incidence of morbidity and mortality. The aim of this study is to identify the risk factors related to the postoperative mortality and complications following hip fracture surgery on elderly patients. METHODS: In this retrospective study, the medical records of elderly patients (aged 65 years or older) who underwent hip fracture surgery from January 2011 to June 2014 were reviewed. A total of 464 patients were involved. Demographic data of the patients, American Society of Anesthesiologists physical status, preoperative comorbidities, type and duration of anesthesia and type of surgery were collected. Factors related to postoperative mortality and complications; as well as to intensive care unit admission were analyzed using logistic regression. RESULTS: The incidence of postoperative mortality, cardiovascular complications, respiratory complications and intensive care unit (ICU) admission were 1.7, 4.7, 19.6 and 7.1%, respectively. Postoperative mortality was associated with preoperative respiratory comorbidities, postoperative cardiovascular complications (P < 0.05). Postoperative cardiovascular complications were related to frequent intraoperative hypotension (P <0.05). Postoperative respiratory complications were related to age, preoperative renal failure, neurological comorbidities, and bedridden state (P < 0.05). ICU admission was associated with the time from injury to operation, preoperative neurological comorbidities and frequent intraoperative hypotension (P < 0.05). CONCLUSIONS: Adequate treatment of respiratory comorbidities and prevention of cardiovascular complications might be the critical factors in reducing postoperative mortality in elderly patients undergoing hip fracture surgery.

Effective dose of dexmedetomidine to induce adequate sedation in elderly patients under spinal anesthesia.

BACKGROUND: During sedation with dexmedetomidine, a dose adjustment may be needed based on the invasiveness of the procedure, the patient's general condition, and their age. We aim here to determine the effective dose (ED) of dexmedetomidine to induce an adequate depth of sedation in elderly patients undergoing spinal anesthesia. METHODS: In this study, 47 patients aged 65 years or older, American Society of Anesthesiologists physical status I or II, undergoing spinal anesthesia were included. Patients were randomly allocated into group I, II, III, IV or V according to the dexmedetomidine loading dose of 0.1, 0.3, 0.5, 0.7 and 1.0 µg/kg, respectively. After spinal anesthesia, the assigned loading dose of dexmedetomidine was infused intravenously for 10 minutes, after which infusion was maintained at a rate of 0.3 µg/kg/h for the next 10 minutes in all groups. We assessed the depth of sedation with the Ramsay sedation scale every five minutes and measured vital signs and the oxygen saturation. The ED50 and ED95 of dexmedetomidine to obtain adequate sedation (Ramsay sedation score ≥ 3) upon the completion of the loading dose were calculated with logistic regression. RESULTS: The ED50 and ED95 of dexmedetomidine for adequate sedation were 0.29 µg/kg (95% confidence intervals [CI] 0.14-0.44) and 0.86 µg/kg (95% CI 0.52-1.20), respectively. Hypotension was frequent in groups IV, V compared to groups I, II, III (31.6 vs. 3.6%, P = 0.013). CONCLUSIONS: ED95 of dexmedetomidine loading dose for adequate sedation is 0.86 µg/kg. However, dose higher than 0.5 µg/kg can lead to hemodynamic instability.

Silencing the α2 subunit of γ-aminobutyric acid type A receptors in rat dorsal root ganglia reveals its major role in antinociception posttraumatic nerve injury.

BACKGROUND: Neuropathic pain (NPP) is likely the result of repetitive high-frequency bursts of peripheral afferent activity leading to long-lasting changes in synaptic plasticity in the spinal dorsal horn. Drugs that promote γ-aminobutyric acid (GABA) activity in the dorsal horn provide partial relief of neuropathic symptoms. The authors examined how in vivo silencing of the GABA receptor type A (GABAA) α2 gene in dorsal root ganglia (DRG) controls NPP. METHODS: After crush injury to the right sciatic nerve of female rats, the α2 GABAA antisense and mismatch oligodeoxynucleotides or NO-711 (a GABA uptake inhibitor) were applied to the L5 DRG. In vivo behavioral assessment of nociception was conducted before the injury and ensuing 10 days (n = 4 to 10). In vitro quantification of α2 GABAA protein and electrophysiological studies of GABAA currents were performed on acutely dissociated L5 DRG neurons at relevant time points (n = 6 to 14). RESULTS: NPP postcrush injury of a sciatic nerve in adult female rats coincides with significant down-regulation of the α2 subunit expression in the ipsilateral DRG (approximately 30%). Selective down-regulation of α2 expression in DRGs significantly worsens mechanical (2.55 ± 0.75 to 5.16 ± 1.16) and thermal (7.97 ± 0.96 to 5.51 ± 0.75) hypersensitivity in crush-injured animals and causes development of significant mechanical (2.33 ± 0.40 to 5.00 ± 0.33) and thermal (10.80 ± 0.29 to 7.34 ± 0.81) hypersensitivity in sham animals (data shown as mean ± SD). Conversely, up-regulation of endogenous GABA via blockade of its uptake in DRG alleviates NPP. CONCLUSION: The GABAA receptor in the DRG plays an important role in pathophysiology of NPP caused by sciatic nerve injury and represents promising target for novel pain therapies.

General anesthesia versus monitored anesthetic care with dexmedetomidine for closed reduction of nasal bone fracture.

BACKGROUND: Reduction of nasal bone fracture can be performed under general or local anesthesia. The aim of this study was to compare general anesthesia (GA) and monitored anesthetic care (MAC) with dexmedetomidine based on intraoperative vital signs, comfort of patients, surgeons and nurses and the adverse effects after closed reduction of nasal bone fractures. METHODS: Sixty patients with American Society of Anesthesiologists physical status I or II were divided into a GA group (n = 30) or MAC group (n = 30). Standard monitorings were applied. In the GA group, general anesthesia was carried out with propofol-sevoflurane-N2O. In the MAC group, dexmedetomidine and local anesthetics were administered for sedation and analgesia. Intraoperative vital signs, postoperative pain scores by visual analog scale and postoperative nausea and vomiting (PONV) were compared between the groups. RESULTS: Intraoperatively, systolic blood pressures were significantly higher, and heart rates were lower in the MAC group compared to the GA group. There were no differences between the groups in the patient, nurse and surgeon's satisfaction, postoperative pain scores and incidence of PONV. CONCLUSIONS: MAC with dexmedetomidine resulted in comparable satisfaction in the patients, nurses and surgeons compared to general anesthesia. The incidence of postoperative adverse effects and severity of postoperative pain were also similar between the two groups. Therefore, both anesthetic techniques can be used during the reduction of nasal bone fractures based on a patient%s preference and medical condition.

Evaluation of moisture effect on low-level CO2 adsorption by ion-exchanged zeolite.

To enhance the capture of low-level indoor CO2, a commercial zeolite (13X) was modified with alkali and alkaline earth metals using an ion-exchange method. Although the calcium-impregnated sorbent (zeo-Ca) showed the largest adsorption capacity, with a strong binding force for carbon dioxide, its regeneration by heat treatment was very difficult. Moisture in the gas flow caused significant decreases in CO2 adsorption capability as well as in the lifetime of the adsorbents. As for the regeneration gas, the test showed that nitrogen would hinder the CO2 adsorption more significantly than helium gas. Water vapour and nitrogen gas molecules are apt to competitively occupy the available sites of the adsorbent over the CO2 molecules.

Rupture of abdominal aortic aneurysm after spine surgery in the patient with Ehlers-Danlos syndrome -A case report-.

Ehlers-Danlos syndrome (EDS) is a rare inherited disorder of the connective tissue that is characterized by hyperextensible skin, hypermobile joints and abnormalities of the cardiovascular system. A 15-year-old girl with Ehlers-Danlos syndrome underwent thoracolumbar surgery for deformity correction. After surgery, an abdominal aortic rupture occurred, and she complained of abdominal distension had an abdominal circumference of 80 cm. Abdominal computed tomography revealed a pseudoaneurysm and a large hematoma at the retroperitoneum. She died of a massive hemorrhage during subsequent abdominal aortic surgery.