The Effect of Prophylactic Steroids on Shivering in Adults Undergoing Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Shivering is common following anesthesia and surgery. Corticosteroids (steroids) have been tried to reduce the risk of shivering, but the evidence in favor of their use is uncertain. The primary objective of this review was to evaluate the effect of steroids on the risk of perioperative (intra- and postoperative) shivering versus controls (placebo and active controls). Additional objectives were to assess the risk of severity of shivering, patient satisfaction with shivering prophylaxis, quality of recovery (QoR), and the risk of steroid-related adverse effects. METHODS: PubMed, Embase, Cochrane Central Registry of Trials, Google Scholar, and preprint servers were searched from inception until November 30, 2022. Randomized controlled trials (RCTs) published in the English language were retrieved, provided they reported on shivering either as a primary or secondary outcome following steroid prophylaxis in adult patients undergoing surgery under spinal or general anesthesia. RESULTS: A total of 3148 patients from 25 RCTs were included in the final analysis. The steroids used in the studies were either dexamethasone or hydrocortisone. Dexamethasone was administered intravenously or intrathecally, while hydrocortisone was administered intravenously. Prophylactic administration of steroids reduced the risk of overall shivering (risk ratio [RR], 0.65 [95% confidence interval {CI}, 0.52-0.82]; P = .0002; I2 = 77%) as well as the risk of moderate to severe shivering (RR, 0.49 [95% CI, 0.34-0.71]; P = .0002; I2 = 61%) in comparison to controls. Administration of intravenous dexamethasone (RR, 0.67 [95% CI, 0.52-0.87]; P = .002; I2 = 78%) and hydrocortisone (RR, 0.51 [95% CI, 0.32-0.80]; P = .003; I2 = 58%) were effective in shivering prophylaxis. For intrathecal dexamethasone (RR, 0.84 [95% CI, 0.34-2.08]; P = .7; I2 = 56%), the null hypothesis of no subgroup difference was not rejected ( P = .47), preventing definitive conclusions about the efficacy of this route of administration. The prediction intervals for both overall shivering risk (0.24-1.70) and risk of severity of shivering (0.23-1.0) precluded generalization of results in future studies. Meta-regression analysis was used to further explore heterogeneity. Factors like the dose and timing of administration of steroids or the type of anesthesia were not found to be significant. Patient satisfaction and QoR were higher in the dexamethasone groups versus placebo. No increased risk of adverse events of steroids was noted versus placebo or controls. CONCLUSIONS: Prophylactic steroid administration may be beneficial in reducing the risk of perioperative shivering. However, the quality of evidence in favor of steroids is very low. Further well-designed studies are needed for establishing generalization.

"Enhanced recovery after surgery - ERAS in elective craniotomies-a non-randomized controlled trial".

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care bundle aimed at the early recovery of patients. Well accepted in gastric and pelvic surgeries, there is minimal evidence in neurosurgery and neurocritical care barring spinal surgeries. We wished to compare the length of intensive care unit (ICU) or high dependency unit (HDU) stay of patients undergoing elective craniotomy for supratentorial neurosurgery: ERAS protocol versus routine care. The secondary objective was to compare the postoperative pain scores, opioid use, glycemic control, and the duration of postoperative hospital stay between the two groups. METHODS: In this pragmatic non-randomized controlled trial (CTRI/2017/07/015451), consenting adult patients scheduled for elective supratentorial intracranial tumor excision were enrolled prospectively after institutional ethical clearance and consent. Elements-of-care in the ERAS group were- Preoperative -family education, complex-carbohydrate drink, flupiritine; Intraoperative - scalp blocks, limited opioids, rigorous fluid and temperature regulation; Postoperative- flupiritine, early mobilization, removal of catheters, and initiation of feeds. Apart from these, all perioperative protocols and management strategies were similar between groups. The two groups were compared with regards to the length of ICU stay, pain scores in ICU, opioid requirement, glycemic control, and hospital stay duration. The decision for discharge from ICU and hospital, data collection, and analysis was by independent assessors blind to the patient group. RESULTS: Seventy patients were enrolled. Baseline demographics - age, sex, tumor volume, and comorbidities were comparable between the groups. The proportion of patients staying in the ICU for less than 48 h after surgery, the cumulative insulin requirement, and the episodes of VAS scores > 4 in the first 48 h after surgery was significantly less in the ERAS group - 40.6% vs. 65.7%, 0.6 (±2.5) units vs. 3.6 (±8.1) units, and one vs. ten episodes (p = 0.04, 0.001, 0.004 respectively). The total hospital stay was similar in both groups. CONCLUSION: The study demonstrated a significant reduction in the proportion of patients requiring ICU/ HDU stay > 48 h. Better pain and glycemic control in the postoperative period may have contributed to a decreased stay. More extensive randomized studies may be designed to confirm these results. TRIAL REGISTRATION: Clinical Trial Registry of India ( CTRI/2018/04/013247 ), registered retrospectively on April 2018.

Myocardial Protection in Adult Cardiac Surgery With del Nido Versus Blood Cardioplegia: A Systematic Review and Meta-Analysis.

BACKGROUND: Myocardial protection in adult cardiac surgery is commonly achieved with either multidose blood cardioplegia or single-dose del Nido crystalloid cardioplegia. AIM: The aim of this systematic review and meta-analysis was to compare the outcomes of del Nido cardioplegia versus blood cardioplegia in adult cardiac surgery. METHOD: All English-language articles were searched in MEDLINE (PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar up to March 2020, to identify randomised control trials, prospective observational studies, and retrospective analyses (with or without propensity matching) reporting any or all of the primary and secondary endpoints. The primary endpoint was all-cause mortality. Secondary endpoints included cardiopulmonary bypass (CPB) and aortic cross-clamp (AoX) time; cardioplegia volume; need for defibrillation after AoX release; intraoperative glucose; postoperative myocardial enzyme release; postoperative left ventricular ejection fraction (LVEF); incidence of postoperative acute kidney injury (AKI), atrial fibrillation (AF), stroke, and low cardiac output syndrome (LCOS); postoperative blood transfusion; duration of mechanical ventilation; and length of intensive care unit (ICU) and hospital stay. RESULTS: Twenty-nine (29) studies were included. There was no difference in the primary outcome of mortality between the two groups (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.82-1.72 [p=0.37]). del Nido cardioplegia was associated with significantly shorter CPB (mean difference [MD], -7.42 minutes; 95% CI, -12.53 to -2.31 [p=0.004]) and AoX times (MD, -6.39 minutes; 95% CI, -10.30 to -2.48 [p=0.001]), and lower cardioplegia volumes. Significantly fewer patients required defibrillation after AoX release in the del Nido group. Intraoperative glucose homeostasis was better preserved in the del Nido group. Postoperative cardiac troponin T release and the number of patients needing transfusions were less in the del Nido group. No differences were seen in postoperative LVEF, or in the incidence of AKI, stroke, AF, and LCOS. Duration of mechanical ventilation, and length of ICU and hospital stay were similar. CONCLUSIONS: Although this meta-analysis failed to find any mortality benefits with del Nido cardioplegia, significant benefits were seen in a number of intraoperative and postoperative variables. del Nido cardioplegia is a safe and favourable alternative to blood cardioplegia in adult cardiac surgery.

Comparison of suction above cuff and standard endotracheal tubes in neurological patients for the incidence of ventilator-associated pneumonia and in-hospital outcome: A randomized controlled pilot study.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common complication with endotracheal intubation. The occurrence of VAP results in significant mortality and morbidity. Earlier studies have shown reduction in the incidence of VAP with subglottic secretion drainage. The incidence of VAP in neurologically injured patients is higher and can impact the neurological outcome. This study aimed to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurologically ill patients and its impact on clinical outcome. METHODS: Fifty-four patients with neurological illnesses aged ≥18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. All the VAP preventive measures were similar between two groups except for the difference in type of tube. RESULTS: The data of 50 patients were analyzed. The incidence of clinical VAP was 20% in SETT group and 12% in SACETT group; (P = 0.70). The incidence of microbiological VAP was higher in the SETT group (52%) as compared to SACETT group (44%) but not statistically significant; (P = 0.78). There was no difference between the two groups for measured outcomes such as duration of intubation, mechanical ventilation, and Intensive Care Unit stay. CONCLUSIONS: In this pilot study in neurological population, a there was no significant difference in incidence of clinical and microbiological VAP was seen between SETT and SACETT, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation.

A comparative study of dexmedetomidine and propofol as sole sedative agents for patients with aneurysmal subarachnoid hemorrhage undergoing diagnostic cerebral angiography.

PURPOSE: Subarachnoid hemorrhage is an acute neurological emergency requiring urgent confirmation of the diagnosis for planning definitive management. Due to altered consciousness, most patients require sedation for conducting this procedure smoothly. Currently, it is unclear if any one particular sedative drug has a favorable profile in patients undergoing cerebral angiography. The aim of this study was to compare the traditionally used sedative drug propofol with a newer alternative, dexmedetomidine, in patients with subarachnoid hemorrhage undergoing cerebral angiography. METHODS: Sixty adult patients with good grade subarachnoid hemorrhage undergoing diagnostic cerebral angiography were prospectively randomized to receive either propofol (n = 30) or dexmedetomidine (n = 30) following ethics committee approval and informed consent. RESULTS: Compared to dexmadetomidine, propofol was associated with an earlier time for onset of sedation (2.3 ± 1.9 min vs. 15.4 ± 5.7 min; P < 0.001), but with an increased number of adverse respiratory events (11/30 vs 1/30; P = 0.003) and movement during the procedure (5/30 vs. 0/30; P = 0.05), necessitating additional supplementation of sedation (13/30 vs. 7/30; P = 0.17) and repetition of the imaging sequences. The total procedure time and time for recovery were similar for the propofol and dexmedetomidine groups, while the heart rate was lower in patients in the dexmedetomidine group. CONCLUSION: Dexmedetomidine appears to be superior to propofol as a sole sedative agent for sedation during cerebral angiography in patients with subarachnoid hemorrhage.

Anesthetic management of patients with Joubert syndrome: a retrospective analysis of a single-institutional case series.

OBJECTIVE: To analyze the anesthetic techniques used for sedation during magnetic resonance imaging (MRI) study of patients with Joubert syndrome (JS) and assess the safety and efficacy of these anesthetic regimens in these children. BACKGROUND: Joubert syndrome is a rare neurological disorder with significant anesthetic implications. This study describes the anesthetic management of children with JS undergoing MRI study with different anesthetic agents and implications of various anesthetic techniques in these patients. MATERIALS AND METHODS: The records of ten patients with JS undergoing MRI study with different anesthetic techniques were retrospectively reviewed over the last 5 years. RESULTS: The patients were aged between 6 months and 21 years. The most commonly used sedation technique involved use of alpha-2 agonists, and this technique had least complications such as apnea and patient movement during imaging. None of the patients had postanesthetic respiratory problems, although one patient receiving propofol had apnea and desaturation on induction requiring airway intervention. CONCLUSION: Alpha-2 agonist based anesthetic technique appears to be most suitable for sedation during MRI study in patients with JS with respect to adverse events and outcome.

Concurrent replacement of four major joints in a woman with advanced rheumatoid arthritis.

We report a case of a woman in her mid-40s with advanced rheumatoid arthritis (RA), with bilateral hip and knee joint involvement, who underwent a one-stage quadruple joint arthroplasty during a single session of anaesthesia. Chronic RA had severely incapacitated her, necessitating this uncommon surgical intervention. The surgical approach involved sequential bilateral total hip and knee replacements, which were completed within 180 min with a cumulative blood loss of 950 mL. The patient showed significant improvement with rapid mobilisation and regained joint function postoperatively. At 8 months post-surgery, the patient resumed her daily activities, showcasing the potential benefits and positive outcomes of quadruple joint arthroplasty in selected RA patients. This case, only the second documented globally, highlights the complexities and possibilities surrounding a single-stage quadruple joint arthroplasty in advanced RA.

Anesthetic challenges in the management of Larsen syndrome: A rare congenital anomaly.

Larsen syndrome is a rare inherited disease associated with dislocations of multiple joints, typical syndromic facies, and multiple spine abnormalities. They often required multiple corrective orthopedic surgeries to regain their functional ability, thus needing repeated anesthesia. Apart from skeletal deformities, they have predicted difficult airway and need extreme care during intubation and positing of the patient. Abnormal posturing due to spinal deformity and poor pulmonary reserve due to kyphoscoliosis creates an extremely challenging situation for the anesthetist to manage the case during the perioperative period. Here we are describing the perioperative anesthetic management of a patient with Larsen syndrome.

Oral Midodrine as an Adjunct in Rapid Weaning of Intravenous Vasopressor Support in Spinal Cord Injury.

Background Majority of acute cervical spinal cord injury end up requiring long-term stay in intensive care unit (ICU). During the initial few days after spinal cord injury, most patients are hemodynamically unstable requiring intravenous vasopressors. However, many studies have noted that long-term intravenous vasopressors remain the main reason for prolongation of ICU stay. In this series, we report the effect of using oral midodrine in reducing the amount and duration of intravenous vasopressors in patients with acute cervical spinal cord injury. Materials and Methods Five adult patients with cervical spinal cord injury after initial evaluation and surgical stabilization are assessed for the need for intravenous vasopressors. If patients continue to need intravenous vasopressors for more than 24 hours, they were started on oral midodrine. Its effect on weaning of intravenous vasopressors was assessed. Results Patients with systemic and intracranial injury were excluded from the study. Midodrine helped in weaning of intravenous vasopressors in the first 24 to 48 hours and helped in complete weaning of intravenous vasopressors. The rate of reduction was between 0.5 and 2.0 µg/min. Conclusion Oral midodrine does have an effect in reduction of intravenous vasopressors for patients needing prolonged support after cervical spine injury. The real extent of this effect needs to be studied with collaboration of multiple centers dealing with spinal injuries. The approach seems to be a viable alternative to rapidly wean intravenous vasopressors and reduce duration of ICU stay.

The effect of perioperative dexmedetomidine on postoperative bowel function recovery in adult patients receiving general anesthesia.

BACKGROUND: Dexmedetomidine has opioid sparing actions but its effect on bowel recovery is controversial. Primary aim of this review was to evaluate the effect of perioperative dexmedetomidine on postoperative bowel recovery. Secondary aim was to evaluate the effect of dexmedetomidine on hospital discharge. EVIDENCE ACQUISITION: Randomized controlled trials in English language reporting any or all of the following parameters of bowel recovery; time to first bowel sounds, first flatus, first feces, or time to oral diet were included. EVIDENCE SYNTHESIS: Twelve hundred and thirty-five patients from 13 studies were analyzed. There were insufficient studies evaluating bowel sounds. Perioperative dexmedetomidine usage significantly reduced the time to first flatus [MD -5.61 h (95% CI: -8.61 to -2.60); P=0.0003; I2=95%], first feces [MD -12.70 h (95% CI: -19.11 to -6.29); P=0.0001; I2=76%] and the composite outcome of bowel recovery (flatus, feces, oral diet) [MD -7.44 h (95% CI: -10.31 to -4.57); P<0.00001; I2=96%]. No difference was seen in the time to oral diet [MD -6.29 h (95% CI: -13.48 to 0.91); P=0.09; I2=88%] or hospital discharge [MD -0.47 days (95% CI: -1.27 to 0.33); P=0.25; I2=86%]. CONCLUSIONS: Perioperative dexmedetomidine usage significantly shortens the time to first flatus, feces and composite bowel recovery but does not result in a shorter time to oral diet or earlier hospital discharge in adult patients receiving general anesthesia. Strength of evidence is however very low for the effect of dexmedetomidine on bowel recovery.

Postoperative Pain Relief Following Lumbar Erector Spinae Plane Block in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Controlled Trial.

OBJECTIVE: To test whether lumbar Erector Spinae Plane Block (ESPB) provides superior analgesia compared to placebo in patients undergoing Percutaneous Nephrolithotomy (PCNL), using reduction in postoperative opioid consumption, delay in rescue analgesia demand and reduction of pain scores as outcome measures. METHODS: 34 adult (18-60 years) ASA I and II patients undergoing unilateral PCNL were randomized into two groups (Bupivacaine and Saline) - both receiving ipsilateral ESPB at L1 vertebral level with either 20 ml 0.25% Inj. Bupivacaine or 20 ml normal saline respectively, at the start of the surgery under general anesthesia. The primary outcome measure was total 24-hour rescue opioid analgesic requirement, while time to first demand of rescue analgesic and pain scores at 2, 12 and 24 hours postoperatively were secondary outcomes. RESULTS: The 24-hour requirement of rescue analgesic Tramadol was significantly lower (53.5 ± 29.6 vs 121.2 ± 51.1 mg) [mean ± SD] (P = .001) and time to first demand of rescue analgesia was more (14.1 ± 8.4 vs 6.0 ± 5.6 hours) [mean ± SD] (P = .001) in the Bupivacaine group as compared to placebo. The pain scores were significantly lower in the Bupivacaine group at 12-hour post-operatively [4 (3,4) vs 5.5 (5,6)] [median (IQR)] (P = .001), while the stone-load, surgical duration and intraoperative opioid use were comparable between the two groups and no block-related complications were noted in any patient. CONCLUSION: Post-PCNL, ipsilateral lumbar ESPB reduced 24-hour opioid consumption and delayed time to demand for rescue analgesia as compared to placebo.

Subanesthetic intravenous ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infra-umbilical surgeries: a non-inferiority randomized, single-blind controlled trial.

BACKGROUND: Subanesthetic intravenous (IV) ketamine acts as an analgesic and has opioid-sparing effects, particularly for acute postoperative pain; however, its effectiveness in children is understudied. The primary aim of this study was to evaluate the non-inferiority of subanesthetic IV ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infraumbilical surgery. METHODS: Children aged < 6 years were enrolled in this single-blind study and randomized to receive either subanesthetic IV ketamine (0.3 mg/kg) or caudal 0.125% bupivacaine (1 ml/kg) along with general anesthesia. Postoperative pain was assessed using the FLACC scale at 30 minutes and 1, 2, 3, and 6 h post-operation. Intra- and postoperative opioid consumption, time to extubation, postoperative vomiting, agitation, sedation, and inflammatory markers were also assessed. RESULTS: Altogether, 141 children completed the study (ketamine group: n = 71, caudal group: n = 70) The cumulative proportion of children without significant postoperative pain (FLACC score < 4) in the first 6 h post-surgery was 45.1% in the ketamine group vs. 72.9% in the caudal group (P < 0.001). More children in the ketamine group required an additional dose of intraoperative fentanyl (33.8% vs. 5.7%, P < 0.001) and postoperative tramadol (54.9% vs. 27.1%, P < 0.001). However, postoperative agitation, sedation, and other secondary outcomes were similar between the groups. CONCLUSIONS: Subanesthetic ketamine is inferior to caudal bupivacaine for postoperative analgesia in children aged < 6 years undergoing infra-umbilical surgeries; however, other postoperative outcomes are similar.

Effect of preoperative dexmedetomidine nebulization on the hemodynamic response to laryngoscopy and intubation: a randomized control trial.

BACKGROUND: Dexmedetomidine, an alpha-2 agonist, has been used for attenuation of hemodynamic response to laryngoscopy but not through the nebulized route. We evaluated the effects of preoperative dexmedetomidine nebulization on the hemodynamic response to laryngoscopy and intubation and examined the intraoperative anesthetic-analgesic requirements and recovery outcomes. METHODS: Overall, 120 American Society of Anesthesiologists I & II adult patients (of either gender) undergoing elective surgeries and requiring tracheal intubation, were randomized to receive nebulized dexmedetomidine (1 µg/kg in 3-4 ml of 0.9% saline) or 0.9% saline (3-4 ml), 30 min before anesthesia induction. Heart rate (HR) and non-invasive systolic blood pressure (SBP) were monitored for 10 min following laryngoscopy. RESULTS: After laryngoscopy, linear mixed effect modelling showed significantly lower trend of increase in HR in the dexmedetomidine group versus saline (P = 0.012); however, there was no difference in the SBP changes between the two groups (P = 0.904). Induction dose of propofol (P < 0.001), intraoperative fentanyl consumption (P = 0.007), and isoflurane requirements (P = 0.013) were significantly lower in the dexmedetomidine group. There was no difference in the 2 h incidence of postoperative nausea and vomiting (PONV) (P = 0.612) or sore-throat (P = 0.741). CONCLUSIONS: Nebulized dexmedetomidine at 1 µg/kg attenuated the increase in HR but not SBP following laryngoscopy and reduced the intraoperative anesthetic and analgesic consumption. There was no effect on early PONV, sore-throat, or increase in incidence of adverse effects. Nebulized dexmedetomidine may represent a favorable alternative to the intravenous route in short duration surgeries.

Nebulised fentanyl for post-operative pain relief, a prospective double-blind controlled randomised clinical trial.

BACKGROUND AND AIM: Intravenous (IV) route for fentanyl administration is the gold standard for post-operative pain relief, but complications such as respiratory depression, bradycardia and hypotension have limited this route. The aim of this randomised controlled trial was to compare the efficacy of nebulised fentanyl with IV fentanyl for post-operative pain relief after lower abdominal surgery. METHODS: In the post-operative care unit, at the time of first onset of pain (visual analogue scale- VAS score > 4) patients were randomised into three groups and fentanyl was administered either IV 2 µg/kg or by nebulisation of solution containing 3 or 4 µg/kg fentanyl over 8 min in 90 patients divided into three groups of 30 each. Observation were made for pain relief by visual analogue scale score 0-10. Adverse effects such as respiratory depression, bradycardia and hypotension were also recoded. Statistical analysis was performed using Medcalc software version 12, 2012. (MedCalc Software, Ostend, Belgium). RESULTS: In the nebulisation group, it was observed that the analgesic efficacy of fentanyl was dose dependent with a delayed onset of analgesia (10 min vs. 5 min). Nebulisation with 4 µg/kg fentanyl produced analgesia at par to 2 µg/kg IV fentanyl with prolonged duration (90 min vs. 30 min) and with significantly less adverse effects. CONCLUSIONS: This study shows that nebulisation with 4 µg/kg fentanyl may be used as an alternative to IV 2 µg/kg fentanyl for adequate post-operative pain relief.