Association between intraoperative remifentanil use and postoperative hyperalgesia in adolescent idiopathic scoliosis surgery: a retrospective study.

BACKGROUND: The liberal use of remifentanil in spine surgery has been associated with an increased incidence of postoperative hyperalgesia. Nevertheless, controversies remain as the existing evidence is inconclusive to determine the relationship between remifentanil use and the development of opioid-induced hyperalgesia. We hypothesized that intraoperative infusion of higher dose remifentanil during scoliosis surgery is associated with postoperative hyperalgesia, manifesting clinically as greater postoperative morphine consumption and pain scores. METHODS: Ninety-seven patients with adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion surgery at a single tertiary institution from March 2019 until June 2020 were enrolled in this retrospective study. Anesthesia was maintained using a target-controlled infusion of remifentanil combined with volatile anesthetic desflurane in 92 patients, while five patients received it as part of total intravenous anesthesia. Intravenous ketamine, paracetamol, and fentanyl were administered as multimodal analgesia. All patients received patient-controlled analgesia (PCA) morphine postoperatively. Pain scores at rest and on movement, assessed using the numerical rating scale, and the cumulative PCA morphine consumption were collected at a six-hourly interval for up to 48 h. According to the median intraoperative remifentanil dose usage of 0.215 µg/kg/min, patients were divided into two groups: low dose and high dose group. RESULTS: There were no significant differences in the pain score and cumulative PCA morphine consumption between the low and high dose remifentanil group. The mean duration of remifentanil infusion was 134.9 ± 22.0 and 123.4 ± 23.7 min, respectively. CONCLUSION: Intraoperative use of remifentanil as an adjuvant in AIS patients undergoing posterior spinal fusion surgery was not associated with postoperative hyperalgesia.

Selective media and real-time PCR improves diagnosis of melioidosis in community-acquired pneumonia in a low-incidence setting in Kuala Lumpur, Malaysia.

Introduction. Burkholderia pseudomallei (melioidosis) is an important cause of community-acquired pneumonia (CAP) in the tropics. Selective medium is recommended for laboratory diagnosis with non-sterile respiratory samples, while PCR is not routinely used due to variable reported performance. The effectiveness of these diagnostic modalities varies by site.Aim. To compare selective media and real-time PCR (qPCR) with routine media in detecting B. pseudomallei in CAP respiratory samples in a low-incidence setting in Kuala Lumpur, Malaysia.Methodology. Respiratory samples were routinely cultured on blood, chocolate and MacConkey agar (RESP-ROUTINE), and compared to culture on selective Ashdown medium (RESP-SELECTIVE) and qPCR. The gold standard was routine culture of B. pseudomallei from any site (ALL-ROUTINE).Results. B. pseudomallei was detected in 8/204 (3.9 %) samples. Overall sensitivity rates differed (P=0.03) for qPCR (100%), RESP-SELECTIVE (87.5%) and RESP-ROUTINE (50%). There was a trend towards lower median days to positive culture for RESP-SELECTIVE (1 day) compared to RESP-ROUTINE (2 days, P=0.08) and ALL-ROUTINE (2 days, P=0.06). Reagent costs for each additional detection were USD59 for RESP-SELECTIVE and USD354 for PCR.Conclusions. In a low-incidence setting, selective culture of respiratory samples on Ashdown was more sensitive and allowed quicker identification than routine media, at reasonable cost. Blood cultures are critical, confirming four cases missed by routine respiratory culture. Selective medium is useful in early pneumonia (pre-sepsis) and resource-limited settings where blood cultures are infrequently done. Real-time PCR is costly, but highly sensitive and useful for high-risk patients with diabetes, cancer or immunosuppressants, or requiring ventilation or intensive care.

Comparison between effect of desflurane/remifentanil and propofol/remifentanil anesthesia on somatosensory evoked potential monitoring during scoliosis surgery-A randomized controlled trial.

BACKGROUND: Drugs used in anesthesia can affect somatosensory evoked potential (SSEP) monitoring, which is used routinely for intraoperative monitoring of spinal cord integrity during spinal surgery. OBJECTIVE: The objective of this study was to determine whether combined total intravenous anesthesia (TIVA) technique with propofol/remifentanil is associated with less SSEP suppression when compared to combined volatile agent desflurane/remifentanil anesthesia during corrective scoliosis surgery at a comparable depth of anesthesia. DESIGN: It is a randomized controlled trial. SETTING: The study was conducted at the Single tertiary University Hospital during October 2014 to June 2015. PATIENTS: Patients who required SSEP and had no neurological deficits, and were of American Society of Anesthesiologist I and II physical status, were included. Patients who had sensory or motor deficits preoperatively and significant cardiovascular and respiratory disease were excluded. A total of 72 patients were screened, and 67 patients were randomized and allocated to two groups: 34 in desflurane/remifentanil group and 33 in TIVA group. Four patients from desflurane/remifentanil group and three from TIVA group were withdrawn due to decrease in SSEP amplitude to <0.3 µV after induction of anesthesia. Thirty patients from each group were analyzed. INTERVENTIONS: Sixty-seven patients were randomized to receive TIVA or desflurane/remifentanil anesthesia. MAIN OUTCOME MEASURES: The measurements taken were the amplitude and latency of SSEP monitoring at five different time points during surgery: before and after the induction of anesthesia, at skin incision, at pedicle screw insertion, and at rod insertion. RESULTS: Both anesthesia techniques, TIVA and desflurane/remifentanil, resulted in decreased amplitude and increased latencies of both cervical and cortical peaks. The desflurane/remifentanil group had a significantly greater reduction in the amplitude ( p = 0.004) and an increase in latency ( p = 0.002) of P40 compared with the TIVA group. However, there were no differences in both amplitude ( p = 0.214) and latency ( p = 0.16) in cervical SSEP between the two groups. CONCLUSIONS: Compared with TIVA technique, desflurane/remifentanil anesthesia caused more suppression in cortical SSEP, but not in cervical SSEP, at a comparable depth of anesthesia.

Effect of intraoperative autologous transfusion techniques on perioperative hemoglobin level in idiopathic scoliosis patients undergoing posterior spinal fusion: A prospective randomized trial.

BACKGROUND: Massive blood loss during posterior spinal fusion for adolescent idiopathic scoliosis remains a significant risk for patients. There is no consensus on the benefit of acute normovolemic hemodilution (ANH) or intraoperative cell salvage (ICS) in scoliosis surgery. METHODS: Patients were randomized to one of two groups. Group A received ANH and ICS during operation, while group B received only ICS. Patients' age, sex, height, weight, body blood volume, number of fusion level, Cobb angle, number of screws, duration of surgery, and skin incision length were recorded. Hemoglobin and hematocrit levels were obtained preoperatively and postoperatively (0 h and 24 h). RESULTS: There were 22 patients in each group. There was no significant difference in total blood loss. The perioperative decrease in hemoglobin levels between preoperation and postoperation 24 h (group A 2.79 ± 1.15 and group B 2.76 ± 1.00) showed no significant difference ( p = 0.93). Group A observed a larger decrease in hemoglobin levels at postoperative 0 h relative to preoperative level (2.57 ± 0.82 g/dl), followed by a smaller decrease within the next 24 h (0.22 ± 1.33 g/dl). Group B showed a continued drop in hemoglobin levels of similar magnitude at postoperation 0 h (1.60 ± 0.67 g/dl) and within the next 24 h (1.16 ± 0.78 g/dl). One patient from group B received 1 unit of allogenic blood transfusion ( p = 0.33). CONCLUSIONS: The addition of ANH to ICS in posterior spinal fusion surgery for AIS resulted in a similar decrease in hemoglobin levels between preoperative values and at 24 h postoperatively.

Feasibility and Outcome of an Accelerated Recovery Protocol in Asian Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: The aim of this study was to determine the feasibility of an accelerated recovery protocol for Asian adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF). SUMMARY OF BACKGROUND DATA: There has been successful implementation of an accelerated recovery protocol for AIS patients undergoing PSF in the western population. No similar studies have been reported in the Asian population. METHODS: Seventy-four AIS (65 F, 9 M) patients scheduled for PSF surgery were recruited. The accelerated protocol encompasses preoperative regime, preoperative day of surgery counseling, intraoperative strategies, an accelerated postoperative rehabilitation and pain management regime. All patients were operated using a dual attending surgeon strategy. Outcome measures included pain scores at five time intervals, length of stay, and detailed recovery milestones. Any complications or readmissions during the first 4 months postoperative period were recorded. RESULTS: Mean duration of operation was 2.2 ±â€Š0.3 hours with a mean blood loss of 824.3 ±â€Š418.2 mL. No patients received allogenic blood transfusion. The mean length of stay was 3.6 ±â€Š0.6 days. Surgical wound pain score was 6.4 ±â€Š2.1 at 12 hours, which reduced to 5.0 ±â€Š2.0 at 60 hours. Abdominal pain peaked at 36 hours with pain scores 2.4 ±â€Š2.9. First liquid intake was at 5.2 ±â€Š7.5 hours, urinary catheter removal at 18.7 ±â€Š4.8 hours, sitting up at 20.6 ±â€Š9.1 hours, ambulation at 27.2 ±â€Š0.5 hours, consumption of solid food at 32.2 ±â€Š0.5 hours, first flatus at 39.0 ±â€Š0.7 hours, and first bowel movement at 122.1 ±â€Š2.0 hours. The complication rate was 1.4% due to superficial wound infection with one patient failed to comply with the accelerated protocol. CONCLUSION: An accelerated recovery protocol following PSF for AIS is feasible without increasing the complication or readmission rates. The total length of stay was 3.6 days and this is comparable with the outcome in western population. LEVEL OF EVIDENCE: 4.

Anesthetic considerations in scoliosis patient with dopa-responsive dystonia or Segawa's syndrome.

Segawa's syndrome or dopa-responsive dystonia is a rare hereditary disorder characterized by progressive dystonia of childhood onset, diurnal fluctuation of symptoms and complete or near complete alleviation of symptoms with administration of low-dose oral levodopa. From our literature search in PubMed, we found only three related publications: two on anesthesia for cesarean section and one on anesthesia for electroconvulsive therapy. We report our experience in providing anesthesia for corrective scoliosis surgery in two biological sisters with Segawa's syndrome. A review of the literature is also included.

Assessment of Intraoperative Blood Loss at Different Surgical Stages During Posterior Spinal Fusion Surgery in the Treatment of Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective clinical study. OBJECTIVE: To analyze the amount of blood loss at different stages of Posterior Instrumented Spinal Fusion (PSF) surgery in adolescent idiopathic scoliosis (AIS) patients. SUMMARY OF BACKGROUND DATA: Knowing the pattern of blood loss at different surgical stages may enable the surgical team to formulate a management strategy to reduce intraoperative blood loss. METHODS: One hundred AIS patients who underwent PSF from January 2013 to December 2014 were recruited. The operation was divided into six stages; stage 1-exposure, stage 2-screw insertion, stage 3-release, stage 4-correction, stage 5-corticotomies and bone grafting, and stage 6-closure. The duration and blood loss at each stage was documented. The following values were calculated: total blood loss, blood loss per estimated blood volume, blood loss per minute, blood loss per vertebral level fused, and blood loss per minute per vertebral level fused. RESULTS: There were 89 females and 11 males. The mean age was 17.0 ±â€Š5.8 years old. Majority (50.0%) were Lenke 1 curve type. The mean preoperative major Cobb angle was 64.9 ±â€Š15.0°. The mean number of levels fused was 9.5 ±â€Š2.3 levels. The mean operating time was 188.5 ±â€Š53.4 minutes with a mean total blood loss 951.0 ±â€Š454.0 mLs. The highest mean blood loss occurred at stage 2 (301.0 ±â€Š196.7 mL), followed by stage 4 (226.8 ±â€Š171.2 mL) and stage 5 (161.5 ±â€Š146.6 mL). The highest mean blood loss per minute was at stage 5 (17.1 ±â€Š18.3 mL/min), followed by stage 3 (12.0 ±â€Š10.8 mL/min). The highest mean blood loss per vertebral levels fused was at stage 2 (31.0 ±â€Š17.7 mL/level), followed by stage 4 (23.9 ±â€Š18.1 mL/level) and stage 5 (16.6 ±â€Š13.3 mL/level). CONCLUSION: All stages were significant contributors to the total blood loss except exposure (stage 1) and closure (stage 6). Blood loss per minute and blood loss per minute per level was highest during corticotomies (stage 5), followed by release (stage 3). However, the largest amount of total blood loss occurred during screw insertion (stage 2). LEVEL OF EVIDENCE: 2.

Posterior parasagittal in-plane ultrasound-guided infraclavicular brachial plexus block-a case series.

BACKGROUND: The brachial plexus at the infraclavicular level runs deeper compared to its course proximally, giving rise to impaired needle visualisation due to the steep angle of needle insertion with the current ultrasound-guided approach. A new posterior parasagittal in-plane ultrasound-guided infraclavicular approach was introduced to improve needle visibility. However no further follow up study was done. METHODS: We performed a case series and a cadaveric dissection to assess its feasibility in a single centre, University of Malaya Medical Centre, Kuala Lumpur, Malaysia from November 2012 to October 2013. After obtaining approval from the Medical Ethics Committee, University Malaya Medical Centre, 18 patients undergoing upper limb surgery were prospectively recruited. A cadaveric dissection was also performed. The endpoints of this study were the success rate, performance time, total anaesthesia-related time, quality of anaesthesia and any incidence of complications. RESULTS: All patients had 100 % success rate. The imaging time, needling time and performance time were comparable with previously published study. There were no adverse events encountered in this study. The cadaveric dissection revealed a complete spread of methylene blue dye over the brachial plexus. CONCLUSION: This study demonstrated that the posterior parasagittal in-plane approach is a feasible and reliable technique with high success rate. Future studies shall compare this technique with the conventional lateral parasagittal in-plane approach. TRIAL REGISTRATION: ClinicalTrials.gov NCT02312453 . Registered on 8 December 2014.

Dexmedetomidine and ketamine sedation for dental extraction in children with cyanotic heart disease.

Treating children with cyanotic congenital heart disease poses many challenges to anesthesiologists because of the multiple problems associated with the condition. The anesthetic technique and drugs used perioperatively can affect a patient's physiologic status during surgery. The adherence to certain hemodynamic objectives and the avoidance of factors that could worsen the abnormal cardiopulmonary physiology cannot be overemphasized. In the present case series, we describe the use of a dexmedetomidine-ketamine combination for dental extraction in spontaneously breathing children with cyanotic congenital heart disease. The anesthetic concerns regarding airway management, the pharmacologic effects of drugs, and maintenance of adequate hemodynamic, blood gases, and acid-base status are discussed.