Anaesthesia for mechanical thrombectomy: a narrative review.

Stroke is a leading cause of death and disability, and is associated with a huge societal and economic burden. Interventions for the immediate treatment of ischaemic stroke due to large vessel occlusion are dependent on recanalisation of the occluded vessel. Trials have provided evidence supporting the efficacy of mechanical thrombectomy in ischaemic stroke due to large vessel occlusion. This has resulted in changes in management and organisation of stroke care worldwide. Major determinants of effectiveness of thrombectomy include: time between stroke onset and reperfusion; location of occlusion and local collateral perfusion; adequacy of reperfusion; patient age; and stroke severity. The role of anaesthetic technique on outcome remains controversial with published research showing conflicting results. As a result, choice of conscious sedation or general anaesthesia for mechanical thrombectomy is often dependent on individual operator choice or institutional preference. More recent randomised controlled trials have suggested that protocol-driven general anaesthesia is no worse than conscious sedation and may even be associated with better outcomes. These and other studies have highlighted the importance of optimal blood pressure management as a major determinant of patient outcome. Anaesthetic management should be tailored to the individual patient and circumstances. Acute ischaemic stroke is a neurological emergency; clinicians should focus on minimising door-to-groin puncture time and the provision of high-quality periprocedural care with a particular emphasis on the maintenance of an adequate blood pressure.

Acupuntura en la recuperación de la anestesia general en pacientes intervenidas quirúrgicamente de nódulo de mama / Acupuncture in the recovery from general anesthesia in patients who underwent a breast nodule surgery

RESUMEN Introducción: en el período de recuperación de la anestesia general se deben metabolizar los medicamentos empleados y restablecer las alteraciones fisiológicas. La acupuntura es un método de tratamiento que ha sido estudiado en el período perioperatorio con diferentes fines; sin embargo, es menos conocido su efecto en la recuperación de la anestesia general. Objetivo: describir el efecto de la estimulación con Acupuntura en la recuperación de la anestesia general balanceada en pacientes intervenidas quirúrgicamente por nódulo de mama. Materiales y métodos: se realizó un estudio observacional prospectivo, en 60 pacientes intervenidas quirúrgicamente de nódulo de mama con anestesia general endotraqueal balanceada, de enero de 2014 a enero de 2016, en el Hospital Provincial Docente José Ramón López Tabrane, de Matanzas. Se conformaron dos grupos: grupo I, al que al finalizar la cirugía se le colocaron agujas de acupuntura en los puntos R1, Du26 y P9; y grupo II, al que no se le realizó acupuntura. El efecto de la acupuntura en la recuperación anestésica se midió a través de la Escala de Aldrete. Resultados: la edad de mayor incidencia fue de 40 a 49 años. El estado físico de las pacientes, según la Sociedad Americana de Anestesiología, es I. Prevaleció un tiempo anestésico de 61 a 90 minutos. Más del 75 % de las féminas tuvieron un tiempo de recuperación anestésica entre 31 y 60 minutos. Se presentaron dos complicaciones leves atribuibles a la acupuntura. Conclusiones: la aplicación de la acupuntura acortó el tiempo de recuperación anestésica en las pacientes estudiadas (AU).

ABSTRACT Introduction: in the recovery period from general anesthesia the used drugs should be metabolized and the physiological alterations restored. Acupuncture is a treatment method that has been studied in the perioperative period with different aims; nevertheless its effect on the recovery from general anesthesia is less well known. Objective: to describe the acupuncture stimulation effect on the recovery from general balanced anesthesia in patients who underwent a breast nodule surgery. Materials and methods: a prospective, observational study was performed in 60 patients who underwent a surgery of breast nodule with balanced endotracheal general anesthesia, from January 2014 to January 2016, at the Provincial Teaching Hospital "Jose Ramon Lopez Tabrane" of Matanzas. Two groups were formed: group I included patients to whom acupuncture needles were placed in R1, Du 26 and P9 acupoints after surgery, and Group II patients to whom acupuncture was not performed. The acupuncture effect on anesthetic recovery was assessed using the Aldrete Scale. Two groups were formed: group I, whose members at the end of the surgery were placed acupuncture needles to in the points R1, Du26 and P9; and group II, whose members did not receive acupuncture. The effect of acupuncture on anesthetic recovery was measured through the Aldrete Scale. Results: the highest incidence age was 40 to 49 years. The physical condition of the patients, according to the American Society of Anesthesiology, was I. An anesthetic time of 61 to 90 minutes prevailed. More than 75% of the women had an anesthetic recovery time between 31 and 60 minutes. There were two minor complications attributable to acupuncture. Conclusions: acupuncture application shortened the anesthetic recovery time in the studied patients (AU).

Prospective Evaluation of a Standardized Opioid Reduction Protocol after Anorectal Surgery.

BACKGROUND: Surgery for anorectal disease is thought to cause significant postoperative pain. Our previous work demonstrated that most opioids prescribed after anorectal surgery are not used. We aimed to evaluate a standardized protocol for pain control after anorectal surgery. METHODS: We prospectively evaluated a standardized opioid reduction protocol over a 13-mo period for all patients undergoing elective anorectal surgery at our institution. Protocol components include preoperative query, procedural local-anesthetic blocks, first-line nonopioid analgesic use ± opioid prescription of five pills, and standardized postoperative instructions. Patients completed questionnaires at postoperative follow-up. Patients with history of opioid abuse or use within 30 d of operation, loss to follow-up, or surgical complications were excluded. Primary outcome was quality of pain control on a five-point scale. Secondary outcomes included use of nonopioid analgesics, opioids used, and need for refill. RESULTS: A total of 55 patients were included. Mean age was 47 ± 17 y with 23 women (42%). Anorectal abscess/fistula procedures were the most common (69%) followed by pilonidal procedures (11%) and hemorrhoidectomy (7%). Most had general anesthesia (60%) with the remainder local anesthesia ± sedation. Fifty-four (98%) had procedural local-anesthetic blocks. Twenty-six patients (47%) were prescribed opioids with a median of five pills. Forty-seven patients (85%) reported the use of nonopioid analgesics. Forty-six patients (84%) reported excellent to very good pain control. About 220 opioid pills were prescribed, and 122 were reported to be used. One patient (2%) received an opioid refill. CONCLUSIONS: Satisfactory pain control after anorectal surgery can be achieved with multimodality therapy with little to no opioid use for most patients.

The Efficacy of Ultrasound-Guided Paravertebral Block in Laparoscopic Cholecystectomy.

Background and objectives: Despite its wide use in thoracic procedures, to date, few studies have assessed the effectiveness of paravertebral block (PVB) in laparoscopic cholecystectomy (LC) in an adult population. In these studies, PVB was performed bilaterally using nerve stimulator guidance. To the best of our knowledge, the effectiveness of unilateral preoperative and postoperative ultrasound-guided PVB has not been evaluated in patients undergoing elective LC. The aim of this study was to evaluate the efficacy of single-dose unilateral paravertebral block (PVB) in patients undergoing laparoscopic cholecystectomy (LC) under general anesthesia. Materials and Methods: Patients undergoing LC were randomly separated into control, preoperative block, and postoperative block groups. PVB was performed unilaterally using bupivacaine under ultrasound guidance. Postoperative pain within the first 24 h, side effects, intraoperative opioid and postoperative analgesic requirements were noted. Evaluation was made of a total of 90 patients (25 males, 65 females) with a mean age of 45.78 ± 14.0 years (range, 19⁻74 years). Results: Opioid and additional analgesic needs and nausea/vomiting rates were significantly reduced in the preoperative block group compared to the other groups (p < 0.05). Visual Analog Scale (VAS) scores were significantly lower in the preoperative and postoperative block groups compared to the control group (p < 0.05 for all). When the VAS scores were compared between the preoperative and postoperative block groups, a significant difference in favor of the preoperative group was observed in terms of the zero minute-, 1st and 2nd h assessments (p < 0.05 for all). Conclusions: Ultrasound-guided PVB is a useful and safe approach for pain management during and after LC. Preoperative block can also reduce the rate of requirement for intraoperative opioid and postoperative analgesia.

Utility of cocaine drug screens to predict safe delivery of general anesthesia for elective surgical patients.

Cocaine has been associated with acute hemodynamic changes, causing anesthesia providers to be concerned about adverse hemodynamic events during general anesthesia. We sought to determine if there were differences in the prevalence of adverse hemodynamic events, and if hemodynamic instability could be predicted in cocaine-positive patients undergoing general anesthesia for elective surgery. A retrospective cohort study was conducted in 300 (150 cocaine-positive, 150 cocaine-negative) consecutive adults with similar general anesthesia plans who were hemodynamically normal at baseline. Subjects were excluded if they were not alert at baseline, or if they required more than 1 surgical procedure. Slightly more than 50% of subjects were female, but cocaine-positive subjects were significantly more likely to be male (chi2 = 5.9; P = .02). Baseline systolic pressure (P = .001; mean difference, 6.5 mm Hg; 95% confidence interval [CI], 2.7-70.2), mean arterial pressure (P = .04; mean difference, 2.9 mm Hg; 95% CI, 1.0-5.7), and heart rate (P = .02; mean difference, 3.3/min; 95% CI, 0.46-6.2) were significantly higher, but not clinically important in the cocaine-positive cohort. Our study demonstrates that use of drug screen results alone is insufficient to predict the safe administration of general anesthesia in patients undergoing elective surgeries.

[Oxygen provision of the brain during carotid endarterectomy in the settings of general and local anaesthesia].

Based on the indices of cerebral oximetry, analysed herein is efficiency of oxygen support of the brain in various types of anaesthesiological provision (total and general anaesthesia) in patients presenting with atherosclerosis of the brachiocephalic arteries during carotid endarterectomy. It was shown that at the expense of preserving the mechanism of autoregulation, the use of local anaesthesia provides higher efficiency of cerebral perfusion than general anaesthesia which is evidenced by the values of cerebral oximetry exceeding 60% at all stages of the operation. Dynamics of cerebral oxygenation during occlusion of the carotid arteries in the setting of local anaesthesia suggests high reactivity of the cerebral vessels in this cohort of patients and hence preservation of the cerebrovascular reserve in them.

Improved neuromuscular blockade using a novel neuromuscular blockade advisory system: a randomized, controlled, clinical trial.

BACKGROUND: Conventional incremental bolus administration of neuromuscular blocking (NMB) drugs is associated with limitations in intraoperative control, potential delays in recovery, and residual blockade in the postanesthetic period. To overcome such limitations, we developed a novel adaptive control computer program, the Neuromuscular Blockade Advisory System (NMBAS). The NMBAS advises the anesthesiologist on the timing and dose of NMB drugs based on a sixth-order Laguerre model and the history of the patient's electromyographic responses. Here, we tested the hypothesis that the use of the NMBAS improves NMB compared to standard care. METHODS: We conducted a prospective, randomized, controlled, blinded, parallel-group, clinical trial with n = 73 patients (ASA physical status I-III) undergoing abdominal surgery under general anesthesia > or =1.5 h with NMB using rocuronium. Patients were allocated to standard care or NMBAS-guided rocuronium administration. The primary outcome variable was the incidence of intraoperative events reflecting inadequate NMB. Secondary outcome variables included train-of-four (TOF) ratios at the end of surgery before reversal, the total doses of rocuronium, reversal agents, anesthetics and other drugs, the incidence of postoperative adverse events, and the incidence of anesthesiologist noncompliance with NMBAS recommendations. RESULTS: Of 73 enrolled patients, n = 30 per group were eligible for analysis. Patient demographics were comparable between the groups. The incidence in total intraoperative events associated with inadequate NMB was significantly lower in the NMBAS group compared to standard care (8/30 vs 19/30; P = 0.004). Mean TOF ratios at the end of surgery before reversal were higher in the NMBAS group (0.59 [95% CI, 0.48-0.69] vs 0.14 [95% CI, 0.04-0.24]; P < 0.0001). Total administered doses of rocuronium, reversal drugs, and other drugs, and the incidence of postoperative adverse events were not different. CONCLUSIONS: Compared to standard practice, NMBAS-guided care was associated with improved NMB quality and higher TOF ratios at the end of surgery, potentially reducing the risk of residual NMB and improving perioperative patient safety.

Anaesthesia-related maternal mortality.

Complications of anaesthesia leading to death in young pregnant women might be prevented if more experienced personnel could be entrusted with the job. The contribution of anaesthesia to maternal mortality in the United Kingdom is 1.7 per million pregnancies with almost similar incidence from United States. The commonest single factor responsible for anaesthesia-related death is difficult or failed intubation. A pregnant woman with a potentially difficult airway should receive aspiration prophylaxis (mechanical or pharmacological) as soon as operative delivery is anticipated. Anaesthetists should make a plan that comes into effect as soon as failure to view the larynx or to intubate the trachea becomes evident. Unsuspected difficult airway can be managed if the skill of the anaesthetists is of high standard. Pulmonary aspiration is one cause of death in obstetric anaesthesia. Regurgitation and vomiting prevention can minimise pulmonary aspiration. In regional anaesthesia, local anaesthetics toxicity is another cause of concern. This should be tackled with some safe local anaesthetics. Preventing a high spinal or epidural block involves ways to detect inadvertent injection of local anaesthetic into the cerebrospinal fluid. Postoperative care after anaesthesia in obstetric cases is very important.

Anestesia local por tumescencia con solución de Klein modificada comparada con anestesia general en la intervención por sinus pilonidal / Local anesthesia using the tumescent technique with modified klein's solution versus general anesthesia in the surgical treatment of pilonidal sinus

Introducción. Existe controversia sobre el método anestésico para el tratamiento quirúrgico del sinus pilonidal. Por un lado, la anestesia general se asocia con un índice de complicaciones poco frecuentes pero importantes, y puede dificultar en algunos casos el alta en los procedimientos de cirugía ambulatoria. Por otro, el uso de anestesia local pura puede no resultar eficaz, o bien puede asociarse a toxicidad si se emplean dosis altas. Los objetivos de este trabajo son: a) analizar los resultados anestésicos de la anestesia local por tumescencia (ALT) con solución de Klein modificada, y b) realizar un estudio comparativo entre la ALT con solución de Klein modificada y la anestesia general, en cuanto a complicaciones postoperatorias. Pacientes y método. Realizamos un estudio prospectivo no aleatorizado sobre 100 pacientes intervenidos de sinus pilonidal en un intervalo de un año (enero a diciembre de 1999). Estos pacientes se dividen en dos grupos en función de su método anestésico: grupo A (n = 50) con anestesia local con solución de Klein modificada, con/sin sedación, y grupo B (n = 50) con anestesia general. La estimación del dolor intraoperatorio se realizó mediante escala visual analógica (EVA). Se valoran de forma comparativa las complicaciones postoperatorias como supuración, seroma, hemorragia e imposibilidad de cumplir criterios de cirugía mayor ambulatoria. Resultados. La estimación del dolor por el paciente mediante EVA arrojó una puntuación media de 1,4, con un rango de 0-8. El porcentaje de pacientes con EVA<= 2 es del 80 por ciento. La supuración aparece en 0 por ciento en el grupo A y en el 6 por ciento en el grupo B, en ambos casos en los primeros 3 meses postoperatorios. El seroma aparece en el 2 por ciento (un caso) en el grupo A y en el 6 por ciento en el grupo B (3 casos). La hemorragia postoperatoria ocurre en el 10 por ciento del grupo A (5 casos) y en el 12 por ciento del grupo B (6 casos). Conclusiones. La ALT mediante solución de Klein modificada es eficaz en el tratamiento quirúrgico del sinus pilonidal. No se produce una mayor hemorragia postoperatoria con esta técnica que con anestesia general y, globalmente, se aprecian pocas complicaciones postoperatorias, por lo que creemos que la utilización de este método anestésico es una buena opción y obtiene ventajas en la práctica diaria sobre la anestesia general, especialmente si se realiza cirugía mayor ambulatoria (AU)

Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia.

OBJECTIVE: This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia. METHODS: Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively. RESULTS: The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups. CONCLUSIONS: The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.

Anaesthesia for caesarean section (epidural and general): effects on the neonate.

Anaesthesia may impair the condition of the neonate either directly (largely mechanically in utero or due to the influence of drugs) or indirectly via alteration of placental perfusion. These influences may further differ during normal caesarean section from those under complicated conditions. The criteria with which neonatal conditions are estimated need to be carefully distinguished with respect to results obtained. Neurobehavioural test results may give different information to the observer. A variety of drugs, not simply one, is used during general anaesthesia (GA). Even the consequences of maternal stress-fetal and neonatal levels of catecholamines or endogenous peptides may play a role. Local anaesthetics are known to cross the placenta as general anaesthetics do; in most cases, their effects are clinically irrelevant. Fetal and neonatal deliterious effects of regional anaesthesia (RA) are mainly related to maternal hypotension and the administration of large doses of local anaesthetics. If adequate doses of local anaesthetics and/or opioids are used, alterations in neurobehavioural scores are subtle and transient. Under normal maternal and fetal conditions, GA and RA are almost identically useful with respect to neonatal well being after caesarean section; subtle and inconsistent neurobehavioral residua may be present for a short period of time following GA. Under conditions of a compromised fetus, the neonate may however benefit from epidural anaesthesia more than from GA.

Anesthetic considerations for pediatric podiatric surgery.

The author reviews anesthetic considerations for the pediatric patient requiring foot and lower leg surgery. He initially describes the physiologic and psychologic differences from adults. Preoperative, intraoperative, and postoperative factors are then evaluated.