Effects of intraoperative low-dose esketamine on postoperative pain after vestibular schwannoma resection: A prospective randomized, double-blind, placebo-controlled study.

AIMS: Esketamine may reduce acute postoperative pain in several settings. However, the effects of low-dose esketamine on postoperative pain after vestibular schwannoma (VS) resection with propofol/remifentanil total intravenous anaesthesia (TIVA) are unclear. The aim of this study is to observe the effects of intraoperative low-dose esketamine on postoperative pain after vestibular schwannoma resection. METHODS: This single-centre, randomized, placebo-controlled, double-blind trial included 90 adults undergoing VS resection via the retrosigmoid approach with TIVA. The patients were randomly allocated to two groups: esketamine or control (n = 45 in each group). Patients received low-dose esketamine (0.2 mg/kg) or a similar volume of normal saline after dural closure. The primary outcome was the pain score during movement (gentle head movement) at 24 h postoperatively. Secondary outcomes included recovery time, bispectral index (BIS) values and haemodynamic profiles during the first 30 min after esketamine administration, and adverse effects. RESULTS: Low-dose esketamine did not reduce pain scores at rest (P > .05) or with movement (P > .05) within the first 24 h after surgery. Esketamine moderately increased BIS values for at least 30 min after administration (P < .0001) but did not affect heart rate (P = .992) or mean arterial blood pressure (P = .994). Esketamine prolonged extubation time (P = .042, 95% confidence interval: 0.08 to 4.42) and decreased the effect-site concentration of remifentanil at extubation (P = .001, 95% confidence interval: -0.53 to -0.15) but did not affect the time to resumption of spatial orientation. Postoperative nausea and vomiting rates did not differ between groups, and no hallucinations or excessive sedation was observed. CONCLUSION: Intraoperative low-dose esketamine did not significantly reduce acute pain after VS resection with propofol/remifentanil TIVA. However, BIS values increased for at least 30 min after esketamine administration.

Awake fiberoptic intubation in a patient with a large thyroid tumor invading the trachea: a case report.

This case report aims to raise awareness about the risk of challenging airway problems in patients with thyroid tumors. We report a case of a patient with a large thyroid tumor invading the trachea, causing trachea narrowing and resulting in breathing difficulties, who required awake tracheal intubation (ATI). A 54-year-old woman underwent surgery for the removal of a thyroid tumor under general anesthesia. The tumor was invading and compressing the trachea, causing difficulty in breathing. To facilitate surgery, thyrocricocentesis and nerve block were considered, but they were difficult to implement. Extracorporeal membrane oxygenation (ECMO) is expensive and has risks of several complications, such as failure of the oxygenation membrane, rupture of the circuit, coagulation of the system, intracranial hemorrhage, acute kidney injury, and infections. The placement of a tracheal stent may worsen airway problems. In this case, the airway was established without ECMO or tracheal stent placement. Local anesthesia of the airway could be an alternative to avoid expensive options and complications, as successful ATI would reduce healthcare costs.

Factors Associated with Prolonged Extubation after Total Intravenous Anesthesia in Patients Undergoing Vestibular Schwannoma Resection.

OBJECTIVE: To identify factors associated with prolonged tracheal extubation after vestibular schwannoma resection in patients receiving propofol-remifentanil-based total intravenous anesthesia (TIVA). STUDY DESIGN: Single-center retrospective study of vestibular schwannoma resection performed by a single neurosurgeon between July 2018 and September 2021. SETTING: Tertiary academic medical center. PATIENTS: Adults receiving TIVA for vestibular schwannoma resection, classified according to extubation time: non-prolonged extubation (<15 min) and prolonged extubation (≥15 min). MAIN OUTCOME MEASURES: Time from end of surgery to extubation, demographic parameters, intraoperative variables, and familiarity between the anesthesia provider and the neurosurgeon were analyzed. Predictors for prolonged extubation were analyzed via multivariate analysis. The primary outcome was the incidence of prolonged extubation. The secondary outcome was factors associated with prolonged tracheal extubation. RESULTS: A total of 234 cases were analyzed. The median (interquartile range) extubation time was 9.4 minutes (7.2, 12.2 min). Extubation was prolonged in 39 patients (16.7%). Factors predicting prolonged extubation were significant blood loss (odds ratio [OR], 12.8; 95% confidence interval [CI], 2.6-61.7; p = 0.002), intraoperative neuromuscular blocking drug infusion (OR, 6.6; 95% CI, 2.8-15.7; p < 0.001), and lack of familiarity between the anesthesia provider and neurosurgeon (OR, 4.4; 95% CI, 1.5-12.3; p = 0.005). CONCLUSION: Significant blood loss, intraoperative neuromuscular blocking drug infusion, and lack of familiarity between anesthesia provider and neurosurgeon were associated with prolonged extubation following TIVA for vestibular schwannoma resection.

Preoperative Psychological Burdens in Patients with Vestibular Schwannoma.

OBJECTIVE: To assess preoperative psychological burden in patients with vestibular schwannoma (VS). METHODS: A total of 100 patients undergoing VS resection between September 2019 and June 2020 completed preoperative psychological screening. The Hospital Anxiety and Depression Scale (HADS) was applied the day before surgery, and a score >14 was considered clinically important. Univariate and multivariate logistic regression analyzes were used to identify risk factors associated with increased preoperative psychological stress. RESULTS: Of the 100 patients who underwent VS resection, 44% were male, with a mean age of 45.9 years. Twenty-two (22%) had HADS scores >14. For the univariate analysis, risk factors associated with elevated psychological burden included time since diagnosis, number of symptoms, headache, vertigo, and nausea and/or vomiting. In the regression analysis, the number of symptoms and greater time from diagnosis to treatment correlated with higher preoperative psychological stress. CONCLUSION: Nearly 1 in 4 patients with VS experienced clinically significant emotional burden preoperatively. Number of symptoms and greater time from diagnosis to treatment contributed to this psychological burden.

A narrative review of ultrasound-guided serratus anterior plane block.

Ultrasound-guided serratus anterior plane block (SAPB) is located using ultrasound at the level of the midaxillary line and the fifth rib, and a certain amount of local anesthetics is injected either superficially or deeply into the serratus anterior muscle, blocking the third to sixth intercostal nerves, the long thoracic and thoracodorsal nerves. It is mainly used in breast surgeries, rib fractures and thoracotomy to manage the pain of the anterolateral chest wall. The surgery of anterolateral chest wall is often accompanied by severe postoperative pain, leading to postoperative infection, atelectasis and other complications, and prolonged hospitalization. However, effective pain management can reduce the occurrence of postoperative pulmonary complications, promote patients to get out of bed as soon as possible, and accelerate the recovery of patients. Recently, with the development of ultrasonic technology and equipment, SAPB has entered the era of visualization, further improving the safety and success rate of operations. SAPB, as a new technology of regional block, has a higher positioning accuracy, a higher success rate, lesser complications, and simpler and more effective postoperative analgesia effect. Compared with thoracic epidural analgesia and thoracic paravertebral block, SAPB has a good ultrasonic anatomical basis; thus, has a broad application prospect in clinics. In this paper, the SAPB in clinical application was reviewed.

The Effect of Ultrasound-Guided Erector Spinae Plane Block Combined with Dexmedetomidine on Postoperative Analgesia in Patients Undergoing Modified Radical Mastectomy: A Randomized Controlled Trial.

INTRODUCTION: One of the most common malignancies in women worldwide is breast cancer. Erector spinae plane block (ESPB) can reduce pain after modified radical mastectomy for breast cancer. The duration of nerve block analgesia is limited if local anesthetic agents are used alone. The purpose of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia during a single injection of local anesthetics. METHODS: In this double-blind, randomized study, 60 female American Society of Anesthesiologists (ASA) I-II patients undergoing modified radical mastectomy were randomized into two groups: ultrasound (US)-guided ESPB with 30 mL of 0.33% ropivacaine (group R) and US-guided ESPB with 30 mL of dexmedetomidine plus 0.33% ropivacaine (group DR). US-guided ESPB at the T3 vertebral level was performed preoperatively in all patients. The indicators were 1-, 6-, 12-, 24-, and 48-h visual analog scale (VAS) pain scores after surgery in the resting state and at 90-degree shoulder abduction. Other measures were a comparison of intraoperative sufentanil and remifentanil, postoperative nausea and vomiting (PONV), flurbiprofen consumption, the lengths of post-anesthesia care unit (PACU) stay and hospital stay, postoperative bradycardia, and hypotension. RESULTS: The VAS pain score was lower in group DR than group R at any time in the resting state, except at 1 h after surgery. The VAS pain score was lower in group DR than group R at 12 and 24 h in an active state after surgery (P < 0.05 for each time interval). The intraoperative dosages of remifentanil and sufentanil in group DR were lower than that in group R. The postoperative dosage of flurbiprofen in group DR was lower than that in group R (P = 0.038). The lengths of PACU stay were longer in group DR than in group R. No significant difference was found in PONV and hospital stay between the two groups. No sinus bradycardia or hypotension after surgery occurred in the two groups. CONCLUSIONS: Dexmedetomidine as an adjunctive to ESPB can effectively relieve pain and significantly reduce the need for opioids during modified radical mastectomy for breast cancer. TRIAL REGISTRATION: The study was registered in the Chinese Clinical Trial Registry (ChiCTR2000031134, principal investigator: Yao Lu, date of registration: 2020-3-22).

Electromyographic Response of Facial Nerve Stimulation Under Partial Neuromuscular Blockade During Resection of Vestibular Schwannoma.

OBJECTIVE: To evaluate whether use of partial nondepolarizing neuromuscular blocking agents, at a train-of-four level 1, compromise facial nerve monitoring during vestibular schwannoma (VS) resection. METHODS: Sixty consecutive patients undergoing VS resection were enrolled into a partial peripheral neuromuscular blockade group or free of neuromuscular blockade group. Stimulation threshold to elicit an electromyographic response amplitude of at least 100 µV was recorded at the proximal and distal facial nerve after VS removal. The proximal-to-distal ratio of amplitude of the orbicularis oculi and oris muscles was calculated. RESULTS: All patients successfully passed the electromyography monitoring test. Mean electrical stimulation thresholds were higher in the peripheral neuromuscular blockade group than in the free of neuromuscular blockade group (0.12 mA vs. 0.06 mA at proximal site, P = 0.001; 0.08 mA vs. 0.03 mA at distal site, P = 0.0002). The differences in median proximal-to-distal amplitude ratios were not statistically significant in both groups. There was a trend toward more patients needing phenylephrine. Recovery profiles were comparable in the 2 groups. CONCLUSIONS: Although mean stimulation threshold to elicit a response amplitude was higher in the peripheral neuromuscular blockade group than in the free of neuromuscular blockade group at the proximal site, the stimulation thresholds in both groups were sufficient for facial nerve monitoring in VS surgery, indicating no clinical difference in both groups.

High immunoglobulin E level is associated with increased readmission in children with bronchopneumonia.

BACKGROUND: Increased immunoglobulin E (IgE) is associated with lower respiratory tract infections. The study aimed to evaluate the association between IgE and the rate of bronchopneumonia-related readmission within 12 months in children. METHODS: A total of 1099 children aged over 1 year with bronchopneumonia, from 1 January 2015 to 31 December 2016, were enrolled. Unplanned readmissions within 12 months after discharge were observed. Multivariate regression analysis was used to identify independent risk factors for rehospitalization. RESULTS: The rate of rehospitalization was 11.4% (125/1099). Compared to the nonreadmission children, IgE levels, the proportion of children with asthma and hospitalization duration were significantly higher in the readmission children (p < 0.05). Compared to the children with normal IgE (≤ 165 IU/ml) levels, the risk of rehospitalization was significantly higher in children with abnormal IgE [odds ratio (OR) 1.781, 95% confidence interval (CI) 1.209-2.624, p = 0.004]. Children with IgE level more than three times the upper limit had even higher risks of readmission (OR 2.037, 95%CI 1.172-3.540, p = 0.012). Meanwhile, the risk of readmission in children with abnormal IgE combined with or without bronchial asthma was significantly higher (OR 2.548 and 1.918, 95% CI 1.490-4.358 and 1.218-3.020, p = 0.001 and 0.005, respectively). CONCLUSIONS: Children aged over 1 year with bronchopneumonia who had higher IgE levels are at increased risk for rehospitalization within the first 12 months of the index hospitalization and IgE level may be used as a predictor of rehospitalization in children with bronchopneumonia.

[Electroacupuncture Relieves Obesity by Up-regulating PGC-1 α/UCP-1 Signaling in White Adipose Tissue in Diet-induced Obesity Rats].

OBJECTIVE: To observe the effect of electroacupuncture (EA) on the activities of peroxisome proliferator-activated receptor gamma coactivator-1 alpha/uncoupling protein-1 (PGC-1 α/UCP-1) signaling pathway in white adipose tissue(WAT)of diet-induced obesity (DIO) rats, so as to reveal its underlying mechanism in body weight loss. METHODS: Thirty-four male Wistar rats were randomly divided into normal diet (control, n＝10), high fat diet (model), sham EA-acupoint and EA groups (n＝8 in each of the latter 3 groups). The obesity model was established by feeding the rats with high fat diet containing lard oil, sugar, albumen powder, cholesterol, salt and sodium cholate for 12 weeks. EA (2 Hz/15 Hz, 1 mA) was applied to bilateral "Zusanli" (ST 36) and "Tianshu" (ST 25) or sham acupoints (about 5 mm beside ST 36 and ST 25) for 30 min, once daily, 5 times per week for a total of 8 weeks. During the treatment, all rats were fed with normal diet, and their body weight and length were measured once a week for calculating the Lee's index. The contents of serum total cholesterol (TC) and triglyceride (TG) were measured by using biochemical methods. The immunoactivity of PGC-1 α and UCP-1 in the abdominal WAT was detected by immunohistochemistry. RESULTS: After modeling, the Lee's index, serum TC and TG contents were significantly increased, and the levels of serum HDL-C, and PGC-1 α and UCP-1 immunoactivity in WAT considerably decreased in the model group relevant to the control group (P<0.05). Following the treatment, the Lee's index, TC and TG contents were significantly down-regulated while HDL-C and PGC-1 α and UCP-1 immunoactivity were obviously up-regulated in the EA-acupoint group relevant to the model group (P<0.05). CONCLUSION: EA can effectively reduce the body weight and adipose content in obesity rats, which may be closely related to its effect in up-regulating PGC-1 α/UCP-1 signaling in WAT, suggesting an efficacy of EA in promoting the browning of WAT.

Dynamic effects of leflunomide on IL-1, IL-6, and TNF-alpha activity produced from peritoneal macrophages in adjuvant arthritis rats.

AIM: To investigate the effects of leflunomide (LEF) on modulating interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor- alpha (TNF-alpha) production induced by lipopolysaccharide (LPS) in peritoneal macrophages (PMphi) in adjuvant arthritis rats and elucidate the possible mechanisms of antiinflammatory and antirheumatoid effects of LEF. METHODS: Freund's complete adjuvant was injected in the hind footpad of rats to induce adjuvant arthritis (AA) rat model. The PMphi samples were taken at different time after medication. IL-1, IL-6, and TNF-alpha activities released from PMphi were measured by ELISA method or bioassay method. RESULTS: Production of IL-1, IL-6, and TNF-alpha was increased in the culture supernatant of PMphi in AA model rat. LEF could inhibit LPS-induced release of IL-1 and TNF-alpha from PMphi of the AA rats and the inhibitory effects were extremely rapid. LEF (10, 25 mg/kg) administrated for 21d could inhibit IL-6 release from PMphi in AA rats. CONCLUSION: The antiinflammatory mechanisms of LEF in AA rats might be related to inhibitory level of IL-1, IL-6, and TNF-alpha from PMphi in vivo.