Use of herbal medication in the perioperative period: Potential adverse drug interactions.

Use of herbal medications and supplements has experienced immense growth over the last two decades, with retail sales in the USA exceeding $13 billion in 2021. Since the Dietary Supplement Health and Education Act (DSHEA) of 1994 reduced FDA oversight, these products have become less regulated. Data from 2012 shows 18% of U.S. adults used non-vitamin, non-mineral natural products. Prevalence varies regionally, with higher use in Western states. Among preoperative patients, the most commonly used herbal medications included garlic, ginseng, ginkgo, St. John's wort, and echinacea. However, 50-70% of surgical patients fail to disclose their use of herbal medications to their physicians, and most fail to discontinue them preoperatively. Since herbal medications can interact with anesthetic medications administered during surgery, the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) recommend stopping herbal medications 1-2 weeks before elective surgical procedures. Potential adverse drug effects related to preoperative use of herbal medications involve the coagulation system (e.g., increasing the risk of perioperative bleeding), the cardiovascular system (e.g., arrhythmias, hypotension, hypertension), the central nervous system (e.g., sedation, confusion, seizures), pulmonary (e.g., coughing, bronchospasm), renal (e.g., diuresis) and endocrine-metabolic (e.g., hepatic dysfunction, altered metabolism of anesthetic drugs). During the preoperative evaluation, anesthesiologists should inquire about the use of herbal medications to anticipate potential adverse drug interactions during the perioperative period.

Anesthetic recommendations for maternal and fetal safety in nonobstetric surgery: a balancing act.

PURPOSE OF REVIEW: Nonobstetric surgery during pregnancy is associated with maternal and fetal risks. Several physiologic changes create unique challenges for anesthesiologists. This review highlights physiologic changes of pregnancy and presents clinical recommendations based on recent literature to guide anesthetic management for the pregnant patient undergoing nonobstetric surgery. RECENT FINDINGS: Nearly every anesthetic technique has been safely used in pregnant patients. Although it is difficult to eliminate confounding factors, exposure to anesthetics could endanger fetal brain development. Perioperative fetal monitoring decisions require an obstetric consult based on anticipated maternal and fetal concerns. Given the limitations of fasting guidelines, bedside gastric ultrasound is useful in assessing aspiration risk in pregnant patients. Although there is concern about appropriateness of sugammadex for neuromuscular blockade reversal due its binding to progesterone, preliminary literature supports its safety. SUMMARY: These recommendations will equip anesthesiologists to provide safe care for the pregnant patient and fetus undergoing nonobstetric surgery.

Accuracy of drawing up liquid medications by veterinary anaesthetists and nurses.

OBJECTIVE: To evaluate the accuracy with which veterinary anaesthetists and nurses of different experience draw up small volumes of liquid. STUDY DESIGN: Prospective blinded randomized study. METHODS: A group of seven European College of Veterinary Anaesthesia and Analgesia (ECVAA) diplomates, six ECVAA residents and six anaesthesia nurses participated in the study. For each participant, five target volumes between 0.01 and 1.0 mL were randomly allocated. They were drawn up 20 times in random order using a 1 mL syringe attached to a 23 gauge needle. A total of 1900 measurements were analysed. An investigator filled the syringe and needle dead space with water for injection before each experiment. The change in mass of the syringe once filled to the target volume was used to calculate the actual volume of liquid drawn up. RESULTS: Large errors were made with measurements < 0.04 mL, so they were excluded from the statistical analysis. There was a significant effect of the target volume (p < 0.001) and of the order (p < 0.01). For each mL increase in the target volume, the absolute error decreased by 4% and from the first to the hundredth withdrawal each participant's absolute error decreased by 1%. The target volume was underestimated in 52.3% of measurements, 42% were overestimated and 5.7% were on target. None of the between-subject predictor variables approached significance. CONCLUSIONS AND CLINICAL RELEVANCE: Accuracy of veterinary anaesthetists and nurses in drawing up medications decreases as the target volume becomes smaller. Small veterinary patients receive small volumes of anaesthetic drugs with higher risks of overdosing compared with larger dogs. Years of experience and staff grade are not associated with greater accuracy. Large percentage errors may be seen with target volumes less than 0.04 mL. Dilutions are recommended for volumes > 0.19 mL in 1 mL syringe.

The use of processed electroencephalography (pEEG) in obstetric anaesthesia: a narrative review.

Accidental awareness under general anaesthesia (AAGA) remains a major complication of anaesthesia. The incidence of AAGA during obstetric anaesthesia is high relative to other specialities. The use of processed electroencephalography (pEEG) in the form of "depth of anaesthesia" monitoring has been shown to reduce the incidence of AAGA in the non-obstetric population. The evidence for using pEEG to prevent AAGA in the obstetric population is poor and requires further exploration. Furthermore, pregnancy and disease states affecting the central nervous system, such as pre-eclampsia, may alter the interpretation of pEEG waveforms although this has not been fully characterised. National guidelines exist for pEEG monitoring with total intravenous anaesthesia and for "high-risk" cases regardless of technique, including the obstetric population. However, none of the currently available guidelines relates specifically to obstetric anaesthesia. Using pEEG monitoring for obstetric anaesthesia may also provide additional benefits beyond a reduction in risk of AAGA. These potential benefits include reduced postoperative nausea and vomiting, reduced anaesthetic agent use, and a shorter post-anaesthetic recovery stay. In addition, pEEG acts as a surrogate marker of cerebral perfusion, and thus as an additional monitor for impending cardiovascular collapse, as seen in amniotic fluid embolism. The subtle physiological and pathological changes in EEG activity that may occur during pregnancy are an unexplored research area in the context of anaesthetic pEEG monitors. We believe that the direction of clinical practice is moving towards greater use of pEEG monitoring and individualisation of anaesthesia.

Anesthetic­specific lncRNA and mRNA profile changes in blood during colorectal cancer resection: A prospective, matched­case pilot study.

Prometastatic and antitumor effects of different anesthetics have been previously analyzed in several studies with conflicting results. Thus, the underlying perioperative molecular mechanisms mediated by anesthetics potentially affecting tumor phenotype and metastasis remain unclear. It was hypothesized that anesthetic­specific long non­coding RNA (lncRNA) expression changes are induced in the blood circulation and play a crucial role in tumor outcome. In the present study, high­throughput sequencing and quantitative PCR were performed in order to identify lncRNA and mRNA expression changes affected by two therapeutic regimes, total intravenous anesthesia (TIVA) and volatile anesthetic gas (VAG) in patients undergoing colorectal cancer (CRC) resection. Total blood RNA was isolated prior to and following resection and characterized using RNA sequencing. mRNA­lncRNA interactions and their roles in cancer­related signaling of differentially expressed lncRNAs were identified using bioinformatics analyses. The comparison of these two time points revealed 35 differentially expressed lncRNAs in the TIVA­group, and 25 in the VAG­group, whereas eight were shared by both groups. Two lncRNAs in the TIVA­group, and 23 in the VAG­group of in silico identified target­mRNAs were confirmed as differentially regulated in the NGS dataset of the present study. Pathway analysis was performed and cancer relevant canonical pathways for TIVA were identified. Target­mRNA analysis of VAG revealed a markedly worsened immunological response against cancer. In this proof­of­concept study, anesthesic­specific expression changes in lncRNA and mRNA profiles in blood were successfully identified. Moreover, the data of the present study provide the first evidence that anesthesia­induced lncRNA pattern changes may contribute further in the observed differences in CRC outcome following tumor resection.

Anestesia multimodal para ressecção de tumor cerebral com monitorização eletroneurofisiológica: relato de caso / Multimodal anesthesia for brain tumor resection with electroneurophysiological monitoring: case report

Introdução: O monitoramento neurofisiológico intraoperatório (MNIO) é uma técnica valiosa, empregada durante procedimentos neurocirúrgicos complexos. Ao monitorar continuamente as vias neurais, o MNIO fornece feedback em tempo real aos cirurgiões durante o procedimento, permitindo tomada de decisões críticas e redução do risco de déficits neurológicos. O papel do anestesiologista na identificação e correção dos fatores de risco modificáveis é fundamental para a prevenção de lesões neurológicas e otimização dos resultados. Sendo assim, a compreensão das limitações do MNIO e das evidências que orientam seu uso é de fundamental importância. Objetivo: Descrever o manejo de uma anestesia multimodal, realizada em conjunto com a equipe de neurofisiologia, para ressecção de um tumor cerebral recidivante e o seu desfecho clinico. Método: Trata-se de relato de caso atendido no Hospital do Servidor Público Municipal de São Paulo. Os dados para realização deste trabalho foram coletados durante a cirurgia, sendo a coleta autorizada pelo paciente por meio da assinatura de termo de consentimento livre e esclarecido. Relato do Caso: Paciente, sexo masculino, 64 anos, ASA II, hipertenso, com história prévia de meningioma atípico, submetido a neurocirurgia e radioterapia em 2021, em uso de anticonvulsivante oral para profilaxia de crises convulsivas. Apresenta lesão tumoral cerebral recidivante em região frontal bilateral. Após a indução anestésica, foi realizada passagem de acesso venoso central em veia jugular interna direita com auxílio de ultrassonografia, monitoração da pressão arterial invasiva após cateterização de artéria radial direita, sondagem vesical de demora, termômetro esofágico, otimização do posicionamento na mesa cirúrgica, índice bispectral e Scalp Block com 20 ml de ropicavaína a 0,375%. Realizou- se manutenção da anestesia com propofol (4-6 mg/kg/h) e remifentanil (0,1 mcg/kg/min) em infusão contínua associado a dexmedetomidina (0,2-0,6 mcg/kg/h) mantendo valores do índice bispectral entre 40-60. As respostas dos potenciais evocados foram obtidas nas extremidades superiores e inferiores durante todo o procedimento pela equipe de neurofisiologia. Durante a manipulação tumoral, foi detectada queda superior a 40% do potencial evocado motor em dimídio corporal esquerdo, e emitido o alerta à equipe cirúrgica. Nenhuma outra intercorrência foi registrada durante o procedimento. Conclusões: Propofol, dexmedetomidina, lidocaína, opioides e anestésicos voláteis potentes de baixa dosagem (menos de 0,5 CAM) associado a técnicas de bloqueios periféricos, fornecem condições compatíveis com monitoramento neurofisiológico intraoperatório. O MNIO contínuo é um complemento indispensável no período perioperatório para pacientes com alto risco de desenvolver complicações neurológicas. Os anestesistas devem fornecer um meio fisiológico e anestésico estável para facilitar a interpretação significativa das mudanças de sinal e precisa orientação cirúrgica. Palavras-chave: Adjuvantes Anestésicos. Potenciais Evocados. Neurocirurgia. Monitorização Neurofisiológica Intraoperatória.

Care for the Obstetric Patient with Complex Cardiac Disease.

The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.

Prevalencia del uso de anestésicos subcutáneos para la realización de gasometrías arteriales en el servicio de urgencias / Prevalence of use of subcutaneous anesthesics for performing arterial blood gas sample in emergency department

Objetivo: Determinar el porcentaje de enfermeras que, siguiendo las normativas actuales de la SEPAR, administran un anestésico subcutáneo previo a la realización de una gasometría arterial en el servicio de urgencias.Método: Se realizó un estudio observacional descriptivo en el servicio de urgencias del Hospital Clínico de Barcelona, mediante un cuestionario de 11 preguntas. En el estudio podrían participar todos los trabajadores de enfermería que hubiesen realizado al menos una extracción de gasometría arterial en el último año.Resultados: 82 respuestas fueron aceptadas para el estudio. 64 mujeres y 28 hombres, un 45,12% de ellos llevaban en el servicio 5 años o menos. Sólo un 15,8% utilizaban de forma habitual algún tipo de anestésico, siendo el espray de cloruro de etilo el método más utilizado, mientras que la mepivacaina subcutánea era el método menos común. Por el contrario, un 84,2% no utilizaban ningún método anestésico para la realización de dicha prueba, siendo el estado de urgencia del paciente el motivo más habitual para justificarlo.Conclusiones: El uso de anestésicos subcutáneos está muy poco extendido en la práctica diaria debido a falta de una formación adecuada y a la presión asistencial. Todo esto, unido al hecho de que el dolor percibido por el paciente está relacionado con la rapidez y la facilidad para realizar la técnica, se pone en evidencia la necesidad de buscar un método rápido y eficaz para el control del dolor en la realización de gasometrías en el servicio de urgencias. (AU)

Objective: To determine the percentage of nurses who, following SEPAR regulations, administer a subcutaneous anesthetic prior to performing an arterial blood gas test in the emergency department.Method: A descriptive observational study was carried out in the emergency department of the Barcelona Clinic Hospital, using an eleven questions survey. All nursing workers who had performed at least one arterial blood gas extraction over the last year could take part in the study.Results: 82 responses were accepted. 64 women and 28 men, 45.12% of them had been in the service for 5 years or less. Only 15.8% extensively used some type of anesthetic, ethyl chloride spray was the most widely used method, while subcutaneous mepivacaine was the least. On the other hand, 84.2% did not use any anesthetic method to perform this test and the patient’s state of emergency was the main reason to justify it.Conclusions: The use of subcutaneous anesthetics is not usual in everyday practice due to the lack of knowledge and the assistance pressure. All this, together with the fact that the pain perceived by the patient is related to the duration and ease to perform the technique, highlights the need to look for a quick and effective method for blood gas puncture pain management at the emergency department. (AU)

The effect of the minimum effective volume for suprainguinal fascia iliaca block in fresh cadavers / El efecto del volumen efectivo mínimo para el bloqueo de la fascia ilíaca suprainguinal en cadáveres frescos

SUMMARY: The goal of ultrasound-guided suprainguinal fascia iliaca block (USG-SFIB) is anesthetic spread to three nerves, which are lateral femoral cutaneous nerve (LFCN), femoral nerve (FN), and obturator nerve (ON). The 90 % minimum effective volume (MEV90) for USG-SFIB is each result of studied showed the successful block and effect in various volume for block. So, Thus, the study purposes to demonstrate the efficiency of the effective volume (MEV90,62.5 ml) for USG-SFIB and confirm the staining of dye in connective tissue of nerve (nerve layer) that focused on the obturator nerve by histological examination in cadavers. The histological result showed the dye staining on the nerve layer of the ON in epineurium (100 %) and un-staining perineurium & endoneurium. Therefore, the minimal effective volume (MEV) is effective for USG-SFIB. Moreover, dye stain at the epineurium of stained obturator nerve only.

RESUMEN: El objetivo del bloqueo de la fascia ilíaca suprainguinal guiado por ecografía (USG-SFIB) es la propagación anestésica a tres nervios, cutáneo femoral lateral, femoral y obturador. El volumen efectivo mínimo del 90 % (MEV90) para USG-SFIB en cada uno de los resultados mostró el bloqueo exitoso y el efecto en varios volúmenes por bloqueo. Por lo tanto, el estudio tuvo como objetivo demostrar la eficiencia del volumen efectivo (MEV90,62.5 ml) para USG-SFIB y confirmar la tinción de tinte en el tejido conectivo del nervio, el cual se centró en el nervio obturador a través del examen histológico en cadáveres. El resultado histológico mostró tinción de colorante en el epineuro (100 %) del nervio obturador, sin embargo no hubo tinción del perineuro y endoneuro. Por lo tanto, el volumen efectivo mínimo (MEV) es efectivo para USG-SFIB.

Comparative study between S-(+)-ketamine­midazolam and fentanyl­droperidol in black-tufted marmosets (Callithrix penicillata) / Estudo comparativo entre S-(+)cetamina-midazolam e fentanil-droperidol em saguis-de-tufo-preto (Callithrix penicillata)

Sedative and antinociceptive effects of two anesthetic protocols in black-tufted marmosets were compared in this study. Twenty-six marmosets underwent chemical immobilization for physical examination, blood sampling, tattooing, and microchipping. Animals were randomly treated with S-(+)-ketamine (10 mg/kg) and midazolam (1 mg/kg) (KM) or fentanyl (12.5 µg/kg) and droperidol (625 µg/kg) (FD) given by intramuscular injection. Heart and respiratory rates were recorded. Sedation, antinociception, muscle relaxation, posture, auditory, and visual responses were evaluated using a scoring system. Sedation in KM was achieved faster (p < 0.001) and lasted for a shorter period of time (p = 0.0009). KM was similar to FD in its cardiorespiratory effects, auditory and visual responses. Both protocols promoted adequate sedation to allow manipulation. Animals in KM assumed lateral recumbency while animals in FD maintained a quadrupedal posture during evaluation. FD produced less intense sedation and muscle relaxation but a higher degree of antinociception compared to KM and is suitable for procedures that require analgesia in black-tufted marmosets.(AU)

O presente estudo comparou os efeitos cardiorrespiratórios, sedativos e antinociceptivos de dois protocolos anestésicos em saguis-de-tufo-preto (Callithrix penicillata). Vinte e seis saguis foram submetidos à contenção química para exame físico, coleta de sangue, tatuagem de identificação e microchip. Os animais foram tratados aleatoriamente com a associação de S-(+)-cetamina (10 mg/kg) e midazolam (1 mg/kg) (KM) ou fentanil (12,5 µg/kg) e droperidol (625 µg/kg) (FD), administrados por injeção intramuscular. Foram avaliadas frequência cardíaca, frequência respiratória, sedação, antinocicepção, relaxamento muscular, postura e resposta ao estímulo auditivo e visual. A sedação em KM foi alcançada mais rapidamente (p <0,001) e teve um tempo hábil mais curto (p = 0,0009). KM foi semelhante a FD nos efeitos cardiorrespiratórios, respostas auditivas e visuais. Os dois protocolos promoveram sedação adequada para manipulação. Os animais do grupo KM permaneceram em decúbito lateral durante a avaliação, enquanto os animais em FD mantiveram postura quadrupedal. FD resultou em sedação e relaxamento muscular de menor intensidade, porém com maior escore de antinocicepção em comparação com KM, sendo adequada para procedimentos que requerem analgesia em saguis-de-tufo-preto.(AU)

Anesthetic management of ventricular-peritoneal shunt implantation in osteogenesis imperfecta type IIB: A case report.

INTRODUCTION: Osteogenesis imperfecta (OI), a rare congenital disorder, has a risk of bone fracture and progressive bone deformity. OI type II is the most serious subtype, and very few reports on its anesthetic management exist. Patients face several anesthetic difficulties, of which easy fracturing of OI-affected bones is critical. Herein, we report our experience with the anesthetic management of a patient with OI type II. PATIENT CONCERNS AND DIAGNOSES: Through genetic testing, a 14-month-old girl (height: 45 cm, weight: 3.9 kg) was diagnosed with OI type IIB due to COL1A gene abnormality. The clinical manifestations included hydrocephalus, blue sclera, dental dysplasia, short stature, limb deformity and shortening, thoracic hypoplasia, rabbit eye, left inguinal hernia, and tricuspid valve regurgitation. Physical examination revealed an enlarged head due to skull dysplasia and hydrocephalus. The pediatrician confirmed that mask ventilation was possible even under spontaneous breathing, and that there was no history of bone fracture during mask holding. INTERVENTIONS AND OUTCOMES: The patient was scheduled for gastrostomy and ventriculo-peritoneal shunt implantation. An arterial pressure line was inserted at the neonatal intensive care unit. Propofol and remifentanil were selected for general anesthesia. Confirming that mask-assisted ventilation was possible under sleep, rocuronium was administered. Attentive mask ventilation was performed via the 2-person method to avoid fractures. We were able to intubate successfully using a Macintosh laryngoscope. A microcuff endotracheal tube was used. For ventilation, pressure control ventilation was selected and sedative dosage was adjusted using the patient state index as an indicator. The patient was sedated, intubated, and returned to the neonatal intensive care unit. She was extubated on the sixth postoperative day. No bone fractures were noted. CONCLUSION: OI type II is the most severe subtype with high mortality, and there are few reports on its anesthetic management. Easy fractures can be a problem in airway maintenance, blood pressure measurement, and repositioning. We performed the procedure attentively, avoiding jaw and cervical fractures during mask ventilation and endotracheal intubation. For respiratory management, we chose pressure control ventilation using a cuffed tracheal tube and circulatory control was attained via an arterial line inserted preoperatively. No complications occurred.

Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC): a modified Delphi process to develop a core outcome set for trials in perioperative care and anaesthesia.

BACKGROUND: Outcome selection underpins clinical trial interpretation. Inconsistency in outcome selection and reporting hinders comparison of different trials' results, reducing the utility of research findings. METHODS: We conducted an iterative consensus process to develop a set of Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC), following the established Core Outcome Measures for Effectiveness Trials (COMET) methodology. First, we undertook a systematic review of RCTs in high-impact journals to describe current outcome reporting trends. We then surveyed patients, carers, researchers, and perioperative clinicians about important outcomes after surgery. Finally, a purposive stakeholder sample participated in a modified Delphi process to develop a core outcome set for perioperative and anaesthesia trials. RESULTS: Our systematic review revealed widespread inconsistency in outcome reporting, with variable or absent definitions, levels of detail, and temporal criteria. In the survey, almost all patients, carers, and clinicians rated clinical outcome measures critically important, but clinicians rated patient-centred outcomes less highly than patients and carers. The final core outcome set was: (i) mortality/survival (postoperative mortality, long-term survival); (ii) perioperative complications (major postoperative complications/adverse events; complications/adverse events causing permanent harm); (iii) resource use (length of hospital stay, unplanned readmission within 30 days); (iv) short-term recovery (discharge destination, level of dependence, or both); and (v) longer-term recovery (overall health-related quality of life). CONCLUSIONS: This core set, incorporating important outcomes for both clinicians and patients, should guide outcome selection in future perioperative medicine or anaesthesia trials. Mapping these alongside standardised endpoint definitions will yield a comprehensive perioperative outcome framework.

Intravenous and Intramuscular Allopregnanolone for Early Treatment of Status Epilepticus: Pharmacokinetics, Pharmacodynamics, and Safety in Dogs.

Allopregnanolone (ALLO) is a neurosteroid that modulates synaptic and extrasynaptic GABAA receptors. We hypothesize that ALLO may be useful as first-line treatment of status epilepticus (SE). Our objectives were to (1) characterize ALLO pharmacokinetics-pharmacodynamics PK-PD after intravenous (IV) and intramuscular (IM) administration and (2) compare IV and IM ALLO safety and tolerability. Three healthy dogs and two with a history of epilepsy were used. Single ALLO IV doses ranging from 1-6 mg/kg were infused over 5 minutes or injected IM. Blood samples, vital signs, and sedation assessment were collected up to 8 hours postdose. Intracranial EEG (iEEG) was continuously recorded in one dog. IV ALLO exhibited dose-proportional increases in exposure, which were associated with an increase in absolute power spectral density in all iEEG frequency bands. This relationship was best described by an indirect link PK-PD model where concentration-response was described by a sigmoidal maximum response (Emax) equation. Adverse events included site injection pain with higher IM volumes and ataxia and sedation associated with higher doses. IM administration exhibited incomplete absorption and volume-dependent bioavailability. Robust iEEG changes after IM administration were not observed. Based on PK-PD simulations, a 2 mg/kg dose infused over 5 minutes is predicted to achieve plasma concentrations above the EC50, but below those associated with heavy sedation. This study demonstrates that ALLO is safe and well tolerated when administered at 1-4 mg/kg IV and up to 2 mg/kg IM. The rapid onset of effect after IV infusion suggests that ALLO may be useful in the early treatment of SE. SIGNIFICANCE STATEMENT: The characterization of the pharmacokinetics and pharmacodynamics of allopregnanolone is essential in order to design clinical studies evaluating its effectiveness as an early treatment for status epilepticus in dogs and people. This study has proposed a target dose/therapeutic range for a clinical trial in canine status epilepticus.

Developing a Real-Time Electroencephalogram-Guided Anesthesia-Management Curriculum for Educating Residents: A Single-Center Randomized Controlled Trial.

BACKGROUND: Different anesthetic drugs and patient factors yield unique electroencephalogram (EEG) patterns. Yet, it is unclear how best to teach trainees to interpret EEG time series data and the corresponding spectral information for intraoperative anesthetic titration, or what effect this might have on outcomes. METHODS: We developed an electronic learning curriculum (ELC) that covered EEG spectrogram interpretation and its use in anesthetic titration. Anesthesiology residents at a single academic center were randomized to receive this ELC and given spectrogram monitors for intraoperative use versus standard residency curriculum alone without intraoperative spectrogram monitors. We hypothesized that this intervention would result in lower inhaled anesthetic administration (measured by age-adjusted total minimal alveolar concentration [MAC] fraction and age-adjusted minimal alveolar concentration [aaMAC]) to patients ≥60 old during the postintervention period (the primary study outcome). To study this effect and to determine whether the 2 groups were administering similar anesthetic doses pre- versus postintervention, we compared aaMAC between control versus intervention group residents both before and after the intervention. To measure efficacy in the postintervention period, we included only those cases in the intervention group when the monitor was actually used. Multivariable linear mixed-effects modeling was performed for aaMAC fraction and hospital length of stay (LOS; a non-prespecified secondary outcome), with a random effect for individual resident. A multivariable linear mixed-effects model was also used in a sensitivity analysis to determine if there was a group (intervention versus control group) by time period (post- versus preintervention) interaction for aaMAC. Resident EEG knowledge difference (a prespecified secondary outcome) was compared with a 2-sided 2-group paired t test. RESULTS: Postintervention, there was no significant aaMAC difference in patients cared for by the ELC group (n = 159 patients) versus control group (N = 325 patients; aaMAC difference = -0.03; 95% confidence interval [CI], -0.09 to 0.03; P =.32). In a multivariable mixed model, the interaction of time period (post- versus preintervention) and group (intervention versus control) led to a nonsignificant reduction of -0.05 aaMAC (95% CI, -0.11 to 0.01; P = .102). ELC group residents (N = 19) showed a greater increase in EEG knowledge test scores than control residents (N = 20) from before to after the ELC intervention (6-point increase; 95% CI, 3.50-8.88; P < .001). Patients cared for by the ELC group versus control group had a reduced hospital LOS (median, 2.48 vs 3.86 days, respectively; P = .024). CONCLUSIONS: Although there was no effect on mean aaMAC, these results demonstrate that this EEG-ELC intervention increased resident knowledge and raise the possibility that it may reduce hospital LOS.

Anesthetic management with remimazolam for a pediatric patient with Duchenne muscular dystrophy.

RATIONALE: With Duchenne muscular dystrophy (DMD) being the most common and most severe type of muscular dystrophy, DMD patients are at risk for complications from general anesthesia due to impaired cardiac and respiratory functions as the pathological condition progresses. In recent years, advances in multidisciplinary treatment have improved the prognosis of DMD patients, and the number of patients requiring surgery has increased. Remimazolam is a benzodiazepine derivative similar to midazolam. Its circulatory stability and the fact that it has an antagonist make it superior to propofol.There are no reports of pediatric patients with DMD undergoing total intravenous anesthesia with remimazolam. PATIENT CONCERNS: A 4-year boy was scheduled for single-incision laparoscopic percutaneous extraperitoneal closure for inguinal hernia under general anesthesia, but the surgery was postponed because his serum creatine phosphokinase level was extremely high. DIAGNOSIS: He was diagnosed with DMD. According to the results of the genetic test, exon deletion of the DMD gene was detected using multiplex ligation-dependent probe amplification, although he had no symptoms of DMD except for elevated serum levels of creatine phosphokinase, etc. INTERVENTION: He was admitted for the same surgical purpose. Anesthesia was induced with 3 mg of intravenously administered remimazolam. He lost the ability to respond to verbal commands. After the intravenous administration of 100 µg of fentanyl, a continuous infusion of remifentanil (1.0 µg/kg/min) and remimazolam (15 mg/h) was started, and the endotracheal tube was inserted smoothly after the administration of 10 mg of rocuronium with which the muscle twitches disappeared in train-of-four monitoring. At the end of the surgery, 15 mg of flurbiprofen was administered intravenously. After surgery, we injected 40 mg of sugammadex to confirm a train-of-four count of 100%. OUTCOMES: Although the dose of remimazolam was reduced to 5 mg/h 30 minutes before the end of the surgery, it took 20 minutes after the discontinuation of remimazolam for the patient to open his eyes upon verbal command. On postoperative Day 2, he was discharged from the hospital without any complications. LESSONS: Remimazolam was shown to be safe to use for general anesthesia in a pediatric patient with DMD.

Repetitive Treatment with Volatile Anesthetics Does Not Affect the In Vivo Plasma Concentration and Composition of Extracellular Vesicles in Rats.

BACKGROUND: Anesthetic-induced preconditioning (AIP) with volatile anesthetics is a well-known experimental technique to protect tissues from ischemic injury or oxidative stress. Additionally, plasmatic extracellular vesicle (EV) populations and their cargo are known to be affected by AIP in vitro, and to provide organ protective properties via their cargo. We investigated whether AIP would affect the generation of EVs in an in vivo rat model. METHODS: Twenty male Sprague Dawley rats received a repetitive treatment with either isoflurane or with sevoflurane for a duration of 4 or 8 weeks. EVs from blood plasma were characterized by nanoparticle tracking analysis, transmission electron microscopy (TEM) and Western blot. A scratch assay (H9C2 cardiomyoblast cell line) was performed to investigate the protective capabilities of the isolated EVs. RESULTS: TEM images as well as Western blot analysis indicated that EVs were successfully isolated. The AIP changed the flotillin and CD63 expression on the EV surface, but not the EV concentration. The scratch assay did not show increased cell migration and/or proliferation after EV treatment. CONCLUSION: AIP in rats changed the cargo of EVs but had no effect on EV concentration or cell migration/proliferation. Future studies are needed to investigate the cargo on a miRNA level and to investigate the properties of these EVs in additional functional experiments.