Obesity and Anesthesia: Challenges in the Perioperative Period.

The obesity epidemic has significant implications for all aspects of healthcare. The physiological changes of obesity affect every area of perioperative medicine. In this article, we discuss several anesthetic concerns regarding obesity. We will specifically discuss preoperative evaluation, perioperative challenges, and postoperative pain control and monitoring.

The Effect of Depth of Anesthesia on Postoperative Pain in Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Trial.

BACKGROUND: Patients with obesity are more sensitive to pain and more likely to have acute postoperative pain (APP). Studies have shown that the depth of anesthesia may affect the incidence of APP. The purpose of the study was to look into the connection between APP and depth of anesthesia in patients with obesity undergoing laparoscopic sleeve gastrectomy. METHODS: This is a prospective, double-blinded randomized clinical trial, 90 patients undergoing laparoscopic sleeve gastrectomy were randomly divided into two groups: the light anesthesia group (Bispectral Index of 50, BIS 50) and the deep anesthesia group (BIS 35). The degree of pain was evaluated by the visual analogue scale (VAS) at 0, 12, 24, 48, and 72 h after surgery. The use of analgesics, grade of postoperative nausea and vomiting (PONV), and the Quality of Recovery-15 (QoR-15) score were recorded. RESULTS: The VAS scores at rest or coughing at 0, 12, and 24 h after surgery in the BIS 35 group were lower than those in the BIS 50 group (P < 0.05). Fewer patients in the deep anesthesia group needed analgesia during the recovery period, and patient satisfaction was higher on the 3rd day after surgery (P < 0.015, P < 0.032, respectively). CONCLUSIONS: For patients with obesity, maintaining a deeper depth of anesthesia during surgery is beneficial to reduce APP causes less need for additional analgesic drugs, and improves patient satisfaction.

Obesity and anesthesia.

PURPOSE OF REVIEW: Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications. RECENT FINDINGS: Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period. SUMMARY: Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.

Neutrophils and Anesthetic Drugs: Implications in Onco-Anesthesia.

Apart from being a significant line of defense in the host defense system, neutrophils have many immunological functions. Although there are not many publications that accurately present the functions of neutrophils in relation to oncological pathology, their activity and implications have been studied a lot recently. This review aims to extensively describe neutrophils functions'; their clinical implications, especially in tumor pathology; the value of clinical markers related to neutrophils; and the implications of neutrophils in onco-anesthesia. This review also aims to describe current evidence on the influence of anesthetic drugs on neutrophils' functions and their potential influence on perioperative outcomes.

Airway and anesthesia management in tracheoesophageal fistula closure implantation: a single-centre retrospective study.

OBJECTIVE: To review and analyze the airway and anesthesia management methods for patients who underwent endoscopic closure of tracheoesophageal fistula (TEF) and to summarize the experience of intraoperative airway management. METHOD: We searched the anesthesia information system of the First Affiliated Hospital of Nanjing Medical University for anesthesia cases of TEF from July 2020 to July 2023 and obtained a total of 34 anesthesia records for endoscopic TEF occlusion. The intraoperative airway management methods and vital signs were recorded, and the patients' disease course and follow-up records were analyzed and summarized. RESULTS: The airway management strategies used for TEF occlusion patients included nasal catheter oxygen (NCO, n = 5), high-flow nasal cannula oxygen therapy (HFNC, n = 4) and tracheal intubation (TI, n = 25). The patients who underwent tracheal intubation with an inner diameter of 5.5 mm had stable hemodynamics and oxygenation status during surgery, while intravenous anesthesia without intubation could not effectively inhibit the stress response caused by occluder implantation, which could easily cause hemodynamic fluctuations, hypoxemia, and carbon dioxide accumulation. Compared with those in the TI group, the NCO group and the HFNC group had significantly longer surgical times, and the satisfaction score of the endoscopists was significantly lower. In addition, two patients in the NCO group experienced postoperative hypoxemia. CONCLUSION: During the anesthesia process for TEF occlusions, a tracheal catheter with an inner diameter of 5.5 mm can provide a safe and effective airway management method.

Medication errors in veterinary anesthesia: a literature review.

OBJECTIVE: To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction. DATABASES USED: PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗]. CONCLUSIONS: Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Endotracheal tube cuff rupture during anesthesia in 2 dogs.

A 15-year-old intact male dachshund dog weighing 4.3 kg and a 5-year-old intact male mixed-breed dog weighing 13.6 kg were referred for examination because of paraparesis and facial paralysis, respectively. Magnetic resonance imaging (MRI) of the thoracolumbar region and brain was performed. The dogs were premedicated with IV butorphanol, 0.2 mg/kg body weight (BW) and midazolam, 0.2 mg/kg BW. Anesthesia was induced with IV propofol, 4 to 5 mg/kg BW and maintained with sevoflurane in oxygen. The dachshund was orotracheally intubated with a 5.0-millimeter internal diameter endotracheal (ET) tube. During positioning in the MRI room, intermittent positive pressure ventilation (IPPV) was applied. The mixed-breed dog was orotracheally intubated with a 6.0-millimeter internal diameter ET tube. After inflation of the ET tube cuff, a leaking test was done by applying positive pressure ventilation. In both dogs, a distinct "popping" sound was heard when positive pressure was applied, after which air leakage from the cuff was evident. Failure to inflate the pilot balloon led to suspicion of a ruptured cuff. Reintubation was completed, both dogs remained stable during anesthesia, and no postanesthetic complications were observed. Rupture of both cuffs, which was visually confirmed, was thought to be caused by overinflation of the cuff, repeated sterilization of the ET tubes, and positive pressure ventilation. Repeated sterilization of ET tubes with ethylene oxide can alter the physical integrity of cuffs. Care should be taken not to overinflate ET tube cuffs, especially when they have been repeatedly sterilized, as cuff rupture may result in failure to provide adequate IPPV. Key clinical message: This report describes 2 cases in which ET tube cuff rupture was noted during anesthesia for MRI.

Rupture du ballonnet du tube endotrachéal pendant l'anesthésie chez 2 chiens. Un chien teckel mâle intact de 15 ans pesant 4,3 kg et un chien croisé mâle intact de 5 ans pesant 13,6 kg ont été référés pour examen en raison de paraparésie et de paralysie faciale, respectivement. Une imagerie par résonance magnétique (IRM) de la région thoraco-lombaire et du cerveau a été réalisée. Les chiens ont reçu une prémédication avec du butorphanol IV, 0,2 mg/kg de poids corporel (PC), et du midazolam, 0,2 mg/kg PC. L'anesthésie a été induite avec du propofol IV, 4 à 5 mg/kg de PC et maintenue avec du sévoflurane dans de l'oxygène. Le teckel a été intubé par voie orotrachéale avec un tube endotrachéal (TE) de diamètre interne de 5,0 millimètres. Lors du positionnement dans la salle d'IRM, une ventilation intermittente à pression positive (VIPP) a été appliquée. Le chien de race mixte a été intubé par voie orotrachéale avec un TE de 6,0 millimètres de diamètre interne. Après le gonflage du ballonnet du TE, un test d'étanchéité a été effectué en appliquant une ventilation à pression positive. Chez les deux chiens, un son distinct de « claquement ¼ a été entendu lorsqu'une pression positive a été appliquée, après quoi une fuite d'air du ballonnet est devenue évidente. Le fait de ne pas gonfler le ballon pilote a fait soupçonner une rupture du ballonnet. Une ré-intubation a été effectuée, les deux chiens sont restés stables pendant l'anesthésie et aucune complication post-anesthésique n'a été observée. La rupture des deux ballonnets, confirmée visuellement, aurait été causée par un surgonflage du ballonnet, une stérilisation répétée des TE et une ventilation à pression positive. La stérilisation répétée des TE avec de l'oxyde d'éthylène peut altérer l'intégrité physique des ballonnets. Il convient de veiller à ne pas surgonfler les ballonnets des TE, en particulier lorsqu'ils ont été stérilisés à plusieurs reprises, car la rupture du ballonnet peut entraîner l'incapacité de fournir une VIPP adéquate.Message clinique clé:Ce rapport décrit 2 cas dans lesquels une rupture du ballonnet du TE a été constatée lors d'une anesthésie pour IRM.(Traduit par Dr Serge Messier).

Anesthesia, Anesthetics, and Postoperative Cognitive Dysfunction in Elderly Patients.

Postoperative cognitive dysfunction (POCD) remains a major issue that worsens the prognosis of elderly surgery patients. This article reviews the current research on the effect of different anesthesia methods and commonly utilized anesthetics on the incidence of POCD in elderly patients, aiming to provide an understanding of the underlying mechanisms contributing to this condition and facilitate the development of more reasonable anesthesia protocols, ultimately reducing the incidence of POCD in elderly surgery patients.

Advances in pediatric perioperative care using artificial intelligence.

PURPOSE OF THIS REVIEW: This article explores how artificial intelligence (AI) can be used to evaluate risks in pediatric perioperative care. It will also describe potential future applications of AI, such as models for airway device selection, controlling anesthetic depth and nociception during surgery, and contributing to the training of pediatric anesthesia providers. RECENT FINDINGS: The use of AI in healthcare has increased in recent years, largely due to the accessibility of large datasets, such as those gathered from electronic health records. Although there has been less focus on pediatric anesthesia compared to adult anesthesia, research is on- going, especially for applications focused on risk factor identification for adverse perioperative events. Despite these advances, the lack of formal external validation or feasibility testing results in uncertainty surrounding the clinical applicability of these tools. SUMMARY: The goal of using AI in pediatric anesthesia is to assist clinicians in providing safe and efficient care. Given that children are a vulnerable population, it is crucial to ensure that both clinicians and families have confidence in the clinical tools used to inform medical decision- making. While not yet a reality, the eventual incorporation of AI-based tools holds great potential to contribute to the safe and efficient care of our patients.

The intersection of pediatric anesthesiology and social determinants of health.

PURPOSE OF REVIEW: There is increasing evidence of racial and ethnic disparities in pediatric perioperative care, which indicates a need to identify factors driving disparities. Social determinants of health (SDOH) play a fundamental role in pediatric health and are recognized as key underlying mechanisms of healthcare inequities. This article summarizes recent research exploring the influence of SDOH on pediatric perioperative outcomes. RECENT FINDINGS: Despite the scarcity of research exploring SDOH and pediatric perioperative outcomes, recent work demonstrates an association between SDOH and multiple outcomes across the perioperative care continuum. Measures of social disadvantage were associated with preoperative symptom severity, longer hospital stays, and higher rates of postoperative complications and mortality. In some studies, these adverse effects of social disadvantage persisted even when controlling for medical comorbidities and clinical severity. SUMMARY: The existing literature offers compelling evidence of the impact of SDOH on perioperative outcomes in children and reveals a critical area in pediatric anesthesia that necessitates further exploration and action. To improve outcomes and address care inequities, future efforts should prioritize the integration of SDOH assessment into pediatric perioperative research and practice.

Nonintubated spontaneous ventilation versus intubated mechanical ventilation anesthesia for video-assisted thoracic surgery in terms of perioperative complications and practitioners' workload assessments: a pilot randomized control study.

BACKGROUND: The use of nonintubated video-assisted thoracoscopic surgery (NI-VATS) has been increasingly reported to yield favourable outcomes. However, this technology has not been routinely used because its advantages and safety have not been fully confirmed. The aim of this study was to assess the safety and feasibility of nonintubated spontaneous ventilation (NI-SV) anesthesia compared to intubated mechanical ventilation (I-MV) anesthesia in VATS by evaluating of perioperative complications and practitioners' workloads. METHODS: Patients who underwent uniportal VATS were randomly assigned at a 1:1 ratio to receive NI-SV or I-MV anesthesia. The primary outcome was the occurrence of intraoperative airway intervention events, including transient MV, conversion to intubation and repositioning of the double-lumen tube. The secondary outcomes included perioperative complications and modified National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores from anesthesiologists and surgeons. RESULTS: Thirty-five patients in each group were enrolled in the intention-to-treat analysis. The incidence of intraoperative airway intervention events was greater in the NI-SV group than in the I-MV group (12 [34.3%] vs. 3 [8.6%]; OR = 0.180; 95% CI = 0.045-0.710; p = 0.009). No significant difference was found in the postoperative pulmonary complications between the groups (p > 0.05). The median of the anesthesiologists' overall NASA-TLX score was 37.5 (29-52) when administering the NI-SV, which was greater than the 25 (19-34.5) when the I-MV was administered (p < 0.001). The surgeons' overall NASA-TLX score was comparable between the two ventilation strategies (28 [21-38.5] vs. 27 [20.5-38.5], p = 0.814). CONCLUSION: The NI-SV anesthesia was feasible for VATS in the selected patients, with a greater incidence of intraoperative airway intervention events than I-MV anesthesia, and with more surgical effort required by anesthesiologists. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2200055427. https://www.chictr.org.cn/showproj.html?proj=147872 was registered on January 09, 2022.

Nanotherapeutics for Alleviating Anesthesia-Associated Complications.

Current management of anesthesia-associated complications falls short in terms of both efficacy and safety. Nanomaterials with versatile properties and unique nano-bio interactions hold substantial promise as therapeutics for addressing these complications. This review conducts a thorough examination of the existing nanotherapeutics and highlights the strategies for developing prospective nanomedicines to mitigate anesthetics-related toxicity. Initially, general, regional, and local anesthesia along with the commonly used anesthetics and related prevalent side effects are introduced. Furthermore, employing nanotechnology to prevent and alleviate the complications of anesthetics is systematically demonstrated from three aspects, that is, developing 1) safe nano-formulization for anesthetics; 2) nano-antidotes to sequester overdosed anesthetics and alter their pharmacokinetics; 3) nanomedicines with pharmacodynamic activities to treat anesthetics toxicity. Finally, the prospects and challenges facing the clinical translation of nanotherapeutics for anesthesia-related complications are discussed. This work provides a comprehensive roadmap for developing effective nanotherapeutics to prevent and mitigate anesthesia-associated toxicity, which can potentially revolutionize the management of anesthesia complications.

Single exposure to anesthesia/surgery in neonatal mice induces cognitive impairment in young adult mice.

BACKGROUND: The effects of a solitary neonatal exposure to anesthesia plus surgery (anesthesia/surgery) on cognitive function and the underlying mechanism in developing brains remains largely undetermined. We, therefore, set out to investigate the impact of single exposure to anesthesia/surgery in neonatal mice. METHODS: Six-day-old male and female mice received abdominal surgery under 3% sevoflurane plus 50% oxygen for 2 h. The new object recognition (NOR) and Morris water maze (MWM) were used to evaluate cognitive function in young adult mice. Western blot, ELISA and RT-PCR were used to measure levels of NR2B and IL-6 in medial prefrontal cortex and IL-6 in blood of the mice. We employed NR2B siRNA and IL-6 antibody in the interaction studies. RESULTS: The anesthesia/surgery decreased the ratio of novel time to novel plus familiar time in NOR and the number of platform crossings, but not escape latency, in MWM compared to sham condition. The mice in anesthesia/surgery group had increased NR2B expression in medial prefrontal cortex, and IL-6 amounts in blood and medial prefrontal cortex. Local injection of NR2B siRNA in medial prefrontal cortex alleviated the anesthesia/surgery-induced cognitive impairment. IL-6 antibody mitigated the anesthesia/surgery-induced upregulation of NR2B and cognitive impairment in young adult mice. CONCLUSIONS: These results suggest that a single neonatal exposure to anesthesia/surgery causes impairment of memory, but not learning, in young adult mice through IL-6-regulated increases in NR2B concentrations in medial prefrontal cortex, highlighting the need for further research on the underlying mechanisms of anesthesia/surgery's impact on cognitive function in developing brains.

Improving morbidity and mortality in hip fragility fractures.

PURPOSE OF REVIEW: Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system. RECENT FINDINGS: There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality. SUMMARY: HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.