Preoperative anxiety in the paediatric population in a tertiary hospital: A descriptive cross-sectional study.

AIM: To analyse preoperative paediatric anxiety in a tertiary hospital and influencing factors. DESIGN AND METHODS: This study was designed as a descriptive cross-sectional study. One hundred patients between two and 12 years old who underwent elective surgical intervention were included. All patients received oral or written information about the anaesthetic-surgical process and waited in a playroom before surgery. Preoperative paediatric anxiety was assessed using the modified Yale Preoperative Anxiety Scale and its short form. Collaboration during anaesthesia induction was evaluated using the Induction Compliance Checklist and postoperative pain evaluated using Wong-Baker Scale. We performed a descriptive and comparative analysis of the results overall. RESULTS: We found a high incidence of preoperative anxiety, especially during anaesthetic induction. Children aged two to five years, female sex and otorhinolaryngology surgery were associated with a higher incidence of preoperative anxiety. CONCLUSIONS: Providing oral and written information and waiting in the playing room before surgery are insufficient measures to prevent preoperative paediatric anxiety.

Perioperative opioid-minimization approach as a useful protocol in the management of patients with Ehlers-Danlos syndrome-hypermobility type, craniocervical instability and severe chronic pain who are to undergo occipito-cervical fixation.

Patients suffering from connective tissue disorders like Ehlers-Danlos syndrome hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) may be affected by craniocervical instability (CCI). These patients experience myalgic encephalomyelitis, chronic fatigue, depression, extreme occipital-cervical pain, and severe widespread pain that is difficult to relieve with opioids. This complex and painful condition can be explained by the development of chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization. Given the challenges in treating such severe physical pain, we evaluated all the analgesic methods previously used in the perioperative setting, and updated information was presented. It covers important physiopathological aspects for the perioperative care of patients with EDS-HT/JHS and CCI undergoing occipital-cervical/thoracic fixation/fusion. Moreover, a change of paradigm from the current opioid-based management of anesthesia/analgesia in these patients to the perioperative opioid minimization strategies used by the authors was analyzed and proposed as follow-up considerations from our previous case series. These strategies are based on total-intravenous opioid-free anesthesia, multimodal analgesia, and a postoperative combination of anti-hyperalgesic coadjuvants (lidocaine, ketamine, and dexmedetomidine) with an opioid-sparing effect.

Thoracolumbar Interfascial Plane Block Results in Opioid-Free Postoperative Recovery After Percutaneous/Endoscopic Transforaminal Lumbar Interbody Fusion Surgery.

OBJECTIVE: To evaluate efficacy in reducing postoperative pain and opioid analgesia of a novel interdisciplinary strategy combining preoperative thoracolumbar interfascial plane (TLIP) block and percutaneous/endoscopic transforaminal lumbar interbody fusion surgery and to determine time to first postoperative ambulation and hospital length of stay. METHODS: In this retrospective review, 42 patients who underwent elective single-level percutaneous/endoscopic transforaminal lumbar interbody fusion surgery between 2015 and 2021 were divided into 2 groups: TLIP group with 17 patients who underwent TLIP block and non-TLIP group with 25 patients. Both groups received the same postoperative analgesia with morphine as patient-controlled rescue medication. Visual analog scale and Oswestry Disability Index scores were evaluated. Statistical evaluation was performed with Student t test. RESULTS: In contrast to the non-TLIP group, in the TLIP group, postoperative mean visual analog scale back score and mean Oswestry Disability Index score significantly decreased from 6.6 to 3.3 (P < 0.01) and 32.8 to 23.6 (P < 0.01), respectively, at hospital discharge. No differences were found between the groups at 1 month. Overall mean follow-up time was 29 ± 18 months (range, 3-78 months). Patients in the non-TLIP group were administered a median postoperative 24-hour morphine dose equivalent of 23 mg (range, 8-31 mg), while patients in the TLIP group did not require opioid analgesia (P < 0.01). Patients in the TLIP group started postoperative ambulation at a median of 4.1 hours (range, 2.5-26 hours) with a median hospital length of stay of 24 hours (range, 20-48 hours) (P = 0.112). CONCLUSIONS: TLIP block significantly improves patient outcome at hospital discharge after transforaminal lumbar interbody fusion surgery without postoperative administration of opioids. A prospective study is recommended to confirm our preliminary results.

Opioid-free anesthesia for patients with joint hypermobility syndrome undergoing craneo-cervical fixation: a case-series study focused on anti-hyperalgesic approach.

BACKGROUND: Patients with Ehlers-Danlos Syndrome/Hypermobility Type (EDS-HT/JHS) and Craneo-Cervical Instability frequently suffer from severe widespread pain which is difficult to control. Chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization may explain this painful condition. The aim of this study was to determine if opioid-free anesthesia plus the postoperative administration of lidocaine, ketamine and dexmedetomidine can reduce postoperative pain and the need of methadone rescues in comparison with opioid-based management in these patients undergoing Craneo-Cervical Fixation (CCF). The secondary aim was to assess the needs of opioids at hospital-discharge, incidence of gastrointestinal complications and the requirement of anxiolytic. METHODS: A retrospective, consecutive case series study was designed. 42 patients with EDS-HT/JHS undergoing CCF were enrolled in two groups: an OFA-plus Group that received opioid-free anesthesia with propofol, lidocaine, ketamine and dexmedetomidine, and OP Group, opioid-based anesthesia-analgesia. The main variables: Preoperative Visual Analogue Score (VAS), postoperative VAS on the 1st, 2nd, 4th and 6th days, sufentanil or morphine requirements, need for methadone rescue, and VAS at hospital-discharge. Data was presented by mean ± SD, percentage, median or interquartile range. Chi-squared or Fisher's test. 95% C.I and P values < 0.05. RESULTS: Nineteen patients in OFA-plus, and 23 patients in OP group. VAS was lower in OFA-plus on the postoperative days evaluated (p < 0.001).VAS at hospital-discharge was lower in OFA-plus: 4.96 (4.54-5.37) vs. OP 6.39 (6.07-6.71) (p < 0.001). Methadone requirement was lower in the OFA-plus (p < 0.001). 78% of patients in OFA-plus didn't need methadone rescue. 95% in OP group needed methadone rescues at high doses(> 15 mg/day). No differences regarding equivalent doses of sufentanil or morphine consumption on the 2nd, 4th, and 6th postoperative days were found. OFA-plus decreased ileus, nausea and vomiting (p < 0.001). 60.9% in OFA-plus group decreased opioid requirements at hospital-discharge compared with preoperative values. A 77% reduction of anxiolytics requirements was shown. CONCLUSION: OFA-plus management for patients undergoing CCF with EDS-HT/JHS shows significant reduction in postoperative pain and at hospital-discharge compared with opioid-based anesthesia. OFA-plus management decreases the total doses of methadone rescues, reduces anxiolytic requirements and gastrointestinal side-effects, except for constipation. OFA-plus management is a feasible option to improve postoperative pain control, reducing the opioids' use and their postoperative side-effects in patients undergoing CCF with EDS-HT/JHS.

Left atrial wall thickness of the pulmonary vein reconnection sites during atrial fibrillation redo procedures.

BACKGROUND: Left atrial wall thickness (LAWT) has been related to pulmonary vein (PV) reconnections after atrial fibrillation (AF) ablation. The aim was to integrate 3D-LAWT maps in the navigation system and analyze the relationship with local reconnection sites during AF-redo procedures. METHODS: Consecutive patients referred for AF-redo ablation were included. Procedure was performed using a single catheter technique. LAWT maps obtained from multidetector computerized tomography (MDCT) were imported into the navigation system. LAWT of the circumferential PV line, the reconnected segment and the reconnected point, were analyzed. RESULTS: Sixty patients [44 (73%) male, age 61 ± 10 years] were included. All reconnected veins were isolated using a single catheter technique with 55 min (IQR 47-67) procedure time and 75 s (IQR 50-120) fluoroscopy time. Mean LAWT of the circumferential PV line was 1.46 ± 0.22 mm. The reconnected segment was thicker than the rest of segments of the circumferential PV line (2.05 + 0.86 vs. 1.47 + 0.76, p < .001 for the LPVs; 1.55 + 0.57 vs. 1.27 + 0.57, p < .001 for the RPVs). Mean reconnection point wall thickness (WT) was at the 82nd percentile of the circumferential line in the LPVs and at the 82nd percentile in the RPVs. CONCLUSION: A single catheter technique is feasible and efficient for AF-redo procedures. Integrating the 3D-LAWT map into the navigation system allows a direct periprocedural estimation of the WT at any point of the LA. Reconnection points were more frequently present in thicker segments of the PV line. The use of 3D-LAWT maps can facilitate reconnection point identification during AF-redo ablation.

Evaluation of Plasmatic Concentration of Propofol 2.5µg/ml by TCI using Marsh Modified Model, during oocyte retrieval for IVF in Latin-American women (Venezuelans).

OBJECTIVE: To evaluate efficacy of Propofol at Cp 2.5 µg/ ml administered by Target Controlled Infusion (TCI) using Marsh Modified Model, in pre-medicated with midazolam/ fentanil Latin-American women (Venezuelans) during oocyte retrieval for In Vitro Fertilization. METHODS: Prospective, descriptive study included 72 women, 18-44 years old, ASA I-II, non obese, undergoing oocyte retrieval, pre-medicated with midazolam 0.04 mg/kg and fentanil 2µg/kg and received anesthesia based in Propofol at Cp 2.5µg/ml by Target Controlled Infusion using Marsh Modified Model. Demographic data, propofol doses, duration of procedure and recovery time was registered using descriptive statistic. Anesthesia efficacy was measured by Biespectral Analysis (BIS), Intra-Operative Movements Scale (0 to 5) graded, Postoperative Pain by Visual Analog Scale (VAS) and nausea/vomits incidence. ANOVA and Pearson Chi2 were used with an error of 0.05. RESULTS: Age average was 33.04±6 years old, procedure average time 18.06±8min, Propofol total doses 146.64±53 mgs, Propofol infusion doses average 155.2±3µg/Kg/min. During procedure, 70.8% of patients had no movement, 22.2% movement Grade I and 6.9% Grade II. (Grade I-II movement did not interfere with procedure continuity). 70.8% achieved BIS 40-50 and 93.1% had BIS equal o less than 60. There was a statistic significant correlation between BIS 40-50 and no movements. Recovery post-anesthesia time was 25.2±8 min. 98.6% of patients reported excellent comfort. CONCLUSION: With midazolam/fentanil pre-medication, Propofol at Cp 2.5µg/ml by TCI using Marsh Modified Model showed a 93% of effectiveness during oocyte retrieval in Latin-American women subjected to IVF, allowing an ultra- fast recovery time.

Laringoscopia e intubación traqueal: uso de sulfato de magnesio para atenuar la respuesta cardiovascular refleja / Laryngoscopy and tracheal intubation: use of magnesium sulfate to blunt reflex cardiovascular response

El propósito del estudio fue investigar los efectos hemodinámicos del sulfato de magnesio 60 mg/kg endovenoso, durante la inducción anestésica con tiopental sódico 5 mg/kg y succinilcolina 1,5 mg/Kg; y evaluar la capacidad del magnesio para atenuar la respuesta cardiovascular refleja a la laringoscopia. Veinte pacientes, ASA I, entre 18-60 años, fueron divididos en dos grupos: (M) recibió sulfato de magnesio 60 mg/kg sobre un minuto durante la inducción, y (C) un volumen equivalente de solución salina. Antes de la intubación, la administración de magnesio incrementó la frecuencia cardíaca significativamente con respecto al valor basal (con p<0,01 de diferencia entre grupos) y la presión arterial se mantuvo estable durante la inducción anestésica en ambos grupos. No obstante, el incrementó inicial de la frecuencia cardíaca durante la inducción en el grupo magnesio (M), la frecuencia cardíaca y la presión arterial después de la intubación fue significativamente menor que en el grupo (C) todo el tiempo (p<0,01). Los resultados obtenidos del presente estudio, sugieren que el tratamiento con sulfato de magnesio (60mg/kg) provee una segura y efectiva atenuación tanto de la respuesta taquicardizante como hipertensiva a la laringoscopia e intubación traqueal en pacientes sanos

Asociación de alfentanil con sulfato de magnesio para atenuar la respuesta hemodinámica a la laringoscopia e intubación traqueal / Association of alfantanyl with magnesium sulphate to attenuate the haemodynamic response a the tracheal intubation and laryngoscopy

El objetivo de este estudio aleatorio y ciego, fue comparar la capacidad de la Asociación de Alfentanil con Sulfato de Magnesio, a dosis mínima efectivas, para atenuar la respuesta hemodinámica a la laringoscopia e intubación traqueal con respecto a cada uno de estos medicamentos por separado a mayores dosis. Treinta pacientes, ASA I-II entre 18-60 años, sometidos a cirugía electiva o de emergencia, divididos en 3 grupos para recibir un bolo pre-inductivo del fármaco a estudiar, durante un minuto, de la manera siguiente: Grupo A45 (n=9) Alfentanil 45 µg/Kg.; Grupo A30/M40 (n=10); Alfentanil 30 µg/Kg. Con Sulfato de Magnesio a 40 mg/Kg, y el Grupo M60 (n=10) Sulfato de Magnesio 60 mg/Kg. La inducción en secuencia rápida con Succinilcolina 0,1 mg/Kg, seguida por Tiopental Sódico a 5 mg/Kg y Succinilcolina a 1,5 mg/kg. Todos los grupos fueron similares con respecto a los datos demográficos. Los resultados obtenidos sugieren que el pre-tratamiento con una combinación de Lafentanil (30 µg/Kg) y Sulfato de Magnesio (40 mg/Kg) provee una segura y efectiva atenuación de la respuesta taquicardizante y abolición de la respuesta hipertensiva a la laringoscopía e intubación traqueal en pacientes sanos, con un mínimo de efectos colaterales en comparación a cada uno de estos medicamentos por separado a mayores dosis. Esta combinación es tan efectiva como el Alfentanil a 45 µg/Kg, y más efectiva que el Sulfato de Magnesio a 60 mg/Kg. puede considerarse como una alternativa para evitar mayores dosis de opioides

Laringoscopia e intubación traqueal: uso del alfentanil con sulfato de magnesio para atenuar la respuesta hemodinámica durante la inducción anestesica de secuencia rapida / Laryngoscopy and tracheal intubation: alphentanyl with magnesium sulfatc to atenuar the hemodinamic response during the anesthesic induction of rapidly sequence

El presente estudio evaluó la capacidad para atenuar la respuesta hemodinámica a la laringoscopia e intubación traqueal, durante la inducción anestésica de secuencia rápida, de la asociación de alfentanil y sulfato de magnesio en dosis reduccidas comparándolo con cada medicamento por separado a mayores dosis. 30 pacientes ASA I-II, entre 18 y 60 años, sometidos a cirugía electiva o de emergencia, fueron distribuidos aleatoriamente en 3 grupos, según el fármaco a estudiar: grupo A (n=9) recibieron alfentanil 45 mgr/kg, grupo A/M (n=10) recibieron alfentanil 30 mgr/kg y sulfato de magnesio 40 mgr/kg y, grupo M (n=10) recibieron sulfato de magnesio 60 mgr/kg. Los 3 grupos fueron comparables estadísticamente. Se excluyó 1 paciente del grupo A por dificultad en la intubación. Los resultados obtenidos sugieren que el pretratamiento con una combinación de alfentanil (30 mgr/kg) y sulfato de magnesio (40 mgr/kg) provee una segura y efectiva atenuación de la respuesta taquicardizante y abolición de la respuesta hipertensiva a la laringoscopia e intubación traqueal, asociacido con una menor incidencia de efectos secundarios; siendo tan efectivo como el grupo A y significativamente más efectivo que el M.