Few Anesthesia-Related Adverse Events in a Retrospective Cohort Study of Patients With Unanticipated Intensive Care Unit Admission After Ambulatory Procedures.

We evaluated whether a hospital-based anesthesia department can validly use automated intensive care unit (ICU) admission data after elective ambulatory procedures to assess the quality of anesthetic care. Among 13,656 patients, 25 (0.2%) had an unplanned hospital length of stay >1 night and ICU admission. On review, only 1 of the 25 cases (0.007%) had an anesthesia-related complication. The false-positive incidence of anesthetic complications was ≥96% for scheduled ambulatory cases with ICU admission. Therefore, fully automated computerized identification of all unexpected ICU admissions after ambulatory procedures without manual review is an unsuitable (invalid) metric of individual anesthesiologists' clinical performance.

Navigating Anesthesia: Muscle Relaxants and Reversal Agents in Patients with Renal Impairment.

This comprehensive review explores the interaction between neuromuscular blocking agents, reversal agents, and renal function, focusing on various drugs commonly used in anesthesia and their effects on kidney health. Succinylcholine, commonly used for anesthesia induction, can trigger elevated potassium levels in patients with specific medical conditions, leading to serious cardiac complications. While studies suggest the use of succinylcholine in patients with renal failure is safe, cases of postoperative hyperkalemia warrant further investigation. Some agents, such as atracurium and mivacurium, are minimally affected by impaired kidney function, whereas others, such as cisatracurium and rocuronium, can have altered clearance, necessitating dose adjustments in patients with renal failure. The reversal agents neostigmine and sugammadex affect renal markers, while cystatin C levels remain relatively stable with sugammadex use, indicating its milder impact on glomerular function, compared with neostigmine. Notably, the combination of rocuronium and sugammadex in rat studies shows potential nephrotoxic effects, cautioning against the simultaneous use of these agents. In conclusion, understanding the interplay between neuromuscular blocking agents and renal function is crucial for optimizing patient care during anesthesia. While some agents can be used safely in patients with renal failure, others can require careful dosing and monitoring. Further research is needed to comprehensively assess the long-term impact of these agents on kidney health, especially in high-risk patient populations. This article aims to review the use of muscle relaxants and reversal for anesthesia in patients with impaired renal function.

Evaluation of the Effects of Repetitive Anaesthesia Administration on the Brain Tissues and Cognitive Functions of Rats with Experimental Alzheimer's Disease.

Introduction: We evaluated the effects of repeated ketamine, propofol, and ketamine + propofol administration on cognitive functions and brain tissue of elderly rat models with streptozotocin-induced Alzheimer's disease. Materials and Methods: Thirty elderly male Wistar Albino rats were divided into five groups: control (Group C), Alzheimer's (Group A), Alzheimer's + ketamine (Group AK), Alzheimer's + propofol (Group AP), and Alzheimer's + propofol + ketamine (Group APK). Alzheimer's disease was induced in Groups A, AK, AP, and APK via intracerebroventricular streptozotocin. Four weeks after surgery, ketamine, propofol, and ketamine + propofol were administered intraperitoneally for 3 days to Groups AK, AP, and APK, respectively. The radial arm maze test (RAMT) was performed in the initial, 1st, 2nd, 3rd, and 4th weeks after surgery and daily following anaesthesia. Blood and brain tissue samples were obtained. Results: The RAMT results of Groups A, AK, AP, and APK decreased compared to Group C 2 weeks after Alzheimer's disease onset. Compared to Group A, the RAMT results increased in Groups AK and APK after the first anaesthesia, and in Group AP after the second anaesthesia. Brain tissue paraoxonase-1 (PON-1) and catalase (CAT) activities were low, and the thiobarbituric acid reactive substance (TBARS) level was high in Group A compared to Group C. TBARS levels of Groups AP and APK were lower than Group A, while CAT activity was higher. PON-1 activity was higher in Groups AK, AP, and APK than in Group A. Histopathological changes decreased in Groups AP and AK. A decrease in p53 was found in Group C compared to Group A. Ketamine and propofol were found to be effective at Bcl-2 immunoexpression, but a decrease in Caspase-3 was observed in Group APK. GFAP immunoexpression increased in Group A compared to Group C and in Group AP compared to Group AK. Conclusions: Repetitive anaesthesia application was found to positively affect cognitive functions. This was supported by histopathological and biochemical markers.

The Association of Brain Insulin Resistance with Anesthesia/Surgery-Induced Cognitive Deterioration Is Female-Specific in 5XFAD Transgenic Mice.

Background: Our previous studies indicated that anesthesia/surgery could aggravate cognitive impairment and tau pathology in female 5XFAD transgenic (Tg) mice. However, it is unknown whether there are sex differences in the susceptibility of developing postoperative cognitive dysfunction in 5XFAD Tg mice. Objective: In this study, we aim to determine whether anesthesia/surgery can have different effects on female and male 5XFAD Tg mice, and to explore the underpinning mechanisms. Methods: The mice received abdominal surgery under isoflurane anesthesia. Morris water maze was used to assess the cognitive function. Hippocampal levels of p-tau (AT8), p-IRS1 (Ser612), IRS1, p-GSK3ß (Tyr216), and p-GSK3ß (Ser9) at postoperative day 1 were evaluated by western blot assays. Results: Anesthesia/surgery exaggerated cognitive impairment and tau pathology in female, but not male 5XFAD Tg mice. The anesthesia/surgery led to elevated hippocampus protein levels of p-IRS1 (Ser612)/IRS1 ratio and p-GSK3ß (Tyr216) and reduced hippocampus protein levels of p-GSK3ß (Ser9) in female, but not male 5XFAD Tg mice. Conclusions: This study demonstrated that female 5XFAD Tg mice were more susceptible to anesthesia/surgery-induced cognitive deterioration and tau pathology aggravation, potentially due to female-specific brain insulin resistance.

Update on the anesthesia management in adult patients with moyamoya disease.

PURPOSE OF REVIEW: The anesthetic management of patients with Moyamoya disease (MMD) is challenging and continues to evolve. The goal of this review is to provide updated recommendations on the anesthetic management of adult MMD patients based on the relevant existing literature. RECENT FINDINGS: Key findings include the importance of aggressive hydration preoperatively to sustain cerebral perfusion. Hypertension induced intraoperatively may prevent cerebral hypoperfusion. Vigilance against cerebral hyperperfusion after revascularization is necessary, with specific blood pressure targets recommended. Fluid management should aim for normovolemia to mild hypervolemia. Maintaining body temperature helps prevent cerebral vasospasm induced by hypothermia. Maintaining adequate oxygen supply during surgery is crucial. In cases of ischemic stroke, managing hematocrit and oxygen carrying capacity is essential to prevent further ischemia. Extubation decisions should consider baseline neurological function, while postoperative normocapnia helps prevent cerebral hyperperfusion and hypertension. In intensive care, cautious blood pressure management is crucial to prevent secondary complications. SUMMARY: Strategies in the preoperative, intraoperative, and postoperative anesthetic management of MMD patients should aim to maintain adequate cerebral perfusion to prevent cerebral ischemia.

Keeping patients in the dark: perioperative anesthetic considerations for patients receiving 5-aminolevulinic acid for glioma resection.

PURPOSE OF REVIEW: 5-Aminolevulinic acid hydrochloride (5-ALA), available under the trade name Gleolan, is an orally administered fluorophore drug used to enhance visual differentiation of cancerous tissue from healthy tissue, primarily during surgical resection of high-grade gliomas. Although given preoperatively, 5-ALA has important implications for anesthetic care throughout the perioperative period. This article reviews pharmacology, safety concerns, and perioperative considerations for patients who receive oral 5-ALA. RECENT FINDINGS: Although approved for clinical use by the United States Food and Drug Administration in 2017, studies and case reports published since then have further delineated side effects of this medication and its mechanisms and pharmacokinetics. SUMMARY: Mitigating the possible side effects of 5-ALA requires an understanding of its basic mechanism as well as focused perioperative planning and communication. Administration of this medication may result in nausea, vomiting, photosensitivity, increase in serum concentration of liver enzymes, and hypotension. Patients who receive 5-ALA must be protected from prolonged light exposure during the first 48 h after consumption and administration of other photosensitizing agents should be avoided (Supplemental Video File/Video abstract).

Anesthesia for traumatic brain injury.

PURPOSE OF REVIEW: Traumatic brain injury (TBI) presents complex clinical challenges, requiring a nuanced understanding of its pathophysiology and current management principles to improve patient outcomes. Anesthetists play a critical role in care and need to stay updated with recent evidence and trends to ensure high-quality treatment. The Brain Trauma Foundation Guidelines, last updated in 2016, have shown moderate adherence, and much of the current management relies on expert opinions. This literature review synthesizes the current evidence and provides insights into the role of anesthetists in TBI management. RECENT FINDINGS: Recent literature has emphasized the importance of tailored anesthetic management principles in treating TBI, focusing on minimizing secondary brain injury during neurosurgical interventions or extracranial surgery. Emerging trends include individualized intracranial pressure approaches and multimodal neuromonitoring for comprehensive assessment of cerebral physiology. SUMMARY: Anesthesia for TBI patients requires a comprehensive approach that balances anesthetic goals with the unique pathophysiological factors of brain injury. Despite recent research expanding our understanding, challenges remain in standardizing protocols and addressing individual patient response variability. Adherence to established management principles, personalized approaches, and ongoing research is crucial for improving the outcomes.

Anaesthetic mortality in cats: A worldwide analysis and risk assessment.

BACKGROUND: Patient safety is essential in small animal anaesthesia. This study aimed to assess anaesthesia-related deaths in cats worldwide, identify risk and protective factors and provide insights for clinical practice. METHODS: A prospective multicentre cohort study of 14,962 cats from 198 veterinary centres across different countries was conducted. Data on anaesthesia-related deaths, from premedication up to 48 hours postextubation, were collected. Logistic regression was used to analyse patient demographics, American Society of Anesthesiologists (ASA) classification, procedure type and anaesthetic drugs. RESULTS: The anaesthesia-related mortality was 0.63%, with 74.5% of deaths occurring postoperatively. Cats with cachexia, a higher ASA status or who underwent abdominal, orthopaedic/neurosurgical or thoracic procedures exhibited elevated mortality. Mechanical ventilation use was associated with increased mortality. Mortality odds were reduced by the use of alpha2-agonist sedatives, pure opioids in premedication and locoregional techniques. LIMITATIONS: Limitations include non-randomised sampling, potential biases, unquantified response rates, subjective death cause classification and limited variable analysis. CONCLUSIONS: Anaesthetic mortality in cats is significant, predominantly postoperative. Risk factors include cachexia, higher ASA status, specific procedures and mechanical ventilation. Protective factors include alpha2-agonist sedatives, pure opioids and locoregional techniques. These findings can help improve anaesthesia safety and outcomes. However, further research is required to improve protocols, enhance data quality and minimise risks.

[Chinese expert consensus on pediatric anesthesia assessment and perioperative risk prediction (2024 edition)].

The incidence of perioperative adverse events in children aged 0 to 15 years was 5.2%. Preoperative scientific and accurate anesthesia assessment is a crucial step in ensuring the safety of pediatric surgery. Perioperative risk prediction is a digital quantitative evaluation of the level of perioperative risk, which classifies the degree of danger. In order to further standardize the methods of anesthesia assessment and identify risk factors, Chinese Society of Anesthesiology organized experts in anesthesiology from children's specialty hospitals and general hospitals, along with statisticians from public health colleges, to jointly draft the "Chinese expert consensus on pediatric anesthesia assessment and perioperative risk prediction (2024 edition)".The anesthesia assessment includes history collection, physical examination, laboratory examination, American Society of Anesthesiologists physical status, difficult airway assessment, and identification and assessment of critically sick children. Perioperative risk prediction includes preoperative anxiety, perioperative respiratory adverse events, regurgitation and aspiration, emergence delirium, postoperative nausea and vomiting, postoperative ICU admission, postoperative acute kidney injury, perioperative mortality, and risk prediction for in-hospital mortality in children with congenital heart disease undergoing non-cardiac surgery.This consensus has formulated a total of 16 recommendations, aiming to promote anesthesiologists' familiarity with the content of pediatric anesthesia assessment, identify risk factors for adverse events during the perioperative period, and take targeted measures to reduce the occurrence of adverse events and improve the safety of children during the perioperative period.

Artificial intelligence and nonoperating room anesthesia.

PURPOSE OF REVIEW: The integration of artificial intelligence (AI) in nonoperating room anesthesia (NORA) represents a timely and significant advancement. As the demand for NORA services expands, the application of AI is poised to improve patient selection, perioperative care, and anesthesia delivery. This review examines AI's growing impact on NORA and how it can optimize our clinical practice in the near future. RECENT FINDINGS: AI has already improved various aspects of anesthesia, including preoperative assessment, intraoperative management, and postoperative care. Studies highlight AI's role in patient risk stratification, real-time decision support, and predictive modeling for patient outcomes. Notably, AI applications can be used to target patients at risk of complications, alert clinicians to the upcoming occurrence of an intraoperative adverse event such as hypotension or hypoxemia, or predict their tolerance of anesthesia after the procedure. Despite these advances, challenges persist, including ethical considerations, algorithmic bias, data security, and the need for transparent decision-making processes within AI systems. SUMMARY: The findings underscore the substantial benefits of AI in NORA, which include improved safety, efficiency, and personalized care. AI's predictive capabilities in assessing hypoxemia risk and other perioperative events, have demonstrated potential to exceed human prognostic accuracy. The implications of these findings advocate for a careful yet progressive adoption of AI in clinical practice, encouraging the development of robust ethical guidelines, continual professional training, and comprehensive data management strategies. Furthermore, AI's role in anesthesia underscores the need for multidisciplinary research to address the limitations and fully leverage AI's capabilities for patient-centered anesthesia care.

The environmental impacts of anesthesia.

PURPOSE OF REVIEW: The healthcare sector has a substantial environmental footprint, and the delivery of anesthesia contributes significantly. Inhaled anesthetics themselves are potent greenhouse gases, unused intravenous medication exert toxic effects on the environment, and the increasing reliance on single-use devices has led to an ever-growing amount of solid waste produced in operating rooms. This review discusses many of these environmental impacts and suggests practices to mitigate the environmental footprint of anesthetic practice. RECENT FINDINGS: The choice of anesthesia maintenance has significant environmental implications, with nitrous oxide and desflurane having the highest carbon footprint of all anesthetic agents. Using low fresh gas flows and supplementing or replacing inhalational agents with propofol leads to a significant reduction in emissions. Many intravenous anesthetic agents pose a risk of environmental toxicity, and efforts should be made to decrease medication waste and ensure appropriate disposal of unused medications to minimize their environmental impacts. Additionally, consideration should be given to replacing single-use devices in the operating rooms with reusable alternatives that are often both environmentally and economically superior. And solid waste generated in the operating room should be segregated thoughtfully, as processing regulated medical waste is a highly energy-intensive process. SUMMARY: Significant opportunities exist to improve the environmental footprint of anesthesia practice, and with the rapidly worsening climate crisis, the importance of implementing changes is greater than ever.

Association of anaesthesia provider sex with perioperative complications: a two-centre retrospective cohort study.

BACKGROUND: Previous studies suggested that surgeon sex is associated with differential patient outcomes. Whether this also applies to anaesthesia providers is unclear. We hypothesised that female sex of the primary anaesthesia provider is associated with lower risk of perioperative complications. METHODS: The first case for all adult patients undergoing anaesthesia care between 2008 and 2022 at two academic healthcare networks in the USA was included in this retrospective cohort study. The primary exposure was the sex of the anaesthesia provider who spent the most time in the operating theatre during the case. The primary outcome was intraoperative complications, defined as hypotension (mean arterial blood pressure <55 mm Hg for ≥5 cumulative minutes) or hypoxaemia (oxygen saturation <90% for >2 consecutive minutes). The co-primary outcome was 30-day adverse postoperative events (including complications, readmission, and mortality). Analyses were adjusted for a priori defined confounders. RESULTS: Among 364,429 included patients, 57,550 (15.8%) experienced intraoperative complications and 55,168 (15.1%) experienced adverse postoperative events. Care by female compared with male anaesthesia providers was associated with lower risk of intraoperative complications (adjusted odds ratio [aOR] 0.95, 95% confidence interval [CI] 0.94-0.97, P<0.001), which was magnified among non-trainees (aOR 0.84, 95% CI 0.82-0.87, P-for-interaction<0.001). Anaesthesia provider sex was not associated with the composite of adverse postoperative events (aOR 1.00, 95% CI 0.98-1.02, P=0.88). CONCLUSIONS: Care by a female anaesthesia provider was associated with a lower risk of intraoperative complications, which was magnified among non-trainees. Future studies should investigate underlying mechanisms.