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PURPOSE OF REVIEW: Chronic Postsurgical Pain (CPSP) and the risk for long-term opioid dependency are known complications following major surgery. The idea of Transitional Pain Service (TPS) has been introduced as an interdisciplinary setting to manage pain in the perioperative continuum. We expand on the basic framework and principles of TPS and summarize the current evidence of the TPS and possible interventions to adress postoperative pain. Areas of future work in TPS-related research are discussed. RECENT FINDINGS: Several studies support the effectiveness of TPS in reducing opioid consumption in the perioperative period and following discharge. Some studies also show an improvement in functional outcome with TPS with patients reporting lower pain severity and pain interference. The TPS aims to halt the progress of acute postoperative pain to CPSP by providing longitudinal support with patient-centered care. While some studies suggest a positive impact of TPS implementation in terms of reduction in postoperative opioid consumption and improvement of some functional outcomes, direct evidence in terms of reduction in the incidence of CPSP is still missing. The cost-effectiveness of TPS and the expansion of TPS through e-health services and digital applications also need to be evaluated.
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Manejo da Dor , Dor Pós-Operatória , Humanos , Dor Pós-Operatória/terapia , Manejo da Dor/métodos , Dor Crônica/terapia , Analgésicos Opioides/uso terapêutico , Cuidado TransicionalRESUMO
BACKGROUND: Postoperative nausea and/or vomiting is a relatively frequent occurrence after general anesthesia in pediatric patients. Supplemental perioperative crystalloid fluid administration has been shown to have a positive effect on the incidence of nausea and/or vomiting in adults undergoing surgery. The question arises whether supplemental intraoperative intravenous fluids in pediatric patients offers beneficial results with regards to pediatric postoperative nausea and/or vomiting. METHODS: Pubmed, EMBASE, Google Scholar, and Web of Science were searched up to March 2022 to perform a systematic review with meta-analysis of randomized controlled trials involving patients ≤18 years undergoing elective surgery under general anesthesia, with one group receiving conventional intraoperative fluids therapy and the other group receiving supplemental intraoperative fluid therapy, with intravenous crystalloids. The outcomes included incidence of postoperative vomiting, postoperative nausea and vomiting, the need for rescue anti-emetics, postoperative thirst, and adverse events attributed to supplemental intravenous fluid therapy. Relative risk (RR) with 95% confidence intervals (CIs) were reported for the outcomes using a random or fixed effects model. RESULTS: Seven randomized controlled trials (864 patients) were included in the final analysis. Supplemental intraoperative crystalloids reduce postoperative vomiting (RR 0.56, 95% CI 0.39-0.80; p = .001), postoperative nausea and vomiting (RR 0.52, 95% CI 0.37-0.74; p = .0003), postoperative thirst (RR 0.21, 95% CI 0.13,0.34; p < .01), and the need for rescue anti-emetics postoperatively (RR 0.60, 95% CI 0.49-0.74; p = .00001). CONCLUSION: Supplemental intraoperative intravenous crystalloids significantly reduce several PONV outcomes in healthy children undergoing relatively simple and superficial surgeries under volatile agent-based general anesthesia.
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Antieméticos , Náusea e Vômito Pós-Operatórios , Criança , Humanos , Náusea e Vômito Pós-Operatórios/epidemiologia , Náusea e Vômito Pós-Operatórios/prevenção & controleRESUMO
BACKGROUND: Conventionally, tracheal tubes have been used for general anesthesia in pediatric laparoscopic surgeries. Recently, supraglottic devices are being used for the same. The performance of supraglottic devices versus tracheal tubes in children undergoing laparoscopic surgery is uncertain. METHODS: A systematic review and meta-analysis of randomized controlled trials that compared supraglottic devices versus tracheal tubes in patients ≤18 years undergoing laparoscopic surgery under general anesthesia was conducted. The outcomes were peak airway pressures (cm H2 O), end-tidal carbon dioxide during pneumoperitoneum (mm Hg), recovery time (min), postoperative sore throat and adverse events. Mean difference and odds ratio, with 95% confidence intervals were reported using a random effect model. RESULTS: Eight trials (n = 591) were included in the final meta-analysis. There was no statistically significant difference in the peak airway pressures (MD 0.58, 95% CI: -0.65 to 1.8; p = .36) and end-tidal carbon dioxide (MD -0.60, 95% CI: -2.00 to 0.80; p = .40) during pneumoperitoneum in the supraglottic device and the tracheal tube group. The tracheal tube group had higher odds of sore throat (OR 3.30, 95% CI: 1.69-6.45; p = .0005) and the supraglottic airway group had faster recovery time (MD 4.21, 95% CI: 3.12-5.31; p < .0001), which were statistically significant. The certainty of evidence is graded low. CONCLUSION: There is low quality evidence to suggest that for pediatric laparoscopic surgeries of short duration, supraglottic devices could provide comparable intraoperative ventilation in terms of peak airway pressures and end tidal carbon dioxide, with lower odds of postoperative sore throat and faster recovery time when compared to tracheal tubes.
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Laparoscopia , Máscaras Laríngeas , Faringite , Pneumoperitônio , Humanos , Criança , Intubação Intratraqueal , Dióxido de Carbono , Pneumoperitônio/etiologia , Faringite/epidemiologia , Faringite/etiologia , Máscaras Laríngeas/efeitos adversosRESUMO
How to cite this article: Bandyopadhyay A, Puri S, Ashok V. Fiberoptic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units: A Comment. Indian J Crit Care Med 2023;27(1):78.
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BACKGROUND: Melatonin and dexmedetomidine have both been used as a premedication to decrease emergence delirium in children. The effectiveness of oral melatonin, compared with atomised intranasal dexmedetomidine, in this role is not well studied. OBJECTIVE: To study the efficacy of pre-operative atomised intranasal dexmedetomidine versus oral melatonin in children scheduled for ophthalmic surgery under sevoflurane. DESIGN: A prospective, randomised, double-blind trial. SETTING: Ophthalmic surgery in a university teaching hospital, April 2021 to October 2021. PATIENTS: A total of 120 children undergoing ophthalmic surgery with sevoflurane anaesthesia. INTERVENTION: Children were randomised to receive pre-operative intranasal dexmedetomidine 2âµg/kg via an atomiser device (dexmedetomidine group) or oral melatonin 0.5âmgâkg -1 (melatonin group), 45âmin before surgery. OUTCOMES MEASURED: The primary outcome was the incidence of emergence delirium assessed by the Paediatric Anaesthesia Emergence Delirium scale. Secondary outcomes included pre-operative sedation, quality of inhalational induction, postoperative sedation and pain. RESULTS: The incidence of emergence delirium was lower in the dexmedetomidine group than in the melatonin group (17 versus 37%, relative risk 0.45, 95% CI: 0.24 to 0.88; P â=â0.01). Children in the dexmedetomidine group were more sedated following premedication and in the postanaesthesia care unit ( P â<â0.05). Postoperative pain scores were lower in the dexmedetomidine group than in the melatonin group: 0 [0 to 3] versus 2.5 [0-4], ( P â=â0.01). The requirement for and dose of rescue fentanyl analgesia postoperatively was comparable between the two groups. CONCLUSION: Atomised intranasal dexmedetomidine significantly reduced emergence delirium in paediatric opthalmic procedures under sevoflurane anaesthesia compared to oral melatonin. TRIAL REGISTRATION: Clinical Trials Registry of India CTRI/2021/03/032388 ( www.ctri.nic.in ).
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Dexmedetomidina , Delírio do Despertar , Melatonina , Criança , Dexmedetomidina/efeitos adversos , Método Duplo-Cego , Delírio do Despertar/diagnóstico , Delírio do Despertar/epidemiologia , Delírio do Despertar/etiologia , Fentanila , Humanos , Hipnóticos e Sedativos/efeitos adversos , Estudos Prospectivos , Sevoflurano/efeitos adversosRESUMO
BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most distressing complications following surgery. Supplemental perioperative fluid therapy might be an effective strategy to reduce PONV in children. OBJECTIVES: The study was conducted to evaluate the effects of intraoperative liberal fluid therapy with crystalloids on PONV in children. METHODS: In this randomized trial, a total of 150 children of 3-7 years undergoing lower abdominal and penile surgery under general anesthesia were randomly assigned into two groups. "Restricted group" received 10 mL kg-1 h-1 and "Liberal group" received 30 mL kg-1 h-1 infusion of Ringer's lactate solution intraoperatively. All patients received a caudal block and intravenous paracetamol for analgesia. No opioids and muscle relaxants were used. All episodes of nausea-vomiting and the requirement of rescue antiemetic were assessed during 24 hours postoperatively. RESULTS: The incidence of PONV was significantly less in the liberal group patients as compared to the restricted group; 33 (45.8%) patients in the restricted group had vomiting as compared to 20 (27.4%) patients in the liberal group (RR 0.59, 95% CI: 0.38-0.93, P=.021). The adjusted odds ratio of PONV for the liberal group vs restricted group was 2.24 (95% CI: 1.12-4.48, P=.022). The incidence of fluid intake during the first 6 postoperative hours was significantly higher in the restricted group patients; 60 (83%) children in the restricted group complained of thirst as compared to 12 (17%) children in the liberal group (RR 0.19, 95% CI: 0.18-0.33, P=.0001). The parents of the liberal group were more satisfied as compared to the restricted group (mean difference -0.9, 95% CI: -1.8, -0.1, P=.04). None of the children had any complication attributed to the liberal fluid therapy. CONCLUSION: Liberal intraoperative fluid therapy was found to be effective in reducing PONV in children undergoing lower abdominal surgery.
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Hidratação/métodos , Náusea e Vômito Pós-Operatórios/prevenção & controle , Abdome/cirurgia , Anestesia Geral , Antieméticos/uso terapêutico , Criança , Pré-Escolar , Soluções Cristaloides , Método Duplo-Cego , Feminino , Humanos , Incidência , Soluções Isotônicas/uso terapêutico , Masculino , Dor Pós-Operatória/epidemiologia , Pais , Satisfação do Paciente , Pênis/cirurgia , Substitutos do Plasma/uso terapêutico , Náusea e Vômito Pós-Operatórios/tratamento farmacológico , Náusea e Vômito Pós-Operatórios/epidemiologiaAssuntos
Anestesiologistas , COVID-19 , Criança , Humanos , SARS-CoV-2 , Síndrome , Síndrome de Resposta Inflamatória SistêmicaRESUMO
Preeclampsia is an important cause of heart failure during pregnancy and the postpartum period. The aim of this review is to elucidate the pathophysiology and clinical features of preeclamptic heart failure and describe the medical and anesthetic management of these high-risk parturients. This article reviews the current evidence base regarding preeclamptic heart failure and its pathophysiology, types, and clinical features. We also describe the medical and anesthetic management of these patients during the peripartum period. Heart failure due to preeclampsia can present as either systolic or diastolic dysfunction. The management strategies of systolic heart failure include dietary salt restriction, diuresis, and cautious use of beta-blockers and vasodilators. Diuretics are the mainstay in the treatment of diastolic heart failure. In the absence of obstetric indications, vaginal delivery is the safest mode of delivery in these high-risk patients, and the use of an early labor epidural for analgesia is recommended. These patients would require increased invasive monitoring during labor and vaginal delivery. Neuraxial and general anesthesia have been used successfully for cesarean section in these patients but require crucial modifications of the standard technique. Uterotonic drugs have significant cardiovascular and pulmonary effects, and a clear understanding of these is essential during the management of these patients. Preeclamptics with heart failure require individualized peripartum care, as cardiac decompensation is an important risk factor for maternal and neonatal morbidity and mortality. These high-risk parturients benefit from timely multidisciplinary team inputs and collaborated management.
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Background and Aims: Ultrasound-guided sacral plexus block has been used for anaesthesia and analgesia in lower limb surgeries. This study aimed to compare the block performance characteristics after ultrasound-guided (USG) sacral plexus nerve block (SNB) using the parasacral parallel shift (PSPS) approach versus the classical approach in patients undergoing orthopaedic below-knee limb surgeries. Methods: In this randomised study, 144 adult patients were randomised to receive USG SNB either by the classical approach (Group C) or the PSPS approach (Group P). A fixed dose of 20 ml of 0.5% ropivacaine was administered. Patients also received USG femoral nerve block with 10 ml of 0.5% ropivacaine. The primary outcome was the scanning time between the two groups. Secondary outcomes were the needling time, sensory and motor block onset and postoperative analgesic characteristics between the two groups. A P value of <0.05 was considered statistically significant. Results: The needling time and the scanning time were significantly lesser in Group P than in Group C (P < 0.05). Complete sensory and motor nerve blockade of the sciatic nerve was significantly higher in Group P (P = 0.029). Block performance time, time for sensory block and time for motor block were significantly less in Group P compared to Group C (P < 0.001). The postoperative analgesic characteristics were comparable between the two groups. Conclusion: The sacral plexus block with ultrasound-guided parasacral parallel shift technique had a lower block performance time with lesser needling and scanning time than the classical approach.
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OBJECTIVE: To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults. METHODS: In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge). RESULTS: We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference. CONCLUSION: Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.
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Estado Terminal , Delírio , Unidades de Terapia Intensiva , Melatonina , Humanos , Melatonina/administração & dosagem , Melatonina/uso terapêutico , Delírio/prevenção & controle , Delírio/epidemiologia , Delírio/tratamento farmacológico , Masculino , Feminino , Pessoa de Meia-Idade , Incidência , Tempo de Internação , Idoso , Respiração Artificial/efeitos adversos , AdultoRESUMO
BACKGROUND: PVI has been shown to be an accurate predictor of fluid responsiveness in paediatric patients. Evidence regarding the role of PVI to guide intraoperative fluid therapy in paediatric abdominal surgery is lacking. We aimed to assess the effect of PVI-guided fluid therapy on the volume of intraoperative fluids administered and post-operative biochemical and recovery profile in children undergoing elective abdominal surgery. METHODS: 42 children, 6 months-3 years scheduled for elective open bowel surgery were randomised to receive either 'conventional liberal intraoperative fluids' (liberal group) or 'goal-directed intraoperative fluids' (GDT group). PVI <13 was targeted in the GDT group. The primary outcome was the volume of intraoperative fluids administered. Postoperative serum lactate, base excess, hematocrit, recovery of bowel function and duration of postoperative hospital stay were the secondary outcomes. RESULTS: The mean fluid administered intra-operatively was significantly lower in the GDT group as compared to the liberal group (24.1 ± 9.6 mL/kg vs 37.0 ± 8.9 mL/kg, p < 0.001). The postoperative hemoglobin concentration (g%) was significantly lower in the liberal group as compared to the GDT group (8.1 ± 1.3 vs 9.2 ± 1.4, p = 0.008). Recovery of bowel function (hours) was significantly delayed in the liberal group as compared to the GDT group (58.2 ± 17.9 vs 36.5 ± 14.1, p < 0.001). CONCLUSION: Intraoperative PVI-guided fluid therapy significantly reduces the volume of intravenous crystalloids administered to children undergoing open bowel surgery. These children also had faster recovery of bowel function and less hemodilution in the immediate postoperative period, compared to those who received liberal intraoperative fluid therapy. TYPE OF STUDY: Randomized Clinical Trial. LEVEL OF EVIDENCE: Treatment Study (LEVEL 1).
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Objetivos , Complicações Pós-Operatórias , Humanos , Criança , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Hidratação , Abdome/cirurgia , Cuidados IntraoperatóriosRESUMO
Background: Data on outcomes of coronavirus disease 2019 (COVID-19) in pregnancy are scarce, although they represent a unique physiological state affecting both the mother and child. We present collated data from a tertiary care center in North India, encompassing the outcome, clinical characteristics, and management of these patients. Materials and Methods: Parturients ≥ 18 years old, with COVID-19 reverse transcriptase polymerase chain reaction positive for severe acute respiratory syndrome coronavirus 2, requiring intensive care unit (ICU) admission at a tertiary care hospital were included. Data were retrospectively collected from April 2020 to November 2021. Results: In all, 26 parturients were admitted to ICU with COVID-19. Five patients were admitted during the first wave, and all were asymptomatic. Twenty-one patients presented during the second wave (March 2021 onward), among which four were asymptomatic and 17 symptomatic (all with severe pneumonia). Three patients presented in the second trimester, all with critical disease, out of which one did not survive. Two patients had twin gestation, and others were singleton pregnancies. Seven patients (27%) were primigravida, and five patients (19.2%) had more than third pregnancy. Twenty critically ill women (77%) delivered during the hospital stay. Six patients died during the second wave, and four deaths (66.7%) were because of COVID-19 acute respiratory distress syndrome (ARDS). Conclusions: The number of admissions and mortality related to COVID-19 ARDS was higher in the second wave than in the first. We report the safe use of remdesivir and tocilizumab in our patients.
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A tracheal pouch is a rare complication of successful repair of a congenital tracheoesophageal fistula (TEF). An 18-month-old child with a repaired congenital TEF was scheduled for esophageal dilation to treat his esophageal stricture. Migration of the distal end of the endotracheal tube into a previously undetected tracheal pouch caused an abrupt failure to ventilate at the end of surgery. Given our experience, we recommend to screen the trachea of every patient with corrected TEF for a tracheal pouch when they are scheduled for another procedure requiring general anesthesia.
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Intubação Intratraqueal/instrumentação , Fístula Traqueoesofágica/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Falha de Equipamento , Humanos , Lactente , Intubação Intratraqueal/efeitos adversos , Masculino , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Fístula Traqueoesofágica/congênitoRESUMO
OBJECTIVE: To assess the extent of preoperative information provided to patients' parents, their expressed need for more information and its effect on paediatric anxiety and parental satisfaction with the perioperative care provided. DESIGN: Prospective observational study. SETTING: Public university hospital. PARTICIPANTS: 100 children, 2-12 years scheduled to undergo elective day-care surgery under general anaesthesia. OUTCOMES MEASURED: The parents were interviewed preoperatively with a questionnaire, which included a list of items about preoperative preparation likely to contribute to patients' satisfaction with the health care services. The baseline anxiety level in the participant children and its possible predictors were recorded. Before discharge, the parents were asked a questionnaire for satisfaction scoring. RESULTS: Eighty-five (85%) parents were aware of the surgical procedure whereas 5 (5%) were aware of anaesthesia. Seventy-five (79%) families were not keen to know about anaesthesia. Amongst all the parents surveyed, 16 (16%) reported that receiving more information on anaesthesia would increase their anxiety while 84 (84%) reckoned that although more information would not increase their anxiety, it was unnecessary. Preoperative baseline anxiety was identified in 71 (71%) of children with a median mYPAS of 46.4 (95%CI: 41.4, 48.64). Amongst the potential predictors of anxiety analysed, low paternal education level was associated with high preoperative anxiety in children (adjusted OR: 3.67; 95%CI: 1.35, 9.99; P=0.01). Ninety-four (94%) and 57 (57%) parents expressed satisfaction with the obtained information from the surgeon and anaesthesiologist, respectively. CONCLUSION: The present study revealed the high incidence of preoperative anxiety in children and highlighted the expectations of parents regarding preoperative preparation suggesting the need to evolve the existing preparatory program in the context of a developing world setting.