Anesthetic management for cesarean delivery in a woman with congenital atlantoaxial dislocation and Chiari type I anomaly: a case report and literature review.

BACKGROUND: The preferable choice of anesthesia for the patients with congenital atlantoaxial dislocation (CAAD) and type I Arnold Chiari malformations (ACM-I) has been a very confusing issue in clinical practice. We describe the successful administration of combined spinal-epidural anesthesia for a woman with CAAD and ACM-1 accompanied by syringomyelia. CASE PRESENTATION: Our case report presents the successful management of a challenging obstetric patient with CAAD and ACM-1 accompanied by syringomyelia. She had high risks of difficult airway and aspiration. The injection of bolus drugs through the spinal or epidural needle may worsen the previous neurological complications. The patient was well evaluated with a multidisciplinary technique before surgery and the anesthesia was provided by a skilled anesthesiologist with slow spinal injection. CONCLUSIONS: An interdisciplinary team approach is needed to weigh risks and benefits for patients with CAAD and ACM-1 undergoing cesarean delivery. Therefore, an individual anesthetic plan should be made basing on the available anesthetic equipments and physicians' clinical experience on anesthetic techniques.

Effect of dexmedetomidine combined with sufentanil for post-caesarean section intravenous analgesia: a randomised, placebo-controlled study.

BACKGROUND: Few studies have investigated the use of dexmedetomidine in obstetric anaesthesia. OBJECTIVE: To evaluate the effect of dexmedetomidine combined with sufentanil for patient-controlled analgesia (PCA) after caesarean section under spinal anaesthesia. DESIGN: An interventional, randomised, double-blinded, placebo-controlled clinical study. SETTING: Department of Anaesthesiology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China. PATIENTS: One hundred and twenty parturients (American Society of Anesthesiologists class 1 or 2) scheduled for elective caesarean delivery under spinal anaesthesia randomly allocated into three groups (n = 40 each). INTERVENTIONS: Group 1: physiological saline bolus after delivery and sufentanil PCA, Group 2: dexmedetomidine bolus (0.5 µg kg) after delivery and sufentanil PCA, Group 3: dexmedetomidine bolus (0.5 µg kg) after delivery and sufentanil with dexmedetomidine PCA (background infusion of 0.045 µg kg h with a bolus of 0.07 µg kg). MAIN OUTCOME MEASURES: The total consumption of sufentanil. Pain scores at rest evaluated with a visual analogue scale (VAS) and Ramsay sedation score (RSS) were recorded at the 4, 8 and 24 h after surgery. The patients' pain threshold (PTh) and pain tolerance threshold (PTTh) were measured before surgery and 1 h after initial study drug administration. Satisfaction scores were collected 24 h after surgery. RESULTS: Sufentanil consumption in group 3 was 43.9 ±â€Š19.2 µg, significantly lower than in group 1 (54.5 ±â€Š23.9 µg) and group 2 (56.3 ±â€Š20.6 µg) (P < 0.05). Compared with group 3, VAS was increased at 4, 8 and 24 h after surgery in groups 1 and 2 (P < 0.05); there was no difference between groups 1 and 2. PTh and PTTh were significantly increased 1 h after drug administration in groups 2 (1.59 ±â€Š0.45, 2.57 ±â€Š0.46 mA) and 3 (1.74 ±â€Š0.37, 2.56 ±â€Š0.48 mA) compared with group 1 (1.49 ±â€Š0.49, 2.42 ±â€Š0.62 mA) (P < 0.05). CONCLUSION: The combination of sufentanil and dexmedetomidine for PCA after caesarean section can reduce sufentanil consumption and improve parturients' satisfaction compared with sufentanil PCA alone. TRIAL REGISTRATION: ChiCTR-TRC-11001442.

Comparison of the bispectral indices of patients receiving remimazolam and propofol for general anesthesia: a randomized crossover trial.

BACKGROUND: Remimazolam is a safe and effective new benzodiazepine sedative that has unique advantages in anesthesia induction and maintenance. The differences in the electroencephalogram bispectral index (BIS) during general anesthesia between propofol and remimazolam deserve further exploration. METHODS: Single-center randomized crossover study. Patients who required multiple hysteroscopic surgery were randomly assigned to use remimazolam (0.27 mg/kg for induction and 1 mg/kg/h for maintenance) first and then propofol (2.0 mg/kg for induction and 6 mg/kg/h for maintenance) during hysteroscopic surgery again 3 months later, or in the opposite order. Both drugs were used at the latest ED95 for unconsciousness. The BIS values (primary endpoint), intraoperative conditions, and incidence of adverse reactions (secondary endpoints) were compared at each time point. BIS values were analyzed with a mixed model of repeated measurements (MMRM). RESULTS: Seventeen patients completed the study. The lowest BIS value in the remimazolam regimen was significantly higher than that in the propofol regimen (p = 0.001). The MMRM analysis of the BIS values revealed significant differences between the regimens at each time point (p < 0.001). The intraoperative diastolic blood pressure and heart rate changes were smaller, the recovery was faster, and there were fewer adverse reactions and less injection pain, but a greater incidence of intraoperative body movement and hiccups, in the remimazolam regimen. CONCLUSION: The trial indicated that remimazolam maintained a higher BIS level than propofol. The correlation between the BIS and the depth of anesthesia induced by remimazolam needs to be further studied. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov: ChiCTR2200064551.

Dexmedetomidine improves cognition after carotid endarterectomy by inhibiting cerebral inflammation and enhancing brain-derived neurotrophic factor expression.

OBJECTIVES: Carotid endarterectomy (CEA) is efficient in preventing stroke for patients with significant carotid stenosis, but results in mild cognitive dysfunction. Dexmedetomidine is neuroprotective in stroke models. We hypothesized that dexmedetomidine may improve cognition after CEA. METHODS: Forty-nine patients scheduled for elective CEA were randomly assigned to intravenous dexmedetomidine treatment group (n = 25) and control group C (normal saline, n = 24). Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA), as well as lactate, TNF-α, IL-6, and BDNF levels in blood, were assessed before, during, and after surgery. RESULTS: MMSE and MOCA scores showed subtle decline in both groups at 24 hours postoperatively; this decline remained at 48 hours postoperatively in group C. Both scores were higher in group D than in group C at 48 and 72 hours postoperatively. TNF-α and IL-6 were lower from 5 minutes post-clamping through 24 hours postoperatively in group D; lactate was lower at 5 minutes post-clamping in group D. BDNF was higher from 5 minutes post-clamping through 1 hour postoperatively in both groups, and remained high in group D at 24 hours postoperatively. CONCLUSIONS: Dexmedetomidine improved recovery of cognition after CEA, potentially due to reduced inflammation and enhanced BDNF expression.

Dexmedetomidine Added to Sufentanil Patient-Controlled Intravenous Analgesia Relieves the Postoperative Pain after Cesarean Delivery: A Prospective Randomized Controlled Multicenter Study.

This study evaluated the efficacy and safety of dexmedetomidine in intravenous patient-controlled analgesia (PCA) after cesarean delivery. This multicenter study enrolled 208 subjects who were scheduled for selective cesarean delivery from 9 research centers. Patients received 0.5 ug/kg dexmedetomidine (study group) or normal saline (control group) after delivery and an intravenous PCA pump after surgery (100 µg sufentanil +300 µg dexmedetomidine for the study group, 100 µg sufentanil for the control group, background infusion: 1 ml/h, bolus dose: 2 ml and lock time: 8 min). The sufentanil consumption, pain scores, rescue analgesia, sedation scores, analgesic satisfaction, the incidence of postoperative nausea and vomiting (PONV) and the first passage of flatus were recorded within 24 h after surgery. The sufentanil consumption in the study group was significantly lower than that in the control group (p = 0.004). Compared with the control group, the study group had lower pain scores (p < 0.01), higher analgesic satisfaction degree [p < 0.001, odd ratio 4.28 and 95% CI (2.46, 7.46)], less requirement of rescue analgesia (p = 0.003), lower incidence of PONV (p = 0.005 and p < 0.001, respectively), and shorter time to first passage of flatus (p = 0.007). Dexmedetomidine added to sufentanil intravenous PCA significantly enhanced the analgesic effects, improved analgesic satisfaction, and had the potential benefits of reducing PONV and the recovery of intestinal functions after cesarean section.

Effects of methylprednisolone on the duration of rocuronium-induced neuromuscular block: A randomized double-blind trial.

BACKGROUND: We aim to investigate whether intraoperative use of methylprednisolone could affect the duration of rocuronium-induced neuromuscular blockade. METHODS: A double blind, randomized, placebo-controlled trial was conducted. A total of 136 patients underwent gynecologic laparoscopic surgery were randomly divided into 3 groups: pregroup, receiving intravenous injection of methylprednisolone (40 mg) 30 minutes before induction of anesthesia; postgroup, receiving intravenous injection of methylprednisolone (40 mg) immediately after induction of anesthesia and intubation; and control group, receiving intravenous injection of normal saline. Patients were intravenously administrated with rocuronium 0.6 mg/kg, and changes in adductor policies evoked twitch responses were measured by ulnar nerve stimulator. RESULTS: We found that all patients achieved maximum blockade effects, and there was no difference in onset time among the 2 groups. For time required to achieve train-of-four ratio (TOFR) 90%, pregroup (64.50 ±â€Š10.52 minutes) and postgroup (65.29 ±â€Š11.64 minutes) were significantly shorter than that of the control group (71.04 ±â€Š10.55 minutes, P = .027), whereas clinical duration and total duration were significantly shorter in the 2 groups received methylprednisolone than the control group. However, there was no significant difference between the 2 treatment groups either in clinical duration and total duration of muscle relaxants, or time required to achieve TOFR 90%. No significant difference was found in recovery index among the 3 groups. CONCLUSION: Our findings suggest that a single intravenous injection of methylprednisolone, no matter preoperatively or intraoperatively, could shorten the duration of rocuronium-induced neuromuscular blockade.